57.07 Resident Training in Robotic Surgery: Acquisition and Durability of Skills on a Simulation Console

Posted on January 18, 2018

K. D. Gray1, J. Burshtein1, T. M. Ullmann1, A. Elmously1, T. Beninato1, C. Afaneh1, T. J. Fahey1, R. Zarnegar1  1NEW YORK-PRESBYTERIAN-CORNELL,New York, NY, USA

Introduction:  Exposure to minimally invasive surgical techniques during residency is becoming increasingly important for surgical trainees. Our center developed a curriculum using the Da Vinci (Intuitive Surgical, Inc., Sunnyvale, CA) robotic simulation console that is available to all residents. We aimed to evaluate if skill acquisition and decay were related to post-graduate year.

Methods:  After implementation of a robotic curriculum in June 2016, residents in General Surgery (GS), Urology, and Obstetrics-Gynecology were given unlimited access to the console equipped with over 50 training modules selected by faculty. An overall score of 90% in each exercise was considered proficient, which was calculated by subtracting a penalty subscore from the efficiency subscore. Individual performance was tracked using unique login identifiers. Data was collected for all residents on the most commonly performed modules (n=18) over the first year of the robotic curriculum and analyzed by exercise type (coordination versus suturing) and PGY level.

Results: A total of 40 residents were included; 32/40 (80%) were GS residents and 23/40 (57.5%) were male. The median number of sessions on the simulator was 3 (range 1 – 15).

PGY level had no effect on initial score in coordination exercises (p = 0.28) or suturing exercises (p = 0.29) or on the number of attempts required to achieve proficiency for a given exercise (p = 0.70). PGY1s were most likely to be penalized for poor economy of motion (p < 0.001), whereas PGY5s were most likely to be penalized for excessive force (p < 0.001). Skill acquisition varied by exercise type (Figure). For coordination exercises, efficiency plateaued after the second attempt, and a passing score was subsequently reached by reduction in the penalty score. For suturing exercises, efficiency continued to increase with the number of attempts until a passing score was reached.  

Decay in skillset over time was observed in coordination exercises but not suturing exercises. In coordination exercises, a significantly greater median number of attempts were required to pass when comparing the initial session to sessions after six months without simulator exposure (3 attempts, IQR 2-5 versus 9 attempts, IQR 4.5 – 22.5, p = 0.006).  This difference was not seen in suturing exercises (3 attempts, IQR 2 – 4.5 versus 3 attempts, IQR 2 – 4, p = 0.31).

Conclusion: Proficiency in robotic training modules can be achieved regardless of level of training.  Coordination and suturing skills are acquired via different pathways, and suturing is a more durable skillset. Regular access to a robotic simulator beginning early in training has the potential to establish and sustain robotic skills. 
 

57.06 Astronaut Crew Non-Technical Skills for Medical Event Management on Deep Space Exploration Missions

Posted on January 18, 2018

S. Yule1,2,4,5, R. Dias2,5, J. Robertson2,5, A. Gupta4, S. Singh2, S. Lipsitz4,5, C. Pozner2,5, D. Smink1,4,5, J. Thorgrimson7, T. Doyle6, D. Musson7  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,STRATUS Center For Medical Simulation,Boston, MA, USA 4Brigham And Women’s Hospital,Center For Surgery & Public Health,Boston, MA, USA 5Harvard Medical School,Boston, MA, USA 6McMaster University,Department Of Electrical And Computer Engineering,Hamilton, ON, Canada 7Northern Ontario School Of Medicine,Thunder Bay, ON, Canada

Introduction:  In the unique context of deep space, long duration exploration spaceflight, an unforeseen inflight medical emergency could compromise crew health and jeopardize mission success. Returning prematurely to Earth or consulting with a flight surgeon via long distance communications may be challenging or impossible. In the operating room, non-technical skills (NTS) such as situation awareness, leadership, and team coordination have been shown to reduce performance errors and the risks associated with high acuity low frequency events. The aim of this study was to develop a NTS taxonomy and behavior markers to support astronaut crew training in preparation for the management of medical emergencies during long duration space missions.

Methods:  A Delphi method with an expert panel comprising physicians, astronauts, health service researchers, human factors scientists and space medicine practitioners (n=28) was used to reach consensus on critical non-technical skills required for an astronaut crew. Panelists ranked the potential impact of NTS on management of 30 medical events defined in NASA’s Space Medicine Exploration Medical Condition List. In a subsequent consensus meeting, panel members were assigned to four parallel groups and identified specific non-technical skills that may assist management of medical events in space.

Results: Panelists ranked the management of obstructed airway, cardiac arrest, shock, decompression sickness, anaphylaxis, and events requiring surgical treatment as most likely to be enhanced by effective NTS of the spaceflight crew. After several rounds of panel discussion, iterative development, and refinement, a taxonomy of the essential 20 behaviors for medical event management were identified and mapped to NASA’s existing team training framework (Figure 1). 

Conclusion: We developed the first medically-focused NTS taxonomy for spaceflight, reflecting an innovative translation of non-technical skills research in surgery. Future studies will test the reliability of the taxonomy using video scenarios filmed in a medical care capable spacecraft simulator. As in surgery, deliberate practice on non-technical skills can improve outcomes in spaceflight medical emergencies, reducing the risk of unanticipated medical events on long duration exploration missions such as a future mission to Mars.

 

57.05 Trauma Simulation Teaching in Cuba – A Model for Other Low- and Middle- Income Countries (LMICs)?

Posted on January 18, 2018

S. Rodriguez1, N. Lin1, M. L. Fabra2, J. A. Martinez2, M. DeMoya3, D. M. Valdés2, T. Zakrison1  2Hospital Universitario Calixto García, University Of Havana,Havana, HAVANA, Cuba 3Massachusetts General Hospital,Boston, MA, USA 1University Of Miami,Miami, FL, USA

Introduction:  Trauma-related injuries are the leading cause of death of youth under the age of 44 globally, disproportionately affecting low-and- middle income countries (LMICs). Cuba has had a long tradition of medical internationalism and the largest medical school in the world for foreign trainees, most originating from other LMICs.  Standardized, excellent trauma training and teaching is an important priority with significant global responsibility. Currently, there is no standardized method to teach trauma across Cuba, with local variability present.  Our objective was to assess the feasibility of teaching the Trauma Evaluation and Management (TEAM) course to medical trainees in Havana, Cuba, as a potential model for other LMICs in to increase exposure to standardized trauma care. 

Methods:  The first TEAM course in Havana, Cuba was taught at a major tertiary hospital in 2016. The course focuses on trauma assessment and management for medical students during clinical years of training and serves as a brief version of the Advanced Trauma Life Support (ATLS). We employed 4 ATLS instructors, (2 Cuban and 2 US trauma surgeons). The course was taught in Spanish using curriculum provided by the American College of Surgeons (ACS). Course materials were donated from the ACS while instructors donated their time. Course instruction included slideshows, books, and exams. We used a mixed methods approach to measure pre-and post-test scores for comprehension combined with qualitative focus groups for feedback and evaluation for improvement. Parametric statistics were used after determining skewedness.

Results:  30 health professional students from 5 countries (Cuba, South Africa, Angola, Chad and Germany) participated in the trauma simulation course. In the pre-test period, 53% of students passed compared to 80% of students in the post-test period (p = 0.00001). When focus groups examined the ideal way of teaching the principles of trauma in Cuba and globally, thematic analysis demonstrated two salient themes: i) the need for more ‘hands-on’ training, using simulation models and ii) standardized trauma courses are urgently needed to ensure a level of competency, consistency and sustainability in trauma care and education.

Conclusion:  Teaching TEAM in a low-income country, to a globally diverse group of medical students is feasible and needed. Promulgation of such courses that standardize trauma teaching and employ simulations should be a priority for the American College of Surgeons and other global surgical organizations. Bringing courses like TEAM to an international level can be a robust platform for global training in trauma that allow for sustainability and standardization of trauma care as well as reciprocal learning and collaboration.

 

57.04 Impact of Novel CVC Simulation Training Program for Residents on Line Associated Complications

Posted on January 18, 2018

C. Cairns1, M. Goyal1,3, J. Day1, A. Kumar4, Z. Winchester1, J. Katz1, J. Bell1, S. Fitzgibbons1,5  1Georgetown University School Of Medicine,Washington, DC, USA 3Medstar Washington Hospital Center,Emergency Medicine,Washington, DC, USA 4MedStar Health Research Institute,Hyattsville, MD, USA 5MedStar Georgetown University Hospital,General Surgery,Washington, DC, USA

Introduction:  Central venous catheters (CVC) are frequently placed by resident physicians in teaching hospitals. Simulation training aims to improve their technical performance and reduce procedure-associated complications. Our objective was to determine the impact of an intense simulation-based training program on residents' rates of CVC-associated complications.  We hypothesized that the CVC-associated complication rates of simulation trained residents (STRs) would be lower than those of traditionally-trained residents (TTRs).

Methods:  A single center, retrospective study was undertaken at an urban tertiary care teaching hospital, evaluating all CVCs placed by residents between October 1st 2014 and January 4th 2017, following hospital-wide introduction of the novel simulation–based training program.  All patients with CVCs placed by residents during the study period were included in the study.  Trained investigators extracted electronic medical record data regarding resident and patient demographics, CVC type, anatomic location, and post-procedure complications.  Complication rates were reported as either rate per lines placed (for immediate complications) or complication per 1000 catheter days (for delayed complications), and were compared between the two study groups using the exact Poisson test with a significant p-value set at 0.05.  

Results: 

During the study period, 931 CVCs were placed by residents, with the majority placed by STRs (62.3%) in the Internal Jugular (IJ) vein (74.22%).  A total of 36 delayed complications, including deep vein thrombosis (DVT), pulmonary embolism (PE) and central line associated blood stream infection (CLABSI), occurred, with more delayed complications occurring at the IJ site following STR insertion (STR 4.54/1000 catheter days vs. TTR 1.51/1000 catheter days, p 0.4256).   The majority of delayed complications were DVTs, with more IJ DVTs occurring after STR (n=17) as compared to TTR (n=5) placement (3.67/1000 catheter days vs. 1.08/1000 catheter days, p 0.017).  There was no difference in delayed complication rates for TTRs vs. STRs at the subclavian or femoral vein sites. 

There was no difference between the total mechanical complication rate (including pneumothorax, hemothorax, and arterial injury)  of STRs vs. TTRs (2.6% vs. 1.7%, p .50).  A total of 5 pneumothoraces occurred following CVC placement by an STR at the IJ site in comparison to 4 pneumothoraces following TTR procedures (1.0% vs. 1.31%, p 1.0).  Only one pneumothorax occurred following a subclavian CVC, placed by a TTR. Only one hemothorax occurred, following an IJ CVC placement by an STR.  IJ CVC catheter placement resulted in 8 arterial injuries, 7 following STR placed CVCs vs. 1 following a TTR placed CVC (1.2% vs. 0.3%, p 0.07).  

Conclusion: Central venous catheters placed by simulation trained residents and traditionally trained residents have an equivalent rate of mechanical complications and a slightly increased rate of DVT following CVC placement. 
 

57.03 Silicone-rubber as a Viable, Cheaper Alternative to Current Commercial Simulated Bowels

Posted on January 18, 2018

K. M. Bell1, B. Wise1, C. Kwan1, A. Witt1, C. M. Pugh1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
Surgical residency programs have relied on cadaveric animal tissue, to practice and teach surgical procedures and techniques. The drawbacks to using animal tissue are short shelf life, sporadic availability, and costs of manpower and management needs. For training purposes, commercial synthetic tissue and virtual reality simulators are also used, but can be very expensive. The aim of this study is to determine if our fabricated silicone-based bowels are valuable for surgical education and competitive with commercial products. We hypothesize that silicone-based bowels can be a useful training tool for general surgery residents and can be more cost effective than commercial products.

Methods:
General Surgery residents (N=6) evaluated three synthetic bowel prototypes. Two synthetic small bowels (Model B and C) were fabricated using cellulose fiber sheets, cotton fiber mesh, and silicone rubbers in different concentrations, to replicate the serosa, muscularis and mucosa. Cost for these models is $5. A third, commercial small bowel was purchased (Model A) for $60. Participants blindly selected what they felt to be most realistic from a covered basin and those choices were documented. Next, participants performed a suturing task on all three samples and evaluated the bowel’s realism using a Likert based survey. Favorable responses were denoted as ‘average’, ‘accurate’, or ‘highly accurate’. Unfavorable responses included ‘highly inaccurate’ and ‘inaccurate’.

Results:
83% of participants had previously used synthetic bowel for learning purposes, and 50% of participants reported performing 1 to 5 bowel Enterotomy repairs per month in the operating room. During the blind identification test, 66% of participants selected one of the silicone-based rubber bowels (B or C), over the commercial bowel (A) as feeling the most realistic. Model A tended to have more favorable responses regarding mechanical functionality of the bowel, with ten-out-of-ten of the favorable survey responses. Model B had seven-out of ten favorable responses, and Model C had a five-out-of-ten favorable responses. All the participants answered ‘accurate’ or ‘highly accurate’ in response to the survey statements confirming that simulation could highlight the strengths or weaknesses in their technical skill.

Conclusion:
The silicone-based bowels, models B and C, were more likely to be selected in the blind identification test. When the favorable properties of model B and C are combined, we will be able to produce a prototype that is financially, tactically, and mechanically competitive to the current commercial products. This study shows that silicone based rubber bowels have value for surgical education, and that with advancement; they can be a viable replacement to cadaveric animal tissue, commercial prototypes, and other, more costly training products.

57.01 Use of Google Glass for Patient Information Presentation for Emergency Response and Training

Posted on January 18, 2018

S. Ganapathy1, S. Raju1, M. C. McCarthy1  1Wright State University,Department Of Industrial And Human Factors Engineering; Department Of Trauma Care And Surgery,Dayton, OH, USA

Introduction:
Small screen devices are becoming ubiquitous in the medical field; especially in the fields of surgery and trauma care. This research focuses on developing guidelines for wearable augmented device, e.g. Google Glass ™, to improve human decision making during transfer of care, and user experience and reduce cognitive workload. The display being a small form factor poses a challenge in presenting information and at the same time making sure that there is no cognitive overload to the user. This could potentially help medical responder in the trauma care center to prepare for treatment materials such as medicine, diagnostic procedures, bringing in specialized doctors or consulting the advice of experienced doctors and calling in support staff as required.

Methods:
An empirical study was conducted to determine the effect of information presentation of patient vitals on Google Glass ™ device for improved transfer-of-care. The pool of participants included physicians and residents from the Department of Trauma and Surgery, Boonshoft School of Medicine, Miami Valley Hospital.  Six residents (3 junior & 3 senior) participated as novice and 6 physicians as residents. The experiment was divided into two parts –visual search task and patient vitals simulation task. Visual search task was conducted and user interface elements such as object size, color, and target location were tested for their influence on visual search. This test also used EEG information to detect the brain areas active during target search. In the patient vitals simulation, the participants were presented with different UI screens and their experience was evaluated.

Results:
Results indicate that there was significant difference in the response time for physicians and residents (F (5,141), p-value < 0.001, ηp2= 0.031). When residents were further analyzed based on their experience, the response time was significantly different for junior residents when compared to senior residents and doctors (F (2,141), p-value < 0.001, ηp2= 0.211). The user response shows that UI1 was comparatively better in the design of screen layout and content on the screen than UI3 and UI2. The EEG data showed that there was more activity in the T8 channel area which included the temporal region as well as the temporal-parietal area and parietal area. Past research shows that the superior parietal lobe was associated with visual search.

Conclusion:
Results indicate that wearable augmented devices can enhance visualization for emergency response without additional mental workload and aid in decision making. Wearable augmented device provides ubiquitous information especially in multitasking scenarios where user can have access to information on an “as needed” basis. The mean channel data shows that for residents the prefrontal area was active and all participants had temporal cortex active. Expert participants pointed out that trending patient vitals data could improve experience which can be achieved through large screen AR devices. Using NASA-TLX for the user’s perceived cognition and at the same time comparing it with brain signals give research insight in designing future products.
 

39.10 Not All Operative Experiences Are Created Equal: 18 Year Analysis of a Single Center’s Case Logs

Posted on January 18, 2018

A. R. Cortez1, V. K. Dhar1, J. J. Sussman1, T. A. Pritts1, M. J. Edwards1, R. Quillin2  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2Columbia University College Of Physicians And Surgeons,Center For Liver Disease And Transplantation,New York, NY, USA

Introduction: As surgical education continues to evolve, so too does the need for surgical educators to better understand how residents learn. Previous analyses of national Accreditation Council for Graduate Medical Education (ACGME) operative log reports have shown that total operative volumes for graduating general surgery residents have remained stable over time, despite changes in duty hour restrictions. However, variability in subspecialty operative volume and its impact on resident training experience has not been well studied. 

Methods: ACGME operative log data from 1999 to 2016 for a single academic general surgery residency program were examined. All residents completed the Kolb Learning Style Inventory during their training and were subsequently classified as action-based or observation-based learners. Statistical analyses were performed using Wilcoxon rank-sum test, Chi-square test and linear regression analysis. A p-value <0.05 was considered to be statistically significant.

 

Results: Over the 18-year study period, 106 general surgery residents graduated from our training program. There were 92 action-based learners (87%) and 14 observation-based learners (13%). These two groups were similar in terms of race, sex and having a dedicated research experience (all p=NS). Linear regression analysis showed no change in total major cases during the 18-year study period (p=0.38). Subcategory analysis, however, revealed a significant increase in operative volume upon graduation in the following defined categories: skin, soft tissue and breast (+2.8 cases/year); alimentary tract (+10.1 cases/year); abdomen (+15.4 cases/year); endoscopy (+3.0 cases/year) and laparoscopy (+10.9 cases/year, all p<0.05). Conversely, a decrease was seen in the following defined categories: liver (-0.44 cases/year), vascular (-1.1 cases/year) and endocrine (-0.5 cases/year, all p<0.05). Learning style analysis revealed that action-based learners completed significantly more cases than observation-based learners in each of the domains in which operative volume increased (Figure).

Conclusions: While the total operative volume of graduates at our center has remained stable over the past 18 years, the operative experience of general surgery residents has become more narrowed toward a less subspecialized general surgery experience. These shifts may be disproportionally impacting trainees, as observation-based learners were found to operate less than action-based learners in select categories. Residency programs should therefore incorporate methods such as learning style assessment to identify residents at risk of having a suboptimal training experience.

39.09 Better ABSITE Performance with Increased Operative Case Load During Surgical Residency

Posted on January 18, 2018

A. R. Marcadis1, T. Spencer1, D. Sleeman1, O. C. Velazquez1, J. I. Lew1  1University Of Miami,DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Common measures of evaluating surgical resident progression during General Surgery residency include American Board of Surgery In-Training Exam (ABSITE) scores and operative case logs. It remains unknown, however, if there is an association between operative case numbers and resident ABSITE performance. This study evaluates the relationship between operative cases performed and ABSITE scores at both the junior and chief resident levels. 

Methods: A retrospective review of ABSITE scores and operative case logs was performed for categorical General Surgery residents at a single institution at the junior (post graduate year [PGY]-2, n=45, from 2009-2017) and chief (PGY-5, n=19, from 2014-2016) levels. For each surgical resident, total number of operative cases logged (major and minor) from the start of their PGY-1 year until the end of either their 2nd or 5th year was calculated and compared to their ABSITE percentile score for that corresponding year using unpaired t-test and linear regression. Outliers with operative cases logged >3 standard deviations from the mean were excluded.

Results:  There was a linear relationship between total number of operative cases logged and ABSITE percentile score for surgical residents at both the junior (slope, m = 1.295) and chief resident (m = 6.109) levels, with a higher number of total operative cases logged being significantly associated with higher ABSITE percentile scores. For both junior and chief residents, there was a statistically significant difference in average number of operative cases logged between those with ABSITE scores below the 50th percentile and those with scores above the 50th percentile (junior cases, 311 vs. 370, p<0.05;  and chief cases, 1352 vs. 1683, p<0.05), respectively.

Conclusion: Surgical residents who perform higher numbers of operative cases do significantly better on the ABSITE than their peers with lower operative case numbers. This association may be due to increased clinical experience, exposure to pathology and/or individual surgical resident motivation.

 

39.08 Vascular Surgery trends among general surgery residents: ’09-‘16

Posted on January 18, 2018

A. T. Mierzwa1, S. F. Markowiak1, S. A. Toraby1, C. Das1, S. Pannell1, M. M. Nazzal1  1University Of Toledo Medical Center,Department Of Sugery,Toledo, OH, USA

Introduction:
The ACGME 80-hour work week, implemented in ‘03-’04, resulted in general surgery residents (GSR) having less exposure to vascular surgery cases in favor to other areas of training, particularly laparoscopic and alimentary tract cases. To rectify this, the ACGME defined category minimums for vascular surgery which increased from 44 to 50 cases per year with a focus on cases traditionally associated with general surgeons. The current trend in vascular care has been shifting from open procedures to endovascular with a decrease in general surgeons performing vascular procedures. With an expected increases in vascular cases nationwide and shortages of formally trained vascular surgeons, the need for general surgeons doing vascular work is unlikely to decrease. The aim of this study was to examine trends in vascular surgery exposure during general surgery residency to help assess the graduating general surgery resident’s preparedness.

Methods:
Data available from Accreditation Council for Graduate Medical Education (ACGME) reports for both General Surgery Residency (GSR), Integrated Vascular, Vascular Surgery Fellowship (VSF) from the years 2009-2016. Case trends were examined for any procedure that had an average number of cases per year greater than 1.5, in any year between ‘09 and ‘16. Trends among major categories in vascular surgery within the same time frame were additionally examined. Each GSR trend was plotted against Integrated and VSF to examine if the trends showed similar variations at each annual time point.

Results:
Carotid Endarterectomy cases are greater than 85% of total Cerebrovascular procedures annually. GSR’s exposure to these cases have decreased (13.6 to 9.8 cases/year), as opposed to increased trend observed in integrated and VSF case volume. Peripheral Obstructive and Vascular Access procedures showed similar trends (23.5 to 20 cases/year and 36.2 to 32.7 cases/year; respectively). Vascular Trauma procedures, however, have increased in both GSR (0.3 to 2.5 cases/year) and Integrated but decreased in VSF.

Conclusion:
Vascular surgery exposure has been limited due to the work-hour restriction with emphasis being placed on alimentary and laparoscopic procedures. Many basic vascular skills are a mainstay in non-vascular surgeries. Using these basic vascular skills, general surgeons can be confident in some of the minor procedures involved with trauma, transplantation, and safe surgical skills overall. With the expected increase in vascular surgery cases nationwide, some minor procedures will inevitably spill over to general surgeons. Our analysis indicates that a percentage (approx. 5-10%) of GSR will not meet the minimum requirement of cases logged for graduation.

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. 
 

39.06 Gender and Faculty Entrustment: An Objective Intraoperative Measurement of Entrustment Behaviors

Posted on January 18, 2018

J. A. Thompson-Burdine1, D. C. Sutzko1, V. C. Nikolian1, A. Boniakowski1, P. E. Georgoff1, K. A. Prabhu1, N. Matusko1, R. M. Minter2, G. Sandhu1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction: Optimizing intraoperative education is critical for development of autonomous residents. Faculty entrustment decisions determine the degree to which a resident gains intraoperative responsibility. Entrustment and entrustability are part of a dual educational responsibility, however little empirical evidence exists evaluating how gender influences faculty-resident entrustment decisions in the operating room. Studies involving perception-based autonomy measurement tools report gender inequities. We sought to assess gender dynamics of entrustment behaviors using OpTrust, a 3rd-party objective measurement tool.

Methods: From September 2015 – June 2017, researchers observed elective surgical cases at the University of Michigan and rated entrustment behaviors using OpTrust, a validated tool designed to assess progressive entrustment in the operating room (OR). Purposeful sampling was used to generate variation in operation type, case difficulty, faculty-resident pairings, faculty experience, and resident training level.

Results: 56 faculty and 73 residents were observed across 225 surgical cases from four surgical specialties: general, plastic, thoracic, and vascular surgery. Independent samples t-tests did not detect a significant difference in faculty entrustment scores by resident gender (F=2.54 vs M=2.35, p=.117). Furthermore, no difference was found in resident entrustability scores between women and men (2.32 vs 2.22, p=.393).

Conclusion: Using OpTrust scores, we found that gender does not appear to influence faculty entrustment in the OR. Faculty entrustment scores for women and men residents are consistent. This indicates that during the intraoperative interaction, faculty are not extending entrustment or opportunities for autonomy differently based on gender. The difference between 3rd-party objective entrustment measurement and perception-based autonomy measurements may be attributed to factors outside of the discrete intraoperative interaction that may contribute to gender bias and confound self-assessment. While it is encouraging that faculty entrustment behaviors in the operating room are impartial, future research is needed to identify and measure perioperative elements that inform resident autonomy and which may contribute to gender inequities for residents.

 

39.05 Narrowing of Surgical Resident Operative Experience: 27 Year Analysis of National ACGME Case Logs

Posted on January 18, 2018

A. R. Cortez1, G. D. Katsaros2, V. K. Dhar1, F. Drake3, T. A. Pritts1, J. J. Sussman1, M. J. Edwards1, R. Quillin4  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2University Of Cincinnati,College Of Medicine,Cincinnati, OH, USA 3Boston University,Department Of Surgery,Boston, MA, USA 4Columbia University College Of Physicians And Surgeons,Center For Liver Disease And Transplantation,New York, NY, USA

Introduction: Operative volume is traditionally used to assess graduating trainees’ readiness for independent practice. Although studies have shown that overall operative volume has remained stable despite implementation of duty hour restrictions, subcategory analyses have revealed shifts in the diversity of resident operative experience. Understanding these differences in operative trends may allow educators to better appreciate the impact of the current training environment on the competency of graduating surgical residents.

Methods: Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 1990 to 2016 were reviewed. Statistical analysis was performed using linear regression analysis. A p-value <0.05 was considered to be statistically significant.

Results: ACGME operative log data was analyzed for 27,851 graduating general surgery residents from 1990 to 2016. During this period, the number of residents increased (+4.87 residents/year) while the number of programs decreased (-1.33 programs/year, all p<0.05), such that each program had on average one more resident at the end of the study period. Linear regression analysis revealed no change in total major cases during the 27-year study period (p=0.54). Subcategory analysis, however, showed an increase in total major cases upon graduation in the following categories: skin and soft tissue (+1.60 cases/year), alimentary tract (+2.6 cases/year), abdomen (+4.01 cases/year) and endoscopy (+0.71 cases/year, all p<0.05). There was a concurrent decrease in breast (-0.54 cases/year), pediatrics (-0.87 cases/year) and trauma (-1.73 cases/year, all p<0.05). During this time, first assistant operative volume decreased markedly (-10.2 cases/year, p<0.05). Residents also completed fewer cases during their chief year (-1.77 cases/year), operated more during their non-chief years (+3.1 cases/year) and taught fewer operations over the course of their residency (-1.9 cases/year, all p<0.05). A decrease in overall operative volume variability (-6.77 cases/year, p<0.05) was seen as a result of a 3.3 cases/year decrease for the 90th percentile and 6.6 cases/year increase for the 10th percentile of total major cases converging toward the median (Figure).

Conclusion: While total major cases upon graduation have remained stable over the past 27 years, the operative experience of general surgery residents has narrowed significantly. Residents appear to be operating more in the early years of training, performing fewer first assist cases and operating less often as teaching assistants. Surgical educators must look beyond total case numbers and be aware of these subtle shifts to ensure all residents achieve technical competency upon graduation.

39.04 The Influence of Gender and Rank on the Resident Evaluation Process

Posted on January 18, 2018

L. Theiss1, B. Corey1, H. Chen1, R. Dabal1,2  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2Children’s Of Alabama,Birmingham, ALABAMA, USA

Introduction: The progress of general surgery residents in the United States is measured both by subjective and objective measures. Peer-to-peer, faculty-to-resident, and student-to-resident evaluations play an important role in measuring resident progress and providing constructive feedback. However, bias is unavoidable in the evaluation process. We sought to determine whether gender or rank had an impact on the way that general surgery residents were evaluated by medical students in skill-independent areas such as integrity and honesty.

Methods: Data was extracted from 2323 medical student evaluations of general surgery residents at a single institution over five years. Scores from five evaluation questions relating to emotional intelligence, patient care, and professionalism were collected. Evaluation responses range from 1-10 for each question. Scores were compared between male and female residents and between PGY 1 and PGY 2-5 residents. Univariate analysis was performed.

Results: In our cohort of 2323 general surgery resident evaluations, 729 (31.4%) of the subjects were female and 1594 (68.6%) were male. 473 (20.4%) were PGY 1 and 1850 (79.6%) were PGY 2-5. Out of 10 possible points, median evaluation score ranged from 8.10-8.43 for the group. Median scores for female residents were as follows: 8.15, 8.26, 8.29, 8.04, 8.36. Median scores for male residents were: 8.39, 8.43, 8.42, 8.13, 8.46. Male residents received higher scores on all five questions related to emotional intelligence and professionalism (p <0.0003 for all questions). There was no statistically significant difference in scores between PGY 1 residents and PGY 2-5 residents.

Conclusion: When evaluated by medical students, female general surgery residents scored lower than male residents in areas relating to professionalism and psychosocial elements of patient care. Scores did not vary based on resident rank, suggesting that gender, rather than resident experience, influenced subjective evaluation. These data reflect the larger issue of gender bias in surgery. As the number of women in surgery continues to grow, further investigation is needed to better understand and draw attention to the inherent biases and expectations that females face in surgical specialties.
 

39.03 Is the operative autonomy granted to a resident consistent with the operative performance quality?

Posted on January 18, 2018

J. P. Fryer4, B. C. George1, B. D. Bohnen2, S. L. Meyerson4, M. C. Schuller4, A. H. Meier5, L. Torbeck3, S. P. Mandell6, J. T. Mullen2, D. S. Smink7, J. G. Chipman8, E. D. Auyang9, K. P. Terhune10, P. E. Wise11, J. N. Choi3, E. F. Foley13, M. A. Choti12, C. Are15, N. J. Soper4, K. D. Lillemoe2, J. B. Zwischenberger14, G. L. Dunnington3, R. G. Williams3  1University Of Michigan,Ann Arbor, MI, USA 2Massachusetts General Hospital,Boston, MA, USA 3Indiana University School Of Medicine,Indianapolis, IN, USA 4Northwestern University,Department Of Surgery,Chicago, IL, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6University Of Washington,Seattle, WA, USA 7Brigham And Women’s Hospital,Boston, MA, USA 8University Of Minnesota,Minneapolis, MN, USA 9University Of New Mexico HSC,Albuquerque, NM, USA 10Vanderbilt University Medical Center,Nashville, TN, USA 11Washington University,St. Louis, MO, USA 12University Of Texas Southwestern Medical Center,Dallas, TX, USA 13University Of Wisconsin,Madison, WI, USA 14University Of Kentucky,Lexington, KY, USA 15University Of Nebraska College Of Medicine,Omaha, NE, USA

Introduction. Surgical residency training should produce surgeons capable of performing core procedures competently and independently. As residents’ operative performances improve, faculty should allow greater autonomy. In this study we seek to identify and define situations where the operative autonomy levels granted to residents was inconsistent with their operative performance.

Methods.  Surgical faculty provided operative performance ratings for PGY1-5 residents from 14 U.S. general surgery residency programs using the SIMPL smartphone app. For each procedure the supervising surgeon assessed the resident’s operative performance and indicated the level of autonomy that the resident was granted during that procedure. Performance was assessed using an ordinal operative performance scale and autonomy was characterized using the Zwisch autonomy scale. Concordance between performance and autonomy scores was defined as concurrent scores of either “practice ready (performance) or above and meaningful autonomy” (Zwisch) [aka PR/MA] or “not practice ready or above and not meaningfully autonomous” [NPR/NMA]. Discordant scores were “practice ready or above and not meaningfully autonomous” (PR/NMA) as well as “not practice ready or above and meaningfully autonomous” (NPR/MA). The supervising surgeon also indicated the patient-related complexity of the case. Multiple variables were investigated to determine their impact on resident operative autonomy including: resident performance, PGY level, patient-related case complexity, procedure-related complexity, procedure frequency, core vs. specialty procedures.

Results. During the study period 10964 SIMPL assessments that included both a performance score and an autonomy score were collected from 493 different surgeons assessing 615 different residents. 80% of assessments were concordant; including 39% rated as PR/MA and 41% as NPR/NMA. Of the 20% of discordant assessments, most (14.4%) were NPR/MA while the remaining 5.6% were PR/NMA. NPR/MA was the predominant discordant rating in PGY1-4 residents. In PGY5 residents PR/NMA ratings (8.9%) were slightly more frequent than NPR/MA ratings (8.2%). All but 7 surgical attendings (1.4%) provided opportunities for meaningful autonomy on at least one occasion. High volume and easy cases were more frequently performed under meaningfully autonomous circumstances. Operative performance quality accounted for 74% of the variance in the faculty surgeons’ decisions about the level of autonomy allowed (F=341.84; p<0.05).

Conclusions. Faculty autonomy granted to surgical residents was concordant with resident performance in most cases. When discordant, faculty most commonly provided meaningful autonomy when the performance was less than practice ready, a combination to be expected on occasion during training. Few surgical attending surgeons provided no opportunities for autonomous resident operative performance.

39.02 Blind spots in the feedback process – exploring trainee and faculty perceptions

Posted on January 18, 2018

S. Scarlet1, A. Reiter1, J. Crowner1, M. O. Meyers1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction:  As surgical training continues to evolve with regard to operative experience and autonomy, the role of timely, high quality feedback has become increasingly important.  Our aim was to characterize trainee and faculty perceptions regarding feedback.     

Methods:  Complementary surveys to characterize trainee and faculty perception of feedback regarding procedural skills using a 5-point Likert scale were distributed to 79 surgical trainees and 70 faculty from a single institution. Statistical analysis was completed using chi-squared testing. 

Results: 35 trainees (17 women) and 26 faculty (8 women) completed the survey; overall response rate was 40.9%. 100% of trainees and faculty agreed/strongly agreed that feedback regarding technical skills is valuable.  However, 51% of residents were dissatisfied with feedback overall. 36% of trainees reported dissatisfaction with feedback on technical skills, while faculty perceived that 8% of trainees were dissatisfied with the feedback they received (p=0.01). 6% of trainees reported receiving feedback following a procedure always/most of the time, whereas 73% of faculty reported delivering feedback on technical skills always/most of the time (p<0.001). 100% of faculty reported delivering feedback when trainees utilized poor technique, but only 64% of residents felt they had received feedback for poor technique (p<0.001). Similarly, 80% of faculty reported giving feedback when residents demonstrated good technique, whereas only 21% of residents reported receiving feedback in this circumstance (p<0.001). 

Conclusion: While both residents and faculty agreed that feedback is valuable, a disconnect exists between perceptions regarding its timing, content, and delivery. Acknowledging differing perceptions of feedback is necessary in order to enhance the quality of the feedback process and cultivate a more optimal training environment. Further study is required to determine how to best reduce the significant differences we observed in perceptions of feedback held by residents and faculty. 

 

39.01 Association Between ABSITE Scoring and Attrition from General Surgery Residency Training

Posted on January 18, 2018

M. M. Symer1, L. Gade3, J. Abelson1, J. A. Sosa2, H. Yeo1  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Duke University Medical Center,Surgery,Durham, NC, USA 3NewYork-Presbyterian / Queens,Surgery,New York, NY, USA

Introduction: The American Board of Surgery In-Training Exam (ABSITE) has been demonstrated to predict passage of the ABS certifying exam, and is intended to guide education rather than penalize residents. Attrition from general surgery training is common and costly but poorly understood. We hypothesized that ABSITE scores would not predict attrition, but changes in score may be correlated with a resident who is struggling and at risk for impending attrition.

Methods: In 2007, all categorical general surgery interns were administered a survey during their first months of residency. De-identified survey results containing resident demographics were linked to a database of ABSITE scores assembled separately by the American Board of Surgery. Attrition was determined based on completion of training during eight years of follow-up. Residents without ABSITE scores, a matching survey, and/or missing scores were excluded. Resident ABSITE scores were analyzed based on average rank, a normalized percentile derived from their raw score. Year-to-year change in ABSITE score was used to compare residents with a significant change in performance as a possible predictor of impending attrition.

Results:Of 837 residents, 739 (88.3%) completed surveys and had continuous ABSITE data until completion or attrition from training. 108 (14.6%) did not complete training. Residents who dropped out were more likely to be female (18.7% vs 12.3% male, p = 0.02) and from programs with ≥6 residents (19.2% vs 13.0% <6 residents, p=0.04). Average ABSITE rank (median normalized percentile) was higher for participants who completed training (51.8 vs 42.7 percentile dropouts, p<0.001). Scores were also higher for residents without family nearby (53.0 vs 48.5 percentile family nearby, p<0.01). There was no difference in attrition between residents with a single ABSITE rank below the 25th percentile (12.2% vs 17.1% without a low ranking, p=0.06). Those residents who experienced an ABSITE score drop of >16.5 percentile points from the previous year were more likely to leave training (13.0% vs 6.0% without such a drop, p=0.003). In adjusted analysis, a one percentile increase in ABSITE rank was associated with decreased odds of attrition (OR 0.98 95%CI 0.97-0.99, p<0.01). 

Conclusion:Lower ABSITE scores are associated with attrition, but there is only a small absolute difference in scores between those residents who complete training and those who drop out. Program directors should focus their efforts on residents with an acute drop in scores, which may signify that a resident is at risk of impending drop out.
 

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

18.17 Evaluating System-Based Financial Knowledge of General Surgery Residents

Posted on January 18, 2018

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

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

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

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

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

 

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