62.16 Trends in and barriers to medical students’ surgical education: a global survey

Posted on January 18, 2016

I. H. Marks3, M. Keem2, A. Diaz1, S. L. Seyedian4, G. S. Philipo9, I. Di Salvo7, H. Munir8, T. Pomerani6, N. Peter5, C. Lavy5 1Virginia Commonwealth University,School Of Medicine,Richmond, VA, USA 2University Of Melbourne,Melbourne, , Australia 3Barts And The London School Of Medicine And Dentistry,London, , United Kingdom 4Tehran University Of Medical Sciences,Student Scientific Research Center,,Tehran, , Iran 5University Of Oxford,Oxford, , United Kingdom 6University Of Florence,Florence, , Italy 7University Of Pavia,Lombardy, , Italy 8Allama Iqbal Medical College,Lahore, , Pakistan 9Mwananyamala Regional Referral Hospital,Mwananyamala, , Tanzania

Introduction: Approximately 5 billion people have no access to basic surgical care. The global burden of noncommunicable diseases and injury requiring surgical care has overtaken that of infectious disease, with conditions such as cancer, heart disease and diabetes, increasing dramatically in less-developed countries. Evidence suggest that barriers to accessing surgical care in low- and middle-income countries include difficulty accessing surgical services due to distance, poor roads, and lack of suitable transport; lack of local resources and expertise; and direct and indirect costs related to surgical care. What is less clear is what elements are responsible for influencing medical students in choosing a career in surgery. The goal of this study is to elucidate the reasons why medical students may or may not choose a career in surgery, identify common themes across different regions, genders and income strata.

Methods: In collaboration with the University of Oxford, we developed an electronic, multi-question survey to help elucidate the reasons why medical students may choose or discount surgical careers. Hosted on a web-based survey platform via the University of Oxford, the survey was distributed via multiple mailing lists as well as social media. The study was open to all medical students and was entirely anonymous and confidential.

Results: 499 medical students from 63 countries in six different regions including Africa, Asia, The Americas, Australasia, Eastern Mediterranean and Europe completed the survey (n=499), 43% (216) of which were male. 68%(339) of responders are considering a surgical career comprising 83% (192) female and 68% (147) male responders. Responses were analyzed both collectively and by region. Those from the East Mediterranean region were the most likely to be considering a career in surgery (81%) while those from Europe and Australasia was the least likely (67%). With the exception of Australasia, all regions disagreed with the statement that medical students had good access to undergraduate surgical education. The cost of postgraduate surgical training was expressed as a significant concern only in the African region. Over half the responders from Asia, Africa and the East Mediterranean agreed that surgeons in their countries dedicated the majority of their time to private sector patients. These regions were also the most likely to say that surgeons had poor access to resources. All regions except for Europe perceived surgeons to be overworked.

Conclusion: While the study is not yet adequately powered, trends in elements influencing medical students to choose a surgical career are appearing within our preliminary data. Whilst applications from female surgeons remain low in different regions globally, enthusiasm amongst female medical students appears to be high. Barriers to female students having successful surgical careers may therefore be more influential after completion of medical school.

62.11 Do Trends in Surgical Resident Case Volumes Justify Additional Oncology Fellowship Training?

Posted on January 18, 2016

A. A. Khan1, S. Desai1, J. Mellinger1, S. Ganai1 1Southern Illinois University School Of Medicine,Springfield, IL, USA

Introduction: Resident case volume and complement has changed over the past decade, possibly due to an increase in minimally-invasive procedures and duty hour reform. Subspecialty fellowship training in complex general surgical oncology has recently received approval for board certification and has been advocated as a pathway to improve proficiency in the performance of complex open oncologic cases in addition to providing comprehensive exposure to the multidisciplinary management of cancer. The purpose of this paper is to evaluate trends in resident exposure to complex oncologic cases.

Methods: A retrospective analysis of National Accreditation Council for Graduate Medical Education (ACGME) case log statistical reports from 2000-2013 was conducted to determine resident case volume for selected oncology-relevant procedures. Average yearly case numbers combining both Surgeon Chief and Surgeon Junior categories were analyzed as cases per graduating resident using linear regression assessing for temporal trends, with the null hypothesis assuming an estimated slope of zero. The Spearman rho test was used to estimate correlation of case trends over time.

Results:Linear regression trends for oncology-relevant procedures are summarized in the attached table. Decreasing trends were observed for major lymphadenectomies (rho -0.93, p<0.0001) and modified radical mastectomy (rho -0.86, p=0.007) during the study period. There was no significant change in exposure to total gastrectomy (rho +0.33, p=0.43) and esophagectomy (rho -0.60, p=0.03). An increasing exposure was noted for hepatopancreaticobiliary cases including major hepatic resection (rho +0.93, p <0.0001) and pancreatectomy (rho +0.93, p <0.0001).

Conclusion:While decreases were noted for exposure to soft tissue lymphadenectomy, there were no differences in foregut cases and an increase in hepatopancreaticobiliary cases. The overall case numbers for several of these complex oncologic procedures remain low, justifying a need for further fellowship training depending on independent resident experience.

62.12 Intraoperative Variation and Acquisition of Complex Operative Techniques: Pancreaticoduodenectomy

Posted on January 18, 2016

S. J. Davidson1, M. Rojnica2, A. J. Langerman2 1University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA

Introduction:
Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between these techniques. We used pancreaticoduodenectomy as a model procedure to catalogue the variability between surgeons within an affiliated health system and investigate the factors that affect fellow’s acquisition of techniques.

Methods:
Semi-structured interviews and operative note analysis were conducted to determine techniques of five attending surgeons, and these data were mapped to identify variations. Identical interviews and subsequent questioning were completed with four recent fellowship graduates whose current practice included pancreaticoduodenectomy.

Results:
All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were actually 21 surgical step data points that differed – far more than previously recognized. Four of five surgeons were unable to identify colleagues’ techniques. Fellows reported that they were more likely to adopt techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Fellows did not feel residency training had a strong influence on their choice of technique, but did report a moderate influence from senior partners after fellowship.

Conclusion:

The true number of variants of pancreaticoduodenectomy based on granular, step-by-step difference is substantially larger than previously described. Results hint that variation may be furthered by the fact that surgeons may not be intimately aware of the techniques employed by colleagues. Interestingly, fellows appear to choose techniques based on factors not directly related to their own outcomes, but rather mentors’ techniques and teaching style. Whether fellows adopt the techniques that will be most optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of surgical variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.

62.13 Comparison of Surgical Clerkship Performance between Medical and Physician Assistant Students

Posted on January 18, 2016

N. N. Alamiri1, C. M. Maliska1, H. Chancellor-Macintosh1, G. Sclabas1 1University Of Oklahoma Health Science Center,College Of Medicine In Tulsa – Department Of Surgery,Tulsa, OK, USA

Introduction:
Third year medical students (MS-III) and second year physician assistant students (PA-S) have similar core clinical rotations during their education. Uniquely at our institution, both groups rotate together and are assessed by the same evaluation and grading standards. This study compares the performance of MS-III and PA-S during their combined surgical clerkship rotation.

Methods:
A retrospective analysis on students’ final clerkship grades, individual grades for Clinical Performance Evaluation (CPE), Objective Structured Clinical Examination (OSCE), faculty tutorials, and National Board of Medical Education general surgery examination (NBME) for academic years 2013 and 2014.

Results:
A total of 95 students were included, 51 MS-III and 44 PA-S. Between both groups’ final grades and OSCE scores, there was no significant statistical difference (p > 0.05). However, MS-III as compared to PA-S had significantly higher CPE, NBME, and tutorial scores (p < 0.05). In comparing 2013 to 2014 MS-III classes, no significant difference existed, but the 2014 PA-S class had a significantly higher NBME and tutorial scores as compared to 2013 PA-S class.

Conclusion:
MS-III performed better in tests evaluating medical knowledge, possibly a reflection of a more intense basic science education MS-III receive. No significant difference in clinical performance was found. This could be attributed to similar clinical education both receive as well as PA-S often have a history of prior professional health care experience. Over the time of the study, PA- S basic science education seemed to improve.

62.09 Assessing Pre-Operative Communication Between Attendings and Residents

Posted on January 18, 2016

S. Sullivan1, J. Steiman1, C. Pugh1 1University Of Wisconsin,Madison, WI, USA

Introduction: The operating room (OR) has traditionally been a place of discovery learning. However, prior reports have shown that residents spend less than 15% of their total residency hours in the OR. Furthermore, use and development of new surgical devices and technologies limits residents’ participation in certain procedures as part of their general training. As such, the OR must increasingly become a place of active, focused learning with each experience. Effective communication should occur prior to the operation to identify learning needs. The goal of this study was to investigate pre-operative communication between attendings and residents.

Methods: Categorical surgery residents (n=20) completed a 39-item survey assessing the following related to operative preparation: 1) when they prepare and the amount of time they spend preparing, 2) what they focus on when preparing, 3) interaction with attendings before the operative case 4) resource use to prepare for the operation and 5) identification of perceived case weaknesses. A 5 point Likert scale was used, with 1= Hardly Ever and 5= Almost Always. In the sample, there were 12 males (60%), and the average age was 32. The majority of the residents (6) were in their program year (PGY) 1, with 4 in both PGY 2 and PGY 3, and 3 in both PGY4 and PGY5.

Results: All of the respondents (see Table 1) said that they usually prepare for operative cases. The majority of residents identify the critical steps of an operation prior to the case. Only a small percentage, however, review these with the attending with regularity, and 95% state they do not typically discuss who will perform these critical steps. Fourteen residents (70%) stated that discussion of personal educational goals prior to cases occurs infrequently. The majority of residents typically do not discuss what parts of the case they will do with the attending beforehand (85%). That being said, most residents reported hardly ever asking to do a certain part prior to operating and stated that weakness identification pre-operatively does not generally occur. Finally, only 30% of residents were largely satisfied with the amount of interaction with attendings prior to cases.

Conclusion: We have identified major deficits in communication between residents and attendings. Explicit communication is therefore needed to improve teaching and learning within the OR. Though patient centric, the OR is also a learning environment for surgical residents. Overall, residents would like more opportunities for pre-operative discussions with attendings. Potential targets for these discussions include residents’ case participation and personal educational goals.

62.10 Fate of Abstracts Presented at the 2009 American Transplant Congress and the 2007-2009 AHPBA

Posted on January 18, 2016

J. B. Durinka1, C. Ortiz2, T. Wenzel2, J. Ortiz2 1University Of Buffalo,Buffalo, NY, USA 2University Of Toledo,Surgery,Toledo, OH, USA

Introduction: Oral and poster presentations at major meetings serve to rapidly present and share study results with the scientific community. On the other hand, full-text publication of abstracts in peer-reviewed journals provides dissemination of knowledge. The purpose of this study was to evaluate the publication rate of abstracts presented at the 2009 American Transplant Congress (ATC), and the annual Americas Hepato-Pancreato-Biliary Association (AHPBA) from 2007-2009 to assess the factors influencing publication and determine the impact factor of these journals.

Methods: All abstracts presented at the 2009 ATC and 2007-2009 ABPBA were included in the study. A Pubmed-Medline search was performed to identify a matching journal article. Topics, country of origin, study type, study center and publication year were tabulated. Journals and impact factors of publication were noted.

Results: Out of 2568 abstracts presented, (474)18% were published as full-text articles. Publication rates according to topics of the meeting and country of origin did demonstrate statistical significant differences (p-value<0.05). Single-centered studies had higher publication rates 70.87% (160/190) than multi-centered studies among oral abstracts. Abstracts from multi-centered studies had higher publication rates among poster abstracts (68.09% vs. 31.91%), and the journals they were published in had higher impact factors than single center studies (4.578 vs. 3.897). The median impact factor of the journals was 4.2 (4.8 for oral presentations and 3.627 for poster presentations) that went on to be published as full text manuscripts. When comparing multi-center and single institutions, the difference between 12 month and 24 month publication rates was not statistically significant (p=0.5443 and 0.1134). However, oral and poster abstracts published by study center (multi/single) did demonstrate a statistically significant difference (p < .0001); comparing the type of study, there was also a statistically significant difference between the oral and poster abstract (p < .0001).

Conclusion: Eighteen percent of abstracts presented at both meetings went on to full text publication. The publication rate for these abstracts presented at both meetings was lower than rates from other fields of medicine. Factors leading to failure require elucidation. Encouraging authors to submit their presentations for full-text publication might improve the rate of publication. Authors should be wary of accepting oral and poster abstracts as dogma; authors should refrain from citing them in publications especially if they are from outside United States.

62.07 Implementing a Resident Acute Care Surgery Service: Improving Resident Education and Patient Care

Posted on January 18, 2016

O. Kantor1, A. B. Schneider1, M. Rojnica1, A. J. Benjamin1, N. Schindler1,2, M. C. Posner1, J. B. Matthews1, K. K. Roggin1 1University Of Chicago,Department Of Surgery,Chicago, IL, USA 2Northshore University Health System,Department Of Surgery,Evanston, IL, USA

Introduction:
The American Board of Surgery recently changed the requirements for graduating surgery residents to a minimum of 25 cases as a teaching assistant (TA). To expand the resident education experience and allow for senior residents to be more autonomous in the management of patients both in the operating room and perioperatively, our program implemented a new Resident-run Acute Care Surgery (RACS) consult service. We hypothesized that creation of this service would increase TA cases and resident satisfaction, as well as be more efficient in evaluating consults.

Methods:
With the implementation of RACS, we switched from an attending-service based call model to a new admitting service that was mainly resident run with alternating attending supervision. Two residents (PGY4 or 5 and PGY2) staffed this service and all new surgical consults were directed to RACS. When appropriate based on resident experience and case complexity, the operative case was done as a TA case with the senior resident taking the junior resident through the case and the attending in the room. We collected information on TA case logs for senior residents pre (n=10) and post (n=11) implementation of the RACS service, independency data on the proportion of each case performed independently by residents, resident evaluations of general surgery services, and consult time (time from consultation to time patient seen) for the first 12 months of the service (June 2014-June 2015).

Results:
The number of total TA cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4-44) for pre-RACS residents to 30.8 ± 8.8 (range 27-36) for post-RACS residents (p<0.01). This increase was seen with a mean of one month spent on RACS for the post-RACS residents. Of 323 operative cases, the residents performed an average of 82% of the case independently. On resident service evaluations of RACS (n=27) compared to other general surgery services (n=127), there was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, p<0.01 on a 1-6 Likert scale) and complexity of cases (mean 5.35 vs 4.94, p<0.01). In addition, creation of a one-team consult service resulted in a more streamlined consult process, with average consult time of 22min for operative consults and 25min for non-operative consults.

Conclusion:
The implementation of a RACS service has increased resident autonomy, TA cases, and satisfaction with operative case variety, as well as increased the efficiency of surgical consultation at our institution.

62.08 Emerging Reimbursement Models in Surgical Practice: General Surgery Resident Perceptions

Posted on January 18, 2016

J. M. Linson1, J. W. Dennis1, E. Lerner1, M. Nussbaum1, J. Tepas1 1University Of Florida College Of Medicine,Surgery,JACKSONVILLE, FL, USA

Introduction:

The shift from Fee- For-Service (FFS) to value and quality based payment has stimulated multiple alternative payment models (APM) that include the Medicare ‘Shared Savings Program (SSP),’ ‘Pay for Performance (P4P),’ ‘Comprehensive Care Payments (CCP),’ and ‘Episode of Care/Bundled Payment (EOC/BP)’. The Department of Health and Human Services (HHS) has declared its goal to tie 30% of Medicare payments to alternative payment models by the end of 2016, and 50% by the end of 2018. Recently enacted legislation repealing the sustainable growth rate (SGR) intends to shift to >75% of reimbursement to APM. Little is currently known about the perception of this among General Surgery residents, who will inherit a system in flux upon completion of their training.

Methods:
An electronic survey was distributed to American General Surgery residents to assess their understanding and perception of these alternative models. Using Likert scale responses, surgical autonomy, patient satisfaction, coordination of care, control of costs, and surgical outcomes were evaluated with respect to these reimbursement models. Model types were compared by level of understanding and perception of impact on key areas of surgical practice.

Results:
255 surveys were distributed individually via program coordinators, and one link was distributed via the Association of Program Directors in Surgery list-serve, yielding a return of 183 responses. FFS and P4P were best known, with >75% of respondents reporting at least moderate familiarity. BP/EOC was at least moderately familiar to 62% of respondents. Conversely, 63.2% indicated limited familiarity with CAP. 60.2% were slightly or not at all familiar with CCP. 71% were either slightly or not at all familiar with SSP. Analysis of impact on surgical practice demonstrated consensus regarding anticipated effect on surgical autonomy and cost control (table). None of the models were seen as improving patient satisfaction. P4P was anticipated to improve outcome by 47.2% of respondents. A need for more education about the new healthcare reimbursement models was indicated by 95.1% of respondents.

Conclusion:

Most residents have limited familiarity with FFS, P4P and BP/EOC. Most also recognized the trade-off between surgical autonomy and cost control. Only FFS was perceived to have a positive effect on autonomy, while all alternative models had a perceived negative effect. Only P4P was perceived to have a positive impact on surgical outcomes by a majority of respondents. An overwhelming majority articulated need for more education in this area and a role in developing and evaluating these alternative models.

62.04 First-Case Delays: Curriculum-based Quality Improvement in Interdisciplinary Teams

Posted on January 18, 2016

A. Botty Van Den Bruele1, M. Main2, C. L. Leaphart1 1University Of Florida,Department Of Surgery,Jacksonville, FL, USA 2UFHealth Jacksonville,Perioperative Services,Jacksonville, FL, USA

Introduction: Quality Improvement (QI) education and Interdisciplinary teamwork for surgical residents are critical areas of program accreditation and practice management. Yet, surgical curriculum applying quality improvement methodology remains largely undefined. Our residency program incorporates a research-based curriculum for categorical interns with foundational instruction in QI methodology. To expand the curriculum and develop systems-based application of QI methodology, we hypothesized that selection of a clinical problem, first-case delays (FCD) in the OR, would provide QI instruction from an interdisciplinary perspective while addressing educational goals.

Methods: After instruction in fundamentals of research, IRB approval was obtained. Resident identification of FCD for the interdisciplinary study was guided by experienced faculty. Literature searches were used to develop data dictionaries of standardized reasons for case delay. The data dictionary was used for direct observation of patient and team-based readiness for in room start at 715 AM. Cases observed were General or Vascular Surgery cases in which residents were involved. Using QI methodology, Pareto analysis was performed to stratify reasons for delay and was compared to computer-recorded staff entries of reasons for delay. Analytical drill-down using Ishikawa diagrams further stratified contributing factors for case delays, providing additional opportunities to expand QI initiatives.

Results: A total of 27 first case starts were observed, of which 25 (92.6%) failed to start on time. Pareto analysis determined the most common reason for delay to be failure of OR room readiness (56%, n=14) followed by near equivalent delays for transport, patient availability, anesthesiology, or surgical reasons. By contrast, computer recorded entries listed surgical team readiness as the primary cause of delay indicating that efforts to address delays could be impaired if not targeted appropriately. Ishikawa diagrams (Figure) demonstrate the complexity of interdisciplinary team function required to prevent FCD while enhancing understanding of how to address delays.

Conclusion: Using clinical issues to apply QI methodology expands resident education in the science of quality improvement and interdisciplinary teamwork while broadening the resident’s understanding of the healthcare system. Ongoing collaboration of teams using QI methodology can be used to prevent first-case delays and improve teamwork in the OR.

62.05 Does Lung Implantation by a Resident Affect Short-Term Outcomes?

Posted on January 18, 2016

J. Price1, D. Williams1, R. Murthy1, J. Waters1, W. Ring1, M. E. Jessen1, M. Peltz1, M. Wait1 1University Of Texas Southwestern Medical Center,Cardiovascular And Thoracic Surgery,Dallas, TX, USA

Introduction: At training institutions, residents often assist with single or bilateral lung transplants. We sought to evaluate the short-term outcomes for these patients, comparing the results when implantation is performed by attending surgeons or when a resident is the implanting surgeon for one side if bilateral or for the entire single lung. We hypothesized that resident participation did not adversely affect outcomes after lung transplantation.

Methods: 243 lung transplant patients at a single center were reviewed. All patients underwent single (SLT) or bilateral lung transplant (BLT). The implanting surgeon and warm implantation time (WIT) were recorded for each side if bilateral or for the single lung, comparing Attending Only (AO) to Resident Participation (RP). We reviewed pre-, intra-, and post-operative variables. Groups were described by mean and standard deviation and compared by t-test, with p-value <0.05 considered significant.

Results: For BLT patients, age and lung allocation score (LAS) did not differ between the groups. While total WIT was significantly shorter in the AO group, cardiopulmonary bypass (CPB) rate, packed red blood cell (pRBC) requirement, duration of intubation, intensive care unit (ICU) stay, postoperative length of stay (LOS), primary graft dysfunction (PGD) grade, and 30-day mortality did not differ between the AO and RP groups. In SLT patients, the age again was similar, but the LAS was significantly higher in the RP group. However, WIT, CPB rate, pRBC requirement, duration of intubation, ICU stay, postoperative LOS, PGD grade, and 30-day mortality did not differ between the two groups. Table 1 summarizes this data.

Conclusion: Lung transplantation is a time-sensitive operation, and often residents are not allowed to perform the donor lung implantation due to this concern. These results show that residents, with proper attending supervision, can perform these difficult procedures with minimal increase in warm implantation time and no compromise in short-term outcomes for these complex patients.

62.06 Sharing Stress in Surgical Training?

Posted on January 18, 2016

S. Alken1, J. Luursema1, C. Fluit1, H. Van Goor1 1Radboud University Medical Center,Nijmegen, N/A, Netherlands

Introduction:

High levels of stress can cause cognitive overload, compromise technical and non-technical abilities of surgeons and can potentially compromise teaching climate and efficiency. This study aims to investigate how stress is perceived by trainees and faculty during a simulation team training, and how subjective stress is related to objective stress data.

Methods:

Data was collected during the Definitive Surgical Trauma Care (DSTC) course, a highly realistic hands-on trauma surgery team training performed on live porcine models. 7 surgical teams participated, each team existing of 1 faculty coaching 2 trainees.

Subjective stress was measured by the State Trait Anxiety Index (STAI; 6= lowest level of stress; 24= highest level of stress) and on a Visual Analogue Scale (VAS; 0= lowest level of stress; 100= highest level of stress). Objective stress was measured by saliva cortisol level, heart rate and heart rate variability. Saliva samples, STAI and VAS scores were collected 2 times at baseline and 4 times during the simulation training. Heart rate and heart rate variability was registered every 4 and 300 seconds respectively with the Health Patch™ (Vital Connect Inc, Campbell, USA) worn by all participants.

Results:

Trainees reported a significant increase of mean subjective stress during training compared to baseline (STAI: 12.44 vs. 9.65, +2.79, Wilcoxon SR Test, P = .005; VAS: 39.06 vs. 20.33, + 18.73, Wilcoxon SR Test, P= .007), whereas faculty did not (STAI: 9.87 vs. 9.21, +0.66, Wilcoxon SR Test, P = .180; VAS: 25.00 vs. 18.57, +6.43, Wilcoxon SR Test, P= .138).

Between the faculty and trainees within the same team, in-training VAS and STAI scores did not correlate (Pearson’s r ranging from -.580 to .765). Strong correlations were found between the in-training cortisol levels of faculty and trainees in 5 of 7 teams (Pearson’s r ranging from .929 to .979). Analysis of cortisol samples and Health Patch™ data is currently done.

Conclusion:

Perceived stress differed between faculty and trainees during a highly realistic damage control surgery team training, whereas objective stress as measured by cortisol did not. Possibly, stress remains unnoticed or neglected by faculty.

62.01 Post-80-hour Workweek Trends in General Surgery Resident Applications

Posted on January 18, 2016

J. A. Keeley1, C. DeVirgilio1, A. Moazzez1, S. Lee1, B. Jarmin2, A. L. Neville1 1Harbor-UCLA Medical Center,General Surgery,Torrance, CA, USA 2Gunderson Medical Foundation,General Surgery,La Crosse, WI, USA

Introduction: Over the past decade, it appears that the number of General Surgery residency applicants has increased. We hypothesized that implementation of the 80-hour workweek in 2003 may have influenced this trend. The purpose of this study was to evaluate national and local trends in applications to surgical residency after implementation of the 80-hour workweek.

Methods: NRMP Results and Data from the Main Residency Match between 1999 and 2014 were interrogated for the number of applicants, available general surgery positions, and ranks per available positions. Data from an academic program (California) and an independent program (Wisconsin) was also collected for available years, 2007 to 2014. Data was statistically analyzed using linear regression (SPSS V22).

Results: Nationally, the number of unfilled residency positions decreased from an average of 44.7 prior to 2003 to 4.1 after 2003, (p= 0.04). Since 2003, the percentage of total US applicants applying to surgery, the percentage of general surgery positions available, and the number of positions per US applicant have been stable (Figure 1). However, the number of ranks submitted per available position increased from 9.6 in 2004 to 11.0 in 2014 (p=0.007).

The number of applications submitted to the two individual programs increased over the last eight years, both in total number and in percentage of the US surgical applicants who applied to each program. Total US applicants (percentage of surgical applicants) increased from 237 (22.7%) and 72 (6.9%) to 377 (29.6%) and 187 (14.7%) respectively for the two programs studied.

Conclusion: Since the introduction of the 80-hour workweek in 2003, there has been an increase in the number of applications to individual programs and the number of ranks per position. This may reflect a perceived increase in the competitiveness of the specialty, particularly given the decreased number of unfilled positions since 2003. However, nationwide, the total number of applicants and number of positions available per applicant has remained stable. The increased number of applications to individual programs increases the difficulty of the interview selection process and suggests the need for a refined approach to selecting candidates.

62.02 An Exploration of Moonlighting Effects on Surgical Skill in Lab Residents

Posted on January 18, 2016

K. Law1, S. J. Gannon2,3, A. D. D’Angelo2, D. A. Wiegmann1, C. M. Pugh1,2 1University Of Wisconsin,Industrial And Systems Engineering,Madison, WI, USA 2University Of Wisconsin,Surgery,Madison, WI, USA 3University Of Wisconsin,Kinesiology,Madison, WI, USA

Introduction: Resident participation in dedicated research is a tradition in general surgery programs. To alleviate concerns regarding maintenance of clinical skill during the research years, some residents take extra call shifts or moonlight to offset potential skill reduction. Several research studies have characterized lab resident experiences during moonlighting. However, few have investigated how residents’ surgical performance is impacted by moonlighting. The aim of this paper was to determine if the effects of moonlighting can be objectively measured during assessments of surgical skill. Our hypothesis is that the quality and accuracy (errors) of resident performance in a simulated laparoscopic ventral hernia (LVH) would be positively correlated with moonlighting experience.

Methods: Thirty-eight surgical lab residents (PGY2-4; 54% female) had 15 minutes to complete two steps of a simulated LVH procedure including securing mesh anchoring sutures to the abdominal wall and affixing the mesh with a laparoscopic tacker. Residents identified how often they take clinical shifts in a pre-simulation general survey. Resident performance was determined by analyzing the hernia skins and errors made during the procedure. Post-simulation, hernia skins were graded on a 24-point scale for quality of repair. Procedural errors were identified using a checklist of previously identified common errors committed during the LVH procedure. Based on their moonlighting activity, residents were grouped into low or high moonlighting groups based on whether they reported one or fewer clinical shifts per month (n=22) or two or more shifts (n=16). A logistic regression analysis was used to predict frequency of moonlighting in lab residents using errors and final hernia grades as predictors.

Results: The logistic regression analysis using repair quality and error scores as predictors reliably distinguished between the two moonlighting groups (χ2 = 7.78, p=.02). The model explained 25.1% (Nagelkerke’s R2) of the between-group variance in predictor scores and correctly classified 73.7% of residents into their respective moonlighting group. Residents’ hernia quality repair scores (p=.021) made a significant contribution to the prediction. Errors did not. Residents in the high moonlighting group had better repair quality scores on average (M=16.5, SD=5.0) than the low moonlighting group (M=14.2, SD=5.2). There was no significant difference in the frequency of errors committed between the two groups (p =.61).

Conclusion: Residents who reported moonlighting had higher quality hernia repair scores compared to those who rarely if ever moonlighted. However there were no differences in the number of errors made between groups. These findings suggest that there is either a qualitative difference in the types of errors made by residents who moonlight or that they are better able to identify and manage errors when they occur, thereby not affecting repair quality.

62.03 Emotional Intelligence in Surgery: Relationship with Resident Performance and Job Satisfaction

Posted on January 18, 2016

R. H. Hollis1, L. M. Theiss1, M. S. Morris1, J. R. Porterfield1, J. M. Grams1, D. Chu1 1University Of Alabama At Birmingham,Dept Of Surgery,Birmingham, AL, USA

Introduction: Emotional intelligence (EI) has been associated with better performance and job satisfaction in several industries. The role of EI in the surgical profession is less clear particularly among surgical residents. Surgical resident performance is currently measured with ACGME competency based milestones and ABSITE scores. We hypothesized that higher EI would be associated with higher measures of resident performance and job satisfaction.

Methods: In 2015, a validated trait EI questionnaire (TEIQ) and job satisfaction survey were distributed to all general surgery residents at a single institution. These data were compared to resident performance which was defined by attending evaluations using the ACGME competency based milestones and standardized test scores (USMLE and ABSITE). Statistical comparison was made using Pearson correlation for continuous variables and ANOVA for categorical variables. The association between milestone scores and global trait EI was also evaluated using a general linear model to adjust for evaluation differences by post-graduate year (PGY).

Results: Overall survey response rate was 68.9%. Global EI did not significantly vary by resident age, gender, marital status, or PGY. Global EI was associated with scores on USMLE Step 2 (r=0.46; p=0.01) and Step 3 (r=0.54; p=0.01) but not ABSITE percentile scores (r=0.06, p=0.77). Clinical milestone scores significantly increased by PGY status (p<0.01), but were not associated with Global EI before or after adjustment for PGY (p>0.05). Global EI was associated with overall job satisfaction (r=0.37, p=0.04). Sub-analysis showed significant correlation between the EI domain of ‘well-being’ and a resident’s satisfaction with work supervision (r=0.47, p<0.01), work communication (r=0.38,p=0.03), and the nature of their work (r=0.45, p=0.01). Job satisfaction was not associated with ABSITE percentile scores.

Conclusion: Emotional intelligence was associated with job satisfaction measures and USMLE performance but not ACGME competency based milestones or ABSITE scores. EI may be an important factor for fulfillment in surgical training that is not currently captured with traditional in-training performance measures.

61.19 Esophageal Duplication Cysts And Closure Of The Muscle Layer

Posted on January 18, 2016

L. O. Benedict1, S. Bairdain2, J. K. Paulus4, C. Jackson1, C. Chen2, C. Kelleher3 1Tufts Medical Center,Pediatric Surgery,Boston, MA, USA 2Children’s Hospital Boston,Pediatric Surgery,Boston, MA, USA 3Massachusetts General Hospital,Pediatric Surgery,Boston, MA, USA 4Tufts Clinical And Translational Science Institute,Boston, MA, USA

Introduction: Foregut duplication cysts are rare congenital anomalies that require surgical intervention with approximately 10-15% of all gastrointestinal duplication cysts originating from the esophagus. Consensus is lacking among surgeons regarding closure of the esophageal muscle layer following resection of an esophageal duplication cyst and long-term outcomes are poorly documented. Therefore, we sought to determine whether closure of the esophageal muscle layer following resection influences short or long-term outcomes.

Methods: A retrospective cohort study performed at three institutions affiliated with childrens hospitals was performed. Patients undergoing resection of esophageal duplication cysts between 1990-2012 were classified according to whether the esophageal muscle layer was closed or left open. Demographic data, surgical technique, pre-operative symptoms and both short-term (< 30 days) and long-term (≥ 30 days) complication rates were abstracted from patient medical records.

Results: Twenty-five patients were identified with a median age of 15 years old (range: 2 months to 68 years old). Eleven patients had the esophageal muscle layer closed after surgical resection (44%). Of those 11 patients, one developed a short-term complication, dysphagia (9%, 95% CI: 2%, 38%). Only one patient returned to the operating room, after 30 days, for an upper endoscopy after developing symptoms of gastroesophageal reflux disease. Of the 14 patients who had their muscle layer left open, 3 patients (21%, 95% CI: 8%, 48%) developed short-term complications, 2 of whom required surgical intervention within 30 days. Furthermore, 2 additional patients required surgical intervention after 30 days for a long-term complication (diverticulum and cyst recurrence).

Conclusion: Surgical complications occurred more frequently in patients who had the muscle layer left open after resection of an esophageal duplication cyst. Additionally, the majority of patients requiring re-operation for both short-term and long-term complications occurred in this group. Though small, this study is the first to evaluate the complications after resecting esophageal duplication cysts. Our results suggest that closing the esophageal muscle layer following removal of an esophageal duplication cyst may be indicated to prevent both complications and the need for reoperations.

61.20 The Impact of Developing a Pectus Center for Chest Wall Deformities

Posted on January 18, 2016

K. W. Gonzalez1, B. G. Dalton1, E. M. Knott1, B. Kurtz1, A. S. Poola1, C. L. Snyder1, S. D. St. Peter1, G. W. Holcomb1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction: In July 2011, we established a dedicated center for patients with chest wall deformities to allow for more effective consultation and to initiate a bracing program for the carinatum patients. In this study, we evaluate the effect of this center on patient volume and management.

Methods: A retrospective review was conducted for 699 patients seen with congenital chest, rib and sternal anomalies between July 2009 – June 2013. Patient demographics, operative interventions, clinic and bracing visits were compared, based on the date of initial consultation, before the center opened (July 2009-June 2011, Group 1), versus after (July 2011-June 2013, Group 2). Comparative analysis was performed utilizing chi square and Mann-Whitney U test.

Results: Three hundred twenty new patients were in Group 1 and 379 in Group 2, for an 18.4% increase in patient volume. The number of excavatum patients increased from 172 (Group 1) to 189 (Group 2). The number of carinatum patients increased substantially from 125 (Group 1) to 165 (Group 2). The number of mixed defects and rib/sternal anomalies was similar between groups. The percentage of patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15.1% (Group 1) to 1.1% (Group 2) (p < 0.01) whereas the percentage of patients undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 20.1% (Group 1) to 62.2% (Group 2) (p < 0.01). Patients traveled between 3 and 1249 miles to visit the center for a single visit suggesting that although the majority of patients are regional, the catchment area has extended beyond adjacent states.

Conclusion: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for patients with pectus carinatum. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.

61.15 Blunt Cardiac Injury: Improved Outcomes or Misdiagnosis?

Posted on January 18, 2016

A. Azim1, B. Joseph1, T. Orouji Jokar1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, D. Green1, G. Vercruysse1, R. Friese1, P. Rhee1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction:
Blunt cardiac injury (BCI) is uncommon. Its diagnosis, treatment and significance remain controversial. When diagnosed it is often treated with anti-arrhythmic drugs but there is little known regarding the outcome or effectiveness. The aim of this study was to assess the trend of reporting BCI using a national database.

Methods:
Retrospective 6-year (2007-2012) review of National Trauma Data Base (NTDB) of all chest trauma patients. Patients with ICD-9 Code of blunt cardiac injury (861.01) were identified. Outcome measures were mortality and admission characteristics. Regression and trend analyses were performed.

Results:

A total of 10,408 patients were included in our study. The rate of BCI was 7.45 per 10,000 patients (10,412/13,957,987) and has been decreasing over years, from 8.9 per 10,000 patients in 2007 to 6.3 per 10,000 patients in 2012 (p < 0.001). Mean age (45 ± 27 vs. 46 ± 28, p = 0.29) and male gender dominance (66.5% vs. 67.4%, p = 0.42), emergency department systolic blood pressure (117 ± 49 vs. 89 ± 39, p = 0.07), and emergency department heart rate (89 ± 39 vs. 91 ± 36, p = 0.12) did not change during the study period. 18 patients (0.2%) were diagnosed to have an associated cardiac arrhythmia. Mortality rate from cardiac contusion declined during the study period (20.7% vs. 13.8%, p < 0.0001). Mortality rate increased with increasing Chest AIS (Chest AIS-1: 4.9% vs. Chest AIS-5: 40%, p=0.001) however there were 420 patients who were diagnosed with BCI without a chest trauma (Chest AIS = 0).

Conclusion:
The incidence of blunt cardiac injury is uncommon and continues to decrease. The mortality rate has also decreased by a third. The true significance as well as relevance is yet unknown.

61.16 Intensive glycemic control reduces mortality and morbidity in cardiac surgery patients:Meta-analysis

Posted on January 18, 2016

K. P. Kulkarni3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

PURPOSE: Optimal glycemic control in cardiac surgery patients remains a laudable but confusing practice. Existing studies have primarily employed two maintenance strategies using either tight glycemic control (maintain <120 mg/dl) or liberal control (<200 mg/dl) with conflicting outcomes. Meta-analysis and meta-regression were performed to better delineate which approach (if any) is associated with reduced perioperative morbidity and/or mortality.

Methods: A comprehensive literature search of PubMed, Google Scholar and the Cochrane Central Registry of Controlled Trials was completed. Keywords searched were ‘insulin’,‘bypass’,’coronary’,’CABG’,’glucose’,’artery’,’intensive’,’cardiac’, and ‘surgery’. Eligible studies were randomized control trials (RCTs) utilizing two different glycemic control strategies with a mortality outcome. Primary outcomes were mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

Results: 14 studies were included in this study. Intensive glucose control significantly reduced mortality (relative risk (RR) = 0.742, 95% CI=0.566 to 0.973; p=0.031) and ICU LOS (Standardized difference of mean (SDM) = -0.352, 95% CI=-0.352 to -0.692; p=0.042) but did not influence overall hospital LOS (SDM= -0.255, 95% CI = -0.722 to 0.211; p=0.283). Significant secondary outcomes were overall infection (RR=0.444, 95% CI=0.322 to 0.611; p<0.001) and atrial fibrillation rates (RR=0.722, 95% CI=0.582 to 0.896; p=0.003). No difference in stroke (RR=2.279, 95% CI=0.525 to 9.885; p=0.271), deep sternal infection (RR=0.599, 95% CI=0.242 to 1.484; p=0.268), acute renal failure (RR=1.337, 95% CI=0.468 to 3.821; p=0.588), or prolonged intubation rates were observed (RR=0.990, 95% CI=0.661 to 1.483; p=0.962).

Conclusion: Optimal glycemic control is significantly linked to improved perioperative outcomes in cardiac surgery patients. Intensive glucose control (< 120 mg/dl) reduces mortality and ICU LOS in cardiac surgery patients, while also decreasing overall postoperative infection and atrial fibrillation rates compared to more liberal glycemic strategies. Additional adequately powered studies are needed to further investigate the nuances of optimal intensity and duration of glycemic control in this patient population.

61.17 Open Access Phone Triage for Veterans with Suspected Malignant Pleural Mesothelioma (MPM)

Posted on January 18, 2016

C. J. Siegert1,2, J. Lally1,4, M. Shoni1,2, P. M. Fisichella4, A. Lebenthal1,2,3 1VA Boston Healthcare System,Section Of General Thoracic Surgery,West Roxbury, MA, USA 2Brigham And Women’s Hospital,Division Of General Thoracic Surgery,Boston, MA, USA 3Brigham And Women’s Hospital,International Mesothelioma Program,Boston, MA, USA 4VA Boston Healthcare System,Department Of Surgery,West Roxbury, MA, USA

Introduction:
The Boston VA Healthcare System (VABHS) is one of a handful of VA hospitals throughout the country offering specialized care for MPM. Thus an increasing number of patients with suspected mesothelioma call to inquire about specialized, multi-modality care. Malignant Pleural Mesothelioma (MPM) is a rare disease affecting approximately 3000 Americans annually. A disproportionate amount of new patients are veterans, accounting for an estimated 1/3. The majority have distant history of asbestos exposure during military service. A latency period of decades is common, and the disease is difficult to diagnose. The treatment options include supportive care, chemotherapy and maximal cytoreductive surgery. Guidelines support multidisciplinary care, with evaluation by surgeons with expertise treating MPM.

Methods:
In 2011 we began to offer open access phone triage to Veterans with newly diagnosed MPM by a general thoracic surgeon and a member of the International Mesothelioma Program (IMP), VABHS. The patients were referred by primary care providers, oncologists, surgeons, veteran advocates or self-referred using online media. A total of 69 patients were triaged world-wide. Further documentation was requested and analyzed including records, diagnostics labs, radiology tests and pathology slides from an initial biopsy. Patients that were reasonable candidates for cytoreductive surgery were encouraged to travel to the WXVA for further assessment.

Results:
Out of 69 callers, 57 were Veterans, and we encouraged 46 to be seen by a surgeon with expertise in the field. 32 veterans were surgically staged at VABHS. 13 of these patients eventually underwent definitive surgery at VABHS, while 16 patients transferred their care to another hospital. 9 veterans opted out of surgery or had a contraindication to surgery. All service branches were represented for veterans with mesothelioma: Army (13), Navy (23), USMC (4), Coast Guard (2), Air Force (4) and unknown (11)

Conclusion:
Open access Phone triage for veterans with findings suspicious of MPM, by a surgeon with expertise in the treating MPM, provides guideline supported care for patients across the nation. Veterans who served in branches other than the Navy have significant representation.

61.18 Septal Myectomy is Safe and Effective at a Medium Volume Center

Posted on January 18, 2016

S. Mokashi1, I. Gosev1, S. McGurk1, M. Yammine1, K. Rajab1, P. S. Shekar1 1Brigham And Women’s Hospital,Cardiac Surgery,Boston, MA, USA

Introduction: Septal myectomy is the standard treatment for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) refractory to medical therapy. To date, only outcomes from high volume centers have been reported. Herein we report mid-term results from a medium volume center.

Methods: A retrospective review of 47 patients undergoing septal myectomy for HOCM over a 10-year period was performed. Primary and secondary endpoints included: mortality, pacemaker placement, peak left ventricular outflow tract (LVOT) gradient and New York Heart Association (NYHA) class.

Results:The mean age was 57yrs ±12, and 47% (22) were women. Mean LVOT gradient was 79mmHg (±30), 39% (18) of patients had moderate or severe mitral regurgitation and 47% (22) were in NYHA class III/IV at baseline. Concomitant procedures included mitral valves (17), CABG (6), and aortas (3). Immediate postoperative LVOT gradient was 14mmHg±7 (p<0.001 vs. baseline). Operative mortality was 2% (1), and 15% (7) patients had new pacemaker placements. Median time to follow-up was 22 months, the mean LVOT gradient was 14mmHg±8 and 9% (4) patients were in NYHA class III/IV (both p ≤0.001 vs. baseline). Among 15 patients who were ≥3yrs from surgery (median 5.2 yrs.), LVOT gradient was 13mmHg±8 (p≤0.001 vs. baseline). There was one late death during the observation period, and one reoperative septal myectomy at 5yrs.

Conclusion: Our series shows a low operative mortality, sustained peak LVOT gradient reductions and improved symptomatology. The outcomes herein are comparable to previously published data from high volume centers. Therefore, septal myectomy at a medium volume center is safe and effective for HOCM.

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