EHR-Driven Delivery of EPA Assessments Significantly Improves Participation.

INTRODUCTION: Digital education tools are a cornerstone in the evolution to CBME through EPAs. Successful implementation requires understanding the variable impacts of EHR-driven delivery of EPAs, flexible digital device access to EPAs, and user-behavior trends. METHODS: Through a HIPAA compliant, flexible-device accessible, surgical education platform, general surgery training programs at 21 institutions collected EPA from July 2023 to April 2024. At 5 EHR-integrated institutions (EHR+), EPA were created for clinical activities based on the OR schedule, automatically pushed to attendings and residents with built in completion reminders. At 16 institutions without EHR integration (EHR-), EPA were initiated manually. To improve user experience, care phases were bundled (cEPA). We compared the EHR+ and EHR- groups, computing descriptive statistics on the cEPAs completed and user behavior metrics. RESULTS: We collected 4187 cEPAs in total, with 82% at EHR+ institutions and 18% at EHR- institutions. Platform triggering dramatically drove cEPA completion for both faculty and residents, 88% and 81%, respectively. Only 3% were initiated by the faculty or resident. Faculty at EHR+ institutions strongly preferred the automated OR-triggered workflow to start their EPAs (Chi-squared test, p ≈ 0). Faculty completed all 3 care phases nearly 80% of the time. Time reminders specifically drive EPA completion for residents and faculty on weekdays and build habits on weekends. 71% of cEPAs completed were by computer, and 29% by phone. More comments were provided when computers were used. Residents reviewed feedback with a median lag of 1 hour and 29 min after results were available. CONCLUSIONS: EHR-driven delivery of EPA leads to a 4.6-fold increase in EPAs completed. EPA initiation is the most critical phase in the workflow and EHR-data driven alerts drive this action. These alerts are also effective drivers of habit formation. Flexible device access is important to increase EPAs completed and improve the usefulness through comments for residents.

Finding Comfort in Discomfort Reflecting on Stories Told.

INTRODUCTION: The 2022 Presidential Address for the Association for Academic Surgery was focused on better understanding the personal and professional challenges faced by surgeons during the COVID-19 pandemic. METHODS: As part of this work, we embarked on a listening tour, inviting surgeons from all over the country to tell us their stories. This led to forming a panel of five selected participants based on how their stories crosscut many of the most prevalent themes during those conversations. Here, we present thematic excerpts of the 2022 presidential panel, intending to capture that moment and challenge surgeons to contribute to an ever-evolving movement that pushes us to unpack some of our greatest areas of discomfort. RESULTS: We found that, in many ways, the COVID-19 pandemic brought into focus what many surgeons from marginalized groups have historically struggled with. Dominant themes from these conversations included the role of surgery in informing identity, the tensions between personal and professional identity, the consequences of maintaining medicine as an apolitical space, and reflections on initiatives to address inequities. Panelists also reflected on the hope that these conversations are part of a movement that leads to sustained change rather than a passing moment. CONCLUSIONS: The primary goal of this work was to center voices and experiences in a way that challenges us to become comfortable with topics that often cause discomfort, validate experiences, and foster a community that allows us to rethink what and whom we value in surgery. We hope this work serves as a guide to having these conversations in other institutions.

Pulmonary Vascular Complication Associated With Coronavirus Infection and Role of Lung Resection.

Pulmonary artery pseudoaneurysms are an uncommon diagnosis and have been minimally described in the coronavirus (COVID-19) literature. In our case, a 31-year-old man presented with severe acute hypoxic respiratory failure, stress cardiomyopathy, and combined septic and cardiogenic shock secondary to COVID-19 pneumonia and Streptococcus anginosus bacteremia. The patient had perfusing granulomas eroding into the pulmonary vasculature, causing impending hemothorax. Thoracic surgical procedures for infectious pulmonary artery pseudoaneurysms or perfusing granulomas in patients who have had COVID-19 should be performed selectively and with thoughtful perioperative planning to prevent the life-threatening complications of rupture and bleeding.

Overcoming Systems Factors in Case Logging with Artificial Intelligence Tools.

INTRODUCTION: Case logs are foundational data in surgical education, yet cases are consistently under-reported. Logging behavior is driven by multiple human and systems factors, including time constraints, ease of case data retrieval, access to data-entry tools, and procedural code decision tools. METHODS: We examined case logging trends at three mid-sized, general surgery training programs from September 2016-October 2020, January 2019-October 2020 and May 2019-October 2020, respectively. Across the programs we compared the number of cases logged per week when residents logged directly to ACGME versus via a resident education platform with machine learning-based case logging assistance tools. We examined case logging patterns across 4 consecutive phases: baseline default ACGME logging prior to platform access (P0 "Manual"), full platform logging assistance (P1 "Assisted"), partial platform assistance requiring manual data entry without data integrations (P2 "Notebook"), and resumed fully integrated platform with logging assistance (P3 "Resumed"). RESULTS: 31,385 cases were logged utilizing the platform since 2016 by 171 residents across the 3 programs.Intelligent case logging assistance significantly increased case logging rates, from 1.44 ± 1.48 cases by manual entry in P0 to 4.77 ± 2.45 cases per resident per week via the platform in P1 (p-value < 0.00001). Despite the burden of manual data entry when the platform's data connectivity was paused, the tool helped to increase overall case logging into ACGME to 2.85 ± 2.37 cases per week (p-value = 0.0002). Upon resuming the data connectivity, case logging levels rose to 4.54 ± 3.33 cases per week via the platform, equivalent to P1 levels (insignificant difference, p-value = 0.57). CONCLUSIONS: Mapping the influence of systems and human factors in high-quality case logs allows us to target interventions to continually improve the training of surgical residents. System level factors such as access to alternate automation-drive tools and operative schedule integrated platforms to assist in ACGME case log has a significant impact on the number of cases captured in logs.

The Attending Meritocracy: Implementation of a Novel Team-Based Approach to Provide Effective Resident Feedback.

OBJECTIVE: Providing timely quality feedback is an essential responsibility of teaching faculty and is critical for resident assessment and development throughout training. Numerous evaluation platforms have been created to provide immediate and big picture end-of-rotation feedback. Faculty suffer burnout from electronic documentation demands and workload and as a result, evaluation activity is relegated to a lower priority leading to poor compliance. We implemented a novel team-based Attending Meritocracy (AM)1 program that encompasses monetary, automated reminder, and punitive components, while adding a competition element to further engage faculty. The aim of this study is to determine effectiveness of AM in increasing compliance with resident feedback. DESIGN, SETTING AND PARTICIPANTS: Surgical faculty (n = 36) were divided into 5 teams according to service and subspecialty. Points could be earned by completing surgical (Firefly, MiniCEX) or rotation (New Innovations) evaluations, leaving comments, and other educational tasks. A prize for the highest scoring team was identified as a dinner financed by the non-winning teams. Data from evaluation platforms was extracted. Continuous variables were compared using Mann-Whitney-U test, and categorical variables using chi-squared test. RESULTS: When comparing July 2019 to February 2020 (control period) with July 2020 to February 2021(initial implementation period), we found a 237% increase in submitted NI evaluations (n = 111-374) and a 42.5% decrease in median time to completion from 60.4 (33.2-106.9) days to 34.7 (24.0-64.5) days, (p = 0.001).2 We observed an increase in operative evaluations completed (Mini CEX n = 4-97, Firefly n = 150-1284). CONCLUSIONS: Implementation of a team-based attending meritocracy program is an effective budget neutral method to increase completion of resident evaluations. Further investigation is needed to assess improvement in quality of feedback as well as to explore it's impact on progression of resident autonomy.

Use of a Secure Web-Based Data Management Platform to Track Resident Operative Performance and Program Educational Quality Over Time.

OBJECTIVE: In surgery residency programs, Accreditation Council for Graduate Medical Education mandated performance assessment can include assessment in the operating room to demonstrate that necessary quality and autonomy goals are achieved by the conclusion of training. For the past 3 years, our institution has used The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) instrument to assess and track operative skills. Evaluation is accomplished in near real-time using a secure web-based platform for data management and analytics (Firefly). Simultaneous to access of the platform's case logging function, the O-SCORE instrument is delivered to faculty members for rapid completion, facilitating quality, and timeliness of feedback. We sought to demonstrate the platform's utility in detecting operative performance changes over time in response to focused educational interventions based on stored case log and O-SCORE data. DESIGN: Stored resident performance assessments for the most frequently performed laparoscopic procedures (cholecystectomy, appendectomy, inguinal hernia repair, ventral hernia repair) were examined for 3 successive academic years (2016-2019). During this time, 4 of 36 residents had received program-assigned supplemental simulation training to improve laparoscopic skills. O-SCORE data for these residents were extracted from peer data, which were used for comparisons. Assigned training consisted of a range of videoscopic and virtual reality skills drills with performance objectives. O-SCORE responses were converted to integers and autonomy scores for items pertaining to technical skill were compared before and after educational interventions (Student's t-tests). These scores were also compared to aggregate scores in the nonintervention group. Bayesian-modeled learning curves were used to characterize patterns of improvement over time. SETTING: University of Massachusetts Medical School-Baystate Surgery Residency and Baystate Medical Center PARTICIPANTS: General surgery residents (n = 36) RESULTS: During the period of review, 3325 resident cases were identified meeting the case type criteria. As expected, overall autonomy increased with the number of cases performed. The 4 residents who had been assigned supplemental training (6-18 months) had preintervention score averages that were lower than that of the nonintervention group (2.25 ± 0.43 vs 3.57 ± 1.02; p < 0.0001). During the respective intervention periods, all 4 residents improved autonomy scores (increase to 3.40 ± 0.61; p < 0.0001). Similar improvements were observed for tissue handling, instrument handling, bimanual dexterity, visuospatial skill, and operative efficiency component skills. Postintervention scores were not significantly different compared to scores for the non-intervention group. Bayesian-modeled learning curves showed a similar pattern of postintervention performance improvement. CONCLUSIONS: The data management platform proved to be an effective tool to track responses to supplemental training that was deemed necessary to close defined skills gaps in laparoscopic surgery. This could be seen both in individual and in aggregated data. We were gratified that at the conclusion of the supplemental training, O-SCORE results for the intervention group were not different than those seen in the non-intervention group.

Education Management Platform Enables Delivery and Comparison of Multiple Evaluation Types.

OBJECTIVE: The purpose of this study was to determine whether an automated platform for evaluation selection and delivery would increase participation from surgical teaching faculty in submitting resident operative performance evaluations. DESIGN: We built a HIPAA-compliant, web-based platform to track resident operative assignments and to link embedded evaluation instruments to procedure type. The platform matched appropriate evaluations to surgeons' scheduled procedures, and delivered multiple evaluation types, including Ottawa Surgical Competency Operating Room Evaluation (O-Score) evaluations and Operative Performance Rating System (OPRS) evaluations. Prompts to complete evaluations were made through a system of automatic electronic notifications. We compared the time spent in the platform to achieve evaluation completion. As a metric for the platform's effect on faculty participation, we considered a task that would typically be infeasible without workflow optimization: the evaluator could choose to complete multiple, complementary evaluations for the same resident in the same case. For those cases with multiple evaluations, correlation was analyzed by Spearman rank test. Evaluation data were compared between PGY levels using repeated measures ANOVA. SETTING: The study took place at 4 general surgery residency programs: The University of Massachusetts Medical School-Baystate, the University of Connecticut School or Medicine, the University of Iowa Carver College of Medicine, and Maimonides Medical Center. PARTICIPANTS: From March 2017 to February 2019, the study included 70 surgical teaching faculty and 101 general surgery residents. RESULTS: Faculty completed 1230 O-Score evaluations and 106 OPRS evaluations. Evaluations were completed quickly, with a median time of 36 ± 18 seconds for O-Score evaluations, and 53 ± 51 seconds for OPRS evaluations. 89% of O-Score and 55% of OPRS evaluations were completed without optional comments within one minute, and 99% of O-Score and 82% of OPRS evaluations were completed within 2 minutes. For cases eligible for both evaluation types, attendings completed both evaluations on 74 of 221 (33%) of these cases. These paired evaluations strongly correlated on resident performance (Spearman coefficient = 0.84, p < 0.00001). Both evaluation types stratified operative skill level by program year (p < 0.00001). CONCLUSIONS: Evaluation initiatives can be hampered by the challenge of making multiple surgical evaluation instruments available when needed for appropriate clinical situations, including specific case types. As a test of the optimized evaluation workflow, and to lay the groundwork for future data-driven design of evaluations, we tested the impact of simultaneously delivering 2 evaluation instruments via a secure web-based education platform. We measured the evaluation completion rates of faculty surgeon evaluators when rating resident operative performance, and how effectively the results of evaluation could be analyzed and compared, taking advantage of a highly integrated management of the evaluative information.

Novel Educational Information Management Platform Improves the Surgical Skill Evaluation Process of Surgical Residents.

OBJECTIVE: We sought to increase compliance and timeliness of surgery resident operative evaluation, by providing faculty and residents with a Platform-linking evaluation to analytics and machine-learning-facilitated case logging. DESIGN: We built a HIPAA-compliant web-based Platform for comprehensive management of resident education information, including resident operative performance evaluations. To assess evaluation timeliness, we compared the lag time for Platform-based evaluations to that of end-of-rotation evaluations. We also assessed evaluation compliance, based on a time threshold of 5 days for Platform evaluations and 2 weeks for end-of-rotation evaluations. SETTING: University of Massachusetts, Baystate Medical Center, General Surgery Residency. PARTICIPANTS: Twenty three attendings and 43 residents for the Platform cohort; 15 services and 45 residents for the end-of-rotation cohort. RESULTS: Three hundred and fifty-eight Platform evaluations were completed by 23 attendings for 43 residents for March through October 2017. Six hundred and ten end-of-rotation evaluations by 15 attendings for 45 residents were used for comparison (September 2015 through June 2017). Of Platform evaluations, 41.3% were completed within 24 hours of the operation (16.5% in 6 hours, 33.3% in 12 hours, and 62.2% in 48 hours), with 24.3% of evaluations completed within 3 hours after e-mail reminders. In the first 6 weeks (March 1 through April 12) 4.5 ± 3.7 evaluations were completed per week compared to 18.8 ± 5.8 in the last (September 18 through October 31). Evaluation lag times improved with the use of the Platform, both for median lag of 35 days earlier (1 ± 1.5 days Platform, 36 ± 28.2 days traditional, p < 0.0001) and a mean lag of 41 days earlier (3.0 ± 4.7 days Platform, 44.0 ± 32.6 days traditional, p < 0.0001). CONCLUSIONS: Our comprehensive Platform facilitated faculty compliance with evaluation requirements and timeliness of availability of performance information (often in near real time) for both residents and residency leadership. The added value of the Platform's integration of evaluations with resident and attending case logging may account for the rapidly increasing number of operative skill evaluations over the short time span since implementation.

Resensitization of breast cancer cells to anoikis by tropomyosin-1: role of Rho kinase-dependent cytoskeleton and adhesion.

Two most common properties of malignant cells are the presence of aberrant actin cytoskeleton and resistance to anoikis. Suppression of several key cytoskeletal proteins, including tropomyosin-1 (TM1), during neoplastic transformation is hypothesized to contribute to the altered cytoskeleton and neoplastic phenotype. Using TM1 as a paradigm, we have shown that cytoskeletal proteins induce anoikis in breast cancer (MCF-7 and MDA MB 231) cells. Here, we have tested the hypothesis that TM1-mediated cytoskeletal changes regulate integrin activity and the sensitivity to anoikis. TM1 expression in MDA MB 231 cells promotes the assembly of stress fibers, induces rapid anoikis via caspase-dependent pathways involving the release of cytochrome c. Further, TM1 inhibits binding of MDA MB 231 cells to collagen I, but promotes adhesion to laminin. Inhibition of Rho kinase disrupts TM1-mediated cytoskeletal reorganization and adhesion to the extracellular matrix components, whereas the parental cells attach to collagen I, spread and form extensive actin meshwork in the presence of Rho kinase inhibitor, underscoring the differences in parental and TM1-transduced breast cancer cells. Further, treatment with the cytoskeletal disrupting drugs rescues the cells from TM1-induced anoikis. These new findings demonstrate that the aberrant cytoskeleton contributes to neoplastic transformation by conferring resistance to anoikis. Restoration of stress fiber network through enhanced expression of key cytoskeletal proteins may modulate the activity of focal adhesions and sensitize the neoplastic cells to anoikis.