2.03 IL6 Is An Important Paracrine Factor Of USC Mediated Intestinal Protection Following Ischemia

Posted on January 18, 2018

B. S. Morocho1, N. A. Drucker1, J. P. Te Winkel1, M. J. Ferkowicz1, T. A. Markel1  1Indiana University School Of Medicine,Pediatric Surgery,Indianapolis, IN, USA

Introduction: Human umbilical mesenchymal stromal cells (USC) improve survival and mesenteric perfusion following intestinal ischemia.  USCs likely act via the paracrine release of specific key mediators, of which IL-6 may serve an important role. We hypothesized that IL-6 would play a key role in stem cell mediated intestinal protection following ischemia and reperfusion (IR) injury.

Methods: Eight to ten week old C57BL/6J male mice were used: 1) IR + Vehicle, 2) IR + USC, 3) IR + Negative Control siRNA treated USC and 4) IR + IL-6 siRNA treated USC. Mice were anesthetized using isoflurane and a midline laparotomy was performed. Initial perfusion of the small intestine was imaged using laser Doppler imaging. The superior mesenteric artery was then occluded for 60 minute with an atraumatic vascular clamp.  After ischemia, the clamp was removed and intestines allowed to recover.  Immediately prior to closure, mice were injected intraperitoneally with either 250 ul phosphate buffered saline vehicle, or with USC transfected with siRNA as above.  siRNA efficacy was confirmed by RT-PCR.  After 24 hours of recovery, perfusion was reassessed, mice were euthanized, and the intestines were harvested for histological analysis. Tissue blocks were H&E stained and sectioned.  Mucosal injury was assessed and graded by an established injury grading scale.  Perfusion was expressed as percentage of baseline (mean+/-SEM) and analyzed by student’s t test.  Histology was presented as injury score (median and IQR) and analyzed by Mann-Whitney.  P<0.05 was significant. 

Results: IL-6 siRNA effectively knocked down USC IL-6 production.  USCs, as well as USCs transfected with a negative siRNA control significantly increased perfusion (A) and improved mucosal injury scores (B) compared to vehicle following injury (Perfusion: Vehicle 42.49+/-9.28%, USC 78.3+/-8.83, siRNA Negative Control: 77.8+/-4.37,p<0.05; Histology: Vehicle: 3(2.75), USC: 1(0.75), siRNA Negative control: 1(1),p<0.05. USCs transfected with IL-6 siRNA yielded significantly lower mesenteric perfusion and worse mucosal injury scores compared to negative control (Perfusion: siRNA Negative control: 77.8+/-4.37, IL-6 siRNA: 28.4+/-5.84,p<0.05; Histology: siRNA Negative control:1(1), IL-6 siRNA: 3.5(2.25),p<0.05). 

Conclusion: USC mediated intestinal protection was negatively impacted by the decrease in IL-6 production from USCs. IL-6 likely acts in an anti-inflammatory manner, possibly through the membrane bound IL-6 receptor. Further studies are required to delineate the downstream effects of IL-6 during stem cell mediated intestinal protection. 

 

2.01 PROMININ-1 Hepatic Progenitor Cell Ablation Increases Hepatic Fibrosis in Bile Duct Ligation

Posted on January 18, 2018

M. R. Fenlon1,2, J. Xu1, J. Zagory1, K. Asahina2, K. Wang1  1Children’s Hospital Los Angeles,Surgery,Los Angeles, CA, USA 2University Of Southern California,Los Angeles, CA, USA

Introduction:
In Biliary Atresia (BA), post-Kasai hepatoenterostomy survival with native liver inversely correlates with extent of liver fibrosis. We previously demonstrated an expansion of Prom1+ Hepatic Progenitor Cells (HPCs) within areas of developing ductular reactions in the Rhesus Rotavirus (RRV) model of experimental BA (Mavila, Hepatology 2014). Here, the degree of Prom1+ cell expansion correlated with the extent of fibrosis. We also previous demonstrated differential regenerative capacity of Prom1+ HPCs in neonatal mice compared to adult (Zhu, Cell, 2016). Moreover, null mutation of Prom1 leads to decreased ductular reaction and periportal fibrosis in RRV-induced BA (Zagory, unpublished data). Herein, we hypothesized that selective Prom1+ cell ablation is associated with decreases ductular reaction and liver fibrosis in an adult model of cholestasis caused by bile duct ligation (BDL).

Methods:
C57BL6 mice were bred to heterozygosity for both Prom1-Cre and inducible-Diphtheria Toxin Receptor (iDTR). 8-10 week old transgenic mice underwent BDL. Two weeks prior to BDL, tamoxifen was administered to induce cre-recombination in Prom1+ HPCs, resulting in targeted expression of iDTR. 1 week prior to BDL, Diphtheria Toxin (DT) or saline was injected to induce selective ablation of Prom1+ HPCs expressing iDTR. At 5 days post-BDL, whole liver tissue was collected and analyzed for histology and gene expression.

Results:
The extent of ductular reaction following BDL ± DT, as demonstrated by biliary epithelial marker CYTOKERATIN-19 (CK19) immunofluorescence, was comparable. Compared to sham, BDL resulted in increased Sirius red staining indicating increased deposition of excess extracellular matrix, a surrogate marker for liver injury (n = 13). Sirius red staining was greater post-BDL in DT treated mice compared to saline. Quantitative PCR analysis of hepatic fibrosis markers demonstrated trends towards increased fibrosis in BDL mice after DT ablation compared to saline group: α-Smooth Muscle Actin 4.19 vs 5.73, p=0.34; Vimentin 1.77 vs 6.31, p=0.15 (median fold expression of NS BDL and DT BDL groups).

Conclusion:
Contrary to our expected result, selective ablation of Prom1-expressing HPC leads to increased fibrosis following BDL in adult mice. This may be the consequence of differential regenerative capacity of Prom1+ HPC in adults compared to neonates. Further studies are essential to elucidate the functional role of Prom1+ HPC in infants with BA.
 

18.20 A Pilot Study of Surgical Resident Familiarity with Value in Healthcare and Surgery

Posted on January 18, 2018

G. T. Fankhauser1, J. Perone1, P. Roughneen1  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA

Introduction: Value in healthcare and surgery involves the pursuit of the highest quality outcome for the resources used. This differs from cost-effectiveness which emphasizes pure outcome more than quality. The distinction is subtle but important in the current healthcare paradigm where reimbursement is often tied to outcome and resources are constrained. We sought to assess surgical resident understanding of value and the focus on it during training.

Methods: We constructed an anonymous nine-question survey and distributed it to residents in all surgical specialties at a university teaching hospital. The survey queried resident familiarity with value, its distinction from cost-effectiveness, prior education on value in healthcare, and sentiments on how much focus value should receive in training and in the healthcare system at-large. Resident surgical specialty and year of residency were recorded.  

Results: 61 surveys were completed (84% response). 58% reported being unfamiliar or vaguely familiar with value in healthcare while 42% reported being fairly or extremely familiar with it. 66% reported the belief that value was the same as cost-effectiveness or unfamiliarity with the difference. 40% reported no education on value during residency with 54% reporting some education and only 6% reporting quite a bit of education. 82% of residents reported that there is not enough focus on value during training while 16% felt the amount was about right and 2% felt there was too much focus on value. In regards to the healthcare system at-large, 79% felt that there should be more focus on value and 13% felt the current focus was about right. 8% felt there should be less or no focus on value in the healthcare system at-large. By year of training, residents earlier in their training tended to have received more education on value during medical school(p=NS). Year of training did not correlate to education on value received during residency or thoughts on how much focus value should receive. There was a positive association between familiarity with value and receiving education on value during medical school(p=NS) but not during residency. Feelings toward how much focus value should receive in residency correlated with thoughts on how much focus value should receive in the healthcare system at-large(p=NS). Residents with more education on value in residency were less likely to think there is insufficient focus on value in the healthcare system at-large(p=NS). Receiving education on value and thoughts about how much focus value should receive did not correlate with surgical specialty.

Conclusion: This pilot study shows a gap in education for surgical residents on value in healthcare. Further study is needed on a national scale to assess surgical resident familiarity with value then design a curriculum accordingly. Medical schools are more recently providing education on value in healthcare but there is still a need for more education on value during surgical training.

 

18.17 Evaluating System-Based Financial Knowledge of General Surgery Residents

Posted on January 18, 2018

L. Ferro1, E. Grenn2, C. Muncie2, D. Parrish1,2, L. Boomer1  1VCU Medical Center,Surgery,Richmond, VA, USA 2University Of Mississippi Medical Center,Surgery,Jackson, MS, USA

Introduction: The General Surgery Milestone Project was instituted by the Accreditation Council for Graduate Medical Education (ACGME) in 2015 as a new way to evaluate general surgery residents in their development into independent physicians based on six core competencies. One of these competency areas focuses on “System-Based Practice.” We hypothesized that resident cost knowledge and cost comparisons of various hospital services is poor, and this lack of knowledge affects their competency in regards to some portions of system-based practice.

Methods: The billing departments of two major academic institutions were queried regarding the charges for specific hospital services (cardiology consult, computed tomography (CT) scan of abdomen/pelvis, chest radiograph (CXR), stat complete blood count (CBC), magnetic resonance imaging (MRI) of the cervical spine, magnetic resonance cholangiopancreatography (MRCP), Hepatobiliary Iminodiacetic acid (HIDA), and right upper quadrant ultrasound). In an attempt to keep things standard, the costs were evaluated for uninsured patients. Once these costs were obtained, the general surgery residents were asked in an open ended survey the costs of each of these services. The residents’ responses were grouped and analyzed as a whole.

Results: Fifty-eight general surgery residents (83%) responded to the survey. The data was first evaluated to identify how many respondents could identify the cost of the service within 25% of the actual cost. The percent of residents that were able to name the cost of the service was low throughout (1.7% to 27.5% depending on service), with <10% of respondents being within 25% of the actual cost for cardiology consult, CXR, and CT scan of the abdomen and pelvis.  When the data was evaluated to see if respondents could come within 50% of the actual cost, the results were improved (6.9% to 53.4%).

Conclusion: The results show a significant lack of knowledge of the costs of hospital services among general surgery residents. We believe that increased education in this area would benefit residents as they progress through their training and into their practices. This improvement in resident knowledge may also lead to cost-savings for both patients and hospitals.

 

18.18 Do Residents Know Duty Hour Limits? How Communicating and Interpreting Duty Hours Impacts Compliance

Posted on January 18, 2018

R. R. Love3, A. Dahlke3, L. Kreutzer3, D. B. Hewitt2,3, K. Y. Bilimoria3, J. K. Johnson3  2Thomas Jefferson University,Surgery,Philadelphia, PA, USA 3Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC),Chicago, IL, USA

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) recently revised requirements to allow programs and residents the flexibility to establish and adhere to duty hours in a manner that optimizes patient safety, resident well-being, and education.  This study used qualitative research methods to explore Program Directors (PDs), Program Coordinators, and faculty members’ understanding of duty hour regulations and how they communicate those regulations to their residents.

Methods: Semi structured interviews were conducted with a total of 98 general surgery PDs, residents, and attending surgeons from institutions enrolled in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Interviewees were asked about their understanding of duty hour regulations and how that information was communicated at their institution. Interviews were recorded, transcribed verbatim, and analyzed thematically using a constant comparative approach. This study was a sub-analysis of a larger study that examined implications of duty hour policies on resident wellbeing.

Results: Several themes related to knowledge of duty hour regulations were identified in our study such as interpreting, communicating, reporting, and compliance. Respondents reported differing levels of knowledge and understanding of duty hour regulations. Communication about duty hours occurs both formally (i.e., official correspondence given to residents and faculty from PDs or Program Coordinators regarding duty hour regulations) and informally (i.e., unofficial discussions of duty hours and implicit expectations among residents or faculty). These communications were thought to have a direct impact on how residents interpret their duty hours and how they report them. Residents who were unable to correctly identify duty hour policies may be more likely to violate those policies, which has an impact on reporting and ultimately compliance to duty hour policies.

Conclusion: Inconsistent communication of duty hours from faculty, PDs, and other residents contributes to a general lack of knowledge regarding ACGME duty hours. If residents are unaware of specific duty hour regulations, then violations seem more likely. Programs should use both formal and informal communication methods to systematically reinforce the message about duty hour regulations.

18.19 Current Trends in Training in the Surgical Management of Acute Appendicitis at a Veteran Affairs Hospital.

Posted on January 18, 2018

M. Ruiz1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Dallas, TX, USA

Introduction:  An open appendectomy used to be one of the most common cases performed by interns and physical exam dictated operative intervention.   We hypothesize that the management of acute appendicitis has drastically changed from these previous practices.    

Methods:  This a retrospective, single institution analysis at the VA North Texas Health Care system (VANTHCS) between 7/05 to 6/17 for all patients who underwent an appendectomy (n=345).  Patients who had an appendectomy for cancer, or incidentally for other reasons were excluded (n=35) as were patients with interval appendectomies (n=16) as well as patients with perforated appendicitis (n=14).  Specific analysis for complications was performed by grouping residents as junior (PGY-1 to 3) and senior (PGY-4 and 5) to determine if there were differences in outcomes.  Using postoperative complications as a dependent variable, univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables.  Significant variables were included in a multiple logistic regression model with postoperative complications as the dependent variable. Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).

Results: There were 280 acute appendectomies during the study period (male=90%; age=46.0±15.7 y.o.; BMI=31.2±18.3 Kg/m2).  Of these, only 8 were performed by interns, PGY-2=30, PGY-3=154, PGY-4=25, and PGY-5=63.  There were 20 minor complications (7.1%) and 30-day mortality was zero. LOS was 3.7±4.3 days. On presentation, 91% of patients had a CT scan and 92% underwent a laparoscopic appendectomy.  Conversion rate was 5%.   Comparing patients operated by senior (PGY-4 and 5) to junior (PGY-1 to -3) residents: patients were of similar age, gender, BMI, ASA, and had similar co-morbid conditions, as well as similar WBC and blood pressure on initial presentation (all p’s > 0.05).  However, OR time was longer (67.2±36.3 vs. 59.7±24.5 min) and EBL was higher (31.4±54.1 vs. 18.5±29.8 mL); both p’s <0.05. Patients also were more likely to have a gangrenous appendix if operated on by senior residents and had a higher heart rate on initial presentation (90.6±19.2 vs. 84.6±16.4; p=0.008). Complications were 10% and 6% for senior and junior residents; respectively (OR 1.1; 95% CI 1.0 to 1.1). 

Conclusion: At the VANTHCS, most patients presenting with suspected appendicitis undergo a CT-scan.  Most cases are performed laparoscopically. Only a small fraction of appendectomies are performed by interns. Senior residents undertake the most difficult laparoscopic cases and, therefore, have more complications.   

 

18.15 Surgical Intern Case Volume Growth in the First Year of Post-graduate Training.

Posted on January 18, 2018

I. A. Woelfel1, D. Strosberg1, S. Abdel-Misih1,2, A. Harzman1,3  1Ohio State University,Department Of Surgery,Columbus, OH, USA 2Ohio State University,Surgical Oncology,Columbus, OH, USA 3Ohio State University,Colon And Rectal Surgery,Columbus, OH, USA

Introduction: The combination of work hour restrictions and a continual increase in the documentation tasks required of all physicians makes clinical efficiency of utmost importance in gaining operative time during the first year of post-graduate training. However, the majority of patient-care responsibilities during the first year of post-graduate training focus on perioperative patient care. While other studies have documented clinical efficiency through discrete observation and recording of all daily activities, we wanted to analyze efficiency by one of its anticipated outcomes: time in the operating room. The aim of this study is to determine if hypothesized increased clinical efficiency throughout the first year of post-graduate training translates into increased time in the operating room.

 

Methods: We completed a retrospective review of all the logged surgical cases from current general surgery residents during their PGY 1 (intern) year at a single large academic training program from 2011-2017. All logged cases are recorded on the General Surgery Operative Log (GSOL) of the Accreditation Council for Graduate Medical Education website by surgical residents using current procedural terminology code (CPT). The cases were categorized according to the month and rotation in which they occurred. A correlation coefficient was calculated to determine the strength of the relationship between month and the operative volume.

 

Results: The ACGME case logs for 25 interns spanning the years 2011 to 2017 were examined, yielding a total 3,751 cases for analysis. We included central line placements, endoscopy, as well as ultrasounds, while excluding intensive care unit and non-operative trauma cases. The number of cases per resident peaked in June of intern year with a median of 18 (range: 3-52) cases; a total of seven more cases than the 11 (range: 1-38) per resident in July.  The average numbers of cases per resident according to month are plotted in Figure 1. (Correlation coefficient = 0.26) Additionally it was found that Surgical Oncology had the highest case volume (Median = 23; range 3-88) while the Surgical Intensive Care Unit rotation had the lowest case volumes (Median = 4; Range 1-22).

 

Conclusion: Our results show that operative experience increases slightly throughout intern year with the highest average case experience in the final month. We hypothesize that this correlates positively with increasing efficiency in non-operative tasks such as documentation and care coordination. Therefore, increased early training in those areas may allow even greater early operative exposure for surgical residents.

 

18.16 Terrorism and the Challenges of Surgical Training in a Third World Country

Posted on January 18, 2018

A. B. Saeed2, F. G. Qureshi1  1UT Southwestern Medical Center,Division Of Pediatric Surgery,Dallas, TX, USA 2Services Institute Of Medical Sciences,General Surgery,Lahore, PUNJAB, Pakistan

Introduction:
Surgical training in low income countries like Pakistan provide opportunities for an extensive patient care experience within a challenging security environment such as terrorist bombings.  Trainees are affected by the event and are also part of the response. This is the experience of senior surgical trainees in Pakistan.
 

Methods:
Services Hospital is an 1160 bed teaching hospital in Lahore, Pakistan and is a receiving center for victims of terrorism. Four surgical chief residents graduate from the program each year. Six surgical, and two orthopedic residents and one junior faculty are on call for emergencies. We evaluated the response our teaching hospital to terrorist events over the last 5 years (2011-2016).  

Results:
There have been three suicide bombings in the last three years with 687 victims; mortality on scene was 152 (22%), 372 patients were transported from the scene, quickly overwhelming our center, and hospital mortality was 76 (20%). Procedures were three chest tubes, 11 laparotomies, two neck explorations and 40 orthopedic cases.  No electronic medical record existsed and patient records were not maintained by a dedicated health information management office. All notes were documented by hand, injuries and outcomes recorded.  Although triage efforts improved over each successive event, information flow from the triage area to the operating room and to concerned family members was often inadequate. Resuscitation efforts were hampered by lack of staff, equipment, training and communication.  Long term outcome data was not available after each event and there was no psychological assessment of either patients or providers. 

Conclusion:
Terrorist events unduly impact our ability to train, learn, educate and provide clinical care. Concerns about our personal safety, our families’ safety and safe transport to the hospital during crisis remain.  As such, events continue to occur, access to dedicated trauma fellowships and courses such as Advanced Cardiovascular Life Support (ACLS), Advanced Trauma Life Support (ACLS), and Advanced Trauma Operative Management (ATOM) will improve care provided.  We will need administrative support to develop better staff and family communication tools, database management and mechanisms to ensure our safety.  Support for our trainees to identify PTSD will be critical. Partnerships with trauma centers across the globe will improve the learning environment and care to the trauma victims of terrorism.
 

18.13 An Interdisciplinary Approach to Surgical Skills Training Decreases Programmatic Costs

Posted on January 18, 2018

M. Snyder1, J. D’Angelo1, J. Bleedorn2, R. Hardie2, E. Foley1, J. A. Greenberg1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,School Of Veterinary Medicine,Madison, WI, USA

Introduction:
Surgical resident duty hour limitations have necessitated operative skill training outside of the OR. Low-cost box trainers and virtual reality systems are useful for resident training; however, they do not replace surgical skill wet-labs, which produce essential learning outcomes in a more realistic and transferable exercise. Unfortunately, materials and human resource requirements make wet-labs utilizing biologic samples cost prohibitive for many residency programs. To resolve this problem, our General Surgery Residency program collaborated with the Institution’s School of Veterinary Medicine Surgery Residency program to pilot a cost-effective, interdisciplinary, surgical skills curriculum.

Methods:
The General Surgery Residency Program Manager and Program Director initiated a collaboration with the Veterinary Surgery Residency.  PGY2 general surgery residents and veterinary surgery residents participated in monthly joint surgical skills practice sessions. A novel interdisciplinary surgical skills curriculum was implemented that incorporated skills beneficial to both sets of trainees.  A cost analysis was conducted for a monthly surgical skills curriculum servicing both programs independently and compared to the actual costs of the collaborative curriculum.   Quantitative and qualitative data were collected to assess learning outcomes and obtain information on session quality.

Results:
8 general surgery residents and 5 veterinary surgery residents have participated in 9 joint skills sessions, taught by both general surgery and veterinary surgery faculty.  Three of the planned sessions did not occur due to holidays and administrative challenges at the beginning and end of the academic year.  The cost analysis estimated total savings generated by the collaborative to be $33,500.00.  An iterative review of qualitative data suggests that skill sessions reinforce knowledge and reflexivity. Participants also indicate that the collaborative skills sessions are an enjoyable and valuable learning activity.

Conclusion:
The skills curriculum collaborative has proven to be a cost-effective and high quality interdisciplinary pedagogic tool. The partnership allows for mutually-beneficial resource sharing and allowed for the initiation of a surgical skills wet-lab that had previously been unavailable to both groups.  While empirical evidence suggests that this activity supports resident skills acquisition, future research will include systematic assessment of operative skill development.
 

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

Posted on January 18, 2018

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

Introduction:

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

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

Results:

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

18.10 Does Resident Competition Within Question Banks Affect ABSITE Scores?

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

18.08 Innovative Teaching Strategies for Surgery Resident Education Sessions

Posted on January 18, 2018

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

Introduction:

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

Methods:

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

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

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

18.05 Residents Teaching Residents: An Innovative Curriculum with Demonstrated Durability in Learning

Posted on January 18, 2018

B. P. Kline1, K. A. Mirkin1, L. R. Myers1, S. R. Allen1  1Penn State University College Of Medicine,Hershey, PA, USA

Introduction:

Surgical residents are required to master a vast and ever-increasing amount of knowledge, making it necessary to create efficient and robust methods of resident education. Our group has previously reported on a novel program encouraging both resident self-directed learning and peer-to-peer teaching, which we call Residents Teaching Residents.  Our sessions are designed to focus on textbook and procedural knowledge that all surgical residents are expected to learn during their training.  After implementation of the program, we now present our findings showing how knowledge is improved after a session and is retained over an extended period of time. 

Methods:

Over the course of the year, we held 3 sessions of Residents Teaching Residents.  Each session contained a didactic lecture on adult education theory, followed by a week in which residents were expected to prepare to take a hypothetical patient to the OR for an upcoming case.  They received an H&P as well as a 10-question pre-test on the topic related to the upcoming surgery.  Topics included colorectal, vascular, and trauma surgery.  After the week elapsed, a faculty member led a discussion on the pre-operative work up, treatment options, and operative planning for the patient.  A flipped classroom model was employed, requiring residents to study the topic before the session and come prepared to actively participate in the discussion.  The residents then performed a simulated case, with emphasis placed on senior residents (PGY 3-5) leading junior residents through the procedure. After the case, a post-test was given.  The test included the 10 original questions from the current session as well as 10 questions from each of the preceding sessions. Results were compared using student’s t-tests.

Results:

The average scores on the pre-test, post-test, and long term follow up test for colorectal surgery were 47%, 56%, and 61%, respectively.  There was significant improvement between pre-test and post-test (p=0.0069) and between pre-test and follow up test (p=0.0478).  For vascular surgery, the average scores on pre-test, post-test, and follow up test were 49%, 70%, and 56% respectively.  There was significant improvement between pre-test and post-test (p<0.0001) and the improvement from pre-test to follow up test approached significance (p=0.0595).  The trauma surgery topic contained a pre-test and post-test, for which scores were 65% and 69% respectively.  These did not vary significantly (p=0.63).  There has not yet been a follow up test for trauma.

Conclusion:

The Residents Teaching Residents curriculum at our institution emphasizes education theory, self-directed learning, near-peer teaching, and simulation based training.  The data obtained from resident knowledge assessments suggest that knowledge improved with the session and was retained over a period of several months. 

18.06 Program Directors' Knowledge of Opioid Prescribing Regulations for Residents: A Survey Study

Posted on January 18, 2018

D. Raygor1, E. Bryant2, G. A. Brat3, D. S. Smink2, M. Crandall1, B. K. Yorkgitis1  1University Of Florida-Jacksonville,Division Of Acute Care Surgery,Jacksonville, FL, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA 3Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA

Introduction: Opioid misuse is a public health crisis that stems in part from over-prescribing by healthcare providers. Surgical residents are commonly responsible for prescribing opioids at patient discharge and residency program directors (PDs) are charged with their residents’ education. Because each hospital and state has different opioid prescribing policies, we sought to assess PDs’ knowledge about local controlled substance prescribing polices.

Methods: A survey was emailed to PDs that included questions regarding residency characteristics and knowledge of local regulations.

Results: A total of 247 PDs were emailed with 110 (44.5%) completed responses. 104 (94.5%) allow residents to prescribe outpatient opioids; 1 was unsure. 63 (57.3%) respondents correctly answered if their state required opioid prescribing education (OPE) for full licensure. 22 (20.0%) were unsure if their state required OPE for licensure. 64 (58.2%) respondents answered correctly if a prescription monitor programs (PMP) exists in their state; 36 (58.1%) stated their residents have access. 29 (26.4%) were unsure if a state PMP existed. 76 (69.1%) SRPD’s answered correctly about their state’s requirement for an additional registration to prescribe controlled substances; 10 (9.1%) did not know if this was required.  29 (27.9%) programs require residents to obtain individual DEA registration; 5 (4.8%) were unsure if this was required.

Conclusion:Most programs allow residents to prescribe outpatient opioids. However, this survey demonstrated a considerable gap in PDs’ knowledge about controlled substance regulations. Because they oversee surgical residents’ education, PDs should be versed about their local policies in this matter. 

 

18.02 Barriers to Reporting Needlestick Injuries Among Surgical Residents

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

 

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