Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium

OBJECTIVE

To determine the relationship between race/ethnicity and case volume among graduating surgical residents.

BACKGROUND

Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed.

METHODS

A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups.

RESULTS

The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period.

CONCLUSIONS

In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents

BACKGROUND

Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not.

METHODS

We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period.

RESULTS

Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01).

CONCLUSION

Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

The "Intern" Label: Introducing Unnecessary Confusion and Bias?

OBJECTIVES

The Oxford English Dictionary defines "intern" as "a student or trainee who works, sometimes without pay, at a trade or occupation in order to gain work experience." In the medical realm, the label "intern" may introduce confusion as well as implicit and explicit bias. In this study, we sought to examine the general public's perception of the label "intern" compared to the more accurate label "first-year resident."

DESIGN

We developed 2 forms of a 9-item survey that assessed an individual's level of comfort with surgical trainees' participation in various aspects of surgical care and knowledge of medical education and work environment. One form used the label "intern" and the other used "first-year resident."

SETTING

San Antonio, TX.

PARTICIPANTS

A total of 148 adults in the general population at 3 local parks on 3 separate occasions.

RESULTS

A total of 148 individuals completed the survey (74 per form). Respondents who did not work in the medical field reported less comfort with interns vs first-year residents participating in various aspects of their care. Only 36% of respondents were able to correctly identify which surgical team members have completed a medical degree. Directly assessing perceptual incongruity between the labels "intern" and "first-year resident," 43% of respondents said interns have a medical degree compared to 59% for first-year residents (p = 0.008), 88% stated that interns work full-time in the hospital compared to 100% for first-year residents (p = 0.041), and 82% stated that interns get paid for their work in the hospital compared to 97% for first-year residents (p = 0.047).

CONCLUSIONS

The label "intern" may confuse patients, family members, and perhaps other healthcare professionals regarding the level of experience and knowledge of first-year residents. We advocate for abolishing the term "intern" and replacing it with "first-year resident" or simply "resident."

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium

OBJECTIVE

To examine differences in resident operative experience between male and female general surgery residents.

BACKGROUND

Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level.

METHODS

Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents.

RESULTS

There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02).

CONCLUSIONS

Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Getting on the Same Page: The Impact of Interviewer Education and Structured Interviews on Interrater Agreement in Residency Interviews

INTRODUCTION

We explored the impact of implementing structured interviews and associated interviewer education on interrater agreement within a large academic residency program.

METHODS

Faculty and senior resident interviewers from a large academic residency program participated in a 3-hour structured interview course. Before and after the course, participants completed a 15-item assessment pertaining to the characteristics, logistics, and guidelines associated with structured interviews. Along with interviewer training, interview day logistics also changed from an unstructured format (no specific questions, one overall 1-9 rating scale) to a structured interview format, including incorporation of behavioral-based competency questions that would be asked of every applicant and behavioral anchored rating scales (1-10; 10 = highest). Interrater agreement was assessed via intraclass correlation coefficients (ICC1) for the 2 years before and 2 years after incorporation of the structured interview format.

RESULTS

A total of 45 faculty and resident interviewers participated in the course in 2018. Participant knowledge significantly increased from an average of 36% to 79% after the course (p < 0.01). Prior to the intervention, overall interrater agreement was "poor" to "fair," with an ICC1 of 0.51 in 2016 and 0.49 in 2017. After the structured interview intervention, overall agreement increased to the "good" level with an ICC1 of 0.71 in 2018 and 0.66 in 2019. The proportion of applicants who received interview scores with at least 2 ratings more than 2 points apart significantly decreased from 59% to 47% after the intervention (p < 0.01).

CONCLUSIONS

Incorporating an interviewer educational session and a structured interview format into residency selection can help increase agreement in ratings between interviewers. However, these data suggest that ongoing refresher trainings may be needed to maintain acceptable levels of interrater agreement.

Identifying Potential Attrition during the Residency Applicant Screening Process Using a Situational Judgment Test

OBJECTIVE

As USMLE Step 1 moves to pass/fail, residency programs are seeking alternate interview selection processes. Attrition in general surgery is reported as high as 26%. Thus, it is important to ensure that programs are selecting and matching applicants with shared values. Situational judgment tests (SJTs) measure educational and cultural values by posing ambiguous situations and individuals rate the effectiveness of possible reactions. SJTs have previously been shown to identify job applicants with shared values while promoting diversity. Scoring categories are high, moderate, or low values congruence. We sought to explore predictive validity of the SJT relative to program attrition.

DESIGN

Residents who matched into our program between 2018 and 2021 completed the SJT. We tracked attrition.

SETTING

UT Health San Antonio, Texas PARTICIPANTS: Fifty-six categorical general surgery residents RESULTS: Per SJT ratings, the numbers of residents who had high, moderate, and low values congruence were 27, 16, and 13, respectively. Attrition numbers for residents who scored high and moderate congruence were similar, indicating that these ratings were indistinguishable. As such, we combined those 2 categories to create a 2 × 2 matrix and used signal detection theory as a framework for analysis. Overall attrition was 16.1% (9/56). Of the 43 residents who scored high or moderate congruence, 90.7% remained in the program. There was a 9.3% chance of attrition for these residents. Of the 13 residents who scored low congruence, 38.5% attrited. While scoring as low congruence on the SJT does not definitively indicate attrition, it does indicate that attrition is 4.14 times more likely for these residents (chi-square, p = 0.0121).

CONCLUSIONS

One of the most important aspects of residency applicant selection and interviewing is mitigating risk by identifying applicants who carry a high risk of attrition. The SJT significantly identifies at-risk applicants.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation

BACKGROUND

There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship.

METHODS

Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed.

RESULTS

There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01).

CONCLUSION

This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Is Beauty in the Eye of the Beholder? Differences in Residency Training Program Preferences Among Women and Minorities

INTRODUCTION

Training programs are now more than ever seeking ways to promote recruitment and retention of a diverse resident workforce. The goal of this study was to examine how gender and ethnic identities affect applicant attraction to surgery training programs.

METHODS

Applicants to general surgery residency in 2018 to 2019 completed a 31-item assessment measuring preferences for training program characteristics and attributes. Differences in preferences across candidate gender and ethnicity were investigated. Factor analyses and analysis of variance (ANOVA) were used to explore these differences.

RESULTS

1491 unique applicants to 7 residency programs completed the assessment, representing 67% of all applicants to general surgery during the 2018 to 2019 season. Women preferred training programs that had high levels of social support (p < 0.001), were less traditional (p < 0.001), and with less turbulence (p < 0.05). Non-white candidates reported greater preference for programs with higher levels of established academics (p < 0.001), clinical experiences (p < 0.001), social support (p < 0.05), traditionalism (p < 0.001), flexibility (p < 0.001), and innovation (p < 0.001).

CONCLUSIONS

Organizational efforts to attract and retain a diverse workforce may benefit from considering the aspects of work that align with female and underrepresented minority preferences.

Measuring the fire in their hearts: assessing passion for the profession among students pursuing surgical careers

Background

Leaders in surgery have posited that passion for the surgery profession is diminishing among entering trainees, and that its scarcity is related to the high levels of attrition observed in general surgery training. This study explores trends in passion for the profession among applicants to general surgery training.

Methods

Applicants to a large midwestern academic general surgery program were invited to complete a voluntary, anonymous 12-item Passion for Surgery Index (PSI) as part of their supplementary application package during the 2020-2021 and 2021-2022 residency selection seasons. The PSI is adapted from a generic work-related passion index and is based on the dualistic model of passion, organizing scores into harmonious passion and consuming passion. Applicants completed the index on a stand-alone website which automatically generated results pertaining to overall passion, harmonious passion, and consuming passion for the surgery profession. Applicants were provided with their results and provided feedback.

Results

Sixty-one percent (871/1428) of invited applicants completed the PSI. Approximately 67.4% (N = 587) of these applicants reported an overall high level of passion for surgery, while 31.1% (N = 271) reported a moderate level and the remaining 1.5% (N = 13) reported a low level. When comparing the two different types of passion, the vast majority of applicants (92.8%; N = 808) reported a high level of harmonious passion and only 7.1% (N = 62) reported a moderate level of harmonious passion. The results for consuming passion were much more varied, with 36.9% (N = 321) reporting a high level, 47.5% (N = 414) reporting a moderate level, and 15.6% (N = 136) reporting a low level of consuming passion for the profession.

Discussion

These results suggest that there is substantial variation in passion for the profession among those pursuing a career in surgery. While the majority of applicants reported a high level of harmonious passion for surgery, less than half of applicants reported a high level of consuming passion for surgery. This variability in consuming passion among entering trainees is concerning, as individuals with low or only moderate passion for the profession may not have the motivation or drive to persist in demanding training environments.

Surgical Inpatient's Attitudes Toward Resident Participation: All About Expectations

OBJECTIVE

Determine whether an educational video can improve surgical inpatients' attitudes toward resident participation in their care.

METHODS

Patients admitted to the Trauma/Emergency General Surgery Service at University Hospital (San Antonio, Texas) were randomly divided into control and intervention groups. Patients in the intervention group viewed a short educational video about the role and responsibilities of medical students, residents, and attending surgeons. All patients then completed a previously published survey.

RESULTS

A total of 140 patients responded to the survey (control = 81 and intervention = 59 patients). Overall, 86.4% of patients were welcoming of resident participation. Patients who were expecting residents to be involved in their care had attitudes that are more favorable on almost all survey questions regardless of their study condition. However, patients in the intervention group who expected resident involvement in their care had more favorable attitudes about senior residents (postgraduate year 3-5) assisting in routine or complicated surgery than those in the control group who were expecting resident involvement (both p ≤ 0.001). This same group of patients also had more favorable attitudes about surgical outcomes and overall surgical health when residents are involved (p = 0.004, p = 0.001, respectively). Most patients (79%) said they had no residents previously involved in their care, or they were unsure if residents were previously involved.

CONCLUSIONS

Patient expectation of resident involvement is one of the most important factors influencing perceptions of inpatients about resident participation in surgery. Our goal should be early and frequent discussion with patients about resident involvement in order to foster an atmosphere of trust, including full transparency regarding resident involvement in surgical procedures. An educational video may help introduce the roles of trainees and attending surgeons but should not be used in lieu of direct discussion with patients.

Can Better Selection Tools Help Us Achieve Our Diversity Goals in Postgraduate Medical Education? Comparing Use of USMLE Step 1 Scores and Situational Judgment Tests at 7 Surgical Residencies

PURPOSE

Use of the United States Medical Licensing Examination (USMLE) for residency selection has been criticized for its inability to predict clinical performance and potential bias against underrepresented minorities (URMs). This study explored the impact of altering traditional USMLE cutoffs and adopting more evidence-based applicant screening tools on inclusion of URMs in the surgical residency selection process.

METHOD

Multimethod job analyses were conducted at 7 U.S. general surgical residency programs during the 2018-2019 application cycle to gather validity evidence for developing selection assessments. Unique situational judgment tests (SJTs) and scoring algorithms were created to assess applicant competencies and fit. Programs lowered their traditional USMLE Step 1 cutoffs and invited candidates to take their unique SJT. URM status (woman, racial/ethnic minority) of candidates who would have been considered for interview using traditional USMLE Step 1 cutoffs was compared with the candidate pool considered based on SJT performance.

RESULTS

A total of 2,742 general surgery applicants were invited to take an online SJT by at least 1 of the 7 programs. Approximately 35% of applicants who were invited to take the SJT would not have met traditional USMLE Step 1 cutoffs. Comparison of USMLE-driven versus SJT-driven assessment results demonstrated statistically different percentages of URMs recommended, and including the SJT allowed an average of 8% more URMs offered an interview invitation (P < .01).

CONCLUSIONS

Reliance on USMLE Step 1 as a primary screening tool precludes URMs from being considered for residency positions at higher rate than non-URMs. Developing screening tools to measure a wider array of candidate competencies can help create a more equitable surgical workforce.

Great Expectations? Future Competency Requirements Among Candidates Entering Surgery Training

INTRODUCTION

We describe a multimethod, multi-institutional approach documenting future competencies required for entry into surgery training.

METHODS

Five residency programs involved in a statewide collaborative each provided 12 to 15 subject matter experts (SMEs) to participate. These SMEs participated in a 1-hour semistructured interview with organizational psychologists to discuss program culture and expectations, and rated the importance of 20 core competencies derived from the literature for candidates entering general surgery training within the next 3 to 5 years (1 = importance decreases significantly; 3 = importance stays the same; 5 = importance increases significantly).

RESULTS

Seventy-three SMEs across 5 programs were interviewed (77% faculty; 23% resident). All competencies were rated to be more important in the next 3 to 5 years, with team orientation (3.87 ± 0.81), communication (3.82 ± 0.79), team leadership (3.81 ± 0.82), feedback receptivity (3.79 ± 0.76), and professionalism (3.76 ± 0.89) rated most highly.

CONCLUSIONS

These findings suggest that the competencies desired and required among future surgery residents are likely to change in the near future.

Surgery Program Director Turnover Correlates With Residency Graduate Failure on American Board of Surgery Examinations in Civilian Residency Programs

PURPOSE

The Review Committee for Surgery requires a minimum program director (PD) tenure of 6 years. The impact of PD turnover on the performance of program graduates is unknown. We hypothesize that (1) the majority of PDs step down before 6-year tenure and (2) higher PD turnover is associated with higher failure rate on American Board of Surgery (ABS) examinations.

METHODS

Start and stop dates of all surgery PDs between January 1, 2000 and December 31, 2017 were obtained for civilian surgery programs. A Kaplan-Meier curve of PD "survival" was constructed. Programs were divided into High Turnover (HT; ≥4 PD changes, n = 33) and Low Turnover (LT; ≤3 PD changes, n = 191) groups. Five-year (2013-2017) ABS pass rates were also obtained. Pass rates and compliance with current standards were compared between groups.

RESULTS

Kaplan-Meier analysis revealed that 40% of PDs do not comply with ACGME policy and serve <6 years. HT programs had lower mean pass rates on ABS certifying exam than LT programs (76% vs 83%, p < 0.01), but not qualifying exam (88% vs 88%). HT programs are less likely to meet the current 65% pass rate standard (82% vs 93%, p < 0.05).

CONCLUSIONS

(1) An estimated 40% of general surgery PDs had tenures of <6 years. (2) Greater PD turnover is associated with lower ABS pass rates among general surgery graduates.

If You Build It, Will They Come? Candidate Completion of Preinterview Screening Assessments

INTRODUCTION

Residency applicant screening practices are inefficient and costly. However, programs may not consider using alternative assessments for fear that candidates will be "turned off" by additional hurdles in the application process. This study explores the relationship between candidate completion of preinterview screening assessments, applicant examination scores, and program factors.

METHODS

Applicants to any of 7 general surgery residency programs were invited to take a preinterview online assessment. Program characteristics and applicant United States Medical Licensing Exams scores were considered in relation to each program's assessment completion rate.

RESULTS

A total of 2960 applicants were invited to take the assessment and 97% (2870/2960) completed it. Program completion rates ranged from 95% to 98%. There was no correlation between program characteristics and applicant completion rates. Candidates who did not complete the assessment had significantly lower United States Medical Licensing Exams scores.

CONCLUSIONS

Incorporating preinterview assessments to objectively measure candidate competencies and fit will not detract applicants from a general surgery program.

An Online System to Help With Mock Oral Examination Administration

OBJECTIVE

Describe an online system used to collect data, compute statistics, and provide reports for mock oral examinations.

DESIGN

Forty general surgery residents, program directors, and faculty serving as examiners completed a survey regarding their experiences with the online mock oral examination system.

SETTING

General surgery residency programs and national surgical conferences.

PARTICIPANTS

General surgery residents, program directors, and faculty.

RESULTS

System users had very positive attitudes toward the online system in terms of usability and reporting functions.

CONCLUSIONS

The mock oral exam management online system is a useful tool that eases the burden of managing a mock oral exam session.

Video-Based Patient Education Improves Patient Attitudes Toward Resident Participation in Outpatient Surgical Care

OBJECTIVE

Decipher if patient attitudes toward resident participation in surgical care can be improved with patient education using a video-based modality.

DESIGN

A survey using a 5-pt Likert scale was created, piloted, and distributed in general and colorectal surgery outpatient clinics that had residents involved with patient care at 2 facilities, both with control and intervention groups. The intervention group viewed a short video (∼4 min) explaining the role, education, and responsibilities of medical students, residents, and attending surgeons prior to answering the survey.

SETTING

General and colorectal surgery outpatient clinics at the University of Texas Health San Antonio, Texas.

PARTICIPANTS

A total of 383 responses were collected, all clinic patients were eligible.

RESULTS

The majority of patients (82%) welcomed resident participation in their health care. Eighteen percent of patients did not expect residents to be involved in their care. Patients had favorable views of residents participating during their surgical procedures with 77% responding "agree" or "strongly agree" to a senior resident assisting with a complicated procedure. Patients who viewed the video versus control were less concerned with how much of the procedure the resident would perform (76% vs 86%, p = 0.010). Patients who viewed the video felt less inconvenienced (p = 0.004).

CONCLUSIONS

The majority of patients are welcoming to resident participation in their surgical care but only 54% were expecting resident involvement at their clinic visit. Early explanation with an educational video of resident roles, education, and responsibilities may help bridge the gap and improve patient experience.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Failure on the American Board of Surgery Examinations of General Surgery Residency Graduates Correlates Positively with States’ Malpractice Risk

It has been suggested that in environments where there is greater fear of litigation, resident autonomy and education is compromised. Our aim was to examine failure rates on American Board of Surgery (ABS) examinations in comparison with medical malpractice payments in 47 US states/ territories that have general surgery residency programs. We hypothesized higher ABS examination failure rates for general surgery residents who graduate from residencies in states with higher malpractice risk. We conducted a retrospective review of five-year (2010–2014) pass rates of first-time examinees of the ABS examinations. States’ malpractice data were adjusted based on population. ABS examinations failure rates for programs in states with above and below median malpractice payments per capita were 31 and 24 per cent ( P < 0.01) respectively. This difference was seen in university and independent programs regardless of size. Pearson correlation confirmed a significant positive correlation between board failure rates and malpractice payments per capita for Qualifying Examination ( P < 0.02), Certifying Examination ( P < 0.02), and Qualifying and Certifying combined index ( P < 0.01). Malpractice risk correlates positively with graduates’ failure rates on ABS examinations regardless of program size or type. We encourage further examination of training environments and their relationship to surgical residency graduate performance.

Rapid decay of transthoracic echocardiography skills at 1 month: A prospective observational study

OBJECTIVE

Focused transthoracic echocardiography (FTTE) is an emerging tool in the management of critically ill patients, but the lack of adequate training models has limited the expansion of this technology. Although basic FTTE training courses have been shown to be sufficient in developing echocardiography skills, limited data exist regarding skill retention. In an effort to develop an adequate FTTE training model, we sought to determine the degree of skill retention after FTTE training.

DESIGN

A prospective, observational study.

SETTING

An academic center.

PARTICIPANTS

Surgical residents and medical students: 31 subjects were enrolled from February to June 2016.

RESULTS

Participants underwent a 2-hour FTTE course including didactics and a hands-on session measuring ejection fraction of left ventricle (LV) and inferior vena cava (IVC) diameter. Written knowledge and performance examinations applying FTTE were conducted before the course, immediately after, and at 1- and 3-month intervals, which were evaluated on a 0 to 9 scale and analyzed with paired t-tests. Performance examination scores obtaining the LV and IVC views preinitial and postinitial training increased from 1.7 to 6.5 (LV) and from 2.0 to 6.8 (IVC) (p < 0.01), decreased to 5.0 and 4.8, respectively, at 1 month (posttraining vs 1 month, p < 0.01), and did not significantly change at 3 months (5.4 and 5.0, respectively). Written examination scores increased from 42% to 62% (pretraining vs posttraining, p < 0.01), decreased to 48% in 1 month (posttraining vs 1 month, p < 0.01), and further decreased to 34% at 3 months (1 month vs 3 month, p < 0.01).

CONCLUSIONS

Although a short training course appears sufficient to impart basic FTTE skills and knowledge, skills are significantly decayed at 1 month and knowledge continually decreases at 1 and 3 months. Future FTTE training models should consider the rapid degradation of knowledge and skills in determining frequency of refresher training and ongoing evaluation.

Failure on the American Board of Surgery Examinations of General Surgery Residency Graduates Correlates Positively with States' Malpractice Risk

It has been suggested that in environments where there is greater fear of litigation, resident autonomy and education is compromised. Our aim was to examine failure rates on American Board of Surgery (ABS) examinations in comparison with medical malpractice payments in 47 US states/territories that have general surgery residency programs. We hypothesized higher ABS examination failure rates for general surgery residents who graduate from residencies in states with higher malpractice risk. We conducted a retrospective review of five-year (2010-2014) pass rates of first-time examinees of the ABS examinations. States' malpractice data were adjusted based on population. ABS examinations failure rates for programs in states with above and below median malpractice payments per capita were 31 and 24 per cent (P < 0.01) respectively. This difference was seen in university and independent programs regardless of size. Pearson correlation confirmed a significant positive correlation between board failure rates and malpractice payments per capita for Qualifying Examination (P < 0.02), Certifying Examination (P < 0.02), and Qualifying and Certifying combined index (P < 0.01). Malpractice risk correlates positively with graduates' failure rates on ABS examinations regardless of program size or type. We encourage further examination of training environments and their relationship to surgical residency graduate performance.

Immediate Auditory Feedback is Superior to Other Types of Feedback for Basic Surgical Skills Acquisition

OBJECTIVE

We examined the effect of timing and type of feedback on medical students' knot-tying performance using visual versus auditory and immediate versus delayed feedback. We hypothesized that participants who received immediate auditory feedback would outperform those who received delayed and visual feedback.

METHODS

Sixty-nine first- and second-year medical students were taught to tie 2-handed knots. All participants completed 3 pretest knot-tying trials without feedback. Participants were instructed to tie a knot sufficiently tight to stop the "blood" flow while minimizing the amount of force applied to the vessel. Task completion time was not a criterion. Participants were stratified and randomly assigned to 5 experimental groups based on type (auditory versus visual) and timing (immediate versus delayed) of feedback. The control group did not receive feedback. All groups trained to proficiency. Participants completed 3 posttest trials without feedback.

RESULTS

There were fewer trials with leak (p < 0.01) and less force applied (p < 0.01) on the posttest compared to the pretest, regardless of study group. The immediate auditory feedback group required fewer trials to achieve proficiency than each of the other groups (p < 0.01) and had fewer leaks than the control, delayed auditory, and delayed visual groups (p < 0.02).

CONCLUSIONS

In a surgical force feedback simulation model, immediate auditory feedback resulted in fewer training trials to reach proficiency and fewer leaks compared to visual and delayed forms of feedback.

Development and Evaluation of a Simulation Model for Microvascular Anastomosis Training

Background Many plastic surgery training programs have implemented microvascular preparatory courses. However, these courses vary in length across institutions, lack formal assessment, and trainees receive certificates of completion rather than competency. In addition, many institutions use animate tissues as practice models which may not be readily available, require special treatment or storage, and lack consistency across vessel segments. In this study, we developed a proficiency-based training microvascular anastomosis curriculum using a synthetic model. In addition, we developed and validated a scoring rubric and patency testing apparatus.

Methods Proficiency benchmarks were developed by evaluating four plastic surgeons performing interrupted end-to-end anastomoses on synthetic vessels mounted superficially and at depth. Using a pretest–posttest design, seven plastic surgery residents from two institutions were asked to train to proficiency on the superficial exercise. Skills transfer was evaluated using a vessel mounted at depth. Each anastomosis was scored on 11 metrics of mechanics, completion time, stenosis, and leakage.

Results Experts outperformed residents prior to engaging in the training curriculum, confirming construct validity. Residents' skills significantly improved on 10 of 14 metrics after training, confirming curriculum effectiveness. Only one resident was able to achieve all proficiency benchmarks on two consecutive training trials. Skills learned on the superficially mounted vessel moderately transferred to the vessel mounted at depth as evidenced by significant pre- to posttest learning gains for 4 of the 14 metrics.

Conclusion The proficiency goals may have been overly stringent; however, residents improved microvascular anastomosis skills on the majority of metrics by engaging in simulation-based training using a readily available synthetic model.

Are General Surgery Residents Accurate Assessors of Their Own Flexible Endoscopy Skills?

BACKGROUND

Surgeons in training must be able to accurately gauge their own ability and performance to better understand where additional practice is needed and can help inform self-directed learning endeavors. This study had the following 3 goals: (1) to examine the accuracy of residents' assessments of their endoscopic skills, (2) to investigate if accuracy improves over time and practice, and (3) to compare the efficacy of 3 interventions-practice only (PO), self-observation (SO), or expert observation (EO)-on self-assessment accuracy.

METHODS

Overall, 30 first-year general surgery residents completed a pretest on a colonoscopy simulator, which measured time to completion, time to reach the cecum, efficiency of screening, percentage of mucosal surface area examined, time the patient was in pain, and time with a clear view. Residents assigned to the SO and EO conditions reviewed a video of their own performances (SO) or an expert's performance (EO). Residents in all conditions engaged in practice trials using an abstract endoscopy training exercise. Residents then completed a posttest. Self-assessment was examined by calculating discrepancy scores by subtracting actual measurements from participant judgments.

RESULTS

Results indicated that performance for participants in the PO group significantly improved from pretest to posttest for 2 of the 6 metrics and participants in the SO and EO groups improved for 4 metrics. In terms of self-assessment discrepancy scores, only the EO group significantly improved for 2 of the 6 metrics (overall time and screening efficiency).

DISCUSSION

Novice trainees are inaccurate self-assessors of their endoscopic skills before training. Allowing trainees to watch videos of themselves or an expert performing an endoscopic task enhances performance. Participants assigned to PO exhibited decreased ability to accurately judge their own performance. Those in the EO group became significantly better at assessing their overall time and overall efficiency.

SUMMARY

Novice trainees are inaccurate self-assessors of their endoscopic skills before training. Allowing trainees to watch videos of themselves or an expert performing an endoscopic task enhances performance.

The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care

OBJECTIVE

To decipher if patient attitudes toward resident participation in their surgical care can be improved with patient education regarding resident roles, education, and responsibilities.

DESIGN

An anonymous questionnaire was created and distributed in outpatient surgery clinics that had residents involved with patient care. In total, 3 groups of patients were surveyed, a control group and 2 intervention groups. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents. The first pamphlet used an analogy-based explanation. The second pamphlet used literature citations and statistics.

SETTING

Keesler Medical Center, Keesler AFB, MS. University of Texas Health Science Center at San Antonio, San Antonio, TX.

PARTICIPANTS

A total of 454 responses were collected and analyzed-211 in the control group, 118 in the analogy pamphlet group, and 125 in the statistics pamphlet group.

RESULTS

Patients had favorable views of residents assisting with their surgical procedures, and the majority felt that outcomes were the same or better regardless of whether they read an informational pamphlet. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care. Further, 52% of patients in the control group agreed or strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% of the patients who read the analogy pamphlet and statistics pamphlet, respectively (p = 0.05). When we combined the 2 intervention groups compared to the control group, this significant difference persisted (p = 0.02).

CONCLUSION

Most patients welcome resident participation in their surgical care, but they expect to be asked permission for resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently.

Predicting Success of Preliminary Surgical Residents: A Multi-Institutional Study

OBJECTIVE

A nondesignated preliminary surgery (NDPS) position encompasses 1 year of training provided by many general surgery residencies. Our aim was to assess factors predicting success and provide evidence for program directors to support career guidance to preliminary residents.

METHODS

Retrospective cohort study of 221 NDPS residents who entered 5 university-based institutions were identified from 2009 to 2013. Records for trainees were reviewed. We defined primary success as obtaining a categorical position in the specialty of choice and secondary success as obtaining a categorical position in any specialty immediately after finishing their NDPS training. Statistical evaluation was performed using chi-square analysis, independent t-test and logistic regression using α <0.05.

RESULTS

Of the 221 NDPS residents, 217 (98%) completed postgraduate year (PGY)-1 and 65 (29%) completed PGY-2. Totally, 90 (41%) obtained categorical general surgery positions, 89 (40%) obtained categorical positions in other specialties, and 42 (19%) failed to obtain a categorical position immediately after their NDPS years. Ultimately, 139 (63%) of residents achieved primary success and 40 (18%) additional residents obtained categorical positions in specialties other than their first choice, resulting in a total of 179 (81%) of residents obtaining categorical positions. Mean United States Medical Licensing Examination step 1 and step 2 scores for those who obtained secondary success were 227 and 234 vs. 214 and 219, respectively, for those who failed to secure a categorical position (p < 0.01). United States Medical Licensing Examination step 2 score was a significant predictor of primary (p < 0.03) and secondary success (p < 0.02). Of 65 PGY-2 NDPS residents, 32 (49%) achieved primary success, and 11 (17%) others achieved secondary success for a total of 43 (66%). For PGY-2 NDPS, American Board of Surgery In-Training Examination was the only significant predictor of primary and secondary success (p < 0.02 and p < 0.05).

CONCLUSIONS

NDPS training provides a viable and successful opportunity for at least 81% of young physicians to pursue their career goals even after an unsuccessful first match.

Predicting and enhancing American Board of Surgery In-Training Examination performance: does writing questions really help?

BACKGROUND

The generative learning model posits that individuals remember content they have generated better than materials created by others. The goals of this study were to evaluate question generation as a study method for the American Board of Surgery In-Training Examination (ABSITE) and determine whether practice test scores and other data predict ABSITE performance.

METHODS

Residents (n = 206) from 6 general surgery programs were randomly assigned to one of the two study conditions. One group wrote questions for practice examinations. All residents took 2 practice examinations.

RESULTS

There was not a significant effect of writing questions on ABSITE score. Practice test scores, United States Medical Licensing Examination Step 1 scores, and previous ABSITE scores were significantly correlated with ABSITE performance.

CONCLUSIONS

The generative learning model was not supported. Performance on practice tests and other data can be used for early identification of residents at risk of performing poorly on the ABSITE.

How do Perceptions of Autonomy Differ in General Surgery Training Between Faculty, Senior Residents, Hospital Administrators, and the General Public? A Multi-Institutional Study

OBJECTIVE

Identify barriers to resident autonomy in today's educational environment as perceived through 4 selected groups: senior surgical residents, teaching faculty, hospital administration, and the general public.

DESIGN

Anonymous surveys were created and distributed to senior residents, faculty, and hospital administrators working within 3 residency programs. The opinions of a convenience sample of the general public were also assessed using a similar survey.

SETTING

Keesler Medical Center, Keesler AFB, MS; the University of Texas Health Science of San Antonio, TX; and the University of Nebraska Medical Center, Omaha, NE.

PARTICIPANTS

A total of 169 responses were collected: 32 residents, 50 faculty, 20 administrators, and 67 general public.

RESULTS

Faculty and residents agree that when attending staff grant more autonomy, residents' self-confidence and sense of ownership improve. Faculty felt that residents should have less autonomy than residents did (p < 0.001). When asked to reflect on the current level of autonomy at their institution, 47% of residents felt that they had too little autonomy and 38% of faculty agreed. No resident or faculty felt that residents had too much autonomy at their institution. The general public were more welcoming of resident participation than faculty (p = 0.002) and administrators (p = 0.02) predicted they would be. When the general public were asked regarding their opinions about resident participation with complex procedures, they were less welcoming than faculty, administrators, and residents thought (p < 0.001). The general public were less likely to think that resident involvement would improve their quality of care (p < 0.001).

CONCLUSION

Faculty and senior residents both endorse resident autonomy as important for resident development. The general public are more receptive to resident participation than anticipated. However, with increasing procedural complexity and resident independence, they were less inclined to have residents involved. The general public also had more concerns regarding quality of care provided by residents than the other groups had.

Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retention and Transfer of Central Venous Catheter Skills

INTRODUCTION

Error management training is an approach that encourages exposure to errors during initial skill acquisition so that learners can be equipped with important error identification, management, and metacognitive skills. The purpose of this study was to determine how an error-focused training program affected performance, retention, and transfer of central venous catheter (CVC) placement skills when compared with traditional training methodologies.

METHODS

Surgical interns (N = 30) participated in a 1-hour session featuring an instructional video and practice performing internal jugular (IJ) and subclavian (SC) CVC placement with guided instruction. All interns underwent baseline knowledge and skill assessment for IJ and SC (pretest) CVC placement; watched a "correct-only" (CO) or "correct + error" (CE) instructional video; practiced for 30 minutes; and were posttested on knowledge and IJ and SC CVC placement. Skill retention and transfer (femoral CVC placement) were assessed 30 days later. All skills tests (pretest, posttest, and transfer) were videorecorded and deidentified for evaluation by a single blinded instructor using a validated 17-item checklist.

RESULTS

Both the groups exhibited significant improvements (p < 0.001) in knowledge and skills after the 1-hour training program, but the increase of items achieved on the performance checklist did not differ between conditions (CO: IJ Δ = 35%, SC Δ = 29%; CE: IJ Δ = 36%, subclavian Δ = 33%). However, 1 month later, the CO group exhibited significant declines in skill retention on IJ CVC placement (from 68% at posttraining to 44% at day 30; p < 0.05) and SC CVC placement (from 63% at posttraining to 49% at day 30; p < 0.05), whereas the CE group did not have significant decreases in performance. The CE group performed significantly better on femoral CVC placement (i.e., transfer task; 62% vs 38%; p < 0.01) and on 2 of the 3 complication scenarios (p < 0.05) when compared with the CO group.

CONCLUSIONS

These data indicate that incorporating error-based activities and discussions into training programs can be beneficial for skill retention and transfer.

What do residents need to be competent laparoscopic and endoscopic surgeons?

BACKGROUND

Despite numerous efforts to ensure that surgery residents are adequately trained in the areas of laparoscopy and flexible endoscopy, there remain significant concerns that graduates are not comfortable performing many of these procedures.

METHODS

Online surveys were sent to surgery residents (98 items, PGY1-5 Categorical) and faculty (78 items, general surgery, and gastrointestinal specialties) at seven institutions. De-identified data were analyzed under an IRB-approved protocol.

RESULTS

Ninety-five faculty and 121 residents responded, with response rates of 65 and 52 %, respectively. Seventy-three percent of faculty indicated that competency of their graduating residents were dramatically or slightly worse than previous graduates. Only 29 % of graduating residents felt very comfortable performing advanced laparoscopic (AL) cases and 5 % performing therapeutic endoscopy (TE) cases immediately after graduation. Over half of interns expressed a need for fellowship to feel comfortable performing AL and TE procedures, and this need did not decrease as residents neared graduation. For these procedures, residents receive only "little to some" autonomy, as reported by both faculty and PGY5s. Residents reported that current curricula for laparoscopy and endoscopy consist primarily of clinical experience. Both residents and faculty, though, reported considerable value in other training modalities, including simulations, live animal laboratories, cadavers, and additional didactics.

CONCLUSIONS

These data indicate that both residents and faculty perceive significant competency gaps for both laparoscopy and flexible endoscopy, with the most notable shortcomings for advanced and therapeutic cases, respectively. Improvement in resident training methods in these areas is warranted.

A Comparison of Teaching Modalities and Fidelity of Simulation Levels in Teaching Resuscitation Scenarios

INTRODUCTION

The purpose of our study was to examine the ability of novices to learn selected aspects of Advanced Cardiac Life Support (ACLS) in training conditions that did not incorporate simulation compared to those that contained low- and high-fidelity simulation activities. We sought to determine at what level additional educational opportunities and simulation fidelity become superfluous with respect to learning outcomes.

METHODS

Totally 39 medical students and physician assistant students were randomly assigned to 4 training conditions: control (lecture only), video-based didactic instruction, low-, and high-fidelity simulation activities. Participants were assessed using a baseline written pretest of ACLS knowledge. Following this, all participants received a lecture outlining ACLS science and algorithm interpretation. Participants were then trained in specific aspects of ACLS according to their assigned instructional condition. After training, each participant was assessed via a Megacode performance examination and a written posttest.

RESULTS

All groups performed significantly better on the written posttest compared with the pretest (p < 0.001); however, no groups outperformed any other groups. On the Megacode performance test, the video-based, low-, and high-fidelity groups performed significantly better than the control group (p = 0.028, p < 0.001, p = 0.019). Equivalence testing revealed that the high-fidelity simulation condition was statistically equivalent to the video-based and low-fidelity simulation conditions.

CONCLUSION

Video-based and simulation-based training is associated with better learning outcomes when compared with traditional didactic lectures only. Video-based, low-fidelity, and high-fidelity simulation training yield equivalent outcomes, which may indicate that high-fidelity simulation is superfluous for the novice trainee.

Current Status of Simulation-Based Training in Graduate Medical Education

The use of simulation in Graduate Medical Education has evolved significantly over time, particularly during the past decade. The applications of simulation include introductory and basic technical skills, more advanced technical skills, and nontechnical skills, and simulation is gaining acceptance in high-stakes assessments. Simulation-based training has also brought about paradigm shifts in the medical and surgical education arenas and has borne new and exciting national and local consortia that will ensure that the scope and impact of simulation will continue to broaden.

Development and construct validity of a low-fidelity training platform for driving large and small suture needles

BACKGROUND

The objective of this study was to describe and validate a novel training platform for driving large and small suture needles, which can ultimately be used for elemental vascular surgical training.

METHODS

We developed a novel trainer and proficiency-based training curriculum that provides a platform for practice with handling fine vascular tools and needles as well as precision in suture targeting. The trainer comprises 2 concentric circles printed on cotton fiber material with 8 evenly spaced targets on each circle. The first exercise was designed for practice with Castroviejo needle drivers and a fine needle such that the needle is passed through all targets in sequential order. A second, larger figure serves the same function but is designed for conventional needle drivers and a larger needle. A total of 5 attending surgeons from vascular and trauma surgery were recruited to serve as "expert" participants. These surgeons completed 3 repetitions of each task, which were used to develop proficiency timing and quality standards for practice. The curriculum was validated by recruiting 10 senior surgical residents and 12 surgical interns. Senior residents completed 3 repetitions of each task. Each first-year resident completed a proctored pretest, trained to proficiency by self-paced practice on the trainer according to standards set by the attending surgeons, and completed a proctored posttest.

RESULTS

First-year residents performed significantly worse on the pretest compared with senior residents and faculty surgeons on both exercises (small figure = 58.9 vs 174.2 vs 201.3, p < 0.001; large figure = 112.1 vs 202.9 vs 198.1, p < 0.001). After proficiency-based practice, first-year residents improved significantly from pretest to posttest (small figure = 216.0 vs 58.9, p < 0.001; large figure = 211.7 vs 112.1, p = 0.001).

CONCLUSIONS

The vascular trainer platform demonstrated construct validity for self-paced elemental vascular surgical practice.

Evaluation of two flexible colonoscopy simulators and transfer of skills into clinical practice

INTRODUCTION

Surgical residents have learned flexible endoscopy by practicing on patients in hospital settings under the strict guidance of experienced surgeons. Simulation is often used to "pretrain" novices on endoscopic skills before real clinical practice; nonetheless, the optimal method of training remains unknown. The purpose of this study was to compare endoscopic virtual reality and physical model simulators and their respective roles in transferring skills to the clinical environment.

METHODS

At the beginning of a skills development rotation, 27 surgical postgraduate year 1 residents performed a baseline screening colonoscopy on a real patient under faculty supervision. Their performances were scored using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES). Subsequently, interns completed a 3-week flexible endoscopy curriculum developed at our institution. One-third of the residents were assigned to train with the GI Mentor simulator, one-third trained with the Kyoto simulator, and one-third of the residents trained using both simulators. At the end of their rotations, each postgraduate year 1 resident performed one posttest colonoscopy on a different patient and was again scored using GAGES by an experienced faculty.

RESULTS

A statistically significant improvement in the GAGES total score (p < 0.001) and on each of its subcomponents (p = 0.001) was observed from pretest to posttest for all groups combined. Subgroup analysis indicated that trainees in the GI Mentor or both simulators conditions showed significant improvement from pretest to posttest in terms of GAGES total score (p = 0.017 vs 0.024, respectively). This was not observed for those exclusively using the Kyoto platform (p = 0.072). Nonetheless, no single training condition was shown to be a better training modality when compared to others in terms of total GAGES score or in any of its subcomponents.

CONCLUSION

Colonoscopy simulator training with the GI Mentor platform exclusively or in combination with a physical model simulator improves skill performance in real colonoscopy cases when measured with the GAGES tool.

External validation and evaluation of an intermediate proficiency-based knot-tying and suturing curriculum

PURPOSE

The purpose of this study was to perform external validation, examine educational effectiveness, and confirm construct validity of a previously developed "intermediate-level, proficiency-based knot-tying and suturing curriculum" in preparing residents to achieve proficiency in more advanced open surgical techniques.

METHODS

A total of 47 postgraduate year-1 (PGY-1) surgery residents completed 6 intermediate-level knot-tying and suturing exercises. Baseline trainee performance was compared with intermediate and senior (PGY-3 and PGY-4) residents (n = 12) and expert faculty (n = 4).

RESULTS

PGY-1 overall proficiency increased from 21.1% at baseline to 92.1% during posttest for all 6 exercises combined (p < 0.001). When compared with the PGY-3 and PGY-4 residents, at baseline intermediate and senior residents scored higher on half of the exercises. However, during posttesting PGY-1 residents not only matched, but also surpassed PGY-3 and PGY-4 residents' performance in 3 of 6 exercises. Significant differences on all 6 exercises were also found during pretesting when comparing interns against faculty, demonstrating construct validity. However, upon completion of the curriculum, PGY-1 residents' posttest scores were equivalent, if not significantly better than expert faculty performance.

CONCLUSION

We obtained similar results as those previously reported, showing external validation. Additionally, we demonstrated that first-year surgical residents could achieve performance levels that match or exceed those of senior residents and experienced surgeons on these exercises with 4 weeks of training.

Virtual reality simulators: valuable surgical skills trainers or video games?

BACKGROUND

Virtual reality (VR) and physical model (PM) simulators differ in terms of whether the trainee is manipulating actual 3-dimensional objects (PM) or computer-generated 3-dimensional objects (VR). Much like video games (VG), VR simulators utilize computer-generated graphics. These differences may have profound effects on the utility of VR and PM training platforms. In this study, we aimed to determine whether a relationship exists between VR, PM, and VG platforms.

METHODS

VR and PM simulators for laparoscopic camera navigation ([LCN], experiment 1) and flexible endoscopy ([FE] experiment 2) were used in this study. In experiment 1, 20 laparoscopic novices played VG and performed 0° and 30° LCN exercises on VR and PM simulators. In experiment 2, 20 FE novices played VG and performed colonoscopy exercises on VR and PM simulators.

RESULTS

In both experiments, VG performance was correlated with VR performance but not with PM performance. Performance on VR simulators did not correlate with performance on respective PM models.

CONCLUSIONS

VR environments may be more like VG than previously thought.

Evaluation of a dedicated, surgery-oriented visiting international medical student program

PURPOSE

Programs dedicated to the successful integration of international medical graduates into the U.S. surgical residency training are scarce and foreign students are often unaware of their availability. In 2007, the Department of Surgery at the University of Texas Health Science Center at San Antonio developed the Visiting International Students in San Antonio (VISSA) program designed to bring international senior medical students to rotate at our institution. The program has enrolled 55 students who rotated through various general surgery services. The purpose of this study was to assess prior participants' professional statuses, career selections, and satisfaction with our program.

METHODS

A 21-item anonymous online survey was distributed via e-mail. Demographic information, current professional status, residency specialty selection, assessment of satisfaction, and personal experience with the VISSA program were collected.

RESULTS

We obtained an 84% (46/55) response rate among participants. Most respondents were men (75.6%) and younger than 25 years of age (82.6%). Students from 14 nations have visited our institution, mostly from Latin America (56.5%) and Asia (36.9%). Before visiting our program, 80.4% considered applying to a residency program in the United States, which increased to 88.9% after rotating at our institution. Of our respondents, 42.1% applied to a residency program in the United States and 17.4% were accepted to a general surgery position (50% categorical and 50% preliminary). Respondents agreed or strongly agreed that being part of the VISSA program helped them obtain a general surgery residency position (90.4%) and considered our program as their first option (77.8%). Independently of their current professional status or residency selection process, 100% of respondents would recommend participation in our program to colleagues at their medical schools.

CONCLUSION

A dedicated, surgery-oriented visiting foreign medical student program has a positive effect in residency selection, application, and professional development.

Practice schedules for surgical skills: the role of task characteristics and proactive interference on psychomotor skills acquisition

OBJECTIVE

Although break periods during training sessions are desirable, it is unclear what learners should do during these breaks. Some educators recommend that learners abstain from all task-related practice; however, it is possible that switching to an alternate exercise during break periods can also be effective. The construct of proactive interference (PI) posits that new learning is disrupted by prior learning. PI can be "released" when the nature of the task is changed after several practice trials. In this study, we examined the existence of PI in motor learning under 5 training conditions that differed in contrast to a target exercise.

DESIGN

Preclinical medical students (n = 75) performed 1 trial of peg transfer as a pretest. Participants were then randomly assigned to 1 of 5 training conditions: mass practice, similar exercise (laparoscopic bean transfer), dissimilar exercise (open suturing), observation, or rest. Participants in the mass practice condition practiced peg transfer in 3 training blocks of 15 minutes, each separated by a 5-minute break. Participants in the other conditions performed 3 training blocks consisting of 15 minutes of peg transfer followed by an interspersed alternate exercise. On completion of 3 training blocks, participants performed 1 additional peg transfer trial as a posttest.

RESULTS

Despite having trained for the same amount of time on the target task, Analysis of Covariance on posttest scores using pretest scores as the covariate indicated a significant main effect for training condition (p = 0.009). Participants engaging in mass practice performed significantly worse than participants in the dissimilar (p = 0.012), observation (p = 0.022), and rest (p < 0.001) conditions. Additionally, participants in the similar exercise condition performed worse than participants in the rest condition (p = 0.03).

CONCLUSIONS

When learning a laparoscopic task, a break comprised of dissimilar practice or unrelated activities is effective in releasing PI and improving performance.

Views of surgery program directors on the current ACGME and proposed IOM duty-hour standards

PURPOSE

The purpose of this study was to survey the experiences of surgery program directors with the current Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards and views of the Institute of Medicine (IOM) proposed duty-hour recommendations.

METHODS

A total of 118 program directors (47.6% of all surgery programs in the US) responded to the survey.

RESULTS

Results showed that the current duty-hour standards have hindered clinical education opportunities by reducing or eliminating rotations on many services, didactic teaching conferences, and clinical bedside teaching opportunities. Additionally, patient safety has been compromised by frequent hand offs of care. Most IOM recommendations were perceived as extremely difficult or impossible to implement, with the exception of the moonlighting recommendation. The results indicated that adopting the IOM recommendations is not feasible given current workforce limitations, and most program directors supported maintaining the current duty-hour standards until such time as there is evidence-based outcomes research to direct change.

CONCLUSIONS

The conclusion was that the current ACGME duty-hour standards have reduced teaching opportunities and narrowed the scope of training.

Effects of ivermectin on control of gastrointestinal nematodes and weight gain in weaner-yearling beef cattle

Four groups of 16 crossbred beef calves were used in evaluating different anthelmintic treatment schedules: group 1 was given ivermectin (IVM) at weaning only (October 31) and grazed on initially safe pasture; group 2 was given IVM at weaning, on January 28, and on April 22, and grazed on contaminated pasture; and group 3 was given IVM at weaning and on April 22, and grazed on contaminated pasture; and group-4 was group treated with fenbendazole (FBZ) at weaning only, with provision for individual salvage treatment, and grazed on contaminated pasture. The investigation was from Oct 31, 1984, to Oct 9, 1985. Initially high fecal egg counts at weaning were more effectively reduced by IVM than by FBZ, and the effect of safe pasture was evident in minimal worm burdens in tracer calves grazed with group-1 cattle during November and least amount of weight loss in group-1 yearlings during winter. Fecal egg counts, pasture larval counts, and plasma pepsinogen concentrations remained low in group 2 after the January treatment. Fecal egg counts of the other groups increased substantially during late winter and spring, but pasture larval counts increased only on group-1 and group-4 pastures. During spring, highest worm burdens were found in group-1 and group-4 tracer calves (grazed in April) and in group-3 and group-4 yearlings (slaughtered in early April). Six cattle of group 4 were salvage treated with FBZ in February and April. Greatest gains were observed from March through June, with group-2 and group-1 cattle gaining the most.(ABSTRACT TRUNCATED AT 250 WORDS)

Three treatments with ivermectin in year-long control of gastrointestinal nematode parasites of weaner-yearling beef cattle

Four groups of 17 crossbred beef weaners were used in an experiment which extended from 14 November 1985 to 8 October 1986 (328 days). All groups began grazing on separate, contaminated pastures at a stocking rate of 5.3 cattle ha-1 and the different treatments were: Group 1, ivermectin (IVM) injectable X 1 (200 micrograms kg-1) on 14 November only, with provision for individual salvage treatment; Group 2, IVM X 3 on 14 November, 4 February and 2 July; Group 3, IVM X 2 on 14 November and 2 July; Group 4, fenbendazole (FBZ) paste X 2 (5 mg kg-1) on 14 November and 2 July. Pairs of parasite-free tracer calves were grazed on all group pastures for 1 month at the beginning of the experiment (13 November-12 December and in spring (1 April-1 May). Yearling cattle from each group were randomly selected and removed from pasture during spring (n = 2 per group, 3 April) and at the end of the experiment (n = 3 per group, 8 October) for slaughter analysis of worm population characteristics and observation of gross pathology in the abomasum and intestinal tract. At monthly intervals, all cattle were weighed and fecal egg counts, pasture larval counts and plasma pepsinogen values were determined. The results of this investigation demonstrated that three IVM treatments of weaner-yearling beef cattle during year-long grazing, were more effective than a single IVM treatment or two treatments with IVM or FBZ in the enhancement of productivity and protection from the effects of infection with nematode parasites.

Gene control by phosphoproteins: a theoretical model for eukarotic DNA regulation

Although gene regulatory mechanisms in eukaryotic cells are complex, some progress is being made in understanding them. Chromosomal proteins may play a significant role in genome function and gene control. More specifically, a central role may be played by the nuclear nonhistone proteins. It appears that both viral transformation and steroid hormone action may be associated with the phosphorylation of these proteins. Recent studies have revealed that some oncogenic viruses are capable of producing viral transforming proteins with protein kinase activity. This suggests how they may subvert normal gene regulatory mechanisms. Furthermore, the effects of the steroid-receptor complex on nuclear nonhistone proteins may be similar to the effects of these viral transforming proteins, but in a controlled sense. A model of gene-regulatory, nuclear phosphorylation reactions is formulated which suggests how some oncogenic viruses may control normal gene regulatory mechanisms and how steroid hormones may interact with these same mechanisms. Such a model may reveal how disruption of these same mechanisms leads to carcinogenesis.

Gene control by phosphoproteins: a theoretical model for eukaryotic DNA regulation

Although gene regulatory mechanisms in eukaryotic cells are complex, some progress is being made in understanding them. Chromosomal proteins may play a significant role in genome function and gene control. More specifically, a central role may be played by the nuclear nonhistone proteins. It appears that both viral transformation and steroid hormone action may be associated with the phosphorylation of these proteins. Recent studies have revealed that some oncogenic viruses are capable of producing viral transforming proteins with protein kinase activity. This suggests how they may subvert normal gene regulatory mechanisms. Furthermore, the effects of the steroid-receptor complex on nuclear nonhistone proteins may be similar to the effects of these viral transforming proteins, but in a controlled sense. A model of gene-regulatory, nuclear phosphorylation reactions is formulated which suggests how some oncogenic viruses may control normal gene regulatory mechanisms and how steroid hormones may interact with these same mechanisms. Such a model may reveal how disruption of these same mechanisms leads to carcinogenesis.