Mary K. Kimbrough

Money matters: a resident curriculum for financial management.

BACKGROUND A 2005 survey reported 87% of surgery program directors believed practice management training should occur during residency. However, only 8% of program directors believed residents received adequate training in practice management [1]. In addition to the gap in practice financial management knowledge, we recognized the need for training in personal finance among residents. A literature review and needs assessment led to the development of a novel curriculum for surgery residents combining principles of practice management and personal finance. METHODS An 18-h curriculum was administered over the 2012 academic year to 28 post graduate year 1-5 surgery residents and faculty. A self-assessment survey was given at the onset and conclusion of the curriculum [2]. Pre-tests and post-tests were given to objectively evaluate each twice monthly sessions content. Self-perception of learning, interest, and acquired knowledge were analyzed using the Wilcoxon signed ranks test. RESULTS Initial self-assessment data revealed high interest in practice management and personal finance principles but a deficiency in knowledge of and exposure to these topics. Throughout the curriculum, interest increased. Residents believed their knowledge of these topics increased after completing the curriculum, and objective data revealed various impacts on knowledge. CONCLUSIONS Although surgery residents receive less exposure to these topics than residents in other specialties, their need to know is no less. We developed, implemented, and evaluated a curriculum that bridged this gap in surgery education. After the curriculum, residents reported an increase in interest, knowledge, and responsible behavior relating to personal and practice financial management.

Are Surgical Milestone Assessments Predictive of In-Training Examination Scores?

OBJECTIVES With the recent utilization of Accreditation Council for Graduate Medical Education developmental milestones as part of resident evaluation, we sought to explore whether milestone-based ratings were associated with American Board of Surgery In-Training Examination (ABSITE) scores. METHODS Mid-year milestone ratings were obtained from the Accreditation Council for Graduate Medical Education Accreditation Database System for years 2014, 2015, and 2016 for all postgraduate years 1-5 general surgery residents in our program and paired with ABSITE scores (n = 69) from January of the following year. Linear regression was used to assess predictor importance of milestones on both ABSITE percentage correct scores and ABSITE percentile scores. RESULTS Minimal to small positive correlations were observed between milestones and ABSITE percentile scores (r = 0.09-0.25), while moderately large correlations were observed between milestones and percentage correct scores (r = 0.65-0.76). The Medical Knowledge 1 (MK1) milestone significantly predicted ABSITE percentage correct scores, and explained 60% of the variance (adjusted R2 = 0.603). MK1 also significantly predicted ABSITE percentile scores, although weaker in magnitude, with MK1 explaining 20% of the variance (adjusted R2 = 0.197). Postgraduate year level and other milestones were not influential predictors of ABSITE scores. CONCLUSIONS The mid-year MK1 milestone rating was predictive of ABSITE scores and may serve as a useful marker for Clinical Competency Committees to identify residents who could benefit from additional support to prepare for the ABSITE, although given the small exploratory nature of this study, additional research is still needed.

Defining severe traumatic brain injury readmission rates and reasons in a rural state

Background Readmissions after a traumatic brain injury (TBI) have significant impact on long-term patient outcomes through interruption of rehabilitation. This study examined readmissions in a rural population, hypothesizing that readmitted patients after TBI will be older and have more comorbidities than those not readmitted. Methods Discharge data on all patients 15 years and older who were admitted to an Arkansas-based hospital for TBI were obtained from the Arkansas Hospital Discharge Data System from 2010 to 2014. This data set includes diagnoses (principal discharge diagnosis, up to 3 external cause of injury codes, 18 diagnosis codes using the International Classification of Disease, 9th Edition, Clinical Modifications), age, gender, and inpatient costs. Hospital Cost and Utilization Project Clinical Classification and Chronic Condition Indicator were used to identify chronic disease and body systems affected in principal diagnosis. Results Of the 3114 cases of significant head trauma, more than two-thirds were attributed to fall injuries, with motor vehicle crashes accounting for 20% of the remainder. The mean length of stay was 6.5 days. 691 of these patients were admitted to an Arkansas hospital in the following year, totaling 1368 readmissions. Of the readmissions, 16.4% of patients were admitted for altered mental status, 12.9% with shortness of breath (SOB), and 9.4% with chest pain. Mental disorders (psychosis, dementia, and depression) and organic nervous symptoms (Alzheimer’s disease, encephalopathy, and epilepsy) were the primary source of readmissions. More than one-third of the patients were admitted in the following year for chronic diseases such as heart failure (8.6%), psychosis (5.2%), and cerebral artery occlusion (4.1%). Discussion This study showed that there is a significant rate of readmissions in the year after a diagnosis of TBI. Complications with existing chronic diseases are among the most reported reasons for admission in this time period, demonstrating the effect severe head trauma has on long-term treatment. Level of evidence Level IV, Retrospective epidemiological study.

Morning report decreases length of stay in trauma patients

Background Modern acute care surgery (ACS) programs depend on consistent patient hand-offs to facilitate care, as most programs have transitioned to shift-based coverage. We sought to determine the impact of implementing a morning report (MR) model on patient outcomes in the trauma service of a tertiary care center. Methods The University of Arkansas for Medical Sciences (UAMS) Division of ACS implemented MR in October 2015, which consists of the trauma day team, the emergency general surgery day team, and a combined night float team. This study queried the UAMS Trauma Registry and the Arkansas Clinical Data Repository for all patients meeting the National Trauma Data Bank inclusion criteria from January 1, 2011 to April 30, 2018. Bivariate frequency statistics and generalized linear model were run using STATA V.14.2 Results A total of 11 253 patients (pre-MR, n=6556; post-MR, n=4697) were analyzed in this study. The generalized linear model indicates that implementation of MR resulted in a significant decrease in length of stay (LOS) in trauma patients. Discussion This study describes an approach to improving patient outcomes in a trauma surgery service of a tertiary care center. The data show how an MR session can allow for patients to get out of the hospital faster; however, broader implications of these sessions have yet to be studied. Further work is needed to describe the decisions being made that allow for a decreased LOS, what dynamics exist between the attendings and the residents in these sessions, and if these sessions can show some of the same benefits in other surgical services. Level of evidence Level 4, Care Management.

Severe acute gallstone pancreatitis with diffuse hemorrhagic gastritis

Abstract A 67-year-old male presented with acute pancreatitis secondary to gallstones, also known as acute biliary pancreatitis, and subsequently developed gastric outlet obstruction and was transferred to our hospital. A gastro-jejunal feeding tube was placed and an open cholecystectomy was performed. The patient had a pancreatic drain placed for interval increase in pancreatic necrosis and then nearly exsanguinated from gastroduodenal artery pseudoaneurysm bleed. This was managed by coiling the gastroduodenal artery. The patient underwent a pancreatic necrosectomy with malencot drain placement and developed a post-operative upper gastrointestinal bleeding. An EGD showed diffuse gastritis, but no varices. And 18 days later the patient rebled, with the same diffuse gastritis. After further complications the patient elected to receive palliative care at a hospice facility. We are presenting this unusual case of diffuse, hemorrhagic gastritis after acute necrotizing pancreatitis.

Dilated cardiomyopathy secondary to acute pancreatitis caused by hypertriglyceridemia

Abstract A 30-year-old male presented to an outside facility with acute pancreatitis and triglycerides of 1594. He was transferred to our facility after becoming febrile, hypoxic and in acute renal failure with triglycerides of 4243. CT scan performed showed wall-off pancreatic necrosis. He underwent continuous renal replacement therapy and his acute renal failure resolved. He was treated with broad spectrum antibiotics and discharged. He developed a fever to 101 a week later and was found to have a large infected pancreatic pseudocyst. This was managed with an IR placed drain. This was continued for 6 weeks. He came to the emergency department several weeks later with shortness of breath and 3+ edema to bilateral lower extremities and lower abdomen. TTE performed showed an EF of 15%. He was diuresed 25 L during that stay. His heart failure was medically managed. We present this case of dilated cardiomyopathy secondary to acute pancreatitis.

Use of Mock Oral Examinations in Vascular Surgery Training Programs: A Nationwide Survey

BACKGROUND Mock oral examinations (MOEs) are valuable tools for knowledge assessment and preparation for the surgical certifying examinations. Use of MOE is not standardized. We sought to determine the current use in vascular residencies/fellowships. METHODS Program directors (PD) of all U.S. vascular training programs were sent anonymous online surveys in July of 2015 evaluating importance of MOEs, current use, barriers to implementation, and preparedness of trainees to sit for the certifying board examination (CE). Comparisons were performed between programs that use MOEs and those that do not. RESULTS Fifty-four percent (59/108) of program directors completed the survey. The majority believed MOEs are important for vascular residents and fellows (86% versus 81%); however, only 51% (30/59) use them. The most common reason for using MOE was to provide feedback about readiness for the CE (90%). Of programs not giving MOE, 69% expected their trainees to get oral examinations at national conferences. The most common barriers to implementation/continuation of MOEs were availability of faculty (48%) or time (31%). Irrespective of whether they used MOE or not, 29% believed vascular fellows were better prepared for the CE than vascular residents. CONCLUSIONS MOEs are regarded as a valuable tool to prepare trainees for the CE. However, it is not a commonly adopted practice, due to variables such as institutional/faculty availability. A third of program directors believed that vascular fellows were more prepared to pass the CE than vascular residents which may warrant further investigation into how programs can more rigorously prepare vascular residents for the vascular CEs.

National Landscape of General Surgery Mock Oral Examination Practices: Survey of Residency Program Directors

INTRODUCTION Mock oral examinations (MOEs) are used within surgery residency programs to prepare trainees for the American Board of Surgery (ABS) Certifying Exam (CE), but little work exists to guide programs in terms of best practices for implementing a general surgery MOE program. This study, endorsed by the Association for Program Directors in Surgery (APDS) Research Committee, aimed to better understand the national scope of current practices for general surgery MOEs. METHODS General surgery residency program directors (PDs) were invited via the APDS listserv to complete a 27-item survey about their perceptions of the importance and correlates of MOEs, how their exams are structured, implementation barriers, and recent revisions to their MOE program. RESULTS Of 98 PDs responding to the survey, 94% (n = 92) responded about the characteristics of their formal MOE programs. The majority required upper level resident participation and held the exams 2 to 3 times annually; far fewer involved lower level residents. Most programs structure their MOEs to mimic the CE format with 3 exam rooms (76%), using premade questions (66%), presenting 4 scenarios per room (59%), and using two examiners per room (85%). Most PDs (88%) believed MOEs were very important or essential for surgery trainees, which correlated with their ratings of how important MOEs are to their Clinical Competency Committee for determining resident advancement (r = 0.32, p < 0.002). Common barriers for implementing MOEs were availability of examiners and scenarios. About half indicated making recent or ongoing revisions to improve their MOEs. Many PDs indicated interest in collaborating regionally or nationally on MOE initiatives. CONCLUSIONS MOEs were largely regarded as a highly valuable tool by PDs to prepare trainees for the general surgery CE. The majority of programs in this study provide a testing experience as similar to the CE as possible, although some variability in the structure of MOEs was identified. PDs also reported significant implementation barriers and a desire for more MOE collaboration.