Amit R.T. Joshi

The predictive value of initial serum lactate in trauma patients.

ABSTRACT Trauma patients require early assessment of injury severity. Trauma scores, although well validated, can be unwieldy in the emergency clinical setting. We sought to evaluate the prognostic value of initial serum lactate (ISL) for mortality, operative intervention (OI), and intensive care unit admission (ICUA) in trauma patients. We conducted an institutional review board–approved retrospective study. We reviewed all trauma patients between January 2007 and June 2012 in our prospectively maintained database. We included only adults whose ISL had been drawn within the first 35 min after arrival. We included only those patients whose interval between injury and arrival was within 24 h. Survivors and nonsurvivors were compared using logistic regression, Mann-Whitney U, and chi-square tests. Discriminating ability of ISL for mortality was assessed with receiver operating characteristic analysis. Our secondary outcomes (ICUA and OI) were evaluated with logistic regression test and receiver operating characteristic analysis. A total of 1,941 patients were included. Overall mortality was 6.2%. Median ISL was 32 mg/dL (interquartile range, 17 – 62) for nonsurvivors versus 21 mg/dL (interquartile range, 14 – 32) for survivors (P < 0.001). In multivariate analysis, ISL was a significant covariate for mortality (P = 0.015). The odds ratio was 1.010 (95% confidence interval, 1.002 − 1.019). The area under the curve was 0.63. The ISL was a significant covariate for OI (P = 0.033). The ISL did not reach significance for ICUA. The ISL is an easily measured, rapid, and inexpensive test that can help to quickly stratify injury severity in trauma patients. We have found that ISL, when used in strictly selected patients, can predict OI and mortality.

Applicant Characteristics Associated With Selection for Ranking at Independent Surgery Residency Programs

OBJECTIVES This study evaluated characteristics of applicants selected for interview and ranked by independent general surgery residency programs and assessed independent program application volumes, interview selection, rank list formation, and match success. DESIGN Demographic and academic information was analyzed for 2014-2015 applicants. Applicant characteristics were compared by ranking status using univariate and multivariable statistical techniques. Characteristics independently associated with whether or not an applicant was ranked were identified using multivariable logistic regression modeling with backward stepwise variable selection and cluster-correlated robust variance estimates to account for correlations among individuals who applied to multiple programs. SETTING The Electronic Residency Application Service was used to obtain applicant data and program match outcomes at 33 independent surgery programs. PARTICIPANTS All applicants selected to interview at 33 participating independent general surgery residency programs were included in the study. RESULTS Applicants were 60% male with median age of 26 years. Birthplace was well distributed. Most applicants (73%) had ≥1 academic publication. Median United States Medical Licensing Exams (USMLE) Step 1 score was 228 (interquartile range: 218-240), and median USMLE Step 2 clinical knowledge score was 241 (interquartile range: 231-250). Residency programs in some regions more often ranked applicants who attended medical school within the same region. On multivariable analysis, significant predictors of ranking by an independent residency program were: USMLE scores, medical school region, and birth region. Independent programs received an average of 764 applications (range: 307-1704). On average, 12% interviews, and 81% of interviewed applicants were ranked. Most programs (84%) matched at least 1 applicant ranked in their top 10. CONCLUSIONS Participating independent programs attract a large volume of applicants and have high standards in the selection process. This information can be used by surgery residency applicants to gauge their candidacy at independent programs. Independent programs offer a select number of interviews, rank most applicants that they interview, and successfully match competitive applicants.

Factors and Influences That Determine the Choices of Surgery Residency Applicants

OBJECTIVE We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer. STUDY DESIGN An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference. SETTING Independent general surgery residency programs. PARTICIPANTS A total, of 1220 applicants were selected to interview at one of 33 independent programs. RESULTS In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs. CONCLUSIONS Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.

Case report of a robotic‐assisted laparoscopic repair of a giant incarcerated recurrent inguinal hernia containing bladder and ureters

Robotic surgery is particularly useful in pelvic procedures, such as prostatectomy and low anterior resection. The paper describes a robotic‐assisted repair of a giant bladder‐ and ureter‐containing incarcerated inguinal hernia.

Surgical Residency Recruitment—Opportunities for Improvement

INTRODUCTION The Association of Program Directors in Surgery convened a panel during Surgical Education Week 2016 to discuss the current state of the general surgery residency application process and to review alternative ways to evaluate the suitability of each applicant to a residency program. METHODS/RESULTS Over 40,000 applicants registered for the National Resident Matching Programs 2016 Main Residency Match. General Surgery had 2345 applicants for 1241 categorical postgraduate year (PGY)-1 positions, and 1239 of those positions were filled when the matching algorithm was processed. Program Directors reported that only 33% of applications received an in-depth review, and 62% were rejected with minimal review. Eventually (after all applications had been reviewed), only 13% of applicants were invited to interview. CONCLUSIONS There are several opportunities for improvement within the current application process. These included standardized letter of recommendation and personal statements, refinement of the interview process, and recalibration of the Medical Student Performance Evaluation.

Characteristics of Independent Academic Medical Center Faculty

OBJECTIVE Little is known about the characteristics of teaching faculty in US surgical residencies based at Independent Academic Medical Centers (IAMCs). The purpose of this study was to survey teaching faculty at IAMCs to better define their common characteristics. STUDY DESIGN An online, anonymous survey was distributed through program officials at 96 IAMCs to their faculty and graduates. Respondents were asked about their demographic information, training history, board certification, clinical practice, and exposure to medical students. Student t-tests and chi-square tests were calculated to evaluate associations between faculty characteristics. SETTING Independent Academic Medical Center general surgery training programs PARTICIPANTS: A total of 128 faculty at 14 IAMCs participated in the study. RESULTS In total, 128 faculty from 14 programs responded to the survey. The mean age of faculty respondents was 52 years and 81% were men. 58% were employed by a nonuniversity hospital, and 28% by a multispecialty practice. 79% of respondents were core faculty. The mean length of time since graduation from surgery residency was 19 years. 86% were currently board certified. 55% of those who were currently board certified had an additional certification. 45% had trained in an IAMC, 50% in an university program, and 5% in a military program. 73% were actively practicing general surgeons, with the majority (70%) performing between 101 and 400 cases annually. The vast majority of faculty (90%) performed <200 endoscopies annually, with 44% performing none. 84% and 35% provided ER and trauma coverage, respectively. 81% listed mentorship as their primary motivation for teaching residents. 23% received a stipend for this teaching. 95% were involved in medical student teaching. Faculty who completed training at university programs had more additional certifications compared with those with IAMC training (67% vs. 43%, p = 0.007). Certification differences by program type were consistent across age and time since residency completion. Age was not associated with residency program type (p = 0.87) nor additional certifications (p = 0.97). CONCLUSIONS IAMC faculty and graduates are overwhelmingly involved in general surgery, and most faculty have additional certifications. 90% of faculty have clinical exposure to medical students. Faculty at IAMCs were as likely to have been trained at an university program as an IAMC. In a time of increasing surgeon subspecialization and anxiety about the ability of 5-year training programs to train well-rounded surgeons, IAMCs appear to be a repository of consistent general surgical training.

A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment

OBJECTIVE The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

Best Practice for Implementation of the SCORE Portal in General Surgery Residency Training Programs

INTRODUCTION The Surgical Council on Resident Education (SCORE) has presented a workshop annually at the annual meeting of the Association of Program Directors (APDS) to discuss the evolution of the SCORE portal and best practices for implementation within residency training programs. METHODS/RESULTS A review of the literature was undertaken, along with a summation of discussion at these several workshops. A history of the SCORE project and a summary of its organizational framework and content are presented. In addition, best practices for use of SCORE within programs are described. CONCLUSIONS The SCORE portal is now a decade old, and is used ubiquitously in US surgical training programs. With this experience, there is data to show the utility of SCORE to support trainee learning and programmatic didactics.

Trends in the clinical presentation, treatment, and survival for pancreatic adenocarcinoma

BACKGROUND We assessed trends in the clinical presentation, treatment, and survival for pancreatic adenocarcinoma. METHODS A retrospective cohort study using data from the SEER program (2004-2014). All patients diagnosed with pancreatic adenocarcinoma over 2 eras were included (A: 2004-2009 vs. B: 2010-2014). Outcomes of interest were the likelihood of metastatic disease at diagnosis, utilization of resection, and overall survival. RESULTS A total of 62,201 patients were included in this study [Era B - 31,998 (51.4%)]. Patients diagnosed in Era B were significantly less likely to have metastatic pancreatic cancer at diagnosis, and demonstrated improved long-term survival after risk-adjustment. Similarly, patients with non-metastatic pancreatic cancer that were diagnosed in Era B were independently more likely to undergo resection. The observed association between era of diagnosis and survival was independent of resection status and the presence of metastatic disease. CONCLUSIONS There have been significant improvements in pancreatic cancer care over the last decade, as evidenced by earlier diagnosis, increased utilization of surgery, and improvement in overall survival for both resected and un-resected patients.

What Can SCORE Web Portal Usage Analytics Tell Us About How Surgical Residents Learn

PURPOSE The Surgical Council on Resident Education (SCORE) was established in 2004 with 2 goals: to develop a standardized, competency-based curriculum for general surgery residency training; and to develop a web portal to deliver this content. By 2012, 96% of general surgery residency programs subscribed to the SCORE web portal. Surgical educators have previously described the myriad ways they have incorporated SCORE into their curricula. The aim of this study was to analyze user data to describe how and when residents use SCORE. METHODS Using analytic software, we measured SCORE usage from July, 2013 to June, 2016. Data such as IP addresses, geo-tagging coordinates, and operating system platforms were collected. The primary outcome was the median duration of SCORE use. Secondary outcomes were the time of day and the operating system used when accessing SCORE. Descriptive statistics were performed, and a p < 0.05 was deemed statistically significant. RESULTS There were 42,743 total SCORE subscribers during the study period (75% resident and 25% faculty) with a mean of 14,248 subscribers per year. The overall median duration of SCORE use was 11.9minute/session (interquartile range [IQR]: 6.8). Additionally, there was a significant increase in session length over the 3 academic years; 10.1 (IQR: 6.4), 11.9 (IQR: 7.2), and 13.2minute/session (IQR: 5.4) in 2013 to 2014, 2014 to 2015, and 2015 to 2016, respectively (p < 0.001). SCORE usage was highest in November to February at 21.0minute/session (14.2) compared to July to October and March to June (12.3 [IQR: 3.2] and 9.6minute/session [IQR: 2.2]), respectively (p < 0.001). This seasonal trend continued for all 3 years. We observed an increased number of sessions per day over the 3 years: median of 1500 sessions/d (IQR: 1115) vs 1706 (IQR: 1334) vs 1728 (IQR: 1352), p < 0.001. (Fig.). Most SCORE sessions occurred at night: 38,011 (IQR: 4532) vs 17,529 (IQR: 19,850) during the day (p < 0.001). Windows was the most frequently used operating system at 48.9% (p < 0.001 vs others). CONCLUSIONS SCORE usage has increased significantly over the last 3 years, when measured by number of sessions per day and length of time per session. There are predictable daily, diurnal, and seasonal variations in SCORE usage. The annual in-training examination is a prominent factor stimulating SCORE usage.