95.20 Using Electronic Health Records (EHR) Data in Practice Audit: Ureteroscopy-“ Stent or No Stent”

Posted on January 18, 2018

E. O. Abara1,2, E. Abara1,2  1Northern Ontario School Of Medicine,Clinical Sciences,Sudbury/Thunder Bay, ONTARIO, Canada 2Richmond Hill Urology Practice & Prostate Institute,Richmond Hill, ONTARIO, Canada

Introduction:

Ureteroscopy is commonly used in the management of stone and other diseases of the ureter. The use of stent before and after ureteroscopic lithotripsy remains controversial. Electronic Health Records (EHR) , a software platform that contains data captured during patient encounter is useful for billing but other applications in research, data analysis, practice audit and quality improvement are gaining momentum. In 2013, we adopted the use of Electronic Health Record(EHR).

The purpose of this study is to understand the basic ways of manipulating EHR data to identify “hot spots” in ureteral stone management and describe the treatment outcomes in a community urology practice.

Methods:
Data recorded in the physician’s clinical notes, operative room records including details of procedure and fluoroscopy times and follow up were reviewed and extracted. Tracking of the procedures were verified using the Diagnostic and Billing codes. For question formation and sequencing, a literature search was completed through PUBMED, Medline, Cochrane Data base using such words and phrases as EHR Ureteroscopy Stent or No Stent, EHR Data analysis. Data collection was between 2001 and 2004 and included patient’s age, sex, stone features, stent or no stent, operating and fluoroscopy times, out-patient or in-patient. Data extracted were then transferred into a random number spread sheet function for analysis.

Results:
There were 192 procedures – 149 ‘Stent’ and 43 ‘No Stent’, ratio 3:1.These two groups were comparable regarding patients , stone features, stone free rates , infections and complications.The mean stone size was 8.5+/-2mm.Stone free rates at 6 weeks was 100% in each group. There was relief of renal colic in all patients immediately. After 2 days, lower urinary tract symptoms (LUTS) were ‘zero’ in ‘non stented’ compared to the ‘ stented’ patients. These results are similar to current literature.

Conclusion:

Data extraction and manipulation from the EHR was successful. In addition to billing purposes, EHR application in research, chronic disease management, quality improvement and practice audit is attractive and will grow.

95.19 USING COGNITIVE TASK ANALYSIS TO DEFINE HEPATO-PANCREATICO-BILIARY INTRAOPERATIVE ULTRASOUND

Posted on January 18, 2018

N. J. Zyromski1, M. G. House1, A. Nakeeb1, M. Boehler1, G. L. Dunnington1  1Indiana University School Of Medicine,SURGERY,Indianapolis, IN, USA

Introduction:
Intraoperative ultrasound (IOUS) is an indispensable asset in contemporary hepato-pancreatico-biliary (HPB) surgery.  However, few formal instructional objectives exist with which to teach this complex task.  The educational construct of cognitive task analysis (CTA) provides ideal methodology with which to deconstruct complex cognitive strategies and goal structures underlying the automated procedural skills of experts. We sought to define specific tasks associated with IOUS by means of CTA.

Methods:
One analyst broadly experienced in CTA evaluated three expert HPB surgeons (mean IOUS experience 15 years).  Evaluation included direct observation of IOUS as well as focused interviews with each expert during which action and decision steps of specific tasks were interrogated.  The results of these interviews were aggregated into a document defining the task, including a stepwise protocol as well as action and cognitive decision points involved with the procedure.

Results:
CTA defined the objective, prerequisite skills and knowledge, conditions and equipment required for HPB IOUS.  The task list included: 1) initial scan and exposure; 2) equipment preparation (orientation, image refinement); and 3) systematic scanning and interpretation.  Systematic scanning steps were defined for the liver, pancreas, and biliary tree.

Conclusion:
Defining concrete measurable procedural steps by cognitive task analysis will facilitate achieving expertise in the complex cognitive technical skill of hepato-pancreatico-biliary intraoperative ultrasound.
 

95.18 Use Of 3d Printed Models For Pre Operative Rehearsal Prior To Complicated Aortic Surgery

Posted on January 18, 2018

J. T. Toniolo1,2, A. Woo1, N. Chiang1, J. Chuen1,2  1Austin Hospital,Department Of Vascular Surgery,Melbourne, VICRORIA, Australia 2The University Of Melbourne,Department Of Surgery,Melbourne, VICTORIA, Australia

Introduction:
We present a simple technique for the pre-operative planning and technical practice of complicated aortic surgery using 3D printed models.

Methods:

A 1040 slice CT of a complicated aortic case was imported into imaging processing software and a stereolithographic replica printed using Formlabs Clear Resin and polished with Dulux Dura-Max plastic primer and White Knight Crystal clear acrylic to improve resin transparency.

 

The aortic model was suspended and secured in a plastic container filled with waterbeads and placed on an angiography suite table. Lengths of transparent polyvinyl tubing 6mm in diameter were aligned against and taped to the subclavian and external iliac arteries of the aortic model. A camera was placed on the gantry and video streamed to a monitor made visible to the operator

 

The surgical procedure was then recreated, allowing the operator to practice cannulating the model through the polyvinyl tubing and feeding chimney stents into the coeliac axis, SMA and bilateral renal arteries of the model aorta.

Results:
Whilst CT imaging is capable of stereoscopic rendering to provide a 3D representation of the aorta; these images can only be viewed in 2D, which makes subtleties of complicated anatomy difficult to appreciate. We offer a simple and cheap model that we predict will improve preoperative planning through a better understanding of the anatomy, improve the operative times through practice of key steps involved in the surgery and reduce complication rates by early identification of issues prior to performing the real surgery.

Conclusion:
The use of 3D printing in medicine affords surgeons the unique ability to simulate complicated operations on anatomy matched to individual patients. We provide an example of how a simple printed model can be used to improve operative planning and reduce both complication rates and operative times.

95.17 Critical Care Education in Rwanda

Posted on January 18, 2018

J. Rickard1,2, E. Tuyishime2,3, F. Ntirenganya2,3, P. Banguti2,3  1University Of Minnesota,Minneapolis, MN, USA 2University Teaching Hospital Of Kigali,Kigaii, , Rwanda 3University Of Rwanda,Kigali, , Rwanda

Introduction:

Critical care resources are limited in low- and middle-income countries. However, many patients present to referral hospitals with advanced critical illness necessitating intensive care unit (ICU) admission. Most ICU teaching in Rwanda  is performed at the bedside. To improve the critical care training at a tertiary referral hospital in Rwanda, we instituted a critical care teaching module. 

Methods:
We describe the development of a critical care teaching module administered in the ICU of a tertiary referral hospital in Rwanda, with lectures tailored to locally available critical care resources. We present an outline and model for teaching critical care in a low-resource setting.

Results:

We developed a series of core critical care presentations to be administered on a bi-monthly basis. These talks supplement routine ICU bedside teaching. Presentations are tailored to relevant resources and availability, but with forward-looking approach, anticipating the growth of local resources over the ensuing years. Topics are aimed at medical students and residents in multiple specialties including anesthesia, surgery and emergency medicine. Lectures are repeated over a two-month cycle, allowing for each rotation of residents and students exposure to these topics. Material is shared with all participants to encourage knowledge dissemination. A pre- and post-rotation assessment is being developed to measure trainees’ knowledge of critical care material at the beginning and end of their rotation.

 

In future iterations, we will expand the curriculum to cover a broader range and more specialized topics for senior residents. Challenges to the teaching program include identification of a local champion and methods of assessment and knowledge retention. Future directions include expanding the critical care teaching program to a multidisciplinary program including ICU nursing education. 

Conclusion:
While ICU resources are limited, teaching critical care topics can have important impacts on patient management. The knowledge gained through these topics applies to patients both in and outside the intensive care unit. Providing a resource bank of lecture material with a defined schedule of topics can be a model of sustainable teaching in a low resource setting. 

95.16 Global Surgery in the 21st Century: Equity in Training Partnerships

Posted on January 18, 2018

J. Rickard1, K. Chu2  1University Of Minnesota,Surgery,Minneapolis, MN, USA 2University Of Cape Town,Surgery,Cape Town, , South Africa

Introduction:  

Safe and affordable surgical care has been recognized as an important component of global health. One of the challenges in providing safe and affordable surgical care is the shortage of trained surgical workforce. Partnerships have developed between institutions in high-income countries (HICs) and low- and middle-income countries (LMICs) to strengthen and expand surgical education in LMICs. As these relationships evolve, emphasis needs to focus on development of equitable, bilateral partnerships. We describe features of successful, equitable, bilateral partnerships supporting surgical education in LMICs and provide a blueprint for developing such a partnership.

Methods:  

We compared different global surgery education partnerships to define features of equitable partnerships. We describe key components and features of successful partnerships and describe how to establish an equitable global surgical education partnership.

Results: 

Key features of equitable global surgical education partnerships include an alignment with local priorities, long term collaborations, and locally integrated, competency-based training. To develop a partnership, both parties must meet and perform a needs assessment of the LMIC institution and jointly agree how the partnership can best address these needs. Partnerships can be enhanced through twinning programs, focusing on faculty teaching roles. Institutions from HICs can fill in gaps in training through observerships, fellowships, or other training opportunities for LMICs trainees. Multi-institutional consortiums provide more consistent support in LMICs. However, these need to be tempered with appropriate organization and structure, avoiding inconsistencies and disorganization amongst HIC partner institutions. Both the HIC and LMIC institutions must clearly define their goals and expectations. Ideally, a set of output measures will be defined to assess the success of the partnership. 

Conclusion:
Improving surgical education in LMIC countries is an integral part of health equity in global surgery. Key components of equitable education partnerships focus on local ownership and long-term relationships. Each party needs to clearly define goals and expectations for the partnership. Strategies for long-term relationships need to be based on both the current and future conditions at the LMIC institution.

95.15 Implementing the Trauma Evaluation and Management (TEAM) Course in Kenya

Posted on January 18, 2018

E. D. Johnson2, K. A. Hill1, M. Lutomia4, K. K. Lee1, J. A. Puyana1, J. MacLeod1,3  1University Of Pittsburgh,Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA 3Egerton University,Surgery,Nakuru, KENYA, Kenya 4Egerton University,Orthopedic Surgery,Nakuru, KENYA, Kenya

Introduction: Trauma is a leading cause of death worldwide and > 90% of injury-related deaths occur in low-and-middle-income countries (LMICs), including Kenya. Trauma skills courses have been modified for low-resource environments in sub-Saharan Africa. Outcomes include knowledge and skills acquisition, as well as improved patient mortality. These courses have primarily been administered to surgeons, surgical residents, medical officers (MOs, initial general practice after medical school), and non-physician providers. Provision of this essential curriculum to undergraduate medical students in LMICs has been infrequently reported.

Methods:  The Trauma Evaluation and Management (TEAM) course adapts concepts of trauma assessment for medical students in their clinical years, and includes lecture presentations, video demonstrations, case scenarios, and skills sessions. Materials were donated by the American College of Surgeons (ACS) and regional surgical training sites, for implementation at the Egerton University Medical School in Kenya. The course was taught over 2 days in January 2017, by an interdisciplinary and multi-institutional team of surgical and radiology faculty and residents. Sixty-one undergraduate medical students in their final (6th) year participated. Adaptations for low-resource practice included: didactic emphasis on history and physical, inclusion of alternatives during skills sessions, and demonstration of point-of-care ultrasound. Formative assessment was integrated into small groups, and summative assessment included pre- and post-test evaluations. Tests were developed by instructors, with differences evaluated using paired t-tests. Participants provided voluntary written feedback on the course itself.

Results: 84% of students improved from pre- to post-testing. Mean pre-test score was 57% (range 25-85) and mean post-test score was 72% (range 45-95), demonstrating significant improvement (p<0.001). The poorest-performing decile of students on pre-testing showed more improvement on post-testing, compared to the highest performers on pre-testing (median improvement 30 percentage-points vs. 0 percentage-points, p<0.05). Narrative feedback on the course was positive, from both students and faculty.

Conclusion: Implementing the TEAM course in Kenya was successful, as measured by knowledge acquisition—especially for students with the least pre-existing knowledge. The course presents principles of trauma, which are otherwise not systematically covered, and which are valuable for students’ general practice as MOs. The experience strengthened institutional partnerships among faculty. Future work could include interval post-course surveys during MO-practice, to determine skill and knowledge maintenance and utility. We demonstrated the course’s effectiveness and feasibility, which can translate to future educational initiatives for the students and faculty of this and other medical schools in LMICs.

 

95.14 Evolution of Hyperthermic Intraperitoneal Chemotherapy (HIPEC). A Glance At What the Future Holds.

Posted on January 18, 2018

R. J. Rivero-Soto1, Z. Hossein-Zadeh1, J. Coleman1, N. Ahuja2, V. Ahuja1  1Sinai Hospital Of Baltimore,General Surgery,Baltimore, MD, USA 2John Hopkins University,General Surgery,Baltimore, MD, USA

Introduction: Cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has evolved as the standard of care for patients with peritoneal spread who were considered incurable or untreatable in the past. This is a paradigm shift where combining new technology and directed chemotherapy has rapidly been adopted, along with utilization of risk stratification for improved patient outcomes. Even though CRS and HIPEC are already stablished treatment modalities, more research is necessary to discover the best approach for better outcomes.

Methods: In this study we focus on a review of the current literature being conducted in attend to further revolutionize CRS and HIPEC.To this day, outcomes from CRS and HIPEC procedures are mixed for peritoneal disease which has pushed us to learn from other cancer treatments. For example, we have observed that cancer treatment is rarely given in a one-time, single dose course, as it is done in HIPEC; thus, as part of the future evolution of this method, we are interested in the role of multiple chemotherapeutic agents and immunotherapy in the setting of personalized medicine.

Results: Extensive debulking procedure was initially described for locally advanced ovarian cancer  in the 1930s. Subsequent reports by Drs. Griffiths and Munnell in the 1960s reported improved survival for stage IV ovarian cancer in patients with CRS and residual tumor size < 2cm. The next major discovery was the introduction of “thermal transfusion infiltration system” (TIFS) for delivery of hyperthermic intracavitary perfusate by Dr. John S. Spratt. In 1979, the first human was subjected to TIFS; a 35 year old male with recurrent Pseudomixoma peritonei who had previously undergone CRS only.
Further research in the early 1980s focused on the delivery of intraperitoneal chemotherapeutic agents at a concentration 30 times greater than conventional intravenous (IV) dosages. One of the first drugs used was Cisplatin. The rationale of such high doses of intraabdominal chemotherapy was that localized concentrations decreased systemic toxicities. In the 1990s, the Peritoneal Cancer Index (PCI) was developed. In 1995, Dr. Sugarbaker described a stepwise technique for peritonectomy in an attempt to standardize the procedure. In the early 2000s Drs. Glehan and Gilly of France developed the completeness of cytoreduction (CCR) score which allows for documentation of the extent of CRS. CRS was further advanced in 2005 with Sugarbaker introducing greater abdominal exposure with a self-retaining retractor.

Conclusion: This important topic highlights new technologies which allow physicians to view peritoneal malignancies as a more localized disease instead of a disseminated non-treatable condition. CRS with HIPEC is evolving; and future research will allow us to develop a better personalized treatment strategy with better outcomes.

 

95.13 New Surgery Residency and Timing of Cholecystectomy for Biliary Pancreatitis

Posted on January 18, 2018

A. D. Kalani1, L. Gomez1, J. R. Popovich1, K. Lee1, S. Cassaro1,2  1Kaweah Delta Medical Center,General Surgery,Visalia, CA, USA 2University Of California – Irvine,Surgery,Orange, CA, USA

Introduction:  Biliary pancreatitis (BP) is a frequent cause of emergency surgical admissions. In most cases BP is clinically mild and resolves rapidly. Current evidence indicates that a cholecystectomy should be carried out before discharge to avoid a frequent recurrence. The implementation of acute care surgery (ACS) services has been reported to positively affect adherence to cholecystectomy during the initial admission for BP, and to decrease average length of stay (ALOS). The presence of surgical residents has been reported to increase operative times. We report our experience with BP before and after the implementation of a dedicated ACS service at our institution to assess the impact of the service and the effects of a newly established Accreditation Council for Graduate Medical Education (ACGME) residency program in General Surgery.

Methods:  We reviewed 420 BP admissions between January 1, 2010 and June 30, 2016 and abstracted demographics, ALOS, time from admission to surgery, time from surgery to discharge, and operative time, then compared them for periods before and after the creation of dedicated ACS service, as well as before and after the first class of surgery residents began its training.

Results: 373 (88%) patients were managed operatively and 47 (12%) non-operatively. A cholecystectomy was performed during the same admission in 352 (83%) patients. After the implementation of the ACS service, both overall and post-procedural ALOS decreased significantly (p<0.05) from 5.4 to 4.4 and from 3.4 to 2.1 days, respectively. There were no significant demographic or management differences between any of the periods reviewed.

Conclusion: Post-procedural ALOS decreased after the ACS started and operative time did not increase after a surgery residency was established. 

 

95.12 A Robotic Surgical Curriculum for Chief Resident Exposure and Experience

Posted on January 18, 2018

M. P. Meara1, C. P. Rodman1, J. S. Schwartz1, D. B. Renton1, A. S. Meara1  1The Ohio State University Wexner Medical Center,Department Of Surgery,Columbus, OH, USA

Introduction:

This abstract will discuss a novel longitudinal curriculum that focuses on exposing residents to robotic surgery early in their training and developing that experience throughout their surgical residency.   Surgical robotics continues to evolve and is becoming more common for a variety of types of surgery.  One of the largest areas of growth is in General Surgery — specifically in hernia repair.  High volume surgeons are often in private practice and thus, ACGME trainees are frequently merely exposed to robotic surgery but have little console exposure or procedural education.  The majority of robotic surgery training is often done in post-resident training or is learned during a clinicians practice, placing a burden on the system and requiring significant funding to teach board certified surgeons expanded skills. There are few programs—and even fewer in general surgery—that describe an ACGME trainee curriculum for robotic surgery, and those which exist are primarily comprised of online modules, simulation, and a varying amount of console cases. Thus, there is a growing need to create a hands-on robotic surgery curriculum in surgical training. 

Methods:
The Ohio State University (OSU) has a single, dual-console Intuitive da Vinci Xi Robotic System with a dedicated General Surgery service line.  There are three attending general surgeons that have been successfully trained in robotic surgery and now help teach the surgical residents and fellows.  Privileges to operate on the console is a combination of online modules, laboratory simulation modules, and bedside assisting prior to console operating.

Results:

Since obtaining the dedicated service line robot in December of 2016, four Chief Surgical Residents have rotated on the surgical service (two-month rotations).  Each resident has performed on average 23.625 console cases per month or 47.25 cases per rotation as the primary console surgeon.  Each of the residents completing the rotation has obtained Intuitive certification of their experience.  This specific rotation can translate to privileging and credentialing at their respective institutions upon graduation.

Conclusion:

Due to the expanding role of robotic surgery, specifically in general surgery, it is vital that surgery-training programs begin to incorporate new curricula to not only expose ACGME trainees to robotic surgery but also develop competent future robotic surgeons.  Robotic curricula are described per the university training program and each is unique. The next step is to create validated assessment measures for the trainees as well as ACGME training expectations.

 

95.10 "Integrating Surgical Philanthropy into Surgical Training"

Posted on January 18, 2018

S. R. Aziz1, S. R. Aziz1  1Rutgers School Of Dental Medicine,Oral & Maxillofacial Surgery,NEWARK, NJ, USA

Introduction: International humanitarian experiences during residency can provide an integral teaching and training experience for the surgical resident. Multiple surgical specialities have documented international resident training experiences; however the question persists if these experiences are truly beneficial to resident education through out the spectrum of surgical specialties

Methods: Review of the  literature of articles from multiple surgical specialties ( Oral/maxillofacial, Plastic, Otolaryngology, orthopedic, and general surgery) on resident experiences during training, specifically looking at whether these opportunities met the Accreditation Council for Graduate Medical Education core competancies 

Results: Multiple articles were reviewed in the general surgical, orthopedic, plastic, otolaryngology, and oral/maxillofacial literature. All articles included surveys of residents in surgical specialties who participated in international medical missions

Conclusion: Literature review revealed that international medical missions were of value and met Accreditation Council for Graduate Medical Education core competencies as long as the medical mission was well structured, proctored, and routinely re-evaluated. Further resident activites ideally must be supervised in a similar fashion to that in the United States. All articles reviewed emphasised that resident participation not only helped with clinical growth but more importantly helped develop residents' cultural competancy

 

95.11 Evaluation of Trauma, Surgical Critical Care, and Acute Care Surgery Fellowship Web Sites

Posted on January 18, 2018

C. K. Cantrell1, N. J. Dahlgren1, B. L. Young2, K. M. Hendershot3  1University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA 2Carolinas Medical Center,Department Of Orthopaedic Surgery,Charlotte, NC, USA 3University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:  Graduating surgery residents are increasingly pursuing fellowships and rely heavily on fellowship programs’ web sites as a primary source of information. Therefore, accessibility, quality, and content of a program web site can encourage or deter an applicant from applying to a particular program. Past web site analyses have shown web page deficiencies across several fellowship programs and significant time and cost burden to general surgery residents during fellowship interview season. The goal of this study was to perform an analysis of trauma, surgical critical care (SCC), and acute care surgery (ACS) fellowship program web sites.

Methods:  A list of trauma, SCC, and ACS fellowship programs was obtained from the Eastern Association for the Surgery of Trauma (EAST) web site. The existence of a functional hyperlink in the EAST program directory and a systematic Google search was assessed to determine web site accessibility. 21 content criteria were used to evaluate accessible web sites.

Results: The EAST directory contained 102 fellowship programs.  Of these, only 37 programs contained functional hyperlinks. 91 programs had web sites accessible through a Google search;11 programs lacked web sites entirely. Content contained in the individual fellowship web sites varied greatly, with no web site containing all 21 criteria. Only 29 web sites contained at least half of the evaluated content criteria.  The most common data point included was program description (97%), while role of seeing patients in clinic (4%) was the least common criteria present. See Table 1 for abbreviated results of the 21 assessed content criteria.

Conclusion: Many programs in the EAST directory lack functional links and accessible web sites. Of the accessible web sites, content important to applicants is lacking in varying degrees. Incorporation of this missing content may benefit both applicants and programs, allowing for more informed decision making when choosing a program, thus promoting better fit of fellows with programs during the application process. 

 

95.09 Mind Mapping to Concept Mapping: A Way to Capture Learner Perception

Posted on January 18, 2018

M. F. Amendola1, B. Kaplan1  1Virginia Commonwealth University,Richmond, VA, USA

Introduction:

Mind mapping[1] is a free response exercise that allows learners to express thoughts and impressions around a central topic. Concept mapping[2] is a diagram that depicts suggested relationships between established concepts. No studies to date have described the use of “mind mapping” coupled with “concept mapping” to capture learners’ perceptions of an educational program.

Methods:

An educational program covering clinical ethics and implications in surgical practice (core case studies in concepts of autonomy, justice, non-maleficence, beneficence, and integrity) was given to all first-year residents as part of an “intern boot camp.” Prior to the program an example of a concept map was explained.  An anonymous paper based pre-program mind mapping exercise was then conducted with the central the topic “clinical ethics.” After the program, each learner was then asked to complete a post-program concept map with the central topic of “surgical ethics.” Maps were examined and matched based on handwriting to allow for a pair-wise comparison. Primary and secondary levels of complexity as well as total words used were collected.

Results: 

A total of 22 mind maps were collected. Using a paired t-test for each learner there was no significant difference between primary and secondary levels of complexity nor total words used. Five or 22.7% of the learners were from our home institution and show significant difference in the same response variables. Most (19 of 22 or 86%) of the learners had a previous ethics educational program; when factoring this factor into pair-wise analysis of the subsequent concept maps, these learners has a significant mean total numbers of words utilized (p=0.004). Of note when learners stated they had not had previous exposure to ethics educational program, none of them utilized a secondary level of complexity in their concept maps. Of the five core concepts in ethics listed in the educational program, “autonomy” was found in most all the pre-program mind maps (14 of the 22 mind maps or 63%). After the program, most the learners (15 of 22 or 68%) mentioned a concrete surgical practice of informed consent (that is centered in autonomy) instead of repeating the previously mentioned abstract concept of “autonomy.”

Conclusions: 

With this novel sampling if learners reported the abstract pre-program concept of autonomy, they were more likely to subsequently answered with the concrete procedure of “informed consent.” These data should encourage other surgical educators about the possibility of using this pairing of pre-program mind mapping with post-program concept mapping to understand learners’ perceptions.

 

[1] Buzan, T., Buzan B. (1996). The Mind Map® book. New York: Penguin Group.

[2] Peter J. Hager, Nancy C. Corbin. Designing & Delivering: Scientific, Technical, and Managerial Presentations, 1997, 163.

95.08 Pediatric Surgeon Click-Bait: Patterns of Access to Email Blast Publication Links

Posted on January 18, 2018

S. S. Ayub1, C. D. Downard2, A. B. Goldin3, D. M. Powell4, S. Islam1, J. A. Taylor1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA 2University Of Louisville,Pediatric Surgery,Louisville, KY, USA 3Seattle Children’s Hospital,Pediatric Surgery,Seattle, WA, USA 4Stanford University,Pediatric Surgery,Palo Alto, CA, USA

Introduction: The American Pediatric Surgical Association (APSA) Committee on Literature Reviews forwards monthly email blasts to its members that include links to peer-reviewed publications.  This member benefit has been anecdotally lauded but the access data not critically reviewed.  We sought to determine the rate of article access and what subjects attracted the most attention.

Methods: Email opening rate and link click-through rate was analyzed for APSA literature review email blasts sent from May 2012 – October 2016.  Individual articles’ access was analyzed based on subject grouping and total access frequency.  Statistical analysis was performed using one-way ANOVA and two-sample t-test (p<0.05).

Results: 137 articles were distributed.  There was a 53% email opening rate and 40% article access rate,  compared to 43% overall opening rate for any APSA emails and 22% overall click-through rate.  By subject, the top four were critical care (62 articles), appendicitis (16), care access (11), and genito-urinary (6).  There was no statistical significance in access frequency when comparing the four groups.  Comparing critical care and appendicitis, access to the appendicitis articles was significantly greater (average number clicks: 240+78.9 vs 191+75.4, p<0.035).  65 articles were accessed at least 200 times.  The most frequently accessed paper was in critical care (470 times), the least frequently accessed paper was also in critical care (47 times).

Conclusion: APSA members access literature reviews more than other emails sent by APSA; access rates also surpass the 2016 industry standard.  While there was a skewing of topics presented, articles focusing on appendicitis continued to be of interest to pediatric surgeons based on the number of times the links were accessed.  This shows that the email blasts are a well-utilized member benefit.  Future attention of the emails may re-direct focus based on subject matter distribution and frequency of access seen thus far.

 

95.07 Implementing Survey-Based Changes in an Online Curriculum for Surgical Interns: A Follow-Up Study

Posted on January 18, 2018

M. E. Alishahedani1, G. A. Sarosi1, J. A. Taylor1  1University Of Florida,Department Of Surgery,Gainesville, FL, USA

Introduction:  To promote the growth of the online curriculum at the authors’ residency program, study habits and learning resources used by surgical interns were previously evaluated and presented in a pilot study. Based on the results, multiple changes were implemented to enhance the interns’ weekly teaching conferences. To assess the use of these curricular changes, the interns were surveyed at the end of the academic year.  The purpose of this study was to use the responses to determine utilization and satisfaction with the new materials, in an effort to continuously evolve the institution’s surgical educational environment.

Methods: Surgical interns at a single academic institution were given an IRB-approved survey at the end of the 2017 academic year.  The survey focused on study habits and material use.  The responses were de-identified; participation was voluntary.  The survey was validated through a modified Delphi technique.  Descriptive statistics were performed on demographics.  Likert responses underwent Mann-Whitney analysis (α = 0.05).

Results: The response rate was 52.9% (n=9). 55.6% of the respondents were male. 33.3% were categorical interns. The Internet was the most-used resource, compared to all others used (p<0.05). All respondents used the Internet to some degree for study.  As in the 2015 pilot, the Surgical Council on Resident Education (SCORE) website was the most-used Internet resource (66.7%). 77.8% used review books, making this the next-most used material. Although 33.3% responded never using textbooks to study, textbooks and the Internet were the two resources that 22.2% of the interns always used. There was a statistically significant increase in access of the Internet for study use between 2015 and 2017 (p<0.05). All other sources were similarly used, to no statistical significance. Regarding new online material organized based on pilot study feedback, 55.6% of interns reported sometimes using the weekly reading links associated with a proprietary question bank. These links aligned with their teaching conference schedule. 66.7% were somewhat satisfied with it. 44.4% were somewhat satisfied with the use of new video links, which were organized in parallel with the This Week in SCORE (TWIS) curriculum. There were no “always” use responses for any new material.

Conclusion: Changes implemented in the surgical interns’ online curriculum were based on previous analysis and survey feedback in a pilot study. Interns were overall satisfied with the enhanced curriculum. The statistically significant increase in the use of Internet resources warrants attention. Material that was organized based on the pilot study feedback was not widely used. This may be due to resource fatigue experienced by the learner. The learner’s interaction with provided material is critical to curricular success. Keeping changes focused in future curricular design may aid in creating a more effective learning environment.

 

95.06 Introducing a Shadowing Experience to Surgical Intern Orientation: Hitting the Ground Running

Posted on January 18, 2018

K. F. Angell1, Z. Senders1, J. T. Brady1, J. Ammori1, J. M. Marks1  1University Hospitals Cleveland Medical Center,Surgery,Cleveland, OH, USA

Introduction: The transition from medical student to surgical intern is a challenging step, encompassing the use of new skills, new clinical sites, utilizing electronic medical records (EMR) systems and providing care for patients while supervising residents may be in the operating room. Surgical orientations covering a multitude of topics have been developed to prepare interns for this transition. Based on our previous orientation surveys, 83% of interns felt a shadowing experience would be very beneficial to internship preparation. We sought to implement a shadowing experience as part of intern orientation to simulate their clinical rotations and best prepare interns with the skills and knowledge required to be a successful intern. Our objective was to assess all orientation activities with a focus on the shadowing experience.

Methods: 15 incoming surgical interns participated in a preparatory orientation preceding the start of internship. Orientation activities included sessions on handoff skills, EMR use, administrative tasks, troubleshooting tubes and drains, surgical instruments and suturing. An optional activity was added for interns to shadow the surgical team on which they would start their internship. Interns participating in the shadowing experience met at one of three hospital rotation sites, attended morning rounds and observed current interns completing daily tasks.  Surveys assessing the value of orientation sessions in preparing for internship were administered to all participating interns 6 weeks after beginning internship.

Results: 13 of 15 incoming surgical interns participated in the shadowing session. The following sessions were assessed for usefulness: site tours, handoff practice, suturing and surgical instrument identification, tubes and drains management and general orientation. The tubes and drains lab and overall orientation were rated as most helpful, while surgical instrument labs and site tours rated as least helpful. The shadowing experience was rated ‘helpful’ by 6 of the participants and ‘very helpful’ by the remaining 7 participants. Comments reported shadowing as more valuable than EMR courses in learning EMR use, and multiple interns requested additional shadowing experiences.

 

Conclusion: The challenge of preparing incoming surgical interns for the transition to internship remains an area for continued improvement. Replicating the tasks required of surgical interns and covering key topics necessary for starting internship is an overwhelming task. A shadowing experience with surgical teams prior to the first day of internship may be a valuable and feasible experience that best exposes incoming interns to the tasks, knowledge and routine of surgical internship. This experience could easily be replicated at any surgical residency program. Surveying additional metrics may provide information to structure the shadowing experience to increase value and positively impact patient safety and workflow.

95.05 Understanding Diagnostic Radiology Education During Undergraduate Medical Education

Posted on January 18, 2018

R. W. Bailer1, R. Martin1  1University Of Louisville,School Of Medicine,Louisville, KY, USA

Introduction:  Diagnostic radiology is an important competency that spans multiple medical specialties, and imaging is a necessary tool to evaluate patients in coordination with physical exam. However, it is often overlooked during medical education, so it is important to incorporate clinically relevant diagnostic radiology into clerkships during medical students’ third and fourth years. The purpose of this study is to understand how diagnostic radiology is being taught, what barriers exist to increasing diagnostic radiology education, and possible solutions to those barriers.

Methods:  Data was gathered from four different sources: a comprehensive review of the literature on diagnostic radiology education during undergraduate medical education, the published AAMC Curriculum Data on radiology, a survey of clerkship directors at the University of Louisville in the departments of Emergency Medicine, Internal Medicine, Neurology, OB/GYN, and Surgery, and the same survey sent to clerkship directors of the same specialties at other public medical institutions.

Results: Literature revealed that students and faculty see value in diagnostic radiology education, but obstacles such as time in curriculum and cost make it difficult to implement changes. However, there have been innovative education initiatives implemented at some institutions such as vertical curricular integration, online modules, flipped classroom exercises, and externships. The AAMC Curriculum data revealed that few institutions require a radiology clerkship, and less priority is placed on radiology compared to other competencies. Responses to the institutional surveys reinforced the idea that diagnostic radiology is a low priority competency during students’ clerkships, even though clerkship directors value diagnostic radiology as a skill within the specialty. There are few dedicated instruction and evaluation methods being used currently, and overall, the directors have low confidence in students' competency upon completion of the clerkship.

Conclusion: There is room for improvement in diagnostic radiology education during undergraduate medical education, but several barriers exist to successfully implementing change. The future of effective diagnostic radiology education will be vertical integration into preclinical medical education as well as integration into core, required clinical clerkships.

 

95.04 Million Life Fighters: Curriculum That Further Enhances the Already Competent

Posted on January 18, 2018

J. K. Wright1, J. Lung1, S. Huffman1, D. Vyas1  1Texas Tech Health Sciences Center,School Of Medicine,Lubbock, TX, USA

Introduction:  The Million Life Fighters program is a multinational initiative whose primary goal is the bettering of prehospital trauma outcomes in rural locations. This initiative strives to reach this goal through training individuals in rural areas in the basics of trauma care. Previous examinations of this program showed its ability to improve the abilities of those with little medical knowledge prior to the training. Further examination was conducted to determine if the initiative improved those with some previous competency in basic prehospital care.  In order to ascertain this information, we studied individuals who began the Million Life Fighters training with high pre-course competence and measured their pre-to-post-curriculum gains in confidence and competence.

Methods:  Over three hundred volunteers from multiple institutions, using multiple languages, were given surveys and tests to score confidence and competence. The majority of participants being from the manipal community in India or from members of a volunteer disaster relief force in Jaipur. The range of possible “competence” scores were divided into thirds and those that scored in the upper third were labeled “high competence”. (The maximum competence score was 26). Those of high competence were further subdivided into low, medium, and high-confidence groups based upon assessed confidence scores.  Possible confidence scores, ranging from zero to 20, were divided equally into the three sub-sets. Paired t test analysis was conducted to measure gains in confidence and competence. The p-value for this study is .001.

Results: The 56 who started in the high competence and low confidence group increased their confidence by 11.98 (t=21.02) and competence by 3.04 (t=7.64). The 27 in the high competence and medium confidence group increased their confidence by 8.07 (t=13.48) and competence by 2.62 (t=5.13). The group who started off with high competence and confidence proved too small to show statistically significant results.

Conclusion: While a fundamental aspect of the Million Life Fighters initiative is to bring prehospital medical education to a wider populace, a population who are often new to any medical training, this program also proves its utility in being able to improve the capability of those who have a proficient understanding.

 

95.01 Mistreatment of Medical Students During the Surgical Clerkship and its Effect on Career Choice

Posted on January 18, 2018

H. E. Pierce1, L. J. Hinyard1, T. L. Schwartz1  1Saint Louis University School Of Medicine, St. Louis, MO, USA

Introduction: Surgical education has historically implemented intimidation and fear into its teaching strategies. Surgical clerkships are thought to be especially authoritarian and experiences during the clerkship may influence a student’s decision to pursue surgery. The objective of this study was to assess medical students’ perceptions of mistreatment during their surgical clerkship and the influence those experiences had on the choice of general surgery as a specialty.

Methods: A modified version of the questionnaire created and published by Dr. Scott and colleagues at the University of Sydney and Melbourne medical schools assessing medical mistreatment was sent to all third year medical students (n = 175). We received 61 completed surveys for a final response rate of 35 percent. Descriptive statistics are reported as counts and proportions.

Results: Experience of personal humiliation was reported by 32 percent of students and 30 percent had witnessed another student be humiliated. Rude behavior from an attending physician or surgical resident was reported by 63 percent of students, while 37 percent of students reported experiencing being yelled at by a resident or attending. Reporting of this mistreatment was low; 93 percent of students did not report mistreatment, even though 83 percent of respondents reported knowing where reports could be made (Table 1). Reasons for not reporting included: 1) would not have impact; 2) normalization of behavior; 3) time constraints; 4) fear of retribution. Of the 61 respondents, only 6 students reported they would be applying to general surgery for their residency and 57 percent of students stated the surgery clerkship affected their career choice.

Conclusion: Perceived mistreatment remains a common theme in medical student education. Experiences during the surgical clerkship that are felt to be humiliating, or embarrassing may deter student from pursuing a career in a surgical specialty.

95.03 #obsm: Early Experience with an Interdisciplinary Social Media Chat on Obesity and Bariatric Surgery

Posted on January 18, 2018

H. J. Logghe1, A. A. Ghaferi2, B. Moeinolmolki4, N. Floch3, S. Arghavan5  1Allies for Health,Reno, NV, USA 2University Of Michigan,Ann Arbor, MI, USA 3Fairfield County Bariatrics And Surgical Specialists,Norwalk, CT, USA 4Moein Surgical Arts,Los Angeles, CA, USA 5Washington University,St. Louis, MO, USA

Introduction:  Thirty-six percent of American adults have obesity. Bariatric surgery is the most effective treatment for obesity, yet less than 1% of eligible Americans undergo surgery. This discrepancy is often blamed on limited understanding of surgical treatments by patients and primary care providers. We hypothesized that tweetchats would be a novel way for surgeons to bridge the education gap and engage with allied health professionals, patients, and advocates. In December 2016, we initiated a monthly #obsm (obesity social media) tweetchat aimed at creating an interdisciplinary, patient-inclusive community to improve awareness of and access to unbiased, evidence-based treatments for those with obesity.

Methods:  Tweetchat dates and topics were announced through blog posts written by the leadership team of five surgeons and posted on personal and institutional websites, which were shared and publicized on Twitter. The tweetchats lasted one hour and occurred monthly. During each chat five pre-determined questions were presented in ten-minute intervals by the #obsm Twitter account. Each chat was moderated by a content expert, with healthcare professionals and other stakeholders recruited to participate. Tweets and corresponding user profiles were prospectively collected through the Symplur Healthcare Hashtag Project. Customized stakeholder categorization of participants was performed using Symplur Signals.

Results: The first six chats resulted in an average of 692 (range: 498-974) tweets, 8.4 (range: 5.4-13.6) million impressions, and 51 (range: 26-74) participants per chat. Participants averaged 14 (range: 10-22) tweets per chat. The interchat periods averaged 12.0 (range: 5.3-21.3) million impressions with 1,232 (range: 612-1,940) tweets by 276 (range: 168-413) participants. Stakeholder categorization revealed representation by individuals and organizations both within and outside healthcare. Table 1 demonstrates select stakeholders in the #obsm community during the 6 months analyzed.

Conclusion: A surgeon-led tweetchat on obesity and bariatric surgery resulted in robust participation and impressions from diverse participants. Discussion was sustained beyond the scheduled tweetchat. Of note, our results only capture active engagement by participants. Twitter, a public social media platform, allows people to see the content freely. As such, the estimates of participation and engagement may be underestimated. Nonetheless our experience suggests tweetchats may serve as powerful forums for surgeons in other subspecialties to engage with their respective stakeholders to improve understanding of treatment options, to enhance the experience of patients, and to reduce barriers to care.

 

75.10 Building TEAMs: Improving Trauma Management in Western Kenya

Posted on January 18, 2018

H. W. Li1, C. Donnelley3, M. Boeck2, C. Keung1  1Indiana University School Of Medicine,Indianapolis, IN, USA 2New York Presbyterian Hospital,New York, NY, USA 3Columbia University College Of Physicians And Surgeons,New York, NY, USA

Introduction: Ninety percent of trauma injuries, responsible for 10% of the world’s deaths, occur in low resource countries like Kenya. This surpasses the combined fatalities due to malaria, tuberculosis, and HIV/AIDS worldwide. Advanced Trauma Life Support (ATLS) is the gold standard for basic trauma training. However, ATLS is limited to training physicians only, and is not designed for medical students. Thus, the condensed Trauma Evaluation and Management (TEAM) course was developed in response. This study retrospectively assessed the effectiveness of incorporating TEAM into the Moi University School of Medicine (MUSM) curriculum in Eldoret, Kenya.

Methods:  The course took place over two afternoons in May 2017. Participants completed a baseline survey, an identical but scrambled 20 question pretest and posttest, and course evaluation. Test scores were analyzed using paired t-tests, and Wilcoxon signed rank test for confidence levels.

Results: N=34 participants met criteria for study inclusion, of which 61.8% (N=21) were male, and the median age was 23 years (IQR 22, 25). There were equal numbers of fourth and sixth year medical students (50.0% vs. 47.1%), and only 29.4% (N=10) reported previous trauma training. Overall mean test scores increased by 12.8% (51.1% vs. 64.0%, SD 12.1, p<0.001) from pre- to post-course. Subjective confidence to provide trauma care (0-5) significantly increased after course completion [median (IQR): pre 2 (1, 3); post 4 (4, 4); difference 2 (1,3); p<0.001].

Conclusion: TEAM was created as a systematic approach to trauma care teaching for medical students. For students in resource-limited areas, this can be their only exposure to formal trauma training. Early results show the course is effective at improving immediate trauma knowledge and subjective confidence levels, and due to its low demands for supplies and personnel, TEAM is a feasible tool that medical schools of all backgrounds can utilize, including those in low resource countries. Investigations into the application of learned knowledge to patient care via follow-up surveys, as well as trauma patient outcomes via a new trauma registry, will further elucidate the true impact of this course to improve trauma care in this region of Kenya. 

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