Michael M. Awad

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

Objective:To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. Methods:A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. Results:There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

National Survey of Burnout among US General Surgery Residents

BACKGROUND Burnout is a complex syndrome of emotional distress that can disproportionately affect individuals who work in health care professions. STUDY DESIGN For a national survey of burnout in US general surgery residents, we asked all ACGME-accredited general surgery program directors to email their general surgery residents an invitation to complete an anonymous, online survey. Burnout was assessed with the Maslach Burnout Inventory; total scores for Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA) subscales were calculated. Burnout was defined as having a score in the highest tertile for EE or DP or lowest tertile for PA. Chi-square tests and one-way ANOVA were used to test associations between burnout tertiles for each subscale and various resident and training-program characteristics as appropriate. RESULTS From April to December 2014, six hundred and sixty-five residents actively engaged in clinical training had data for analysis; 69% met the criterion for burnout on at least one subscale. Higher burnout on each subscale was reported by residents planning private practice careers compared with academic careers. A greater proportion of women than men reported burnout on EE and PA. Higher burnout on EE and DP was associated with greater work hours per week. Having a structured mentoring program was associated with lower burnout on each subscale. CONCLUSIONS The high rates of burnout among general surgery residents are concerning, given the potential impact of burnout on the quality of patient care. Efforts to identify at-risk populations and to design targeted interventions to mitigate burnout in surgical trainees are warranted.

Early Results from the Flexibility in Surgical Training Research Consortium: Resident and Program Director Attitudes Toward Flexible Rotations in Senior Residency

OBJECTIVE To assess the attitudes of residents and program directors (PDs) involved in flexible training to gauge satisfaction with this training paradigm and elicit limitations. DESIGN Anonymous surveys were sent to residents and PDs in participant programs. Respondents were asked to rate responses on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). SETTING A total of 9 residency programs that are collaborating to prospectively study the effect of flexible tracks on resident performance and outcome. PARTICIPANTS A total of 138 residents who were in clinical years 4 and 5 and 10 PDs. RESULTS Of the 138 possible residents, 100 responded to the resident survey (72.5% response rate). Among resident respondents, 33% were participating in a flexible track option. The most frequently listed specialties of focus were cardiothoracic surgery (19%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%). Participants in flexible tracks tended to strongly agree that their career would be enhanced by flexible rotations; interestingly, of those not in flexible tracks, most tended to also agree that flexible rotations would enhance their future careers. Flexible track participants report receiving greater autonomy on flexible rotations and believe they would be better prepared for fellowship and career. They express overall very high satisfaction with the flexible experience. Limitations expressed by residents (in flexible tracks or not) include uncertainty for how this paradigm serves those interested in comprehensive general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. Overall, 87.5% of PD respondents agreed or strongly agreed that those in flexible tracks have greater opportunities for mentorship in their chosen field. PDs also expressed high levels of satisfaction with flexible rotations. Limitations include concerns that the flexibility option presents scheduling difficulties and does not go far enough in reforming postgraduate education. CONCLUSIONS This survey of 9 residency programs participating in flexible tracks indicates satisfaction with this training option. The role of comprehensive general surgery as a training end point and scheduling difficulties remain as major challenges. Outcomes of graduates in these tracks and control peers are being prospectively evaluated.

A novel, new robotic platform for natural orifice distal pancreatectomy.

Laparoendoscopic technology has revolutionized the practice of surgery; however, surgeons have not widely accepted laparoscopic techniques for pancreatic surgeries due to the complexity of the operation. Natural orifice transluminal endoscopic surgery (NOTES) offers a great new potential for pancreatic procedures, with early data showing benefits of reduced visible scarring and the potential for decreased wound infections, hernias, pain, and postoperative complications. However, there are significant limitations to the currently used flexible endoscopy tools, including a diminished visual field, spatial orientation and tissue manipulation issues, and 2-dimensional visual feedback. We have adopted a novel snake-like robot, the minimally invasive cardiac surgery (MICS) robot, which addresses these issues. In the current pilot study, the MICS robot was evaluated for transrectal distal pancreas exploration and resection in 2 nonsurvival porcine models. Abdominal navigation and accessing the pancreas was investigated in the first pig, and based on its success, pancreas resection was studied in pig 2. The MICS robot was successful in accessing and visualizing the right upper, left upper, and left lower quadrants of the abdomen in pig 1 and was able to perform a successful complex NOTES procedure with distal pancreas resection in pig 2, with only minimal laparoscopic retraction assistance. In conclusion, preliminary results showing the MICS robot in natural orifice distal pancreatectomy are positive. Enhancements to optics and instrumentation will help further increase the usability in pancreatic interventions. Future indications may include transgastric NOTES approaches, endoluminal procedures, and single-port applications.

Physicians-in-training are not prepared to prescribe medical marijuana

BACKGROUND While medical marijuana use is legal in more than half of U.S. states, evidence is limited about the preparation of physicians-in-training to prescribe medical marijuana. We asked whether current medical school and graduate medical educational training prepare physicians to prescribe medical marijuana. METHODS We conducted a national survey of U.S. medical school curriculum deans, a similar survey of residents and fellows at Washington University in St. Louis, and a query of the Association of American Medical Colleges (AAMC) Curriculum Inventory database for keywords associated with medical marijuana. RESULTS Surveys were obtained from 101 curriculum deans, and 258 residents and fellows. 145 schools were included in the curriculum search. The majority of deans (66.7%) reported that their graduates were not at all prepared to prescribe medical marijuana, and 25.0% reported that their graduates were not at all prepared to answer questions about medical marijuana. The vast majority of residents and fellows (89.5%) felt not at all prepared to prescribe medical marijuana, while 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. Finally, only 9% of medical school curriculums document in the AAMC Curriculum Inventory database content on medical marijuana. CONCLUSIONS Our study highlights a fundamental mismatch between the state-level legalization of medical marijuana and the lack of preparation of physicians-in-training to prescribe it. With even more states on the cusp of legalizing medical marijuana, physician training should adapt to encompass this new reality of medical practice.

Outcomes of a proficiency-based skills curriculum at the beginning of the fourth year for senior medical students entering surgery

INTRODUCTION We hypothesized that a proficiency-based curriculum administered early in the fourth year to senior medical students (MS4) would achieve outcomes comparable to a similar program administered during surgical internship. METHODS MS4 (n = 18) entering any surgical specialty enrolled in a proficiency-based skills curriculum at the beginning of the fourth year that included suturing/knot-tying, on-call problems, laparoscopic, and other skills (urinary catheter, sterile prep/drape, IV placement, informed consent, electrosurgical use). Assessment was at 4-12 weeks after training by a modified Objective Structured Assessment of Technical Skills (OSATS). Suturing and knot tying tasks were assessed by time and OSATS technical proficiency (TP) scores (1 [novice], 3 [proficient], 5 [expert]). Outcomes were compared with PGY-1 residents who received similar training at the beginning of internship and assessment 4-12 weeks later. Data are presented as mean values ± standard deviation; statistical significance was assessed by Students t test. RESULTS Fifteen of 18 MS4 (83%) reached proficiency on all 15 tasks, and 2 others were proficient on all but 1 laparoscopic task. Compared with PGY-1s, MS4 were significantly faster for 3 of 5 suturing and tying tasks and total task time (547 ± 63 vs 637 ± 127 s; P < .05). Mean TP scores were similar for both groups (MS4, 3.4 ± 0.5 vs PGY-1, 3.1 ± .57; P = NS). MS4 OSATS scores were higher for IV placement, informed consent, and urinary catheter placement, but lower for prep and drape and for management of on-call problems. CONCLUSION MS4 who participate in a proficiency-based curriculum taught early in the fourth year are able to meet proficiency targets in a high percentage of cases. This approach should better prepare MS4 for surgical internship.

Fundamentals of Laparoscopic Surgery: Not Only for Senior Residents

OBJECTIVE Fundamentals of laparoscopic surgery (FLS) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to teach the physiology, fundamental knowledge, and technical skills required for basic laparoscopic surgery. We hypothesize that residents are doing more laparoscopic surgery earlier in residency, and therefore would benefit from an earlier assessment of basic laparoscopic skills. Here, we examine FLS test results and ACGME case logs to determine whether it is practical to administer FLS earlier in residency. DESIGN FLS test results were reviewed for the 42 residents completing FLS between July 2011 and July 2016. ACGME case logs for current and former residents were reviewed for laparoscopic cases logged by each postgraduate year. Basic and complex laparoscopic cases were determined by ACGME General Surgery Defined Category and Minimums Report. Descriptive statistics were used for analysis. SETTING Academic general surgery residency, Washington University in St. Louis School of Medicine. PARTICIPANTS Current and former general surgery residents. RESULTS A total of 42 residents took and passed FLS between July 2011 and July 2016. All residents successfully passed the FLS knowledge and skills examinations on the first attempt regardless of their postgraduate year (PGY 3n = 13, PGY 4n = 15, and PGY 5n = 14). Total laparoscopic case volume has increased over time. Residents who graduated in 2012 or 2013 completed 229 laparoscopic cases compared to 267 laparoscopic cases for those who graduated from 2014 to 2016 (p = 0.02). Additionally, current residents completed more laparoscopic cases in the first 2 years of residency than residents who graduated from 2012 to 2016 (median current = 38; former = 22; p < 0.001). Examining laparoscopic case numbers for current residents by PGY demonstrated that the number of total and complex laparoscopic cases increased in each of the first 3 years of residency with the largest increase occurring between the PGY 2 and PGY 3 years. In the PGY 4 and PGY 5 years, most laparoscopic cases were complex. CONCLUSION Increased use of laparoscopic surgery has led to a corresponding increase in laparoscopic case volume among general surgery residents. We would advocate for FLS testing to serve as an early assessment of laparoscopic knowledge and skill and should be performed before a significant increase in complex laparoscopic surgery during training.

Analysis of surgical motions in minimally invasive surgery using complexity theory

Traditional Minimally Invasive Surgery (MIS) training paradigm in which interns and junior residents perform operations under the supervision of faculty surgeons lacks objective means of assessing surgical skills. This paper studies novel real–time measures that can dynamically quantify surgical motions. In this study, the proposed measures were tested through two phases of experimental study. In the first phase, ten volunteered subjects who have no prior experience of MIS completed three trials of a surgical exercise using a laparoscopic instrument on which a motion sensor was attached. In the second phase, an MIS surgeon performed three standard surgical exercises with five replications. Then, time–delay and Hurst exponent analysis were used to measure the degree of synchronisation in surgical motions. As the results, improvement in surgical motions was observed such that the range and thickness of time–delay plots are reduced while Hurst exponents increase, as the subjects gain experience.

Ergonomic analysis of laparoscopic and robotic surgical task performance at various experience levels

IntroductionTraditional laparoscopic surgery (TLS) has increasingly been associated with physical muscle strain for the operating surgeon. Robot-assisted laparoscopic surgery (RALS) may offer improved ergonomics. Ergonomics for the surgeon on these two platforms can be compared using surface electromyography (sEMG) to measure muscle activation, and the National Aeronautics and Space Administration Task Load Index (NTLX) survey to assess workload subjectively.MethodsSubjects were recruited and divided into groups according to level of expertise in traditional laparoscopic (TLS) and robot-assisted laparoscopic surgery (RALS): novice, traditional laparoscopic surgeons (TL surgeons), robot-assisted laparoscopic surgeons (RAL surgeons). Each subject performed three fundamentals of laparoscopic surgery (FLS) tasks in randomized order while sEMG data were obtained from bilateral biceps, triceps, deltoid, and trapezius muscles. After completing all tasks, subjects completed the NTLX survey. sEMG data normalized to the maximum voluntary contraction of each muscle (MVC%), and NTLX data were compared with unpaired t tests and considered significant with a p ≤ 0.05.ResultsMuscle activation was higher during TLS compared to RALS in most muscle groups for novices except for the trapezius muscles. Muscle activation scores were also higher for TLS among the groups with more experience, but the differences were less significant. NTLX scores were higher for the TLS platform compared to the RALS platform for novices.DiscussionTLS is associated with higher muscle activation in all muscle groups except for trapezius muscles, suggesting greater strain on the surgeon. Increased trapezius muscle activation on RALS has previously been documented and is likely due to the position of the eye piece. The differences seen in muscle activation diminish with increasing levels of expertise. Experience likely mitigates the ergonomic disadvantage of TLS. NTLX survey data suggest there are subjective benefits to RALS, namely in the perception of temporal demand. Further research to correlate NTLX data and sEMG measurements, and to investigate whether these metrics affect patient outcomes is warranted.

Opioid Medication Use in the Surgical Patient: An Assessment of Prescribing Patterns and Use

BACKGROUND With the epidemic of prescription opioid abuse in the US, rates of opioid-related unintentional deaths have risen dramatically. However, few data exist comparing postoperative opioid prescriptions with patient use. We sought to better elucidate this relationship in surgical patients. STUDY DESIGN A prospective cohort study was conducted of narcotic-naïve patients undergoing open and laparoscopic abdominal procedures on a minimally invasive surgery service. During the first 14 post-discharge days and at their first postoperative clinic visit, patients recorded pain scores and number of opioid pills taken. Clinical data were extracted from the medical record. Descriptive statistics were used in data analysis. RESULTS From 2014 through 2017, one hundred and seventy-six patients completed postoperative pain surveys. Mean age was 60.4 ± 14.9 years and sex was distributed equally. Most patients (69.9%) underwent laparoscopic procedures. Hydrocodone-acetaminophen was the most commonly prescribed postoperative pain medication (118 patients [67.0%]), followed by oxycodone-acetaminophen (26 patients [14.8%]). Patients were prescribed a median of 150 morphine milligram equivalents (MME) (interquartile range [IQR] 150 to 225 MME), equivalent to twenty 5-mg oral oxycodone pills (IQR 20 to 30 pills). However, by their first postoperative visit, they had only taken a median 30 MME (IQR 10 to 90 MME), or 4 pills (IQR 1.3 to 12 pills). Eight (4.5%) patients received a refill or an additional prescription for pain medications. At the first postoperative visit, 76.7% of respondents were satisfied or very satisfied with their overall postoperative pain management. CONCLUSIONS Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion.