Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

OBJECTIVE: The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training. METHODS: 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. RESULTS: Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level. CONCLUSIONS: These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

The PASS Course: Practical Anatomy and Surgical Skills Course as a Pragmatic Primer for Senior Medical Students Pursuing Surgical Residency.

The senior year of undergraduate medical education has been scrutinized for lacking emphasis from educators and value for students. Surgical residency program directors and medical students have reported different sets of perceived weaknesses as surgical trainees enter residency. With this in mind, we developed a novel rotation for senior medical students pursuing surgical residency. The rotation incorporates practical didactics, robust skill and simulation training, and an enriching anatomy experience that entails dissections and operations on embalmed and fresh tissue cadavers. To our knowledge, this is the first reported formal training experience for medical students that involves working with fresh tissue cadavers, which have been described as effective models for live human tissue in the operating room. We describe our multifaceted curriculum in detail, discuss its organization, and elaborate on its potential value. We also provide detailed explanations of the curriculum components so that other surgical educators may consider adopting them.

The surgical management of complicated peptic ulcer disease: An EAST video presentation.

BACKGROUND: Peptic ulcer disease (PUD), once primary a surgical problem, is now medically managed in the majority of patients. The surgical treatment of PUD is now strictly reserved for life-threatening complications. Free perforation, refractory bleeding and gastric outlet obstruction, although rare in the age of medical management of PUD, are several of the indications for surgical intervention. The acute care surgeon caring for patients with PUD should be facile in techniques required for bleeding control, bypass of peptic strictures, and vagotomy with resection and reconstruction. This video procedures and techniques article demonstrates these infrequently encountered, but critical operations. CONTENT VIDEO DESCRIPTION: A combination of anatomic representations and videos of step-by-step instructions on perfused cadavers will demonstrate the key steps in the following critical operations. Graham patch repair of perforated peptic ulcer is demonstrated in both open and laparoscopic fashion. The choice to perform open versus laparoscopic repair is based on individual surgeon comfort. Oversewing of a bleeding duodenal ulcer via duodenotomy and ligation of the gastroduodenal artery is infrequent in the age of advanced endoscopy and interventional radiology techniques, yet this once familiar procedure can be lifesaving. Repair of giant duodenal or gastric ulcers can present a challenging operative dilemma on how to best repair or exclude the defect. Vagotomy and antrectomy, perhaps the least common of all the aforementioned surgical interventions, may require more complex reconstruction than other techniques making it challenging for inexperienced surgeons. A brief demonstration on reconstruction options will be shown, and it includes Roux-en-Y gastrojejunostomy. CONCLUSION: Surgical management of PUD is reserved today for life-threatening complications for which the acute care surgeon must be prepared. This presentation provides demonstration of key surgical principles in management of bleeding and free perforation, as well as gastric resection, vagotomy and reconstruction. LEVEL OF EVIDENCE: Video procedure and technique, not applicable.

Sex Disparities in the Presentation of Gallbladder Disease.

INTRODUCTION: Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients. METHODS: All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted. RESULTS: Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient. CONCLUSION: These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.

Mastering the Match: Recruiting a Successful Surgery Resident.

PURPOSE OF REVIEW: The objective of general surgery residency is to produce competent surgeons. At a minimum this requires being procedurally and clinically capable and able to pass the board exams. Recruitment is designed to select those residents who can successfully do so. But there is more to being a successful resident than that. In this review, we attempt to define a "successful resident" and how to attract them to your program. RECENT FINDINGS: Resident applicants are still most concerned with matching to a program that will prepare them for a surgery career. Though there is variation of importance for different applicants, resident life, comradery, and relationships with faculty or mentors do factor into residency ranking. The program website remains the most utilized resource for applicants. However, social media (SM) has an increasing role in applicants' evaluation of a program. SM and the preinterview gathering seem to expose the subjective aspects of a program most effectively. Additional assessments evaluating personality, grit or career goals may assist in screening applicants for good "fit." SUMMARY: In order to recruit successful residents, it is necessary to determine which applicant attributes are important to the program. Additionally, a program must maintain an updated website with clearly delineated resident expectations and program strengths. The screening and interview process must be maximized to target residents with career goals complimentary to available program opportunities. If SM is utilized, post should be frequent with relevant information pertaining to both resident life and educational or clinical opportunities.

Lacking Advanced Degrees are not a Barrier to Entry into Academic Surgery Leadership.

BACKGROUND: Undergraduate and graduate medical education offerings continue to create opportunities for medical students to pursue MD+ degree education. These educational endeavors provide formal education in fields related to surgery, which gives trainees and surgeons diverse perspectives on surgical care. This study sought to assess current prevalence of additional advanced degrees among leaders in academic surgery to assess the relationship between dual degree attainment and holding various leadership positions within surgical departments. METHODS: The Association for Program Directors in Surgery database was used to identify academic surgical programs, which comprised our study population. Each department of surgery website in the APDS database was interrogated for departmental leaders and their reported academic degrees. RESULTS: Among 3223 identified surgeon leaders, 14.6% (470/3223) were found to possess MD+ degrees. Most common degrees possessed included MBA, MPH, and PhD. In comparing different types of surgeon leaders such as chairs, program directors, and division chiefs, no group was found to have a significantly higher prevalence of MD+ degrees than others. CONCLUSION: Prevalence of MD+ degrees among current academic surgery leaders is low, and the lack of an advanced degree should not be considered a barrier to entry into leadership positions. We hypothesize that these findings are likely to evolve as larger proportions of trainees obtain MD+ degrees during medical school and academic development time throughout residency.

Rural Surgical Training in the United States: Delineating Essential Components Within Existing Programs.

BACKGROUND: Rural access to surgical care has reached crisis level. Practicing in rural America offers unique challenges with limited resources and specialists. Most training programs do not provide enough exposure to the endoscopic or the surgical subspecialty skills to prepare a resident for an isolated rural environment. As awareness has increased, many programs have modified curriculum to address this need. The Advisory Council on Rural Surgery (ACRS) of the American College of Surgeons set out to delineate important components of rural training programs and measure to what degree the existing heterogeneous programs contain these components. STUDY DESIGN: The ACRS identified 4 essential components of rural surgical training based on literature and expert opinion. These components included rotations in a rural setting, broad exposure to surgical specialties, endoscopy experience, and lack of competing specialty learners. A list of Accreditation Council for Graduate Medical Education programs from a prior publication was updated with the 2019 Fellowship and Residency Electronic Interactive Database self-identified "rural track" programs, reviewed, and categorized. RESULTS: We identified 39 programs that self-identified as having a rural emphasis. Depending on the extent of which 4 essential components were included, programs were categorized as either "Broad" (12 programs), "Basic" (20 programs), or "Indeterminate" (7 programs). CONCLUSION: The ACRS described the optimal components of a rural surgical training program and identified which components are present in those surgical residencies which self-identified as having a rural focus. This information is valuable to students planning a future in rural surgery and benefits programs hoping to enhance their curriculum to meet this critical need.

Optimal Resources for Rural Surgery.

BACKGROUND: Timely access to emergency general surgery services, including trauma, is a critical aspect of patient care. This study looks to identify resource availability at small rural hospitals in order to improve the quality of surgical care. METHODS: Forty-five nonteaching hospitals in West Virginia were divided into large community hospitals with multiple specialties (LCHs), small community hospitals with fewer specialties (SCHs), and critical access hospitals (CAHs). A 58-question survey on optimal resources for surgery was completed by 1 representative surgeon at each hospital. There were 8 LCHs, 18 SCHs, and 19 CAHs with survey response rates of 100%, 83%, and 89%, respectively. RESULTS: One hundred percent of hospitals surveyed had respiratory therapy and ventilator support, computerized tomography (CT) scanner and ultrasound, certified operating rooms, lab support, packed red blood cells (PRBC), and FFP accessible 24/7. Availability of cryoprecipitate, platelets, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) decreased from LCHs to CAHs. The majority had board-certified general surgeons; however, only 86% LCHs, 53% SCHs, and 50% CAHs had advanced trauma life support (ATLS) certification. One hundred percent of LCHs had operating room (OR) crew on call within 30 minutes, emergency cardiovascular equipment, critical care nursing, on-site pathologist, and biologic/synthetic mesh, whereas fewer SCHs and CAHs had these resources. One hundred percent of LCHs and SCHs had anesthesia availability 24/7 compared to 78% of CAHs. DISCUSSION: Improving access to the aforementioned resources is of utmost importance to patient outcomes. This will enhance rural surgical care and decrease emergency surgical transfers. Further education and research are necessary to support and improve rural trauma systems.

A review of general surgery resident experience in common bile duct exploration in the ERCP era.

BACKGROUND: Use of minimally invasive techniques for management of common bile duct (CBD) stones has led to declining number of CBD explorations (CBDE) performed at teaching and non-teaching institutions. We evaluate the impact of this decline on surgery training in bile duct procedures. STUDY DESIGN: National operative data for general surgery residents (GSR) were examined from 2000 to 2018. Biliary operations including, cholecystectomy open and laparoscopic, and CBDE open and laparoscopic were evaluated for mean number of cases per graduating GSR. RESULTS: Despite increases in number of GSR, case numbers for laparoscopic cholecystectomy increased 39% from 84 to 117, p < .00001, per GSR. Mean number of cases for open CBDE, however, decreased 74% from 2.7 to 0.7, p < .00001, per GSR and laparoscopic CBDE declined 22% from 0.9 to 0.7 per resident. CONCLUSION: GSR operative case volume in CBDE has declined significantly creating a training deficiency for this complex skill. Novel simulation, including fresh cadavers, may offer the best option with high-fidelity, dynamic training to mitigate the loss of low volume, high acuity procedures.

Enhancing the Educational Value and Faculty Attendance of a Morbidity and Mortality Conference.

OBJECTIVE: There exists significant variation in the approach to and execution of morbidity and mortality conference (M&MC). Faculty attendance remains a working challenge. We sought to change our department's M&MC and hypothesized improved educational value and attendance. DESIGN: Complications were submitted in Clavien-Dindo format. A designated M&MC moderator facilitated discussion. A teaching point (TP) was assigned to each complication intended to be the focus of discussion. Presentations followed a structured 6-slide PowerPoint template. A web-based tool using Google Forms was developed and distributed as an "App" for tracking of attendance. An anonymous online survey was distributed to participants to elucidate perception of M&MC following the intervention. SETTING: Academic medical center. PARTICIPANTS: Postgraduate year-1 to 5 surgery residents and faculty at West Virginia University, Morgantown. RESULTS: Forty-eight of sixty-three surveys were returned (response rate 76%). Twenty-five faculty (70%) and 23 residents (82%) responded. A predetermined TP was viewed as the most favorable change made by both faculty and residents. 65% of faculty and residents acknowledged improved educational value, 58% found a single moderator to help streamline Morbidity and Mortality (M&M) presentations and 71% felt that a standard PowerPoint template improved quality of presentations. Both residents (96%) and faculty (68%) believed a predetermined TP improved the educational value of the conference and medical knowledge during preparation. More residents (43%) than faculty (16%) believed that changes to the department's M&MC format allowed better identification of quality improvement issues. Furthermore, the majority of residents (83%) believed that changes to the department's M&M format allowed better identification of system factors compared to faculty (32%), p = 0.003. Faculty participation increased from 60% to 80% after changes (p = 0.03). CONCLUSIONS: The educational value of M&MC and attendance can be improved with simple changes, but faculty and residents may have different expectations and perceptions.

Initial report on the impact of a perfused fresh cadaver training program in general surgery resident trauma education.

BACKGROUND: Operative trauma volume for general surgery residents (GSR) continues to decline. This pilot study examines the impact of utilizing perfused cadavers in trauma surgical skills training for GSR. METHODS: GSR (post graduate year (PGY) 1 through 4) participated in trauma surgical skills training utilizing perfused cadavers. GSR completed surveys assessing confidence in their ability to perform critical procedures before and after training. RESULTS: Sixteen GSR participated in trauma skills training. All PGY 1-2, reported increases in confidence in skills. PGY 4 GSR reported significant increase in confidence in most skills sets including surgical airway, resuscitative thoracotomy/cardiac injury, and abdominal vascular injury. The majority of GSR retained confidence in these skills at 6 months. CONCLUSIONS: Integration of perfused cadavers into GSR curriculum provides high fidelity and dynamic model for training trauma surgical skills. Studies are needed for development and validation of this training and assessment method.

Gender Disparities in the Presentation of Gallbladder Disease.

Although gallbladder disease (GBD) is more common in females, we have noticed a trend toward more complicated cases in male patients. We reviewed all cholecystectomies performed at our institution over the last five years. After eliminating cases with confounding variables, we identified 1529 records. Charts were reviewed for age, gender, BMI, procedure performed, operative time, length of stay, and preoperative diagnosis. Descriptive and inferential statistical analyses were conducted along with linear regression. There were 1444 laparoscopic, 64 laparoscopic converted to open, and 21 primary open cases. Patients were 1008 (66%) females and 521 (34%) males. Average operative time was 89.8 minutes. Cholecystectomy averaged 17.7 minutes longer in males (P = 0.0046). Two per cent of female patients and 7.9 per cent male patient converted to open. Males were more likely to have complicated GBD, whereas women had uncomplicated disease. Average age was 51.9 years for males versus 42.7 years for females. Age, gender, BMI, length of stay, and preoperative diagnosis were all independently significant in predicting operative time. In our study, women presented with uncomplicated GBD, whereas men presented with complicated GBD. This suggests that male patients present at a later stage of disease.

Laparoscopic Removal of Angelchik Prosthesis Followed by Interval Sleeve Gastrectomy.

INTRODUCTION: The Angelchik prosthesis (AP) is a historic antireflux device which consists of a C-shaped silicone ring placed around the gastroesophageal junction (GEJ) and secured by Dacron tape. We present a rare experience with an AP and its impact on bariatric surgical outcomes. CASE: Our patient is a 66-year-old woman who had an open antireflux procedure with an AP in 1987. She presented to a bariatric clinic for consideration of bariatric surgery for the treatment of morbid obesity and associated comorbidities. She also reported significant problems with reflux and dysphagia. After an appropriate work-up, an AP was identified at her GEJ. She was taken to the operating room for laparoscopic removal with planned interval laparoscopic sleeve gastrectomy. Intraoperatively, the AP was identified around the GEJ; after extensive adhesiolysis, the prosthesis was removed. Postoperatively, in order to determine if the AP had caused any lasting esophageal motility problems, the patient underwent a high-resolution esophageal manometry which demonstrated normal esophageal motility. Interval laparoscopic sleeve gastrectomy was performed safely 9 weeks later. CONCLUSION: Although rarely used, it is still possible to encounter an Angelchik prosthesis in practice. General and bariatric surgeons need to be aware of this rare device and understand how to manage its related complications.

Reap What You Sow: Which Rural Surgery Training Programs Currently Exist and Do Medical Students Know of Their Existence?

BACKGROUND: There exists an acute need to recruit and train general surgeons for rural communities. To assist medical students interested in rural surgery, the American College of Surgeons (ACS) website lists general surgery residencies, which are tailored to train the rural surgeon by providing exposure to endoscopy, gynecology, urology, orthopedics, and otolaryngology. Another available reference is the American Medical Association Fellowship and Residency Electronic Database (FREIDA). FREIDA allows programs to indicate availability of a rural training scheme. This is an effort to identify programs which demonstrate a commitment to training rural surgeons and evaluate accessibility of this information to medical students. METHODS: Each ACGME general surgery residency program in the United States and Canada received an electronic survey. They were queried on commitment to training rural surgeons and their ability to provide 3 to 12 months of subspecialty training. RESULTS: Of the 261 programs surveyed, 52 (19.9%) responses were obtained; 11 had established rural tracks and 15 were willing to customize a program. We identified 14 additional rural training programs not identified by either the ACS website or FREIDA. In total, 44 programs identified by ACS, FREIDA, and our survey indicate they can accommodate the rural surgical resident. CONCLUSIONS: For a medical student interested in rural surgery, several obstacles must be overcome to find the appropriate residency program. A complete and updated list of established tracks or customizable training schemes does not exist. Review of the ACS website and FREIDA online in addition to our survey has identified 44 of 261 (16.9%) ACGME accredited programs either with an existing rural surgical track or willing to customize their program accommodate a resident. To facilitate the recruitment of medical students into rural surgery, we support the maintenance of a complete and routinely updated list that identifies available training programs.

Assessing the 16 hour intern shift limit: Results of a multi-center, mixed-methods study of residents and faculty in general surgery.

BACKGROUND: The study explores how residents and faculty assess the ACGME's 16-h limit on intern shifts. METHODS: Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes. RESULTS: Few view the intern shift limit as a positive change. Views differ (P < 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected. CONCLUSIONS: The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty.

The promise and problems of non-physician practitioners in general surgery education: Results of a multi-center, mixed-methods study of faculty.

BACKGROUND: Nurse Practitioners and Physician Assistants - called non-physician practitioners or NPPs - are common, but little is known about their educational promise and problems. METHODS: General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. RESULTS: NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. CONCLUSIONS: NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes.