George M. Fuhrman

Perceptions of Graduating General Surgery Chief Residents: Are They Confident in Their Training?

BACKGROUNDnDebate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today.nnnSTUDY DESIGNnIn May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR).nnnRESULTSnOf the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills.nnnCONCLUSIONSnCurrent graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery.

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

Background Some anticipated that the Accreditation Council for Graduate Medical Education duty hours restrictions would foster a team-focused “new professionalism” among residents. This study explores the prevalence and challenges of a new professionalism and whether they vary by program size. Method Questionnaires distributed in 15 general surgery programs produced an 82% response rate (N = 306); 52 semistructured follow-up interviews were completed. Results include means, percentage who “agree or strongly agree,” significance tests, and main themes from the interviews. Results A new professionalism is limited by residents reluctance to pass work from day to night teams, unclear guidance regarding stay-or-go decisions during shift transitions, little educational emphasis on sign-outs, and the practice of long hours in the name of professionalism. Program size is largely unassociated with these beliefs and behaviors. Conclusions A new professionalism represents a stalled revolution among surgical residents. The new professionalisms emphasis on teamwork requires additional attention to staffing and workload management.

Professional values, value conflicts, and assessments of the duty-hour restrictions after six years: a multi-institutional study of surgical faculty and residents

BACKGROUNDnthe aim of this study was to explore professional values, value conflicts, and assessments of the Accreditation Council for Graduate Medical Educations duty-hour restrictions.nnnMETHODSnquestionnaires distributed at 15 general surgery programs yielded a response rate of 82% (286 faculty members and 306 residents). Eighteen items were examined via mean differences, percentages in agreement, and significance tests. Follow-up interviews with 110 participants were explored for main themes.nnnRESULTSnresidents and faculty members differed slightly with respect to core values but substantially as to whether the restrictions conflict with core values or compromise care. The average resident-faculty member gap for those 13 items was 35 percentage points. Interview evidence indicates consensus over professional values, a gulf between individualistic and team orientations, frequent moral dilemmas, and concerns about the assumption of responsibility by residents and real-world training.nnnCONCLUSIONSnthe divide between residents and faculty members over conflicts between the restrictions, core values, and patient care poses a significant issue and represents a challenge in educating the next generation of surgeons.

Application Submission Date Reflects Applicant Quality

PURPOSEnApplications for general surgery residency are submitted through the Electronic Residency Application Service (ERAS) beginning in early September. The purpose of this study was to determine whether the date of application submission could be used in the screening of an applicant for general surgery residency.nnnMETHODSnThe 2007 ERAS data for an independent program that accepts 2 categorical residents per year was evaluated. International medical graduates were excluded because no international applicants were considered for interviews. Applicants for preliminary positions were also excluded. The remaining graduates from medical schools accredited by the Liaison Committee on Medical Education (LCME) who applied for categorical positions were evaluated based on United States Medical Licensing Examination (USMLE) scores and on medical school performance, as well as on the quality of their personal statements and letters of recommendation. Medical school performance was determined from deans letters and transcript information, and each applicant was classified as outstanding, average, or poor. The date of application submission was compared with USMLE scores and medical school performance. The lag time to submit an application was also evaluated and compared with whether a student was offered an interview and the assessment of the quality of that interview. Results were evaluated using analysis of variance and the Pearson correlation test to evaluate for significance.nnnRESULTSnA total of 155 applications from LCME-accredited schools for categorical positions were received. The mean lag time to application for students with an outstanding medical school performance was 15.2 +/- 15.5 days compared with 37.4 +/- 26.2 days for poorly performing students (p < 0.01). A negative correlation between USMLE score and the lag time to application was noted (p < 0.01 USMLE I and USMLE II). Applicants offered an interview demonstrated a lag time to submit their application of 19.2 days +/- 21.7 versus 34.0 days +/- 25.8 for applicants not selected to interview (p < 0.01).nnnCONCLUSIONSnThe results of our study suggest that the date of application submission can provide important screening information about an applicant for general surgery residency. If nearly all high-quality applications are received in September, programs could begin the interview process in early November, which gives students an opportunity to visit more programs and increase their exposure to a broader variety of training options.

Pro: SLNB in DCIS

The role of sentinel node mapping and biopsy in the management of ductal carcinoma in situ (DCIS) remains controversial. A debate about the use of a staging technique for the evaluation of a malignancy without metastatic potential seems absurd. However, this debate is fueled by two factors. First, some patients diagnosed with DCIS will ultimately prove to have invasive carcinoma. Second, the status of the sentinel node is the most powerful predictor of prognosis and surgeons want to ensure that those patients with invasive carcinoma have sentinel node mapping for staging and treatment planning. In order to understand this debate an appreciation of the evolution of breast cancer management over the past decade is essential. The two most important historical events in this evolution have been the appreciation of the relationship of prior lumpectomy and its impact on lymphatic drainage from the breast to the sentinel node, and the increasing use of image guided core needle breast biopsies to sample mammographic abnormalities that may underestimate the extent of breast pathology. When Morton et al. 1 initially described the use of sentinel node mapping for melanoma, a minimally or undisturbed primary tumor site was considered essential for accurate identification of the sentinel node. In fact, a wide excision of a primary melanoma prior to referral for sentinel node mapping was considered a contraindication and these patients were denied sentinel node staging. When sentinel node mapping was initially described for breast carcinoma, a precise injection of colloid and/or dye around an intact primary tumor were considered important technical aspects in order to identify the correct sentinel node in the axilla. 2 Like melanoma patients, if the primary breast tumor was removed prior to referral for sentinel node mapping, the potential inaccuracy of the technique was used as a criterion to exclude patients from mapping. Mapping was done routinely at the time of DCIS management to avoid losing the opportunity to stage the axilla after excision when invasive carcinoma was subsequently identified. Subsequent experience in melanoma and breast sentinel node mapping has demonstrated that the technique is still accurate after wide excision of the primary tumor. 3,4 The evidence that mapping

Program directors' views on general surgery resident travel for transplant rotations

BACKGROUNDnSome program directors in surgery (PDs) must maintain transplant rotations at nonintegrated (away) hospitals. This study investigated the opinions of PDs related to resident travel for transplant surgery experience.nnnMETHODSnAn Internet-based survey was e-mailed to 251 PDs in the United States.nnnRESULTSnAltogether, 131 PDs (52%) responded. Of those, 66% have a transplant service at integrated hospitals. Small majorities of PDs believed transplant rotations offer a good educational experience (59%) and comply with duty hours (71%). Few PDs believed transplant rotations provide excellent operative experience (47%) and mandate service over education (38%). PDs leading community-affiliated and smaller programs employed away rotations more commonly. Affected PDs used commuting (48%) and purchased temporary housing (52%). Most believed travel is a poor aspect of the experience (78%) and transplant rotations should become an optional component of residency training (60%). PDs using away hospitals more often believed this content area should be eliminated.nnnCONCLUSIONSnAlthough away transplant rotations minimally impact opinions of PDs related to select educational issues, most PDs challenge the existing paradigm of transplant surgery as essential content.

Venous Thromboembolism after Inpatient Surgery in Administrative Data vs NSQIP: A Multi-Institutional Study

BACKGROUNDnPrevious studies have documented significant differences between administrative data and registry data in the determination of postoperative venous thromboembolism (VTE). The goal of this study was to characterize the discordance between administrative and registry data in the determination of postoperative VTE.nnnSTUDY DESIGNnThis study was performed using data from the American College of Surgeons NSQIP merged with administrative data from 8 different hospitals (5 different medical centers) between 2013 and 2015. Occurrences of postoperative vein thrombosis (VT) and pulmonary embolism (PE) as ascertained by administrative data and NSQIP data were compared. In each situation where the 2 sources disagreed (discordance), a 2-clinician chart review was performed to characterize the reasons for discordance.nnnRESULTSnThe cohort used for analysis included 43,336 patients, of which 53.3% were female and the mean age was 59.5 years. Concordance between administrative and NSQIP data was worse for VT (κ 0.57; 95% CI 0.51 to 0.62) than for PE (κ 0.83; 95% CI 0.78 to 0.89). A total of 136 cases of discordance were noted in the assessment of VT; of these, 50 (37%) were explained by differences in the criteria used by administrative vs NSQIP systems. In the assessment of postoperative PE, administrative data had a higher accuracy than NSQIP data (odds ratio for accuracy 2.86; 95% CI 1.11 to 7.14) when compared with the 2-clinician chart review.nnnCONCLUSIONSnThis study identifies significant problems in ability of both NSQIP and administrative data to assess postoperative VT/PE. Administrative data functioned more accurately than NSQIP data in the identification of postoperative PE. The mechanisms used to translate VTE measurement into quality improvement should be standardized and improved.

Postoperative Myocardial Infarction in Administrative Data vs Clinical Registry: A Multi-Institutional Study

BACKGROUNDnPrevious studies have documented significant differences between administrative data and registry data in the determination of postoperative MI. The goal of this study was to characterize discordance between administrative and registry data in the determination of postoperative myocardial infarction (MI).nnnSTUDY DESIGNnThis study was performed using data from the American College of Surgeons NSQIP merged with administrative data from 8 different hospitals, between 2013 and 2015. From each of these sources, the occurrence of a postoperative MI, as ascertained by administrative data and NSQIP data, were compared. In each situation in which the 2 sources disagreed (discordance), a 2-clinician chart review was performed to generate a gold standard determination as to the occurrence of postoperative MI.nnnRESULTSnA total of 43,289 operations met our inclusion criteria for analysis. Within this cohort a total of 230 cases of MI were identified by administrative data and/or NSQIP data (administrative rate 0.41%, NSQIP rate 0.42%). A total of 89 discordant ascertainments were identified, of which 42 were admin+/NSQIP- and 47 were admin-/NSQIP+. Accuracy (99.9% for both) and concordance (kappaxa0= 0.89 [95% CI 0.86 to 0.92] for administrative data, kappaxa0= 0.87 [95% CI 0.84 to 0.91] for NSQIP data) of the 2 systems were similar when compared against our gold standard (chart review). The majority of errors were related to false negatives, with sensitivity rates of 81% in both data sources.nnnCONCLUSIONSnIn this multi-institutional study, administrative data and NSQIP demonstrated a similar ability to determine the occurrence of postoperative MI. These findings do not demonstrate an advantage of registry data over administrative data in the determination of postoperative MI.

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

OBJECTIVEnThe 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.nnnDESIGNnDetails 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.nnnSETTINGnCCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016.nnnRESULTSnOverall, 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.nnnCONCLUSIONSnSurgery 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.

Miscellaneous Disorders and Their Management in Gastric Surgery: Volvulus, Carcinoid, Lymphoma, Gastric Varices, and Gastric Outlet Obstruction

This article focuses on less common diseases that surgeons are called on for management options. Five topics-volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction from peptic ulcer disease-are frequently used to evaluate surgical knowledge. Knowledge of these topics is useful for residents preparing for an in-training examination or board certification. Patients with these diseases require multidisciplinary management with oncologists and/or gastroenterologists, and mastery of these topics allows surgeons to effectively participate in the multidisciplinary care of these patients and advocate for surgical management when appropriate.