A Scoping Review of the Literature on Entrustable Professional Activities in Surgery Residency Programs

OBJECTIVE

Entrustable professional activities (EPAs) are a crucial component of contemporary postgraduate medical education with many surgery residency programs having implemented EPAs as a competency assessment framework to assess and provide feedback on the performance of their residents. Despite broad implementation of EPAs, there is a paucity of evidence regarding the impact of EPAs on the learners and learning environments. A first step in improving understanding of the use and impact of EPAs is by mapping the rising number of EPA-related publications from the field of surgery. The primary objective of this scoping review is to examine the nature, extent, and range of articles on the development, implementation, and assessment of EPAs. The second objective is to identify the experiences and factors that influence EPA implementation and use in practice in surgical specialties.

DESIGN

Scoping review. Four electronic databases (Medline, Embase, Education Source, and ERIC) were searched on January 20, 2022, and then again on July 19, 2023. A quasi-statistical content analysis was employed to quantify and draw meaning from the information related to the development, implementation, assessment, validity, reliability, and experiences with EPAs in the workplace.

PARTICIPANTS

A total of 42 empirical and nonempirical articles were included.

RESULTS

Four thematic categories describe the topic areas in included articles related to: 1) the development and refinement of EPAs, including the multiple steps taken to develop and refine unique EPAs for surgery residency programs; 2) the methods for implementing EPAs; 3) outcomes of EPA use in practice; 4) barriers, facilitators, and areas for improvement for the implementation and use of EPAs in surgical education.

CONCLUSIONS

This scoping review highlights the key trends and gaps from the rapidly increasing number of publications on EPAs in surgery residency, from development to their use in the workplace. Existing EPA studies lack a theoretical and/or conceptual basis; future development and implementation studies should adopt implementation science frameworks to better structure and operationalize EPAs within surgery residency programs.

Development of a Tool to Assess Surgical Resident Competence On-Call: The Western University Call Assessment Tool (WUCAT)

BACKGROUND

A central tenet of competency-based medical education is the formative assessment of trainees. There are currently no assessments designed to examine resident competence on-call, despite the on-call period being a significant component of residency, characterized by less direct supervision compared to daytime. The purpose of this study was to design a formative on-call assessment tool and collect valid evidence on its application.

METHODS

Nominal group technique was used to identify critical elements of surgical resident competence on-call to inform tool development. The tool was piloted over six months in the Division of Plastic & Reconstructive Surgery at our institution. Quantitative and qualitative evidence was collected to examine tool validity.

RESULTS

A ten-item tool was developed based on the consensus group results. Sixty-three assessments were completed by seven staff members on ten residents during the pilot. The tool had a reliability coefficient of 0.67 based on a generalizability study and internal item consistency was 0.92. Scores were significantly associated with years of training. We found the tool improved the quantity and structure of feedback given and that the tool was considered feasible and acceptable by both residents and staff members.

CONCLUSIONS

The Western University Call Assessment Tool (WUCAT) has multiple sources of evidence supporting its use in assessing resident competence on-call.

Are COVID-Era General Surgery Interns Starting Residency Behind on Basic Surgical Skills?

OBJECTIVE

To compare incoming general surgery interns' performance on a basic skills assessment before and after the COVID pandemic.

DESIGN

A retrospective cohort study compared surgical skill performances of incoming general surgery interns. Each underwent an evidence-based standardized assessment (pretest) with 12-basic surgical knot tying and suturing tasks. A post-test was administered after a 3-month self-directed skills curriculum. Student's t-tests compared proficiency scores from pre-COVID vs. COVID-era general surgery interns before and after curriculum completion. p < 0.05 was significant.

SETTING

Data was collected from surgical residents in an academic general surgery program in the United States.

PARTICIPANTS

General surgery interns from 2017 to 2019 (pre-COVID) and 2021 to 2022 (COVID-era) were included. Interns with missing data or extreme outliers were excluded. A total of 100 interns in general surgery were included in the pretest cohort (59 pre-COVID, 41 COVID-era) and 101 interns were in the post-test cohort (66 pre-COVID, 35 COVID-era).

RESULTS

COVID-era interns scored significantly lower on the pretest compared to pre-COVID interns (COVID-era 721.9+/-268.8 vs. pre-COVID 935.9+/- 228.0, p < 0.001). After the skills curriculum both cohorts improved their proficiency scores. However COVID-era interns still scored significantly lower (COVID-era 1255.0+/-166.3 vs. pre-COVID 1369.8+/-165.6, p = 0.001).

CONCLUSIONS

This analysis objectively described deficits in fundamental surgical skills for incoming interns whose medical school education was disrupted by the COVID-19 pandemic. A targeted surgical skills curriculum partially remediated these deficiencies. However, many surgical interns may need additional intervention and potentially more time in order to fully develop their surgical skills and meet the competency requirements required for advancement.

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair

INTRODUCTION

Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science.

METHODS

A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation.

RESULTS

Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation.

CONCLUSIONS

This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

Practice-Based Learning and Improvement: Improving Morbidity and Mortality Review Using Natural Language Processing

INTRODUCTION

Practice-Based Learning and Improvement, a core competency identified by the Accreditation Council for Graduate Medical Education, carries importance throughout a physician's career. Practice-Based Learning and Improvement is cultivated by a critical review of complications, yet methods to accurately identify complications are inadequate. Machine-learning algorithms show promise in improving identification of complications. We compare a manual-supplemented natural language processing (ms-NLP) methodology against a validated electronic morbidity and mortality (MM) database, the Morbidity and Mortality Adverse Event Reporting System (MARS) to understand the utility of NLP in MM review.

METHODS

The number and severity of complications were compared between MARS and ms-NLP of surgical hospitalization discharge summaries among three academic medical centers. Clavien-Dindo (CD) scores were assigned to cases with identified complications and classified into minor (CD I-II) or major (CD III-IV) harm.

RESULTS

Of 7774 admissions, 987 cases were identified to have 1659 complications by MARS and 1296 by ms-NLP. MARS identified 611 (62%) cases, whereas ms-NLP identified 670 (68%) cases. Less than one-third of cases (299, 30.3%) were detected by both methods. MARS identified a greater number of complications with major harm (457, 46.30%) than did ms-NLP (P < 0.0001).

CONCLUSIONS

Both a prospectively maintained MM database and ms-NLP review of discharge summaries fail to identify a significant proportion of postoperative complications and overlap 1/3 of the time. ms-NLP more frequently identifies cases with minor complications, whereas prospective voluntary reporting more frequently identifies major complications. The educational benefit of reporting and analysis of complication data may be supplemented by ms-NLP but not replaced by it at this time.

How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education

OBJECTIVE

To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among.

SETTING

Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals.

PARTICIPANTS

Clinical faculty within the Department of Surgery.

RESULTS

A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care.

CONCLUSIONS

Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.

Gaps in Practice Management Skills After Training: A Qualitative Needs Assessment of Early Career Surgeons

PURPOSE

Shifts in American healthcare delivery mechanisms pose significant hurdles to new physicians. Surgeons are particularly susceptible to these changes, but surgical residency educational efforts primarily focus on technical and clinical training to the exclusion of business and management practices. This study conducted a needs assessment of perceived gaps in practice management skills among early career surgeons to guide future training curricula.

METHODS

This study was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify early career (<5 years following fellowship completion) surgeons across the United States. A semi-structured interview guide was created from interviews with surgical administrators and physician administrative curricula. Transcripts were de-identified and analyzed using a constructivist grounded theory approach.

RESULTS

Ten surgeons from 6 specialties and 6 institutions were interviewed along with 3 surgeon administrators. Three major domains of need were identified: (1) fundamentals of procedural coding, clinical billing, & compliance, (2) finding/building a practice, and (3) navigating organizational challenges. First, surgeons thought trainees would benefit from a better understanding of reimbursement schema and the basics of health policy. They also thought that more exposure to malpractice litigation, especially for handling case review or expert witness requests, would be helpful for discerning how to handle such issues early in their career. In addition, early career surgeons expressed a desire to have dedicated mentorship time, a primer on evaluating job offers with simulated contract negotiation, and guidance regarding administrative roles. Finally, surgeons requested training in change management techniques, care pathway construction, and the basics of staffing decisions.

CONCLUSIONS

There are significant practice management gaps in surgical training which may be amenable to targeted educational efforts during a residency or fellowship program. Future research will test the generalizability of these findings as well as build curricula that adequately meet these needs.

Applying VitalTalkTM Techniques to Best Case/Worst Case Training to Increase Scalability and Improve Surgeon Confidence in Shared Decision-making

OBJECTIVE

Best Case/Worst Case (BC/WC) is a communication tool designed to promote shared decision-making for high-risk procedures near the end of life. This study aimed to increase scalability of a BC/WC training program and measure its impact on surgeon confidence in and perceived importance of the methodology.

DESIGN

A prospective cohort pre-post study; December 2018 to January 2019.

SETTING

Multi-center tertiary care teaching hospital.

PARTICIPANTS

Forty-eight resident surgeons from general surgery and otolaryngology.

RESULTS

Learners were 24 to 37 years old with 52% in post graduate year 1 to 2. Although learners encountered high-stakes communication (HSC) frequently (3.6 [0.7] on 5-point Likert scale), most reported no HSC training in medical school (74.5%) or residency (87.5%). BC/WC training was accomplished with an instructor to learner ratio of 1-to-5.3. After training, learner confidence improved on all measured communication skills on a 5-point scale (e.g., exploring patient's values increased from 3.6 [0.8] to 4.1 [0.6], p = <0.0001); average within-person improvement was 0.72 (0.6) points across all skills. Perceived importance improved across all skills (e.g., basing a recommendation on patient's values increased from 4.4 [0.8] to 4.8 [0.5], p = 0.0009); average within-person improvement was 0.46 (0.5) points across all skills. Learners reported this training would likely help them in future interactions (4.4 [0.73] on 5-point scale) and 95.2% recommended it be offered to resident physicians in other residency programs and to attending surgeons.

CONCLUSIONS

Formal training in BC/WC increases learners' perception of both the importance of HSC skills and their confidence in exercising those skills in clinical practice. VitalTalk^TM methodology permitted scaling training to 5.3 learners per instructor and was highly recommended for other surgeons. Ongoing training, such as this, may support more patient-centered decision-making and care.

Resident Night Float or 24-hour Call Hospital Coverage: Impact on Training, Patient Outcome, and Length of Stay

OBJECTIVE

The impact of neurosurgical resident hospital coverage system, performed via a night float (12-hour shifts overnight) or a 24-hour call, on neurological surgery resident training and patient care is unknown.

DESIGN

Retrospective review comparing night float and 24-hour call coverage on trainee surgical experience, elective time, annual program surveys, patient outcomes, and length of stay.

SETTING

The Ohio State Wexner Medical Center Neurosurgery residency program, Columbus, Ohio.

PARTICIPANTS

The neurosurgical residents from 2016 to 2019.

RESULTS

Monthly cases performed by junior residents significantly increased after transitioning to a 24-hour call schedule (18 versus 30, p < 0.001). There were no differences for total cases among program graduates during this time (p = 0.7). Trainee elective time significantly increased after switching to 24-hour call coverage (18 versus 24 months after the transition; p = 0.004). Risk-adjusted mortality and length of stay indices were not different (0.5 versus 0.3, p = 0.1; 0.9 versus 0.9; p = 0.3). Program surveys had minimal change after the transition to 24-hour call.

CONCLUSIONS

Transitioning from a night float to a 24-hour call coverage system led to improved junior resident case volume and elective time without detrimental effect on patient-related outcomes.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

OBJECTIVE

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years.

DESIGN

Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents.

SETTING

ACGME accredited general surgery residency programs.

PARTICIPANTS

Not applicable.

RESULTS

General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend.

CONCLUSIONS

The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Development of an Automated Smartphone-Based Suture Evaluation System

OBJECTIVE

Quantification of skill level in surgical training is necessary for effective skill development. In this study, we report the development of a smartphone application that automatically and objectively evaluates training in stitching goldfish scoop poi, a fragile material currently used for practice by young surgeons in Japan.

METHODS

The application, named "e-Suture," enables the automatic evaluation of surgical technique quality by evaluating the gap between the mark printed on the poi and the insertion/extraction point of the needle (Accuracy), analyzing suture placement (Deflection), detecting tears in the poi material/tissue (Tears), and the time taken to perform the exercise (Time). The algorithm for scoring used a sigmoid function, and the coefficients were adjusted so that the scores of a sample of 20 cases ranged between 20 and 100 points.

RESULTS

The e-Suture prototype was completed. The e-Suture-derived ranking for 20 poi after training was significantly correlated with the mean of the rankings evaluated by 9 experts (correlation coefficient: 0.728; p = 0.000). We also tested which items the experts rated as the most important. The overall ratings obtained from the experts correlated with the e-Suture accuracy scoring results with a correlation coefficient of 0.836 (p = 0.000) for Accuracy, 0.31 (p = 0.173) for Deflection, and 0.518 (p = 0.019) for Tear.

CONCLUSION

The e-Suture application can easily and accurately quantify and evaluate the suturing skills of novie surgeons. Further studies should improve the accuracy of data to be analyzed by collecting more surgical data and applying it to other surgical techniques.

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.

Validation of Use of Flipped Classroom for Surgery Core Clerkships

BACKGROUND

The flipped classroom (FC) is an integrated learning paradigm that equips students with self-directed study materials before scheduled meeting times allowing for the deeper application of acquired knowledge with an instructor. There is limited data on the application of FC to clinical undergraduate medical education and particularly as it applies to a surgical clerkship.

METHODS

This study is a four-year retrospective study that includes two cohorts of students who matriculated through two training paradigms, traditional classroom (TC) and FC. Information regarding the FC cohort was collected from June 2018 to July 2020 (N=166). A two-year matched historical cohort of students enrolled in the clerkship and taught with the TC paradigm from June 2016 to July 2018 was used for comparison (N=157). The primary aim of this study is to assess the National Board of Medical Examiners (NBME) surgery shelf performance when the FC model is utilized compared to the TC model. This study will validate a prior similar study that had a smaller cohort with different secondary endpoints. Therefore, the secondary aim of this study assesses how teaching style can affect other performance metrics of a rotation (such as clinical performance, quizzes, Objective Structured Clinical Examinations (OSCE), and practicums) and how time was utilized by faculty, staff, and students.

RESULTS

There was no difference in overall NBME surgery shelf performance when comparing the FC to the traditional classroom teaching (68.94 vs 70.34, P= 0.1667). Likewise, there was no difference in quiz performance. The FC did allow instructors to spend more time in other clinical components of the curriculum leading to a significant difference in student practicum (84.2 vs 88.26, P = 0.0186) and OSCE grades (87.54 vs 90.58, P <0.0001).

CONCLUSION

The surgery NBME shelf performance is not compromised by FC and therefore can be used as an alternative to traditional classroom setting for teaching medical knowledge to surgery clerkship students. In addition, the FC can improve time management for instructors allowing for improved teaching and development in other components of the surgery curriculum.

Surgical Society Podcasts: A Novel Way to Engage and Educate the Community

BACKGROUND

Podcasts are increasingly being utilized in the surgical field as an asynchronous educational resource. This article discusses podcasts devoted to the field of surgery and their growing contribution to surgical education.

METHODS

We provide examples of current podcasts and their varied structures, including those that distribute clinical and educational content, discuss recent literature and advancements, interview leaders in the field, and/or showcase unique perspectives on topics such as career development, diversity, and wellness.

RESULTS AND CONCLUSIONS

Podcasts generated from surgical societies stand on unique ground to educate and engage the surgical community.

An Orthopaedic Virtual Clinical Clerkship for Visiting Medical Students: Early Successes and Future Implications

OBJECTIVE

The visiting orthopaedic clerkship is viewed by both students and program directors as an important part of the orthopaedic surgery residency application process, despite being criticized as costly and inefficient. Restrictions due to the COVID-19 pandemic prevented students from participating in in-person clerkships at institutions other than at their home programs, necessitating a virtual replacement for the in-person orthopaedics clerkship experience. It remains unclear how the virtual clerkships will affect the application process this year, and moving forward. We describe and review our institution's initial experience with a virtual orthopaedic clerkship. We hypothesize that students would view the virtual clerkship as valuable, and that students would see a role for such clerkships going forward.

DESIGN

A virtual orthopaedic surgery clerkship was created and students were invited to enroll. Thirty-one 4th-year medical students participated. Each clerkship included 8 two-hour sessions. Each session was moderated by a faculty member, and participants included only medical students. Students presented virtual cases, which provided the basis for the discussion and education. At the conclusion of each clerkship, students were given an anonymous survey assessing various aspects of the clerkship.

RESULTS

Twenty-seven students responded to the survey. Overall, 15 students rated the experience as outstanding, 11 excellent, and 1 good. Twenty-two students saw a role for virtual clerkships moving forward, and five students did not see a role moving forward. Student reported strengths of the clerkship included direct faculty interaction, structured curriculum, and student-centered discussions. Lack of hands-on experience was cited as the biggest weakness.

CONCLUSIONS

Students valued the opportunity for a virtual clerkship, and most could envision a role for such virtual clerkships moving forward. We suggest that virtual clerkships may be a cost-effective and useful tool in helping both students and programs navigate the residency selection process.

The Effect of a Microlearning Module on Knowledge Acquisition in Surgery Clerkship Students

OBJECTIVE

Microlearning has been found to be beneficial in other areas of healthcare education. The purpose of this study was to investigate the effect of a microlearning module compared to a traditional online learning module in undergraduate medical education.

DESIGN

A microlearning module was developed to cover the etiology and management of gallbladder disease. Surgery clerkship students were randomized into 2 groups. One group began with the microlearning module (MLM). The second group began with a 45 minute commercially available module centered on gallbladder disease (WISE-MD™). Halfway through the clerkship, the groups crossed over to the other learning intervention. Student knowledge was assessed with a test at three time points (pre-test, post-test1, post-test2).

SETTING AND PARTICIPANTS

Third year surgery clerkship students at George Washington University.

RESULTS

There were 56 students in the MLM and 57 in WISE-MDTM groups. In the MLM group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, but significantly decreased from post-test1 to post-test2. In the WISE-MD™ group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, with no significant change from post-test1 to post-test2. After the initial intervention, test scores of post-test1 of the MLM group were significantly higher than the WISE-MD™ group, while there were no significant differences between groups at the pre-test or post-test2 time points.

CONCLUSIONS

Students exposed to the microlearning module first performed significantly better on a post intervention test than students that used a commercially available product in our standard curriculum. Therefore, the use of microlearning modules may lead to improved knowledge acquisition in surgery clerkship students.

Trends in Female Plastic Surgery Resident Authorship - Signs of Changing Times?

OBJECTIVE

Gender discrepancies exist in academia for leadership positions, advancement opportunities, and research. As of 2019, the ratio of total male-to-female attending plastic and reconstructive surgeons was 4.8:1. However, the ratio of male-to-female residents in integrated plastic surgery programs fell to 1.3:1, indicating rising female representation. With more balanced gender distributions of residents, the authors sought to determine whether this translates to greater equality of opportunities and achievements. Specifically, this study compares the academic productivity of male and female integrated plastic surgery residents.

METHODS

A list of integrated plastic surgery residency programs was obtained from the Accreditation Council for Graduate Medical Education website and ranked by reputation using the Doximity Residency Navigator. Integrated plastic surgery residents from 2019 to 2020 were identified via program websites and social media accounts. Works published during residency were identified through PubMed and Scopus from July 1 of each resident's intern year through August 10, 2020. Demographic variables for residents, including training class and medical school, as well as for programs, including geographic region, Doximity ranking, and medical school affiliation, were collected. Medical schools were ranked according to US News by research. Research productivity was assessed through the number of total research articles with authorship position (first, second, or last), the number of articles published in plastic surgery journals with the highest impact factors (Plastic and Reconstructive Surgery and Aesthetic Surgery Journal), and H-indices. Chi-Squared tests and Mann-Whitney U-tests were used to make comparisons between male and female residents (α = 0.05).

RESULTS

In total, 931 residents in 81 integrated plastic surgery programs were identified, including 534 (57.4%) male and 397 (42.6%) female residents. There were no differences between male and female residents in terms of training year or program geography. Female residents were more likely to come from a top-50 medical school than males (54.7% vs. 48.1%, p = 0.049). There were no significant differences in gender distribution of residents from top-20 programs or programs affiliated with a top-20 medical school. The median (IQR) number of publications in total, and for each gender, was 3 (1-6). There was no difference in the number of total publications by training year by gender, besides the second-year resident class where male residents had a median (IQR) of 2 (1-4) compared to 1 (0-3) (p = 0.028). Male and female residents did not differ with regards to authorship position or proportion of times publishing in top journals. The distribution of H-indices for male residents was slightly higher than female residents (p = 0.003), but the median (IQR) was the same at 3 (1-5).

CONCLUSIONS

Currently, male and female integrated plastic surgery residents have similar levels of academic productivity. This suggests that female representation is slowly increasing along the pipeline in academia, representing a paradigm shift from previous trends of gender inequality in plastic surgery.

Closing the Gap: Evaluation of Gender Disparities in Urology Resident Operative Autonomy and Performance

OBJECTIVE

Gender disparities have demonstrated influence on several areas of medical trainee academic performance and surgeon professional attainment. The impact of gender on perceived operative autonomy and performance of urology residents is not well understood. This single-institution pilot study explores this relationship by evaluating urology faculty and resident assessment of resident operative autonomy and performance using the Society for Improving Medical Professional Learning app.

DESIGN

Using Society for Improving Medical Professional Learning, trainees in a single urology residency program were assessed in operative cases on three scales (autonomy, performance, and case complexity). Intraoperative assessments were completed by both faculty and residents (self-evaluation). Respective evaluations were compared to explore differences in ratings by gender.

SETTING

University of Michigan Health, Ann Arbor, MI.

PARTICIPANTS

University of Michigan Urology Residents and Faculty.

RESULTS

A total of 516 evaluations were submitted from 18 urology residents and 20 urology faculty. Self-reported ratings among female and male residents did not differ significantly for autonomy (p = 0.20) or performance (p = 0.82). Female and male residents received overall similar autonomy ratings that were not significantly different from female faculty (p = 0.66) and male faculty (p = 0.81). For female residents, there was no significant difference in performance ratings by faculty gender (p = 0.20). This finding was consistent when the resident was male (p = 0.70).

CONCLUSIONS

At our institution, there is no overall gender-based difference in self-rated or faculty-rated operative autonomy or performance among urology trainees. Understanding relevant facets of institutional culture as well as educational strategies between faculty and residents may identify factors contributing to this outcome.

Interns Without Subinternships

Surgical interns who have completed medical school in the era of Covid-19 will not have the same experience gained through the traditional multi-month fourth-year surgical subinternships. During subinternships, medical students learn relevant anatomic and radiographic features of surgical pathologies, hone technical skills, and gain exposure to surgical consults and procedures. This lack of intensive exposure will have this cohort starting at a lower comfort and knowledge level compared to years prior. Residency programs, especially subspeciality programs, should review and utilize national resources to facilitate the transition to intern year, such as the American College of Surgeons Entering Resident Readiness Assessment and American College of Surgeons/ Association of Program Directors in Surgery/Association for Surgical Education Resident Prep Curriculum. We recommend the use of a specialty-tailored intern boot-camp and longitudinal curriculum that focuses on learning procedural skills and surgical conditions, anatomy, pathology, clinical examination, radiographic findings, surgical approach, and postoperative complications. These steps will help address knowledge gaps and promote intern readiness in this cohort of individuals.

Take 10: A Resident Well-Being Initiative and Burnout Mitigation Strategy

OBJECTIVE

Physician training is associated with stressors which contribute to burnout. Individual and institutional level strategies can be employed to address resident burnout; however, time is an often-reported barrier in initiating recommended well-being activities. We hypothesize that brief bursts of well-being activities that are conducive to a resident schedule can mitigate burnout.

DESIGN

This is a prospective observational study following burnout after implementation of an institution-wide, well-being initiative called "Take 10."

SETTING

In the present study, the "Take 10" initiative, meditating or exercising for a minimum of 10 minutes per day 3 times a week, was encouraged at Vanderbilt University Medical Center, a tertiary care center in Nashville, Tennessee.

PARTICIPANTS

Following implementation of the initiative, 254 residents from surgical, procedural, and non-procedural specialties were invited to complete surveys assessing compliance with encouraged "Take 10" activities as well as rates of burnout over a 5-month period. A total of 201 surveys were completed during the study period.

RESULTS

Overall, burnout rates were worse for females (Odds Ratio [OR] = 3.7 | Confidence Interval [CI] = 1.57, 9.05), better for those living with others (OR = 0.22 | CI = 0.07, 0.64), and better for those participating in "Take 10" initiatives (OR = 0.71 | CI = 0.58, 0.86). There was a significant difference in resident-reported burnout (Control = 85.3% vs Intervention = 58.2% | p < 0.01) and Resident Well-Being Index score (Control = 3.73 vs Intervention=2.93 | p < 0.01), when "Take 10" initiatives were employed.

CONCLUSIONS

"Take 10" is a low cost and low intensity initiative for individuals and programs to use to mitigate burnout.

Occupational Radiation Exposure Among General Surgery Residents: Should We Be Concerned?

BACKGROUND

Low-dose ionizing radiation exposure is associated with development of solid organ tumors as well as increased risk of cataract formation in a linear-dose response. While occupational radiation exposure has been studied across subspecialties with regular fluoroscopy exposure such as interventional radiology and urology, the contribution of increasing endovascular case volume to occupational radiation exposure among general surgery residents remains largely unreported. In this study, we sought to determine typical occupational radiation exposure among a pool of general surgery residents as part of a formal radiation safety curriculum.

METHODS

A radiation safety program was introduced to a group of 28 general surgery residents who rotate on a vascular surgery service with a high endovascular volume in a hybrid room setting. All residents received training in proper use of a radiation dosimeter and minimizing exposure during fluoroscopy times in the operating room. Data was collected from radiation film dosimetry badges distributed to general surgery residents on a bimonthly basis throughout the year, and radiation exposure in mRem was compared between residents rotating on vascular and nonvascular surgical services during 4-week rotations.

RESULTS

A total of 14 months of data were collected. Resident compliance was 84% with regular use and return of dosimeters at the end of each bimonthly cycle. The radiation exposure among residents rotating on vascular surgery was significantly higher compared to those on nonvascular rotations (mean = 71 mRem vs 3.13 mRem, p = 0.02). Exposure among senior residents was not statistically different than that of attending vascular surgeons (mean = 212 mRem vs 164 mRem, p = 0.20). All exposures were significantly lower than institutional ALARA dose limits for radiation exposure (5000 mRem/year).

CONCLUSION

General surgery residents are routinely exposed to measurable occupational radiation levels, especially while participating in endovascular procedures during their training. However, data from our study suggests that these levels are below ALARA dose limits and senior surgical residents are not at greater risk than vascular surgery attending surgeons while on their vascular rotation. The results of this study will be used to help guide resident education on radiation safety and identify institution-specific practices which can minimize exposure and improve radiation safety adherence.

Perioperative Clerkship Design for Students with Physical Disabilities: A Model for Implementation

OBJECTIVE

Disability inclusion is an important and growing area of focus for medical education that may be stymied by stereotypes about disabilities, lack of knowledge about accommodations for students with physical disabilities, or outdated technical standards that preclude participation of people with mobility disabilities. To support the inclusion of students with physical disability in surgical clerkships, we describe a proactive, progressive approach to the accommodations process for a student with a thoracic spinal cord injury entering a surgical clerkship.

DESIGN

Working proactively, medical school leadership, disability professionals and the clerkship team collaborated on the development of reasonable accommodations for a student with a thoracic spinal cord injury entering a surgical clerkship.

SETTING

University of Colorado, Department of Surgery and Department of Medical Education, Aurora, CO.

PARTICIPANTS

A third-year medical student and faculty from the medical school and surgical clerkship leaders.

RESULTS

An M3 student with a thoracic spinal cord injury successfully completed an 8-week surgical clerkship completing all required procedural and clinical skills utilizing reasonable accommodation. The student achieved a grade of honors for the rotation.

CONCLUSIONS

Early communication and planning for disability-related adjustments are critical to ensure an accessible experience for students with physical disabilities. The addition of a student with a disability adds to a better understanding of inclusive practices for surgical education and adds to the diversity of thought and experience for the medical education community.

Are You Thinking What I'm Thinking? Exploring Response Process Validity Evidence for a Workplace-based Assessment for Operative Feedback

OBJECTIVE

Workplace-based assessments (WBAs) are used in multiple surgical specialties to facilitate feedback to residents as a form of formative assessment. The validity evidence to support this purpose is limited and has yet to include investigations of how users interpret the assessment and make rating decisions (response processes). This study aimed to explore the validity evidence based on response processes for a WBA in surgery.

DESIGN

Semi-structured interviews explored the reasonings and strategies used when answering questions in a surgical WBA, the System for Improving and Measuring Procedural Learning (SIMPL). Interview questions probed the interpretation of the three assessment questions and their respective answer categories (level of autonomy, operative performance, case complexity). Researchers analyzed transcripts using directed qualitative content analysis to generate themes.

SETTING

Single tertiary academic medical center.

PARTICIPANTS

Eight residents and 13 faculty within the Department of Otolaryngology-Head and Neck Surgery participating in a 6-month pilot of SIMPL.

RESULTS

We identified four overarching themes that that characterized faculty and resident response processes while completing SIMPL: (1) Faculty and resident users had similar content-level interpretations of the questions and corresponding answer choices; (2) Users employed a variety of cognitive, behavioral, and emotional processes to make rating decisions; (3) Contextual factors influenced ratings; and (4) Tensions during interpretation contributed to rating uncertainty.

CONCLUSIONS

Response processes are a key source of evidence to support the validity for the formative use of WBAs. Evaluating response process evidence should go beyond basic content-level analysis as contextual factors and tensions that arise during interpretation also play a large role in rating decisions. Additional work and a continued critical lens are needed to ensure that WBAs can truly meet the needs for formative assessment.

Impact of Research Training on Performance in General Surgery Residency

INTRODUCTION

It is common for North American surgical trainees to interrupt clinical training to complete 2 or more years of research training. The impact of this practice on surgical aptitudes is unknown. The University of Toronto has large general surgery and surgeon scientist training programs. We compared the examination scores of general surgery residents in continuous clinical training with those of residents whose training was interrupted by research.

METHODS

We collected anonymized scores obtained at written and oral annual in-training examinations by general surgery residents at the University of Toronto from 2011 to 2016, inclusive. The written exam assessed knowledge, while the oral exam assessed judgment. Residents were dichotomized into continuous versus non-continuous clinical training streams. We compared performance prior to, during, and following divergence for research training both within and between the 2 groups.

RESULTS

At the junior resident level, future enrollment in research training was associated with higher examination performance (P_written = .003). Annual scores plateaued during research training, while scores of residents who continued in continuous clinical training improved year over year (P_written = .009). Non-continuous stream resident exam scores remained stagnant after 1 year then improved in the second year after return to clinical training (P_written = .00007). Scores obtained in the final year of residency training did not significantly differ between residents who underwent continuous versus non-continuous clinical training. Results from written and oral exams trended concordantly.

CONCLUSIONS

We demonstrate that interruption of clinical training for 2 or more years of research is associated with a stagnation of performance on annual in-training examinations assessing both knowledge and judgment. This phenomenon is followed by an eventual catching-up after at least 2 years return to full-time clinical training. This may inform residency program curriculum design.

Ranking United States University-Based General Surgery Programs on the Academic Achievement of Surgery Department Faculty

OBJECTIVE

Rankings of residency programs are highly influential and utilized by residency applicants. Existing ranking resources often use opaque criteria that may include bias or do not accurately represent the academic achievement of current faculty. This study aims to create an updated general surgery residency ranking list based on the academic achievements of their respective surgery department faculty members.

DESIGN

One hundred and six general surgery residency programs were selected from the American Medical Association Residency & Fellowship Programs Database. The names of faculty members affiliated with the departments of surgery were manually obtained. Lifetime and five-year h-indexes, a sum of grant awards from the National Institute of Health and Veterans Affairs, and a tally of journal editorial board positions were collected for the faculty. Metrics were compared among surgical departments, and the corresponding residency programs were ranked accordingly.

SETTING

The study evaluated university-based general surgery residency programs in the United States from 2017 to 2019 via assessing their respective institutions' departments of surgery.

PARTICIPANTS

A total of 7568 faculty members were evaluated. Faculty were required to be full-time, clinical surgeons to meet inclusion criteria.

RESULTS

Based on a composite of all measured criteria, the top overall surgery department was at the University of Michigan. Massachusetts General Hospital had the highest lifetime and five-year h-indexes. Brigham and Women's Hospital had the most National Institute of Health funding, and the University of Pittsburgh Medical Center had the most Veterans Affairs funding. Washington University in St. Louis/Barnes Jewish Hospital had the most editorial board positions in their department.

CONCLUSIONS

The academic success of departments of surgery was evaluated to develop a ranking list of general surgery residency programs. Through utilizing standardized methods and several measures of academic achievement, this comprehensive general surgery residency classification system will allow residency applicants to make more informed decisions.

Recruitment of General Surgery Residents into Vascular Surgery

BACKGROUND

Vascular surgery fellowship applications among general surgery residents have declined. Given this steady downward trend in vascular applicants in conjunction with a predicted critical shortage of vascular surgeons, a call to action for increased recruitment is needed. To improve recruitment efforts, a subgroup analysis of general surgery residents was performed to explore factors that influence interest in vascular surgery.

METHODS

A cross-sectional national survey of residents (n = 467) was conducted from September 2016 to May 2017. In addition to collection of demographic and occupational characteristics, assessment of psychological, work-life balance, and job-satisfaction variables were obtained. Residents were grouped based on their interest in pursuing a fellowship. Chi-squared and Fisher's exact test was performed to determine significant variables.

RESULTS

Residents were grouped into "interest in non-vascular fellowship" (n = 350), "interest in vascular fellowship" (n = 21), and "not interested in fellowship" (n = 96). Significant variables between the groups included age, geographic location, residency size, and type of institution (p < 0.05). Those interested in vascular surgery tended to be older. Residents not interested in fellowship were more commonly located in the Midwest and at smaller, community residencies. No significant difference was found between mental wellness and work-life balance variables. Those residents interested in a vascular surgery fellowship were more dissatisfied with their current salary as compared to other residents (p = 0.021).

CONCLUSIONS

There is a predicted critical shortage in the vascular surgery workforce making recruitment of the best and brightest residents into the specialty vital to its future. In order to invigorate and broaden our group of vascular surgeons, focused recruitment of younger, Midwest, general surgery residents at smaller, community programs may provide the most yield. Publicizing the strengths of a vascular surgery career including the diversity of patients, continuity of care, proficiency in technical skill, and higher monetary rewards should be emphasized in recruiting these target populations.

Creating a Proficiency-based Remote Laparoscopic Skills Curriculum for the COVID-19 Era

OBJECTIVE

Social distancing restrictions due to COVID-19 challenged our ability to educate incoming surgery interns who depend on early simulation training for basic skill acquisition. This study aimed to create a proficiency-based laparoscopic skills curriculum using remote learning.

DESIGN

Content experts designed 5 surgical tasks to address hand-eye coordination, depth perception, and precision cutting. A scoring formula was used to measure performance: cutoff time - completion time - (K × errors) = score; the constant K was determined for each task. As a benchmark for proficiency, a fellowship-trained laparoscopic surgeon performed 3 consecutive repetitions of each task; proficiency was defined as the surgeon's mean score minus 2 standard deviations. To train remotely, PGY1 surgery residents (n = 29) were each issued a donated portable laparoscopic training box, task explanations, and score sheets. Remote training included submitting a pre-test video, self-training to proficiency, and submitting a post-test video. Construct validity (expert vs. trainee pre-tests) and skill acquisition (trainee pre-tests vs. post-tests) were compared using a Wilcoxon test (median [IQR] reported).

SETTING

The University of Texas Southwestern Medical Center in Dallas, Texas PARTICIPANTS: Surgery interns RESULTS: Expert and trainee pre-test performance was significantly different for all tasks, supporting construct validity. One trainee was proficient at pre-test. After 1 month of self-training, 7 additional residents achieved proficiency on all 5 tasks after 2-18 repetitions; trainee post-test scores were significantly improved versus pre-test on all tasks (p = 0.01).

CONCLUSIONS

This proficiency-based curriculum demonstrated construct validity, was feasible as a remote teaching option, and resulted in significant skill acquisition. The remote format, including video-based performance assessment, facilitates effective at-home learning and may allow additional innovations such as video-based coaching for more advanced curricula.

Intramedullary Fixation of Trochanteric Fractures Can Be Safely Performed by Senior Residents Without Immediate Consultant Supervision

OBJECTIVE

To assess the safety of senior residents performing trochanteric hip fracture surgery without immediate consultant supervision DESIGN: A retrospective chart review of trochanteric hip fractures (AO-OTA 31-A) operated in a single center between years 2011 and 2016 (inclusive). Operations were divided into three groups: Group 1 - surgeon was a senior resident without any immediate supervision; Group 2 - surgeon was a consultant and Group 3 - surgeon was a senior resident supervised by a consultant. The follow-up period was a minimum of 2 years or until death. All re-operations and surgical related mortality were assessed.

SETTING

Helsinki University Hospital, Finland. A tertiary level trauma center.

PARTICIPANTS

987 consecutive trochanteric fractures on 966 patients treated by operative fixation of an intertrochanteric fracture with an intramedullary nail between 2011and 2016 (inclusive).

RESULTS

The total number of reoperations was smaller in Group 1 where the surgeon was a senior resident without any immediate supervision compared to Group 2 where the surgeon was a consultant (5.5 % vs 8.8 %, p < 0.05). There were no significant differences in mortality or length of surgery. The total rate of mechanical complications was 2.0 %, with no significant differences between groups. The observed blade cut-out rate was low: 1.3 %, suggesting a good overall quality of surgery.

CONCLUSIONS

Senior residents can safely perform intramedullary nailing of trochanteric fractures without immediate supervision.

Comparing the Quality of Narrative Comments by Rotation Setting

OBJECTIVE

To investigate the effect of rotation setting on trainee-directed narrative comments within a Canadian General Surgery Residency Program. The primary outcome was to use the McMaster Narrative Comment Rating Scale (MNCRS) to evaluate the quality of narrative comments across five domains: valence of language, degree of correction versus reinforcement, specificity, actionability and overall usefulness. As distributed medical education in the postgraduate training context becomes more prevalent, delineating differences in feedback between various sites will be imperative, as it may affect how narrative comments are interpreted by clinical competency committee (CCC) members.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of 2,469 assessments obtained between July 1, 2014 and May 5, 2019 from the General Surgery Residency Program at the University of British Columbia (UBC) was conducted. Narrative comments were rated using the McMaster Narrative Comment Rating Scale (MNCRS), a validated instrument for evaluating the quality of narrative comments. A repeated measures Analysis of Variance (ANOVA) was conducted to explore the impact of rotation setting, academic, urban tertiary, distributed urban, and distributed rural on the quality of narrative feedback.

RESULTS

Overall, the quality of the narrative comments varied substantially between and within rotation settings. Academic sites tended to provide more actionable comments (p = 0.01) and more corrective versus reinforcing comments, compared with other sites (p's < 0.01). Comments produced by the urban tertiary rotation setting were consistently lower in quality across all scale categories compared with other settings (p's < 0.01).

CONCLUSION

The type of rotation setting has a significant effect on the quality of faculty feedback for trainees. Faculty development on the provision of feedback is necessary, regardless of rotation setting, and should appropriately combine rotation-specific needs and overarching program goals to ensure trainees and clinical competence committees receive high quality narrative.

Natural Language Processing and Assessment of Resident Feedback Quality

OBJECTIVE

To validate the performance of a natural language processing (NLP) model in characterizing the quality of feedback provided to surgical trainees.

DESIGN

Narrative surgical resident feedback transcripts were collected from a large academic institution and classified for quality by trained coders. 75% of classified transcripts were used to train a logistic regression NLP model and 25% were used for testing the model. The NLP model was trained by uploading classified transcripts and tested using unclassified transcripts. The model then classified those transcripts into dichotomized high- and low- quality ratings. Model performance was primarily assessed in terms of accuracy and secondary performance measures including sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC).

SETTING

A surgical residency program based in a large academic medical center.

PARTICIPANTS

All surgical residents who received feedback via the Society for Improving Medical Professional Learning smartphone application (SIMPL, Boston, MA) in August 2019.

RESULTS

The model classified the quality (high vs. low) of 2,416 narrative feedback transcripts with an accuracy of 0.83 (95% confidence interval: 0.80, 0.86), sensitivity of 0.37 (0.33, 0.45), specificity of 0.97 (0.96, 0.98), and an area under the receiver operating characteristic curve of 0.86 (0.83, 0.87).

CONCLUSIONS

The NLP model classified the quality of operative performance feedback with high accuracy and specificity. NLP offers residency programs the opportunity to efficiently measure feedback quality. This information can be used for feedback improvement efforts and ultimately, the education of surgical trainees.

Training the Next Generation of Obstetrics and Gynecology Leaders, A Multi-Institutional Needs Assessment

OBJECTIVE

To assess resident and faculty interest in, as well as content and preferred format for, a leadership curriculum during obstetrics and gynecology residency DESIGN: From June to July 2019, a needs assessment survey on leadership training was distributed to residents and academic faculty at 3 United States obstetrics and gynecology residency programs. Descriptive and bivariate analyses were performed. Open ended questions were analyzed for themes.

SETTING

Three ob/gyn residency programs across the United States: Kaiser Permanente East Bay in Oakland, California, Baylor College of Medicine in Houston, Texas, and Weill Cornell Medicine in New York, New York.

PARTICIPANTS

Surveys were distributed to all residents (n = 111) and affiliated academic faculty (n = 124) at each of the 3 participating sites.

RESULTS

Resident response rate was 71% (79/111) and faculty rate was 63% (78/124). Postgraduate year (PGY) 1 residents were more likely to believe there was sufficient leadership training during residency (17/23, 74%) compared to PGY 2-4s (16/56, 29%) and faculty (20/76, 26%; p < 0.01). Most residents (66/79, 84%) and faculty (74/78, 82%) expressed that residents would benefit from a leadership curriculum. Both deemed small group exercises and leadership case studies taught by physicians were the preferred format for this curriculum. Residents and faculty agreed on 3 of the top 4 topics for a leadership curriculum - effective communication, team management, and time management - while residents chose self-awareness and faculty chose professionalism as the fourth of their top domains. Open-ended survey questions revealed that leadership demands in obstetrics and gynecology are similar to other specialties but differ in emphasis on crisis management, situational awareness, and advocacy training.

CONCLUSIONS

Given unique aspects of leadership within the specialty, obstetrics and gynecology residents and faculty see benefit for specialty-specific formalized leadership training.

The Glaring Gender Bias in the Operating Room: A Qualitative Study of Factors Influencing Career Selection for First-Year Medical Students

OBJECTIVE

Despite greater female than male-identifying Canadian medical graduates, women continued to be underrepresented in surgical specialties. The aim of this study was to explore the role of lifestyle challenges and gender-specific considerations in career selection for first-year medical students following early exposure to surgery through an immersive surgical program.

DESIGN

A single institution, qualitative study consisting of structured focus groups before and after completion of a 2-week surgical program was used to explore medical student perceptions of surgery. The program consisted of shadowing, surgeon-led talks, and surgical skills workshops in all direct-entry surgical specialties within the Department of Surgery at the University of Toronto. Six entry and exit interviews were conducted by 2 authors. Interviews were recorded, transcribed, and coded for thematic analysis.

SETTING

Teaching hospitals affiliated with the University of Toronto, Canada PARTICIPANTS: Thirty first-year medical students with interest in surgery participated in the program and the focus groups.

RESULTS

Four prominent themes emerged: gender imbalances in the work environment, the importance of female mentors, gender-specific challenges of parenting, and the importance of flexible work hours for both male and female students. Greater exposure to female surgeons improved the outlook of medical students on work-life balance. Medical students are concerned with the challenges of pregnancy in a surgical profession. Both male and female students consider parenting, supportive partners, and flexibility of work hours in their career selection.

CONCLUSION

This study demonstrates the prevalence of gender bias in surgical specialties, raising gender-specific challenges that impact career selection for first-year medical students. In an effort to address these perceptions, this study supports efforts to implement formalized mentorship programs for women in surgery early in medical education. Furthermore, concerns surrounding childbearing further support the need for well-established parental leave policies in the Canadian postgraduate medical education system.

The Impact of the ACGME/AOA Single Accreditation System on Osteopathic Surgical Specialties, Residents, and DO Students

OBJECTIVE

This article examines the outcomes and impact of the AOA/ACGME Single Accreditation System (SAS) on 6 osteopathic surgical specialties, their program directors, residents, and students and how growth in osteopathic medical schools and students affects ACGME surgical training.

DESIGN

The study charts the choices of 159 osteopathic surgical residencies regarding the acquisition of ACGME accreditation, decisions made by ACGME Review Committees, and how they affected program leadership, residents, and osteopathic medical students as reflected in results of residency matching programs.

SETTING AND PARTICIPANTS

According to the SAS, the osteopathic profession ceded its accreditation operations and have its programs acquire ACGME accreditation between 2015 and 2020 to form a unified accreditation system under the ACGME.

RESULTS

More than one-fourth (26%) of eligible osteopathic surgical programs either did not submit an application or voluntarily withdrew from the ACGME accreditation process. For the 118 surgical programs that did achieve ACGME Initial Accreditation, subsequent site visits and Review Committee decisions sparingly granted Continuing Accreditation status. In addition, 49% of the osteopathic applications listed an MD program director. Osteopathic surgical residents encountered few disruptions in transitioning to the ACGME. The full impact of the SAS was felt by osteopathic graduates in 2020 who encountered fewer DO-oriented ACGME programs and the historic trend of established ACGME surgical programs favoring candidates from American allopathic medical schools. As the osteopathic profession continues its rapid growth, competition for surgical training will only increase.

CONCLUSIONS

Participation in the SAS resulted in the loss of 41 surgical programs and marked reductions in training positions during a period of rapid osteopathic growth. Results from matching programs indicate that integration of DOs into established ACGME surgical residencies will be a slow, gradual process. The SAS succeeded in creating a unified standard for surgical training yet generated negative consequences on osteopathic surgical training.

Ethnic/Racial Bias in Medical School Performance Evaluation of General Surgery Residency Applicants

OBJECTIVE

Differential use of communal terms (caring/unselfish traits) versus agentic terms (goal-oriented/leadership/achievement traits) may reveal bias and has been extensively reported in letters of recommendation for residency. We evaluated bias in medical student performance evaluations (MSPE) of general surgery residency applicants.

DESIGN

This is a retrospective study evaluating ethnic/race bias, as measured by differential use of agentic and communal terms, in MSPEs of residency applicants. 50% of MSPEs were randomly selected. An ethnic bias calculator derived from an open-source online gender bias calculator was populated with a list of validated agentic and communal terms. Relative frequency of communal and agentic terms was used to estimate bias. Multivariable regression was used to assess the association between the terms and ethnicity/race.

PARTICIPANTS

US medical students applying for a categorical surgery residency position at a single academic institution for a single Match cycle.

RESULTS

A total of 339 MSPEs were reviewed from 119 US medical schools. Genders were equally represented (women, 51.6%); most participants were white and Asian applicants (79.1%). Overall, MSPEs were more agency biased (65.2%) than communal biased (16.2%) or neutral (18.6%). MSPEs for Black and Hispanic/Latinx applicants were more likely to contain communal rather than agentic terms (adjusted OR: 3.02, 95% CI: 1.52-6.02) when compared to white and Asian applicants. This finding was independent of MSPE writer's gender or rank.

CONCLUSIONS

Surgery residency applicants self-identifying as Black and Hispanic/Latinx were more likely to be described using communal traits compared to white and Asian applicants, suggesting ethnic/racial bias. Such differences in language utilized in MSPEs may impact residency opportunities for applicants who are under-represented in medicine. Educational efforts aimed at MSPE writers may help to reduce bias.

A Comparison Between In-Person and Virtual Fellowship Interviews During the COVID-19 Pandemic

IMPORTANCE

Traditional in-person fellowship interviews require great time and financial commitments. Here, we studied the response of program directors (PDs) and applicants to virtual interviews. Virtual interviews could decrease both financial and time commitments.

OBJECTIVE

To determine if most applicants and PDs believed that virtual interviews should be used more widely in the future.

DESIGN

After the 2020 cardiothoracic fellowship match, an e-mail survey was sent to 66 program directors and 107 applicants using the Qualtrics platform.

SETTING

During the 2020 cardiothoracic fellowship interview cycle, the COVID-19 pandemic shut down travel for in-person interviews. This forced a transition to virtual interviews.

PARTICIPANTS

Of 107 applicants emailed, 46 (44%) participated with a completion rate of 87%. sixty-six PDs were contacted and of those, 36 (55%) participated with a 92% survey completion rate.

EXPOSURE

All survey participants were participants in the 2020 cardiothoracic match. MAIN OUTCOME(S) AND MEASURE(S): (1) The percent of participants who agree that virtual interviews should be continued in the future and the percent of participants who agree that virtual interviews could be replacements for in person interviews. (2) Were virtual interviews perceived to have a negative impact on one's ultimate match? (3) What is the current cost of an in-person interview in travel and lodging for an applicant?

RESULTS

Fourty-six applicants (44% participation rate) and 36 PDs (55% participation rate) participated in the survey. Seventy-nine percent of program directors and 55% of applicants either agreed or strongly agreed that virtual interviews should be offered in the future. However, just 15% of PDs and 20% of applicants either agreed or strongly agreed that virtual interviews should be offered without the option of an in-person interview. Twenty-five percent of PDs and applicants agreed or strongly agreed that virtual interviews negatively impacted their chance of matching one of their top applicants/programs. The median cost of an in-person interview was $600 (interquatile range 500-725).

CONCLUSIONS AND RELEVANCE

Most applicants and PDs agree that virtual interviews should be offered in the future. Twenty-five percent of participants reported that they believed virtual interviews negatively impacted their match. Given the overall acceptance of virtual interviews and the cost of in-person interviews, virtual interviews could be useful to incorporate into future interview seasons.

Female Residents Give Themselves Lower Scores Than Male Colleagues and Faculty Evaluators on ACGME Milestones

OBJECTIVE

Orthopedic surgery is one of the specialties with the lowest number of women residents and practicing surgeons. The gender discrepancy in orthopedic residency training may drive a competency bias. We asked whether female orthopedic surgery residents score themselves lower on the Accreditation Council for Graduate Medical Education (ACGME) Milestones than their male counterparts, and lower than their faculty evaluators.

DESIGN

We conducted a retrospective review of ACGME Milestone data from faculty and residents over a 4-year period. The data were analyzed using a snapshot of PGY2 (n = 20 residents) and PGY4 (n = 19 residents) scores, and using a Generalized Estimation Equation (GEE) to account for additional data points from the same residents over the 4-year data collection period.

SETTING

Assessment scores were compiled from a single orthopedic surgery residency at Oregon Health & Science University from 2014 to 2017.

PARTICIPANTS

The residency program has 5 residents in each program year (PGY1 through PGY5); a total of 25 residents during each year of the study were included.

RESULTS

On average, female residents scored themselves lower than both their male counterparts and their faculty mentors. Female PGY2 self-evaluation scores were lower than males in both patient care (p = 0.005) and medical knowledge (p < 0.001). When the GEE model was applied to 99 responses from 41 residents over a 4-year period, there were no gender-related differences in resident self-evaluation scores and in faculty scores of male and female residents, with the exception of meniscal tear. For this milestone, faculty rated female residents lower than males. Furthermore, the differences between faculty evaluation scores and resident self-evaluation scores were significantly lower for males than for females for 4 of the clinical domains, as well as the systems-based practice domains of cost and communication.

CONCLUSIONS

Our results indicate female residents are at risk for a competency bias during training, as reflected by evaluations using the ACGME Milestones.

Deliberate Practice in Simulation-Based Surgical Skills Training: A Scoping Review

BACKGROUND

In recent years there has been a shift from traditional Halstedian methods toward more simulation-based medical education (SBME) for developing surgical skills. Questions remain about the role and value of SBME, although feedback and engagement in repetitive practice have been associated with positive learning outcomes. Regardless of approach, the principles of deliberate practice align with both the Halstedian traditions and ways of implementing SBME. Whilst deliberate practice is well described in the wider literature, the extent to which it is an effective instructional approach in surgical training remains unknown.

OBJECTIVE

To explore the effectiveness of deliberate practice as an instructional design for developing surgical skills through SBME interventions, as assessed by improvements in trainee performance and/or patient outcomes.

METHODS

A combined search was conducted in PUBMED, CINAHL, EMBASE, MEDLINE, PSYCHINFO, and Google Scholar. Three hundred one articles were screened and 17 met the inclusion criteria for analysis.

RESULTS

There was heterogeneity of study methods with 6 randomized control trials, 7 pretest/post-test design, 2 nonrandomized comparisons and 2 observational studies. All articles demonstrated positive learner outcomes following SBME with deliberate practice, although there was no direct comparison to another instructional method. Two studies demonstrated skill transfer to the clinical environment and 1 demonstrated improved patient outcomes.

CONCLUSION

Deliberate practice informed SBME interventions appeared effective for developing surgical skills among trainee surgeons, however the reliability of these conclusions was limited by the modest quality of the research studies and the design elements of deliberate practice were inconsistently applied. There was little evidence that deliberate practice led to skills retention beyond 30 days, although participant numbers were low and the quality of studies was modest.

Trends in Strategic Napping in Surgical Residents by Gender, Postgraduate Year, Work Schedule, and Clinical Rotation

OBJECTIVE

To identify surgical resident and clinical rotation attributes which predict on-shift napping through objectively measured sleep patterns and work schedules over a 2-month period.

DESIGN

In a cross-sectional study, participants provided schedules, completed the Epworth Sleepiness Scale (ESS), and wore sleep-tracking devices (Zulu watch) continuously for 8 weeks. Multiple linear regression predicted percent days with on-shift napping from resident and rotation characteristics.

SETTING

Greater Washington, DC area hospitals.

PARTICIPANTS

Twenty-two (n = 22) surgical residents rotating in at least 1 of 5 different clinical rotation categories.

RESULTS

Residents slept 6 hours within a 24-hour period (370 ± 129 minutes) with normal sleep efficiency (sleep efficiency (SE): 87.13% ± 7.55%). Resident ESS scores indicated excessive daytime sleepiness (11.64 ± 4.03). Ninety-five percent (n = 21) of residents napped on-shift. Residents napped on-shift approximately 32% of their working days and were most likely to nap when working between 23:00 and 05:00 hours. Earlier shift start times predicted less on-shift napping (B = -0.08, SE = 0.04, β = -2.40, t = -2.09, p = 0.05) while working more night shifts (B = 1.55, SE = 0.44, β = 4.12, t = 3.52, p = 0.003) and shifts over 24 hours (B = 1.45, SE = 0.55, β = 1.96, t = 2.63, p = 0.01) predicted more frequent on-shift napping.

CONCLUSIONS

Residents are taking advantage of opportunities to nap on-shift. Working at night seems to drive on-shift napping. However, residents still exhibit insufficient sleep and daytime sleepiness which could reduce competency and represent a safety risk to themselves and/or patients. These findings will help inform intervention strategies which are tailored to surgical residents using a biomathematical model of fatigue.

Fingerprints of Teaching Interactions: Capturing and Quantifying How Supervisor Regulate Autonomy of Residents in the Operating Room

OBJECTIVE

Supervisors and residents agree that entrusted autonomy is central to learning in the Operating Room (OR), but supervisors and residents hold different opinions about entrustment: residents regularly experience that they receive insufficient autonomy while supervisors feel their guiding is not appreciated as teaching. These opinions are commonly grounded on general experiences and perceptions, instead of real-time supervisors' regulatory behaviors as procedures unfold. To close that gap, we captured and analyzed when and to what level supervisors award or restrain autonomy during procedures. Furthermore, we constructed fingerprints, an instrument to visualize entrustment of autonomy by supervisors in the OR that allows us to reflect on regulation of autonomy and discuss teaching interactions.

DESIGN

All interactions between supervisors and residents were captured by video and transcribed. Subsequently a multistage analysis was performed: (1) the procedure was broken down into 10 steps, (2) for each step, type and frequency of strategies by supervisors to regulate autonomy were scored, (3) the scores for each step were plotted into fingerprints, and (4) fingerprints were analyzed and compared.

SETTING

University Medical Centre Groningen (the Netherlands).

PARTICIPANTS

Six different supervisor-resident dyads.

RESULTS

No fingerprint was alike: timing, frequency, and type of strategy that supervisors used to regulate autonomy varied within and between procedures. Comparing fingerprints revealed that supervisors B and D displayed more overall control over their program-year 5 residents than supervisors C and E over their program-year 4 residents. Furthermore, each supervisor restrained autonomy during steps 4 to 6 but with different intensities.

CONCLUSIONS

Fingerprints show a high definition view on the unique dynamics of real-time autonomy regulation in the OR. One fingerprint functions as a snapshot and serves a purpose in one-off teaching and learning. Multiple snapshots of one resident quantify autonomy development over time, while multiple snapshots of supervisors may capture best teaching practices to feed train-the-trainer programs.

Let's Not Throw the Baby Out with the Bath Water - Keep the ABSITE a Numerically Scored Exam

The American Board of Surgery In-Training Examination (ABSITE) is a low-stakes, validated, objective measure of the medical knowledge of our surgical residents and is an important predictor of ABS Qualifying Exam (QE) passage. It was never intended to serve as a global assessment of resident performance or aptitude, to assess any competency other than medical knowledge, or to serve as the sole criterion by which to judge resident promotion to the next PGY level. Though the scoring of the ABSITE and the use of the exam by some PDs and fellowship directors may be imperfect, let's not throw the baby out with the bath water and destroy the utility of the ABSITE by changing its grading to pass/fail. Rather, let's set rigorous, high standards for our residents in preparation for the ABSITE, as well as for PDs and fellowship directors in the proper interpretation of the ABSITE as a formative assessment of resident knowledge progression as opposed to a high-stakes summative exam.

A Strategy for Undergraduate Medical Education in Urology During the COVID-19 Pandemic

OBJECTIVE

To provide a framework for a virtual curriculum during the COVID-19 pandemic for medical student educators that introduces and teaches clinical concepts important in urology and surgical specialties in general.

METHODS

We created a 1-week virtual urology course utilizing interactive lectures, case-based exercises, and faculty-proctored surgical video reviews. Students were assigned self-study modules and participated in case-based discussions and presentations on a topic of their choice. Students' perceptions of urology as a specialty and the utility of the course was evaluated through pre- and postcourse surveys. Understanding of urologic content was evaluated with a multiple-choice exam.

RESULTS

A total of nine students were enrolled in the course. All students reported increased understanding of the common urologic diagnoses and of urology as a specialty by an average of 2.5 points on a 10-point Likert scale (Cohen's measure of effect size: 3.2). Additionally, 56% of students reported increased interest, 22% reported no change and 22% reported a decreased interest in pursuing urology as a specialty following the course. Students self-reported increased knowledge of a variety of urologic topics on a 10-point Likert scale. The average exam score on the multiple-choice exam improved from 50% before the course to 89% after the course.

CONCLUSIONS

Various teaching techniques can be employed through a virtual platform to introduce medical students to the specialty of urology and increase clinical knowledge surrounding common urologic conditions. As the longevity of the COVID-19 pandemic becomes increasingly apparent and virtual teaching is normalized, these techniques can have far-reaching utility within the traditional medical student surgical curriculum.

Robotic Surgical Training at Home: A Low-Fidelity Simulation Method

OBJECTIVE

Laparoscopic box simulators provide surgical residents a cost-effective and accessible learning tool to practice basic laparoscopic skills. Despite effective, high-fidelity simulators used in robotic surgery training, a similar low-fidelity alternative simulation method is not available. The objective of this report and accompanying video is to introduce a low-fidelity method to help those new to robotic-assisted surgery learn fundamental skills even before sitting at the console.

METHOD

Using 2 fine-point metal tweezers with Velco loops for finger slots, I developed a user-friendly way to practice basic needle handling and intracorporeal knot tying activities similar to those encountered on a high-fidelity robotic simulator. These simple tools mimic the controllers at the actual robot console.

EXPERIENCE

This teaching tool is meant to help surgical trainees and those new to robotic surgery develop the initial dexterity and economy of motion for performing basic tasks. I have greatly improved my own surgical confidence and experience anecdotally using these tools before I sat for actual cases. I hope a motivated trainee may discover the same benefit.

CONCLUSIONS

A low-fidelity simulation method may enhance a learner's initial proficiency in robotic-assisted surgery, but future performance studies using this method will be needed.

Training Novice Raters to Assess Nontechnical Skills of Operating Room Teams

OBJECTIVE

To our knowledge, no curricula have been described for training novice, nonclinician raters of nontechnical skills in the operating room (OR). We aimed to report the reliability of Oxford Non-Technical Skills (NOTECHS) ratings provided by novice raters who underwent a scalable curriculum for learning to assess nontechnical skills of OR teams.

DESIGN

In-person training course to apply the NOTECHS framework to assessing OR teams' nontechnical skill performance, led by 2 facilitators and involving 5 partial-day sessions of didactic presentations, video simulation, and live OR observation with postassessment debriefing. NOTECHS ratings were submitted after each of 11 video scenarios and 8 live operations for the total NOTECHS team rating (including surgical/anesthesiology/nursing subteams) and for each NOTECHS skill category-situation awareness, problem solving and decision making, teamwork and cooperation, leadership and management. Inter-rater reliability was determined by calculating the intraclass correlation coefficient (ICC, range 0-1).

SETTING

Training for outcome measurement during a quality improvement initiative focused on surgical safety in 3 public hospitals in Singapore. Two trainings were conducted in May 2019 and January 2020.

PARTICIPANTS

Ten novice raters who were existing hospital staff and had overall minimal OR experience and no prior experience with nontechnical skill assessment.

RESULTS

ICC for the total NOTECHS team rating was 0.89 (95% confidence interval [CI], 0.87-0.91). ICCs for each NOTECHS category were as follows: situation awareness, 0.83 (95% CI, 0.78-0.88); problem solving and decision-making, 0.76 (95% CI, 0.70-0.83); teamwork and cooperation, 0.84 (95% CI, 0.79-0.88); leadership and management, 0.81 (95% CI, 0.75-0.86).

CONCLUSIONS

This training curriculum for nontechnical skill assessments of OR teams was associated with high inter-rater reliability from novice raters with minimal collective OR experience. Using scalable training materials to produce reliable measurements of OR team performance, this nontechnical skills assessment curriculum may contribute to future QI projects aimed at improving surgical safety.

Optimizing Resident Wellness During a Pandemic: University of British Columbia's General Surgery Program's COVID-19 Experience

OBJECTIVE

The University of British Columbia's General Surgery Program delineates a unique and systematic approach to wellness for surgical residents during a pandemic.

SUMMARY BACKGROUND DATA

During the COVID-19 pandemic, health care workers are suffering from increased rates of mental health disturbances. Residents' duty obligations put them at increased physical and mental health risk. It is only by prioritizing their well-being that we can better serve the patients and prepare for a surge. Therefore, it is imperative that measures are put in place to protect them.

METHODS

Resident wellness was optimized by targeting 3 domains: efficiency of practice, culture of wellness and personal resilience.

RESULTS

Efficiency in delivering information and patient care minimizes additional stress to residents that is caused by the pandemic. By having a reserve team, prioritizing the safety of residents and taking burnout seriously, the culture of wellness and sense of community in our program are emphasized. All of the residents' personal resilience was further optimized by the regular and mandatory measures put in place by the program.

CONCLUSIONS

The new challenges brought on by a pandemic puts increased pressure on residents. Measures must be put in place to protect resident from the increased physical and mental health stress in order to best serve patients during this difficult time.

Understanding the Trends and Variability in Procedures Performed During Orthopedic Spine Surgery Fellowship Training: An Analysis of ACGME Case Log Data

OBJECTIVE

To understand trends and variability of procedures performed by orthopedic spine surgery fellows during training.

DESIGN

Cross-sectional survey.

SETTING

Accreditation Council on Graduate Medical Education (ACGME) case logs.

PARTICIPANTS

Fellows enrolled in ACGME-accredited "Orthopaedic Surgery of the Spine" fellowships from 2010 to 2015.

RESULTS

The 2010 to 2015 ACGME fellowship case logs for "Orthopaedic Surgery of the Spine" were retrieved. Spine cases in case logs are grouped into the following categories: (1) Excision, (2) Osteotomy, (3) Fracture and/or Dislocation, (4) Decompression, (5) Anterior fusion/arthrodesis, (6) Posterior fusion, (7) Deformity surgery, (8) Exploration, (9) Instrumentation, and (10) other/uncategorized. The total number of spine cases logged by each fellow increased from 821 in 2010 to 1134 in 2015 (38.2% increase). The greatest increases were noted from fracture/dislocation cases (77.9%), followed by posterior fusions (62.2%), anterior fusions (43.6%), decompressions (36.3%), and instrumentation (29.5%). The average number of deformity cases decreased from 23 in 2010 to 19 in 2016 (18.6% decrease). The average number of adult-only cases increased from 770 in 2010 to 1100 in 2015 (42.8% increase), whereas the average number of pediatric-only cases declined from 51 in 2010 to 35 in 2015 (32.1% decrease). Based on case logs from 2015, the greatest variation in case volume between the 10th centile and 90th centile of fellows was noted for deformity cases, followed by decompressions and posterior fusions.

CONCLUSIONS

Even though there has been a 38% increase in the overall number of spine cases performed by fellows during training, a large amount of variation in type of case exposure exists between fellowships. The findings of our study call for the establishment of minimal case volumes and/or uniformity of training spectrums across the nation to ensure appropriate surgical care is made accessible to all patients.

Recent Trends in Cardiothoracic Surgery Training: Data from the National Resident Matching Program

OBJECTIVE

In 2008, integrated thoracic residency programs (IP) for cardiothoracic (CT) training were created in response to a decline in CT trainees. However, few studies have reported on trends in the CT training pathway since the inception of IPs. This manuscript examines the current trends related to the overall number of surgical trainees entering CT surgery training following the introduction of IPs into the National Resident Match Program (NRMP).

DESIGN

Main and specialty match data were gathered from NRMP annual reports between 2008 and 2018. Descriptive statistics were used to analyze program size, applications, and filled and unfilled positions for IPs and traditional CT residency programs. Pearson's correlation coefficient was used to determine associations between program variables.

SETTING

NRMP main and specialty match in 2008 to 2018.

PARTICIPANTS

Participants of the NRMP main and specialty match in 2008 to 2018.

RESULTS

IPs increased from 2 programs offering 3 positions in 2008 to 28 programs offering 36 positions in 2018. However, during the same time period, the number of available traditional CT residency positions have decreased by 29% (130 to 92). As the number of IPs increased, there was a significant decrease in the number of traditional CT residency positions (ρ = -0.95, p < 0.001). Although, the overall number of CT residency programs (traditional and IP) remained largely unchanged, the proportion of filled CT residency positions increased from 67.7% in 2008 up to 97.7% in 2018.

CONCLUSION

The IP training format has shown success in increasing the number of trainees entering into CT training programs. Consideration should be given to increasing the number of IP positions or increase interest in CT among general surgery residents to increase the number of CT surgery trainees with the goal of increasing the size of the future CT workforce.

A Randomized Prospective Blinded Study Evaluating the Effect of Music on Novice Surgical Trainees' Ability to Perform a Simulated Surgical Task

OBJECTIVE

To determine if playing music would affect novice surgical trainees' ability to perform a complex surgical task.

BACKGROUND

The effect of music in the operating room (OR) is controversial. Some studies from the anesthesiology literature suggest that OR music is distracting and should be banned. Other nonblinded studies have indicated that music improves surgeons' efficiency with simple tasks.

DESIGN/METHODS

A prospective, blinded, randomized trial of 19 novice surgical trainees was conducted using an in vitro model. Each trainee performed a baseline vascular anastomosis (VA) without music. Subsequently, they performed one VA with music (song validated to reduce anxiety) and one without, in random order and without prior knowledge of the study's purpose. The primary endpoint was a difference in differences from baseline with and without music with respect to time to completion, acceleration/deceleration (using a previously validated hand-tracking motion device), and video performance scoring (3 blinded experts using a validated scale). The participants completed a poststudy survey to gauge their opinions regarding music during tasks.

RESULTS

Overall, 57 VAs by 19 trainees were evaluated. Average time to completion was 11.6 minutes. When compared to baseline, time to completion improved for both the music group (p = 0.01) and no-music group (p = 0.001). When comparing music to no music, there was no difference in time to completion (p = 0.7), acceleration/deceleration (p = 0.3), or video performance scorings (p = NS). Among participants, 89% responded that they enjoy listening to music while performing tasks.

CONCLUSIONS

Using three outcome measures, relaxing music did not improve the performance of novice surgical trainees performing a complex surgical task, and the music did not make their performance worse. However, nearly all trainees reported enjoying listening to music while performing tasks.

Binary Reporting of USMLE Step 1 Scores: Resident Perspectives

The recent consensus from the Invitational Conference on USMLE Scoring has recommended a transition to a binary pass/fail reporting on the USMLE Step 1 exam to be implemented from January 22, 2022. While this change was instituted in an effort to decrease medical student stress and re-iterate the importance of the Step 1 as merely a licensing or qualifying exam, this decision has profound implications for medical graduates of both United States and foreign medical schools. In addition to compounding the difficulties of resident selection by residency programs, the new system could exert significant mental and financial burden on medical students, and potentially affect the diversity of graduate medical education in the United States. This article draws attention to the downstream effects of a pass/fail system on the future of medical and surgical education.

Surgery Resident Perceptions of the Clicker Evaluation System: A Novel Approach to Collecting and Utilizing Clinical Faculty Performance Data

OBJECTIVE

Medical trainees often have a process in place to receive feedback from clinical faculty regarding overall performance. While there is guidance on effective methodologies for faculty to provide feedback for learners, there is a dearth of literature analyzing trainees' evaluation of faculty performance. We sought to identify an effective and anonymous method for surgery residents to evaluate clinical faculty.

DESIGN

The Department of Orthopedic Surgery at Virginia Commonwealth University (VCU) Health implemented a novel process to gather annual clinical faculty performance data from residents for the purpose of program improvement starting in 2012. Specifically, residents used a web-based audience response system, also known as a "clicker" system, to evaluate faculty performance over the academic year. During the June 2018 evaluation session, residents also completed an anonymous, 9 question survey to assess the residents' perceptions regarding this clicker evaluation process.

SETTING

VCU Health System, a tertiary care hospital in Richmond, Virginia.

PARTICIPANTS

All 24 orthopaedic surgery residents at VCU Health participated in the evaluation process and completed the perception survey in 2018.

RESULTS

Ninety-six percent (n = 23) of the residents agreed that they are able to accurately rate their attendings' performance, felt confident that their responses remained anonymous, and that their departmental chair values their opinion when evaluating their attendings' performance through the clicker process. Qualitative responses identified anonymity as a strength of the clicker process, while opportunities for improvement included refinement of questions.

CONCLUSIONS

The clicker evaluation system is an effective and anonymous method for resident evaluation of clinical faculty performance in academic settings. Future steps include refinement of questions based on departmental goals for education, adoption of the clicker evaluation system by other specialties, as well as research into ways to optimize the clicker evaluation process. Additional research should be done to see if and how the clicker evaluation feedback translates into change in clinical faculty behavior.

Operating Room Times For Teaching and Nonteaching Cases are Converging: Less Time for Learning?

OBJECTIVE

To compare differences in operating room (OR) times between teaching and nonteaching cases across calendar years. We hypothesize that time devoted to intraoperative resident education is decreasing, therefore, OR times for teaching and nonteaching cases will be converging.

BACKGROUND

Teaching cases take longer than similar nonteaching cases, in part due to intraoperative resident education. Pressures to improve OR efficiency and patient safety may threaten resident education and leave less time for intraoperative learning; however, the magnitude of impact is unknown.

SETTING/PARTICIPANTS

National Surgical Quality Improvement Program (NSQIP) deidentified national databases from 2006 to 2012, queried for 30 most common General surgery procedures and case teaching status (i.e., teaching vs. nonteaching cases).

DESIGN

The NSQIP database was retrospectively reviewed to identify the 30 most common General Surgery procedures. Teaching cases included all operations in which a resident participated. Multivariable regression analyses were constructed to determine the impact of resident involvement on OR times, controlling for year, resident participation, procedure, and patient demographics and comorbidities. Difference-in-difference analysis was performed to assess OR time differences between teaching and nonteaching cases across calendar years and within subpopulations.

RESULTS

A total of 693,223 cases met inclusion criteria. Average overall OR times were 98.89 minutes (teaching) vs. 74.22 minutes (nonteaching), with a difference of 24.67 minutes (95% confidence interval [CI] 24.34-24.99 minutes, p < 0.001). In multivariable analyses, the difference between teaching and nonteaching cases was 21.94 minutes (95% CI = 21.11-22.76) in 2006 and 13.95 minutes (95% CI = 10.62-17.28) in 2012, with a difference-in-difference of 7.99 minutes per case. A similar trend was observed across individual PGYs and several individual procedures.

CONCLUSIONS

OR times for teaching and nonteaching cases converged by approximately 8 minutes per general surgery procedure during the 7-year study period, representing a 36% reduction in the difference between groups. We must seek to better understand the source of this convergence, and in doing so ensure to preserve and enhance the intraoperative learning experience of surgical trainees.