Thomas H. Hartranft

Factors Associated With General Surgery Residents’ Desire to Leave Residency Programs: A Multi-institutional Study

IMPORTANCE General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition. OBJECTIVE To determine how often categorical general surgery residents seriously consider leaving residency. DESIGN, SETTING, AND PARTICIPANTS At 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not. MAIN OUTCOMES AND MEASURES Factors associated with the desire to leave residency. RESULTS The survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the presence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, P = .04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; P = .03). CONCLUSIONS AND RELEVANCE A majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.

Using United States Medical Licensing Examination® (USMLE) Examination Results to Predict Later In-Training Examination Performance Among General Surgery Residents

OBJECTIVE To examine the relationship between and predictive nature of United States Medical Licensing Examination(®) (USMLE) Step 1, Step 2, and American Board of Surgery In-Training Examination (ABSITE) postgraduate year (PGY) 1-5 scores from 2 general surgery programs from 1999-2009, with a goal of discerning how Step 1 and Step 2 scores should be used in resident selection and screening. DESIGN A descriptive, retrospective, correlational study was conducted using data from existing program records. SETTING Two accredited Midwestern community teaching hospital general surgery residency programs. PARTICIPANTS Data were collected from the records of N = 34 residents completing the programs in the years 1999-2009. RESULTS Although a statistically significant correlation exists between USMLE Step 1 and ABSITE PGY 3 scores, Step 2 scores were more highly correlated to ABSITE scores from all years of residency training. In both hierarchical and simple regression models, Step 2 scores were superior in predicting ABSITE PGY 1-5 scores, with the strongest predictability for PGY 3 and PGY 5 scores. CONCLUSIONS USMLE Step 1 scores showed limited utility in predicting later ABSITE scores whereas Step 2 scores were more predictive of all years of ABSITE scores. These findings should prompt additional research into the relationship between examination performances at different points along the general surgery education continuum. In the mean time, general surgery program directors and faculty might do well to examine the relationships between Step 1 and Step 2 scores and ABSITE scores in their own programs to evaluate the usefulness of considering either score when ranking potential residents for selection into a program.

Nonsurgical removal of a rectal foreign body using a vacuum extractor

PURPOSE: Rectal foreign bodies can be extracted by non-surgical methods. However, glass objects require technical considerations to minimize morbidity and may necessitate surgical extraction. We describe a technique that allowed safe transanal extraction of a glass foreign body and avoided laparotomy. METHODS: A patient with a history of a previous rectal foreign body that required laparotomy presented with another incarcerated rectal foreign body. After attempts at manual extraction failed, spinal anesthesia was induced, and an obstetric vacuum extractor was used to transanally withdraw the glass foreign body. RESULTS: The glass foreign body was withdrawn uneventfully using the vacuum extractor. Laparotomy was avoided. The patient was hospitalized for observation and discharged 24 hours later. CONCLUSIONS: Use of the delivery vacuum extractor provided a safe, cost-effective method of glass foreign body removal by the transanal route. Literature review found no other reports of rectal foreign body removal by this method.

Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance

IMPORTANCE Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations. OBJECTIVES To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide. MAIN OUTCOMES AND MEASURES Scores from the 2014 ABSITE. RESULTS A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance. CONCLUSIONS AND RELEVANCE Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition

Importance Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear. Objectives To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate. Design, Setting, and Participants This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses. Main Outcomes and Measures Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared. Results The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: “I feel that it is my responsibility as a program director to redirect residents who should not be surgeons.” Conclusions and Relevance The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies

Purpose Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. Method Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. Results A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. Conclusions Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Right Vertebral Artery Stenosis with Left Hemispheric TIA: A PerplexingEtiology

A 59-year-old female presented with symptoms concerning for left hemispheric transient ischemic attacks. Multiple imaging modalities confirmed the presence of acute left sided cerebral infarcts along with complete left internal carotid artery occlusion. Following discharge on appropriate medical therapy, the patient represented weeks later with similar complaints. Angiography confirmed left internal carotid artery occlusion and identified a right vertebral artery supplying the entire contralateral hemisphere. A segment of severe stenosis at the vertebral artery origin was identified and stented. Post-operatively, the patient recovered well and was discharged home without significant neurological deficits. During follow-up, in-stent restenosis developed at 7 months requiring additional intervention with balloon angioplasty and re-stenting. To date the patient suffers no significant neurologic deficits, is maintained on maximal medical therapy, and continues follow up with serial exams and ultrasound imaging.

New Trends In The Treatment Of Calculus Disease Of The Biliary Tract

Background: New treatment methods for calculus disease of the biliary tract offer options that can benefit a variety of patients. Laparoscopic surgery, for example, has revolutionized biliary surgery and is now the preferred approach for the majority of patients. Methods: Using the key words “biliary tract,” “calculus disease,” and “cholecystectomy,” MEDLINE files were searched from 1982 to the present. Articles dating before 1982 were accessed from the reference lists of the more recent articles. Results and Conclusions: This review describes the various procedures that could be effective options for patients with biliary stone disease, including an algorithm showing a proposed scheme for evaluating and treating this disease. Cholecystectomy — either laparoscopic or open — will likely remain the treatment of choice for most patients. The newer options, however, for treatment of both acute and chronic cholecystitis have proved effective in select cases.