18.14 Surgical Residents Wellbeing and Life Satisfaction: A description of general surgery residents’ lifestyle.

Posted on January 18, 2018

O. O. Osuchukwu1, J. Tieman1, H. McClafferty2, M. Chang1, C. Coverley1, D. Cole1, T. S. Riall1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA 2University Of Arizona,Arizona Center For Integrative Medicine,Tucson, AZ, USA

Introduction:

A negative impact on lifestyle has been cited as one of the reasons for the declining popularity of general surgery residency and poses a challenge in maintaining general surgery workforce.  While burnout amongst surgical residents has been clearly documented, few studies formally evaluate general surgery residents’ lifestyle habits. Our goal was to describe surgical residents’ lifestyle to guide interventions for improving resident wellbeing. 

Methods:
In July 2016, our General Surgery residency program started the “Energy Leadership Resiliency and Wellbeing Program.” As part of the program, residents took the validated Arizona Lifestyle Inventory. This descriptive study provides information about resident sleep, eating habits, pain, and stress relieving activities.

Results:

49 of 50 general surgery residents participated in the program (PGY1=19, PGY2=8, PGY3=7, PGY4=8, PGY5=7).  28.6% were female, 89.8% were 25-34 years old. 38.1% were married, 11.9% were unmarried but living with partners, and 50% were single. Pain was common with 23.8% reporting pain >3 days/week. 69.8% of residents eat 5 or more fruits and vegetables >3 days/week and 25.6% eat breakfast every day. Caffeine consumption was high, with 66.7% of consuming caffeine 7 days/week. One quarter (25.5 %) of residents in this program slept for 9 hours >3 days/week. Moreover, only 38.1% reported feeling rested after sleep. 44.2% of residents participated in stress reducing activities >3 days of the week; these activities were varied across residents and included time with family, church, meditation, playing video games, fishing, sports (basketball, running, swimming), listening to music, cooking and sleeping. Deep breathing exercises were used by 20.9% of residents >3 days/week. 18.6 % do vigorous activities >3 days/week and 30.2% do moderate activity >3 days/week. The minority of residents (12.2%) was very or completely satisfied with their work-life balance or their health and wellness (24.5%). 

Conclusion:
While some residents maintain healthy lifestyles, the majority does not regularly participate in moderate or vigorous exercise, do not sleep regularly or well, and experience pain regularly. In addition, General Surgery residents are not satisfied with their health behaviors or work-life balance. These data have been used to design interventions to encourage healthy behaviors including physical activity challenges, healthy behavior challenges, and a variety of group activities that can serve to improve support and reduce stress for residents.

18.11 Five-year Audit of Trainee-focused Program for Surgical Management of Peritoneal Dialysis Catheters

Posted on January 18, 2018

V. Kurbatov1, C. Ibarra1, R. Haywood1, P. S. Yoo1  1Yale University School Of Medicine,General Surgery,New Haven, CT, USA

Introduction:
Laparoscopic peritoneal dialysis catheter (PDC) insertion has been determined to be the optimal method for establishing access for peritoneal dialysis. The modality allows direct intra-abdominal visualization and extraperitoneal tunneling, making it ideal for patients with significant obesity or intraabdominal adhesions.  Using a standardized and simplified surgical technique that eschews additional procedures such as omentopexy and extensive lysis of adhesions, we have developed a resident-led consulting service for laparoscopic peritoneal dialysis catheter insertion. Using a reproducible strategy, residents are trained to safely establish PDC access, ensure adequacy of function, and recognize and manage complications of PDCs.  

Methods:
We performed a 5 year retrospective chart review of a single surgeon’s experience supervising the resident-led service, as part of the transplant surgery rotation at a quaternary academic medical center. Under the direct supervision of a single attending surgeon, trainees performed all aspects of pre-operative, operative, and post-operative care.  Demographic and clinical data were collected to evaluate technical outcomes.

Results:
89 patients underwent laparoscopic primary placement of PDC. A 94.3% technical success rate at 60 days was achieved. 1-year and 2-year catheter technical success rates were 92.4% and 91.9%, respectively. 12.5% of patients required a repositioning procedure, obesity and history of previous surgery were more common in this group. Mean time to reposition was 224 days. 11.2% of patients underwent removal of PD catheter after renal transplantation.

Conclusion:
Our experience serves as a model for fostering surgical trainee expertise with laparoscopic peritoneal dialysis catheter insertion and management without sacrificing a high level of quality. Under the close supervision of an attending surgeon, clinical outcomes are comparable or superior to reported rates. Effective training of general surgery residents in laparoscopic peritoneal dialysis catheter insertion with standardized simplified technique is a key means to ensuring laparoscopic placement continues to be standard of care for peritoneal dialysis catheter placement.
 

18.12 How Well Would Digitally Native Surgery Residents Adapt to a Hospital Ransomware Attack?

Posted on January 18, 2018

J. Zhao1, E. Kessler1, C. Cooper1, J. Brewer1, S. Schwaitzberg1, W. A. Guo1  1State University Of New York At Buffalo,Buffalo, NY, USA

Introduction:  A ransomware attack during the spring of 2017 shut down all hospital-wide health information systems at an academic-affiliated tertiary referral and adult level I trauma center for two months. We used this unique opportunity to investigate the adaptability of modern day general surgery residents when faced with an abrupt shutdown of access to electronic medical records (EMR) and internet.

Methods: All surgical residents who had rotated at the affected hospital during the cyberattack were invited to complete a survey about their experience. Participants responded to 15 Likert scale format questions regarding their attitude toward medical record documentation, order placement, communication, and information access during the downtime. Semi-structured interviews were also conducted with 10 residents with representation from all year groups and with 5 attending surgeons to explore the downtime impact on surgical education in greater detail. A grounded theory approach was used to analyze the transcriptions.

Results: A total of 18 residents responded to the survey with a response rate of 85.7%. As shown in the table, face-to-face communication significantly increased, while access to online educational resources significantly decreased during the cyber attack. The ordinal logistic regression model revealed that level of post-graduate years (PGY) was a predictor of stress in daily order placement without an order set (OR 2.55, 95% CI 1.24-5.25, p=0.005).  However, there is no significant association between the PGY level and medical record documentation. Interviews with residents and attendings revealed that surgical residents adapted better than expected to the abrupt loss of EMR access. Recurrent themes were that surgical residents worked excellently as a team, were proactive, and managed their time well at baseline; these skills came to the forefront during the downtime. Furthermore, attendings continued to view surgical residents as competent, since operative ability was gauged exclusive of the EMR.      

Conclusion: Our study demonstrated that surgical residents adapted well to an unexpected shut down of the hospital computer system due to a ransomware attack, despite the necessary increase in face-to-face communication and dearth of online educational resources. Our study refutes the common misconception that digitally-native Millennials lack the adaptability to handle a paper-based system. With the increasing level of cyber security threats in healthcare, preparedness should be included in the GME curriculum.

 

18.09 Measuring Burnout in Surgical Residents: Do Traditional Indices Accurately Represent The Issue?

Posted on January 18, 2018

C. R. Coverley1, J. Tieman1, M. Chang1, D. Cole1, O. Osuchukwu1, T. S. Riall1  1Banner University Medical Center – Tucson – Banner Health,Surgery,Tucson, AZ, USA

Introduction: Burnout poses a significant threat to the surgical workforce and has been shown to affect surgeons-in-training. In studies assessing burnout in residents, surgeons, and physicians, physicians are classified as “burned out” if they meet criteria on any one subscale of the Maslach Burnout Inventory (MBI) – Emotional Exhaustion (EE), Depersonalization (DP), or Personal Accomplishment (PA). These criteria have been criticized as potentially over representing true burnout. Our goal was to evaluate resident burnout based on these criteria and to correlate these with other measures of life satisfaction and wellbeing.

Methods: In 2016 we instituted the Energy Leadership Resiliency and Wellbeing Program as part of the formal training experience for our general surgery residents. We compared residents who met the criteria for burnout in one or more of three subscales of the MBI with resident-reported satisfaction in 14 different areas of life as measured by the validated Energy Leadership Index (ELI). These areas were: Financial Success, Leadership, Work Relationships, Family Relationships, Intimate Relationships, Engagement at Work, Personal Freedom, Communication, Productivity, Time Management, Work-Life Balance, Health and Wellness, Energy Level, and Spiritual Satisfaction. We then compared satisfaction in the 14 areas in residents who did or did not meet criteria on one, two, or all three subscales.  

Results: Forty-three surgical residents, 30.2% female and 69.8% male, completed the MBI and ELI. 53.5% of our residents met criteria for burnout on at least one subscale of the MBI; 41.9% met criteria on 2 subscales, and 7.0% met criteria on all 3 subscales. Our analysis demonstrated that residents who met the definition of burnout in one subscale had decreased satisfaction in almost all surveyed areas. They also had higher perceived stress levels, higher depression rates, and lower wellbeing overall as measured by the Physician Well Being Index (PWBI) (Table). The percent of residents Very Satisfied or Completely Satisfied in each area uniformly decreased as the number of burnout subscales that were positive increased.

Conclusion: Our hypothesis explored the possibility that traditional MBI measures may not take into account the multifaceted nature of a rigorous surgical training experience and may overestimate true burnout. The results of our analysis highlight the validity of the MBI as a measure for identifying residents who already are displaying symptoms of burnout and dissatisfaction in multiple areas of their lives. Identifying surgical residents at risk and reaching out through implementation of formal wellbeing programs will play a critical role in training a resilient, productive, and professionally satisfied surgical workforce.

18.10 Does Resident Competition Within Question Banks Affect ABSITE Scores?

Posted on January 18, 2018

K. Hudak1, J. Porterfield2, H. Chen2, J. White2  1University Of Alabama At Birmingham,School Of Medicine,Birmingham, AL, USA 2University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction: Technology-driven online educational tools have expanded educational opportunities for surgical residents beyond the traditional formats. We sought to evaluate changes in American Board of Surgery In-Training Exam (ABSITE) percentage scores with participation in a competitive software-based question bank.

Methods: We designed a novel software program at our institution, which utilizes a gamified web-based competition to encourage participation in general surgery question banks. Questions were designed and evaluated by surgical faculty members. General surgery residents at a large academic medical center who participated in the ABSITE exam during 2016 and 2017 were given the option to participate in question-based competition rounds. We analyzed the percent correct score increase in ABSITE scores for participants and non-participants.

Results: Thirty residents completed the ABSITE exam in both 2016 and 2017. Twenty-two residents participated in the question gaming platform.  Participants averaged 20.8 percent completion of the extensive question bank. The average ABSITE score percentage for participants was 73.4 percent correct, while non-participants averaged 71.6 percent correct. The average ABSITE score percent increase from 2016 to 2017 was calculated for both participants and non-participants (3.25% vs. -0.28%).

Conclusion: Surgical residents at our institution who participated in our gamified surgical knowledge competition, on average increased their ABSITE score relative to non-participants. This suggests that incorporation of this novel educational tool is a method for improving general surgery resident performance on the ABSITE.

 

18.07 Surgical Resident Use of Google™ and YouTube™ for OR Preparation

Posted on January 18, 2018

A. Khalifeh1, B. Buckingham1, R. Kantar1, E. Reardon1, S. Kidd-Romero2, K. Luumpkins2, S. M. Kavic2  1University Of Maryland Medical Center,Department Of Surgery,Baltimore, MD, USA 2University Of Maryland,School Of Medicine,Baltimore, MD, USA

Introduction:
Information in surgical training has expanded beyond print books to include various electronic and internet resources. We aimed to evaluate the use of online information in a surgical residency.

Methods:
A survey was distributed to 52 general surgery residents (preliminary and categorical) at an academic medical center in April 2017.  This study was deemed exempt from IRB review. The survey explored demographics, social media literacy, use of print and internet sources in preparation for the operating room (OR), use of smartphones in patient care in addition to residents’ perception of internet sources.  The survey questions were structured using a Likert-type scale and results were analyzed using Fischer’s t-test. 

Results:
Forty-two residents returned completed surveys, 81% response rate. The mean age was 31 years, and 50% of the respondents were female. Residents frequently used print books, electronic books (e-books), YouTube, Google, and other web sources in preparation for the OR. The majority frequently accessed information from their smartphones. When analyzed per academic year, senior residents were more likely to use print books; while juniors were more likely to use e-books, YouTube and Google. While most residents agreed that the digital era made access to information easier, they were skeptical about the reliability of some internet sources.

Conclusion:
The majority of modern surgical residents access e-books and other internet sources. Interestingly, as residents progress in their training there is a trend to prefer print books rather than internet resources when preparing for the OR. 
 

18.08 Innovative Teaching Strategies for Surgery Resident Education Sessions

Posted on January 18, 2018

A. Awe1, M. Burger1, A. C. Abrams1, G. Caldito1, Q. Chu1, N. Samra1  1Louisiana State University Health Sciences Center- Shreveport,General Surgery,Shreveport, LA, USA

Introduction:

Recently a direct effort has been made by faculty and residents to explore ideas that effectively help improve resident education in preparing for the ABSITE and ultimately surgical board exams. The idea that our resident education faculty adopted was instead of lecturing with PowerPoint presentations on SCORE curriculum topics a pre-lecture activity (PLA) with high-yield questions and concepts surrounding a topic was used as a tool to teach. This innovative teaching strategy used in the setting of resident protected didactic sessions was birthed from the principles of the cognitive load theory. The idea was created to foster a more enjoyable active learning environment during these weekly 30 minute sessions.

Methods:

This project was designed to analyze the preference of the residents about the new teaching approach with PLA in comparison to the previous teaching style with PowerPoint presentations during our weekly didactic session. Our null hypothesis states the residents would not prefer the PLA approach for our weekly didactic sessions and prefer being lectured using PowerPoint presentations alone. We conducted a four question Likert Scale survey among 27 surgical residents to determine their preference. To analyze the survey results, the one-sided Z-test for a proportion was used to test our research hypothesis. To reject our null hypothesis the proportion of residents who would either “Strongly Agree” or “Agree” to each of the questionnaire items would be greater than 50%.

Results:
All 27 residents completed the survey anonymously. The majority of residents (88.9%) agree or strongly agree that having a PLA was more useful in comparison to using online portal from SCORE to prepare for didactic session. (Z- 4.06, p value <0.001). Additionally, 66.67% of residents strongly agree or agree the discussion of high yield score topics from PLA is more beneficial than a lecture about topic via a PowerPoint presentation. (Z- 1.74, p value <0.041). More than half (55.56%) strongly agree or agree during their independent study using notes from discussion of PLA was more helpful than having a copy of a PowerPoint presentation with a third (33.33%) being undecided and (11.11%) disagreeing or strongly disagreeing (Z- 0.58, p value 0.281). Lastly, 78% of residents want to continue with PLA as opposed to being lectured with PowerPoint presentations alone (Z- 2.89, p value 0.002).

Conclusion:
Using Items 1 to 4 in the Likert Survey completed by the surgical residents we were able to measure a resident’s preference for the use of PLA over the use of lectures using PowerPoint during didactic sessions. Our survey results indicate preference for PLA by more than 50% for Items 1, 2 and 4 with statistically significant p values. We were able to reject our null hypothesis for all items except for Item 3. With these results we see a preference by the residents for PLA to be used to assist with preparing for weekly didactic sessions.

18.02 Barriers to Reporting Needlestick Injuries Among Surgical Residents

Posted on January 18, 2018

K. Kapp1, M. Mendez1, A. Bors1, R. Corn1, F. Sharif1, F. Alemi1  1University Of Missouri Kansas City,Department Of Surgery,Kansas City, MO, USA

Introduction: The Centers for Disease Control estimate there are over 300,000 needlestick injuries in the US each year (with 23% occurring in the operating room) resulting in productivity loss of $82.2 million.  The Accreditation Council for Graduate Medical Education data demonstrated 99% of residents had at least one needlestick by their final year of training with over half going unreported and 16% involving patients with HIV, Hepatitis B, Hepatitis C, or history of IV drug use.  Morbidity from needlesticks has devastating effects on surgeons both personally and financially.  The purpose of this study is to evaluate barriers to residents disclosing injuries to their healthcare system so that efficient means of reporting can be proposed to improve processes since early reporting leads to post-exposure prophylaxis and treatment decreasing sero-conversion and chronic infection.

Methods: An anonymous survey was distributed in person among residents of surgical specialties during didactic sessions.  Survey items canvassed included post-graduate training year, number of past needlesticks, facility location of occurrence, activity during occurrence, number of needlesticks reported, who they reported to, barriers to reporting including knowledge of how to report, time of day, fear of repercussions, previous poor experience, severity of injury, fear of or lack of confidentiality, bother to the patient, perceived low risk of disease transmission, estimated time away from clinical activity for reporting, overall personal experience in reporting, and whether they would report a future injury based on prior experience.  Data was analyzed with comparisons made between specialties.

Results:Surveys yielded responses from 76 residents in 6 surgical subspecialties.  Most needlestick injuries occurred in the Operating Room or Emergency Department.  70% of residents had a needlestick with 14% of injuries never being reported.  Forty-five percent of residents reported needlesticks less than 75% of the time.  Top reasons residents didn't report include:  Process is too time consuming, Lack of time, and Patient appeared low risk.  The majority estimated time away from clinical activity was 30-120 minutes.

Conclusion:Needlestick injuries are underreported by surgical residents nationally and in our institution with the main barrier to reporting being time constraints. Despite measures to improve safety and decrease the occurrence, the CDC reports needlestick injuries in the OR have increased by 6.5%.  Delayed reporting causes significant morbidity resulting in personal and financial harm to surgical residents.  Streamlining the process particularly the paper work by giving resident Occupational Health education during orientation and providing surgeons with reporting packets at the beginning of each academic year with basic resident and facility information prefilled to save time may increase needlestick injury reporting by surgical residents.

 

18.03 Women in Surgical Academia: Is Underrepresentation due to Lack of Competitive Inflow?

Posted on January 18, 2018

M. D. Moore1, K. D. Gray1, J. Abelson1, D. Fehling1, T. J. Fahey1, T. Beninato1  1Weill Corenll Medicine,Surgery,New York, NY, USA

Introduction: One of the goals of academic general surgery (GS) residency programs is to train future academic surgeons.  Women representation in surgical academia remains low despite the near-equilibration of men and women entering medical school and the increase in woman applicants to GS residency.  A correlation between high rank position and pursuit of an academic career among applicants to an academic GS residency program has been previously shown.  We aimed to elucidate if underrepresentation of women in academic surgery is due to gender disparity in applicants to an academic GS residency program and their position on the rank list.

Methods: Rank lists at an academic GS program were used to determine proportion of female ranked candidates from 1992-2016. The lists were further examined to determine proportion of women ranked in the top 20 positions.  The proportion of women enrolled in GS programs nationwide during the same time period was determined using available JAMA GME annual reports.

Results: Twenty-five rank lists with 2231 candidates (621 females, 1610 males) were evaluated.  The proportion of women candidates ranked increased from 24% in 1992 to 46% in 2016 with a maximum of 46% in 2016. The percentage of women enrolled in GS residency nationwide increased during that time from 16% to the current high of 39%. In the years 1992-1994, 1997, and 2006, a significantly higher percentage of women were ranked by our program than the percentage of women who were enrolled in GS programs nationally.  In the remaining years, the proportion ranked by our program was similar to the national applicant pool. The proportion of women ranked in the top 20 was no different than the proportion of women on the entire rank list.

Conclusion: The proportion of female applicants to a single academic GS program has either exceeded or paralleled national trends in proportion of women enrolled in surgery programs.  Similar proportions of women were ranked competitively in the top 20 positions.  Underrepresentation of women in surgical leadership positions does not appear to be due to a lack of inflow of qualified, competitive female candidates.

 

18.01 A Competency-Based Curriculum to Teach and Assess the Fundamental Skills of Open Surgery (FSS)

Posted on January 18, 2018

J. W. Menard1, F. Shariff1, W. Goering1, A. Deladisma1, R. Damewood2, D. S. Lind1  1University Of Florida-Jacksonville,General Surgery,Jacksonville, FL, USA 2Wellspan Health York Hospital,General Surgery,York, PA, USA

Introduction: While modular curricula exists to teach/assess the fundamentals of laparoscopic (FLS) and endoscopic (FES) surgery, no similar curriculum exists for the fundamental skills of open surgery (FSS). Therefore, we describe our efforts to create, validate and distribute a competency-based curriculum to teach/assess the basics skills of open surgery.

Methods: Using a modified Delphi approach, we created a 15-point binary checklist for the steps required to open and close an abdomen. Construct validity was then determined by videotaped assessment of novice and experts performing a laparotomy on a simulated model (Simulab Corporation, Seattle, WA). We then developed a comprehensive, competency-based curriculum regarding the knowledge/skills required for open surgery. Finally, to facilitate distribution, we employed an innovative, web-based platform (ApprenNet) to provide learners with on-line content, video-based evaluation and expert feedback (see Figure 1).

Results: Using a 15-point binary checklist, experts performed significantly better than novices on the simulated abdomen (0.88 vs. 0.27; p=0.06). The FSS curriculum has been successfully implemented in 7 general surgery residency programs at the PGY1/2 level (N=110). For distant learning, we effectively employed an app-based, educational platform (ApprenNet). Learners used the app to record/submit their simulated laparotomy using their personal smart-devices. 

Conclusion: We have successfully created, validated and distributed a competency-based curriculum to teach/assess the fundamental skills of open surgery (FSS). Similar to FLS/FES, general surgery training programs should require all residents to successfully complete the FSS curriculum.

 

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