20.10 How Case Specific Learning Goals are Born: The Evolution within Residents along Post-Graduate Year

Posted on January 31, 2019

I. Woelfel1, D. Strosberg1, B. Q. Smith2, A. Harzman1, R. Salani2, A. Cochran1, X. (. Chen1  1Ohio State University,Department Of Surgery,Columbus, OH, USA 2Ohio State University,Department Of Obstetrics And Gynecology,Columbus, OH, USA

Introduction:  Developing resident autonomy in the operating room (OR) is a complex process that involves resident readiness, preparation and flexibility; instructor feedback and guidance; and is impacted by environmental and patient factors. Resident-established case specific learning goals have long been promoted as a way to increase resident OR training efficiency and the preparedness for autonomy. However, little is known about residents’ experience of identifying learning goals for a given case. The aim of this study was to investigate the developmental process of residents’ case specific goals based upon residency training level. 

Methods:  After obtaining IRB consent, we conducted focus group interviews with 18 general surgery residents across five clinical postgraduate years (PGY) using convenience sampling. Audio recordings of each interview were transcribed and iteratively analyzed. Emergent themes were identified using a framework method. 

Results: A total of eight junior (PGY 1-2) and 10 senior (PGY 3-5) residents participated; 10 were female and 8 were male. Focus group participants indicated that the ability of residents to self-identify case specific learning goals for an upcoming surgical case is closely associated with residents’ medical knowledge and surgical experience throughout residency training. The more experience and knowledge gained, the easier for residents to identify a specific learning goal for a case. In the early stage of residency training, residents have difficulty self-identifying actionable case specific learning goals. Junior residents tend to rely on attending and/or senior residents to assign a learning goal. During the intermediate stage of residency training, residents were more comfortable in specifying a goal for some high-volume common procedures than the junior residents. Approaching the final stage of residency training, residents are able to articulate specific and achievable learning goals for most cases. However, they perceived practical challenges when serving as a Teaching Assistant in the OR with junior residents. Numerous internal and external factors influence the development of residents’ case specific learning goals, including resident operative experience, resident self-entrustment and entrustment of attending, as well as case assignment timeline, attending teaching style and attending reputation in granting operative autonomy. 

Conclusion: Although self-identifying case specific learning goals functions well for senior residents, it is not practical for junior residents to develop actionable, specific goals due to their limited medical knowledge and operative experience. Residency programs could provide a set of procedure-based learning goals for junior residents to enhance their training efficiency and to solidify their foundation for future OR autonomy. Resident-as-Teacher programs would be beneficial to enhance senior residents' identification of learning goals for their junior peers.

 

20.09 Perceptions of Residents' Autonomy in the Operating Room

Posted on January 31, 2019

Z. Rahaman1, M. Arafeh1, G. Munene1, L. Miller1, S. Shebrain1  1Western Michigan University Homer Stryker MD School of Medicine,Department Of General Surgery,Kalamazoo, MICHIGAN, USA

Introduction: Graded autonomy is an essential component of General Surgery training. This study compares perceptions of autonomy between residents and faculty in the operating room.

Methods:  Operative procedures performed by general surgery residents between July 2016 and June 2018 were each assigned an autonomy score by the operating surgeon and the surgical resident using the Zwisch score. The degree of agreement between the residents’ self-evaluated measure of autonomy and surgeons’ evaluation of resident autonomy was assessed.

Results: Over the study period, 23 faculty members and 24 residents scored 546 operative cases (total 1,092 evaluations) using the Zwisch scale. About half of these evaluations were completed by PGY5 (24.4%) and PGY2 (24.2%), while the rest were completed by PGY1 (16.3%), PGY3 (21.1%) and PGY4 (14.1%). Overall, there was moderate agreement between resident and faculty evaluation with Cohen’s Kappa of 0.50 (95% CI 0.41, 0.58). PGY5 and PGY1 residents appeared to have more agreement with the faculty (0.51, 0.50 respectively) than PGY2 (0.39), PGY3 (0.37) and PGY4 (0.47) residents. Spearman correlation between ranks of resident and faculty evaluations of resident autonomy was 0.31 (p<0.001). Case-difficulty did not affect perception of autonomy. 

Conclusion: Surgical faculty and residents appear to share similar perceptions of autonomy in the operating room.

 

20.08 Assessing The Adherence Of Operative Notes For Laparoscopic Appendectomy With The RCS Guidelines

Posted on January 31, 2019

F. Mannan1, R. Gill1, A. R. Alvi1  1The Aga Khan University Hospital,General Surgery,Karachi, SINDH, Pakistan

Introduction:

Operative notes are one of the most essential components of good surgical practice. It forms an important record of intervention performed on the patient with its medicolegal implications.Proper documentation of these notes ensures the patient continuity of care is maintained and quality of care is enhanced which may also have an impact on follow up and future management of the patient. Royal College of Surgeons has issued guidelines to standardize operative note documentation. We aimed to determine the frequency of adherence of laparoscopic appendectomy operative notes with the RCS guidelines at our tertiary care centre.

Methods:  

The Study was conducted at the Aga Khan University hospital Karachi over a six month period between January and June 2018 after seeking approval from the Ethics Review Committee. It was a crossectional study and data was analysed by using SPSS version 21. Descriptive analysis of continuous variables along with overall score of operative notes was deduced to assess the frequency of adequate practice compared to the RCS guidelines. Stratified analysis was done for effect modifiers and p value of < 0.05 was taken as statistically significant.

Results:

A total of 74 operative notes relating to laparoscopic appendectomy were reviewed during the study period. Majority of the cases were carried out as inpatient procedures (91.9%). The average age of resident writing the notes was 27 year +/-1.97.  Forty Six percent notes were written by year one residents. Female residents contributed to around 55 percent of operative notes. Twenty four percent operative notes showed adequacy of practice in concordance with RCS guidelines. The most lacking component in operative notes was mentioning of the operative time, port sites, intra operative complications and details of specimen removed. Stratified analysis of operative notes did not reveal any association between age, gender and level of training of residents to affect the adequacy of operative note documentation.

 

Conclusion:

There is a huge gap in documentation of operative notes compared to the Royal College of Surgeons guidelines for good medical practice. Only a quarter of our documentation fulfils the criteria for adequacy of practice. Residents need to be educated and familiarized with these guidelines to improve documentation of operative procedures. Strategies need to be formulated and tested to improve our performance.

 

 

 

 

 

 

20.07 Acquisition of Surgical Skills by Medical Students in State-Owned Medical Schools of Cameroon.

Posted on January 31, 2019

A. Chichom-Mefire1, G. N. Keith1, P. Fokam1, D. S. Nsagha1, M. Ngowe-Ngowe1  1Faculty of Health Sciences, University of Buea,Department Of Surgery,Buea, Cameroon

Introduction: Surgery plays an important role in provision and support of primary health care services. The World Health Organization recommends that basic surgical care be administered at the district level. Due to limited availability of qualified surgeons, general practitioners need to be competent in a number of practical surgical skills in order to reduce the number of referrals for emergency and selected elective surgical procedures. Curriculum of medical schools in low and middle-income countries must be designed accordingly. The aim of this study was to report the level of exposure of final year medical students to practical surgical skills.

Methods:

A descriptive cross-sectional study was carried out in the four state owned medical schools in Cameroon. The target population was final year medical students who have completed all clinical rotations. All final year medical students were approached.

A structured self-administered questionnaire was proposed to these students in order to assess their exposure to basic surgical skills and selected surgical procedures. Self-confidence in performing basic surgical skills (BSS) was assessed using a Likert scale. Adequate exposure for a given surgical procedure was defined as at least one of the following: (1) observing the procedure five or more times and participating as fist assistant at least four times and performing it at least once under supervision. (2) Observing the procedure five times and participating as first assistant at least five times. Data analysis was performed using EPI INFO version 7.2 and statistical significance was set at P < 0.05.

Results:
Of the 347 final year medical students approached, 304 returned filled questionnaires giving a response rate of 87.6%. Male to female ratio was 5:4 and females were significantly younger than males (P < 0.001). Their comfort in basic surgical skills ranged from 25% (manual surgical node tying) to 86% (surgical scrubbing). Adequate exposure to selected surgical procedures was 87% for perineal tear repair after vaginal delivery, 81% for caesarean section and incision and drainage of an abscess, 73% for cast immobilisation of a limb fracture, 55% for hernia repair and 53% for appendectomy. It was as low as 3% for bowel resection and anastomosis. The choice to perform extra-curricular activity for skills improvement was significantly associated with adequate exposure (P < 0.05).

Conclusion:
Overall, the performance rate of practical surgical skills by final year medical students in medical schools in Cameroon is poor. However, the majority of students are likely to be able to perform a sizeable number of surgical procedures by the end of their training. There is need to reinforce the training and assessment to ensure that medical students who do not master basic clinical skills and are not adequately exposed to common procedures are given an opportunity to be exposed before graduation.

20.06 #Ilooklikeasurgeon: 20-year Review of Gender and Racial Diversity in Academic General Surgery

Posted on January 31, 2019

L. Marcia1, A. Moazzez1,2, R. Miranda1, D. Y. Kim1,2, C. DeVirgilio1,2  1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 2Harbor-UCLA Medical Center,Surgery,Torrance, CA, USA

Introduction:  For years there has been ongoing efforts to diversify medicine as the United States (US) population continues to change. Our objective was to assess the past and current state of gender and racial diversity in general surgery.

Methods:  Demographic data from 1997-2016 was obtained from publications on graduate medical education by the Journal of American Medical Association, and the Association Medical Colleges. The percent change per year was calculated using a linear regression model.

Results: In 2016, women represented 50.8% of the US population, but only 10.4% of full professors, 20.0% of associate professor, 26.7% of assistant professors and 49.2% on instructors. The highest increase per year was seen among female instructor 1.16%, p<0.001) and the least among full professor (0.39%, p<0.001). From 1997 to 2016, the percentage of female general surgery residents increased from 20.5 to 38.4. Hispanic/Latino represented 17.8% of the population, but only 4.96% of faculty, and 8.24% of general surgery residents. African American represented 13.3% of population, but only 2.69% of faculty, and 5.50% of general surgery residents. American Indian/Alaskan Native represented 1.3% of population, but only 0.10% of faculty and 0.19% of general surgery residents.

Conclusion: In the last 20 years, there has been increase in gender and racial diversity in surgery. However, women, American Indian, African American and Hispanic continue to be underrepresented in certain categories of the surgical pipeline. 
 

20.04 Trends in United States Residency Match Rates for International Medical Graduates

Posted on January 31, 2019

C. Buonpane1, S. Hayek1, M. Fluck1, H. Ellison1, M. Shabahang1  1Geisinger Medical Center,General Surgery,Danville, PA, USA

Introduction: Every year the United States (US) Main Residency Match seeks to couple medical school graduates with available residency positions. Historically, there have been more applicants than available positions. The majority of applicants completed their undergraduate medical education in the US; however, a growing portion of applicants are coming from international medical schools. International medical graduates (IMGs) play a crucial role in the physician work force in the US, filling shortages that cannot be met by US allopathic and osteopathic graduates alone. This study seeks to examine the trends in match rates of IMGs into US allopathic residency positions over the past thirty years.

Methods: US residency match data was obtained from the National Resident Matching Program (NRMP) for the years of 1986 to 2016. Linear trends were used to evaluate match data over time and subspecialty analysis was performed. Longitudinal 10-year match rate projections were also made.

Results:

In 1986, IMGs composed 4,965 of 21,357 applicants and 27.8% of IMGs successfully matched into a US allopathic residency. In 2016, IMGs composed 6,638 of 35,476 applicants and 52% matched (87% increase). IMGs were then separated into American citizens (US-IMG) and those who did not have American citizenship (non US-IMG). From 1986 to 2016, US-IMG match rates increased by 40% and non-US IMG match rates increased by 110%. 

 

Allopathic residencies in primary-care specialties demonstrated overall growth in available positions over the study period and an increase in reliance on US-IMGs to fill those positions.  Internal medicine filled 4.8% of 4,682 positions with US-IMGs in 1986 and 14.6% of 6,938 positions in 2016 (204% increase).  Family medicine programs filled 4.3% of 1,960 positions in 1986 and 23.6% of 3,083 positions in 2016 (449% increase).  Longitudinal ten-year match rate projections suggest that 15.3% of internal medicine and 30.2% of family medicine US allopathic residency positions will be filled by US-IMGs in 2026.  

 

Categorical general and orthopedic surgery positions were also analyzed. In general surgery, US-IMG filled positions increased over 400% (from 1.3% of 1,249 positions in 1986 to 6.6% of 1,239 positions in 2016) with a projection of 8.1% of positions being filled by US-IMGs in 2026. In orthopedic surgery, US-IMGs filled 0.29% of 342 positions in 1986 and 0.83% of 717 positions in 2016 (186% increase).

 

During the study period, non US-IMG match rates also increased.  Non US-IMG applicant filled positions increased from 9-29% in internal medicine (222% increase), 1.8-12.4% in family medicine (589% increase), 3.8-4.6% in general surgery (21% increase) and 0.58-1.1% in orthopedic surgery (90% increase).

Conclusion:The percentage of IMGs filling US allopathic residency positions has increased over the last 30 years and is projected to continue increasing. This increase in reliance on IMGs has been particularly strong in primary care fields. 
 

20.03 Medical Student Grit: Impact of Third Year on Medical Students’ Perseverance of Effort

Posted on January 31, 2019

N. E. Anton1, M. A. Rendina1, K. Stanton1, J. N. Choi1  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction:
Grit, a psychological trait characterized by passion and perseverance for long-term goals, enables individuals to work towards the completion of long-term goals in spite of repeated challenges, failure, and adversity. Grit has been identified as a predictor of resident attrition in surgical residency, and a marker of residents at risk for poor psychological well-being in the future. Among medical students, grit is associated with learning and performance in gross anatomy, which may indicate that grit is an important element of medical student success. However, in United States medical schools, the third year of medical school (MS3) presents unique challenges related to patient care, interacting with diverse senior healthcare providers, and determining one’s eventual career path. Thus, unlike the first two years of medical school, the distinct challenges of MS3 may erode medical students’ grit. Accordingly, our goal in the present study was to assess the impact of MS3 on medical students’ grit.

Methods:
Incoming MS3s were recruited to voluntarily participate in our study at the start of their third year. Following informed consent, participating MS3s completed the Short Grit Scale, which is an eight-item self-report measure of grit. A single grit score is derived, in addition to two subscales, which include consistency of interest and perseverance of effort. At the conclusion of their third year, participating MS3s were contacted via electronic mail to complete Short Grit Scale again. Paired two-tailed t-tests were utilized to assess pre- to post-MS3 differences in grit and the two subscales. P-values less than 0.05 were considered significant.

Results:
One hundred and seven MS3s (39.8% Female) completed both Short Grit Scales. From pre-MS3 to post-MS3, there was a significant decrease in grit scores (Pre: 3.99±0.46 to Post: 3.87±0.49, p<0.001). Regarding subscale items, there were no differences in pre- to post-MS3 consistency of interest scores. However, there was a significant decrease in perseverance of effort from pre- to post-MS3 (Pre: 4.18±0.48 to Post: 4±0.51, p<0.001).

Conclusion:
Medical student grit, particularly perseverance of effort, may be at risk to decrease significantly due to the rigors of their third year, which consists of unique challenges that they have not been previously exposed to, as well as important decisions regarding their future career paths. It is currently unclear what specific factors contribute to medical students’ decreased grit during their third year, but it is apparent that there is a need for dedicated training to enhance medical student grit due to its importance for their psychological well-being in residency. Accordingly, interventions designed to promote medical student resilience and grit during their third year are warranted.
 

20.02 Medical Student Perception of Morbidity and Mortality Conference

Posted on January 31, 2019

A. P. Worden1, P. Kandagatla1, A. H. Gupta1, C. Steffes1  1Henry Ford Health System/Wayne State University,Surgery,Detroit, MICHIGAN, USA

Introduction:  Morbidity and mortality (M&M) conference has long been a vital educational tool for medical students, residents, and staff. It allows for learning and quality improvement through discussion of noteworthy cases. There is, however, a paucity of data on the how M&M is perceived by medical students, especially as a function of their interest, or lack thereof, in surgery. The objective of this study was to fill this void by measuring the perceptions of medical students regarding M&M conference.

Methods:  Medical students in a single medical school class voluntarily took part in a survey after their surgical rotation. The survey gauged students’ interest in surgery as a career and their overall rating of M&M. Students were specifically asked to recall if specific types of cases (resident at fault, medical error, non-therapeutic operation, pre- or post-operative mismanagement, multiple levels of error, and preventable or non-preventable error) were discussed. They were also asked to recall if tenets of surgical care (patient safety, quality improvement, root cause analysis, never events, time out/critical pause, complication vs preventable error) were discussed during M&M. Responses were tabulated and descriptive statistics were performed to summarize the data. Univariate analysis with a Chi-squared test, or Fisher’s Exact test when appropriate, was performed for association.

Results: A total of 251 students were surveyed over four clinical sites. Of these students, 236 (94.0%) felt they understood the purpose of M&M, and 233 (88.8%) students felt they understood quality improvement in medicine and surgery. However, only 136 (54.2%) students reported M&M as a valuable learning experience. Discussion of the following was associated with a positive experience: examples of patient safety (93.4% vs 84.3%, p=0.02), preventable (91.2% vs 75.4%, p<0.01) or non-preventable (76.5% vs 55.3%, p<0.01) errors, quality improvement (95.6% vs 71.9%, p<0.01), and root cause analysis (59.6% vs 40.4%, p<0.01). Students were less likely to have a positive experience if they perceived M&M as a resident ‘grilling session’ (31.6% vs 51.4%, p<0.01). There was no association between interest in a surgical subspecialty and perceiving M&M as a positive learning experience (48.5% vs 50.5%, p = 0.29).

Conclusion: Overall, only a very small majority of medical students view M&M as a positive learning experience. Introducing structured concepts focusing on quality improvement may serve as a viable strategy to enhance the learning experience. Prospective studies incorporating such a curriculum are warranted.

20.01 Correlation Between Burnout, Stress, Work-Family Conflict, and Self-Efficacy in Surgical Faculty

Posted on January 31, 2019

M. R. Smeds1, M. Harlander-Locke2, H. K. Sandhu3, S. Allen4, K. Amankwah5, P. Ansari6, K. Charlton-Ouw3, D. Hess7, P. Jackson8, M. Johnson9, M. K. Kimbrough10, D. Knight11, G. M. Longo12, B. Shames13, J. Shelton14, P. Yoo15, M. Smeds1  1Saint Louis University School Of Medicine,Division Of Vascular And Endovascular Surgery,St. Louis, MO, USA 2Lake Erie College of Osteopathic Medicine,Bradenton, FL, USA 3McGovern Medical School at UTHealth,Houston, TX, USA 4Penn State Hershey Medical Center,York, PA, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6Lenox Hill Hospital,New York, NY, USA 7Boston University,Boston, MA, USA 8Medstar Georgetown University Hospital,Washington, DC, USA 9University of South Dakota,Vermillion, SD, USA 10University of Arkansas for Medical Sciences,Little Rock, AR, USA 11Waterbury Hospital,Waterbury, CT, USA 12University Of Nebraska College Of Medicine,Omaha, NE, USA 13University of Connecticut School of Medicine,Farmington, CT, USA 14University Of Iowa,Iowa City, IA, USA 15Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that has become prevalent in all areas of medicine.  We sought to understand factors associated with burnout in surgical faculty including self-efficacy, perceived stress, work-family relationship and depression.

Methods:
Anonymous electronic surveys consisting of demographic information as well as validated scales for burnout, depression, perceived stress, self-efficacy, social support, and work-family conflict were sent to all surgical faculty at 14 general surgery residency programs.  Respondents were grouped into quartiles based on burnout level, and predictors of burnout were determined using univariate and multivariate analysis comparing those in the highest quartile to all others.

Results:
Of 731 invitations sent, 240 (33%) surgeons responded.  Those in the highest quartile of burnout were younger (45.5 vs. 48.1, p=0.049), more likely to have higher perceived stress (p<0.001), work-family conflict (p<0.001), and moderate or severe depression (p<0.001) and lower perceived social support (p<0.001) and self-efficacy (p<0.001).  Amount of educational debt, years out from training, gender, marital status, proximity of immediate family, and having children did not correlate with burnout, nor did work-related factors of frequency of call, number of hospitals covered, percent clinical involvement, number of cases performed per week, attainment of divisional/departmental leadership roles or overall compensation.  On multivariate logistic regression analysis, higher perceived stress (OR 1.51, p<0.001), depression (OR 2.730, p=0.004), and work-family conflict (OR 1.2, p=0.012) were related to higher levels of burnout while self-efficacy was protective against burnout (OR 0.89, p=0.046).  Those with the highest levels were unlikely to select surgery as a career if they could do it all over again (OR 0.093, p=0.001).

Conclusion:
Burnout in surgical faculty is associated with depression, high perceived stress, increased work-family conflict, and low self-efficacy.  Improving work-family balance and self-efficacy and decreasing stress may improve levels of burnout in surgical faculty.
 

19.20 Measuring Uncertainty Intolerance in Surgical Residents Using Standardized Assessments

Posted on January 31, 2019

L. Ying1, R. Assi1, A. Harrington1, C. Thiessen1, M. Hubbard1, G. Nadzam1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction: Due to ambiguities inherent to medical and surgical practice, a physicians’ intolerance for uncertainty (uncertainty intolerance, UI) can significantly impact the quality of their practice and their own mental well-being. Many residency programs, including our own, have introduced new education initiatives aimed at improving UI in our residents. However, currently there is no standard protocol to measure the effectiveness of such interventions, and there are no established methods for identifying the residents who would most benefit from the training. In this study, our goal is two-fold: 1. To validate the use of the Physician Reaction to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales assessments for uncertainty intolerance, and 2. To determine if Myers-Briggs Type Indicator (MBTI) personality factors are associated with PRU and PRA scores and can be used to identify residents who are more likely to have higher UI.

Methods: The PRU and PRA scales, and the MBTI assessment were administered to a total pool of 71 general surgery residents. In addition to the survey questions, residents were asked to provide information regarding their gender (Male or Female), and stage of training (Junior or Senior).

Results: In total, 45 male residents and 25 female residents responded to the survey and completed the PRA and PRU scales (98.6%). There were no statistically significant differences found when comparisons were made between Junior versus Senior residents or Male versus Female residents. 37 male residents and 18 female residents also completed the MBTI assessment (80.4% and 72%, respectively). PRU and PRA scores were analyzed with respect to personality factors to determine if certain dichotomies are associated with increased uncertainty intolerance. Individuals identifying as Perceiving had significantly higher scores in the PRU category of “Concern about Bad Outcomes” (J: 8.76±3.39, P: 10.47±3.08; p<0.05), and on the PRA scale (J: 22.55±3.58, P: 20.71±2.34; p<0.05). Additionally, individuals identifying as Sensing had significantly higher scores on the PRU category of “Reluctance to Disclose Mistakes to Physicians” (S: 4.68±1.36, N: 3.74±2.40; p<0.05).

Conclusion: In this study, we have validated a new assessment for measuring the success of our education initiatives aimed at improving uncertainty tolerance. We found that the PRU and PRA assessments were simple to administer, and had a high completion rate due to buy-in from the residents. We have also demonstrated for the first time that specific personality factors are linked to higher uncertainty intolerance in surgical residents. These results will allow us to better identify residents who would benefit most from uncertainty intolerance training and to monitor their progress. 

 

19.19 A Pilot Study of a Resident-Led ABSITE Review Course

Posted on January 31, 2019

D. Cassidy1, S. McKinley1, A. Mansur1, J. Mullen1, E. Petrusa1, R. Phitayakorn1, D. Gee1  1Massachusetts General Hospital,General Surgery,Boston, MA, USA

Introduction:  Resident performance on the American Board of Surgery In-Training Examination (ABSITE) may correlate with passage rates on the American Board of Surgery Qualifying Examination. ABSITE scores are also an increasingly key component of fellowship applications. The best methodology for sustained study habits of residents and subsequent ABSITE performance is still unclear. Peer teaching increases motivation and knowledge acquisition and retention for both the learner and peer teacher.  This pilot program introduced and tested the feasibility of a targeted, structured ABSITE review curriculum utilizing peer teaching from senior surgical residents.

Methods:  An 8-week resident-led ABSITE review course was offered to surgical residents prior to the administration of the 2018 ABSITE exam. Topics were selected based on resident input and analysis of historic exam knowledge deficiencies within our institution. Each session was led by a volunteer senior surgical resident (PGY3 level or above). Participation was voluntary, and attendance was recorded at each session. 2018 ABSITE score reports were transcribed into a deidentified, digital database. ABSITE scores from residents who participated in 3 or more sessions were compared to all general surgery residents with no participation with subgroup analysis at each post-graduate level.

Results: Total preparation time for this course was 20 hours. Each session lasted 1 hour. There were 4 resident volunteer teachers. Out of 57 residents who took the ABSITE, 17 (30%) residents came to at least one session and 13 (23%) participated in 3+ sessions. Participants ranged from 50% of PGY1 residents (n=5) to 0% of PGY4 residents. Residents who participated in 3+ sessions did not have statistically significant higher ABSITE percentile scores (70.3 vs. 57.7; t=1.33, p=0.10) compared to residents who did not participate. The greatest difference in percentile scores was seen in PGY1 residents (85.6 vs. 67.8; U=8.5, p=0.23), although this was not statistically significant. A post-exam survey demonstrated high levels of resident satisfaction with the course and interest in continued participation.

Conclusion: A peer-taught ABSITE review course is both feasible and useful to participants with high rates of participant satisfaction. Residents who participated did not have statistically significant higher percentile scores than residents who did not participate. While the sample size prohibited findings of significance, future studies are underway to establish a more formalized program with analysis of a larger dataset for the 2018-2019 academic year.

 

19.18 Diversity in a General Surgery Residency in the South

Posted on January 31, 2019

M. K. Mandabach1, E. N. Williams1, H. Chen1, L. C. Tanner1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:  General surgery residencies have been historically dominated by Caucasian males, especially in the South. The purpose of this study is to examine how the demographics of surgical residents, including race, gender, and medical school region, have changed from 1980 to 2017.  We hypothesize that there has been an increase in diversity over time.

Methods:  Demographic information of the general surgery residents from 1980 to 2017 was collected. The race, gender, medical school, year of application, and categorical status were recorded. The resident’s medical school was classified into one of five regional groups: Southern, Central, Northeast, Western, and foreign. The Southern, Central, Northeast, and Western regions were defined by the Association of American Medical Colleges (AAMC), while the foreign group contained medical schools that fell outside of the United States and Canada and the classification of the AAMC. The residents were compared by five-year increments.  

Results: During this 37-year period, 639 residents were in general surgery training. The percentage of women in the resident population increased from 9% in 1980-1984 to 36% in the 2015-2017 group. The percentage of non-Caucasian students increased from 3% in the 1980-1984 group to 26% in 2015-2017 group.  While 90% of the residents were from the South in the 1980-1984 group, only 69% of residents were from the South between 2015-2017.   

Conclusion: This Southern general surgery residency program has increased in diversity over the course of nearly forty years.  More women and minorities are becoming surgeons, and our institution has stretched to recruit students from across the United States and worldwide. While much progress has been made to further surgeon diversity in all respects, continued efforts must be made to grow a surgeon population that mirrors the diversity in the population they intend to serve.

 

19.17 Developing a Screening Tool to Evaluate Burnout Risk in Surgery Residents

Posted on January 31, 2019

A. Jambhekar1, Z. Nasrawi2, R. Lee2, H. Ali2, J. Rucinski2  1Columbia University College Of Physicians And Surgeons,Breast Surgery Division,New York, NY, USA 2New York Presbyterian Brooklyn Methodist Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction:  Current literature identifies burnout as a significant problem in all residency programs with emphasis on the highest risk for burnout in surgical residents. Several screening tools have been developed and validated, but none have been developed specifically pertaining to the surgical culture. The objective of the current study was to develop a screening tool to evaluate burnout risk in surgical residents.

Methods:  The Surgery Burnout Survey was developed through the collaboration of two university affiliated community programs with components detailing emotional health, physical health, work-life balance, interpersonal relationships, compassion fatigue, and resilience. The survey was given to current surgical or surgical subspecialty residents in postgraduate years two through five (n = 7) as well as recent graduates (n= 7). Recent graduates were defined as surgical fellows and attendings who had graduated from residency in the past two years. The tests were scores out of a total of 200 points with higher scores indicating greater risk for burnout. Statistical analysis was conducted using Student’s t-test. Data is expressed as mean +/- standard deviation.

Results: The current surgical residents had a mean score of 138.1 +/- 18.0 compared to 109.7 +/- 12.4 for the recent graduates (p = 0.004). The residents scored higher in physical health, interpersonal relationships and resilience, and similar to recent graduates in emotional heath, work life balance, and fatigue. Qualitative interviews with all of the participants revealed they felt the survey captured the pressures of residency well and that many of these issues were not specifically addressed in other screening tools.  

Conclusion: The Surgery Burnout Survey identified current surgical residents at higher risk for burnout compared to recent graduates. The breakdown of the scores suggested that current residents are experiencing stress in the areas of physical health, resilience, and interpersonal relationships which may allow for targeted interventions. Further studies are ongoing to validate the screening tool in a larger group of current surgical residents.

 

19.16 Effective Resident Oral Case Presentation Skills During Surgical Consultations

Posted on January 31, 2019

J. W. Feimster1, S. W. Knight1, M. L. Boehler1, C. J. Schwind1, H. Han2, R. H. Kim1  1Southern Illinois University School Of Medicine,Department Of Surgery,Springfield, IL, USA 2Southern Illinois University School Of Medicine,Department Of Medical Education,Springfield, IL, USA

Introduction: Resident oral patient case presentations are important means for physician-physician communication and a key component of a resident’s progression from a junior resident to a senior resident role. Entrustment decisions by faculty attendings are based, in part, on resident communication through oral case presentations. Despite this importance, there are few guidelines that define an effective surgical oral case presentation. This preliminary study aims to discover assessment criteria that characterize effective and authentic surgical oral presentation skills that could be utilized to develop guidelines for the assessment of surgical oral case presentations.

Methods: Utilizing qualitative research methodology, audio recordings and transcriptions from actual surgical consults that were presented by a resident to an attending surgeon were evaluated by 3 evaluation panels of surgeons and senior residents. The evaluation panel discussions were moderated, recorded, coded, and analyzed by three experienced qualitative researchers. Themes were then identified from the data that characterized effective and non-effective presentation skills.

Results: Preliminary data analysis of the panel discussions indicated that authentic assessment criteria should embrace various contextual considerations including time of the day, level of training, mutual trust, and attending variability. Themes identified that characterized effective communication included an opening summary statement, concise and succinct presentation, mutual trust between the presenter and attending surgeon, and a deductive flow. These themes are interrelated and dynamically shape the nuance of assessment criteria of the skills. Themes that were associated with non-effective communication skills included vague introductions, inclusion of unrelated or irrelevant history, and following an inductive flow pattern. The length of a presentation was deemed to be equivocal, as more complex cases or junior level resident presentations may require more supporting evidence for their reasoning in presentations.

Conclusion: This preliminary study identified themes that characterize effective and non-effective communication skills that attending surgeons use to internally assess surgical residents during a surgical oral case presentation. These themes can be utilized to develop standardized guidelines for the assessment of surgical oral case presentations.

 

19.15 Case-Based Simulation Workshop to Teach Surgical Residents the Skills of Goals-of-Care Discussions

Posted on January 31, 2019

M. Fiorentino1, F. Hwang1, K. Oberoi1, S. Pentakota1, A. Kunac1, S. Lamba1, A. C. Mosenthal1  1New Jersey Medical School,Surgery,Newark, NJ, USA

Introduction:
Surgical residents report lack of confidence and training in discussing goals-of-care (GOC) with patients and families, especially in emergency surgery settings.  Effective July 2019 the ACGME will mandate training in GOC discussions. We evaluated the feasibility and efficacy of a simulation workshop to teach surgical residents the skills of effective communication in discussing GOC.

Methods:
Surgical residents (PGY 1 and 2) attended a two-hour simulation workshop during their weekly education time. The curriculum included: 1) an interactive didactic session on a step-by-step guide for GOC discussions, 2)  small group simulation/role play sessions with 2 case scenarios with a standardized patient (SP)/family portrayed by a senior resident, and 3) debriefing and feedback by senior residents, a surgical attending board-certified in hospice and palliative medicine, and members of palliative care team.  The case scenarios focused on eliciting treatment preferences from family of a patient with sepsis and a prolonged postoperative ICU stay and from a patient with a malignant bowel obstruction. A pre and post questionnaire (5-point Likert like) assessed residents’ attitudes and knowledge about GOC discussions. The responses were analyzed using a paired t-test.

Results:
20 junior surgical residents (PGY-1 and 2) participated in the workshop. Post intervention scores (“somewhat agree” or “strongly agree”) increased on knowledge (65% to 100%) and comfort in having GOC discussions (35% to 70%). Despite the increase in knowledge and comfort level, only 35% of residents felt comfortable teaching how to have GOC discussions. When comparing pre and post test workshop responses each resident, showed improvement in knowledge and comfort in discussing and teaching GOC(Table).

Conclusion:
A two-hour structured workshop increased residents’ knowledge and comfort in having GOC discussions. This session addresses a perceived gap by trainees.  Case-based simulation to teach GOC discussion is feasible and effective for surgical residency programs to reproduce within budget and time constraints.
 

19.14 Factors that Influence Publication Rates of Abstracts Presented at the Academic Surgical Congress

Posted on January 31, 2019

H. L. Minton2, S. Goyer1, K. Feng1, H. Chen1, B. L. Corey1,3  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 3Birmingham Veteran’s Affairs Medical Center,Department Of Surgery,Birmingham, AL, USA

Introduction:

As medical school and residency programs encourage increased student and resident research, thousands of abstracts are submitted to conferences annually. The purpose of this study is to determine the rate of publication of the oral and plenary presentations from the 2017 Academic Surgical Congress (ASC) and assess factors that influence the likelihood of publication.

Methods:  

Abstracts selected for oral and plenary presentations at the 2017 ASC were evaluated for publication status via PubMed, Google Scholar, and NIH Reporter searches. Publication status, including date of publication and journal title, the academic rank of first and senior authors, and the type of study, such as basic science (BS), clinical outcomes (CO), and education (Edu) were collected. The impact factor of each journal was determined using the 2017 Journal Citations Report. Impact factors were categorized as low (0-3), moderate (3.1-7), or high impact (7.1-10+). In addition, senior author funding status, source, and amounts were cataloged. Statistical analysis was conducted using SAS.

Results: 

There were a total of 360 oral and plenary presentations. 41.4% (n=149) of oral and plenary presentations were published, including one by correspondence. BS, CO, and Edu presentations had publication rates of 31.7%, 51.1%, and 57.7%, respectively. Senior authors with an academic rank of Professor, Associate Professor, and Assistant Professor had publication rates of 41.8%, 49.4% and 43.3% respectively. First authors were primarily residents, students, or fellows and had publication rates of 40.4%, 59.5%, and 45.7%, respectively. None of these factors were statistically significant (p= 0.07, 0.697, and 0.183).

159 (44.2%) senior authors had a source of funding, of which 129 (35.8%) were from the National Institute of Health. 57.8% of abstracts with a source of funding were published. 36.6% of abstracts without funding were published. Funding sources had a positive association with publication (p <0.001). Manuscripts were published 1 to 16 months after ASC. Published abstracts were primarily printed in low or moderate impact journals, with 51.9% in low, 35.9% in moderate, and 12.2% in high impact journals. The majority of manuscripts were CO (62.8%) in nature, followed by BS (25.6%), then Edu (11.5%).

Conclusion:

After 16 months, 41.4% of the oral and plenary presentations had achieved publication, a rate similar to previous studies within other fields. Academic rank of first or senior authors had no influence on publication rate, while a funding source increased the likelihood of publication. Further investigation of factors that influence publication should be completed, as well as a follow-up study including additional ASC conferences.
 

19.13 Integration of Interactive Quiz Technology into Modern Surgical Education

Posted on January 31, 2019

D. Dolan1, J. Aalberg2, C. Divino1  1The Mount Sinai Hospital,General Surgery,New York, NEW YORK, USA 2Tufts University School of Medicine,School Of Medicine,Boston, MA, USA

Introduction:
The didactic lecture style used to teach residents hasn’t significantly changed since the beginning of the 20th century. Only in the last 20 years has problem-based learning begun to accompany lectures. Previously, questions were asked via PowerPoint© and Personal Digital Assistants (PDAs) during lectures. Now digital applications (apps) on smartphones have replaced PDAs. One example of an app is PollEverywhere© which allows audience response to questions, surveys, and images posted by the presenter. The presenter can then assess learners’ understanding and address problem areas. By using the app with the lectures given during surgical education, it was hypothesized that both subjective satisfaction with learning and objective scores on the American Board of Surgery In-Training Exam (ABSITE) would increase.

Methods:
The 31 categorical surgery residents at the Icahn School of Medicine of postgraduate year (PGY) 2 or higher in January 2017 were eligible to participate. PollEverywhere© was used to ask quiz questions in large group lectures from Fall 2016 to the 2017 ABSITE. After IRB approval and individual consent was obtained, the residents were surveyed before and after the 2017 ABSITE and data on previous test performance acquired including all ABSITE raw, calculated out of 800 total points, and percentile scores. Satisfaction score and raw score changes were then calculated.

Results:

19 of 31 residents (61%) completed the pre- and post-ABSITE surveys. 53% believed using the app contributed to their learning. 74% were satisfied with the current way the app was used. 84% were interested in continuing to use the app in the next academic year. ABSITE raw score change before PollEverywhere© in 2015-2016 was determined for each PGY level and then compared to the raw score change of the same PGY level from 2016-2017 to measure the app's effect. After PollEverywhere©, raw scores improved in the PGY 1-2 and 2-3 groups but this was not noted to be statistically significant (Table 1). Previous test performance, sleep prior to exam, and difficulty of rotation were not found to be modifying propensity factors.

Conclusion:

Most residents were satisfied with PollEverywhere© and believed it contributed to their learning. The ABSITE cannot test all concepts taught within the academic year and so sample error of the test itself will change the score changes seen. Despite this, scores generally improved with use of the app. This study lacked statistical power due to sample size. Further work is needed with a larger sample to determine statistical significance, refine how to better implement the technology to improve satisfaction and scores, and determine any propensity modifying factors.

19.12 Mentorship: Easier Than We Think

Posted on January 31, 2019

K. E. Bingmer1, C. M. Wojnarski1, J. T. Brady1, V. P. Ho2, E. Steinhagen1  1Case Western Reserve University School Of Medicine,General Surgery,Cleveland, OH, USA 2MetroHealth Medical Center,General Surgery,Cleveland, OH, USA

Introduction:
Mentorship is often identified as a key component in surgical education, and is associated with decreased rates of burnout and attrition. Residents are more likely to identify and meet with a mentor if their institution has a formal mentorship program (MP), which many residencies lack, possibly due to the perceived time and energy required to implement an impactful program. There is scant data evaluating the change in resident experience following introduction of a MP. We aimed to measure the difference in resident experience and perceptions after the implementation of a formal MP.

Methods:
An anonymous survey was distributed to all general surgery residents at a single academic institution before (PRE) and after (POST) implementation of a MP. The program involved assigned mentors for all residents, two social events, and a recommendation that mentors and mentees meet three times; all events and meetings were voluntary. Responses were recorded on a five-point Likert scale to assess differences in resident perception.

Results:
The PRE and POST respondents were similar in age, post graduate year, and gender (all p>0.05).  Half of respondents (n=17, 53%) attended at least one event, and over half (n=21, 66%) had at least one meeting with their mentor. The maximum number of meetings reported was 4 (n=4). The number of residents who identified a faculty mentor increased from 59% PRE intervention to 75% POST. Mean responses to most questions were improved on the POST survey, however this was not significant. The most influential aspect of the program was found to be interaction with mentors. When stratified by number of meetings, residents with two or more mentor meetings (n=12, 38%) were more likely to feel faculty were interested in teaching and cared about their development (both p<0.001). They were more likely to identify faculty they could speak to about academic (p<0.001), performance (p<0.02) and outside of work (p<0.005) concerns. These residents were also more likely to be satisfied with the amount of mentorship received (p<0.002), as well as their operative and clinical skill levels (p<0.05). Overall, active participation in the program resulted in a positive effect on resident perception (Table 1).

Conclusion:
Implementation of a formal mentorship program resulted in an improvement in resident perception of faculty involvement and support. Meeting as few as two times with a mentor resulted in a significant improvement in resident perception. Simply implementing a mentorship program can improve resident experience, and few interactions are needed to affect change.
 

19.11 Use of Oral Competency Exams Early in Residency: Improved Educational Value Over Traditional Exams

Posted on January 31, 2019

K. Y. Hu1, J. P. Dux1, P. N. Redlich2, R. W. Treat3, T. B. Krausert2, M. J. Malinowski2  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Education, Department Of Surgery,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Academic Affairs,Milwaukee, WI, USA

Introduction:
Traditional surgical resident education is based on didactic curriculums with performance gains reliably assessed by time-honored multiple-choice question (MCQ) exams. This assessment tool is common for junior residents, then transitions to clinical scenario-based teaching with oral competency examinations (OCE) for senior residents. Standardized oral examinations during residency have been reported to significantly improve certifying examination pass rates; however, limited information exists on the impact of oral examinations at the junior resident level. We hypothesized that junior residents would report improved confidence in their clinical performance and increased satisfaction with inclusion of OCE compared to traditional written post-test evaluations following didactic lectures.

Methods:
We modified our PGY-1 protected block curriculum in June 2016 to include OCE while maintaining the traditional post-test MCQ exams. In each curriculum block, residents were assessed with OCE consisting of two clinical scenarios over 16 minutes in front of an audience of five to seven peers, covering topics addressed in the curriculum’s didactic sessions. At the end of each academic year (2016-2017 and 2017-2018), participants were asked to complete a survey rating the perceived impact of OCE using a combination of 5-point Likert scales (1=poor, 5=excellent) and dichotomous responses (yes/no). Analysis was generated with IBM® SPSS® 24.0.

Results:
Of the 24 PGY-1 residents (12 in each academic year) who completed the voluntary survey, 91% thought the oral examination experience led to improved clinical performance in complex patient scenarios. Residents perceived that OCE improved their understanding of surgical indications (71%), preoperative work-up (88%), postoperative care (83%), and surgical complications (88%). The majority of residents (88%) rated the quality of teaching during OCE to be good or excellent, correlating with 92% who found benefit in observing their colleagues being examined (Spearman rho=0.6, p=0.002). Overall, 87% of residents thought OCE served as a better review of didactic materials than a written exam, strongly correlating with those who thought OCE provided good or excellent value as an educational activity (88%, r=0.7, p<0.001). The dynamic quality of teaching during OCE was also significantly correlated to its value as an educational activity (r=0.6, p=0.001), as well as to the improved review of materials (r=0.6, p=0.001).

Conclusion:
Assessment using OCE during PGY-1 curriculum sessions coupled with peer observation has additional educational value and adds enhanced confidence in clinical performance compared to traditional MCQ testing. Further study is warranted on the impact of OCE on in-training exam scores and senior resident mock oral board examination performance.
 

19.10 Exposure to Non-Preferred Music May Alter the Learning Curve for Surgical Trainees

Posted on January 31, 2019

K. B. Gil1, T. J. Mouw1, M. Jones1, P. J. DiPasco1  1The University of Kansas Medical Center,Surgery,Kansas City, KANSAS, USA

Introduction:
Previous studies have tested the effect of music on surgeons’ performance. These studies have shown reduced autonomic reactivity, improved quality and time of wound closure, and improved suture tying and mesh alignment using a robotic surgical system, while listening to preferred music. There is growing evidence supporting the benefits of preferred music on task performance, however there is a paucity of data regarding the potential impact on surgical and procedural learners. Surgical residents and medical students are often subjected to the preferred music of the attending surgeon, which may often be a non-preferred genre for the learner. There is currently no data evaluating the impact of listening to nonpreferred music on the performance of untrained individuals who are learning new surgical tasks. 

Methods:
31 medical students at the University of Kansas Medical Center, Kansas City were recruited by email to participate. Each participant filled out a survey to collect demographic information, music preferences, and assign each participant to a randomization group. Each participant underwent three training modules on the Da Vinci Si simulator under silent conditions. Each participant was then randomized to perform the same experimental task twice while listening to both preferred music and non-preferred music. Randomization determined whether a participant would listen to preferred music on their first trial vs their second trial. This was done to control for improvement that a participant may show simply by repeating the task. Following completion, each participant was given a score calculated by the Da Vinci surgical system.  Scores range from 0-100 and are a composite based on metrics such as time to completion, number of errors, and economy of motion.

Results:
31 participants participated in this study. The group which began testing with preferred music and repeated the task with non-preferred music had no significant change in their test scores (72.73 vs 74.33, p=0.34). However, the group that began with non-preferred music and repeated the task with preferred music showed significant improvement between trial runs (70.31 vs 81.88, p<0.001). There was no significant difference between the initial runs for each group. When analyzed irrespective of group assignment, there was a significant increase in scores for preferred music vs non-preferred music (77.45 vs 72.26 p=0.025).

Conclusion:
Participants showed expected improvement with task repetition. This improvement may have been offset by exposure to non-preferred music during repeat runs. Our findings suggest that the impact of music was nearly as large as the impact of prior exposure to the task. This may have implications for environmental conditions during resident procedural training, especially early in residency training when new tasks are being introduced and the skill level of the learner is still low. 
 

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