94.17 Medical School Clerkship Experience: Influence on Specialty Choice

Posted on January 18, 2018

A. D. Kaminski1, G. N. Falls1, P. P. Parikh1  1Wright State University,Department Of Surgery,Dayton, OH, USA

Introduction:
The primary objective of this study was to determine the influence of clerkship experience on specialty choice. Since students only experience six specialty rotations throughout third year, our goal was to determine if the lack of exposure is deterring students from certain specialties. We also identified factors that influence decision of students who choose a specialty that is not a part of third year curriculum.

Methods:
An IRB-approved questions based survey on Qualtrics was prepared and sent to all graduating 4th year medical students at our institution. The survey included questions related to specialty interests before and after clerkships and influence of clerkship experience on specialty choice. Students also provided descriptive response on specific factors influencing their specialty choice and things medical school could do to facilitate their decision. The data were then analyzed descriptively and qualitatively to identify themes.

Results:
Majority of students (87%) had at least minimal exposure to their chosen specialty prior to the clerkship. This exposure increased significantly following the clerkship (97%). 70% of students reported that the role of clerkship experience in selecting a specialty was either extremely significant or significant. Various aspects of clerkships were influential, as shown in Table 1. Specialty interests before and after clerkships were variable, for example 10 students were interested in surgery prior to clerkships, and 8 decided to pursue surgery as career. The most influential reasons for a student’s specialty choice to change after clerkships, were clerkship experience (56%) and mentors (28%). 34% of students chose a specialty that was not a part of 3rd year clerkships. Of those students, the most significant factors influencing their specialty choice were shadowing experience (65%) and lifestyle (61%). Qualitative analysis of data indicated that students requested earlier and more exposure to various specialties in order to make specialty selection process easier. 

Conclusion:
Clerkship experience plays a major role in selecting a specialty. Earlier exposure would help the decision-making process. Students who ultimately choose a non-core specialty would benefit from more shadowing and earlier exposure. 
 

94.18 Minimally invasive surgical exposure among U.S. and Canadian pediatric surgery fellows, 2004 – 2016

Posted on January 18, 2018

S. B. Cairo1, C. M. Harmon1,2, D. H. Rothstein1,2  1Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 2State University Of New York, University At Buffalo,Department Of Surgery,Buffalo, NY, USA

Introduction:  Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, but little is known about the penetration of minimally invasive surgery (MIS) training in U.S. and Canadian pediatric surgery fellowship programs.

Methods:  We performed a time series analysis of Accreditation Council for Graduate Medical Education (ACGME) pediatric surgery fellow case logs from 2004 to 2016. Procedures were included if they had both open and MIS options. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time.

Results: There was a 30.9% increase in average number of cases reported per fellow over the study time period.  Twenty-three procedures included MIS and open options (17 abdominal, 3 thoracic, and 3 genitourinary procedures). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for abdominal, thoracic, and genitourinary operations, respectively. Significant variability was observed between individual fellows in all categories as demonstrated by reported laparoscopic and open inguinal hernias ranging from 0 to 85 and 9 to 152 per trainee, respectively, in the final year of data collection (Table 1).   When examining a high volume procedure with a substantial increase in application of MIS, such as pyloromotomy, an overall increase in the proportion of cases performed MIS vs open of 83.3% was observed.  The minimum and maximum number of cases recorded ranged from 0 to 114 during the eight years in which minimally invasive pyloromyotomy was recorded.

Conclusion: Minimally invasive surgery case exposure among graduating U.S. and Canadian pediatric survey fellows increased substantially during the study period, although data on cases of particular interest, such as repair of tracheoesophageal fistula and congenital diaphragmatic hernia, are not captured.  More data from surgical case logs, national databases, graduating fellows, and fellowship directors are needed to better define the current operative experience and criteria for determination of competency in advanced MIS. 
 

94.16 Improving Surgical Outreach in Palestine: Assessing Goals of Local and Visiting Surgeons

Posted on January 18, 2018

A. D. McDow1, S. O. Salman2, K. L. Long1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WISCONSIN, USA 2University Of Florida-Jacksonville,Oral And Maxillofacial Surgery,Jacksonville, FLORIDA, USA

Introduction:
Short-term surgical mission trips are often criticized due to lack of sustainability and lasting relationship formation with local providers.  As global surgical capability increases, focus has begun to shift from offloading of disease burden to education of local providers.  We sought to assess the educational goals of local surgeons in the Palestinian Territories (PT), and compare these to goals and intentions of visiting volunteer surgeons.

Methods:
Electronic surveys were sent to a variety of Palestinian surgical providers who have worked with volunteer surgeons from the Palestinian Children’s Relief Fund (PCRF).  These surveys were then compared with previously collected data from evaluations filled out by volunteer PCRF mission surgeons from North America, Europe, and South America.  All surveys and evaluations were completed voluntarily. 

Results:
Fifty two percent (12/23) of Palestinian providers responded to the survey.  All but one provider indicated that they would prefer protected time in each mission trip for formal didactic lectures or teaching.  Ninety-one percent felt they were best able to learn new techniques by performing skills on patients with expert surgeons observing and providing live feedback.  All surveyed requested more than one trip from the same visiting surgeon, feeling it would help advance their skills.  The majority of respondents felt that adding either case reviews prior to the operating room (6/12) or a debriefing session after completion of surgical cases (4/12) would be most desirable.  
Data from 41 volunteer mission surgeons was also available, and although retrospective, indicates that 86% of prior mission trips involved training for local providers.   The most common positive feedback from volunteer surgeons related to teamwork and teaching of the local providers.  Volunteer surgeons felt that the absence of pre-screening data of patients and lack of knowledge about the facility capabilities hindered their overall success at times.  Despite this, 100% of volunteer physicians who completed the PCRF survey indicated they would volunteer with the organization again in the future.

Conclusion:
Surgical education is a vital component to any successful outreach program.  Adult learning theory has long emphasized the necessity of understanding the specific educational needs of participants in order to foster the most successful learning environment.  This survey highlights the value of tailoring surgical specialty outreach to the explicit needs of both local providers and local patient populations.   Additionally, this survey clearly demonstrates the importance of protected non-clinical time for formal educational components as a critical focus of future surgical humanitarian endeavors. 
 

94.14 To Lead Others, Know Yourself First: 360-Degree Assessment to Enhance Educational Leadership Skills

Posted on January 18, 2018

S. Misra1, R. Casanova2, M. Marsh2, J. Luk3  1Brandon Regional Hospital,Surgical Oncology,Brandon, FL, USA 2Texas Tech University Health Sciences Center,Medical Education,Lubbock, TX, USA 3Dell Medical School,Medical Education,Austin, TX, USA

Introduction:  The value of using 360° assessment tools to enhance leadership skills is well validated.  Standardized 360° assessment tools to understand personality and behavior pertaining to educational leadership can be very long and overwhelming leading to assessor fatigue and inaccuracy of feedback. This study focused on creating a succinct substitute incorporating various elements of educational leadership domains.  

Methods:  The leadership in education and development (LEAD) 360° assessment profile © sponsored through the Association of American medical Colleges (AAMC) formed the initial template.  After an extensive literature review and based on personal needs, a significantly modified version of this tool was created. Mentor and peer feedback was initially obtained on picking out the right questions for the survey. Two questions each from four domains of leadership effectiveness with three areas each of sub-competencies were selected. Total 24 questions and two open areas for comments were used for assessment.  The survey was graded on a 1 to 5 point Likert scale. Appendix A for sample questions.  

A fair distribution of observers was selected by including two super ordinates, two non-departmental colleagues, two peers from the department and two subordinates who can meaningfully provide anonymous, feedback regarding activities as an educational leader. A self- assessment of the questionnaire was done for effective comparison with pooled assessor responses.  Survey was sent out electronically with instructions that responses be sent to a trusted administrative personnel who will tally the results and provide unidentified, aggregate data. 

Results: 100% of the survey questionnaire was returned with all areas being responded. Total time spent per assessor was less than 10 minutes. Objective data was obtained from the scaled questionnaire while important subjective opinions were summarized for ongoing reflection and behavior modification. The evidence-based leadership effectiveness domains included 1) setting direction, 2) developing people, 3) developing organizations and 4) managing and administering.  There were interesting variances between areas of self perceived strengths and weaknesses and observers assessments.  

Conclusion: Periodic 360° assessment helps greatly to understand one owns educational leadership traits. Subsequent reflective behavior will further develop skills for self-improvement. In-depth assessment of certain domains can be undertaken after use of this initial brief survey tool.  The main validated questionnaire could be adapted for personalized development of departmental faculty to achieve their educational leadership goals. 

 

94.15 An Informed Consent Update for Academic Surgeons

Posted on January 18, 2018

S. E. Raper1, J. Joseph2  2University Of Pennsylvania Health System,Quality And Risk Management,Philadelphia, PA, USA 1Perelman School Of Medicine,Surgery,Philadelphia, PA, USA

Introduction: ~~Informed consent (IC) of the patient is a constantly evolving ethical imperative and legal duty imposed on surgeons prior to the performance of an operation. IC is also a risk management tool as well as a means for enhancing surgeon-patient communication. To update academic surgeons, a short course in IC was developed.

Methods: ~~Curriculum: 1) ethical principles and legal precedent; 2) current federal, state, and accreditation requirements; and 3) new developments including a federal requirement to disclose overlapping surgery. Success was defined as participation of > 80% of surgical faculty. A short post-test was developed to test comprehension and results tabulated as % correct. An anonymous Likert-scale evaluation tool was used to assess strengths and opportunities to improve future courses. The weighted average of each question was calculated.

Results:~~Of 100 surgery faculty members, 74 attended live and 10 online. A majority of respondents for the post-test got the answers correct for each of the five T/F questions, confirming comprehension (# in parentheses = % correct): 1) In [State], inadequate informed consent is legally a battery (93%); 2) In [State] a physician has an affirmative duty to disclose his/her professional credentials, training and experience performing the particular procedure for which consent is being secured (72%); 3) In [State], the standard for judging the adequacy of the informed consent is based on the consensus in the medical community on what information about the procedure, the risks and the alternatives is required to make an informed decision (57%); 4) In [State], qualified practitioners are allowed to provide information regarding informed consent (97%); 5) In [State], to recover in an action for lack of informed consent, the patient must prove that receiving the information that was not provided would have been a substantial factor in his/her decision to undergo the procedure (79%). Evaluations were positive for the seven questions; all with a weighted average of > 4.5 (Table, N=45). Free text responses provided opportunities to improve future courses (not shown).

Conclusion:~~A proper understanding of informed consent remains critically important in the practice of surgery, but the requirements continue to evolve. A short course updating surgeons on principles of informed consent quantitatively confirms the effectiveness of this approach to teaching IC as an important risk management tool and fostering good surgeon-patient communication skills.

 

94.12 Prediction Of Postoperative Surgical Risk: A Needs Assessment For Formal Curriculum

Posted on January 18, 2018

S. L. Ahle1, J. M. Healy1, K. Y. Pei1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction:  For medically complex patients, determining postoperative surgical risk is challenging.  Previous studies demonstrated that resident and attending surgeons significantly overestimate risk of complications and death when compared to the ACS NSQIP risk calculator.  Given that medical students learn through observation and clinical exposure during their clerkships, they may model similar prediction practices to their teachers.  Medical students’ abilities to predict postoperative complications and death are unknown.  We hypothesize that medical students will lack confidence in determining surgical risk, and will significantly overestimate surgical risk for post-operative morbidities and mortality.  

Methods:  Following completion of their clerkships, third year medical students at an urban, tertiary, academic medical center were invited to participate in an online, anonymous survey to assess their abilities to predict surgical risk. General Surgery residents were also invited to participate in the same assessment.  The survey presented seven complex clinical scenarios representative of a diverse general surgery practice. Students were asked to assess the likelihood of any morbidity, mortality, surgical site infection, pneumonia, and cardiac complications on a 0-100% scale. Morbidity and mortality predictions were compared to the ACS NSQIP risk calculator.  Using independent samples t-tests and Mann-Whitney U non-parametric tests, we determined if students and residents had statistically different risk assessments for each case.

Results: 24 students (80% response rate) and 76 residents (64% response rate) participated in the assessment. Most students were not confident about predicting post-operative complications (83.3%) or mortality (70.8%).  Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly over-estimated post-operative morbidities and mortality. For 3 cases, resident estimates were higher than medical students, but both groups still significantly overestimated when compared to the risk calculator.  Estimates varied significantly, with wide 95% confidence intervals.  Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals (Figure 1: representative scenario). 

Conclusion: Medical students overestimate morbidity and mortality following surgery in complex patients.  Additionally, they lack confidence in their ability to predict surgical complications, and feel they are not adequately learning this skill on their surgical clerkship. A formal curriculum for risk prediction is needed for medical students. 

 

94.13 Development of Rating Criteria for Providing Peer Feedback on Surgical Technical Skill

Posted on January 18, 2018

S. Bharadwaj1, S. Meyerson1, R. Love1,2, A. Bharat1, M. DeCamp1, D. D. Odell1,2  1Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA 2Northwestern University Surgical Outcomes & Quality Improvement Center (SOQIC),Surgery,Chicago, IL, USA

Introduction: Surgeon technical skill has been shown to correlate with post-operative complication rates in a variety of surgical procedures. However, variation in technical skills has not been assessed in pulmonary surgery. The objective of this project is to pilot a platform through which thoracic surgeons can give and receive anonymous peer feedback on their technical skills in thoracoscopic lobectomy.

Methods: A review of technical literature was first performed to develop definitions for the key surgical steps involved in a thoracoscopic lobectomy – port placement; hilar exposure; isolation and division of the pulmonary artery, pulmonary vein, and bronchus respectively; and division of the interlobar fissure. The steps were further broken down into subtasks (i.e. establish exposure, mobilize the pulmonary artery) to allow for more detailed discrimination. A literature search was conducted to isolate common errors and difficulties encountered during each subtask (i.e. phrenic nerve injury during hilar exposure). Using these common errors and the well-established Objective Structured Assessment of Technical Skill (OSATS) criteria as a guideline, a scoring rubric was developed to assess surgical technical skill in each subtask using a 5-point Likert scale. This rubric was presented for feedback to a focus group of four experienced thoracic surgeons.

Results: Surgeons identified significant variability in the operative approach to resection of each anatomic lobe (i.e. right upper vs. left lower). Right upper lobectomy was identified as having as the most consistent anatomy and surgical approach. Five keys steps were identified by the expert panel as important, consistent components of the operation and were chosen for discrete measure development. These included isolation and division of the pulmonary vein, truncus anterior, posterior ascending artery, airway, and minor fissure. Port placement and hilar exposure were deemed highly variable in technique and nonessential for assessing technical skill. The panel favored development of a skill-centric scoring rubric without subtask and error stratification. Using the OSATS global 5-point rating scale, the panel identified the most significant outcome measures for evaluating technical skill as “Time and Motion,” “Establishing Exposure,” “Respect for Tissue,” and “Flow of Operation and Forward Planning.” Based on this feedback, new rating criteria were created including (1) a Global Scoring Criteria, developed using the above OSATS measures on a 5-point Likert scale, and (2) a free-text form to provide constructive, individualized feedback.

Conclusion: Development of a technical rating system specific for lobectomy will allow for the first ever assessments of technical skill in thoracic surgery. A multi-institution trial incorporating this rating system as a basis for anonymous peer feedback is currently underway.

 

94.11 There is No Routine Gallbladder: A Call to Enhance the “Culture of Safety in Cholecystectomy”

Posted on January 18, 2018

T. T. Jayakrishnan1, M. Chimukangara1, T. P. Webb1, C. S. Davis1  1Medical College Of Wisconsin,Division Of Trauma, Critical Care, And Acute Care Surgery,Milwaukee, WI, USA

Introduction: Cholecystectomy for gallbladder disease is a common general surgery procedure. A “culture of safety in cholecystectomy” has been proposed to minimize bile duct injuries. However, the proposed culture fails to incorporate careful scrutiny of pre-operative imaging and laboratory analysis, as well as how to address unusual pathology.

Methods: We present three interesting cases of unusual gallbladder anatomy and pathology and propose an algorithm for a safe cholecystectomy that extends beyond aberrant biliary anatomy and the critical view of safety.

Results: With a prevalence less than 0.3%, a truly left-sided gallbladder is a rare anomaly that may provide a surprise during cholecystectomy if not identified pre-operatively. Intra-operative identification may necessitate modification of standard technique, assessment for possible vascular anomalies, and the addition of adjuncts such as intra-operative cholangiogram. Surgery can be performed safely in most cases without conversion to open technique. Similarly, foci of gallbladder wall calcification and the post-operative finding of ectopic pancreatic tissue in the gallbladder wall may lead to management dilemmas, especially when associated with other confounding factors such as elevated tumor markers. Our review of the literature identified no algorithm that incorporates pre-operative imaging, laboratory analysis, or expert consultation in the event that the atypical gallbladder is encountered.

Conclusion: Careful review of pre-operative imaging and laboratory results are critical to a safe treatment plan for patients with gallbladder pathology. Similarly, expert consultation in the event of atypical gallbladder pathology should be liberally entertained. In addition to safe surgical technique, these factors enhance the culture of safety in cholecystectomy and should be incorporated into an algorithm useful for both teaching and clinical purposes.

94.10 Empowering Bystanders to Intervene: Chicago South Side Trauma First Responders Course

Posted on January 18, 2018

B. Wondimu1, S. Speedy1, T. Barnum1, F. Cosey-Gay2, S. Regan3, L. Stone3, M. Shapiro1, M. Swaroop1, L. C. Tatebe1  1Northwestern University,Chicago, IL, USA 2University Of Chicago,Chicago, IL, USA 3University Of Illinois At Chicago,Chicago, IL, USA

Introduction:
The city of Chicago has one of the highest rates of violence in the country, and this violence has been shown to disproportionately affect socioeconomically disadvantaged neighborhoods in the south side. The paucity of trauma centers in the south side of Chicago leads to prolonged transport times, increasing morbidity and mortality for those affected by penetrating traumas. A community based Trauma First Responders Course (TFRC) designed for bystanders could potentially mitigate this effect.  Bystanders are present at 60-97% of traumas and more likely to assist if given prior training. We seek to design and implement an evidence-based, community driven course designed for the general public to empower bystanders to intervene.

Methods:
A three-hour TFRC was designed using community based focus groups and qualitative analysis of the bystander effect. The course addressed basic first aid, trauma wound care, principles of bystander care, and the psychological impact of trauma. The course was taught in community centers, churches, and schools, to both minor and adult participants. Pre- and post-course questionnaires were offered. Eight evidence-based empowerment questions were assessed on a scale of 1 to 10. Ten knowledge-based questions were presented as single best of four multiple choice answers. The change in empowerment measures and knowledge scores were analyzed using chi-squared methods with p<0.05 considered significant.

Results:
Over the 7 courses offered thus far, 92 participants completed both the pre- and post-course assessments. The mean increase in empowerment was 2.42 out of 10 (0.41-4.66). The area with most improvement was ability to apply a tourniquet, followed by ability to render first aid. Improvement in 5 knowledge-based questions reached significance: tourniquet usage (p<0.01), management of impaled object (p=0.01), exposure to bodily fluids (p<0.01), initial trauma care (p<0.01), and scene safety (p<0.01). Over all 10 questions, participants had a 14% improvement (p=0.02).

Conclusion:
An evidence-based community TFRC is currently being offered throughout Chicago’s south side. The course has been shown to improve both bystander empowerment and knowledge of initial trauma care in the field, particularly trauma wound management and scene safety. Enrollment is ongoing and will improve the power of the study. In addition, 6-month follow-up assessments will be performed to assess knowledge retention and applicability.
 

94.08 Rural First Responder Needs Assessment Using Mathematical Modelling

Posted on January 18, 2018

G. E. Sorensen1, M. Aranke1, M. Bhatia1, S. Yang2, D. Vyas3  1Texas Tech University Health Science Center School Of Medicine,Lubbock, TX, USA 2Texas Tech University Health Science Center,Pathology,Lubbock, TX, USA 3Texas Tech University Health Science Center,Surgery,Odessa, TX, USA

Introduction:
Rural areas often lack sufficient first responder densities (FRD) which can result in decreased pre-hospital care that a trauma victim receives. Prompt, well-executed pre-hospital care by first responders can lead to a reduction in motor vehicle mortalities. The importance of first responders is widely agreed upon by the healthcare and public health community, yet no mathematical model currently exists that gives a reliable estimate of the number of first responders a certain community needs to provide improved pre-hospital care. The objectives of our study were to quantify the relationship between FRD and state census data, and to develop a model that will effectively estimate the number of responders needed to reduce motor vehicle accident mortality rate.

Methods:
Data was collected from state census databanks for all 50 states and subset into urban and rural. A total of 10 rural area variables were used in the analysis which include: population density, first responders (firemen and EMTs), total state area (sq. km), number of total hospitals, hospital density (km), surgeon density, total rural road density, poverty density, median household income, and motor vehicle accident mortality rate. Initial relationships among the variables was determined using a Pearson Correlation Coefficient. A multiple regression analysis was used to estimate FRD based on a subset of significant variables from the correlation analysis. A simple regression was then used to determine the direct relationship between FRD and motor vehicle mortality rate.

Results:
The top model estimating FRD included hospital density, poverty density, and median household income (Adj. R-Sq = 0.96; P<0.001). Thus, as hospital density, poverty density, and median household income increased, there was an increase in first responder density. There is an inverse relationship between FRD and motor vehicle mortality rate (Adj. R-Sq = 0.54; P<0.001).

Conclusion:
Our models demonstrate that FRD in rural areas was a function of the number of hospitals as well as income status (i.e. poverty and household income). Furthermore, as FRD increased, motor vehicle mortality rates decreased. These models hold the potential for determining which rural areas lack the appropriate level of pre-hospital care which warrant the need to increase pre-hospital education and the number of first responders. The models are simple and could be expanded, however our goal was to develop a nationwide preliminary model that used FRD and motor vehicle mortality to address pre-hospital care. Further modeling efforts could elucidate additional regional factors and ultimately, lead to better allocation of public health resources with the overall goal of reducing MVA mortality rate. This study will enable us to engage policy makers and allow states to make informed decisions about appropriate resources for training/education for first responders to reach the goal of improving rural pre-hospital trauma care.
 

94.09 Live Tweeting the Academic Surgical Congress: Four Years of Growth and Focus

Posted on January 18, 2018

H. J. Logghe7, J. W. Suliburk5, A. Cochran4, N. J. Gusani1, L. S. Kao5, B. C. Nwomeh6, C. D. Jones2  1Penn State Hershey Medical Center,York, PA, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA 3Baylor College Of Medicine,Baltimore, MD, USA 4University Of Utah,Salt Lake City, UT, USA 5University Of Texas Health Science Center At Houston,Houston, TX, USA 6Nationwide Children’s Hospital,Columbus, OH, USA 7Allies For Health,Reno, NV, USA

Introduction:  Social media coverage of academic conferences has rapidly evolved from a novelty to an expectation. The first peer-reviewed publication describing the use of Twitter at a major surgical meeting reported tweeting about the 2013 Academic Surgical Congress (ASC), including quantification of posts and retweets. To evaluate the expansion of social media in a similar setting, the current study seeks to quantify the Twitter activity surrounding the 2016 and 2017 ASC and to compare findings to those of the previous work.

Methods:  Evaluation of tweets about the 2016 and 2017 ASC was designed to replicate the methods used in the 2013 study wherever possible. Tweets including the #ASC2016 and #ASC2017 hashtags were prospectively gathered using the Symplur Healthcare Hashtag Project and descriptive statistics were obtained for tweets posted from 1 day before to 1 day following the conference. Based on the prior categorization of 2013 tweets, power analysis was performed (α=0.05, β=0.2) to detect a small difference in proportions of tweets in each category (352). Thus, a random sample of 400 #ASC2016 tweets was obtained and manually categorized to one of four categories to compare the proportions of tweets in the same categories between 2013 and 2016 (the most recent year for which complete data was available).

Results: In combined original and retweet analysis, there were 6,288 tweets from #ASC2016 and 11,521 tweets from #ASC2017, representing 14 and 27-fold increases from 2013 respectively (443 #ASC2013 tweets). These were posted respectively by 1,089 and 2,108 participants, up from 58 in the original study, representing 19 and 36-fold increases. While 4 individuals (a designated “Twitter team”) posted 56% of all tweets in 2013, the top 4 posters in 2017 were responsible for only 16% (1835/11521) of tweets. Of the 334 random #ASC2016 tweets categorized, 184 (55%) were related to content of sessions, 85 (25%) were promotional, and 53 (16%) were social in nature, statistically significantly more containing research content (p<0.01) and less containing promotional content (p=0.01) in 2016 than in 2013. (Figure)

Conclusion: Live tweeting of the Academic Surgical Congress has evolved quickly from the product of a small team of users to a crowdsourced effort, while increasing the proportion of tweets reflective of session content. Live tweeting of this surgical conference demonstrates an improved ability to share knowledge and promote academic activity beyond the physical confines of the meeting. Social media’s use related to academic conferences should be considered integral to the mission of knowledge distribution.

 

94.06 Readability Analysis Of Online Materials Related To Open And Endovascular Abdominal Aortic Aneurysm Repair

Posted on January 18, 2018

B. B. Scott1, B. N. Tran2, A. F. Doval2, B. T. Lee2  1Beth Israel Deaconess Medical Center,Department Of General Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Department Of Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Patients commonly use online materials as a source of health information.  Since poor health literacy has been shown to correlate with negative outcomes, the National Institutes of Health and American Medical Association recommend patient-directed materials be written at a sixth-grade reading level.  This study evaluates the readability and understandability of commonly accessed online materials on both endovascular and open repair of abdominal aortic aneurysm.

Methods:  Searches for “endovascular repair abdominal aortic aneurysm” and “open repair abdominal aortic aneurysm” were performed on both Google and Bing, and the top ten websites from each search engine were identified.  Location services and user preferences were disabled.  Sponsored content, medical device websites, and websites requiring a log-in were excluded.  Relevant websites (total n=28, endovascular n=15, open n=15, two redundant sites) with patient directed content were analyzed.  Readability was assessed using 9 established methods and understandability was assessed using the PEMAT scoring system.

Results: The average reading grade level across all sites was 12.8, with a range from 10.8 (New Fog Count) to 14.8 (Simple Measure of Gobbledygook).  Endovascular sites averaged a reading grade level of 13.6 with a range from 11.5 (FORCAST) to 15.6 (Gunning Fog).  Open repair websites had an average of 12.1 with a range from 9.9 (New Fog Count) to 14.1 (Simple Measure of Gobbledygook).  Readability was found to be inversely related to understandability, with a Pearson correlation coefficient of -0.5603 (p=0.001942).  Zero websites were rated as at or below the recommended sixth-grade reading level, and only 7.14% of the individual websites were rated by any readability measure as being at or below eighth-grade reading level.

Conclusion: Patient directed online health information regarding open and endovascular repair of abdominal aortic aneurysm exceeds the recommended sixth-grade reading level.  Increasing complexity of health websites correlates with poor understandability.  Modifications such as shorter sentences, fewer words with more than six letters, and increasing usage of clear visual aids can increase readability and understandability. 

 

94.04 Using Bradford’s Law of Scattering to Identify the Core Journals of Pediatric Surgery

Posted on January 18, 2018

N. Desai1, L. V. Veras1, A. Gosain1  1Univeristy Of Tennessee Health Science Center,Surgery,Memphis, TN, USA

Introduction:
While Pediatric Surgery is a small discipline, advances in the field expand upon discoveries made within many other disciplines, making it challenging for the practitioner to keep pace with advancing knowledge. Bradford’s Law of Scattering defines an exponentially diminishing return when extending a search for references in journals, and can be used to identify the “core” journals in a field. The purpose of this study was to identify the core journals of Pediatric Surgery.

Methods:
With IRB approval, we identified the top academically-productive Pediatric Surgeons in the US (5-year h-index >1 SD above the mean for Pediatric Surgeons at US Fellowship Training Programs). Scopus was used to gather each author’s publication history, # of publications, # of citations, lifetime and 5-year h-index, journals in which authors published, # of references/publication, and the journals each of those references were found in. The verbal formulation of Bradford’s law, which states that journals can be divided into p zones: c:ck:ck^2…ck^(p-1) where c is the number of core journals, and k is the Bradford multiplier between zones, was used to identify the core journals for p=3-8 zones. Pearson’s correlation coefficient was determined for actual vs. theoretical distributions.

Results:
We identified 69 Pediatric Surgeons (28±1.4 lifetime, 10±0.2 5-year h-index). These authors published 10031 articles(145±11/surgeon) which were cited 250841(3635±413/surgeon) times. The top 5 journals in which Pediatric Surgeons published were Journal of Pediatric Surgery, Journal of Surgical Research, Pediatric Surgery International, Seminars in Pediatric Surgery, and Annals of Surgery. Pediatric Surgeons’ articles contained 199507 references(2891±176/surgeon). We analyzed 58310 references from the top 20 journals in which each Pediatric Surgeon published. Bradford’s law identified a single core journal for all values of p=3-8, with p=3 providing the best correlation between predicted and actual values(R^2=0.9996). The core journal for Pediatric Surgery is Journal of Pediatric Surgery (Figure).

Conclusion:
We utilized Bradford’s law to identify the core journals of Pediatric Surgery. These core journals include the two leading Pediatric Surgery-specific journals, as well as the highest impact factor journals in Surgery (Annals of Surgery) and Medicine (NEJM). These findings can help busy Pediatric Surgeons focus their reading to stay current in a rapidly evolving field.
 

94.05 Team-Based Learning in Surgery Clerkship: Perception and Impact on NBME Subject Examination Scores

Posted on January 18, 2018

C. Babbitt1, A. Kaminski1, M. C. McCarthy1, M. Roelle1, R. Markert1, P. P. Parikh1  1Wright State University,Dayton, OH, USA

Introduction:   Team-based learning (TBL) has been studied in several preclinical and a few clinical settings, but there is less evidence for its effectiveness in specialties, such as Surgery.  We developed and instituted TBLs in a 3rd year surgery clerkship and compared Surgery Subject Exam scores before and after implementation.  We also analyzed students’ feedback for their perception of TBLs.

Methods:   The study was approved by Wright State University’s IRB.   The TBLs were transitioned into the curriculum during the 2013-2014 academic year.  Thus, the before implementation period was the two academic years prior (2011-2013), and the after implementation period was 2014-2016. NBME Subject Examination scores at our institution and nationally were compared using the independent samples t-test.  Satisfaction with the clerkship was assessed with AAMC Graduation Questionnaire data. Student feedback regarding TBLs was gathered at the end of each surgery rotation (six per year) and were analyzed for themes, both positive and negative, using constant comparative method.

Results:  Table 1 shows that NBME Surgery Subject Exam mean score was higher at our institution than nationally, both before (77.10±8.75 vs. 75.20±8.95, p=0.032) and after (74.65±8.0 vs. 73.10±8.55, p=0.071) TBL implementation. The NBME Subject Exam mean was lower following TBL implementation at our medical school (77.10±8.75 vs. 74.65±8.00, p=0.039), but the mean was also lower at the latter period on a national basis  (75.20±8.95 vs. 73.10±8.55, p<0.001).  Further, students at our medical school were more likely to rate the surgery clerkship good or excellent after TBL implementation (84.6% vs. 73.7%).  Overall, qualitative assessment perceived our TBLs to be educationally effective.  Learners stated that TBLs were informative, helpful in studying for the shelf exam, and viewed them as an opportunity for interactive learning. Some students also requested more TBLs.  Areas for improvement included reading materials, TBL instructions, and organization of sessions.  Some students viewed TBLs as more time-consuming than traditional instruction.

Conclusion:  Team-based learning has been found to be an effective collaborative learning strategy in medical education.  Since introducing TBL into our surgery clerkship, student perception of TBL has been both positive and provided feedback for improvement.  In addition, our medical school graduates have continued to assess their surgery experience as good/excellent by large majorities.  Concurrently, our NBME Subject Exam scores remain one-half to one standard deviation above the national mean.  In summary, we believe our medical students benefit from a well-organized TBL and its active approach to learning during surgery clerkship with no loss of fundamental surgery knowledge.
 

94.02 Is there Gender Bias on the General Surgery Certifying Examination?

Posted on January 18, 2018

T. Q. Ong2, J. P. Kopp1, A. T. Jones1, M. A. Malangoni1  1American Board Of Surgery,Philadelphia, PA, USA 2James Madison University,Harrisonburg, VA, USA

Introduction: Candidates pursuing certification in general surgery by the American Board of Surgery (ABS) must first pass a written qualifying exam and then an oral certifying exam (CE). Examiners evaluate candidates’ clinical ability to diagnose and manage problems encountered across the breadth of general surgery on the CE. Previous research in other contexts has found that examiners may exhibit bias toward examinees based on demographic variables such as gender. Systematic examiner bias threatens the fairness, reliability, and validity of the examination. We explored whether the gender of examinees or examiners were associated with CE scores and the likelihood of passing the CE.

Methods: Data from examinees who attempted the general surgery CE in the 2016-2017 academic year were analyzed. There were 1,341 examinees (61% male) and 216 examiners (82% male). Each examinee was rated by three pairs of examiners (one board examiner and one associate examiner). Factorial ANOVA and logistic regression analyses were conducted to examine whether examinee and examiner gender influenced CE scores and the likelihood of passing the exam. All effects were examined for both statistical and practical significance.

Results: ANOVA results indicated examiner and examinee gender did not influence average exam scores or pass rates. CE average scores were not associated with examinee gender (p = .24), board examiner gender (p = .14), or associate examiner gender (p = .10). All interaction effects between examiner and examinee gender were also nonsignificant (p’s > .05). Similarly, the likelihood of passing the CE was not associated with examinee gender (p = .88), board examiner gender (p = .77), associate examiner gender (p = .49), or any interactions between examinee and examiner gender (p’s > .05).

Conclusion: These results show there was no significant gender bias on the ABS general surgery CE. As the proportion of women entering the field of surgery increases, it will remain important to continue monitoring exam results to ensure no gender bias occurs in the future. The ABS has implemented implicit bias training for examiners to help mitigate the possibility of bias. Future research is needed to examine possible bias due to other factors.

94.03 Qualitative Analysis of a Cultural Dexterity Program for Surgeons: Feasible, Impactful, and Essential

Posted on January 18, 2018

R. Udyavar1, D. Smink1,2, J. Mullen3, T. Kent4, A. Green3, A. Harlow1, M. Castillo-Angeles1, A. Columbus1,2, A. Haider1,2  1Brigham And Women’s Hospital, Center For Surgery And Public Health,Department Of Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 3Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 4Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA

Introduction: Ineffective cross-cultural communication has been shown to contribute to adverse outcomes for minority patients. To address this, we developed a novel curriculum for surgical residents built on the principle of cultural dexterity, emphasizing adaptability to clinical and sociocultural circumstances to tailor the approach to the needs of the individual patient within a cultural context. Our objective was to evaluate the feasibility, acceptability, and residents’ perception of this program upon conclusion of its first year. 

Methods: The curriculum was implemented at 3 general surgery programs. It employed a flipped classroom model consisting of independent study via e-learning modules and interactive role-playing sessions for skills application. Skills focused on the physician/patient relationship, limited English proficiency, informed consent, and pain management. Sessions took place during compulsory didactic sessions over the course of 1 academic year. We conducted 4 focus groups, each with 6-9 participants, to get rich feedback on the curriculum and delivery model. Two of the focus groups consisted of PGY-1 categorical and preliminary general surgery interns, while the remaining 2 consisted of general surgery residents distributed across all levels of training. Focus groups were held during residents’ protected academic time and recorded, transcribed, and coded for content analysis. 

Results: Five major themes emerged from the data: (1) Role modeling from senior residents, fellows, and faculty members is integral in developing communication/interpersonal skills and attitudes towards cultural dexterity. (2) Residents understand that cultural dexterity is relevant and crucial to the provision of high-quality surgical care. (3) Nevertheless, residents express a sense of personal helplessness regarding their ability to implement macro-level improvements. (4) They emphasize the need to encourage “buy-in” at all levels of the institution as a whole to ensure that cultural dexterity becomes engrained in the system’s ethos. (5) Cultural dexterity training encourages residents to discuss the challenges and triumphs of providing surgical care to a diverse population, and it is the shared experience that residents find most engaging and impactful. 

Conclusion: Early implementation of the novel cultural dexterity curriculum revealed that the tension between surgical residents’ desire to improve their cross-cultural communication skills and the systemic/practical obstacles to providing culturally dexterous care are not insurmountable. Combining surgically relevant didactic materials with experiential learning activities has the potential to change the paradigm of surgical education. 

94.01 Medical Student Utilization of Social Media

Posted on January 18, 2018

D. Ruter1, L. A. Shirley2, C. Jones3  3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 1The Ohio State University College Of Medicine,Columbus, OH, USA 2The Ohio State University College Of Medicine,Department Of Surgery,Columbus, OH, USA

Introduction: A wide variety of social media platforms exist and are believed to be heavily utilized by medical students. However, although studies on professional student social media use have been conducted in other fields, professional and educational use of these platforms by medical students remains unknown. Medical schools have attempted to incorporate social media platforms into their curricula without adequate knowledge of the platforms students utilize for education purposes and their views on its use. As such, we sought to understand the usage patterns and opinions of social media by medical students for educational and professional purposes.

Methods: A ten question online survey was created and disseminated to the Deans of Student Affairs at all allopathic American Association of Medical College member schools for approval of participation. Upon approval, a short description of the study and survey link was emailed to the participating school’s students by the Dean. In addition to brief demographics, survey questions elicited what social media platforms students utilized for personal, educational, and professional purposes. Reasons for not utilizing social media for educational and professional purposes, and the perceived effect of social media on professional development were assessed. This study was approved by our institutional review board.

Results: Eight institutions agreed to participate and 715 students responded, a response rate of 14.5%. Ninety-one percent of respondents were between ages 21 to 28, and respondents from each of the four years of medical school made up at least 20% of the responses. The top three social media platforms used for any purpose were Facebook (94%), YouTube (77%), and Snapchat (72%). For educational purposes, 74% utilized YouTube and 48% used Facebook, with all other platforms used by less than 8% of students. Ten percent of respondents did not use social media educationally, citing a lack of perceived value and unknown quality of information. Forty percent of students responded that social media was not incorporated into their medical school curriculum. Forty-five percent of students do not use social media for professional networking, with two thirds of those respondents preferring a more traditional method of communication.

Conclusions: Social media platforms are used by 99% of medical students, with 90% doing so for educational purposes, and 55% for professional networking. Despite this large usage rate, many students state that social media is not incorporated into their curriculum. With this information, medical schools have the opportunity to improve incorporation of the specific social media platforms medical students already use into their education and professional development.

77.03 Gendered Differences in Letters of Recommendation for Transplant Surgery Fellowship Applicants

Posted on January 18, 2018

A. L. Hoffman1, W. J. Grant1, M. F. McCormick1, E. E. Jezewski1, A. N. Langnas1  1University Of Nebraska Medical Center, Surgery, Omaha, NE, USA

Introduction: Recent studies have examined gender differences in letters of recommendation for men and women in academic positions, research grant applications, and residency programs. No published study has explored such gender differences in applications to surgical subspecialty fellowships.

Methods: We conducted a retrospective review of 317 letters of recommendation to a transplant surgery fellowship written for residents finishing United States general surgery residency programs. We created a dictionary of communal and agentic terms (Table 1) and determined whether there were differences in the terms, characteristics, and length of the letters based on applicant’s gender as well as the academic rank and gender of the author.

Results: Of the 317 reviewed letters, 235 were letters of recommendation written for male applicants. Male surgeons wrote 91.76% of letters written for female applicants and 93.2% of letters written for male applicants. Full professors wrote 58.7% of the letters, associate professors wrote 19.2% and assistant professors wrote 21.13%. Male applicant letters were significantly more likely to contain agentic terms than female applicant letters (p=0.00086).  Additionally, male applicant letters were significantly more likely to contain the term “future leader” than female letters (p=0.047). Letters containing the term “future leader” were more agentic (p=< 0.0001) and less communal (p=0.047) than letters that did not contain this term.  Letters written by full professors, division chiefs, and program directors were significantly more likely to describe female applicants using communal terms like compassionate, calm and delightful (p=0.0301, p=0.036,p= 0.036 respectively).  In letters written by assistant professors, female letters had significantly more references to the applicants family (p= 0.036) and were longer (p=0.00554) than male letters. We identified terms only found in male letters “no doubt will become extremely successful”, “is a great rarity”, “indestructible machine”, and “unlimited power”, as well as terms only found in female letters “successfully balancing work and family”, “blossomed”, “achieved without drama” and “lives the Girl Scout values”.

Conclusion: Gendered differences exist in letters of recommendation for transplant surgery fellowship applicants. This research may provide insight into the inherent gender bias that is revealed in letters supporting candidates entering the field.  This is the largest published study to identify differences in terms, length, and family references in a cohort of residents applying for a surgical fellowship.

77.04 Racial and Ethnic Disparities in Promotion and Retention of Academic Surgeons

Posted on January 18, 2018

G. Eckenrode1,2, M. Symer1, J. Abelson1, A. Watkins1, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy,New York, NY, USA

Introduction: Racial and ethnic diversity is low in academic surgery, especially in leadership positions. However, no study has quantified differences in the rates of retention and promotion of racial and ethnic minority surgeons in academia. We used the American Association of Medical Colleges (AAMC) Faculty Roster to track a large cohort of academic surgeons and evaluate their rates of promotion and retention by race.

Methods: The AAMC Faculty Roster is a comprehensive database which aggregates national, longitudinal data on academic faculty. All first-time assistant and associate professors appointed between January 1, 2003 and December 31, 2006 in surgery were included. Individuals were followed for up to 10 years from their initial appointment; until they were promoted, stayed at their current rank, or left full-time academia. Faculty who switched institutions were included in the analysis. Log-rank test was used to determine the impact of race and ethnicity on promotion (increase in academic rank) and retention (persistence in academic surgery regardless of rank). Individuals of Black, Hispanic, or Other race/ethnicity (such as American Indian or other/multiple/unknown) were grouped due to data limitations. 

Results:There were 3,966 academic surgeons who began academic appointments from 2003 to 2006, of whom 2,683 were assistant professors and 1,283 were associate professors. Faculty were predominantly White (n=2,617), followed by Asian (n=559), and Black, Hispanic, or Other race/ethnicity (n=790). There was a non-significant trend toward lower promotion of Black/Hispanic/Other assistant professors (Black/Hispanic/Other 26.7% promoted at 10 years, Asian 33.3%, White 34.4%, p=0.07). There was a similar difference in 10-year promotion rates of associate professors between these groups (Black/Hispanic/Other n=53, 28.8%; Asian n=43, 30.3%; White n=294, 30.7%; p=0.10). However, retention rates were significantly higher for White assistant professors (n=1,017, 61.3% retained at 10 years) than Asian (n=220, 52.8% retained) or Black/Hispanic/Other faculty (n=308, 50.8% retained; p<0.01). There was no significant difference in 10-year retention rates among associate professors based on race/ethnicity (Black/Hispanic/Other 71.2%, Asian 69.7%, White 69.3%, p=0.72).

Conclusion:Overall, promotion rates in academic surgery over a 10-year period were low, with a trend to lower rates among underrepresented minorities. In addition, there is a clear disparity in the retention of minority assistant professors of surgery. Other differences in the retention and promotion of minority faculty were not significant, possibly due to the small numbers of minority faculty even in this national study. Racial/ethnic minority faculty face unique barriers in remaining in academic surgery particularly at the start of their career. To build a diverse workforce in academic surgery, a renewed focus should be made on retaining early-career minority faculty.

77.02 Are Residents Really Burned Out? A Comprehensive Study of Surgical Resident Burnout and Well-Being

Posted on January 18, 2018

B. Hewitt1, J. W. Chung1, A. R. Dahlke1, A. D. Yang1, K. E. Engelhardt1, E. Blay1, J. T. Moskowitz2, E. O. Cheung2, F. R. Lewis3, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Northwestern University,Osher Center For Integrative Medicine,Chicago, ILLINOIS, USA 3American Board Of Surgery,Philadelphia, PENNSYLVANIA, USA

Introduction:  Despite great interest in resident wellness, little is known about actual rates of resident burnout as current data are limited by poor response rates, small sample sizes, or use of non-validated measures. Surgical residents are hypothesized to be at particular risk for burnout and poor well-being. We used novel national survey data with responses from nearly all U.S. general surgery residents to (1) examine burnout and poor well-being prevalence and (2) identify factors associated with burnout and well-being.

Methods:  All general surgery residents were surveyed (99% response rate) at the time of the January 2017 American Board of Surgery In-Training Examination (ABSITE) regarding wellness, duty hour violations, preparation for residency, and occupational safety. The main resident wellness outcomes were burnout (abbreviated Maslach Burnout Inventory – 6 items) and psychiatric well-being (General Health Questionnaire-12 which identifies those at risk for non-psychotic psychiatric illness). Hierarchical logistic regression analyses were performed to examine resident and program factors associated with burnout and well-being.

Results: Of 7,441 residents offered the survey, 7,387 residents (99.3%) in 260 surgical residency programs completed all items related to resident wellness. Overall, burnout was reported in 23.8% (n=1,756) of residents and poor psychiatric well-being in 44.3% (n=3,270). From the burnout assessment, 16.0% (n=1,184) of residents responded that they “do not really care what happens to some patients” at least a few times a month, and 18.1% (n=1,337) of residents responded that they daily “feel fatigued in the morning having to face another day on the job.” In multivariable models, burnout was more likely among male residents (OR 1.15 [95% CI 1.01-1.31]), those who felt unprepared for residency (OR 1.65 [95% CI 1.44-1.90]), and those who violated the 80 hour weekly average duty hour limit (violations in 1-4 of the past 6 months: OR 1.54 [95% CI 1.35-1.77]; violations in ≥5 months: OR 2.35 [95% CI 1.80-3.07]) compared to no violations. Burnout was not significantly associated with post graduate year (PGY). Poor psychiatric well-being was associated with similar factors with the exception of female residents (OR 1.25 [95% CI 1.12-1.38]) and PGY 1 residents (OR 1.19 [95% CI 1.04-1.35]) compared to PGY 4/5 residents who were more likely to report poor psychiatric well-being. There was no significant difference in burnout or psychiatric well-being between the Flexible and Standard arms of the FIRST Trial.

Conclusion: In this national survey including 99% of clinically active surgical residents in the U.S., burnout and poor psychiatric well-being were prevalent in surgical residents and more likely in residents who reported feeling unprepared for residency and those who violated duty hour limits. Solutions to improve resident wellness are needed and should address these associated factors.

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