77.10 Impact of the Senior Year of Medical School on Procedural Skill Acquisition

Posted on December 22, 2014

S. S. Kim1, M. O. Meyers1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA

Introduction:   Acquisition of procedural skills during medical school continues to evolve.  In this study, we examine the impact of the 4th year on actual and desired procedural competence. 

 

Methods:   Under IRB approval, we conducted a survey of 3rd and 4th year students over a three-year period.  Experience, actual and desired levels of competence were measured for nine procedural skills using a 4-point Likert scale (1=unable to perform; 2= major assistance; 3= minor assistance; 4=independent). Responses were compared by Fisher’s exact test.

 

Results: 4th year students in 2012 reported a greater number of procedures performed for every skill assessed as compared to 2011 3rd year students (p<0.001 for all); 2013 4th years reported greater numbers only for NG(p=0.01), intubation(p,0.001), IV(p<0.001), Art(p<0.001),  LP(p<0.001) and Thor(p=0.04).  Actual skill level for selected procedures is reported in the table.  2011 3rd year students desired greater competence than their graduating counterparts for Foley(p=0.01), NG(p=0.003), venipuncture(p=0.006), IV(p=0.002), Art p=0.0005) and LP(p=0.003). In 2012 this was true only for IV(p=0.03).  For no skill was there a greater level of actual or desired competence by 4th year students. A greater level of desired competence than actual competence was seen in both 3rd and 4th year for all skills (p<0.001). 

 

Conclusion:  No difference in competence was seen between 3rd and 4th year students, despite having greater experience at the end of 4th year.  Interestingly, 3rd year students were more likely to desire a higher level of independence with procedures than their 4th year counterparts.  Both groups desire a greater level of competence than they accomplish. 

 

77.11 Development of a Novel Tool to Aid Medical Student Decisions During the Resident Application Process

Posted on December 22, 2014

S. C. Daly1, R. A. Jacobson1, J. L. Schmidt1, B. P. Fleming1, A. Krupin1, M. B. Luu1, M. C. Anderson1, J. A. Myers1  1Rush University Medical Center,Chicago, IL, USA

Introduction:
The interview process for medical students places significant financial stress on a group already facing mounting debt. Undergraduate students applying to medical school have ample access to resources that guide application decisions. For example, many medical schools publish matriculating students’ median MCAT scores and GPA, which is used as an informal guide to gauge students’ individual competitiveness for admission. No such resource currently exists for medical students interviewing for residency positions. Our aim was to develop a specialty and site-specific tool that medical students could reference when applying for residency positions. We hypothesize that this tool could help prospective residents make informed decisions on where to seek interviews based on their individual competitiveness. If our hypothesis is proven correct, this information could lead to both time and cost savings for future residency applicants.

Methods:
This is a retrospective review of all matriculating medical students (n=1,125) from a single, large medical school between 2008-2014. Data analyzed included age, sex, number of interviews granted, number of interviews completed, match site, clerkship grades, USMLE Step 1 scores, USMLE Step 2 scores, GPA and completion of away rotations. Data were first grouped by specialty and then by specific program site. Median values and ranges were calculated for data points contributing to an individual’s competitiveness at a specific program within a specific specialty.

Results:
For individual programs within each specialty we determined the median and the range USMLE step 1 scores, USMLE step 2 scores and medical school GPA for matriculating students. In addition, we enhanced our competitive student profile by quantifying the number of students accepted who received honors, high pass, or pass in the corresponding clinical clerkship. The numbers of interviews granted and completed were included, as well as the number of students completing away rotations. This profile was established for over 250 sites in over 20 specialties. The results of this effort have been made available to our current medical students.

Conclusion:
Current and future students going through the application process can use this novel tool as a guide to assess their competitiveness for being granted an interview and eventual matriculation into target programs. Used effectively, our data may produce cost savings and improve interview efficiency for medical students. Ongoing analysis includes identification of data points that are most predictive of interview invitation and/or matriculation, and students’ perceptions of the tool. Further development plans include Match outcome analysis over the years to come, when students at our institution are given access to our compiled data prior to residency application. Future implementation of this tool on a social media platform could improve outcomes for applicants on a national scale.
 

77.12 Epidemiology of Paediatric Surgery Disorders: Implications for Developing Undergraduate Curriculum

Posted on December 22, 2014

A. O. Ademuyiwa1, C. O. Bode1, B. C. Nwomeh2  1University Of Lagos,Paediatric Surgery/Surgery/College Of Medicine,Lagos, LAGOS, Nigeria 2Ohio State University,Paediatric Surgery/Surgery,Columbus, OH, USA

Introduction:  Curriculum review is a dynamic process. Products of a medical curriculum must be prepared to meet the health challenges in their own communities. The aim of this study was to assess the epidemiology of paediatric surgical diseases in a low and middle income country and classify competences that medical students must acquire during their clerkship, with emphasis on conditions most prevalent in the community. 

Methods:  We analysed the diagnoses of 1000 consecutive patients managed in the paediatric surgery unit of a university teaching hospital in southwestern Nigeria. Conditions that represented more than 5% of the diagnoses were classified as ‘compulsory – must know’ (CMK); 2.0 – 4.9% classified as ‘required – should know’ (RSK) and <2% classified as ‘selective – may know’ (SMK).

Results: 

Competency levels were assigned based on the frequency of each diagnosis and the data is presented as a table.

Conclusion: More than half of the patients seen in paediatric surgery practice are represented by 6 diagnoses classified as CMK. Under this framework, these conditions will receive the greatest emphasis during the clerkship and students will be expected to develop competences in their embryology, pathophysiology, clinical presentation, diagnostic testing, and therapeutic decision-making.

 

77.13 Trauma Education in a State of Emergency: A Curriculum-based Analysis

Posted on December 22, 2014

S. D. Waterford1, M. Williams4, P. M. Fisichella3, A. Lebenthal2,3  1Massachusetts General Hospital,Department Of General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Thoracic Surgery,Boston, MA, USA 3Boston VA Healthcare System,Department Of Surgery,Boston, MA, USA 4Oakwood Southshore Medical Center,Department Of General Surgery,Trenton, MI, USA

Introduction:  Trauma is the leading cause of death among persons aged 1-44 in the United States and is the 5th leading cause of death overall. It accounts for more lost years of life than atherosclerosis and cancer combined. Trauma education in American medical schools has received little attention. In this pilot project, we sought to quantify the number of curricular hours devoted to each of the 5 leading causes of death in the United States.

Methods:  We performed a review of the pre-clinical curriculum at a northeastern Medical School with full LCME accreditation and hospital affiliations with three adult and one pediatric American College of Surgeons verified Level I trauma centers. We tabulated the total number of hours devoted to education of the 5 leading cause of death in the United States and we included class lectures as well as small group case-based meetings with a faculty preceptor. We then compared the total number of curricular hours devoted to trauma to other major causes of death in the United States. For the statistical analysis we used standard ANOVA with a p < 0.05 significance threshold.

Results: Of the leading 5 causes of death, heart disease was the most covered topic with 128 hours of dedicated curriculum time (Table I).  Chronic respiratory disease was the second most discussed topic with 80 hours of dedicated curriculum time.  The number of hours of curriculum time devoted to heart disease, chronic lower respiratory diseases, malignant diseases, and cerebrovascular diseases far exceeded that devoted to trauma. This was statistically significant for all 5 leading causes of death except cerebrovascular disease.  In the first two pre-clinical years of curriculum 6.5 hours were dedicated to trauma. Six hours of tutorial time was devoted to a single trauma case, involving an accidental blunt trauma. A half hour lecture on orthopedic fractures concluded the total time allocation. No lectures were given on the basic management of trauma patients.

Conclusion: A pilot study comparing curricular hours of the 5 leading causes of death demonstrated a statistically significant discrepancy in the allocated time devoted to trauma education compared to other causes. Based on these preliminary data, we advocate a broader multi-institutional study to further ascertain the amount and quality of trauma education in American medical schools.

77.14 Improvement of an Acute Care Surgery Medical Student Rotation:Use of Feedback & Loop Closure

Posted on December 22, 2014

J. R. Cherry-Bukowiec1, D. A. Machado-Aranda1, K. To1, K. Raghavendran1, M. J. Englesbe1, L. M. Napolitano1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:

The unpredictable and sometimes chaotic environment present in an Acute Care Surgery Services (Trauma, Burn, Surgical Critical Care, Non-Trauma Emergency Surgery) can cause high levels of anxiety and stress that could impact a medical students’ experience during their M3 surgical clerkship. This negative perception perhaps is a determinant influence in diverting talented students into other medical subspecialties. We sought out to objectively identify potential areas of improvement through direct feedback and implement programmatic changes to address these areas. We hypothesized that as the changes were made students perception of the rotation would improve.

Methods:

Review of end of clerkship M3 Trauma Burn Surgery Rotation evaluations and comments was performed for the 2010-2011 academic year. Trends in negative feedback were identified and categorized into 5 areas for improvement: Logistics, Student Expectations, Communication, Team Integration, and Feedback. (Table 1.) A plan was designed and implemented for each category. Feedback on improvements to the rotation was monitored via surveys and during monthly end of rotation face-to-face student feedback sessions with the rotation faculty facilitator and surgery clerkship director. Data was compiled and reviewed

Results:

Perceptions of the rotation markedly improved within the first month of the changes, and continued to improve over the study time frame (2011-2013) in all five categories. We also observed an increase in the number of students who rotated through the ACS service selecting a surgical residency in the NRMP Match from a low of 8% in 2009-2010 prior to any interventions, to 25% after full implementation of improvement measures in 2011-2012.

Conclusion:
A systematic approach using direct feedback from students to address service specific issues improves perceptions of students on the educational value of a busy Trauma –Burn Acute Care Surgery Service and may have a positive influence on students considering surgical careers to pursue a surgical specialty.

77.15 Medical Student Perceptions of the Operating Room in Acute Care Surgery

Posted on December 22, 2014

D. A. Machado-Aranda1, J. Cherry-Bukowiec1, K. To1, M. Englesbe2, L. M. Napolitano1, K. Raghavendran1  1University Of Michigan,Division Of Acute Care Surgery/Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Division Of Transplant Surgery/Department Of Surgery,Ann Arbor, MI, USA

Introduction: Declining medical student interest in surgical careers has been a worrisome trend in the last few years. A repetitive criticism in modern surgical education is the decreased value of educational experiences in the operative room. The unpredictable and intimidating atmosphere in the operating theater of Acute Care Surgery (ACS), including Trauma, Burns, Surgical Critical Care and Emergency Surgery Services, can lead to an poor perception among medical students, creating a negative experience that could divert talented students from choosing a career in ACS. However tools to evaluate teaching in the operating room remain poorly developed. We set out to interrogate this ACS operative perception in order to maximize its educational value and convert it into a positive experience.  

Methods: Third-year medical students (M3) rotating through a four-week long course in ACS from the 2013-2014 academic years were the subject of this study.  A tool (OR-card) was created to deconstruct the phases within the operative process (preoperative, intra-operative and postoperative debriefs) and capture potential areas of improvement.

Results: A total of 12 students were included in the initial sample.  Close to 30 OR-cards were collected.  All students (100%) correctly identified and named the operative procedure and its indication.  However, only 66.6% could enumerate pertinent preoperative workup.  Conversely, 83.3% could review principles of anatomy and physiology important for the operation, and 83.3% had a clear postoperative plan. Importantly, despite the unpredictable nature of ACS, only 16.6% of operations changed from the proposed surgery.  Using an analogue scale where a “10” was exact to discussion and “1” was completely different from discussion, students' appreciation score was an 8.3 ±  2.4.  Best memorable learning experiences were Anatomical Review (66.6%), Participation (50%), Individual Skill (50%) and Operative Surgical Principles (50%).  Finally, the highest sources of information for students were residents (83.3%) followed by surgical attending (33.3%), whereas no traditional references were used (textbooks, peer-reviewed publications or atlases). 

Conclusions: Despite the unscheduled nature of ACS operations, medical students were able to greatly follow through the different phases of the majority of emergency surgical interventions.  Potential areas of improvement include understanding of pertinent preoperative workup, strengthening anatomical review, and inviting more participation within the intervention.  Finally, attending surgeons should assume their critical role as teachers within the OR, as students are greatly depending on sources that are still in-training (residents).

77.16 The Characteristics of Lurkers for a Twitter-based International General Surgery Journal Club

Posted on December 22, 2014

S. B. Bryczkowski1, C. Jones4, N. J. Gusani3, L. Kao5, B. C. Nwomeh4, K. Reid Lombardo7, M. E. Zenilman6, A. Cochran2  1New Jersey Medical School,Surgery,Newark, NJ, USA 2University Of Utah,Surgery,Salt Lake City, UT, USA 3Penn State University College Of Medicine,Surgery,Hershey, PA, USA 4Ohio State University,Surgery,Columbus, OH, USA 5University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA 6Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 7Mayo Clinic,Surgery,Rochester, MN, USA

Introduction:  The International General Surgery Journal Club (IGSJC) is a Twitter-based journal club that was initiated in March, 2014.  This monthly asynchronous moderated event extends over 2 days using a pre-identified freely available high-impact general surgery article for discussion.  An author of the selected article and a moderator help stimulate discussion during the designated time period for the journal club.  The purpose of this study was to identify characteristics of “lurkers”, those who followed the discussion but did not post tweets using the #IGSJC hashtag, in an effort to increase active participation from this group.

Methods:  Symplur.com transcripts were reviewed to identify lurker data and the number of tweets posted using the #IGSJC hashtag during monthly discussions. Lurkers were defined as followers of the @IGSJC Twitter account who did not tweet during monthly discussions. Followers were classified by their level-of-training and geographic location according to information provided in their Twitter profile augmented by Internet search. Percent of lurkers was calculated by dividing the number of lurkers by the number of followers.

Results: During the four IGSJC discussions from March to June 2014 there were 159 unique Twitter users from more than 14 countries who posted 2,848 tweets using the #IGSJC hashtag; 452 unique followers of the @IGSJC account were identified.   Of those followers whose roles could be identified (n=409, 90%), trainees (medical students, residents, and fellows) were the group most likely to lurk (99/108, 92%), (Table 1).  Other followers who lurked included associations, nurses, patient advocates, and marketers (83%). Attending physicians were the most likely to contribute and the least likely to lurk (77%).

Conclusion: Of those whose characteristics could be identified, trainees including medical students, residents and fellows, were the most likely Twitter users to lurk without actively tweeting during the moderated monthly IGSJC discussions.  The basis for non-contribution by trainees may be perceived lack of expertise in a topic area, fear of questioning established surgeons and researchers, or simply a product of many Twitter users’ lack of active tweeting.  Using simple metrics as we have, it is not possible to evaluate the impact of the IGSJC on lurkers.  Future directions for increasing IGSJC participation include surveying followers of the IGSJC Twitter account and directly encouraging trainees to tweet during the monthly IGSJC discussions.

8.01 Surgical Management and Morbidity of Magnet Ingestions in Children: A Survey of AAP Surgeons

Posted on December 22, 2014

A. M. Waters1, D. H. Teitelbaum2, D. T. Bartle1, V. Thorne1, A. Bousvaros3, R. A. Noel4, E. A. Beierle1  1University Of Alabama,Birmingham, Alabama, USA 2University Of Michigan,Ann Arbor, MI, USA 3Children’s Hospital Boston,Boston, MA, USA 4Baylor College Of Medicine,Houston, TX, USA

Introduction: In children, most ingested foreign bodies will pass spontaneously without incident however; several reports describe significant sequelae associated with rare earth magnet ingestions.  The maker of the most popular of these toys, Buckyballs® , has stopped production, but these magnets continue to be found in items marketed to adults.  The aim of this survey was to determine the surgical interventions and outcomes of magnet ingestions in the pediatric population. 

Methods: Following IRB approval, an online survey tool was developed and distributed via email to all pediatric surgeons with membership in the Surgical Section of the American Academy of Pediatrics.  Respondents were anonymous and data tallied by a blinded investigator.   

Results: Out of about 630 surgeons polled, 101 responded reporting data on 99 magnet ingestions.  The majority of ingestions reported (71%) occurred after year 2010.  Two thirds (66%) of the ingestions were in boys, the median age at ingestion was 3.7 years (range: 1-16 years), and most of the children were Caucasian (80%).  In 34% of the children, over 48 hours lapsed between the reported time of ingestion and initiation of interventions.  All but one child had an x-ray study for magnet localization and abdominal films were the most commonly ordered test.  Thirty-two patients (32%) underwent endoscopy with successful removal of magnets in 70%; primarily from the esophagus, stomach and duodenum.  At endoscopy, multiple magnets were commonly found (65%) (range: 2 to 27 magnets) and removed.  One quarter of these children required subsequent surgery for complications noted on endoscopy.  In total, 73 children required either laparotomy (51) or laparoscopy (22) for magnet removal, and removal was successful in over 96% of attempts.  At surgery, 90% of children were discovered to have ingested more than one magnet with the number of magnets retrieved ranging from 1-45.  In addition, 17% of the children were found to have at least one perforation or fistula and 34% of children had multiple perforations or fistulae.  Most did well following their surgical interventions, but some (n=8) required prolonged (>7 days) hospitalization or additional surgical procedures (n=4) including reoperations for missed perforation and leak from a colotomy resulting in a colostomy.  Reported long-term outcomes (>30 days) included 9 children requiring long-term care for their injuries including repeat endoscopies.  One child died following hemorrhage from an esophago-aortic fistula.   

Conclusion: The findings of this survey demonstrate that rare earth magnets remain a serious health hazard for children, especially in the younger age ranges.  Ingestions of these objects may result in serious injuries to the gastrointestinal tract, even when removed expeditiously.  Surgeons must look for multiple magnets when encountered with such cases, and every effort should be made to remove these objects either by endoscopic or surgical means when discovered. 

 

8.02 An Assessment of Morbidity from Gastrojejunal Feeding Tubes in Children

Posted on December 22, 2014

I. Campwala1, E. Perrone1, G. Yanni2, M. Shah2, G. Gollin1  1Loma Linda University School Of Medicine,Pediatric Surgery,Loma LInda, CA, USA 2Loma Linda University School Of Medicine,Pediatric Gastroenterology,Loma LInda, CA, USA

Introduction: Long-term gastrojejunal (GJ) feeding is an increasingly popular alternative to gastric fundoplication for children with pathological reflux, particularly in patients with neurological impairment.   We sought to evaluate the morbidity associated with GJ feeding tubes in a large population of children.

Methods: The records of all children under 18 years of age who underwent placement of a GJ feeding tube in a large children’s hospital between January, 2005 and September, 2012 were reviewed.  Subjects were followed for an average of 5 years (range, 2-9 years). The indications for GJ feedings were noted.  Events including a requirement for tube replacement, small bowel obstruction requiring laparotomy, intestinal perforation, and a subsequent requirement for operative jejunostomy were evaluated.  Risk factors for morbidity were assessed.

Results: 124 children underwent GJ tube placement during the study period at an average age of 5.0 years (range, 2 months to 16 years).  51 (41%) subjects were neurologically impaired and 55 (44%) had undergone prior laparoscopic fundoplication.  Recurrent reflux symptoms occurred in 22 (18%).  Tubes were electively changed under sedation an average of 4 times per child and jejunal limbs dislodged 1.2 times per patient and more than 3 times in 17 (14%).   In 9 cases (7%), an operative jejunostomy was constructed due to difficulties with GJ feeding. Five children (4%) required emergent laparotomy for GJ tube complications including intestinal obstruction (2) and intestinal perforation (3).  These subjects were younger (9 months) than those without complications that required laparotomy (5.2 years, p=0.05).

Conclusion: GJ feeding tubes were associated with notable morbidity ranging from persistent reflux to dislodgement, intestinal obstruction and perforation.   Together with issues of inconvenience with continuous feedings, these complications should be taken into account in children, and particularly infants, with gastroesophageal reflux in whom GJ feedings are being considered as an alternative to fundoplication.

 

8.03 Prenatal Measurements of Vessel Size May Improve ECMO Cannulation for Infants with CDH

Posted on December 22, 2014

S. J. Clark2,3, F. Sheikh2,3, A. C. Akinkuotu2,3, I. J. Zamora2,3, T. C. Lee2,3, O. O. Olutoye2,3, A. Mehollin-Ray1,3, D. L. Cass2,3  1Baylor College Of Medicine,Radiology,Houston, TX, USA 2Baylor College Of Medicine,MIchael E. DeBakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Fetal Center,Houston, TX, USA

Introduction: Infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) may not be candidates for veno-venous (VV), and thus require veno-arterial (VA) ECMO, due to small right jugular vein sizes. The purpose of this study was to evaluate ECMO cannula types and sizes used in the treatment of infants with CDH, and to begin to determine whether prenatal imaging of right neck vessel size may help guide cannula selection.

Methods: The charts of all prenatally diagnosed neonates with CDH treated at a comprehensive fetal center from 2000 to 2013 were reviewed. Perinatal outcomes collected included fetal internal jugular vein (IJ) diameter as measured on fetal ultrasound, need for ECMO, ECMO cannula size, cannula cost, and number of cannulas used per operation.

Results: Of 201 CDH patients, 52 were treated with ECMO (6 VV and 47 VA) at mean day of life 2 ± 4 (range, 0-11 days). All patients treated with VV had 13 F cannulas, whereas those treated with VA ECMO had cannula sizes of 12 or 10 F venous and 10 or 8 F arterial. Thirty-two CDH patients had fetal measurement of right IJ size, of which 7 required ECMO. Of these 7, VV cannulation was attempted in 5 patients but successful only in the infant with prenatal right IJ size of > 4mm (Table 1). One patient was discovered to have an absent right IJ at attempted cannulation, and retrospective review of fetal imaging confirmed this finding. In total, 24 cannulas attempted on 22 patients (cost $349-$2699) were discarded at operation because they did not fit.

Conclusion: Many CDH patients cannulated for ECMO are not candidates for VV ECMO and/or have cannulas discarded from the surgical field due to inadequate right IJ vein size. Prenatal measurement of fetal neck vessels may be predictive of optimal cannula size, which may guide surgical management and maximize operative cost-savings.    

 

8.04 Protocol Workup for Suspected Pediatric Appendicitis Limits Computed Tomography Utilization

Posted on December 22, 2014

J. Tashiro1, B. Wang1, M. Curbelo2, E. A. Perez1,2, A. R. Hogan1,2, H. L. Neville1,2, J. E. Sola1,2  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Miami, FL, USA

Introduction: Appendicitis is the most common surgical emergency in children. However, diagnosis by history and physical exam can be challenging in children as classical signs and symptoms are often lacking and other childhood conditions can mimic appendicitis. Despite concerns for radiation, computed tomography (CT) is the favored imaging modality at many children’s hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children’s hospital by adopting an algorithm (Figure 1), relying on 24-hour ultrasound (US) as the primary imaging study.

Methods: A standardized protocol was adopted at the end of fiscal year (FY) 2011 using US as the primary imaging study for diagnosing appendicitis in the emergency department (ED). Pediatric surgery service assumed patient care after US had been performed. A prospectively recorded database was analyzed 12 months prior to and 24 months after the employment of the protocol. The usage for each imaging test was adjusted per number of appendectomies performed. Training of ED staff continued for over 1 year after protocol implementation. Statistical analysis was performed using PASW Statistics V.21. Student t test was used to compare continuous data. Significance was determined at P value < 0.05.

Results: For FY 2011, 644 abdominal CT, and 1088 appendix U/S were ordered from the ED and 249 laparoscopic appendectomies (LA) were performed. After implementation of the protocol, FY 2012: 535 CT, 1285 appendix U/S, and 265 LA were performed; and FY 2013: 330 CT, 1235 appendix U/S, and 236 LA were performed. Paired t-test comparing monthly incidence of appendectomy between the three years did not show any significant difference. Length of stay decreased from FY 2011 to FY 2013 (2.57 ± 0.29 vs. 1.90 ± 0.15 days) and from pre- to post-protocol (2.57 ± 0.29 vs. 2.15 ± 0.11 days), both p<0.001. There was a 42% decrease in number of abdominal CT utilized per appendectomy performed from FY 2011 to FY 2013 (2.43 vs. 1.40, p<0.001) and 30% from pre- to post-protocol (2.43 vs. 1.70, p<0.001). In addition, a corresponding 27% increase in number of appendix US pre- to post protocol (4.11 vs. 5.20 US/appendectomy, p=0.004) occurred.

Conclusion: Protocol driven workup with US significantly reduced CT utilization and thereby radiation exposure in children with suspected appendicitis. Ongoing training of ED staff after implementation is required to ensure protocol compliance. 

8.05 Atypical Teratoid Rhabdoid Tumors: Epidemiology and Outcomes for 174 Patients

Posted on December 22, 2014

C. S. Lau1,3, K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Atypical teratoid rhabdoid tumors (ATRT) are rare, highly malignant embryonal malignancies of the central nervous system (CNS) accounting for ~3% of pediatric brain tumors, but ~20% of CNS tumors in children under the age of 3. To date few cases of ATRT have been reported, and no large patient series exist. This study examined a large cohort of ATRT patients to determine demographic, clinical, and pathologic factors which determine prognosis and survival.

Methods: Demographic and clinical data were abstracted on 174 patients from the SEER database from 1973–2010 and statistical analysis was performed using Chi-square test, paired t-test, multivariate analysis, and Kaplan-Meier functions.

Results: 174 cases of ATRT, with a mean age of 2.84 years were identified. 140 (80.5%) patients were <3 years old, 31 were 4-19 (17.8%) and 3 were ≥ 20 (1.7%), p<0.001. ATRT had a higher incidence in males (56.3% vs. 43.7%, p<0.001) and Caucasians (59.1%, p<0.001). The most common primary tumor sites were the cerebellum (17.8%), ventricles (16.1%), and frontal lobe (12.6%). Mean overall survival for ATRT was 3.2 ± 0.4 years, while overall and cancer specific mortality were 63.2% and 60.5% respectively (p=0.005). The majority of ATRT cases were treated with surgery alone (58.0%), followed by combination surgery and radiation (34.3%), no treatment (6.5%), and radiation alone (1.2%). The percentage of ATRT cases managed by combination surgery and radiation was significantly higher in the 2005-present study period compared to the 1973-2004 period (38.4% vs. 22.3%, p<0.001), while primary surgical resection and radiotherapy rates remained approximately the same. Longest survival was amongst ATRT patients receiving surgery and radiation (5.9 ± 0.7 years), followed by radiation alone (2.8 ± 1.2 years), surgery alone (1.9 ± 0.4 years) and no treatment (0.3 ± 0.2 years), p<0.001. Multivariate analysis identified distant metastases (OR 4.6, CI=2.7-6.9) as independently associated with increased mortality, p<0.005. Conversely, combination surgery and radiation treatment (OR 0.4, CI=0.1-2.0) was independently associated with reduced mortality, p<0.005.

Conclusions: ATRT is a rare, highly aggressive embryonal malignancy of the CNS that presents more often in male Caucasian children under the age of three, in the cerebellum, ventricles and frontal lobe with locoregional distribution and tumor sizes over 4cm. Combination surgery and radiotherapy significantly improves survival, and its use has been increasing since 2005. All ATRT patients should be enrolled into clinical trials or registries to allow for more defined multimodality management to achieve the best prognosis.

8.06 Using Preoperative Imaging to Predict Symptom Improvement in Children with Biliary Dyskinesia

Posted on December 22, 2014

J. B. Mahida1,2, J. P. Sulkowski1,2, J. N. Cooper1, A. King1, K. J. Deans1,2, P. C. Minneci1,2, D. R. King2  1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction: The diagnosis and management of children with biliary dyskinesia are controversial. Our objective was to identify clinical determinants of pain improvement in children undergoing cholecystectomy for biliary dyskinesia.

Methods: This retrospective institutional cohort study included patients who underwent cholecystectomy for biliary dyskinesia between 2006 and 2013. All patients had their gallbladder ejection fraction (EF) measured by either cholecystokinin stimulated HIDA scan, fatty meal ultrasound (FUS; measures the change in gallbladder volume after consumption of a high fat meal), or both. Patients without postoperative follow up were excluded. Data collected included patient demographics, medical history, preoperative imaging, details of the surgery, and postoperative outcomes. The ability of the preoperative diagnostic tests to predict pain improvement was evaluated by examining overall accuracy, sensitivity, specificity, and negative and positive predictive values (PPV). Multivariable logistic regression models were used to identify preoperative characteristics associated with pain improvement.

Results: Of the 153 included patients, 76% were female, 89% were Caucasian, and 51% were either overweight (BMI >85th to ≤ 95th percentile; 12%) or obese (BMI >95th percentile; 39%). At postoperative evaluation, improvement of pain was reported by 82% of the patients. The median (interquartile range) gallbladder EFs were not statistically different in patients with and without pain improvement for both the HIDA (pain improvement EF 18% (17-31%) vs. no pain improvement EF 22% (3-36%), p=0.66) and the FUS (EF 35% (24-50%) vs. EF 41% (33-51%), p=0.31). For both the HIDA and FUS, the sensitivity of the test to predict pain improvement increased with higher ejection fractions while the PPV remained around 80% (Table). There was no correlation between EF measurements from HIDA and FUS in patients who had both tests (N=0.29, r=28, p=0.15), neither test showed superior performance, and the results were similar in obese and non-obese patients. Preoperative characteristics that were independent predictors of pain improvement included a shorter duration of pain (odds ratio of pain relief, 95% CI, p-value) (per month: 1.02, 1.0-1.05, p=0.03), a history of vomiting (2.62, 1.02-6.76, p=0.045), and absence of fever (3.95, 1.23-12.65, p=0.02).

Conclusion: Over 80% of patients undergoing cholecystectomy for biliary dyskinesia reported pain improvement. This study provides additional information on a combination of preoperative clinical characteristics and diagnostic test results that can be used to counsel patients and their families on the role of cholecystectomy in treating biliary dyskinesia.

76.11 Teaching the Core Competency of Practice-Based Learning and Improvement Through Surgical Debates

Posted on December 22, 2014

P. P. Patel1, E. Y. Chan1  1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction:

Practice-based Learning and Improvement (PBL) is one of the six core competencies set by the Accreditation Council for Graduate Medical Education.  It is defined as the ability to investigate and evaluate care of patients, appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.  Although this competency has been established for more than 10 years, many general surgery training programs have struggled with the best method to incorporate this skill into their curriculum.  The purpose of our study is to demonstrate that the preparation and presentation of surgical debates by residents is an effective method of applying PBL.

Methods:
Senior residents were assigned controversial debate topics that focused on common general surgery scenarios based on self-identified strengths, deficiencies and limits in their knowledge base.  They were provided a month to set learning goals and complete the appropriate learning activities. These learning activities focused on locating and critically appraising evidence from scientific studies relating to their clinical scenario and assimilating this information into a grand rounds presentation in the form of a debate. The debates were conducted by two senior residents who using evidence based data centered on current literature defended their surgical approach to approximately 50 surgical attendings and residents.  Four debates were held throughout the year. To evaluate the efficacy of this teaching method, presenters were asked if participation in this debate increased proficiency at acquiring and critically reviewing medical literature.  Additionally, they were asked if the skills acquired during the debate would be applied to practice evidence based surgery and improve patient care in the future.  As a secondary measure, the audience was asked if this debate influenced their approach.

Results:

In preparing for their presentation, each resident reviewed on average 20 articles and cited 14 journal articles.  Half of the residents stated they felt more comfortable searching for and reading scientific literature after completing their presentation.  At the conclusion of the year, 75% of residents expressed that they were now more likely to practice evidence-based surgery and refer to literature to justify their patient care plan.  As a secondary measure, more than 50% of the audience stated that the debate influenced their decision on approach to the clinical scenario presented.

Conclusion:

Overall, the debate format to acquire the core competency of PBL was successful in more than 50% of participants. Surgical debates provide an innovative and effective way to incorporate PBL into the general surgery residency curriculum.

76.12 Effect Of 80-Hour Work Week On Resident Publication Frequency

Posted on December 22, 2014

J. D. Forrester1, M. L. Melcher1  1Stanford University,Surgery,Palo Alto, CA, USA

Introduction:

Expressing ideas, decisions, and research findings clearly in writing is an essential skill for surgeons in leadership and academic positions. An intriguing consequence of the 80-hour work week is the possibility for increased academic productivity among surgical residents.  We hypothesized that graduating chief residents would have a greater publication frequency after work-hour restriction implementation.

Methods:  

Names of graduating chief residents from 1983 to 2013 from a single academic institution were cross-referenced with SCOPUS identification numbers to determine first-author publication frequency. Publication frequency of residents graduating before 2003 were compared to those graduating after 2003 accounting for gender distribution and graduating resident volume. Statistical evaluation was performed using Epi Info™  Version 7.1.1.14 (Centers for Disease Control and Prevention, Atlanta, GA) and comparisons were performed using the Mann-Whitney U-test or Fisher’s Exact where appropriate.

Results:

From 1983 to 2013, 116 graduating chief residents produced 153 first-author publications. There were a median 0.5 publications per resident (range [0-12], n=90) graduating before 2003, and there were a median 2 publications per resident (range [0-16], n=63) graduating in 2003 or later. This difference was statistically significant (p=0.014).

Conclusions:

A statistically significant difference in the publication frequency of resident graduating before 2003 and those graduating after 2003 was observed at a single academic institution. Surgical residents graduate with a wide range of publications suggesting that there are opportunities for intervention to help residents with fewer publications.  Educational programs directed at improving resident writing could promote additional academic productivity.

76.13 Impact of Resident Involvement on Surgical Outcomes after Hepatic and Pancreatic Resections

Posted on December 22, 2014

A. Ejaz1, G. Spolverato1, Y. Kim1, C. Wolfgang1, K. Hirose1, M. Weiss1, T. M. Pawlik1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:  Resident participation and level of involvement during major hepatic and pancreatic resections varies.  The impact of resident participation on surgical outcomes in major hepatic and pancreatic resections is poorly defined.  

Methods:  We identified 25,511 patients undergoing a hepatic or pancreatic resection between 2006-2012 using the American College of Surgeons National Surgical Quality Improvement Program database.  Operations were categorized based on resident participation.  Outcomes were analyzed in a propensity score-matched cohort adjusting for nonrandom assignment of resident participation.

Results: Resident participation was found in the majority of cases (n=21,857, 85.7%). Median patient age was 62 years (IQR: 53, 62) and comorbidities were common (ASA Class 3&4: n=17,093, 67.1%).  Pancreatic resections (n=16,045, 62.9%) were more common than liver resections.   Resident participation was more common in younger patients (OR 1.10, 95%CI 1.02-1.18), females (OR 1.09, 95%CI 1.01-1.16) (both P<0.05).  Resident participation resulted in longer mean operative times for both hepatic (9 minutes) and pancreatic (22 minutes) resections (both P<0.01).  Need for perioperative transfusion, total hospital length of stay, and reoperation rates were unaffected by resident participation (all P>0.05).  After adjusted analysis in the propensity score-matched cohort, resident participation resulted in higher risk of perioperative morbidity (OR 1.35, 95%CI 1.21-1.51; P<0.001) but equivalent 30-day mortality (OR 1.27, 95%CI 0.97-1.67; P=0.08).  

Conclusion: Resident participation during hepatic and pancreatic resections results in longer operative times, higher rates of morbidity, but equivalent rates of mortality.  As such, resident participation and involvement should be encouraged during these complex cases.  

 

76.14 How clinical training influences trainees’ perceptions of the clinical scope of a pediatric surgeon

Posted on December 22, 2014

D. Schindel1,3, L. Burkhalter3, L. Chen2, D. Schindel1,3  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Baylor University Medical Center,Department Of Surgery,Dallas, TX, USA 3Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA

Introduction: We sought to evaluate the perceptions of third year medical students and second year pediatric residents of the clinical scope of a pediatric surgeon and determine the impact of a pediatric surgical clerkship on these views.

Methods: Over a two year period, 73 trainees (50 third year medical students and 23 second year pediatric residents) were given a multiple choice questionnaire surveying their views on the training and clinical scope of a pediatric surgeon.  The questionnaire was provided both before and after the 4-week clinical rotation. The trainees were queried as to what surgeon type would be expected to provide “surgical management” to several commonly seen surgical diagnoses at tertiary referral urban children’s hospital.  In addition, the questionnaire queried the participant’s expectations of the role of a pediatric surgeon in areas of postoperative management.  Descriptive and non-parametric analyses were used in the analyses of the data.

Results:Twenty-one,  (91%) pediatric residents reported having not rotated on a pediatric surgery service during their medical school training.  Forty-six (63%) trainees, prior to the rotation, correctly defined a pediatric surgeon’s training being a “2 year fellowship after completing a general surgery residency.”  Prior to the rotation, trainees opined  a pediatric surgeon would not be expected to manage many of the surgical conditions common to the field as noted in Figure 1.  The majority of trainees also answered that a nonsurgical physician or care-provider would be expected to manage a patient’s postoperative need for pain medication, antibiotics, or parenteral nutrition.  Following the rotation, as noted in Figure 1, trainees correctly identified a “pediatric surgeon” to manage those surgical diagnoses only managed by a pediatric surgeon (p<0.001) and answered that a “pediatric surgeon” would be expected to manage patients’ postoperative needs. (p<.0001).

Conclusion:Most trainees would not expect a pediatric surgeon to manage many of the surgical conditions common to the field.  Exposure to the clinical scope of a pediatric surgeon during a clinical rotation appears to modify the trainee’s views significantly and may prove vital to the success of pediatric surgery as a subspecialty.  Awareness of trainees’ perceptions will assist  pediatric surgical educators with designing experiences that promote a broad knowledge, appreciation and interest in the field.

76.15 Working at home: A qualitative study of general surgery residents

Posted on December 22, 2014

F. G. Javier1, L. S. Lehmann4, M. J. Erlendson1, K. A. Davis2, M. R. Mercurio3, C. Thiessen2  1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 3Yale University School Of Medicine,Department Of Pediatrics,New Haven, CT, USA 4Brigham And Women’s Hospital,Department Of Medicine,Boston, MA, USA

Introduction: Electronic medical records (EMRs) have emerged as residents face increasing duty hour restrictions. EMRs allow residents to perform patient care work at home. Our study investigated this work-shifting phenomenon.

Methods: We conducted semi-structured interviews of general surgery residents. We randomly selected one intern and one chief resident at each of 13 participating US programs and invited them to complete a 20-30 minute telephone interview. We asked about EMR access; frequency and magnitude of, type of, and reasons for work at home; and whether residents included work at home in their recorded duty hours. Interviews were recorded, transcribed, and coded using an iterative major and minor coding process in Dedoose.

Results: Fourteen surgery residents from 11 US programs completed interviews (8 interns, 6 chiefs, 6 women, 8 men). All participants had remote access to their institution’s EMR and all reported working at home at least occasionally. The majority (12/14) reported working at home for approximately 5 hours per week (range 15 minutes-20 hours). They checked patient’s labs and results (14/14), prepared for cases (11/14), and reviewed charts before new rotations (11/14). Most residents (11/14) expressed the “need to get out of the hospital…take a break and just finish things later on in the evening.” Half preferred the comfort of home: “It’s just more relaxed. If it’s at the end of the day and there’s some paperwork, I’d rather not do it at the hospital, I’d rather do it in my pajamas in my bed.” Working at home “because they can’t get the full job done at the hospital” or to finish work that “gets pushed off things like dictations…patient notes” was a common theme (7/14). Review of labs and results was often prompted by a sense of responsibility for patient care or “out of a personal curiosity that that patient had not done well during the day and I was wondering how they were going to do at night.” Many residents invoked work at home as training for becoming an attending. Working at home was “just part of being a physician”: “as an attending, you’re always on pager call…you need to be aware of what’s going on and checking in on your patients.” This perception was reinforced by “hav[ing] seen our attendings do it” and the fact that they “ended up getting quite a few home calls” because “attendings don’t always know when we’re in the hospital or not.” No participant recorded work at home in their duty hours. Most felt that “it’s not in-hospital work.” Many stated that their work at home was too little or too much to count.

Conclusion: Our results indicate that general surgery residents often work at home to follow-up on patients or complete required documentation, without counting this time as duty hours. Working at home is primarily driven by professionalism and preference. The extent of working at home is not yet fully recognized; institutional and ACGME policies responsive to work-shifting should be developed.

76.16 Resident Perceptions after the Acquisition of a Community Surgery Residency by a University Program

Posted on December 22, 2014

J. J. Tackett1, W. E. Longo1, A. H. Lebastchi1, G. S. Nadzam1, R. Udelsman1, P. S. Yoo1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction:
Attitudes, career goals, and educational experiences of general surgery residents are profiled during the acquisition of a community residency program by an academic residency program.

Methods:
The study population includes all general surgery residents PG2-5 in a tertiary academic medical center divided into community program matriculates (CPM) or academic program matriculates (APM). A survey compared perceptions before and after residency amalgamation in seven training categories: relationships among residents, relationships with faculty, systems interactions, clinical training, surgical training, scholarship, and career plans. Responses were recorded on a Likert scale. Fisher’s exact test and one-sided t-test were applied.

Results:
Thirty-five trainees (83%) participated. There were 23 APM (66%) and 12 CPM (34%).  Neither cohort reported significant perceptions of negative effects regarding surgical training, career planning, or scholarship (p>0.05).  There was a greater likelihood of significant negative perceptions regarding inter-resident relationships among CPM (p<0.05). CPM perceived significantly improved opportunities for scholarship (p<0.01) and nationwide networking through faculty (p<0.05) after acquisition. There was a nearly-significant trend toward CPM perceiving greater access to competitive specialties after acquisition. Overall, CPM perceptions were affected more often after acquisition; however, when affected, the APM were less likely to be positively affected (Odds Ratio 2.9).

Conclusion:
Acquisition of a community surgery residency by an academic program does not seem to negatively affect trainees’ perceptions regarding training. The effect of such acquisition on Community Program Matriculates decision to pursue competitive fellowships remains ill-defined, but Community Program Matriculates perceived improved research opportunities, faculty networking, and programmatic support to pursue a career in academic surgery.
 

76.17 The Role of International Electives in a Surgical Residency Program

Posted on December 22, 2014

M. A. Boeck1,3,4, Y. Woo1, A. L. Kushner1,3,4, T. D. Arnell1, M. A. Hardy1,4  1Columbia University Medical Center,Department Of Surgery,New York, NY, USA 3Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA 4Surgeons OverSeas (SOS),New York, NY, USA

Introduction:  General surgical care is critical for adequate healthcare delivery around the world. With training in North America increasingly focused on surgical specialization, international electives during residency enable future surgical leaders to return to the foundations of general surgery. The validation of international rotations by the American Board of Surgery (ABS) and ACGME Residency Review Committee (RRC) in 2011 formalized this effort. Despite this, and ample evidence of resident and program director interest, the number of such electives remains relatively limited. Here we present the evolving international surgical elective experience at New York Presbyterian Hospital-Columbia.

Methods:  From 2008 – 2013 categorical senior general surgery residents participated in non-ACGME RRC accredited international surgical electives, selected jointly by the program director and participant. Prompt post-rotation analyses, combined with a recent anonymous survey, were reviewed to effectively evaluate and improve the program.

Results: A total of 13 international electives at 8 sites (Brazil, Ethiopia, France, India, Israel, Kenya, S. Korea and Thailand) were completed since 2008, with 0-4/7 (mean=2) residents participating per year, each for a period of 6-8 weeks. The Graduate Medical Education office and the Department covered salaries and other expenses, respectively. Perceived strengths included adaptation to the use of limited resources, open surgeries, significant supervised operative autonomy, advanced disease presentations, honing physical exam skills, and teaching prospects at all levels. Criticisms focused on large variations in case volume, limited operating room involvement, language barriers hindering patient and staff interactions, inadequate guidance on living logistics, and a lack of adequate medical and leisure supplies. 100% (7/7) survey respondents would repeat the experience if given the opportunity, with the same number expressing a continued interest in global surgical work due to the elective.

Conclusion: Some residency programs affiliate with one international location, minimizing the importance of resident preference for site selection. Columbia’s approach, despite challenges in creating multiple, concurrent surgical international electives, is favored by the residents. Site inspections by a faculty member, including evaluation of projected case volume, level of supervision, degree of clinical involvement, language proficiencies, potential for research, and bidirectional exchange, are essential. Further reflection is needed to ensure educational, mutually beneficial, sustainable, standardized rotations. The potential returns and effects on career trajectories are undeniable, providing incentive for program directors to strongly consider making international rotations available to trainees.

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