Jonathan Dort

Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database.

Multiple studies have evaluated the effect of anesthesia type on carotid endarterectomy with inconsistent results. Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database. All patients listed in National Surgical Quality Improvement Program database that underwent carotid endarterectomy under general anesthesia and local or regional anesthesia from 2005 to 2011 were included with the exception of patients undergoing simultaneous carotid endarterectomy and coronary artery bypass grafting. The data revealed substantial differences between the two groups compared, and these were adjusted using multiple logistic regression. Postoperative myocardial infarction, stroke, and death at 30 days were compared between the two groups. A total of 42,265 carotid endarterectomy cases were included. A total of 37,502 (88.7%) were performed under general anesthesia and 4763 (11.3%) under local or regional anesthesia. Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality. Carotid endarterectomy under local or regional anesthesia carries a decreased risk of postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia. Therefore, patients at risk of postoperative myocardial infarction undergoing carotid endarterectomy, consideration of local or regional anesthesia may reduce that risk.

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.

Talk the Talk: Implementing a Communication Curriculum for Surgical Residents.

OBJECTIVES The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program. DESIGN The curriculum is presented in quarterly modules over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios. SETTING Surgical simulation center in a 900-bed tertiary care hospital. PARTICIPANTS Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios. RESULTS We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum. CONCLUSIONS Our approach using Trauma Survivors Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice.

Interrater Reliability of Hospital Readmission Evaluations for Surgical Patients.

Value-based purchasing initiatives have helped shift attention to the accuracy of hospital readmission information at the most clinically detailed level. The purpose of this study was to determine the interrater reliability (IRR) of surgical experts in assessing surgical inpatient readmissions for categorical causes, relation to index procedure, and potential preventability. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program local database. Of 1840 cases, 156 patients (8.5%) were readmitted within 30 days of the procedure. Surgical site infection was the most common readmission cause (32%), followed by obstruction or ileus (17%). IRR was moderate for readmission cause (60% agreement, κ = 0.51), substantial for readmission in relation to surgical procedure (92%, κ = 0.70), and lowest for potential preventability of readmissions (57%, κ = 0.18). Results suggest that readmission cause and relation to surgical procedure can be determined with moderate to high degree of IRR, while preventability of readmissions may require stricter definitions to improve IRR.

Crisis Management of a Hemorrhagic Emergency in the OR

n 2011, Classen et al found that one-third of adults admitted to hospitals sustain an adverse event, and many of them are surgical patients. The invasiveness of surgery, the effects of anesthesia, and the complexity of the technology used, coupled with the intricacies of teamwork and communication make the perioperative period a high-risk time for patients. Responding to crises that occur in the OR requires rapid, coordinated management among surgeons, nurses, and anesthesia professionals in stressful, time-critical settings, and the success of the response relies largely on the experience, knowledge, and skill of all the team members. One such crisis to be addressed is hemorrhage. Massive bleeding may result in coagulopathy and hemorrhagic shock, and may pose a potential threat to the patient’s life. Hemorrhagic shock is a pathophysiological state in which the circulatory system is unable to perfuse tissues adequately and thus meet the body’s oxygen requirements. Patients who are bleeding require concurrent hemorrhage control and blood replacement therapy. In addition to the effective restoration of blood volume, the specific goal of transfusion management should be to restore the patient’s oxygen-carrying capacity. These goals cannot be successful without the

SAGE(S) advice: application of a standardized train the trainer model for faculty involved in a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) hands-on course

IntroductionCurrently, no prerequisite teaching qualification is required to serve as faculty for SAGES hands-on courses (SAGES-HOC). The Lapco-Train-the-Trainers (Lapco-TT) is a course for surgical trainers, in which delegates learn a standardized teaching technique for skills acquisition. The aims of this study were to 1) determine if this curriculum could be delivered in a day course to SAGES-HOC faculty and 2) assess the impact of such training on learners’ educational experience taught by this faculty at a subsequent SAGES-HOC.Methods and proceduresSix experts attended a one-day Lapco-TT course. SAGES-HOC participants were split into two groups: Group A taught by Lapco-TT trained, and Group B by “untrained” course faculty. Opinion surveys were completed by both the SAGES-HOC learners and the Lapco-TT trained course faculty. Furthermore, the latter underwent self-, learner-, and observer-based evaluation using a previously validated teaching assessment tool (cSTTAR). Mean scores were reported and analyzed [Mann–Whitney U, t test (p < 0.05)].ResultsAll 6 Lapco-TT delegates found the course useful (5), and felt that it would influence the way they taught in the OR (4.83), that their course objectives were met (4.83), and that they would recommend the course to their colleagues (4.83). Of the SAGES-HOC participants, compared to Group B (n = 22), Group A learners(n = 10) better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]) and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), and that performance feedback was sufficient (5 vs. 3.9 [p = 0.028]) and effective (5 vs. 3.95 [p = 0.028]). Group A faculty were rated significantly higher by their learners on the cSTTARs than Group B (p < 0.0005). Group A faculty rated themselves significantly lower than both expert observers (p < 0.0005) and compared to the Group B faculty’s self-assessment (p < 0.002).ConclusionsThe Lapco-TT course can be delivered effectively over one day and impacts the educational experience of learners at a SAGES-HOC. This could help establish a standardized method of teaching at SAGES-HOCs and thereby increase their value for learners.

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.

Clinical Predictors of Positive Postoperative Blood Cultures.

Objective: To define clinical features of surgical patients in whom postoperative blood cultures are likely to identify pathogens. Background: Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are routinely used for evaluation of postoperative bacteremia, but are costly and not always diagnostic. Better methods are needed to select patients in whom BCx identify pathogens. Methods: We reviewed records of patients ≥18 years old with BCx drawn ⩽10 days after surgery in 2013 seeking independent predictors of positive cultures by simple and multiple logistic regression models with statistical significance at &agr; = 0.05. Results: Of 1804 BCx, excluding contaminants yielded 1780 cultures among 746 patients for analysis. The yield was low, with only 4% identifying potential pathogens. Positive BCx were most common after cardiac, ear/nose/throat, obstetric, and urologic procedures [odds ratio (OR) =10.3, P < 0.001 vs low-yield procedures: eg, gynecologic, neurosurgical, plastic surgical, podiatric, transplant]. Cultures more often grew pathogens when drawn in association with higher peak temperature (Tmax, P = 0.001) and longer interval from procedure to Tmax (P = 0.001). Antibiotic therapy at time of culture reduced yield (2.9% with vs 5.5% without antibiotics, P = 0.007). Multivariable logistic regression analysis found antibiotics at culture, procedure specialty, Tmax, and postoperative timing of Tmax were associated with blood culture results. Conclusions: Ordering blood cultures based on fever or another single predictor inconsistently identifies pathogens. Our dataset, the largest available, identify clinical predictors in the first 10 postoperative days to guide identification of patients with bacteremia.