95.15 Career Trajectories after Complex General Surgical Oncology Fellowship Training

Posted on January 26, 2017

F. S. Dahdaleh1, J. Tseng1, K. Roggin1, M. Posner1, K. Turaga1  1The University Of Chicago Medicine,Section Of General Surgery/Surgical Oncology,Chicago, IL, USA

Introduction:
Fellowship positions in surgical oncology programs accredited by the Society of Surgical Oncology (SSO) are competitive with a match rate of 68.6% in 2016. Having recently become an ACGME-accredited fellowship, data on trainee career trajectories is lacking. We sought to describe the practice types and locations of graduates from the 2011 and 2012 fellowship match years.

Methods:

Publicly available SSO match lists from 2011 and 2012 were utilized. Data on trainees’ medical schools, residency training programs, fellowships, and practice types and locations were collected using keyword internet searches. Locations of training and practice were categorized geographically into the Northeast, Midwest, South, West, Canada and other. Pair wise correlation and chi-square tests were used to test for statistical significance.

Results:

106 graduates completed fellowship training at 19 SSO-accredited programs (53 matched in 2011, and 53 in 2012). Sixty-three (67%) were males. The majority of fellows were trained in the Northeast (n=37, 35%), followed by the South (n=28, 26%). Fellows were more likely to hold academic faculty positions (n= 62/101, 61%). This varied significantly among fellowship programs (100% academic to 100% private practice in certain programs, chi-squared 39.08, p<0.001). International medical graduates were equally likely to choose academic practices when compared to US and Canadian graduates (65% vs. 62%, p=0.86). Graduates were more likely to choose a practice location in the same region as their residency program (r2=0.56, p<0.001) or their fellowship program (r2=0.50, p<0.001). Fellows who received their medical degrees, completed residency or fellowship training in the South chose a practice location in the same region (67%, 68%, 63% respectively) more often than those from other geographic areas.

Conclusion:
The majority of graduating SSO-accredited fellows chose to practice in academic settings in locations within the same region as their residency or fellowship programs. This information allows programs and applicants to better understand the growing workforce of surgical oncologists and serves as the first part of our attempt to describe this group.
 

95.14 Global Collaborative Healthcare: Assessing resource requirements at a leading academic medical center

Posted on January 26, 2017

N. Rosson1, H. Hassoun1  1Johns Hopkins Medicine International,Department Of Surgery,Baltimore, MD, USA

Introduction:
Historically, global collaborations involving US academic medical centers (AMCs) focused on specific diseases and public health issues in less developed countries. Recently, rapid privatization of healthcare systems, economic development, and a shift in the disease burden have led providers in emerging countries to seek partnerships with AMCs with hopes of improving care to its citizens. This new paradigm is termed Global Collaborative Healthcare, and since 1999 Johns Hopkins Medicine International (JHI) has been at its forefront, facilitating global expansion of the Johns Hopkins Medicine (JHM) mission. We investigated the institutional faculty and staff resource requirements to support the JHI operating model. 

Methods:
The size and scope of JHI’s engagements have increased from consulting to projects of greater complexity, such as affiliations, hospital management and joint ventures, with past engagements in over 50 countries and currently 18 active projects in 16 countries. JHI engages subject matter experts (SMEs) from the entities that comprise JHM.  To facilitate and monitor the use resources, JHI develops workorders that define the terms and services provided which are retained in a JHI database. Data was extracted from this database on a query for all work completed in a 3 year period (Jan, 2013-Dec, 2015), sorted and analyzed to determine total utilization (hours and full time equivalent (FTE), professional category of staff, and clinical and non clinical departments, schools, and institutes.   For purposes of this analysis, 1 FTE = 2,080 hours. 

Results:
JHI utilized on average 21,940 hours annually, or 10.55 FTEs of SMEs.  The majority work was performed by faculty from the School of Medicine, representing 77% percent or on average 16,894 hours annually. The remaining 23% (5,046 hours) is a combination of nursing, allied health and non-clinical staff.  Clinical and allied health departments had an average annual utilization of 17,642 hours or 7.8 FTEs, while non clinical departments, schools and institutes averaged 4,298 hours or 1.9 FTEs, representing 80.4% and 19.6% respectively. Within the clinical and allied health departments, Medicine and Nursing had the highest utilization, with an annual average 5,239 hours and 2,537 respectively followed by Surgery and Research with 1,603 hours and 1,309 hours respectively. Within non clinical departments, schools, and institutes, the Armstrong Institute for Quality and Patient Safety had the highest utilization with 1,914 hours annually. 

Conclusion:

The global healthcare market is massive and expanding, providing a platform for leading AMCs to enter into collaborative partnerships with healthcare organizations around the world.  In evaluation of the JHI model, we found that significant human resources are required within a broad range of SMEs, and that with adequate forecasting AMCs can successfully engage in these collaborations while continuing to fulfill their core mission at home.

 

95.13 Outcomes of a Pediatric Surgical Oncology Fellowship in a Pediatric Cancer Institution

Posted on January 26, 2017

I. Fernandez-Pineda1, D. Sanders1, B. N. Rao1, S. J. Shochat1, A. M. Davidoff1  1St. Jude Children’s Research Hospital,Surgery,Memphis, TN, USA

Introduction:

Specific training in Pediatric Surgical Oncology (PSO) is not widely

available internationally, but it may be a way for improving global pediatric cancer care. We

aimed to investigate the outcomes of the PSO training fellowship at our pediatric cancer

institution.

Methods:

Twenty PSO fellows trained during the last 20 years (1994-2014) at our institution.

One fellow was still in training at the time of survey and was excluded from the analysis. Each

fellow was surveyed about personal demographics, education, basic/clinical research, and current

surgical practice. A citation and H-index calculation was performed to assess scientific

productivity of the former PSO fellows.

 

Results:

The survey response rate was 84% (16 of 19). Ten fellows (62%) trained at our

institution after completion of pediatric surgery fellowship, 3 (19%) after general surgery

residency and 3 (19%) were junior pediatric surgery attendings at the time of PSO fellowship. 

Mean time from PSO training to survey completion was 10 years (range, 2-22). Seven fellows

(44%) came from countries in Asia, 6 (37%) from America (North America: 3, South America:

2, Central America: 1,) and 3 (19 %) from Europe. Three of 16 (19%) fellows were women.

Eleven (69%) fellows currently practice surgery in their countries of origin, 3 (19%)

international fellows practice surgery in USA and 2 (12%) fellows practice surgery

in a different country from their country of origin. Twelve (75%) fellows obtained an academic

appointment in the first 2 years after the completion of the PSO fellowship. Thirteen (81%)

fellows currently work in an academic setting and participate in a pediatric tumor board. Nine

(57%) fellows reported PSO as 25% of their practice, 5 (31%) as 75%, 1 (6%) as 100% and 1

(6%) as 0%. Ten (62%) fellows do clinical research, 3 (19%) do clinical and basic research and 3

(19%) do not do research. Mean number of citations among fellows was 188 (range, 0-1241,

SD=342.35) and mean H-index was 5 (range, 0-20, SD=5.62).

Conclusion:

The fellowship at our institution has successfully trained national and

international surgeons for practice in PSO. Most of the fellows have returned to their country of

origin and work in an academic setting with significant time dedicated to PSO. Most do clinical

research and participate in a pediatric tumor board.

95.12 Opportunity for Milestone Progress: a Novel Metric to Assess Feasibility of CGSO Milestones

Posted on January 26, 2017

B. K. Bednarski1, T. A. Aloia1, J. E. Lee1, E. G. Grubbs1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction:  As a board-certified, ACGME-approved specialty, 24-month Complex General Surgical Oncology (CGSO) fellowships are required to evaluate trainees using new CGSO Milestones. The evaluation includes ten disease site-specific patient care milestones (PCMs) scored every 6 months to assess fellow progression. The purpose of this study is to report a novel metric to assess the feasibility of implementation of these new milestones in a large CGSO fellowship.

Methods:  Disease site-specific rotation schedules for all fellows completing fellowship in June 2016 and June 2017 were reviewed. Clinical rotations were categorized into PCM groups [PCM1/2 Hepatobiliary (HPB); PCM3/4 Endocrine/Head and Neck (Endo/HN); PCM5/6 Gastrointestinal/Gynecology/Thoracic (GI/Gyn/Thor); PCM7/8 Breast; PCM9/10 Melanoma/Sarcoma (Mel/Sarc)]. The number of rotations per fellow in each PCM category per 6-month evaluation period was determined. The Opportunity for Milestone Progress (OMP) score was defined as the percentage of fellows having subsequent 6–month PCM evaluations in the same category to allow assessment of progression. OMP-0, OMP-1, OMP-2 and OMP-3 were calculated for each PCM pair with 0, ≥ 1, ≥ 2 and 3 subsequent PCM evaluations.

Results: Over the study period, the rotation schedules of 13 fellows were reviewed. The total number of clinical rotations was 224 with an average of 17.2 rotations/fellow. The rotations contributed to 255 evaluable rotations in the 5 PCM categories as some rotations map to two disease sites.  During the study period, 52 theoretical PCM assessments could be performed. The median number of PCM categories evaluated per 6-month period was 3 (Range 2-4). The OMP scores were highest for PCM5/6 (GI/Gyn/Thor) and PCM9/10 (Mel/Sarc) where the OMP-2 scores were 100%, and OMP-3 scores were 76.9% and 38.5%, respectively. On the other hand, PCM7/8 (Breast) and PCM3/4 (Endo/HN) faired much worse whereby 30.8% and 77.8% of fellows never had subsequent milestone assessments (Table 1).

Conclusion: In a large CGSO fellowship program, the implementation of disease site-specific PCMs results in assessment of only 60% of eligible milestones in a 6-month period. Moreover, the subsequent assessment of fellows’ progress in achieving the PCMs is limited as measured by the novel OMP scores. Challenges with the current disease site-specific PCMs are related to the content, frequency, and timing of clinical rotations during the 24-month fellowship. Future studies examining the outcome of disease site-specific PCM assessment as it correlates to OMP scores and new CGSO case requirements is warranted to determine the optimal number of assessments per milestone and the adequacy of this approach to fellow evaluation.

95.11 Development And Implementation of a Minimally-Invasive Surgery Curricula in Ghana: Lessons Learned

Posted on January 26, 2017

G. E. Hsiung1,2, G. Ortega4, F. Abdullah1,2, D. Rhee5, K. A. Barsness1,2  1Northwestern University,Department Of Surgery,Chicago, IL, USA 2Ann And Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA 3Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 4Howard University College Of Medicine,Outcomes Research Center, Department Of Surgery,Washington, DC, USA 5Memorial Sloan-Kettering Cancer Center,Division Of Pediatric Surgery,New York, NY, USA

Introduction:  

There is a paucity of evidence regarding the existing utilization of minimally-invasive surgery in resource-limited settings.   With an estimated one-third of the global burden of disease still attributed to treatable surgical conditions and a growing prioritization of surgical care among the global community, we sought to determine the local usage of minimally-invasive surgical techniques and to develop and implement a minimally-invasive surgical curricula in a resource-limited setting.    

Methods:
After IRB exemption was determined, a 25-item needs assessment questionnaire was designed with expert consultation to determine the utilization and availability of minimally-invasive surgical equipment and techniques for five operations (appendectomy, hernia repair, small bowel resection, Nissen fundoplication and cholecystectomy).    During a minimally-invasive surgery course held in May 2016 in Accra, Ghana, twenty participants received technical and non-technical instruction using a pre-designed curriculum that included didactics and operative mentorship. Participants took a 10-item pre-test that assessed their comfort level with minimally-invasive surgery, as well as a post-test upon successfully completing the curricula.

Results:

Although the curricula was developed for physicians, only 20% of participants were physicians while 80% of participants were nurses representing 5 hospitals in two countries – Ghana and Nigeria.  More than three-fourths of participants were not comfortable with performing the five operations we inquired about and one-third of participants did not feel comfortable with patient selection for minimally invasive surgical procedures.  Only 10% of participants had performed more than 20 laparoscopic procedures.    The leading three barriers to performing minimally-invasive surgery were expense, unfamiliarity with surgical technique and lack of equipment. All participants were interested in participating in ongoing telementoring.   

Conclusion:

There is the desire for more training and education in minimally-invasvie surgery even in resource-limited settings. Lessons learned included the importance of performing a priori needs assessment in designing a curricula that would meet the local needs based on resource availability and training. 

 

95.10 Faculty and Resident Perspectives on the Usage of a Web-based Operative Assessment Platform

Posted on January 26, 2017

B. Hasty1, E. Shipper1, J. Lau1, D. Lin1  1Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:
Currently we are in a paradigm shift from the apprenticeship model of surgical training to a competency based model therefore increasing the need for resident assessment. Web-based assessment platforms have grown in popularity among residency programs however still lack the portability and accessibility of mobile-based applications. Today, operative assessments are required to be board eligible in general surgery, however, residents have difficulty gathering assessments on operative competency in a timely, accurate, and reliable manner. Our purpose was to characterize the current use of our web-based platform and identify barriers to its use by both faculty and residents.

Methods:

An anonymous voluntary survey was distributed to residents and faculty in a general surgery subspecialty at a single institution. Selected response questions were used to asked participants to describe their use of our current web-based platform and barriers to its use. The data were tabulated using Qualtrics and were analyzed using basic descriptive statistics. 

Results:
Between July 2016 and August 2016 twelve faculty and five residents completed the survey with a response rate of 65% and 33% respectively. Most faculty had greater than 15 years of experience in their field and all were familiar with the web-based platform. On average, faculty completed one assessment per resident per month with 67% of faculty completing assessments greater than one week from the operation. 83% of faculty required prompting from their department prior to completing an assessment. 40% of residents had not received an operative assessment in the last month reporting they were “Not satisfied at all” with the frequency of assessments. 67% of residents also rated the quality of their assessments as “Average” and most faculty noted no change in operative performance as a result of their web-based assessments. The most common barriers to the completion of assessments included perceived lack of time and accessibility of the assessments.

Conclusion:

It has been estimated that residents require 20 assessments per year in order to accurately and reliably assess resident operative performance. Our findings suggest resident assessments are neither timely nor frequent, thus limiting their utility in accurately evaluating resident performance and also impacting the way they operate. The most cited barriers to the completion of operative assessments were perceived lack of time and accessibility. Furthermore, a mobile-based platform for resident assessment would potentially alleviate these barriers and therefore increase the timeliness, accuracy, and reliability of assessments.  
 

95.09 Application of Student Research Objectives in an International Elective: Circumcision in Swaziland

Posted on January 26, 2017

A. R. Oddo1, A. Bales1, R. Siska1, D. J. Dennis1, E. VanderWal2, H. VanderWal2, R. Markert1, M. McCarthy1  1Wright State University Boonshoft School Of Medicine,Department Of Surgery,Dayton, OHIO, USA 2The Luke Commission,Sidvokodvo, MANZINI, Swaziland

Introduction:  Educational objectives for medical student international electives are an important part of any travel program. Objectives such as learning research methodology or engaging in research projects focus students during their travels and are a valuable way to reinforce curriculum goals. Our project focuses on the use of an international database by medical students to produce clinically significant findings impacting international health policy. Our study examines the adverse event rate in voluntary medical male circumcision, a procedure demonstrated to reduce HIV transmission by over 60%. Not only is voluntary medical male circumcision a method of HIV prevention; it is also nearly 40 times more cost effective in comparison with the treatment of HIV using antiretroviral medications. By engaging in an academic research study during the international elective students increased the educational value of the trip.

Methods:  The Luke Commission is a NGO that provides mobile health outreach to rural Swaziland, including HIV testing and prevention.  They perform more than 100 voluntary medical male circumcisions each week. The Luke Commission maintains a database demonstrating program productivity and effectiveness. Information collected from 1500 Swazi males during the first six months of 2014 was de-identified and analyzed after approval by the Wright State University School of Medicine IRB. 

Results: During this time period 34 adverse events occurred in 31/1500 patients, these included bleeding, infection, and wound dehiscence. The overall adverse event rate for the procedure was 2.3%.  Boys ≤12 years old had adverse events in 22/1022 circumcisions (2.2%) and patients ≥13 incurred 11/478 (2.3%; p=0.66).  Patients ≤29 kg body weight had 19/662 (2.9%) and patients ≥30 kg had 13/838 (1.6%; p=0.40).  There were no adverse events reported in 75 HIV-positive patients included. There were more wound dehiscences during the summer months, 10/333 (3.0%) versus 10/630 (1.6%) in fall and 0/517 (0%; p=0.001) in winter.  

Conclusion: Aid organization databases provide a source of information that can be used by medical students for research during international medical electives. The relationship between aid organizations, medical students, and patient populations can be a collectively beneficial one. Global health research has many complexities, but through careful planning and cultural awareness, medical students can contribute by publishing research that brings attention to global health issues and improves policies while having a significant positive effect on their own educational experience.

 

95.08 The Importance of Design Validation in Global Health Surgical Innovation

Posted on January 26, 2017

T. Schwab1,3, B. Fassl2, R. Patel2, J. Langell1,3  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Pediatrics,Salt Lake City, UT, USA 3University Of Utah,Center For Medical Innovation,Salt Lake City, UT, USA

Introduction:  Creating high-quality new clinical technology solutions requires an in-depth understanding of user needs and environmental constraints. Accurately capturing market requirements, user needs, and design specifications for medical device innovation is multifactorial and challenging.   Through on-site observation and design validation, innovators may develop better solutions to unmet medical needs and provide products with tremendous potential to impact healthcare delivery.  Our study objective was to determine the effectiveness and value of design validation in medical devices designed to address the global healthcare needs. 

Methods:  An observational comparative effectiveness study and survey were used to collect data involving multiple stakeholder viewpoints (provider, patient, regulatory, industry, academic and societal).  The study setting consisted of a community hospital in rural India.  A random population-based cohort sample was used to conduct a semi-longitudinal assessment of exposure-outcome relations from device prototype use and design validation.  Medical device prototypes were exposed to potential users ranging from ages 1-92 years old.  Sixty-two subjects were observed for a 4-week duration.  User needs, market requirements, and design inputs were created using standard operating procedures for a novel non-invasive hemoglobin detection device according to the code of federal regulations governing the US FDA—21 CFR 820. Design requirements included user needs, product description, regulatory standards, functional requirements, performance and physical requirements, use environment, human and system interfacing, conceptual designs, and market analysis. After validation, each component of the traceability matrix was either marked “no change,” “significant change,” or “new addition” as defined in the methods section.

Results: The study evaluated 156 original design requirements and specifications.  Ten percent of the final design requirements were considered “new additions” and 12% were considered “significant changes.”  Sixteen percent of the final design specifications were considered “new additions” and 22% were considered “significant changes.”  Overall, 22% of the original marketing requirements and 38% of the design specifications changed significantly (Figure 1)

Conclusion: All of the changes and additions to the design requirements and specifications increased medical device design quality and safety, while reducing potential risk of lost time and investment. We strongly recommended environmental immersion for early validation of user needs and design specifications during design conception, and continue through prototyping process. 

 

95.07 Resident Attitudes Toward Competency-Based Training: A Single-Institution Survey

Posted on January 26, 2017

M. L. Cox1, S. R. Sprinkle1, U. Nag1, M. C. Turner1, R. Sudan1  1Duke University Medical Center,Durham, NC, USA

Introduction:
Surgical training has evolved tremendously since the first program was started by William Halstead in 1904. Arguably, the most impactful change occurred in July 2003 with implementation of the 80-hour work week after patient safety concerns were raised by the Libby Zion case. Since that time, there has been increased emphasis on patient outcomes in the academic environment and a new focus on competency-based training in surgical education. Many pilot studies and competency curriculums are evolving across the nation, but resident input on these changes has yet to be investigated. Our aim was to solicit opinions from residents at our institution prior to implementing a competency-based simulation curriculum.

Methods:
A survey was created using Qualtrics (Provo, UT, http://www.qualtrics.com) and distributed to 44 general surgery residents at a single institution. Anonymous responses were collected from January to February 2016 with a total of three email invitations to participate. Most questions utilized a corresponding five point Likert scale with space for free-text commentary. Categorical variables were analyzed by chi-squared tests using SAS (version, 9.4; SAS Institute Inc., Cary, NC).

Results:
Thirty residents (68.2%) participated with an 86.7% (26/30) survey completion rate. According to 63.0% (17/27) of residents, instituting modules to test competencies prior to performing a skill in the operating room should be a high priority compared to 22.2% (6/27) rating it as a low priority and 14.8% (4/27) categorizing it as not necessary (p=0.004). If a resident were to fail a particular competency, 73.1% (19/26) of residents felt a personalized remediation program would be somewhat to very useful (p<0.001). However, 61.5% (16/26) of residents did not believe a resident should be prevented from advancing to the next clinical year after failure to pass a competency (p=0.006). Subjective comments revealed concerns regarding the validity of the metrics utilized to determine competency as well as the quality and reproducibility of simulators used for testing. Residents requested that a well-defined curriculum with milestones be developed with the expectation of increased operating room autonomy once a competency is achieved. 

Conclusion:
Competency-based training is important for patient safety and is the future of surgical education, but such curricular changes directly affect residents. Our institutional study reveals that residents are accepting of a competency-based curriculum and believe its implementation is a high priority. However, some reservations exist, and this type of curriculum requires thoughtful implementation to produce valid metrics, maintain objectivity, and set expectations for increased autonomy. Once a competency-based curriculum is instituted, further evaluation will consist of resident surveys, individual competency data, resident case-logs, and patient outcomes to maximize the utility of the new educational model.
 

95.06 Using Implementation Science to Adapt a Program to Assist Surgeons with High-Stakes Communication

Posted on January 26, 2017

L. J. Taylor1, S. K. Johnson2, T. C. Campbell2, A. Zelenski2, J. Tucholka1, M. Nabozny1, M. Schwarze1  1University Of Wisconsin,Surgery,Madison, WI, USA 2University Of Wisconsin,Medicine,Madison, WI, USA

Introduction: Surgeons bear responsibility for the conduct of preoperative discussions about end-of-life care, yet surgical training provides little formalized communication instruction. Best Case/Worst Case is a communication framework designed to help surgeons structure challenging decision-making conversations with frail older adults who have acute surgical problems. We initially used a one-on-one resource intensive format to train surgeons to use this framework that was difficult to scale for wide-spread dissemination. Our objective was to use implementation science to streamline training and generate an implementation package to teach groups of surgeons to use Best Case/Worst Case. We sought to test and refine this implementation strategy with surgical residents.

Methods:  We initially trained 25 attending surgeons using intensive didactic instruction and one-on-one coaching with standardized patients. We used the conceptual framework developed by Proctor to iteratively revise the training to build a less resource-intensive program to teach groups of surgeons. This new training program includes an instructional video, role-play, and small-group coaching. We then trained residents in general surgery, vascular surgery, and urology at a single institution. After training, participants completed a standardized assessment of competence and a survey to evaluate implementation outcomes including feasibility, fidelity, acceptability, adoption, and appropriateness. We used these results to evaluate and refine the training program to construct a final implementation package.

Results: We used training completion rates to assess feasibility; of the 42 eligible participants, 24 completed the 2-hour training. We measured fidelity of tool enactment using a standardized post-training assessment; residents scored a mean of 13.2 points (range 11-15) using a checklist of 15 essential Best Case/Worst Case elements. Elements residents most commonly missed were breaking bad news and making a treatment recommendation. Regarding acceptability, adoption, and appropriateness, 100% report Best Case/Worst Case is better than what they usually do to help patients make decisions, 50% are using the tool with patients 2 months after training, and 67% strongly agree that the Best Case/Worst Case approach is suitable to help patients make value-laden choices.

Conclusion: We developed an implementation package to train groups of surgeons to use the Best Case/Worst Case framework. Our findings suggest that training can be implemented with high fidelity and the tool is acceptable to end users. We learned valuable lesson which were incorporated within the implementation package including the importance of buy-in from local surgical leadership to increase participation, tool elements that need emphasis during training, and specific guidance to facilitate success of the role-play component. Future study will evaluate the effect of this implementation package at other institutions.

 

95.05 Have We Come as Far as We Had Hoped? Discrimination in the Residency Interview.

Posted on January 26, 2017

K. M. Hessel1, L. Kilgore1, C. Shelley1, A. Perry1, J. Wagner1, P. DiPasco1  1University Of Kansas Medical Center,General Surgery,Kansas City, KS, USA

Introduction:  The National Residency Matching Program (NRMP) governs the residency match in the United States. Questions regarding family planning are considered illegal questions by the NRMP.  Previous data has indicated that women are more likely to be asked these questions than male applicants, particularly on surgical interviews. Our goal was to determine whether female applicants were more likely to be asked discriminatory questions regarding family planning than their male counterparts and to determine whether this was more prevalent in medicine vs surgery.

Methods:  A 20 question survey was distributed to fourth year medical students at the University of Kansas. Data was analyzed in SPSS, using univariate and multivariate analysis.

Results: Of the 57 survey respondents, female applicants were more likely to be asked about their desire to have a family than males (p<0.05). However, both sexes were equally likely to be asked specifically whether they had or intended to have children on both medical and surgical interviews. 

Conclusion: Though the number of women applying to all specialties has increased, our results suggest that gender discrimination in the residency interview has not been eradicated. Our data suggest that women are more likely to be asked illegal questions regarding their desire to have a family on residency interviews. A national study is warranted to determine if these findings apply to the larger applicant pool. Further education of interviewers appears necessary regarding illegal questions during the residency interview.

 

95.04 Block Conference in Vascular Surgery Residency Improves Trainee Satisfaction with Education

Posted on January 26, 2017

R. B. Robbins1, S. Sullivan2, B. Smith2  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Wisconsin-Madison,Department Of Surgery,Madison, WI, USA

Introduction:  The Accreditation Council for Graduate Medical Education (ACGME) mandates regularly scheduled didactic sessions for residency training programs but allows flexibility in conference design. Work hour restrictions, patient care duties, and demanding operative schedules create attendance barriers for surgical trainees. We explored vascular surgery trainee and faculty perceptions of the impact of implementing a block conference schedule on trainee preparation for the vascular surgery in-training exam (VSITE), ability to prepare for and participate in operative cases, and overall fund of knowledge. 

Methods:  The vascular surgery conference schedule at a single academic institution was changed from 1-hour evening conferences three times weekly, to a single, protected 3-hour morning conference once weekly. A survey to assess perceptions of the impact of the change was administered to vascular surgery residents, fellows and faculty before (pre-intervention, January 2015) and 5 months after (post-intervention, May 2015) implementation of the block conference. The survey included Likert-scale questions (1- strongly disagree to 5- strongly agree) and open-ended, free text responses.

Results: The response rate for trainees and faculty was 83% (5 of 6) and 71% (5 of 7) pre-intervention and 66% (4 of 6) and 57% (4 of 7) post-intervention, respectively.  Prior to the block conference, 60% of trainees and 100% of faculty agreed that the conferences were worthwhile while 40% of trainees agreed the conferences improved their preparedness for operations, the VSITE or improved their overall fund of knowledge. Only 20% of trainees and 40% of faculty were satisfied with the surgical indications conference. After implementation of the block conference, 100% of both trainees and faculty agreed the conferences were worthwhile, improved trainees’ preparedness for operations and improved trainees’ overall fund of knowledge. Seventy-five percent of trainees agreed the conference improved their preparedness for the VSITE exam. Post-intervention, 100% of trainees and 75% of faculty were satisfied with the surgical indications conference. Pre-intervention, 20% of both trainees and faculty thought the conferences interfered with opportunities to operate, compared to 75% of trainees and 25% of faculty after the block conference was initiated. 

Conclusion: This single-institution pilot study demonstrates a positive association in surgical trainee and faculty attitudes regarding trainee preparation for the VSITE and overall fund of knowledge with implementation of a protected block conference schedule.  Trainees are more concerned than faculty that mandatory didactic time detracts from their operative experience, however it is unclear whether this is clinically significant.  Further delineation of the impact of didactic schedules on surgical resident education and clinical experience is warranted in order to optimize utilization of limited training time in the setting of work hour restrictions.

 

95.03 Quantification of Resident Work in Colorectal Surgery

Posted on January 26, 2017

E. A. Bailey1, A. Johnson2, I. Leeds3, E. C. Wick4, M. Rachel5, S. W. Cowan2, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics, Department Of Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 4University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 5Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA

Introduction:  Residents play an integral role in patient care, yet their contribution in the operating room is incompletely understood. We created a novel tool to quantify the work that residents perform in the operating room. This study examines resident intraoperative participation by clinical year.

Methods:  This was a prospective multi-institutional study with 7 institutions over a 3 month period. Operative residents from each institution’s colorectal surgery service were queried after each colectomy. Residents were asked about their communication strategy with the attending, their overall level of participation, and techinical aspects of the operation including construction of the anastomosis, fascial closure, and skin closure. Survey data was collected in REDCap. Descriptive statistics were performed for each item. Logistic multivariable regression was used to test the association between resident work and resident participant status.

Results: Sixty-three residents participated in this study with 417 surveys completed (range 19-79 per institution) resulting in a 95.4% response rate across all sites (range 42-100% per institution). Respondents ranged from clinical year 1 (CY1) to fellows. CY3’s (35.7%) and CY5’s (34.7%) were most heavily represented. Only 117 (27.3%) indicated that they discussed the case with the attending prior to the day of surgery (DOS). Most (65.0%) discussed the case only on the DOS. Earlier resident communication increased by CY with 0% of CY1’s, 23.1% (33) CY3’s, and 39.6% (55) CY5’s reporting communication prior to the DOS (p<0.001). Overall, residents were actively involved in all aspects of the surgical procedure. Increasing autonomy was associated with advancing CY and inversely related to complexity of technical skill (e.g., less autonomy with anastomosis than skin closure) (Figure 1). Resident perception of overall participation revealed learners of all stages: Observer (12%, n=48), Assistant (54%, n=224), Surgeon (34%, n=141), and Teacher (1%, n=4). Level of perceived autonomy increased with CY level with 11.2% of CY3’s, 52.5% of CY5’s, and 80.9% of fellows describing themselves as either surgeon or teacher. Residents who discussed the case prior to the DOS were twice as likely to rate themselves as Surgeon or Teacher (OR 2.01) when controlling for CY (p=0.011).

Conclusion: Brief surveys can easily capture resident work in the operating room. Residents reported a graduated level of perceived autonomy associated with CY, yet early communication with the attending was also significantly associated with autonomy regardless of CY. Rich data such as this may be used by individuals and programs to inform and enhance best practices in surgical education.

95.02 Beyond Clinical Knowledge: How to Objectively Assess Resident Signout Communication

Posted on January 26, 2017

S. Liu1, J. Unkart1, D. Hemming1, G. R. Jacobsen1, J. Baumgartner1, B. J. Sandler1  1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:

In the era of work hour restrictions and increased patient hand offs, one of the cornerstones of surgery resident education is being able to effectively communicate high yield clinical information during signout. This study uses a novel method to evaluate the residents’ ability to communicate high yield clinical information during signout and compares their clinical judgment to the collective experience of their attendings. The scores of all the residents are then compared across years of training.

Methods:
From May to July of 2016, residents and 4th year medical students applying to surgery residency were asked to take a test titled “Sign out Scenarios” during education conference. The test gives 5 hypothetical patient vignettes, each with 10 pieces of underlined clinical information. The resident is asked to assume the role of the resident giving signout, and is asked to select 3 of the most important pieces of information in each vignette to emphasize to the on call resident. Three general surgery attendings were also asked to complete the same test. A grading rubric is created by assigning points to each piece of information in the vignette based on how many times an attending selects it, thus giving each piece of information a point between 0-3. The resident tests are then scored based on this rubric and compared between Post Graduate Years (PGY).

Results:
A total of 37 residents and 8 medical students took the test. There was a clear step-wise improvement in score (see graph below) with increasing PGY year. Statistically significant changes are observed between PGY1 to PGY3 year with an increase of score from 28.6 to 31.25 (P=0.039). Residents also had significantly higher scores when compared to the medical student at PGY 2 (P=0.026), PGY 3 (P=0.02) and PGY 4/5 (P=0.028).

Conclusion:
Giving effective signout is a skill that surgery residents are expected to master. Our test is unique because it uses the collective experience of attendings to weigh the test answers in order to evaluate how closely a resident is able to think like an attending. We show a stepwise increase in signout competency across PGY levels with the most improvement at PGY3 year. This makes sense in our institution because nightfloat rotations are completed at the end of PGY2, giving these residents practice in identifying high yield signout information. This assessment tool can be very valuable for evaluating resident progress because we would expect incremental improvement in score until PGY3. Additionally, this tool may be effective in identifying residents with deficiencies if they are below the expected for their PGY.

95.01 Contemporary Trends in Scholarly Productivity and Funding in Integrated Subspecialty Residencies

Posted on January 26, 2017

F. M. Davis1, N. Matusko2, P. K. Henke1  1University Of Michigan,Section Of Vascular Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of General Surgery,Ann Arbor, MI, USA

Introduction: During the past decade, concern has grown about the viability of research conducted by surgeons, citing diminished funding for surgical research, declining involvement of surgeons in laboratory-based investigations, and diminished academic productivity. Several surgical subspecialties, particularly cardiothoracic, plastic, and vascular surgery, have developed integrated training programs (0+5 or 0+6) in an effort to concentrate clinical training. As a consequence, these trainees get their research experience during this period rather than during the traditional general surgery time.  The aim of this study was to describe the current state of research in these residency programs with a focus on faculty, h-index and NIH funding.

Methods: Demographics and individual data were collected for academic cardiothoracic, plastic or vascular surgery faculty with integrated residency training programs (24 cardiothoracic surgery programs, 67 plastic surgery programs, and 51 vascular surgery programs).  Number of publications, citations, h-index, and NIH funding history were determined using SCOPUS and the NIH Research Portfolio Online Reporting Tools. Mann-Whitney U-tests and Kruskal-Wallis tests were used for comparison of continuous data as appropriate.

Results: Overall, of the 1,348 faculty, there were 44.6% assistant, 22.1% associate, and 33.3% full professors. Women comprised 13.5%; 4.4% were MD-PhDs and 2.5% PhDs. By surgical subspecialty, mean total publications/citations between 2012-2015 were: vascular, 14/534; plastic, 18/334; and cardiothoracic, 24/773 (P<0.05). The mean h-index and percent of faculty with current or former NIH funding for given surgical specialties included: vascular h-index 15.87, 12.3% NIH funding; cardiacthoracic surgery h-index 17.94, 19.0% NIH funding; plastic surgery h-index 11.01, 7.0% NIH funding (Table I; P<0.05). The odds of current or former NIH funding increases by 6.2% with each unit increase in h-index.  Overall, h-index is significantly associated with current or former NIH funding (p < 0.05). 

Conclusions: Academic productivity as defined by publications, citations, and NIH funding varies greatly between academic cardiothoracic, plastic, and vascular surgery departments with integrated residency programs.  The impact of these departmental variations on trainees and junior faculty success bears close observation long term.

 

94.20 Preoperative Bowel Preparation Does Not Influence the Management of Colorectal Anastomotic Leaks

Posted on January 26, 2017

K. Zorbas1, A. Choudhry2, H. Ross1, D. Yu2, M. Philp1  1Temple University,Department Of Surgery/Lewis Katz School Of Medicine,Philadelpha, PA, USA 2Temple University,Lewis Katz School Of Medicine,Philadelpha, PA, USA

Introduction: Controversy exists regarding the impact of preoperative bowel preparation on patients undergoing colorectal surgery. This is due to previous research studies, which fail to demonstrate protective effects of mechanical bowel preparation (MBP) against postoperative complications.  However, in recent studies, combination therapy with oral antibiotics (AB) and MBP seems to be beneficial for patients undergoing an elective colorectal operation. We aimed to determine the association between preoperative bowel preparation and postoperative anastomotic leak management.  We hypothesized that patients experiencing anastomotic leaks following preoperative AB+MBP would require reoperation for leak management less frequently.

Methods: Patients with anastomotic leak after colorectal surgery were identified from the 2013 and 2014 Colectomy Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and were employed for analysis.  Every patient was assigned to one of four groups based on the type of preoperative preparation that had received [Mechanical Bowel Preparation and antibiotic (MBP/AB), Mechanical Bowel Preparation alone (MBP), Antibiotic use alone (OAB) and no-preparation (Nothing)]. First, descriptive statistics were used to cite preoperative patient’s characteristics (Table 1). The association between preoperative bowel preparation and postoperative anastomotic leak management was assessed using chi-square test.

Results:Of 1678 patients who had anastomotic leak after a colorectal resection, 695 had adequate information. Baseline characteristic were assessed and found that there were no statistically significant differences between the four groups in terms of age, gender and ASA score. However, we found a higher percentage of patients with Caucasian ancestry. A Chi-Square test of homogeneity was conducted and there was no statistically significant difference between proportion of re-operated patients in the four categories of bowel preparation and operative leak management; p= 0.303.

Conclusion:The implementation of mechanical bowel preparation and antibiotic use in patients who are going to undergo a colon resection does not influence the treatment of any possible anastomotic leakage.

 

94.19 Glove and Instrument Handling in Cancer Surgery: A Survey of Surgeons’ Beliefs and Practices

Posted on January 26, 2017

D. Berger-Richardson1, A. Govindarajan1, R. S. Xu1, R. A. Gladdy1, A. McCart1, C. J. Swallow1  1University of Toronto,Department Of Surgery,Toronto, Ontario, Canada

Introduction:

The changing of gloves and instruments following the extirpative phase of cancer surgery is done with the intent of reducing the risk of local and wound recurrences. Although malignant cells have been identified in washings from gloves and instruments used during resection of upper aero-digestive squamous cell and basal cell cancers, no evidence definitively demonstrates that cells retained on gloves and instruments can cause tumor seeding and recurrence. To determine the potential impact of further investigation of this question, we surveyed the practice and beliefs of a broad spectrum of surgeons who operate on cancer.

Methods:

A pilot-tested survey was mailed to all general surgeons listed in the public registry provided by the College of Physicians and Surgeons of Ontario, Canada using a modified Dillman approach. Respondents were retained for analysis if they met inclusion criteria: staff surgeons in active practice who perform oncologic resections. 

Results:

438 of 945 surveys were returned, 351 of which met inclusion criteria, yielding an American Association of Public Opinion Research adjusted response rate of 46%. Based on their years in practice (60% at least 10 years), gender (24% female), subspecialty training (66% with clinical fellowship training of some type), and proportion of operative practice consisting of cancer surgery (52% self-reporting less than one third), the respondents were representative of the spectrum of general surgeons of the province of Ontario. 52% of respondents reported that they change gloves during cancer resections with the intent of decreasing the risk of tumor seeding, and 40% said they change instruments for this purpose. The most common circumstances cited for changing gloves were: before reconstruction, and when direct tumor handling was suspected (e.g. perforated tumor). Instruments were most commonly changed when the procedure involved discontiguous surgical fields (e.g. tumor bed and graft harvest site). 73% of respondents said they routinely take measures to protect the wound during laparoscopic cancer resection (wound protector, specimen retrieval bag), compared to 31% during open resection (wound barriers, irrigation) (p<0.01). Type of subspecialty fellowship training and years in practice predicted some of these behaviors. The majority of respondents opined that gloves and instruments are likely to harbor malignant cells, while the minority thought it likely that these retained cells contribute to tumor recurrence.

Conclusion:

There is no consensus on how gloves and instruments should be handled in cancer operations. Future studies should determine whether surgical gloves and instruments actually harbor malignant cells that are capable of seeding wounds, since the protective strategies currently employed by some surgeons and institutions carry significant financial and environmental burdens.

94.18 Single Incision Laparoscopic Proficiency Correlates with Residency Training Level

Posted on January 26, 2017

M. C. Mora1, K. E. Wong1, G. L. Fernandez1, M. V. Tirabassi2  1Baystate Medical Center,Surgery,Springfield, MA, USA 2Baystate Children’s Hospital,Pediatric Surgery,Springfield, MA, USA

Introduction:
The SAGES Fundamentals of Laparoscopic Surgery (FLS) program has shown to be a reliable marker of performance in the operating room when compared to performance in simulation.  Currently no validated program exists to evaluate skills for single incision laparoscopy (SIL), thus we are unable to test proficiency in SIL.  With experience, certain psychomotor skills should translate from standard laparoscopy to SIL. We proposed to compare all PGY levels and determine if experience translated to improved SIL skills. 

Methods:
Surgical residents of all PGY levels at our institution were included in this study and grouped based on clinical PGY level. Baseline survey was obtained to determine resident level exposure to both SIL and standard laparoscopic cases. Participants performed the following tasks: running of the bowel, endoloop placement, extracorporeal suture tying, and intracorporeal suture tying.  All tasks were performed on a commercially provided simulated organ model. Participants were given five-minutes to complete each task. All data was collected and analyzed by an impartial certified FLS proctor.  Data were analyzed using chi-square test.

Results:
A total of 31 residents participated in the study (PGY5- 4, PGY4- 4, PGY3- 6, PGY2- 6, PGY1- 11).  Overall, there was minimal SIL exposure among all residents; only one resident had greater than 10 assisted SIL cases. As expected, PGY level correlated with increased ability to complete the tasks within the allotted time.  There was a statistically significant difference in the percentage of individuals able to complete a task based on PGY level for all given tasks (p<0.0001).  With increased difficulty, the percentage of higher-level residents able to complete the task decreased. Only one individual in the PGY-3 level was able to complete the intracorporeal suture task, highlighting its difficulty in SIL. 

Conclusion:
Certain psychomotor skills appear to translate to SIL skills.  In our program there is no specific SIL training provided in the simulation center and exposure in the operating room is rare.  With increased post-graduate training experience, SIL performance improves. However, further dedicated SIL training is required to better develop surgical skills devoted to this field, such as intracorporeal suturing. 
 

94.16 Cognitive Simulation In Surgical Critical Care: A 'Booster Shot' Is Needed To Limit Knowledge Decline

Posted on January 26, 2017

M. Sivarajah1,2, I. Staff1,2, K. Butler1,2  1Hartford Hospital,Surgical Critical Care,Hartford, CT, USA 2University Of Connecticut,Surgery,Hartford, CT, USA

Introduction:
Simulation in critical care education represents an emerging tool that allows deliberate practice of cognitive skills in a simulated patient environment where mistakes are explored, assessments refined and feedback provided to improve performance.    Clinical competency in surgery requires increasing experience with direct patient care and incremental gains in knowledge as the training program progresses. Achieving these milestones permits safe patient care as residents transition from junior to senior levels.  We have previously shown that, in first year residents, cognitive simulation improves shock recognition and management.  It is unclear if retention of simulation-imparted knowledge during the PGY-1 year occurs as the resident progresses through the next four years of training. The purpose of this quality project is to determine if there is deterioration of simulation-induced knowledge and if so, at what point does it appear. 

Methods:
The results of resident performance on a 12-item multiple-choice question test (MCQ) designed to measure the knowledge of shock recognition and management were analyzed. Construct validity of the MCQ was previously determined using known-groups validation. Residents in the PGY2-5 years completed the MCQ at the midpoint of the academic year (January) and the results (percentage correct) were analyzed to assess knowledge retention from the simulation experience gained during the PGY-1 year.  Comparisons between PGY-1, PGY-2 and PGY 3-5 residents were made.   MCQ results were analyzed for overall differences among all three groups with Kruskal-Wallis test; pairwise comparisons were made with Wilcoxon Ranked Sum test.

Results:
Test results were available from 17 PGY-1, 8 PGY-2 and 6 PGY-3-5 residents.  Comparisons among the three groups showed a significant effect of resident year (p=0.002).  There was a decline in knowledge (MCQ test performance) seen during the PGY 2 year and then an increase in PGY- 3-5 (80%±9 vs. 74%±13 vs. 96%±7 for PGY-1 vs. PGY-2 vs. PGY-3,4,5 respectively).  Performance of the PGY 3-5 residents on the MCQ was significantly better compared to their PGY-1 and PGY-2 junior counterparts (p=0.002 and p<0.005, respectively).

Conclusion:
Knowledge gained during the PGY-1 year from manikin-based simulation on the recognition and management of shock declines during the PGY-2 year. It is essential for educators to be aware that knowledge declination may occur following cognitive simulation. We believe that a ‘booster shot’ from simulation to maintain the critical skill of recognition and management of shock may be necessary during this crucial training year. This may represent an important opportunity for enhancing surgical training and improving patient safety.
 

94.15 Evaluation of an Intensive Surgical Immersion Experience Curriculum for Pre-Clinical Medical Students

Posted on January 26, 2017

E. S. Shipper1, S. Miller1, B. Hasty1, S. Merrell1, D. Lin1, J. Lau1  1Stanford University,Palo Alto, CA, USA

Introduction:
A challenge with developing an interest in surgery among preclinical medical students is capturing their interest prior to the clerkship experience while providing representative experiences that will allow them to make an informed decision prior to committing to a career in surgery.  To address these challenges, our institution designed an intensive surgical immersion experience curriculum for pre-clinical medical students.  Here, we evaluate the curriculum for its efficacy, and perform a needs assessment to direct future iterations of the curriculum.

Methods:
Our curriculum consisted of advanced skills training followed by high fidelity operative simulations taught by faculty.  Students were then offered a voluntary online course evaluation survey.  For this study, we compiled survey data from the last 4 years. Students reported on their confidence levels (on a scale of 1 to 5) before and after completing the course in performing the following surgical skills: knot-tying, basic suturing, advanced suturing, hand-sewn bowel anastomoses, laparoscopic surgical skills, and vascular anastomoses.  They also reported how seriously they were considering a career in surgery, before and after completing the course.  Lastly, students were asked to comment on suggestions to improve the course. The data were analyzed for basic descriptive statistics and compared using an unpaired, two-tailed t test.

Results:

Of the 72 learners who completed the course over the last 4 years, 41 learners (57.0%) responded to the course evaluation survey.  The mean pre- confidence level, the mean post- confidence level, and the p value for each surgical skill are reported below:

Knot-tying (1.95, 3.91, <0.001)

Basic suturing (2.05, 3.68, <0.001)

Advanced suturing (1.59, 3.14, <0.001)

Hand-sewn bowel anastomoses (1.14, 2.50, <0.001)

Laparoscopic surgical skills (1.45, 2.68, <0.001)

Vascular anastomoses (1.09, 2.14, <0.001)

 

The mean level of interest in a career in surgery before the course was 3.56 (SD=1.16), after the course was 3.95 (SD=0.97) (p=0.10).

 

Results of the primary reason respondents reported taking the course are presented below:

40.9%: to achieve proficiency in surgical techniques prior to beginning clerkships.  22.7%: to pursue a known interest in a career in surgery as a preclinical medical student

18.2%: to gain exposure without necessarily gaining proficiency.   

13.6%: to inform a decision about a career in surgery

4.6%: “other”

Conclusion:
Our intensive surgical immersion experience curriculum achieved its goals of increasing pre-clinical interest in surgery.  Interestingly, our needs assessment showed that our learners identified the curriculum less as an opportunity to investigate an interest in surgery, and more as a way to achieve proficiency in basic surgical skills prior to beginning the surgery clerkship.  Further study is needed to define the essential components of this resource-intensive surgical immersion program.

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