80.10 Nanoscale-based Approaches to Non-viral Reprogramming of Surgically Accessible Tissues

Posted on January 18, 2018

N. Higuita-Castro1,2, C. Wier3, J. Moore1,2, S. Duarte-Sanmiguel2,5, A. Sunyecz1, C. K. Sen1, S. J. Kolb3,4, D. Gallego-Perez1,2  1The Ohio State University,Department Of Surgery,Columbus, OHIO, USA 2The Ohio State University,Department Of Biomedical Engineering,Columbus, OHIO, USA 3The Ohio State University,Department Of Neurology,Columbus, OHIO, USA 4The Ohio State University,Department Of Biological Chemistry & Pharmacology,Columbus, OHIO, USA 5The Ohio State University,OSU Nutrition,Columbus, OHIO, USA

Introduction: Autologous tissue reprogramming has the potential to enable a myriad of highly promising cell therapies. Status quo methodologies for tissue reprogramming, however, face numerous hurdles, including heavy reliance on viral infection, and a highly stochastic nature among others. We developed a novel nanotechnology-enabled platform to reprogram surgically accessible tissues (i.e., virus-free) in a highly deterministic and benign manner. Such an approach was demonstrated in mice using peripheral nerve, spinal cord, brain, skeletal muscle and subcutaneous fat as model tissues. 

Methods: Cleanroom-based manufacturing was used to nanofabricate miniaturized devices for nanochannel-mediated reprogramming factor delivery into surgically accessible tissues of adult mice. Such channels were used to controllably nanoporate the cell membranes and electrophoretically drive a wide variety of reprogramming factors into the tissue cells in a highly controlled manner. Delivery efficiency, cargo uptake dynamics and reprogramming outcomes were assessed via immunofluorescence microscopy and qRT-PCR. 

Results: Tissue sections collected immediately after transfection revealed successful cytosolic cargo delivery following the implementation of a millisecond-long pulsed electric field. No adverse behavioral effects were noted in mice that underwent the transfection procedure. Immunofluorescence analysis and qRT-PCR confirmed strong gene expression in the targeted tissues. Localized delivery of reprogramming factors led to the conversion of support tissue stroma into functional tissue parenchyma of various types depending on the nature of the reprogramming factors. 

Conclusion: We developed a novel and straightforward approach to controllably transfect and modulate the fate of surgically accessible stromal tissue using a nanofabricated chip platform. Preliminary findings support the feasibility of non-viral gene delivery to targeted tissues and subsequent stromal reprogramming.  Ongoing studies are currently focused on developing reprogramming-based autologous cell therapies conducive to tissue regeneration following focal injury.

 

80.08 Viscoelastic Clot Strength Correlates to Hypercoagulable Conditions Under Flow Model of Hemostasis

Posted on January 18, 2018

P. J. Lawson1, H. B. Moore1, E. E. Moore1, M. E. Gerich1, G. R. Stettler1, A. Banerjee1, J. A. Schoen1, R. D. Schulick1, T. L. Nydam1  1University Of Colorado Denver,Aurora, CO, USA

Introduction:
Elevated clot strength (MA) measured by thrombelastography (TEG) is associated with thrombotic complications. However, it remains unclear how MA translates to thrombotic risks, as this measurement is independent of time and blood flow. We hypothesize that under flow conditions, increased clot strength correlates to time dependent measurements of coagulation.

Methods:
Surgical patients at high risk of thrombotic complications were analyzed with TEG and T-TAS (Total Thrombus-formation Analysis System). TEG hypercoagulability was defined as an R<11.2min, Angle>49, MA>60 or LY30<0.9% (based off of healthy control data, n=160). The platelet chip (PL) of T-TAS was used to measure clotting at arterial shear rates. PL measurements include: occlusion time (OT), occlusion speed (OSp), and total clot generation [area under the curve (AUC)]. These measurements were correlated to TEG indices.

Results:
Thirty patients were analyzed. 56% had TEG detected hypercoagulability based on R, 63% angle, 73% MA, and 64% LY30. When correlated to PL chip output, only the MA significantly correlated to OT (Rho -0.418 p=0.022), OSp (Rho 0.446 p=0.014), and AUC (Rho 0.439 p=0.015). Hypercoagulability defined by MA was associated with significantly decreased OT (4:06 min vs 6:42 p=0.016), faster OSp (21 kPA/min vs 11 p=0.014), and increased clot generation (AUC 430 kPKA*min vs 350 p=0.035). Other TEG variables were not associated with PL measurements.

Conclusion:
Clot strength measured by TEG correlates to flow measured coagulation changes, and is consistent with clinical data implicating MA with thrombotic events. This in vitro data supports feasibly using MA or T-TAS PL to guide the treatment of hypercoagulability with antiplatelet medication, and warrants prospective evaluation.

8.10 Variation in supply cost for appendectomy and cholecystectomy across a healthsystem.

Posted on January 18, 2018

M. E. Mallah1, M. Barringer2, M. E. Thomason1, E. Ross3, B. Matthews1, C. E. Reinke1  3Carolinas Healthcare System,Cost Analytics,Charlotte, NC, USA 1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA 2Carolinas Medical Center-Cleveland,Shelby, NC, USA

Introduction: Supply cost variation for surgical procedures is poorly described in the literature.  Prior studies have demonstrated that implementation of a standardized preference card was able to reduce costs.  Our aim was to describe variation in supply cost across a cohort of surgeons within a large healthcare system.  

Methods: Cost of operative supplies is prospectively recorded for all cases.  Total operating room supply cost was calculated for all laparoscopic appendectomy and laparoscopic cholecystectomy cases performed between January 2016 and June 2017.  Other variable and fixed operating room costs were not included. The primary surgeon was identified for each case and the number of cases and mean cost per case was calculated per surgeon.   Surgeons who had performed less than 5 cases in either category during the 18-month period were excluded from that analysis.  

Results:Across 8 facilities in our healthcare system 3,250 cholecystectomies and 1,678 appendectomies were performed by 79 surgeons over an 18-month period.  Low volume surgeons were excluded (16 for cholecystectomy, 18 for appendectomy).  Mean OR supply cost was $528 for a cholecystectomy (mean cost/surgeon ranged from $303-1091) and $885 for an appendectomy (mean cost/surgeon range $585-1374).  There was significant variation by surgeon, with the mean cost/case for the most expensive surgeon being more than three times more expensive than the lowest cost surgeon for a cholecystectomy and almost more than 2 times as much for a cholecystectomy.  Surgeon volume was not significantly correlated with mean cost (Figure 1, p>0.05 for both).  Increased OR supply cost was significantly associated with increased OR time for cholecystectomies (p<0.01) but not for appendectomies (p=0.44).  

Conclusion:We identified wide variation in mean supply cost per case for laparoscopic appendectomies and laparoscopic cholecystectomies across a large healthcare system.  Higher cost cases were associated with longer operative time for cholecystectomies but not appendectomies.  Future studies to assess methods to decrease variation and the effect of operating room supply cost on patient outcomes are needed.

 

8.11 Surgical Cost Correlation within Hospitals

Posted on January 18, 2018

S. P. Shubeck1,2,3, U. Nuliyalu3, J. B. Dimick1,3, H. Nathan1,3  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 3University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA

Introduction: The Centers for Medicare and Medicaid Services have implemented many bundled payment programs focused on reducing the costs of specific surgical procedures or service lines. These bundled payment models hold hospitals accountable for the costs of entire episodes of surgical care, thereby encouraging efficiency and cost containment. However, little is known about whether hospital costs across different procedures are correlated. If so, hospital-wide efforts to improve efficiency might be useful; if not, these efforts would need to be targeted and service-specific. We therefore sought to determine the degree of cost correlation for surgical procedures within hospitals.  

Methods: Using 100% Medicare claims data for 2010-2013, we identified patients aged 65-99 years undergoing elective surgical procedures including: colectomy, proctectomy, coronary artery bypass grafting (CABG), total hip replacement (THR), total knee replacement (TKR), esophagectomy, pancreatectomy, and abdominal aortic aneurysm repair (AAA). We calculated price-standardized, risk-adjusted Medicare payments for the entire “surgical episode” from the index admission through 30 days after discharge. The average cost for each procedure at each hospital was then calculated. We quantified cost associations between procedures for hospitals in the highest quintile of spending using Kappa statistics, ranging from 0-1, that take into account the possibility of agreement by chance alone. 

Results: This study included 3530 hospitals performing colectomy, 2399 performing proctectomy, 1158 performing CABG, 3176 performing THR, 3390 performing TKR, 792 performing esophagectomy, 875 performing pancreatectomy, and 1645 performing AAA. Hospitals in the highest quintile of costs in one procedure were seldom high-cost in others. As expected, clinically unrelated procedures had weakly related costs (pancreatectomy and esophagectomy, K=0.12; proctectomy and TKR, K=0.06; esophagectomy and AAA, K=0.01, Figure 1A). Surprisingly, even some clinically similar procedures demonstrated only moderate cost relationship, such as colectomy and proctectomy (K=0.16,  Figure 1B). The strongest relationship was found for THR and TKR, K=0.5 (Figure 1C). 

Conclusion: We found that almost all procedures included in this study had weak cost relationships with other common procedures. The main exception to this finding was THR and TKR. Our findings suggest that broader inferences about hospital efficiency cannot be based on the institution’s performance in a single surgical procedure or service line. Additionally, initiatives to reduced surgical spending that are targeted at certain procedures are unlikely to have spillover effects on unrelated procedures in the same hospital.

 

8.07 Time is Money-Quantifying Savings in Outpatient Appendectomy

Posted on January 18, 2018

E. T. Bernard1, D. L. Davenport1, B. Benton1, A. C. Bernard1  1University Of Kentucky,General Surgery,Lexington, KY, USA

Introduction:  Recent evidence suggests laparoscopic appendectomy can be performed on a fast-track, short stay, or even outpatient basis. This outpatient appendectomy protocol has been proven to provide high success rates, low morbidity, and low readmissions rates, in addition to a shorter length of hospital stay. Cost savings from outpatient appendectomy have not been reported in the United States. We hypothesize that outpatient laparoscopic appendectomy is associated with cost savings.

Methods:  We performed a retrospective analysis of patients undergoing laparoscopic appendectomy between July 2013 and April 2017 at our academic medical center before and after implementation of an outpatient protocol which began on January 1, 2016. We assessed direct costs (OR costs, ED costs, diagnostics, pharmaceuticals), indirect costs, net revenue, contribution margin, and net profit.

Results: The percent of PACU to home discharges increased from 3.4% during the pre-implementation period to 27.0% in the post-implementation period (Chi-square P < .001). The proportion of inpatient and post-OR observation cases decreased by 12.1% and 5.4% respectively. On average, the PACU to home group had a total hospital cost of $4,734 versus $5,787 in the post-OR observation group, for savings of $1,053 per patient. Before and after implementation of the protocol, the average total observation time (pre and post-OR) decreased by 4 hours in those placed in observation post-OR, by 3 hours in those discharged from PACU and 1 hour in those admitted: across all groups total observation time decreased by 2 hours on average (P<.001).

Conclusion: Outpatient appendectomy is associated with approximately $1,000 cost savings per patient. Implementation of an outpatient appendectomy pathway is likely to effect gradual results, but improved resource utilization should occur immediately with respect to shorter observation hours, even for those who are assigned a bed. Considering previous reports that have established safety of the laparoscopic outpatient appendectomy method, our data strongly support widespread implementation of an outpatient appendectomy protocol. 

 

77.04 Racial and Ethnic Disparities in Promotion and Retention of Academic Surgeons

Posted on January 18, 2018

G. Eckenrode1,2, M. Symer1, J. Abelson1, A. Watkins1, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy,New York, NY, USA

Introduction: Racial and ethnic diversity is low in academic surgery, especially in leadership positions. However, no study has quantified differences in the rates of retention and promotion of racial and ethnic minority surgeons in academia. We used the American Association of Medical Colleges (AAMC) Faculty Roster to track a large cohort of academic surgeons and evaluate their rates of promotion and retention by race.

Methods: The AAMC Faculty Roster is a comprehensive database which aggregates national, longitudinal data on academic faculty. All first-time assistant and associate professors appointed between January 1, 2003 and December 31, 2006 in surgery were included. Individuals were followed for up to 10 years from their initial appointment; until they were promoted, stayed at their current rank, or left full-time academia. Faculty who switched institutions were included in the analysis. Log-rank test was used to determine the impact of race and ethnicity on promotion (increase in academic rank) and retention (persistence in academic surgery regardless of rank). Individuals of Black, Hispanic, or Other race/ethnicity (such as American Indian or other/multiple/unknown) were grouped due to data limitations. 

Results:There were 3,966 academic surgeons who began academic appointments from 2003 to 2006, of whom 2,683 were assistant professors and 1,283 were associate professors. Faculty were predominantly White (n=2,617), followed by Asian (n=559), and Black, Hispanic, or Other race/ethnicity (n=790). There was a non-significant trend toward lower promotion of Black/Hispanic/Other assistant professors (Black/Hispanic/Other 26.7% promoted at 10 years, Asian 33.3%, White 34.4%, p=0.07). There was a similar difference in 10-year promotion rates of associate professors between these groups (Black/Hispanic/Other n=53, 28.8%; Asian n=43, 30.3%; White n=294, 30.7%; p=0.10). However, retention rates were significantly higher for White assistant professors (n=1,017, 61.3% retained at 10 years) than Asian (n=220, 52.8% retained) or Black/Hispanic/Other faculty (n=308, 50.8% retained; p<0.01). There was no significant difference in 10-year retention rates among associate professors based on race/ethnicity (Black/Hispanic/Other 71.2%, Asian 69.7%, White 69.3%, p=0.72).

Conclusion:Overall, promotion rates in academic surgery over a 10-year period were low, with a trend to lower rates among underrepresented minorities. In addition, there is a clear disparity in the retention of minority assistant professors of surgery. Other differences in the retention and promotion of minority faculty were not significant, possibly due to the small numbers of minority faculty even in this national study. Racial/ethnic minority faculty face unique barriers in remaining in academic surgery particularly at the start of their career. To build a diverse workforce in academic surgery, a renewed focus should be made on retaining early-career minority faculty.

77.02 Are Residents Really Burned Out? A Comprehensive Study of Surgical Resident Burnout and Well-Being

Posted on January 18, 2018

B. Hewitt1, J. W. Chung1, A. R. Dahlke1, A. D. Yang1, K. E. Engelhardt1, E. Blay1, J. T. Moskowitz2, E. O. Cheung2, F. R. Lewis3, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Northwestern University,Osher Center For Integrative Medicine,Chicago, ILLINOIS, USA 3American Board Of Surgery,Philadelphia, PENNSYLVANIA, USA

Introduction:  Despite great interest in resident wellness, little is known about actual rates of resident burnout as current data are limited by poor response rates, small sample sizes, or use of non-validated measures. Surgical residents are hypothesized to be at particular risk for burnout and poor well-being. We used novel national survey data with responses from nearly all U.S. general surgery residents to (1) examine burnout and poor well-being prevalence and (2) identify factors associated with burnout and well-being.

Methods:  All general surgery residents were surveyed (99% response rate) at the time of the January 2017 American Board of Surgery In-Training Examination (ABSITE) regarding wellness, duty hour violations, preparation for residency, and occupational safety. The main resident wellness outcomes were burnout (abbreviated Maslach Burnout Inventory – 6 items) and psychiatric well-being (General Health Questionnaire-12 which identifies those at risk for non-psychotic psychiatric illness). Hierarchical logistic regression analyses were performed to examine resident and program factors associated with burnout and well-being.

Results: Of 7,441 residents offered the survey, 7,387 residents (99.3%) in 260 surgical residency programs completed all items related to resident wellness. Overall, burnout was reported in 23.8% (n=1,756) of residents and poor psychiatric well-being in 44.3% (n=3,270). From the burnout assessment, 16.0% (n=1,184) of residents responded that they “do not really care what happens to some patients” at least a few times a month, and 18.1% (n=1,337) of residents responded that they daily “feel fatigued in the morning having to face another day on the job.” In multivariable models, burnout was more likely among male residents (OR 1.15 [95% CI 1.01-1.31]), those who felt unprepared for residency (OR 1.65 [95% CI 1.44-1.90]), and those who violated the 80 hour weekly average duty hour limit (violations in 1-4 of the past 6 months: OR 1.54 [95% CI 1.35-1.77]; violations in ≥5 months: OR 2.35 [95% CI 1.80-3.07]) compared to no violations. Burnout was not significantly associated with post graduate year (PGY). Poor psychiatric well-being was associated with similar factors with the exception of female residents (OR 1.25 [95% CI 1.12-1.38]) and PGY 1 residents (OR 1.19 [95% CI 1.04-1.35]) compared to PGY 4/5 residents who were more likely to report poor psychiatric well-being. There was no significant difference in burnout or psychiatric well-being between the Flexible and Standard arms of the FIRST Trial.

Conclusion: In this national survey including 99% of clinically active surgical residents in the U.S., burnout and poor psychiatric well-being were prevalent in surgical residents and more likely in residents who reported feeling unprepared for residency and those who violated duty hour limits. Solutions to improve resident wellness are needed and should address these associated factors.

77.01 Gender and Self-concept in the General Surgery Trainee: Experiences that Shape Professional Identity

Posted on January 18, 2018

S. P. Myers1, K. J. Nicholson1, K. Hill1, E. B. Littleton2, G. Hamad1, M. Rosengart1  1University Of Pittsburgh Medical Center,General Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA

Introduction:  Few studies focus on how gender affects the formation of professional identity during residency. Professional identity is integral to academic achievement and represents an essential component of the more comprehensive construct of self-concept. For surgeons, competence requires non-technical behaviors that support surgical learning and the development of professional identity. As residency is a formative period during which these intangible skills are acquired, we hypothesize that experiences during training diverge among genders and may be associated with differences in self-concept and professional identity.

Methods:  A qualitative mixed-methods study of general surgery residents at the University of Pittsburgh Medical Center was performed. General Surgery residents participated in two survey instruments, a questionnaire and interview, that interrogated domains of self-concept and professional identity. Transcribed interviews were coded for recurring content using inductive methods. Coded data were evaluated for emerging themes. Data and interrater reliability were analyzed using Fisher’s exact tests and Cohen’s Kappa respectively. A p-value <0.05 was considered significant.

Results: Study participants included forty-two (87.5%) general surgery residents (24 males, 18 females), and the kappa values for coded data ranged from (0.63-0.83). Fewer female residents self-identified as a ‘surgeon’ (11.1% vs. 37.5%, p<0.001). All subjects reported that patients more frequently dismissed female residents’ professional role (p<0.001), that support staff hostility was more commonly directed at women trainees (p=0.015), and that attendings preferred working with male residents (p=0.001). Significantly more females recounted episodes of another physician disregarding their professional title (p<0.001), being the target of unprofessional sexual conduct (p<0.001), and hostile behaviors from attendings (p>0.001).  All residents reported that women but not men were negatively stereotyped (p<0.001): cast as lacking confidence or authority, being physically or emotionally weak, having low professional or societal worth and being overly-aggressive. Significantly more female residents reported experiencing feelings of lack of mentorship, discomfort, feeling pressured to accept or participate in unprofessional behaviors, having difficulty completing tasks and having to adapt to overcome barriers (p<0.001). Nearly all the residents who communicated concern over barriers to career advancement were women. 

Conclusion: Key events in training perpetuate preconceived impressions that women are inferior to their male counterparts. These can be disruptive to the development of self-concept and professional identity.

 

76.02 Editorial (Spring) Board?: Gender Composition in High-Impact General Surgery Journals

Posted on January 18, 2018

C. A. Harris1, T. Banerjee7, M. Cramer4, S. Manz6, S. Ward5, J. B. Dimick3, D. A. Telem2  1University Of Michigan,Division Of Plastic Surgery, Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Michigan Women’s Surgical Collaborative,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 4Cornell University,Ithaca, NY, USA 5University Of Michigan,Division Of Cardiac Surgery, Department Of Surgery,Ann Arbor, MI, USA 6University Of Michigan,Ann Arbor, MI, USA 7University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA 8University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA

Introduction: Serving on an editorial board is an important step in many surgeons’ careers; however, evidence suggests that access to these positions may differ based on gender. Analyses of medical journals indicate although women’s representation is improving, they remain a clear minority. Whether similar trends exist in surgery and whether women surgeons face different qualification thresholds for appointment remains unknown. To address this knowledge gap, we quantify the current gender composition of ten high-impact surgery journals, evaluate qualification metrics by gender, and delineate how board composition has changed over time.

Methods: Ten prominent general surgery journals were selected for inclusion based on impact factor. Editor characteristics were assigned using faculty websites, Scopus profiles, and the American Board of Surgery certification database. We performed cross-sectional analyses of editorial board composition by gender for 1997, 2007, and 2017 using univariate and logistic regression analysis. Variation in qualifications by gender was assessed by comparing H-index, academic rank, and number of additional degrees. Gender-based differences in editorial board member turnover and multiple board positions were evaluated for each time interval.

Results: Over 20 years, women’s editorial presence has increased from 5% to 19%. Initial univariate analysis demonstrated significant qualification differences. Compared to women, men had higher mean H-indices (39.1 vs 21.9; p<0.001) and more full professorships (70.2% vs 55.8% p=0.02); whereas, a higher percentage of women had additional degrees (36.1% vs 21.9% p=0.004). Following logistic regression controlling for length of time since board certification, these associations became non-significant (degrees p= 0.051; academic rank p=0.56; H-index p=0.35). Both women and men were equally likely to hold multiple board positions (1997 p=0.74; 2007 p=0.42; 2017 p=0.69). Journals retained higher proportions of men in each time interval (1997-2007 p=0.003; 2007-2017 p= <0.001; 1997-2017 p=0.01) and retention rates increased over time (Figure 1).

Conclusion: Women surgeons have a small but growing presence on surgical editorial boards, and any qualification differences by gender are likely attributable to practice length. Although this suggests improved gender parity, gaps remain, and may be perpetuated by inequitable retention. More importantly, rising retention rates may limit next-generation surgeons’ opportunities regardless of gender. Strategies such as imposing term limits or instituting merit-based performance reviews may help balance the need for high-level expertise with efforts to ensure that editorial boards capture the field’s changing demographics.

 

75.08 Can a Haptic Robotic Train New Interns to Place Central Venous Lines?

Posted on January 18, 2018

C. C. Sonntag1, M. A. Yovanoff3, D. F. Pepley2, R. S. Prabhu5, S. R. Miller4, J. Z. Moore2, D. C. Han1  1Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA 2Penn State University,Department Of Mechanical And Nuclear Engineerging,University Park, PA, USA 3Penn State University,Department Of Industrial Engineering,University Park, PA, USA 4Penn State University,Department Of Engineering Design And Industrial Engineering,University Park, PA, USA 5Penn State University,Department Of Engineering Design,University Park, PA, USA

Introduction: Ultrasound guided central venous catheterization (USCVC) training is typically performed using mannequin simulators that cannot simulate anatomic variations in vessel depth and position. Mannequin training also requires the presence of a preceptor to provide real time meaningful feedback to the learner. A virtual reality haptic robotic simulator that provides anatomic variation and immediate qualitative feedback has been previously validated. The goal of this study was to assess the effectiveness of the robotic simulator as a new intern training device using Verification of Proficiency (VOP) testing as the outcome measure.

Methods: Resident USCVC training curriculum currently consists of an introductory video, didactic instruction, procedure demonstration, and three simulation sessions prior to VOP testing.  New surgical interns were randomly assigned to either robotic (n=13) or mannequin (n=13) training, and all 26 interns performed a pretest USCVC on the same mannequin that was used for training. Both the first and second simulation sessions consisted of ten ultrasound guided venous aspirations on their assigned training modality. Feedback was provided by either the robotic simulator (robotic group) or an experienced preceptor (mannequin group).  The training mannequin was used in the third session by both groups. This session consisted of two USCVC with feedback by an experienced preceptor. VOP testing was performed on a mannequin with vessel depth and position that was dissimilar to the mannequin used for simulator training. A standardized rubric grading system was used by a single experienced educator to assess VOP performance. Two-way mixed ANOVA was used to evaluate results.

Results: Baseline demographics and pre-test time to insertion were not significantly different between groups. All robotic simulation residents (13 of 13) passed VOP testing on their first attempt, compared to 92% of residents trained on mannequin simulation. Reason for the exam failure in the mannequin group was unintentional arterial access. Average time to perform ultrasound guided venous aspiration for mannequin trained residents was 134 seconds, compared to 86 seconds for robotic trained residents training (p = 0.07).

Conclusion: The virtual reality haptic robotic simulator for USCVC demonstrated improved results compared to standard mannequin training with respect to first time pass rate on VOP testing. Interns who used the robotic simulator showed a faster time to perform USCVC compared to mannequin testing, although this did not quite reach statistical significance. In addition to the ability to simulate anatomic variations, another potential advantage of the robotic simulator for USCVC is the immediate

74.10 Utilizing Handoff Checklists Enhances Nurse-Physician Communication and May Prevent On-Call Fatigue

Posted on January 18, 2018

C. J. Hendrix1, A. E. Graham1, J. J. Lu1, S. W. Chen1, T. E. Ju1, L. Rivas1, I. N. Haskins1, K. Vaziri1  1George Washington University School Of Medicine And Health Sciences,Department Of Surgery,Washington, DC, USA

Introduction:
Frequent non-urgent paging between nurses and physicians can lead to interruptions in patient care, physician rest, and also result in pager fatigue for the on-call surgery resident. Overnight on-call residents are particularly vulnerable due to high patient volume and decreased staff availability for support. Studies have explored how to reduce non-urgent pages between nurses and providers using collaborative education and protocols to determine which calls may be labeled as “non-urgent” and thus be deferred until more staff are available or until morning rounds. Recently, the use of checklists within the healthcare system has proven to enhance patient care and outcomes, particularly for surgical safety. This study aims to investigate the utilization of checklists at evening sign out to improve communication between nurses and physicians, limit the incidence of non-urgent paging, and help minimize resident physician work burden.

Methods:
A survey was provided to the nursing staff and surgery resident physicians to determine the most common calls made to surgical interns on overnight shifts. A list was compiled based on these survey results. This list was then given to surgery interns to track calls or pages received overnight. The results were used to identify the five most common preventable, non-urgent overnight calls. A list of these items was provided to residents and daytime nursing staff to be utilized at time of evening handoffs. Both physicians and nurses were encouraged to address these items for each patient prior to start of night-shift. Calls and pages were again logged following this intervention to assess the frequency of non-urgent, preventable calls and pages. Calls and pages were recorded in the middle weeks of February and March only on weekdays (from 6pm to 6am) to avoid weekend coverage confounders. A T-test was used for data analysis.

Results:
Of the 270 calls recorded during the pre- and post-intervention data collection period, 173 calls were for common, non-urgent matters. Pre-intervention, residents received an average of 19 (0.55/patient) preventable calls overnight. After the checklist was instituted, residents received an average of 9 (0.26/patient) preventable calls overnight with a p-value of 0.016.

Conclusion:
Implementing a handoff checklist prior to night-shift to address the most common preventable issues necessitating overnight pages significantly decreased the number of calls made from the nurses to on-call resident physicians at night at our institution. This pilot study suggests that handoff checklists and multidisciplinary sign out can decrease non-urgent calls which may help prevent pager fatigue and improve resident physician work burden.

 

74.08 Post-Operative Surgical Trainee Opioid Prescribing Practices: A National Survey

Posted on January 18, 2018

P. Underwood1, J. Mira1, M. Hoffman2, D. Hall1, H. Keshava3, K. Olsen4, J. Hardaway5, K. Hawley6, A. Antony4, T. Vasilopoulos4, N. Mouawad7  1University Of Florida,Department Of Surgery,Gainesville, FL, USA 2University Of North Carolina,Department Of Surgery,Chapel Hill, NC, USA 3Cleveland Clinic,Department Of General Surgery,Cleveland, OH, USA 4University Of Florida,Department Of Anesthesiology,Gainseville, FL, USA 5Michigan State University,Department Of Surgery,Lansing, MI, USA 6MedStar Union Memorial Hospital,Department Of Surgery,Baltimore, MD, USA 7Mclaren Bay Region,Department Of Surgery,Bay City, MI, USA

Introduction:
Death from opioid overdoses continues to rise, prompting increased attention towards preventing opioid abuse. A significant portion of previously opioid naïve patients develop persistent opioid use after surgery. The impact of surgical trainees on the opioid epidemic is unclear. There is little data examining the association of surgical trainee education in pain management and opioid prescribing practices.
 

Methods:

An anonymous, online survey was created by a multidisciplinary team at six institutions. The survey was tested and is reliable based on statistical evaluation of a pilot survey. The survey was distributed to surgical trainee members of the Resident and Associate Society of the American College of Surgeons. The survey covered five themes: education and knowledge, prescribing practices, clinical case scenarios, policy, and beliefs and attitudes. Linear mixed models were used to evaluate the influence of respondent characteristics and case scenarios on reported morphine milligram equivalents (MME) prescribed for four common general surgery clinical scenarios.

Results:
Of the 427 survey respondents, 54% indicated receiving formal training in post-operative pain management during medical school and 66% received training during residency. Only 35% agreed that they had received adequate training in prescribing opioids. There was a significant association between undergoing formal pain management training in medical school and prescribing fewer MME for common outpatient general surgery scenarios (94±15.2 vs 108±15.0; p = 0.003; Figure).  Similarly, formal pain management training in residency was associated with prescribing fewer MME in the survey scenarios (92.6±15.2 vs 109±15.2; p = 0.002).

Conclusion:
Data informing general surgery programs on the utility of surgical trainee education in pain management is lacking. In this survey, nearly two-thirds of surgical residents felt that they were inadequately trained in opioid prescribing. Further, our data suggest that improving education may result in increased resident comfort with managing surgical pain and lead to more responsible opioid prescribing. Further studies are needed to inform residency programs on developing educational curricula for opioid prescribing best practices.
 

74.05 Impact of Medical School Experience on Attrition from General Surgery Residency

Posted on January 18, 2018

J. S. Abelson1, H. L. Yeo1,4, M. Symer1, N. Wong1, F. Michelassi1, R. Bell5, J. A. Sosa2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Duke University Medical Center,Surgery,Durham, NC, USA 3American Board Of Surgery, Inc,Philadelphia, PA, USA 4Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA 5Temple University,Lewis Katz School Of Medicine,Philadelphia, PA, USA

Introduction: Medical school experience plays a role in the decision to pursue graduate surgical education.  However, no studies have examined the effect of medical school experiences on a resident’s likelihood of completing general surgery training.

Methods:  This is a national prospective longitudinal cohort study of all categorical general surgery (GS) interns who entered training in the 2007-2008 academic year. Interns were asked a series of questions related to their medical school experience and reasons for pursuing general surgery residency. Responses were linked with American Board of Surgery residency completion data. The primary outcome was completion of residency training. Multivariable Cox proportional hazards modeling was used to evaluate the association between medical school experiences and residency attrition. 

Results: 792/1043 (76%) GS interns had complete survey data; 287 (36%) were female, 252 (32%) non-White, and 70 (8.8%) Hispanic. The overall attrition rate was 20%. After multivariable adjustment for survey respondent gender, race/ethnicity and residency program type and size, two factors related to medical experience were found to be associated with completion of training. Residents who had medical school experiences with surgery attendings who were happy with their careers were more likely to complete training than those who did not (Hazard Ratio [HR] = 0.60; p=0.01). In addition, residents who matched at their first choice training program were more likely to complete their residency compared to those who did not match at their top choice (HR = 0.69; p = 0.04).  Having completed a sub-internship in surgery or having spent more time (0-8 wks vs. 9-12+ weeks) on surgical clerkships in the 3rd and 4th year were not associated with lower rates of attrition.

Conclusion: This is the first prospective national study to evaluate the potential association between medical school experiences and completion of general surgery residency.  These findings offer important insight into how exposure to surgery during medical school may impact a learner’s likelihood of finishing residency training and underlines the importance of positive role models and mentors for the development of trainees. 

 

74.02 Type of Surgical Rotation Does Not Affect Students’ Technical and Academic Development

Posted on January 18, 2018

P. Kandagatla1, R. Rinaldi1, Z. Al Adas1, E. Field1, C. Steffes1, H. Abdallah1, L. Kabbani1  1Henry Ford Health System,Detroit, MI, USA

Introduction:  During a surgical clerkship, medical students rotate through various specialties. There is little research on the effect of this diversity of rotations on students. Some programs allow students to select their rotations while others assign them in an attempt to provide a similar experience to everyone. The purpose of this study is to assess the effect of taking core rotations compared to specialty rotations on students’ technical and academic development.

Methods:  Students going through a surgical clerkship at our institution were given a suturing workshop at the beginning of their clerkship. A questionnaire was also given to students to record any prior interest in surgery or previous hands-on experience. Immediately after the workshop, they were asked to perform a simple and a complex suturing task. The tasks were repeated again at the end of the 2-month clerkship and a post clerkship questionnaire filled out. These tasks were videotaped, the times to completion were recorded, and the proficiency scored by a blinded attending surgeon. The times and scores were analyzed to assess for any improvement. The students were then divided into two groups depending on the number of core surgical rotations they rotated through. Groups were compared using uni-variate and multi-variate analyses and the variables compared included objective scores, time to complete tasks, and exam scores.

Results: Thirty-eight students were included in the study. By the end of the rotation there was a decrease in the average time to perform the simple task (5.1 vs 4.1 min, p<0.01) and the complex task (7.9 vs 6.3 min, p<0.01). There was also an increase in proficiency of the simple task (14.2 vs 16.4, p=0.035) and the complex task (12.9 vs 16.5, p<0.01). Using multi-variate analysis, we found that reported hours in the operating room per week and previous hands-on experience affected proficiency of the simple suturing task. 

Sixteen students had predominantly core surgical rotations. When compared to the 22 students with more subspecialty rotations, there was no difference in terms of age, hours logged in the operating room per week, amount of practice, previous interest in surgery, and previous hands-on experience. There was a difference in gender (more males in the core surgical rotations, 50% vs 87.5%, p=0.02). There was no significant difference in the completion times (p=0.964, 0.821), the proficiency scores (p=0.057, 0.198), the shelf exam scores (p=0.572), and oral exam pass rates (p=0.885) between the two groups.

Conclusion: After completion of a general surgery clerkship most students’ technical skills improved. This was not affected by the type of rotations (core vs subspecialty) they were assigned.  In this small study, it appears that neither their surgical skills development nor their knowledge is associated by their choice of rotation.

74.03 “Competencies and Areas for Improvement in Surgical Clerkship Instructors: A Qualitative Study”

Posted on January 18, 2018

D. M. Carmona Matos1, M. K. Mandabach1, A. W. Chang1, B. R. Herring1, V. Strickland1, H. Chen1, B. L. Corey1  1University Of Alabama at Birmingham,Surgery Department,Birmingham, Alabama, USA

Introduction: Medical students’ interest in surgical careers has declined progressively over the past few decades. Nevertheless, it is known that positive learning experiences can foster student interest in potential fields of study. In this project, we sought to identify the competencies and areas of improvement of surgical clerkship instructors as perceived by third year medical students.

 

Methods: Our medical school has a mandatory 8-week surgical clerkship for third-year medical students. At the end of their clerkship students are required to complete surveys on their surgical clerkship instructors. Surveys were collected during a period of 3 academic years (2012-2015) and individual summaries per instructor were generated. The analysis was limited to the open feedback sections: “What was done well?” and “Suggestions for improvement”. A survey content analysis was carried out using the qualitative data analysis software ATLAS.ti Scientific Software Development GmbH, Berlin (MAC version 1.6.0).

 

Results: A total of 533 survey summaries were analyzed. Instructors were sorted by rank: interns (12.4%), residents (49.1%), assistant professors (15.8%), associate professors (9.8%) and full professors (12.9%). Most instructors belonged to the general surgery, orthopedic surgery, vascular surgery and plastic surgery divisions. We found 89.5% of the summaries comprised feedback on competencies while 64.5% had suggestions for improvement. The most frequently used words were: teach/er/ing (n=1236), time (n=897), work/ing (n=834), surgeries/procedures (n=701), patients (n=629), questions (n=537). There were no significant differences in most common words based on instructor rank, gender or division. A quotation analysis showed that surgical instructors were most valued in terms of their teaching ability, enthusiasm, and availability. In addition, instructor work ethic, student hands on experiences and team based learning were highly regarded. In terms of improvements, students focused on issues such as providing clear expectations, allotting additional non-lecture instruction time, and improving student feedback.

Conclusion: These results suggest that, regardless of instructor rank, gender or division, students valued a set of common competencies. Students consistently described what surgical clerkship instructors did well as: making time for questions and education, showing enthusiasm for teaching, and allowing students to be involved with patients in clinics and the OR. Students desire clear expectations, increased non-lecture instruction time, and better feedback. This information can help reinforce and improve individual instructor’s skills and the   surgical clerkship experience.

73.09 Resident Involvement and Outcomes after Surgery: A Double Edge Sword

Posted on January 18, 2018

M. Zeeshan1, M. Hamidi1, A. Tang1, E. Zakaria1, N. Kulvatunyou1, A. Jain1, L. Gries1, T. O’Keeffe1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Diverticular disease is one of the leading causes for outpatient visits and hospitalizations. Resident participation in surgical procedures is essential for training. However, there is paucity of data regarding the outcomes after resident involvement in surgical procedures for diverticulitis. The aim of our study was to determine if the resident participation in surgery correlates with outcomes for patients undergoing surgical procedures in diverticulitis.

Methods:
We analyzed the National Surgical Quality Improvement Program database (2005-2012). We included all patients who had diagnosis of diverticular disease and underwent surgical management. Patients were stratified into two groups based on presence of resident during surgery: attending alone (No-RES) vs. attending with resident (RES). Groups were matched using propensity score matching for demographics, surgical procedure, morbidity probability and comorbidities. Outcomes of interest were compared for patients with and without resident participation in surgery (RES vs no-RES). We performed a sub-analysis of RES group by dividing it into junior (PGY 1-3), and senior residents (PGY 4-5), and fellows (PGY ≥ 6).

Results:
26,172 patients met the inclusion criteria, of which 6912 (3456: No-RES, 3456: RES) were matched. Mean age was 58.8 ± 14.3 years, and 46.7% were males. There was no difference in mortality in both groups (p=0.58), however, overall 30-d complication rates were higher in RES group (18% vs. 15.1%, p<0.01). Operative time (OR time) was longer in the RES group (175 min vs. 142 min, p<0.01), while there was no difference of hospital length of stay (HLOS) between the two groups (p=0.17). Table 1 shows the sub analysis based on level of residency. Mortality rate was highest in senior residents (p<0.01), while operative time was highest in operation performed by fellows (p<0.01).

Conclusion:
Resident involvement in surgical management of diverticulitis increases the rate of complications without an increase in mortality. Resident involvement is an important component of surgical residency. Identifying the factors and increased supervision by attendings may lead to improved outcomes. 
 

73.10 Management of Acute Cholecystitis with Significant Risk of Common Bile Duct Stone:The ‘SaFE’ Approach

Posted on January 18, 2018

K. O. Memeh1, S. Jhajj1, K. Tran1, R. A. Berger1,2, T. S. Riall1, A. Aldridge1,2  1University Of Arizona,Surgery,Tucson, AZ, USA 2Flagstaff Medical Center,Surgery,Flagstaff, AZ, USA

Introduction:

About 3-8% of acute calculous cholecystitis (ACC) present with common bile duct stone (CBDS). The 2010 American Society of Gastrointestinal Endoscopy (ASGE) and the 2016 World Society of Emergency Surgery (WSES) guideline on the management of gallstone with significant risk(high risk[HR] and intermediate risk[IR]) of CBDS recommend pre-operative imaging and ERCP for patient with IR and HR for CBDS respectively. Our group adopted a different approach; primary laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) for all patients HR and IR for CBDS, and then proceed with intra-operative ERCP (IOERCP) for patients with positive IOC, with the intention of reducing length of stay (LOS) and hospital cost (HoC) without negatively impacting outcome.We believe that this approach is Safe, Fast and cost Effective ( ‘SaFE’) and we thus review the outcome of the ‘SaFE’ approach and compares it with the traditional (ASGE/WSES guided) approach.

Methods:

We retrospectively reviewed the medical record of consecutive patients, 18 years and older presenting with ACC with significant risk for CBDS who underwent LC + IOC +/- IOERCP between Jan 2015 and Feb 2017 in our institution. Patients with cholangitis and pre-operative imaging suggestive of CBD mass (other than stone) were excluded. Patients were stratified into ASGE Intermediate risk (ASGE-IR) and ASGE High risk (ASGE-HR) for CBDS based on the published ASGE criteria. We reviewed pre-operative liver function test, total bilirubin and imaging.Complications( cystic duct leak, post ERCP pancreatitis) and hospital charges (HoC) were evaluated. The student t-test was utilized to analyse difference in LOS when compared to similar patients managed prior to the implementation of the SaFE approach.

Results:

A total of 568 patients presented with ACC and suspicion for CBDS, hence had LC + IOC. IOERCP was performed for positive IOC in 87(15%) patients. Of the 87 patients, 34(39%) was ASGE-HR for CBDS.Medain pre-op T bil was 4.1 and 0.8 for ASGE HR and IR respectively.2 IR patients had negative IOERCP. Average LOS was 1.8 days for both HR and IR patient groups. There was no cystic duct leak and no conversion to open cholecystectomy in any of the 87 patients. Two (1 patient per group) had mild post ERCP pancreatitis. Mean HoC was $10,099 per patient.Prior to implementing the SaFE approach( i.e using the  ASGE/WSES guideline),similar cohort of patients had an average LOS of 3.4 days( p < 0.000) , and mean HoC of $14,320 a diffence of $2,941 with estimated cost saving of $255,867 in the 2 year period.

Conclusion:

Our findings suggest that ACC patients who are ASGE-HR, WSES- HR, and ASGE-IR for CBDS could be managed similarly using the ‘SaFE’ approach with significant reduction in both LOS and HoC without any increase in procedure-related morbidity. 

 

 

 

 

 

 

73.07 Trends in Mortality and Cardiac Complications in Major Abdominal Surgery by Operative Volume.

Posted on January 18, 2018

Y. Sanaiha1, Y. Juo1, K. Bailey1, E. Aguayo1, A. Iyengar1, V. Dobaria1, Y. Seo1, B. Ziaeian2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Cardiology,Los Angeles, CA, USA

Introduction:

Cardiovascular complications are the leading cause of death following noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have elevated risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, postoperative myocardial infarction, and cardiac arrest after major abdominal operations and to determine the presence of potential volume-outcome relationships. 

Methods:
We performed a retrospective analysis of the Nationwide Inpatient Sample (NIS) for patients having elective open gastrectomy, pancreatectomy, nephrectomy, splenectomy, and colectomy (major abdominal surgery: “MAS”) during 2008-2014. Chi-squared analysis was used to compare demographic and hospital characteristics between groups. Logistic regression was performed to determine predictors of in-hospital mortality, postoperative cardiac arrest (POCA) and myocardial infarction (POMI).  

Results:
Of the 1,300,794 patients undergoing MAS, 49,589(3.70%) experienced in-hospital mortality, 16,542 (1.24%) POMI, and 9,496 (0.76%) POCA. The annual all-cause mortality and POMI rates remained stable while the incidence of POCA steadily rose.  Average Elixhauser score also increased from 1.8 to 2.2 during this study period. Odds of mortality were significantly lower for medium and large volume hospitals compared to small volume hospitals after adjustment (Table). Hospital operative volume did not significantly impact the odds of POMI or POCA. In contrast, larger hospital bedsize was associated with higher odds of mortality and POCA. Subgroup analysis demonstrated lower odds of mortality with higher operative volume over 2008-2014 for all operations except for splenectomy. Significant risk factors for POMI/POCA included age > 65, peripheral vascular disease, and congestive heart failure, while female gender and higher income quartile had decreased odds of these complications (P<0.02). 

Conclusion:
The rate of POCA amongst patients having MAS has increased in the US without a concomitant rise in POMI or mortality. Hospital operative volume appears to reduce odds of postoperative mortality over the entire study period. The effect of operative volume on rate of postoperative cardiac complications is not consistent over time as odds of POCA are significantly lower for higher volume hospitals only in 2008-2011 population. Operative volume does not significantly impact risk of POMI or POCA in the 2012-2014 subgroup. Increased odds of mortality and POCA at larger hospitals by bedsize could reflect patient or hospital factors that are not well represented in NIS. Non-ischemic causes of POCA need further investigation to delineate opportunities for quality improvement. 
 

73.08 Local Referral of High-Risk Patients to Reduce Surgical Costs

Posted on January 18, 2018

M. Smith1,2, U. Nuliyalu2, S. P. Shubeck1,2,3, J. B. Dimick1,2, H. Nathan1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA

Introduction: Improving the value of healthcare delivery is a major focus of healthcare reform. Previous studies have documented substantial cost savings for surgical care delivered in high quality hospitals, with particularly large cost differences for high-risk patients. Practically, shifting high-risk patients to high-quality hospitals must be done within small geographic areas. We sought to determine the availability of high-quality hospitals, the distribution of high-risk patients, and the potential benefit of referral of high-risk patients for surgery within small geographic areas.

Methods: Using 100% Medicare claims data for 2012-2013, we identified elderly patients undergoing elective colectomy (Col), lung resection (Lung), total hip arthroplasty (THA), and total knee arthroplasty (TKA). Risk- and reliability-adjusted hospital rates of serious complications were assessed using a hierarchical logistic regression model, and hospitals were grouped into quintiles; lowest complication rate = high quality. A similar model was used to stratify patients into quintiles of high and low risk for complications. Price-standardized, risk-adjusted Medicare payments were calculated for the entire “surgical episode” from index admission through 30 days after discharge. The geographic units of analysis were Metropolitan Statistical Areas (MSAs), which consist of a relatively high population density (≥50,000) and include surrounding areas that roughly mirror typical commuting distances.

Results: The proportion of MSAs containing a high quality hospital ranged from 47% (Lung) to 58% (THA). A minority of MSAs contained both a high quality and low quality hospital (n=79, 22% Lung; 118, 30% Col; 120, 31% TKA; 122, 32% THA). In these MSAs, 25% of high-risk patients received care at the lowest quality hospitals (TKA 23%, THA 24%, Lung 26%, Col 27%), and 38% of high-risk patients were treated at high quality hospitals (34% Col, 38% TKA, 39% Lung, 39% THA). There was wide variation in costs between high and low quality hospitals within MSAs, and this difference was particularly large for high-risk patients (Figure). Referral of a high-risk patient from a low to high quality hospital within a MSA would generate an average savings of $13,840 for Lung ($31,659 vs $45,499), $8,981 for Col ($29,230 vs $38,211), $2,583 for THA ($20,954 vs $23,537), and $1,936 for TKA ($19,992 vs $21,928, all P <0.001).

Conclusion: In small geographic areas containing high and low quality hospitals, 25% of high-risk patients received care at the lowest quality hospitals. Triaging of high-risk patients to high quality hospitals within small geographic areas may serve as a template for strategic local referral as a means of reducing costs in Medicare.

73.05 Surgical Coaching Relationships: Early Evidence from the Michigan Bariatric Surgical Collaborative

Posted on January 18, 2018

S. P. Shubeck1,2,3, A. E. Kanters1,2, G. Sandhu1, C. C. Greenberg4,5, J. B. Dimick1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 4University Of Wisconsin,Department Of Surgery,Madison, WI, USA 5University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction: There has been an increased focus on building effective surgical coaching programs for practicing surgeons to develop their technical skills. In this context, we sought to evaluate early coaching conversations in the Michigan Bariatric Surgery Collaborative compared to existing models for effective surgical coaching.

Methods: This qualitative study evaluated 10 video coaching conversations between 20 bariatric surgeons at the Michigan Bariatric Surgery Collaborative meeting in October 2015. Using grounded theory approach, the coaching encounter transcripts were coded in an iterative process with comparative analysis in order to identify emerging themes. For this analysis, we focused on the dynamics between participants and content of coaching conversations.

Results: Two major themes emerged in our analysis when comparing early coaching conversations to existing models. (1) While the roles of coach and coachee were defined before the coaching exercise, participants often did not adhere to assigned roles. For example, there were repeated instances in these interactions when a coach would defer to the coachee, indicating they felt less qualified in a particular technique or procedure. (2) The coaching conversations tended to have limited direct coaching, but rather an emphasis on bidirectional exchange of ideas with both participants offering expertise when appropriate. For example, the coach and coachee frequently engaged in back and forth conversation about specific techniques, instrument selection, and decision points.

Conclusions: In early coaching conversations among bariatric surgeons in the Michigan Bariatric Surgery Collaborative, we observed a propensity for participants to gravitate toward a peer to peer dynamic. Future programs aimed at improving technical skill through surgical coaching should explicitly consider the role of bidirectional feedback. 

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