05.13 Introduction to Lap/Endoscopic Skills During Orientation Boosts Intern Confidence and Preparedness

Posted on January 18, 2016

O. Kantor1, D. S. Loeff1, K. K. Roggin1, N. Schindler2, M. B. Ujiki2 1University Of Chicago,Department Of Surgery,Chicago, IL, USA 2Northshore University Health System,Department Of Surgery,Evanston, IL, USA

Introduction:
Implementation of curriculum-based skills modules have been successful in resident education across surgical disciplines. We hypothesized that skills modules in introduction to the laparoscopic tower, endoscopic tower, and laparoscopic abdominal access during surgery intern orientation would increase intern confidence and ability in these skills.

Methods:
In this intern orientation-based pilot of three introductory curriculum modules, six categorical general surgery interns underwent attending-led modules on introduction to the laparoscopic tower, endoscopic tower, and laparoscopic abdominal access. Both confidence and ability to perform the skill were assessed pre and post module on a 1-5 Likert scale (1=unable to do, 3=able to do with verbal cues, 5=able to do independently). Paired t-tests were used to compare means.

Results:

Of 6 interns, 1 had zero hours of simulation training in medical school, 3 had 1-5 hours, and 2 had 6-10 hours. History of simulation training did not correlate with pre-module confidence in any module (p>0.05).

The introduction to the laparoscopic tower module assessed the ability to identify components of the tower, completely set up the tower, assemble the scope, white balance the scope and turn on the insufflator, and troubleshoot an alarming insufflator. Intern confidence increased significantly from a pre-module mean of 2.83 to a post module mean of 4.77 (range 1-5 to 4-5, p<0.01). Ability to perform the skills increased from a pre-module mean of 3.12 to post-module mean of 4.97 (range 1-5 to 3-5, p<0.01).

The introduction to the endoscopic tower module assessed the ability to identify an upper and lower endoscope, identify the function of the buttons and dials, assemble the tower, and troubleshoot the scope camera. Intern confidence significantly increased from a pre to post module mean of 2.56 to 4.06 (range 1-4 to 2-5, p<0.01) and ability to perform the skills increased from a pre to post module mean of 3.90 to 5.00 (range 3-5 to 5, p<0.001).

The introduction to laparoscopic abdominal access assessed the ability to identify different approaches (Hassan, Veress, optical), explain complications and contraindications, and obtain abdominal access. Intern confidence significantly increased from a pre to post module mean of 1.90 to 3.90 (range 1-4 to 2-5, p<0.01). Due to time constraints, pre-testing was not assessed for the abdominal access module. On post-test, the mean score was 2.88 (range 1-4).

Conclusion:
Our pilot study showed a statistically significant increase in both intern confidence and ability to perform skills on three introductory modules. By incorporating these modules into surgery intern orientation, we were able to introduce important basic skills to better prepare for residency.

05.14 Factors and Methods to Improve the Success Rate of Intravenous Catheterization by Medical Students.

Posted on January 18, 2016

I. Woelfel3, K. Takabe1,2,4 1Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA 2Virginia Commonwealth University,Division Of Surgical Oncology,Richmond, VA, USA 3Virginia Commonwealth University,Richmond, VA, USA 4Massey Cancer Center,Richmond, VA, USA

Introduction: Intravenous cannulation (IV) is one of the most basic and essential medical procedures. The Association of American Medical Colleges lists it among the eight procedures in which all graduating medical students should be competent. However, it was reported that 30% of third year, and 23% of fourth year medical students have never placed an IV. IV cannulation can be a source of anxiety for medical students as it is often their first procedural patient care. We sought to investigate what barriers medical students face in successfully honing this skill and what factors have a positive impact on the success rate of IV placement.

Methods: A confidential web-based survey consisting of 12 free response and multiple choice questions was created and distributed via email to total of 367 third and fourth year students at a single US allopathic medical school. The responses were collected over a 2-week period in July 2015. The data were then imported and analyzed by two-tailed, unpaired T-tests.

Results: The response rate was 49.0% (180/367). The mean age of respondents was 25.4 years old, with males making up the predominant sex at 54.8%. 65.5% of the M3 class and 21.8% of the M4 class have never even attempted to place an IV due to lack of opportunity in the hospital environment but this is most likely because the survey was conducted at the beginning of the year. Common difficulties cited include: improper positioning of the needle and failure to identify the most appropriate insertion site. Also contrary to our expectation, prior preparation such as reading, watching videos or lectures did not increase the success rate. Interestingly, 91.6% of students who reported 1 attempt were successful in that first placement. With each successive attempt the mean rate of failure trended down from 50.0% at 2 attempts to 25.6% for over 9 attempts. The success rate was significantly better after 10 attempts than at attempts 2-9. Students who had training prior to medical school demonstrated a significantly higher success rate compared to students without. As we expected the success rate was significantly higher in EMTs (81.4%, p=0.038) but surprisingly it was also higher in lab researchers (86.6%, p=0.014).

Conclusion: A significant percentage of students were not given opportunities to attempt IV cannulation. We found that neither the type of preparation nor the preferred location of placement has any affect on success rate. The first attempt had a high rate of success likely due to an increased level of supervision and attention. Prior experience, not only as an EMT but also as a lab researcher, significantly increases the success rate. Therefore, it is important for medical educators to target those with no prior experience in the healthcare field and ensure adequate training so that this impediment to their success can be overcome.

05.09 The Use of Social Media in Surgical Education: An Analysis of Twitter

Posted on January 18, 2016

B. J. Smart1, N. Nagarajan2, J. K. Canner2, M. Dredze3, E. B. Schneider2, M. Luu1, Z. Berger4,5,6, J. A. Myers1 1Rush University Medical Center,Department Of Surgery,Chicago, IL, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 3Johns Hopkins University School Of Medicine,Department Of Computer Science,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Division Of General Internal Medicine,Baltimore, MD, USA 5Johns Hopkins University School Of Medicine,Berman Institute Of Bioethics,Baltimore, MD, USA 6Johns Hopkins University School Of Medicine,Department Of Health, Behavior And Society, Johns Hopkins School Of Public Health,Baltimore, MD, USA

Introduction:
Billions of people worldwide use social media platforms to share information and surgeons are beginning to recognize the potential of these platforms for furthering surgical education. Social media such as Twitter allows educators to cost-effectively distribute information across geographical borders while allowing learners to customize the information they receive. However, there has been a lack of research on assessing the use of social media to further surgical education. We sought to examine the use of Twitter for surgical education.

Methods:
Individual tweets were identified using the hashtag ‘surgicaleducation’ for one entire month. Individual users who generated these tweets were identified to determine user characteristics such as location, gender and type of affiliation. The content of the tweets were qualitatively analyzed to determine whom the tweet was directed towards, the overall purpose, the associated surgical discipline, the contents of links, and if the tweets were associated with a scholarly conference.

Results:
In total, 84 English language tweets with the hashtag ‘surgicaleducation’ were collected with 52 unique users. Overall, 48 (57.14%) of the tweets were directed exclusively towards other clinicians and a majority of the tweets contained content that was an opinion about surgical education (26 [30.95%]) followed by promotion of scholarly activity (23 [27.38%]) and announcing an educational event or opportunity (13 [15.48%]). In total, 18 (21.43%) of the tweets were related to a surgical conference. There were 53 (63.10%) tweets that had an associated link and of these links a majority were to a peer-reviewed journal article (19 [35.85%]), followed by healthcare-related websites (15 [28.30%]), and multi-media (10 [18.87%]). A majority of the users were located in the United States (32 [61.54%]) with the central (10 [31.25%]) and northeast (9 [28.13%]) regions of the United States having the most users. 28 (53.85%) of the users were private users, of whom 17 (60.71%) were identified as male. Overall, 29 (55.77%) were affiliated with university hospitals, 8 (15.38%) with non-profit organizations and 6 (11.54%), with peer-reviewed journals.

Conclusion:
Social medial platforms, such as Twitter, are a powerful tool to share information in the field of surgical education. Of those who use Twitter for surgical education, most are from university programs in the United States and use the medium to share personal opinions, promote scholarly activity and inform others about educational events and opportunities. Future efforts should be directed at better understanding and utilizing this new paradigm in scholarly communication.

05.10 Examining the Effectiveness of a Novel Mental Skills Curriculum to Reduce Surgical Novices’ Stress

Posted on January 18, 2016

D. Stefanidis1,2, N. E. Anton1, L. D. Howley1, M. Pimentel1, C. K. Davis1, C. Brown3 1Carolinas HealthCare System,Carolinas Simulation Center,Charlotte, NC, USA 2Carolinas HealthCare System,Department Of Surgery,Charlotte, NC, USA 3Head In The Game Inc,Charlotte, NC, USA

Introduction:
Stress has been shown to negatively impact surgical performance, and surgical novices are particularly susceptible to its effects. Mental skills are psychological strategies designed to enhance performance and reduce the impact of stress to consistently facilitate the ideal mental conditions that enable performers to perform their best. Mental skills have been used routinely in other high-stress domains (e.g., with Navy SEALs, military pilots, elite athletes, etc.) to facilitate optimal performance in challenging situations. We have developed a novel mental skills curriculum (MSC) to aid surgical trainees in optimizing their performance under stressful conditions. The purpose of this study was to determine the effectiveness of this MSC in reducing novices’ stress.

Methods:
The MSC was implemented with a convenience sample of surgical novices over 8 weeks. Two stress tests were administered prior to and after completion of the MSC to assess its effectiveness in reducing trainee stress. The Trier Social Stress Test (TSST) is a validated method of measuring participants’ stress responses; it was implemented by giving participants ten minutes to prepare for an impromptu presentation, and five minutes to present it in front of a medical education expert who would be assessing them. The O’Connor Tweezer Dexterity Test (OTDT) is a test of fine motor dexterity; participants competed against each other in small groups who would complete the test the fastest. Such competition has been shown to cause acute stress in performers.

To assess stress, heart-rate (HR), perceived stress (STAI-6), and perceived workload (NASA-TLX) were completed during all testing sessions.

Results:
Nine novices (age 23 ±7 years, 55% women) completed the MSC. While heart rate increased significantly during all tests, participants perceived less stress during the TSST and OTDT tests (p<.05) after completion of the MSC. In addition, they reported significantly less workload during the second OTDT administration (p<.05) and showed a trend towards faster completion of this test (see table 1).

Conclusion:
The novel mental skills curriculum implemented in this study was effective at reducing surgical novices’ perceived stress and workload based on two validated stress tests. Although not statistically significant, participants’ enhanced performance during the OTDT is encouraging. This curriculum may be valuable to help surgical trainees and surgeons reduce intraoperative stress and increase patient safety in the operating room. Additional study utilizing a larger sample size is currently underway at our institution to validate the effectiveness of this curriculum.

05.11 Evaluation of Surgical Residents’ Perception of Personal Clinical Outcomes

Posted on January 18, 2016

W. E. Raible1, G. Luetters1, A. Bhakta1, T. D. Beyer1, S. C. Stain1 1Albany Medical College,Department Of Surgery,Albany, NY, USA

Introduction:

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) tracks 30-day surgical outcomes. Improvement in clinical outcomes has been displayed by providing NSQIP data to surgeons. Recently, the ACS created the Quality In-Training Initiative (QITI). QITI is provides surgical residents with their own NSQIP outcomes data. We aim to show that current surgical residents have limited knowledge of their personal clinical outcomes. With current resident duty hour requirements and increasing shift towards outpatient management of diseases, we believe surgical residents’ perception of their outcomes is anecdotal.

Methods:

IRB approval was obtained and an anonymous electronic survey was distributed to general surgery program coordinators for distribution to general surgery residents. Objective data collected includes training program, post-graduate year, major cases logged, and NSQIP and/or QITI participation. Subjective data includes resident perception of post-op length of stay (LOS), surgical site infection (SSI), readmission, and death. The remaining data collected relates to the resident’s perceived benefit of receiving personal surgical outcome data, the frequency resident’s follow patients post-operatively and until discharge. Statistical analysis of this data was performed.

Results:

To date, 40 survey responses were received. Residents training in academic programs included 28/40 (70%). There are 24/40 (60%) PGY-3 or above residents. The average number of cases logged amongst respondents was 503. Most residents’ programs participate in NSQIP, 37/40 (92.5%). However, only 4/40 (10%) of residents’ programs participate in QITI. All programs that participate in QITI provide outcomes data to the residents, of which all residents report ‘excellent’ knowledge of their surgical outcomes (LOS, SSI, readmission, deaths). From the programs that do not participate in QITI, resident knowledge of surgical outcomes was ‘fair,’ 32/36 (89%) ‘agree’ or ‘strongly agree’ QITI outcomes data would improve their training, and 27/36 (77%) ‘agree’ or ‘strongly agree’ QITI outcomes data would improve their surgical outcomes. Lastly, 36/40 (90%) were ‘likely’ or ‘highly likely’ to follow their post-operative patients to discharge, but only 5/40 (12.5%) were ‘likely’ or ‘highly likely’ to see their post-operative patients in clinic.

Conclusions:

Resident perception of their personal postoperative outcomes (LOS, SSI, readmission, death) is limited without the use of QITI data. Further contributing to residents being unaware of postoperative outcomes may be the limited outpatient follow up. Residents believe receiving QITI data will improve their training experience and improve their postoperative outcomes, which we plan to study in a future trial.

05.06 Women in Breast Surgery – Does a Shared Anatomy Equate to a Shared Interest?

Posted on January 18, 2016

S. P. Beierle1, J. Lewis1, R. E. Heidel1, E. Stewart1, J. McLoughlin1 1University Of Tennessee,Graduate School Of Medicine,Knoxville, TN, USA

Introduction: Women are increasingly choosing general surgery as a career now comprising 37% of surgical residents. However, nearly 88% of members of the Association of Women Surgeons perceived gender based discrimination in residency. We observed a trend of junior female residents being assigned to more breast cases than their male counterparts. We hypothesized that a gender bias begins in the early years of surgical training with the assumption that females are more interested in a career in breast surgery.

Methods: We reviewed all partial mastectomies performed at our institution from July of 2010 through June of 2015 and recorded the PGY level and gender of the resident participating. A total of 850 cases were identified. Cases with no resident participating were excluded as well as cases with a male and a female resident scrubbed in together. The data was compared by PGY level as well as categorical vs. non-categorical status. Data was analyzed with SPSS to calculate significant differences using the Chi-square test.

Results: Female residents at our institution comprised 30% to 55% of the resident compliment depending on the academic year. When divided into PGY-level, female residents were responsible for a larger than expected proportion of the hookwire cases than their male counterparts for all but one year. The disproportionate representation reached statistical significance with a P of <.05 in 6 categories (2011-2012 all residents, PGY1-3, and categorical PGY1-3; 2012-2013 Categorical PGY1-3; 2013-2014 Categorical PGY-1, and 2014-2015 categorical PGY-2) When we looked at the attrition rate of the program there were 4 residents, all female, who left the program during the time period examined. Three left after the second year of residency and of the 3 residents who left after second year each had the highest percentage of hookwire cases of their class in the PGY-1 year.

Conclusion: There appears to be a trend in resident case assignment towards a higher proportion of female residents being assigned to breast cases compared to their male resident counterpart. This bias is likely multi-factorial but may have a significant influence on a female resident’s career choice. This bias may not only assume that a female resident only wants to perform breast surgery but also assumes conversely that they are not interested in a broad based surgical career. Further multi-institutional studies are needed to better assess this trend.

05.07 Strong support for use of context-specific Non-Technical Skills for Surgeons (NOTSS) tool in Rwanda

Posted on January 18, 2016

J. W. Scott1,4, G. Ntakiyiruta3, Z. Mutabazi3, D. S. Smink1,2, R. Riviello1,4, S. Yule1,2 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,STRATUS Center For Medical Simulation,Boston, MA, USA 3Kigali Univerity Teaching Hospital,Academic Department Of Surgery, University Of Rwanda,Kigali, KIGALI, Rwanda 4Harvard Medical School,Program For Global Surgery & Social Change,Boston, MA, USA

Introduction:
Non-technical skills (NTS) have been identified as critical to high-quality surgical performance in high-income countries (HICs), but the role of NTS for surgeons in low- and middle-income countries (LMICs) has not been evaluated. Specifically, little is known about the NTS used by providers in LMICs or how to adapt existing NTS educational tools to the LMIC context. The aim of this study was to characterize the attitudes of Rwandan surgical care providers on existing and modified NTS curricula.

Method:
We conducted 35 interviews with Rwandan surgeons, anesthetists, and nurses and observed >50 hours in Rwandan operating rooms (ORs). We used these data to adapt the existing Non-Technical Skills for Surgeons (NOTSS) curriculum for the Rwandan context. These findings were presented to 30 Rwandan clinicians and trainees at a one-day NOTSS masterclass at the Kigali University Teaching Hospital. The masterclass utilized simulated OR videos from HICs to reinforce learning of NTS. We then surveyed participants regarding their impressions of the NOTSS skill categories (situation awareness, decision making, teamwork/communication, leadership), the 4 newly identified contextual factors, and applicability of a NOTSS-like course to the Rwandan surgical context. Clinicians’ attitudes regarding the accuracy, contextual applicability, and preferred use of a NTS curriculum in Rwanda were assessed using questionnaires with a 4-point Likert scale.

Results:
Survey completion rate was 83% (25/30). Participants found the existing NOTSS skill categories highly consistent with their experience (agreement ranged from 87% for situation awareness to 100% for teamwork and communication). The existing NOTSS videos, however, were less representative with only 20% of respondents reporting strong clinical similarity to their context and 32% reporting little or no similarity to their context. 92% of respondents would prefer videos filmed in Rwanda with more applicable clinical scenarios. Regarding the 4 contextual factors identified through interviews and observations, participants identified ‘multi-lingual communication skills’ (96% agree) and ‘dynamically changing provider roles’ (94% agree) as the two most consistent with their daily experience—though 83% reported both ‘resource variability’ and ‘diminished capacity for rescue’ were also consistent. Nearly all (96%) participants would like a variant of NOTSS to be taught in Rwanda, and the vast majority (76%) prefer a context-specific curriculum.

Conclusion:
Rwandan clinicians in a NTS masterclass report that a NOTSS-like curriculum is applicable and should be used; but such a curriculum should be context-specific, integrating unique aspects of the LMIC context and relevant clinical scenarios. These findings should be used to adapt NOTSS to LMIC contexts and tested for usability, reliability, and effectiveness in improving surgeons’ NTS throughout the world.

05.08 A Perioperative Care Map Improves Compliance with Best Practices for Morbidly Obese Patients

Posted on January 18, 2016

I. Solsky2, A. Edelstein1, P. Shamamian2, M. Brodman1, R. Kaleya4, M. Rosenblatt1, C. Santana2, D. L. Feldman3, P. Kischak3, D. Somerville3, S. Mudiraj3, I. Leitman1 1Mount Sinai School Of Medicine,Surgery,New York, NY, USA 2Albert Einstein College Of Medicine,Surgery,Bronx, NY, USA 3Hospitals Insurance Company,New York, NY, USA 4Maimonides Medical Center,Brooklyn, NY, USA

Introduction: The impact of morbid obesity in complicating perioperative management is becoming increasingly recognized. Best practice guidelines have been published but are typically followed in bariatric surgical patients only. Little is known regarding physician awareness of and compliance with these clinical recommendations for non-bariatric surgical procedures. The present study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese surgical patients.

Methods: A care map outlining best practices for morbidly obese surgical patients was distributed to all surgeons and anesthesiologists at four urban teaching hospitals in 2013. Pre and post-intervention surveys were sent to all participants in 2012 and again in 2015 to evaluate changes in clinical practice. A chart audit was also performed post-intervention to determine physician compliance with the distributed best practice guidelines.

Results: 567 physicians completed the survey in 2012 and 375 completed it in 2015. Post-intervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese surgical patients to comply with best practices preoperatively (89% vs. 59%), intra-operatively (71% vs. 54%), post-operatively (80% vs. 57%,), and overall (88% vs. 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the four hospitals combined found that 167 (98%) cases were compliant with best practices.

Conclusion: After distributing the morbid obesity perioperative care map, the percentage of surgeons and anesthesiologists who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.

05.03 Enhanced Interprofessional Communication and Teamwork in Surgery Using Simulated Clinical Scenarios

Posted on January 18, 2016

S. Joseph1, D. Goodwin3, E. Gully3, I. Okwuwa2, S. Cannon3, S. Joseph1 1Texas Tech University Health Sciences,Department Of Surgery,Odessa, TX, USA 2Texas Tech University Health Sciences,Department Of Family Medicine,Odessa, TX, USA 3Texas Tech University Health Sciences,Department Of Nursing,Odessa, TX, USA

Introduction:

In 2005 the Joint Commission estimated that poor communication was the primary cause of 65% of hospital sentinel events between 1995-2004. When these events are analyzed, poor communication and failure of the surgical team are the most common underlying cause. While the emphasis within the hospital has been on teamwork and communication, medical school education has not adapted these techniques. This has led to a number of students never working in multidisciplinary teams and student dissatisfaction.

Methods:

We developed an interprofessional curriculum for medical students, PA students, and nursing students to help promote communication and teamwork in simulated surgical scenarios. Students are briefed prior to simulation and teams are formed. The team is allowed to spend some time interacting and developing rapport. Nursing students are introduced to the clinical scenario and allowed to assess prior to calling for the medical and PA students. The team is allowed to manage the clinical scenario for 15 minutes. The scenarios are recorded and monitored by faculty. After completion of the scenario debriefing and film review is done with faculty insight. Circular evaluation and team dynamics are also used to encourage student engagement. After completion of the curriculum, the students are surveyed on the effectiveness of the team dynamics as well as their perceptions of team training. Surgical scenarios are chosen from cases the students have been exposed to during their surgical rotation.

Results:

Since implementation 51 students have participated. Of all participants 66% have shown growth and improvement on post-curriculum survey. 100% of participants believe the curriculum was educational and met their needs. 20% of students have requested to repeat the curriculum. Amongst nursing students the majority felt better equipped to work in a surgical setting and felt comfortable to speak up during sentinel events. Medical students showed the greatest decline in their abilities when faced with moral and ethical scenarios. The students felt undertrained to deal with these scenarios during their non-clinical years of medical school.

Conclusion:

This data indicated that formalized communication training utilizing simulation scenarios enhances teamwork amongst students. Furthermore, early training of students allows for the fundamental aspects of communication and teamwork prior to entrance into clinical practice.

By exposing students to interprofessional education, we have shown that student satisfaction and perceptions of learning have significantly improved. Finally, we have identified knowledge gaps within medical student education that can be addressed during their clinical years and prepare them for medical practice.

05.04 Long-term Evaluation of Palliative Care Training for Medical Students and Retention of Skills

Posted on January 18, 2016

P. P. Parikh1, M. T. White1, K. Tchorz1, L. Smith1, P. P. Parikh1 1Wright State University,Surgery,Dayton, OH, USA

Introduction: Palliative and end-of-life care training have been introduced in medical education. However, the impact of such training and the retention of skills and knowledge have not been studied in detail. This work provides information on long-term follow up on the training, evaluation, and skill retention in medical students.

Methods:
All the medical students received simulation based palliative care training in their third year of Surgery clerkship at our institution. The training included three scenarios that reflected surgical patients and conditions commonly encountered during the surgical clerkship. Moreover, the training was intended to expose students to: (i) learning about diversity and importance of religious beliefs, (ii) experience with advance directives, (iii) learning about palliative care management, (iv) giving bad news, (v) end-of-life preferences/DNR, (vi) talking about death and dying, (vii) talking about religious/spiritual values as they contribute to end-of-life care. All the students were surveyed after one year to ascertain if they used any skills/knowledge learned in this training in their other rotations, any knowledge they retained, and their overall perception of the training.

Results:
The survey was sent to all the graduating fourth year medical students (105) in our program out of which 69 students completed the survey (66% response rate), where 57% were male. All (100%) students agreed that the palliative care training is essential in medical school training. Seventy percent of the students agreed that the training they received at our institution helped them develop the skills needed for palliative/end-of-life care communication with the most useful part of the training being ‘giving bad news’ (85%). Moreover, when a question on knowledge or skill retention was asked after a year of training, the majority of students felt that they had retained the skills on giving bad news (80%), talking about death and dying (45%), and end-of-life preferences/advance directives/DNR (44%). A small number of students (16%) claimed they retained their skills on talking about religious/spiritual values. Several students mentioned that more of such training (probably in other rotations) would be beneficial and also indicated the value of seeing their residents or physicians leading these conversations during their clinical rotations.

Conclusion:
Early training in palliative and end-of-life care communication is feasible during clerkships and students retain the skills and knowledge they gain from this experience. However, more practical experience would help by getting students involved in such discussions or just by seeing their attendings or residents leading such discussions during their clinical rotations.

05.05 Results of a Mandatory Department of Surgery Faculty Mentoring Pilot Program

Posted on January 18, 2016

R. Phitayakorn1, R. Hodin1 1Massachusetts General Hospital,General And GI Surgery,Boston, MA, USA

INTRODUCTION

Mentoring of junior faculty by senior faculty is an important part of promotion/tenure and enhanced job satisfaction. However, the best method to implement and assess the results of a department-wide mentorship program in surgery is unclear.

METHODS

We implemented a departmental faculty mentoring program in July 2014 that consisted of both structured and informal meetings between junior faculty mentees and assigned senior faculty mentor. All senior faculty mentors attended a brief mentor training session. We then developed an evidence-based mentorship instrument that featured standardized metrics of academic success. This instrument was completed by each mentee and then reviewed at the junior faculty’s annual career conference with their division chief. A survey was distributed in July 2015 to assess junior faculty satisfaction with the new mentorship program.

RESULTS

Junior/senior faculty consisted of 6/3 women and 16/11 men respectively. Junior faculty were 38±3 years of age and had been an attending for 4±3 years. Mentorship meetings occurred approximately 3 times during the year (range=0 to 10). Total meeting time with senior mentors was a mean of 90 minutes (range=0 to 300 minutes). Over 75% of junior faculty were very or somewhat satisfied with the mentorship program and would like to continue in the program. The best aspect of the program was the opportunity to meet with an accomplished surgeon outside of their division. Opportunities to improve the program included better matching of mentor to mentee by disease or research focus. Interestingly, almost the entire junior faculty tended to have at least 2 other mentors besides the mentor assigned to them in this program.

In terms of program outcomes, junior faculty agreed that the mentorship program improved their overall career plans and enhanced their involvement in professional organizations, but did not help with academic productivity, home/work balance, and overall job satisfaction.

CONCLUSIONS

A mandatory, structured mentorship program with senior surgeons benefits most junior faculty in terms of academic advancement. More research is required to understand the best method to pair mentors and mentees and more objective measurements of academic surgery success.

09.14 Barriers to Participation in Preoperative Risk Reduction Programs at A Safety-Net Hospital

Posted on January 18, 2016

B. Henchcliffe1, J. L. Holihan1, J. R. Flores1, T. O. Mitchell1, T. C. Ko1, L. S. Kao1, M. K. Liang1 1University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA

Introduction:

Patients presenting with a ventral hernia often have modifiable risk factors. Preoperative risk reduction programs have been shown to be efficacious in behavior modification; however, generalizability of these outcomes to underserved patients may be hindered by unrecognized barriers. The aim of this study is to identify patient-reported barriers to successful implementation of a preoperative risk reduction program at a safety-net hospital.

Methods:

This was a prospective exploratory qualitative study. The study was initiated concurrently with a new preoperative risk reduction program. One-on-one semi-structured interviews were conducted. Latent content analysis applying inductive coding methods was used to code and condense raw qualitative data.

Results:

The study population (n=43) was largely unemployed (77.1%) and uninsured (81.4%), minorities (88.3%). Patients self-identified as being overweight (76.7%), a smoker (18.6%), and diabetic (20.9%). Over half (51.2%) of respondents reported a barrier to participation in the preoperative program including lack of transportation (20.9%), lack of time (9.3%), distance from the program site (7.0%), and scheduling conflicts (7.0%). Administration of the survey correlated with an improved enrollment rate in the preoperative program (20.8% vs 66.7%, p=0.006).

Conclusion:

Patients at a safety-net hospital report numerous barriers to participation in a preoperative risk reduction program despite significant potential benefits. Integrating patients as key stakeholders in the development of clinical programs and initiating interactions with open ended questions may stimulate self-reflection, patient interest, and adaptive changes that can improve enrollment and effectiveness.

05.02 Are Animal Models Useful For Training a Preclinical Medical Student?

Posted on January 18, 2016

S. C. DeMasi1, E. Katsuta1, K. Takabe1 1Virginia Commonwealth University School Of Medicine And Massey Cancer Center,Division Of Surgical Oncology, Department Of Surgery,Richmond, VA, USA

Introduction: Traditionally, exposure to surgery to preclinical medical students has been remarkably limited which leads to an unfair, negative connotation towards the specialty. Restriction is not only limited in time, but also to learning in the operating room. Use of alive animals for training preclinical medical students has been a topic of debate, from animal protection and cost stand point. Use of an alive porcine model was reported to most closely prepare the medical students for the anxiety and perioperative demands required in the OR, with most students reporting that it was an imperative part of their education. On the other hand, porcine operations are widely expensive. Therefore, we hypothesize that even small animal (murine) models will be a vital component of training preclinical medical education.

Methods: Murine breast cancer E0771 cells were orthotopically implanted in female Blk/6 mice to generate breast tumor. A radical mastectomy, defined as the surgical removal of the tumor with surrounding skin and pectoralis major muscle, was performed on Female C57Blk6 mice of various ages. Wound parameters, time to complete procedure, number of sutures per minute, and weight of tissue removed, were recorded.

Results: Improvement of surgical skills was observed in all parameters we recorded. Wound closure was successful in all widths attempted from 0.5cm to 1.5cm. The number of stitches per minute nearly doubled after only 6 wound closure experiences. The time required to complete the radical mastectomy procedure decreased by almost half by the 9th case. Finally, the appropriate stitch interval of 2-3mm was ascertained after the 5th wound closure. Notably a single animal died immediately after the operation, which was found due to inappropriate anesthesia management during the removal of a large tumor, which was contrary to the anticipation that death can occur by inexperienced surgical skills such as failure to control bleeding or unable to close the wound. However, it was the lack of understanding of the overall operative environment that actually resulted in the death of the animal. This highlights the importance of preclinical medical students being exposed to an environment that resembles the stress and responsibility that the OR demands, where a life is at stake, even if it is an animal’s.

Conclusion: The animal model to train preclinical medical students provides an invaluable learning experience, not only to improve surgical skills, but also to realize the importance of overall operative care, such as anesthesia management, even in small animals. Learning surgical techniques in an environment that can simultaneously teach medical students ‘what is essential to maintain life in the OR’, will without question improve preclinical medical education, in addition to positively shifting the attitudes of medical students towards the field of surgery.

05.01 Use of SIM to Evaluate Resident Performance During Complex Scenarios in Urinary Catheter Insertion

Posted on January 18, 2016

J. N. Nathwani1, K. E. Law2, R. D. Ray1, B. R. O’Connell Long1, R. M. Fiers1, A. D. D’Angelo1, C. M. Pugh1 1University Of Wisconsin,General Surgery,Madison, WI, USA 2University Of Wisconsin,Industrial And Systems Engineering,Madison, WI, USA

Introduction: Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created by the American College of Surgeons on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that while placing catheters, residents will make consistent choices for initial and subsequent catheters.

Methods: Forty-five general surgery residents (PGY 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios. Scenarios varied in difficulty: A) female trauma patient with a bladder injury, B) female patient with labial constriction, C) male patient with complete obstruction of the urinary tract, and D) male patient with benign prostatic hypertrophy with partial blockage of the urinary tract. Residents were allowed 15 minutes to complete three scenarios. Scenario A was performed by all residents. Residents were presented with five different catheter choices and the option to consult an on-call Urologist. A Chi Squared test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision making for each scenario.

Results: All (N=45) residents performed scenario A; 45% performed scenario B; 67% performed scenario C and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, p's<.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, p<.01). The variation in first choice of catheters is shown in Table 1. Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (p<.001). Chi-Square analyses showed no relationship between residents’ first and subsequent catheter choices for each scenario (p’s >.05).

Conclusion: Evaluation of clinical decision making shows initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or inadequate training in clinical decision making with regards to urinary catheter choices in residents.

09.15 Treating Hospital Type Affects Race-Based Differences in LOS among Tricare-Insured CABG Patients.

Posted on January 18, 2016

R. Chowdhury1,2,3, W. Jiang1, C. K. Zogg1, E. B. Schneider1,2, A. H. Haider1,2 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Harvard School Of Medicine,Surgery,Brookline, MA, USA 3Harvard School Of Public Health,Boston, MA, USA

Introduction: Patient race has been associated with length of stay (LOS) after Coronary Artery Bypass Graft (CABG) surgery in hospital-based claims data. Previous reports have included patients with a wide variety of payer types. We sought to test the hypothesis that Black vs. White race-based differences in LOS would not exist among patients who have medical coverage as a result of their affiliation with the United States Armed Forces using the Tricare database which contains individuals eligible for the Tricare insurance program. We examined this hypothesis comparing findings among patients treated at military hospitals and those treated at civilian facilities.

Methods: Using Tricare data, which include uniformed service personnel, dependents and retirees, we identified patients aged 18-65 years without Medicare coverage who underwent their first reported CABG (ICD-9CM 36.10 -36.20) between 2006-2010. Patients with concurrent valve surgeries or who had length of stay < 1 day or >30 days were excluded. Patient demographics were compared between Black and White patients using standard descriptive methods, stratified by gender. Linear regression models examined Black vs. White differences in patient LOS, controlling for patient and hospital-level factors. Analyses were conducted among patients treated in military facilities and, separately, among patients receiving care in civilian hospitals.

Results:Of the 3247 CABG patients, 2884 (89%) were White, of whom 9.9% were female. Among Black patients, 78 (21.5%) were female. Most patients were retirees or their dependants (86.8%). 30% of White and 33% of Black patients underwent emergent CABG (p=0.23). In gender stratified adjusted analyses, Black males experienced greater LOS vs. White male patients (7.8 vs. 7.2 days respectively, p=0.02); however, there was no difference in LOS between Black vs. White females (p=0.12). On subset analysis, race-based difference in LOS among males was observed only in civilian hospitals (8.2 vs. 7.3 days, p=0.004); there was no difference in LOS between Black and White male patients treated in military hospitals (p=0.37). Among female patients, LOS did not differ by race between military and civilian hospitals. Older age and emergent CABG were associated with longer stay for both male and female patients across both races and facility types.

Conclusion:In this cohort of younger adult CABG patients insured through military affiliation, Black race was associated with greater LOS among male, but not female, patients. This race-based variability in LOS was associated with care in civilian facilities. Factors underlying this race-based difference in LOS, present only in civilian hospitals, should be elucidated.

04.21 Targeting HDM-2 Over-Expression in Multi-Drug Resistant Ovarian Cancer

Posted on January 18, 2016

E. Gleeson1, H. Glatthorn1, D. Zimmerman1, C. Carballo1, S. Mahmood4, P. Love1, M. F. Shaikh1, W. F. Morano1, S. D. Richard2, M. R. Pincus3, W. B. Bowne1 1Drexel University College Of Medicine,Surgery,Philadelphia, Pa, USA 2Drexel University College Of Medicine,Gynecologic Oncology,Philadelphia, Pa, USA 3New York Harbor Healthcare System VAMC,Pathology,New York, NY, USA 4University Of Pittsburg,Pittsburgh, PA, USA

Introduction: Of an estimated 22, 000 women diagnosed with ovarian cancer in the United States each year, 80% will develop lethal multi-drug resistance (MDR) to conventional chemotherapy. HDM-2 over-expression in the cancer cell membrane may be a potential anti-cancer target. We tested this target using a p53-derived, HDM2-binding peptide for anti-cancer activity in MDR ovarian cancer.

Methods: Western blot analysis was used to demonstrate expression of HDM-2 in MDR SKOV-3 human ovarian cancer cell membranes compared to the membranes of untransformed fibroblasts. 5×104 cells were treated with HDM2-binding construct PNC–27 and control peptide. Anti-cancer activity and mechanism of PNC-27 were studied for cell viability (MTT), necrosis (LDH), apoptosis (Caspase-3) and co-localization of HDM-2 with PNC-27 (immunofluorescence).

Results: HDM-2 was strongly expressed in the cell membranes of MDR SKOV-3 by western blot analysis. Accordingly, PNC–27 was selectively cytotoxic to these cells, inducing nearly 100% reduction in cell proliferation compared to control PNC–29 and untreated cells (p<0.001; See Figure). We observed a rapid (4h) cellular necrosis with a 2.5 fold increase in LDH (p<0.001) and no caspase-3 activity. This was shown to occur in a dose-dependent manner. In contrast, PNC-27 had no effect on untransformed fibroblasts. This observed effect was due to over-expression of HDM-2 in MDR SKOV-3 cells which demonstrated co-localization of PNC–27 and HDM–2 along their membranes.

Conclusion: These findings demonstrate that HDM-2 over-expression in MDR ovarian cancer cells may be used as a potential target for anti-cancer therapy. Therapies that target HDM-2 in ovarian cancer cell membranes may increase our armamentarium for the treatment of this lethal disease.

04.17 MicroRNA dysregulation associated with function of the impaired monocyte

Posted on January 18, 2016

N. J. Galbraith1, S. Walker1, M. Cahill1, S. Gardner1, H. C. Polk1 1Price Institue Of Surgical Research,Department Of Surgery,Louisville, KY, USA

Introduction:
Major trauma often leads to impaired host defenses. Specifically, subnormal monocyte function (seen in approximately a sixth of all such patients) has repeatedly been shown to be associated with infection-related complications. However, identifying the ‘at risk’ patient, as well as understanding the pathophysiology behind this disturbance, continues to elude the investigators. MicroRNAs hold the potential as stable biomarkers that fine tune host defenses. We aim to identify novel microRNA (miRNA) associated with the impaired monocyte response.

Methods:
We produced ‘impaired’ human monocytes by exposure to LPS 10ng/mL (each containing 2.5 x 105 monocytes) and compared them to similarly incubated naïve monocytes. Both preparations were then challenged with LPS 100ng/mL and the production of TNFα, IL-6 and IL-10 (ELISA) and HLA-DR expression (flow cytometry) were determined. MiRNA profiling was undertaken using microfluidic array technology (n = 4 for each determination).

Results:
Monocytes exposed to LPS 10ng/mL were found to have lower TNFα, IL-6 and IL-10 production in response to an LPS 100ng/mL challenge, when compared to the naïve monocyte (p < 0.05, paired T-test). Furthermore, these impaired cells had lower HLA-DR expression (p<0.05). MiRNA profiling revealed that when compared to the naïve monocyte, the LPS-impaired cells had upregulated miRNA- 487a & miRNA-655, yet downregulated miRNA-433 & miRNA-450a (p = <0.05).

Conclusion:
The precise processes behind immune dysfunction that appear following major trauma remain unclear. We have identified four dysregulated miRNAs associated with the impaired monocyte inflammatory response. Further study of these, and approximately 20 more differentially expressed miRNAs based on our preliminary data and literature consultation, may identify other markers, some of which may be associated with important signaling mechanisms present in the high risk patient.

04.18 Hm-Chitosan Gauze: A New And Effective Topical Hemostat

Posted on January 18, 2016

A. Chaturvedi2, M. B. Dowling4, J. P. Gustin3, T. M. Scalea2, S. R. Raghavan3, M. Narayan2 2University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 3University Of Maryland,Department Of Chemical & Biomolecular Engineering,College Park, MD, USA 4University Of Maryland,Fischell Department Of Bioengineering,College Park, MD, USA

Introduction:
Currently, the standard of care for treating severe hemorrhage in a military setting is Combat GauzeTM(CG). Previous work has shown that hydrophobically modified (hm) chitosan has great hemostatic potential. This work aims to create a hm-chitosan coated gauze to directly compare to CG as well as ChitoGauze® (ChG) in a lethal in vivo hemorrhage model.

Methods:
Twelve Yorkshire swine were randomized to receive either hm-chitosan gauze (n = 4), ChG (n = 4), or CG (n = 4). A standard hemorrhage model was used in which animals underwent a splenectomy prior to a 6 mm punch arterial puncture of the femoral artery. Thirty seconds of free bleeding was allowed before dressings were applied and compressed for 3 minutes. Baseline mean arterial pressure was preserved via fluid resuscitation. Experiments were conducted for three hours after which any surviving animal was euthanized.

Results:
Hm-chitosan gauze was found to be at least equivalent to both CG and ChG in terms of overall survival(100% v 75%), number of dressing used(6 v 7), and duration of hemostasis (3 hrs v 2.25 hrs). Total post-treatment blood loss was significantly lower in the hm-chitosan gauze treatment group (4.7 mL/kg) when compared to CG(13.4 mL/kg) and ChG(12.1 mL/kg) groups (p =< 0.0001)

Conclusion:
Hm-chitosan gauze appears to have outperformed both CG and ChG in a lethal hemorrhage model. However given the small treatment group size, the only measured outcome that was significantly different was total post-treatment blood loss. Future comparison of hm-chitosan gauze to CG and ChG will be performed on a hypothermic and coagulapathic model that should allow for outcome significance to be differentiated under small treatment groups.

04.19 DPR Increasd sICAM-1 But Not Lung Integrin-aL or Integrin-aM in Resuscitated Hemorrhagic Shock

Posted on January 18, 2016

S. C. Jones1, P. J. Matheson1,2, C. D. Downard1,2, J. C. Frimodig1, C. J. McClain1,2, R. N. Garrison1,2, J. W. Smith1,2 1University Of Louisville,Department Of Surgery,Louisville, KENTUCKY, USA 2Robley Rex VAMC,Department Of Surgery,Louisville, KENTUCKY, USA

Introduction: ~~Hemorrhagic shock (HS) in trauma patients can result in gut and liver hypoperfusion and a pro-inflammatory systemic condition, which often initiates acute lung injury (ALI) or the more severe acute respiratory distress syndrome (ARDS). The pathophysiology of ALI/ARDS is multifactorial, but can involve alarmins, activated immune cells, and inflammatory chemokines/cytokines. DPR improves intestinal and hepatic blood flow to prevent gut-associated inflammatory changes and thus might also prevent or mitigate ALI/ARDS. We hypothesized that soluble intracellular adhesion molecule-1 (sICAM-1), which is sloughed from endothelial cells in inflammatory conditions, might be elevated in resuscitated HS, and that DPR might prevent that event.

Methods: ~~Male Sprague-Dawley rats (225-250g) were anesthetized and randomized to groups (n=8/group): 1) Sham (no HS, no conventional resuscitation or CR); 2) HS/CR; or 3) HS/CR+DPR. HS was 40% of mean arterial pressure for 60 minutes. CR was shed blood plus two equal volumes of lactated Ringers over 30 minutes total. DPR was 25mL of pre-warmed 2.5% glucose peritoneal dialysis solution at the time of blood infusion. Serum and lung tissue were collected at 4 hours post-CR. Adhesion molecule levels were measured by ELISA: serum sICAM-1, lung integrin-alpha L (ITGAL or LFA-1), and lung integrin-alpha M (ITGAM or MAC-1).

Results:~~HS/CR increased sICAM-1 levels compared to Sham, and DPR increased sICAM-1 further compared to Sham or HS/CR (see Figure). There were no differences in lung LFA-1 or MAC-1 levels in HS/CR or HS/CR+DPR compared to Sham.

Conclusion:~~These data suggest that circulating levels of sICAM-1 are not mediated by gut blood flow and/or gut-associated inflammatory mediators in this model of resuscitated shock at this 4-hour post-CR time point. Other post-resuscitation time points might reveal a benefit to DPR, which has been shown to improve the number of lungs suitable for organ transplant in human organ donors compared to donors who did not receive DPR treatment.

04.14 Monocyte Differentiation Alters CHRFAM7A: Implications for a Human-Specific Inflammatory Response

Posted on January 18, 2016

S. M. Langness1, B. Eliceiri1, R. Coimbra1, A. Baird1, T. W. Costantini1 1University Of California – San Diego,Trauma, Surgical Critical Care, Burns And Acute Care Surgery,San Diego, CA, USA

Introduction: In humans, the alpha-7 nicotinic acetylcholine receptor (a7nAChR) is encoded by the CHRNA7 gene and mediates an anti-inflammatory response to injury and infection. However, the human genome also encodes a uniquely human gene called CHRFAM7A that is an antagonist to a7nAChR-mediated signaling. Several studies have suggested that in humans, the ratio of CHRNA7 to CHRFAM7A modulates receptor activity. We have previously shown that: a) CHRFAM7A is highly expressed in human leukocytes; b) the ratio of CHRNA7 to CHRFAM7A gene expression in leukocytes varies widely amongst individuals; and c) CHRFAM7A is biologically active in the human THP1 pre-monocyte cell line. Here, we postulated that PMA differentiation of these monocyte precursors to monocytes might alter the CHRNA7 to CHRFAM7A ratio and alter monocyte gene expression. The effects of preventing a change in differentiation-induced CHRFAM7A gene expression was evaluated by its constitutive expression using gene delivery.

Methods: THP-1 cells were used in all experiments and monocyte differentiation was induced by incubation with PMA for 3 days in culture. Cell appearance and viability was assessed by light microscopy and flow cytometry respectively. CHRNA7 and CHRFAM7 gene expression was measured by quantitative RT-PCR. Constitutive expression of CHRFAM7A was achieved with lentiviral transfection prior to PMA-induced differentiation. Gene expression in transfected CHRFAM7A and GFP-transduced differentiated monocytes were compared using RNA-seq with subsequent pathway analyses.

Results: CHRFAM7A expression was decreased by 70% in PMA-differentiated monocytes compared to untreated THP-1 cells. In contrast, there was no difference in CHRNA7 expression resulting in a net 5-fold increase in the expression of CHRNA7 compared to CHRFAM7A (see Figure). Over-expression of CHRFAM7A in differentiated monocytes produced viable cells with monocytic phenotype based on microscopic appearance and the presence of monocyte cell surface markers like CD14, CD22 and CD163. In contrast, the constitutive expression of CHRFAM7A in differentiated monocytes changed the expression of genes in pathways traditionally associated with regulating inflammatory response signaling and antigen presentation.

Conclusions: The ratio of CHRNA7 to CHRFAM7A gene expression in THP1 cells changes after differentiation to monocytes. Preventing this change by gene transfection, CHRFAM7A has no effect on differentiation but alters the expression of genes that mediate the inflammatory response. Because CHRFAM7A is unique to the human genome, these data support the existence of a human-specific mechanism that regulates a7nAChR anti-inflammatory signaling and hence, the human immune response to injury and infection.

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