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

Posted on January 18, 2018

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

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

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

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

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

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

39.07 Effects of Implementing a Breast Surgery Rotation on ABSITE Scores and Surgical Case Volume

Posted on January 18, 2018

P. Kandagatla1, A. Woodward1, L. Newman1, L. Petersen1  1Henry Ford Health System,Detroit, MI, USA

Introduction:  Despite expansion of surgical breast oncology fellowship programs, little is known about optimal education of general surgery trainees regarding management of breast problems. Our goal was to measure the impact of a dedicated breast surgery rotation on American Board of Surgery In-Service Examination (ABSITE) scores and operative case volumes in a large general surgery training program.

Methods:  A dedicated breast surgery rotation was implemented at our program in the academic year of 2016-2017. We obtained the January 2017 ABSITE scores for PGY 1-3 residents, and compared results for the residents that completed the breast surgery rotation prior to the ABSITE to those of residents completing the rotation after taking the ABSITE. We performed a similar comparison for the skin, soft tissue, and breast (SSB) category of ABSITE questions. For the residents that had the rotation prior to the ABSITE, we also compared their 2017 scores to their 2016 scores. We also obtained the case volume totals for residents during the years 2015-2016 and 2016-2017. We compared the average number of major cases and SSB cases between the two groups.

Results: Nine residents completed the breast rotation prior to their ABSITE exam and nine residents completed the rotation after. There was no difference in the average ABSITE overall percentage correct between the two groups of residents (70.2% vs 71.72%, p = 0.55). There was also no difference in the average percentage of SSB questions correct between the two groups (70% vs 71.4%, p = 0.72). The nine residents also did not have a significant change in overall percentage correct when compared to their 2016 scores (69.6% vs 71.3%, p = 0.36). There were 19 PGY 1-3 residents during the 2015-2016 academic year and 17 PGY 1-3 residents during the 2016-2017 academic year. A PGY year-to-year comparison revealed a significant increase in the average number of total major cases among the PGY 1 residents (93.8 cases vs 166.8, p = 0.02). When comparing SSB cases, there was an increase in average cases among the PGY 1 (29.5 cases vs 59.6 cases, p < 0.01) and PGY 2 (58.7 cases vs 72.3 cases, p < 0.02) years.

Conclusion: A dedicated breast surgery rotation had no effect on ABSITE scores, but increased the case volume of both SSB and total major cases among junior residents. Given the new American Board of Surgery requirement for at least 250 operations by the end of the PGY 2 year, implementing a dedicated breast surgery rotation appears to be a valuable strategy for strengthening surgical case volumes and meeting these benchmarks. 
 

32.04 Impact of Frailty on Failure to Rescue After Low Risk and High Risk Inpatient Surgery

Posted on January 18, 2018

R. Shah1, K. Attwood6, S. Arya2, D. E. Hall3, J. M. Johanning5, N. N. Massarweh4  1Henry Ford Health System,General Surgery,Detroid, MI, USA 2Emory University School Of Medicine,Division Of Vascular And Endovascular Therapy/ Department Of Surgery,Atlanta, GA, USA 3University Of Pittsburg,Center For Health Equity Research And Promotion, Veterans Affairs Pittsburgh Healthcare System,Pittsburgh, PA, USA 4Baylor College Of Medicine,VA HSR&D Center For Innovations In Quality, Effectiveness And Safety, Michael E DeBakey VA Medical Center,Houston, TX, USA 5University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA 6Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA

Introduction:  Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publically reported quality measure. However, little is known about the impact of frailty on FTR—in particular, after lower risk surgical procedures.

Methods:  Retrospective cohort study of 984,550 patients from the National Surgical Quality Improvement Program (2005-2012) who underwent inpatient general, vascular, thoracic, cardiac and orthopedic operations. Frailty was assessed using the clinically applicable Risk Analysis Index (RAI) and patients were stratified into five groups based on RAI score (<=10, 11-20, 21-30, 31-40 and >40). Procedures were categorized as low (≤1%) or high mortality risk (>1%). The association between RAI, the number of post-operative complications (0, 1, 2, 3+), and FTR was evaluated using hierarchical modeling. 

Results: Among the most frail (RAI >30) patients in the cohort, ~20% were aged 55 years or younger. Regardless of procedural risk, increasing RAI score was associated with both an increased occurrence of post-operative complications and the number of complications. For those who underwent low risk surgery, major complication rates were 3.2%, 8.6%, 13.5%, 23.8% and 36.4% for RAI scores of <=10, 11-20, 21-30, 31-40 and > 40, respectively and for patients undergoing high risk surgery, the corresponding rates of major complications were 13.5%, 23.7%, 31.1%, 42.5% and 54.4%, respectively. Stratifying by the number of complications, significant increases in FTR rates were observed across RAI categories after both low and high risk procedures (Figure 1; trend test, p<0.001 for all). Increasing RAI was associated with an increased risk of FTR that was most pronounced after low risk procedures. For instance, the odds ratios (ORs) for FTR after 1 major complication for patients undergoing a low risk procedure were 4.8 (3.7, 6.2), 8.1 (5.9, 11.2), 19.3(12.6, 29.6) and 48.8 (22.7, 104.9) for RAI scores of 11-20, 21-30, 31-40 and > 40, respectively and for patients undergoing a high risk procedure, the corresponding ORs were 2.6 (2.4, 2.8), 5.2 (4.8, 5.6), 9.3 (8.5, 10.3) and 19.5 (16.8, 22.6) respectively. 

Conclusion: Frailty has a dose-response relationship with complications and FTR that is similarly apparent after low and high risk inpatient surgical procedures.  Tools facilitating rapid assessment of frailty during preoperative assessment, may help provide patients with more accurate estimates of surgical risk and could improve patient engagement in peri-operative interventions that enhance physiologic reserve and can potentially mitigate aspects of procedural risk.