Chris M. Reid

Factors Associated With General Surgery Residents’ Desire to Leave Residency Programs: A Multi-institutional Study

IMPORTANCEnGeneral surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition.nnnOBJECTIVEnTo determine how often categorical general surgery residents seriously consider leaving residency.nnnDESIGN, SETTING, AND PARTICIPANTSnAt 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not.nnnMAIN OUTCOMES AND MEASURESnFactors associated with the desire to leave residency.nnnRESULTSnThe survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the presence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; Pu2009=u2009.003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, Pu2009=u2009.04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; Pu2009=u2009.03).nnnCONCLUSIONS AND RELEVANCEnA majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.

Specific inactivation of two immunomodulatory SIGLEC genes during human evolution

Sialic acid-recognizing Ig-like lectins (Siglecs) are signaling receptors that modulate immune responses, and are targeted for interactions by certain pathogens. We describe two primate Siglecs that were rendered nonfunctional by single genetic events during hominin evolution after our common ancestor with the chimpanzee. SIGLEC13 was deleted by an Alu-mediated recombination event, and a single base pair deletion disrupted the ORF of SIGLEC17. Siglec-13 is expressed on chimpanzee monocytes, innate immune cells that react to bacteria. The human SIGLEC17P pseudogene mRNA is still expressed at high levels in human natural killer cells, which bridge innate and adaptive immune responses. As both resulting pseudogenes are homozygous in all human populations, we resurrected the originally encoded proteins and examined their functions. Chimpanzee Siglec-13 and the resurrected human Siglec-17 recruit a signaling adapter and bind sialic acids. Expression of either Siglec in innate immune cells alters inflammatory cytokine secretion in response to Toll-like receptor-4 stimulation. Both Siglecs can also be engaged by two potentially lethal sialylated bacterial pathogens of newborns and infants, agents with a potential impact on reproductive fitness. Neanderthal and Denisovan genomes show human-like sequences at both loci, corroborating estimates that the initial pseudogenization events occurred in the common ancestral population of these hominins. Both loci also show limited polymorphic diversity, suggesting selection forces predating the origin of modern humans. Taken together, these data suggest that genetic elimination of Siglec-13 and/or Siglec-17 represents signatures of infectious and/or other inflammatory selective processes contributing to population restrictions during hominin origins.

Correlating surgical clerkship evaluations with performance on the National Board of Medical Examiners examination.

BACKGROUNDnEvaluation of medical students during the surgical clerkship is controversial. Performance is often based on subjective scoring, whereas objective knowledge is based on written examinations. Whether these measures correspond or are relevant to assess student performance is unknown. We hypothesized that student evaluations correlate with performance on the National Board Of Medical Examiners (NBME) examination.nnnMETHODSnData were collected from the 2011-2012 academic year. Medical students underwent a ward evaluation using a seven-point Likert scale assessing six educational competencies. Students also undertook the NBME examination, where performance was recorded as a percentile score adjusted to national standards.nnnRESULTSnA total of 129 medical students were studied. Scores on the NBME ranged from the 52nd to the 96th percentile with an average in the 75th percentile (±9). Clerkship scores ranged from 3.2-7.0 with a mean of 5.7 (±0.8). There was a strong positive association between higher NBME scores and higher clerkship evaluations shown by a Pearson correlation coefficient of 0.47 (P<0.001). Students clustered with below average ward evaluations (3.0-4.0) were in the 69.5th percentile of NBME scores, whereas students clustered with above average ward evaluations (6.0-7.0) were in the 79.2th percentile (P<0.001).nnnCONCLUSIONSnA strong positive relationship exists between subjective ward evaluations and NBME performance. These data may afford some confidence to surgical faculty and surgical resident ability to accurately evaluate medical students during clinical clerkships. Understanding factors in student performance may help in improving the surgical clerkship experience.

Impact of a Third-Year Surgical Apprenticeship Model: Perceptions and Attitudes Compared with the Traditional Medical Student Clerkship Experience

BACKGROUNDnCurrent literature suggests that medical students may have negative misconceptions of a surgical career partly due to the traditional hierarchical structure of the surgical clerkship. We hypothesized that a novel medical student apprenticeship would result in positive changes in perceptions of both surgeons and surgical careers.nnnSTUDY DESIGNnIn the 2011 academic year, third-year medical students were offered a 2-week apprenticeship elective, in addition to the standard 8-week surgical clerkship. Unlike a traditional service, students apprenticed directly with participating faculty on a one-on-one basis. At the clerkships end, students received a structured questionnaire assessing perceptions and attitudes toward surgeons and a career in surgery. Subjects responded anonymously using a 5-point Likert scale. A Wilcoxon Rank-Sum was performed comparing students who participated vs those who did not participate in the apprenticeship.nnnRESULTSnThere was a 99% survey response (105 of 106). Of those, 50 (48%) participated in the apprenticeship. Apprenticeship students were more likely to view surgeons as content (p < 0.001), well-balanced (p < 0.01), respectful (p = 0.01), and as role models (p < 0.005). Apprenticeship students were also more likely to participate in the operating room (p < 0.05) and in patient management (p < 0.05). There was no difference in an interest to pursue a surgical career between groups both before and on completion of the clerkship.nnnCONCLUSIONSnStudents participating in a surgical apprenticeship had a more positive view of surgeons and the field of surgery compared with students not participating. An apprenticeship model enhances the surgical clerkship experience and improves medical student perceptions of surgery as a career.

Validated Assessment Tools and Maintenance of Certification in Plastic Surgery: Current Status, Challenges, and Future Possibilities.

Background: The transition to the Next Accreditation System is well underway, and a shift toward competency-based assessment in the form of milestones is now the standard. A significant effort has been completed by the Plastic Surgery Milestones Working Group to develop specific milestones and assessment tools for plastic surgery training. Methods: The history of the development toward competency-based assessment was reviewed. Data regarding the trends and regulations associated with board certification and the role of maintenance of certification were reviewed. Results: The work of the Plastic Surgery Milestones Working Group has sparked interest in assessment and created an opportunity for further development. The efforts toward validating assessment tools by our colleagues working in other surgical specialties serve as a suitable roadmap for further progress. Board certification is an integral part of successful practice and should be regarded as an expectation. Despite the burdens associated with maintenance of certification, it serves a valuable function in ensuring optimal patient care and is often retrospectively seen as an important component of practice. Conclusions: The competency-based milestones are the new standard, and work on this new methodology of assessing plastic surgery trainees is expected to continue. Accurate assessment is critical to the pathways for board certification and maintenance of certification, which serve important roles for all parties involved in the delivery of medical care.

Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance

IMPORTANCEnFew large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations.nnnOBJECTIVESnTo identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance.nnnDESIGN, SETTING, AND PARTICIPANTSnAn anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide.nnnMAIN OUTCOMES AND MEASURESnScores from the 2014 ABSITE.nnnRESULTSnA total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P =u2009.03; USMLE 2, 0.3 [0.19-0.44], P <u2009.001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P =u2009.002), high opinion of ABSITE significance (P <u2009.001), surgical textbook use (11 [6-16]; P =u2009.02), daily studying (13 [4-23]; P =u2009.02), and high satisfaction with study materials (P <u2009.001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P <u2009.001), MCAT score (0.6 [0.2-1.0]; P =u2009.003), opinion of ABSITE significance (9.2 [6.9-11.6]; P <u2009.001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P =u2009.03) were identified as positive predictors of ABSITE performance.nnnCONCLUSIONS AND RELEVANCEnMost residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

Implementing Assessment Methods in Plastic Surgery.

Background: Principles of effective assessment have become increasingly popular topics in graduate medical education. Changes in the structure of plastic surgery training demand a thorough understanding of the state-of-the-art in assessing surgical trainees. Moreover, the authors’ understanding of different domains and methods of assessment and the available tools continues to grow. Methods: The authors reviewed the available literature regarding assessment in graduate medical education, specifically as it pertains to plastic surgery. In addition, the authors present principles of effective assessment and report on the currently available assessment methods. Results: Assessment is multifaceted and impacts everyone, not just the individual learner. For assessments to be useful, they need to possess validity and reliability. Moreover, there is a necessary pragmatism limiting different methods and tools for assessing learners. Some types of assessment are universally familiar and include examples such as written examinations and procedural logs. Other emerging areas that are actively being researched involve simulation, nontechnical skills, and procedure-specific technical assessments. Conclusion: Updating the thoroughness and multidimensionality with which plastic surgery trainees are assessed is an evolving area and one that is ripe for continued research.

Analysis of a Resident Aesthetic Clinic: Process for Rhinoplasty, Resident Experience, and Patient Satisfaction

Goals/Purpose Plastic surgery residents often desire additional training in rhinoplasty than what is provided by their residency program. The goal of this study was to define and evaluate a specific process used to structure preoperative, intraoperative, and postoperative protocols for rhinoplasty patients in the resident aesthetic clinic (RAC) to enhance qualitative and quantitative experience. Complication rates and patient/resident satisfaction scores were also examined. Methods Resident clinic rhinoplasty patients underwent a well-defined and established process that included patient education and informed consent, preoperative planning in a conference-based session, specific adherence to established surgical techniques, and structured postoperative management and follow-up. This process also included supervision criteria for residents in the operating room and clinical setting. Patient and resident satisfaction at the RAC was evaluated by a Web-based survey. A database of procedural complications and methods was compiled and evaluated. Results Between June 2012 and June 2015, 146 aesthetic resident cases were completed through the University of California, San Diego Residency Aesthetic Surgery Program. Of these cases, 34 (17%) were rhinoplasty procedures. Residents at our institution assisted on an average of 55 rhinoplasty procedures with the faculty and performed an average of 12 rhinoplasty procedures as primary surgeons. The residents surveyed felt that they had a good autonomous experience (P < 0.001), and 90% reported confidence with rhinoplasty. Postoperative complications were recorded and included asymmetry (n = 4, 10.5%), septal perforation (n = 1, 2.6%), and difficulty in breathing (n = 6, 15.8%). There were no patients who experienced infections, and the complication rate requiring revision in the operating room was 0%. Conclusions Optimizing protocols in rhinoplasty in an RAC has allowed for the RAC to flourish in the breadth and complexity of rhinoplasty operations. This has enabled residents to gain a structured and autonomous exposure to rhinoplasty cases. Cases were done with an acceptable complication rate and with good patient and resident satisfaction. This is a unique report in that it provides a structured process for preoperative, intraoperative, and postoperative care in rhinoplasty operations.

Staged Hybrid Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula

There is a growing body of literature expanding the indication of endovascular aneurysm repair, from prophylactic treatment of aneurysms to other indications such as ruptured and complicated ruptured abdominal aneurysms. Concomitant aortocaval fistula is rare, and reports of open and endovascular repair exist. We report a unique hybrid approach to a case of a ruptured abdominal aortic aneurysm with aortocaval fistula, repaired primarily via endovascular approach in a hybrid, two-staged fashion. Representative images are presented in addition to a short review of this pathology.

Craniofacial fracture patterns in all terrain vehicle injuries

BackgroundA multicenter, retrospective study was conducted to determine the frequency and distribution of craniofacial fractures sustained from all terrain vehicle (ATV) accidents. MethodsMedical records of all patients presenting to 2 trauma centers with ATV-related craniofacial trauma from 2001 to 2013 were reviewed. Patient notes and radiographic images were analyzed for detailed craniofacial injury data. The identified fractures were classified as: frontal/skullbase, naso-orbital, maxilla/zygoma, and mandible. In addition, patient demographic information, length of stay, airway status, intensive care unit stay, Glasgow coma scale, use of safety equipment, associated traumatic brain injury, and surgical intervention were compiled. ResultsOne hundred fifty-six patients with craniofacial fractures secondary to ATV accidents presented from 2001 to 2013. The incidence of craniofacial fractures found in patients with ATV injuries was 12.2%. Sixty-one patients (39.1%) suffered frontal/skullbase fractures, 98 (62.8%) naso-orbital fractures, 62 (39.7%) maxillary/zygoma fractures, and 35 (22.4%) mandibular fractures. Forty-one patients (26.3%) required surgical intervention to correct their craniofacial injuries. ConclusionsThe most common craniofacial fractures experienced in ATV injuries are naso-orbital fractures. The correlation of nonuse of safety equipment and associated traumatic brain injuries displays the importance of using helmets when operating ATVs. Future studies can be conducted examining ATV-related upper extremity injuries, among others.