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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

 

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

38.09 Put Me in the Game Coach! Resident Participation in High Risk Surgery in the Big Data Era

Posted on January 18, 2018

A. N. Cobb1, E. Eguia1, P. C. Kuo1  1Loyola University Medical Center,General Surgery,Maywood, IL, USA

 Introduction: General surgery resident participation continues to be an important topic of conversation regarding resident education, particularly with the more restrictive 80 hour work week and emphasis on quality metrics guiding reimbursement. Previous literature has shown that resident participation does not negatively impact patient outcomes in low risk procedures. The aim of this study was to confirm that resident participation remains safe, as well as to explore changes in postoperative outcomes over time for high risk general surgery procedures (those where residents may get fewer opportunities to actively participate) cases performed with resident physicians.

Methods:
The National Surgical Quality Improvement Program database (2005-2012) was used to identify patients undergoing one of five high risk procedures: esophagectomy, open abdominal aortic aneurysm repair, laparoscopic paraesophageal hernia repair with Nissen fundoplication, pancreaticoduodenectomy, abdominoperineal resection, and hepatectomy. Outcomes were compared for patients with and without resident participation. Groups were created using a 2:1 propensity score match on the basis of age, sex, race, morbidity probability, ASA class, surgical specialty, comorbidities, and procedures. Postoperative outcomes were calculated using univariate statistics; chi square and ttest for categorical and continuous variables respectively. Trends in outcome over time were assessed using the Cochrane-Armitage test for trend. Predictors of mortality and overall complications were analyzed using decision tree analysis.

Results:
25,363 patients met our inclusion criteria. Following matching, the res and non-res groups had 500 patients each and were comparable for matched characteristics. 30 Day mortality was similar between the groups (2.4% v. 2.6% p=0.839). Deep surgical site infection (0% v. 1.6% p=0.005), urinary tract infection (5% v. 2.5% p=0.029), and operative time (275.6 min v.250 min p=0.0064) were all significantly higher in the resident participation group. Rates of other outcomes such as total length of stay, superficial surgical site infection, and sepsis were not significantly different.  In examining trends over time, overall resident participation has decreased slightly from 2005 to 2012 (p=0.0061). 30 Day mortality has remained the same over time, while operative time, LOS, and returns to the OR have all decreased over time (all with p<0.001). Resident participation was not predictive of mortality or complications; while age, ASA class, and functional status were leading predictors of both. 

Conclusion:
Despite growing time constraints and pressure to perform, surgical residents continue to perform at a high level and do not negatively affect postoperative outcomes. Residents should continue to be given active and engaging roles in the operating room, even in the most challenging cases.
 

38.10 3-Year Longitudinal Analysis of Emotional Intelligence in Surgical Residents: It Decreases Over Time

Posted on January 18, 2018

K. D. Cofer1, L. Wood1, R. Hollis1, J. Richman1, M. Morris1, J. Porterfield1, B. Lindeman1, D. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Emotional intelligence (EI) is believed to be a characteristic that can change over time, however, it is unclear how it changes through the course of surgical training. In this study, we evaluated the change in EI levels of general surgery residents as they progressed over three years. We hypothesized that resident EI levels would be stable over time.

Methods:  General surgery residents at a single institution were surveyed in June of 2015 (n = 36) using the Trait EI Questionnaire (TEIQ) and June of 2016 (n = 40) and 2017 (n = 52) using the Trait EI Questionnaire-Short Form (TEIQ-SF). The TEIQ contained all items comprising the TEIQ-SF in identical format. We limited resident responses to the TEIQ-SF items to allow for identical analyses to be performed throughout all survey administrations. Residents were categorized according to their PGY level in 2015. Changes in EI were analyzed using ANOVA and t-test by PGY group for overall EI and sub-scores.

Results: A total of 16 residents completed the survey all three years. From 2015 to 2017, 13 (81%) had a decrease in overall EI, 2 residents had increased EI (13%), and a single resident had no change (6%). Overall, the mean EI score change was -0.21 (p<0.01). For sub-scores, the mean change in well-being was +0.11 (p=0.33), self-control -0.33 (p=0.03), emotionality -0.08 (p=0.63), and sociability -0.46 (p<0.01). There was no significant difference in mean baseline EI scores by PGY group, and among sub-scores, only sociability differed significantly by PGY group ranging in mean scores from 3.8 for PGY2 to 4.7 for incoming residents (p=0.01). All PGY groups had an average decline in EI, but the most significant decline occurred for the research residents (mean change -0.29, p=0.03). Of the sub-scores, the only significant change in a PGY group was a mean change of -1.1 in sociability for incoming residents (p=0.02).

Conclusion: Surgical residents’ EI levels decreased over a three-year period, driven largely by decreases in sociability and self-control. Future studies should evaluate the effects of decreased EI in surgical residents to help mitigate these potentially harmful changes.
 

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

Posted on January 18, 2018

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

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

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

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

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

38.08 Personality Testing May Help To Identify Applicants Who Will Become High Performing Residents

Posted on January 18, 2018

R. Radhakrishnan1, D. S. Tyler1  1University Of Texas Medical Branch,Surgery,Galveston, TX, USA

Introduction:  

Identification of successful surgical residents remains a challenging endeavor for program directors (PD).  PD’s must rely on conventional application information such as standardized tests, letters of recommendation, extracurricular activities, and short, unstructured interviews to help identify applicants who will perform well in residency.  This approach has led to a national attrition rate in general surgery residencies of approximately 20% per year.

The Big 5 Personality traits (Extroversion, Agreeableness, Conscientiousness, Emotional Stability, and Openness to new ideas) and the Grit Scale have been extensively studied in many industries and have correlated with monetary and academic success in different fields.  To date, the data are lacking on the use of these tests to identify successful surgery residents. 

We hypothesized that personality testing using these two tests would provide useful additional information to identify successful surgery residents when compared with conventional application information alone.

Methods:
We performed a retrospective review of all categorical surgery residents (n=37) at the University of Texas Medical Branch from 2015-2017.  Conventional application information was scored by a single observer using our standardized scoring system which factors in all aspects of the application. Based on their performance in residency, residents were classified by the PD into two categories: low performing (ACGME milestones < 25th percentile, remediation, or leaving program, n=13) or high performing (all others, n=24).  Residents were then given personality tests.  Next, our most recent resident applicant class (n=81) was ranked in NRMP using conventional application information based on our scoring system.  During the application process, personality testing was administered to all applicants to our program.  Correlation of personality and conventional scoring to final rank position was calculated. Student’s t-test and Pearson’s correlation were used with significance set at p < 0.05. 

Results:
The Big 5 personality test identified significantly higher Extroversion, Conscientiousness, and Emotional Stability scores in high performers.  There was no significant difference in STEP, ABSITE, Grit, or applicant scores. Our final rank list appears to correlate most closely with conventional data obtained from interviews and the ERAS application.  Applicants with higher extroversion, conscientiousness, and emotional stability scores do not appear to be ranked higher using the conventional process alone.

Conclusion:
 The Big 5 test may prove to be a useful adjunct to the traditional residency application in identifying high performing residents.  Conventional interviews and ERAS application information alone may not identify potential high performing residents.

38.07 Does Implicit Gender Bias Occur in Teaching Evaluations of Surgical Faculty?

Posted on January 18, 2018

M. M. Romine1, Z. Aburjania1, H. Chen1, L. Tanner1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:

Many studies exist which compare performance evaluation between males and females in the fields of research, technology and business. Objective data is limited to evaluate the effect of gender on evaluations, especially in medicine. As evaluations are often used to determine consideration for promotions and career advancements we aim to discover how gender impacts evaluations of the surgical faculty at one medical school. 

Methods:
We conducted a retrospective analysis of faculty evaluations by medical students during the 2012-2015 academic years. The questionnaire consisted of 18 questions with a scale of 0-10 and a separate section for comments. The comments were classified as positive, neutral or negative. The mean scores between rank and gender were compared. For data analysis a chi-squared test, t-test and ANOVA was used where appropriate. P-value less than 0.05 was considered significant.

Results:

There percentage of females in each faculty ranking were 25, 29 and 2 percent in the assistant, associate and full professor roles respectively. Overall, full professors received higher mean scores in questions related to education and providing feedback compared to assistant and associate professors. When comparing genders, males were ranked higher compared to females in availability, providing constructive feedback and teaching. 

Conclusion:
Objective analysis of the impact gender has on performance evaluation in medicine is lacking. In this study, we demonstrate discrepant scores between male and female faculty despite similar academic standing. Implicit gender bias may play a role in evaluation of medical faculty and therefore negatively impact perceived ability.
 

38.05 Surgical resident wellness and opportunities for improvement: A single center pilot survey

Posted on January 18, 2018

P. Marincola Smith1, P. N. Chotai1, J. L. Padgett1, S. K. Geevarghese1, K. P. Terhune1  1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA

Introduction:  

Surgical residents are at risk of burnout, depression, and poor compliance with health guidelines. We surveyed our trainees to understand their physical and mental health, and compared answers to age-appropriate health guidelines for the population at large.

Methods:  

General surgery residents at a large university-affiliated program were invited to participate in a 34-question, anonymous survey examining factors that affect physical and mental health, including self-reported work hours, compliance with age-appropriate health guidelines, and current diet and exercise habits. Validated depression (PHQ9) and fatigue (Epworth Sleepiness Scale, ESS) scales as well as questions on perceived barriers to health and wellness were included. Data was analyzed using chi-square and Mann-Whitney U tests with SPSS software. 

Results: 

Seventy-two percent of residents participated (n=55, 42% female). Most worked an average 71-80 hours per week (78%) and reported an average of 5 hours of sleep or more per night (75%). Most had at least three hours of leisure time (76.5%) or physical activity (42%), and up to one hour for religious activities (73%) or community activities (80%), per week. Lack of time was the most common (94.5%) barrier to more physical activity. Compliance with recommended primary care physician (PCP), dentist and vision visits was 25%, 23.5% and 42%, respectively. Those who saw their PCP in the last year were more satisfied with their health (p=0.049). Among female residents, 78% complied with cervical cancer screening recommendations. The majority (80%) of residents felt they did not focus enough on health. Barriers to health maintenance visits were time (80%), schedule unpredictability (76%) and appointment availability (67%). Forty-nine percent were interested in participating in work-place wellness programs, including fitness classes(56%), massages(56%), sports teams(49%), ergonomic assessments(36%) and running programs(31%). Although most (71%) reported no mental health concerns, median PHQ9 score was 5 (“mild depression”), and 11% scored in the “moderately severe” or “severe” depression category. The median ESS was 14, corresponding to moderate excessive daytime sleepiness. ESS and PHQ9 scores were positively correlated (p≤0.0001). Male and female residents scored similarly on ESS(p=0.945) and PHQ9(p=0.056) scales. Significant differences in daytime sleepiness were noted among residents in different years of training(p=0.007). Perceived mental health problems correlated with higher scores on ESS(p=0.049) and PHQ9(p≤0.0001) scales.

Conclusion: 

This single-center pilot survey identified barriers to resident wellness as well as opportunities for targeted intervention, a next intended step. Future multi-center collaborations are proposed to further promote wellness among surgical trainees. A specific target should be facilitating trainees’ abilities to meet age-appropriate health guidelines.

38.06 Surgical Resident Burnout: Does it Change Over Time?

Posted on January 18, 2018

K. D. Cofer1, L. Goss1, R. Hollis1, M. Morris1, J. Porterfield1, B. Lindeman1, D. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Burnout is common among surgical residents. It is unclear what factors predict burnout and whether burnout changes over time. In this study we examined the association of burnout with emotional intelligence (EI) and performance scores as well as the changes in burnout over time. We hypothesized that resident burnout would be stable over time and associated with EI but not performance scores.

Methods:  General surgery residents at a single institution were surveyed in June of 2016 (n = 52) and 2017 (n = 58) using the Maslach Burnout Inventory (MBI) and Trait EI Questionnaire-Short Form (TEIQ-SF). Burnout was defined as scoring above pre-defined levels in at least two of the three components of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Job performance was evaluated using faculty evaluations of clinical competency-based surgical milestones and standardized test scores including the American Board of Surgery In-Training Exam (ABSITE) and the United States Medical Licensing Examination (USMLE). Statistical comparison was made using Pearson correlation and simple linear regression adjusting for PGY level. 

Results: Forty residents participated in 2016 (77%) and 10 of these residents were burned out (25%). In 2017, 52 residents participated (90%) and 12 residents were burned out (23%). Of 46 residents who received the survey in both 2016 and 2017, 26 residents (57%) participated in both years with 3 residents having burn out in both years. Changes in burnout status from 2016-2017 were not associated with changes in EI or job performance scores, including changes in ABSITE percentile. Of the 26 residents that participated in both years, 15 (58%) exhibited a change in the number of burnout components they experienced.  These changes were not associated with EI or job performance scores. Of the individual burnout components, EE was associated with marital status in 2017, with single residents experiencing higher levels of EE (p=0.01). An increase in DP scores over the year was associated with higher EI scores in 2017 (r=0.39; p=0.05). Increases in PA scores were associated with increases in EI (r=0.41; p=0.04).

Conclusion: Burnout remains prevalent in surgical residents and demonstrates change over time. Single residents reported greater levels of EE. Strategies to better predict burnout are needed as current evaluation methods may not capture the factors needed to assess a resident’s risk for development of burnout. 

 

38.03 Taking Care of Our Own – An Assessment of Perceptions of Burnout in General Surgery Trainees

Posted on January 18, 2018

M. L. Williford1, S. Scarlet1, M. Meyers1, S. Meltzer-Brody2, C. Goettler3, J. Green4, A. Hildreth5, T. Clancy6, D. Luckett7, T. M. Farrell1  7University Of North Carolina At Chapel Hill,Public Health,Chapel Hill, NC, USA 1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Psychiatry,Chapel Hill, NC, USA 3East Carolina University Brody School Of Medicine,Surgery,Greenville, NC, USA 4Carolinas Medical Center,Surgery,Charlotte, NC, USA 5Wake Forest University School Of Medicine,Surgery,Winston-Salem, NC, USA 6New Hanover Regional Medical Center,Surgery,Wilmington, NC, USA

Introduction:
The delivery of high value health care requires that health care providers be healthy themselves. Despite robust prevalence data for burnout and depression among physicians as a whole, relatively little is known about how these conditions are perceived within the surgical community. The aims of this study were twofold. First, this study aimed to establish the prevalence of burnout and depression among surgery trainees using validated methods. Second, this study aimed to characterize how resident and attending surgeons perceived burnout and depression, and to identify potential causative factors and barriers to seeking care that were amenable to change.

Methods:
All resident and attending surgeons practicing at the 6 General Surgery training programs in North Carolina were identified as potential subjects. Anonymous electronic surveys were created for each cohort, and were collected from November 2016 to March 2017. The resident survey utilized validated tools to characterize the risk of burnout (Maslach Burnout Inventory or MBI) and depression (Patient Health Questionnaire or PHQ-9). The attending survey focused on the attending perception of resident burnout. Both surveys included questions regarding potential causative factors of burnout and depression.

Results:

The response rate for the resident survey was 58% (n=92). According to the MBI, 75% of residents were at high risk of burnout. According to the PHQ-9, 40% of residents were at moderate to severe risk of depression. Burnout was significantly associated with an increase in PHQ-9 score (p<0.001). Nine residents (12%) acknowledged suicidal ideation in the past 2 weeks, compared to a national average of 3%. All residents acknowledging suicidal ideation scored at high risk for burnout and depression.

The majority of residents (53%) correctly estimated that greater than half of residents were experiencing burnout, but only 18% estimated the true prevalence quartile. The majority of attendings (61%) believed that less than half of residents were experiencing burnout, and only one attending estimated the true prevalence quartile. The majority of attendings (75%) and residents (51%) underestimated the percentage of residents at moderate to severe risk of depression.

Ninety percent of residents and attendings identified the same top 3 factors contributing to burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care.

Conclusion:
The prevalence of burnout, depression, and suicidality among surgery residents is markedly elevated which is consistent with previous studies. Both residents and attendings identify the same causative factors of burnout.  However, both cohorts underestimate the true prevalence of resident burnout and depression which may hinder wellness interventions. A greater understanding of these perceptions offers an opportunity for education and the development of concrete solutions.

38.04 Lack of peer and attending support increases the likelihood of burnout in general surgery residents

Posted on January 18, 2018

S. Scarlet1, M. L. Williford1, C. Goettler3, J. Green2, T. Clancy5, A. Hildreth4, D. J. Luckett1, S. Meltzer-Brody1, M. O. Meyers1, T. M. Farrell1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2Carolinas Medical Center,Charlotte, NC, USA 3East Carolina University Brody School Of Medicine,Greenville, NC, USA 4Wake Forest University School Of Medicine,Winston-Salem, NC, USA 5New Hanover Regional Medical Center,Wilmington, NC, USA

Introduction:  General surgery trainees experience high rates of burnout syndrome. Burnout syndrome has many sequelae – it increases the risk that physicians will develop serious psychiatric conditions, provide low quality health care, and commit medical errors. Burnout is associated with attrition, which is notably high amongst general surgery trainees. Although many studies have focused on the prevalence of burnout, fewer have attempted to identify risk factors. In this study, we aimed to characterize the relationship between burnout and perceived social support amongst general surgery trainees. 

Methods:  All general surgery trainees at each of the six general surgery programs in the state (n=158) were invited to complete an anonymous survey used a web-based platform. The survey was conducted between November 2016 and March 2017. The survey contained the Maslach Burnout Inventory, which is used to identify burnout syndrome, and several questions regarding social support. Descriptive statistics were calculated. Comparisons between resident responses to questions were made using Fisher’s exact or chi-squared tests, wherever appropriate. 

Results: Response rate was 58%. 75% of residents met criteria for burnout syndrome. 89% of residents agreed or strongly agreed that they had a person from whom they received support. There was no association between burnout and having a support person (p=0.672). 68% of residents agreed or strongly agreed that other residents were interested in what was going on in their lives. Perceived lack of co-resident interest in one’s life was associated with burnout syndrome – 60% of residents with burnout versus 94% of those without burnout believed that resident colleagues were interested in their lives (p=0.008). 32% of residents agreed or strongly agreed that their attendings were interested in what was going on their lives. Perceived lack of attending interest in one’s life was associated with burnout syndrome – 22% of residents with burnout versus 61% of those without burnout believed that attending colleagues were interested in their lives (p=0.004). 33% of residents agreed or strongly agreed that there were sufficient sources for addressing burnout at their institutions. Perceived institutional support was not associated with presence of burnout syndrome (p=0.574). 

Conclusion: Given its high prevalence and significant implications on patient care and provider health and well-being, interventions that prevent and treat burnout syndrome are necessary. In this study, the majority of residents felt that resources at their institutions for addressing burnout were insufficient. Residents experiencing burnout syndrome were less likely to feel that their resident colleagues and attendings were interested in their lives. These data suggest that fostering a culture of peer and attending support within residency training programs may decrease the likelihood that trainees experience burnout. 

 

37.10 Overweight Patients with Chronic Mesenteric Ischemia Require More Diagnostic Studies

Posted on January 18, 2018

C. W. Elliott1, J. Cullen2, J. Mehaffey2, W. Robinson2, K. J. Cherry2, M. C. Tracci2, G. R. Upchurch2  1University Of Virginia,School Of Medicine,Charlottesville, VIRGINIA, USA 2University Of Virginia,Department Of Surgery,Charlottesville, VIRGINIA, USA

Introduction:
With the increasing prevalence of obesity and atherosclerotic vascular disease, there is potential for an increasing incidence of overweight patients presenting with chronic mesenteric ischemia (CMI). The impact obesity plays on the clinical presentation and treatment of CMI is an understudied area of potential clinical importance.  The purpose of this study was to evaluate if obesity impacts the diagnosis and treatment of CMI.

Methods:
Records of patients who received a procedure for CMI at a single center from 2007 to 2017 were obtained and reviewed. Patients were stratified into overweight (Body Mass Index [BMI] > 25) or non-overweight (BMI < 25). The primary outcome of interest was the number of preoperative diagnostic studies performed to make the diagnosis. Secondary endpoints included primary patency of the vascular reconstruction and 30-day mortality. Preoperative diagnostic studies included abdominal plain films, ultrasounds, cross-sectional imaging, endoscopy/colonoscopy, and angiogram.

Results:
A total of 90 patients were identified, and stratified into overweight (51.1%) and non-overweight. The number of preoperative diagnostic studies, a surrogate for delayed diagnosis, was significantly higher among the overweight (3.6 ± 1.9 vs. 2.7 ± 1.8, p = 0.04). These differences were driven by significantly more non-contrast CT scans (58.7% vs 25.0%, p=0.001) in the overweight group. However, overweight patients received fewer upper endoscopies (17.4 vs 36.4%, p=0.04). Endovascular interventions were the most common procedure to treat CMI, with 74% of overweight patients and 73% of non-overweight patients undergoing mesenteric vessel stenting (p = 0.9). There was no difference in the number of multi-vessel procedures performed in the overweight group (17.4% vs. 27.3% p=0.7). Thirty-day mortality (7.8% vs. 3.3%, p = 0.2) and time to loss of primary patency (19.25 ± 19.38 vs. 19.38 ± 18.36 months p = 0.8) did not differ between the groups.

Conclusion:
Overweight patients undergo an increased number of diagnostic tests prior to intervention to treat their CMI. An increase in the number of studies performed prior to CMI intervention in the overweight could be a proxy for a delay in time to diagnosis. Nevertheless, primary patency did not differ significantly between the two groups. As obesity continues to increase in prevalence, healthcare providers need to include CMI in their differential diagnosis for overweight patients.
 

38.01 Are General Surgery Residents Being Coerced to Exceed Duty Hour Limits? A FIRST Trial Analysis.

Posted on January 18, 2018

E. Blay1, K. E. Engelhardt1, B. Hewitt1, C. Quinn1, A. R. Dahlke1, A. D. Yang1, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA

Introduction: As of July 1, 2017, the Accreditation Council for Graduate Medical Education (ACGME) has instituted duty hour limit flexibility by waiving caps on daily shift lengths, while maintaining the 80-hour-per-week cap. Importantly, residents can only stay after a 24-hour call if it is their choice to stay longer.  Our objectives were to understand how often and why residents in the Flexible Arm of the FIRST Trial were working longer than standard duty hour limits and whether this was due to coercion by attendings and senior residents or a voluntary decision made by the individual resident to stay longer.

Methods: All clinical General Surgery residents taking the 2017 American Board of Surgery In-Training Examination (ABSITE) were surveyed. This analysis was limited to residents in the Flexible Arm of the FIRST Trial. The main outcome was number of times the resident exceeded 2011 duty hour limits in a typical month dichotomized into 0 or ≥ 1 event.  If residents indicated that their duty hours exceeded limits in a typical month, they were asked additional questions about duty hour expectations and coercion on a 5-point Likert scale from “Strongly Agree” to “Strongly Disagree.” Rates were compared and regression models were developed to (1) identify resident and program factors associated with exceeding standard duty hour limits and (2) identify predictors of coercion to stay longer.

Results: In the Flexible Arm of the FIRST trial, 1838/1838 (100%) of clinical residents in 58 programs responded to the survey. Of 68% (n=1258) residents who exceeded duty hour rules, 22% (n= 273) of residents said their programs expected them to stay longer than standard duty hour limits.  When residents stayed longer than standard duty hour limits, 78% (n= 983) responded that they voluntarily stayed longer, while 7% (n=93) reported coercion from attendings and 9% (n=117) reported coercion from senior residents. Although females (OR 1.89, 95% CI [1.52-2.34]), interns (OR 4.47, 95% CI [3.32-6.03]) and junior residents (OR 1.43, 95% CI [1.14-1.81]) were more likely to report exceeding standard duty hour limits, there were no significant resident or program characteristics associated with coercion by attendings or senior residents to exceed duty hour limits.

Conclusion: When duty hour flexibility was utilized in the Flexible Arm of the FIRST Trial, it was generally due to the residents choosing to stay voluntarily; however, there was some coercion by attendings and senior residents. As duty hour rules transition into an era of flexibility, programs should be cognizant of ensuring residents are staying for clinical and educational purposes of their own accord and are not being coerced to break ACGME duty hour regulations unnecessarily.

 

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