Kyla P. Terhune

Surgical Training, Duty-Hour Restrictions, and Implications for Meeting the Accreditation Council for Graduate Medical Education Core Competencies Views of Surgical Interns Compared With Program Directors

OBJECTIVE To describe the perspectives of surgical interns regarding the implications of the new Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for their training. DESIGN We compared responses of interns and surgery program directors on a survey about the proposed ACGME mandates. SETTING Eleven general surgery residency programs. PARTICIPANTS Two hundred fifteen interns who were administered the survey during the summer of 2011 and a previously surveyed national sample of 134 surgery program directors. MAIN OUTCOME MEASURES Perceptions of the implications of the new duty-hour restrictions on various aspects of surgical training, including the 6 ACGME core competencies of graduate medical education, measured using 3-point scales (increase, no change, or decrease). RESULTS Of 215 eligible surgical interns, 179 (83.3%) completed the survey. Most interns believed that the new duty-hour regulations will decrease continuity with patients (80.3%), time spent operating (67.4%), and coordination of patient care (57.6%), while approximately half believed that the changes will decrease their acquisition of medical knowledge (48.0%), development of surgical skills (52.8%), and overall educational experience (51.1%). Most believed that the changes will improve or will not alter other aspects of training, and 61.5% believed that the new standards will decrease resident fatigue. Surgical interns were significantly less pessimistic than surgery program directors regarding the implications of the new duty-hour restrictions on all aspects of surgical training (P < .05 for all comparisons). CONCLUSIONS Although less pessimistic than program directors, interns beginning their training under the new paradigm of duty-hour restrictions have significant concerns about the effect of these regulations on the quality of their training.

Transition to surgical residency: a multi-institutional study of perceived intern preparedness and the effect of a formal residency preparatory course in the fourth year of medical school.

Purpose To evaluate interns’ perceived preparedness for defined surgical residency responsibilities and to determine whether fourth-year medical school (M4) preparatory courses (“bootcamps”) facilitate transition to internship. Method The authors conducted a multi-institutional, mixed-methods study (June 2009) evaluating interns from 11 U.S. and Canadian surgery residency programs. Interns completed structured surveys and answered open-ended reflective questions about their preparedness for their surgery internship. Analyses include t tests comparing ratings of interns who had and had not participated in formal internship preparation programs. The authors calculated Cohen d for effect size and used grounded theory to identify themes in the interns’ reflections. Results Of 221 eligible interns, 158 (71.5%) participated. Interns self-reported only moderate preparation for most defined care responsibilities in the medical knowledge and patient care domains but, overall, felt well prepared in the professionalism, interpersonal communication, practice-based learning, and systems-based practice domains. Interns who participated in M4 preparatory curricula had higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication skills, and overall preparation, at statistically significant levels (P < .05) with medium effect sizes. Themes identified in interns’ characterizations of their greatest internship challenges included anxiety or lack of preparation related to performance of technical skills or procedures, managing simultaneous demands, being first responders for critically ill patients, clinical management of predictable postoperative conditions, and difficult communications. Conclusions Entering surgical residency, interns report not feeling prepared to fulfill common clinical and professional responsibilities. As M4 curricula may enhance preparation, programs facilitating transition to residency should be developed and evaluated.

The Feasibility of Real-Time Intraoperative Performance Assessment With SIMPL (System for Improving and Measuring Procedural Learning): Early Experience From a Multi-institutional Trial

PURPOSE Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs. METHODS Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail. RESULTS A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures. CONCLUSIONS SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.

Impact of implementation of a pediatric surgery fellowship on general surgery resident operative volume.

OBJECTIVE The purpose of this study was to determine the impact of the initiation of a pediatric surgery fellowship on general surgery resident operative volume at 1 major academic institution. DESIGN Retrospective review of operative records obtained from the Accreditation Council for Graduate Medical Education (ACGME) general surgery resident and pediatric surgery fellow case logs. Data collected included number and type of pediatric index cases per year, number of total pediatric surgery cases per year, and number of total cases logged as primary surgeon to date. SETTING Vanderbilt University School of Medicine Department of Surgery, which has an accredited general surgery program, finishes 7 chief residents per year during the study period, and instituted a new pediatric surgery fellowship in 2007. PARTICIPANTS Case logs submitted by third and fourth year general surgery residents and first and second year pediatric surgery fellows were studied. RESULTS The number of pediatric attending surgeons, relative value units (RVUs), and hospital admissions increased from 2003 to 2011. The median number of pediatric index cases performed by a resident decreased after the onset of fellowship from 34 cases to 23.5 cases per year (p < 0.001). The median number of total cases that residents performed on the pediatric surgery rotation also decreased from 74 to 53 cases per year after onset of the fellowship (p < 0.001). CONCLUSIONS Even with an increase in the number of attending surgeons, RVUs, and admissions, the fellowship resulted in a decrease in general surgery resident index and overall case volume in pediatric surgery. Although operative volume is only 1 measure of surgical educational value, these findings suggest that the addition of surgical fellowships affects the educational experience of general surgery residents. We recommend that residency programs establish goals and calculate any potential impact on general surgery resident case volume before initiating a new surgical fellowship.

Sigmoid-urachal-cutaneous fistula in an adult male.

An infected urachal cyst is an uncommon finding in adults. We report the first case of a sigmoid-urachal-cutaneous fistula that resulted from rupture of an infected urachal cyst in an adult male. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments and bowel anastomosis.

Readiness of US General Surgery Residents for Independent Practice

Objective: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. Background: The American Board of Surgery has designated 132 procedures as being “Core” to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. Methods: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. Results: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at “Practice Ready” or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%–94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy (“Passive Help” or “Supervision Only”) increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence (“Supervision Only”) was 33.3%. Conclusions: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

International medical graduates in general surgery: increasing needs, decreasing numbers.

BACKGROUND The current residency training system in the United States (US) has inherent dependence on the international medical graduate (IMG). This article discusses the physician workforce shortage, especially related to general surgery, and examines the distribution of IMGs in general surgery ranks. STUDY DESIGN We performed a cross-sectional study using the American Medical Association Masterfile database of physicians licensed to practice in at least 1 state and determined the number and location of general surgeons in practice. We then stratified the distribution of these practicing surgeons, both IMGs and non-IMGs, according to rural urban commuting areas into small rural, large rural, or urban areas. RESULTS There were 17,727 general surgeons. IMGs were older (52 +/- 8 years versus 47 +/- 8 years; p < 0.001), more likely to be male (93% versus 82%; p < 0.001), and more likely to be further out of training (46% versus 28% > or =20 years out of training; p < 0.001). There were 2,216 IMGs in urban cores, constituting 15% of general surgeons in these areas. Large rural areas contained 223 IMGs (12% of general surgeons in these cores) and small rural areas contained 163 IMG general surgeons (16% of total general surgeons in these cores). CONCLUSIONS General surgeons are in high demand, and until now have remained inherently dependent on IMGs to reinforce their ranks. Current numbers of IMGs in practice are declining. This decline, coupled with inadequate numbers of trainees in domestic general surgery programs, creates a crisis of urgency.

Physician Shortages and Our Increasing Dependence on the International Medical Graduate: Is There a Mutually Beneficial Solution?

ntil the late 1990s, it was predicted that the nation would xperience a surplus of physicians in the United States. Howver, we have instead encountered the realization that there has ot been a surplus but a deficit. This deficit is not because we ave accurately predicted and averted a crisis, but because the ace of medicine, in unpredictable but typical market fashion, as grown in unexpected ways with an ever-increasing demand. dditionally, the advent of managed care has not brought about he decrease in usage of medical services that was predicted. The basic economic principles of supply and demand seem imple when one harks back to introductory economics. Howver, accurately predicting supply and demand as well as proecting and implementing changes in the market to meet future rends is decidedly much more difficult, especially when both re based on changing dynamics such as population growth, ealth of the population, and increasingly specialized and comlicated medical technology. Such is the case with the discipline f general surgery, and as such, the field is not immune to these rends.

Does intentional support of degree programs in general surgery residency affect research productivity or pursuit of academic surgery

OBJECTIVE Many residents supplement general surgery training with years of dedicated research, and an increasing number at our institution pursue additional degrees. We sought to determine whether it was worth the financial cost for residency programs to support degrees. DESIGN We reviewed graduating chief residents (n = 69) in general surgery at Vanderbilt University from 2001 to 2010 and collected the data including research time and additional degrees obtained. We then compared this information with the following parameters: (1) total papers, (2) first-author papers, (3) Journal Citation Reports impact factors of journals in which papers were published, and (4) first job after residency or fellowship training. SETTING The general surgery resident training program at Vanderbilt University is an academic program, approved to finish training 7 chief residents yearly during the time period studied. PARTICIPANTS Chief residents in general surgery at Vanderbilt who finished their training 2001 through 2010. RESULTS We found that completion of a degree during residency was significantly associated with more total and first-author publications as compared with those by residents with only dedicated research time (p = 0.001 and p = 0.017). Residents completing a degree also produced publications of a higher caliber and level of authorship as determined by an adjusted resident impact factor score as compared with those by residents with laboratory research time only (p = 0.005). Degree completion also was significantly correlated with a first job in academia if compared to those with dedicated research time only (p = 0.046). CONCLUSIONS Our data support the utility of degree completion when economically feasible and use of dedicated research time as an effective way to significantly increase research productivity and retain graduates in academic surgery. Aggregating data from other academic surgery programs would allow us to further determine association of funding of additional degrees as a means to encourage academic productivity and retention.

Can this resident be saved? Identification and early intervention for struggling residents.

Received April 24, 2014; Revised June 17, 2014; Accepted June 18 From the Department of Surgery, Section of General Surgery, Div Gastrointestinal Surgery, University of Michigan Medical School, bor, MI (Minter), Department of Surgery, Division of Breast Oncology, Indiana University School of Medicine, Indianapolis, IN nington), Department of Surgery, Metabolic and Weight Loss D Duke University School of Medicine, Durham, NC (Sudan), Div General Surgery, Vanderbilt University School of Medicine, N TN (Terhune), Department of Surgery, Division of Trauma, U of Texas Medical School, San Antonio, TX (Dent), and Departmen gery, Division of Plastic Surgery, University of Florida College of M Gainseville, FL (Lentz). Correspondence address: Rebecca M Minter, MD, FACS, Depart Surgery, University of Michigan, 1500 East Medical Center D 5343, Taubman Center TC 2210D, Ann Arbor, MI 48109-5343 rminter@umich.edu