Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

The "Intern" Label: Introducing Unnecessary Confusion and Bias?

OBJECTIVES: The Oxford English Dictionary defines "intern" as "a student or trainee who works, sometimes without pay, at a trade or occupation in order to gain work experience." In the medical realm, the label "intern" may introduce confusion as well as implicit and explicit bias. In this study, we sought to examine the general public's perception of the label "intern" compared to the more accurate label "first-year resident." DESIGN: We developed 2 forms of a 9-item survey that assessed an individual's level of comfort with surgical trainees' participation in various aspects of surgical care and knowledge of medical education and work environment. One form used the label "intern" and the other used "first-year resident." SETTING: San Antonio, TX. PARTICIPANTS: A total of 148 adults in the general population at 3 local parks on 3 separate occasions. RESULTS: A total of 148 individuals completed the survey (74 per form). Respondents who did not work in the medical field reported less comfort with interns vs first-year residents participating in various aspects of their care. Only 36% of respondents were able to correctly identify which surgical team members have completed a medical degree. Directly assessing perceptual incongruity between the labels "intern" and "first-year resident," 43% of respondents said interns have a medical degree compared to 59% for first-year residents (p = 0.008), 88% stated that interns work full-time in the hospital compared to 100% for first-year residents (p = 0.041), and 82% stated that interns get paid for their work in the hospital compared to 97% for first-year residents (p = 0.047). CONCLUSIONS: The label "intern" may confuse patients, family members, and perhaps other healthcare professionals regarding the level of experience and knowledge of first-year residents. We advocate for abolishing the term "intern" and replacing it with "first-year resident" or simply "resident."

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Identifying Potential Attrition during the Residency Applicant Screening Process Using a Situational Judgment Test.

OBJECTIVE: As USMLE Step 1 moves to pass/fail, residency programs are seeking alternate interview selection processes. Attrition in general surgery is reported as high as 26%. Thus, it is important to ensure that programs are selecting and matching applicants with shared values. Situational judgment tests (SJTs) measure educational and cultural values by posing ambiguous situations and individuals rate the effectiveness of possible reactions. SJTs have previously been shown to identify job applicants with shared values while promoting diversity. Scoring categories are high, moderate, or low values congruence. We sought to explore predictive validity of the SJT relative to program attrition. DESIGN: Residents who matched into our program between 2018 and 2021 completed the SJT. We tracked attrition. SETTING: UT Health San Antonio, Texas PARTICIPANTS: Fifty-six categorical general surgery residents RESULTS: Per SJT ratings, the numbers of residents who had high, moderate, and low values congruence were 27, 16, and 13, respectively. Attrition numbers for residents who scored high and moderate congruence were similar, indicating that these ratings were indistinguishable. As such, we combined those 2 categories to create a 2 × 2 matrix and used signal detection theory as a framework for analysis. Overall attrition was 16.1% (9/56). Of the 43 residents who scored high or moderate congruence, 90.7% remained in the program. There was a 9.3% chance of attrition for these residents. Of the 13 residents who scored low congruence, 38.5% attrited. While scoring as low congruence on the SJT does not definitively indicate attrition, it does indicate that attrition is 4.14 times more likely for these residents (chi-square, p = 0.0121). CONCLUSIONS: One of the most important aspects of residency applicant selection and interviewing is mitigating risk by identifying applicants who carry a high risk of attrition. The SJT significantly identifies at-risk applicants.

Getting on the Same Page: The Impact of Interviewer Education and Structured Interviews on Interrater Agreement in Residency Interviews.

INTRODUCTION: We explored the impact of implementing structured interviews and associated interviewer education on interrater agreement within a large academic residency program. METHODS: Faculty and senior resident interviewers from a large academic residency program participated in a 3-hour structured interview course. Before and after the course, participants completed a 15-item assessment pertaining to the characteristics, logistics, and guidelines associated with structured interviews. Along with interviewer training, interview day logistics also changed from an unstructured format (no specific questions, one overall 1-9 rating scale) to a structured interview format, including incorporation of behavioral-based competency questions that would be asked of every applicant and behavioral anchored rating scales (1-10; 10 = highest). Interrater agreement was assessed via intraclass correlation coefficients (ICC1) for the 2 years before and 2 years after incorporation of the structured interview format. RESULTS: A total of 45 faculty and resident interviewers participated in the course in 2018. Participant knowledge significantly increased from an average of 36% to 79% after the course (p < 0.01). Prior to the intervention, overall interrater agreement was "poor" to "fair," with an ICC1 of 0.51 in 2016 and 0.49 in 2017. After the structured interview intervention, overall agreement increased to the "good" level with an ICC1 of 0.71 in 2018 and 0.66 in 2019. The proportion of applicants who received interview scores with at least 2 ratings more than 2 points apart significantly decreased from 59% to 47% after the intervention (p < 0.01). CONCLUSIONS: Incorporating an interviewer educational session and a structured interview format into residency selection can help increase agreement in ratings between interviewers. However, these data suggest that ongoing refresher trainings may be needed to maintain acceptable levels of interrater agreement.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Is Beauty in the Eye of the Beholder? Differences in Residency Training Program Preferences Among Women and Minorities.

INTRODUCTION: Training programs are now more than ever seeking ways to promote recruitment and retention of a diverse resident workforce. The goal of this study was to examine how gender and ethnic identities affect applicant attraction to surgery training programs. METHODS: Applicants to general surgery residency in 2018 to 2019 completed a 31-item assessment measuring preferences for training program characteristics and attributes. Differences in preferences across candidate gender and ethnicity were investigated. Factor analyses and analysis of variance (ANOVA) were used to explore these differences. RESULTS: 1491 unique applicants to 7 residency programs completed the assessment, representing 67% of all applicants to general surgery during the 2018 to 2019 season. Women preferred training programs that had high levels of social support (p < 0.001), were less traditional (p < 0.001), and with less turbulence (p < 0.05). Non-white candidates reported greater preference for programs with higher levels of established academics (p < 0.001), clinical experiences (p < 0.001), social support (p < 0.05), traditionalism (p < 0.001), flexibility (p < 0.001), and innovation (p < 0.001). CONCLUSIONS: Organizational efforts to attract and retain a diverse workforce may benefit from considering the aspects of work that align with female and underrepresented minority preferences.

Measuring the fire in their hearts: assessing passion for the profession among students pursuing surgical careers.

Background: Leaders in surgery have posited that passion for the surgery profession is diminishing among entering trainees, and that its scarcity is related to the high levels of attrition observed in general surgery training. This study explores trends in passion for the profession among applicants to general surgery training. Methods: Applicants to a large midwestern academic general surgery program were invited to complete a voluntary, anonymous 12-item Passion for Surgery Index (PSI) as part of their supplementary application package during the 2020-2021 and 2021-2022 residency selection seasons. The PSI is adapted from a generic work-related passion index and is based on the dualistic model of passion, organizing scores into harmonious passion and consuming passion. Applicants completed the index on a stand-alone website which automatically generated results pertaining to overall passion, harmonious passion, and consuming passion for the surgery profession. Applicants were provided with their results and provided feedback. Results: Sixty-one percent (871/1428) of invited applicants completed the PSI. Approximately 67.4% (N = 587) of these applicants reported an overall high level of passion for surgery, while 31.1% (N = 271) reported a moderate level and the remaining 1.5% (N = 13) reported a low level. When comparing the two different types of passion, the vast majority of applicants (92.8%; N = 808) reported a high level of harmonious passion and only 7.1% (N = 62) reported a moderate level of harmonious passion. The results for consuming passion were much more varied, with 36.9% (N = 321) reporting a high level, 47.5% (N = 414) reporting a moderate level, and 15.6% (N = 136) reporting a low level of consuming passion for the profession. Discussion: These results suggest that there is substantial variation in passion for the profession among those pursuing a career in surgery. While the majority of applicants reported a high level of harmonious passion for surgery, less than half of applicants reported a high level of consuming passion for surgery. This variability in consuming passion among entering trainees is concerning, as individuals with low or only moderate passion for the profession may not have the motivation or drive to persist in demanding training environments.

Surgical Inpatient's Attitudes Toward Resident Participation: All About Expectations.

OBJECTIVE: Determine whether an educational video can improve surgical inpatients' attitudes toward resident participation in their care. METHODS: Patients admitted to the Trauma/Emergency General Surgery Service at University Hospital (San Antonio, Texas) were randomly divided into control and intervention groups. Patients in the intervention group viewed a short educational video about the role and responsibilities of medical students, residents, and attending surgeons. All patients then completed a previously published survey. RESULTS: A total of 140 patients responded to the survey (control = 81 and intervention = 59 patients). Overall, 86.4% of patients were welcoming of resident participation. Patients who were expecting residents to be involved in their care had attitudes that are more favorable on almost all survey questions regardless of their study condition. However, patients in the intervention group who expected resident involvement in their care had more favorable attitudes about senior residents (postgraduate year 3-5) assisting in routine or complicated surgery than those in the control group who were expecting resident involvement (both p ≤ 0.001). This same group of patients also had more favorable attitudes about surgical outcomes and overall surgical health when residents are involved (p = 0.004, p = 0.001, respectively). Most patients (79%) said they had no residents previously involved in their care, or they were unsure if residents were previously involved. CONCLUSIONS: Patient expectation of resident involvement is one of the most important factors influencing perceptions of inpatients about resident participation in surgery. Our goal should be early and frequent discussion with patients about resident involvement in order to foster an atmosphere of trust, including full transparency regarding resident involvement in surgical procedures. An educational video may help introduce the roles of trainees and attending surgeons but should not be used in lieu of direct discussion with patients.

Great Expectations? Future Competency Requirements Among Candidates Entering Surgery Training.

INTRODUCTION: We describe a multimethod, multi-institutional approach documenting future competencies required for entry into surgery training. METHODS: Five residency programs involved in a statewide collaborative each provided 12 to 15 subject matter experts (SMEs) to participate. These SMEs participated in a 1-hour semistructured interview with organizational psychologists to discuss program culture and expectations, and rated the importance of 20 core competencies derived from the literature for candidates entering general surgery training within the next 3 to 5 years (1 = importance decreases significantly; 3 = importance stays the same; 5 = importance increases significantly). RESULTS: Seventy-three SMEs across 5 programs were interviewed (77% faculty; 23% resident). All competencies were rated to be more important in the next 3 to 5 years, with team orientation (3.87 ± 0.81), communication (3.82 ± 0.79), team leadership (3.81 ± 0.82), feedback receptivity (3.79 ± 0.76), and professionalism (3.76 ± 0.89) rated most highly. CONCLUSIONS: These findings suggest that the competencies desired and required among future surgery residents are likely to change in the near future.

Can Better Selection Tools Help Us Achieve Our Diversity Goals in Postgraduate Medical Education? Comparing Use of USMLE Step 1 Scores and Situational Judgment Tests at 7 Surgical Residencies.

PURPOSE: Use of the United States Medical Licensing Examination (USMLE) for residency selection has been criticized for its inability to predict clinical performance and potential bias against underrepresented minorities (URMs). This study explored the impact of altering traditional USMLE cutoffs and adopting more evidence-based applicant screening tools on inclusion of URMs in the surgical residency selection process. METHOD: Multimethod job analyses were conducted at 7 U.S. general surgical residency programs during the 2018-2019 application cycle to gather validity evidence for developing selection assessments. Unique situational judgment tests (SJTs) and scoring algorithms were created to assess applicant competencies and fit. Programs lowered their traditional USMLE Step 1 cutoffs and invited candidates to take their unique SJT. URM status (woman, racial/ethnic minority) of candidates who would have been considered for interview using traditional USMLE Step 1 cutoffs was compared with the candidate pool considered based on SJT performance. RESULTS: A total of 2,742 general surgery applicants were invited to take an online SJT by at least 1 of the 7 programs. Approximately 35% of applicants who were invited to take the SJT would not have met traditional USMLE Step 1 cutoffs. Comparison of USMLE-driven versus SJT-driven assessment results demonstrated statistically different percentages of URMs recommended, and including the SJT allowed an average of 8% more URMs offered an interview invitation (P < .01). CONCLUSIONS: Reliance on USMLE Step 1 as a primary screening tool precludes URMs from being considered for residency positions at higher rate than non-URMs. Developing screening tools to measure a wider array of candidate competencies can help create a more equitable surgical workforce.

Resident training experience with robotic assisted transabdominal preperitoneal inguinal hernia repair.

BACKGROUND: General surgery is the fastest growing field in the adoption of robotic assisted laparoscopic surgery. Here, we present the results of one institution's experience in training surgical residents in robotic assisted transabdominal preperitoneal inguinal hernia repairs. METHODS: Data were prospectively collected on patients undergoing robotic assisted laparoscopic inguinal hernia repair with residents. Data points included patient age, gender, complications, hernia difficulty, resident technical competency as measured by GEARS, Zwisch scores, operative time, and the number of robotic console cases reported by residents as primary surgeon. RESULTS: Residents who performed >30 robotic cases had significantly higher mean modified GEARS scores (p ≤ .002). Residents who completed 10 or fewer robotic cases achieved significantly lower mean modified GEARS and Zwisch scores than those who completed 11 or more (p < .001). CONCLUSIONS: Resident competency and autonomy improve with increasing total robotic case load. Attending surgeons grant more autonomy to residents with higher competency scores.

Surgery Program Director Turnover Correlates With Residency Graduate Failure on American Board of Surgery Examinations in Civilian Residency Programs.

PURPOSE: The Review Committee for Surgery requires a minimum program director (PD) tenure of 6 years. The impact of PD turnover on the performance of program graduates is unknown. We hypothesize that (1) the majority of PDs step down before 6-year tenure and (2) higher PD turnover is associated with higher failure rate on American Board of Surgery (ABS) examinations. METHODS: Start and stop dates of all surgery PDs between January 1, 2000 and December 31, 2017 were obtained for civilian surgery programs. A Kaplan-Meier curve of PD "survival" was constructed. Programs were divided into High Turnover (HT; ≥4 PD changes, n = 33) and Low Turnover (LT; ≤3 PD changes, n = 191) groups. Five-year (2013-2017) ABS pass rates were also obtained. Pass rates and compliance with current standards were compared between groups. RESULTS: Kaplan-Meier analysis revealed that 40% of PDs do not comply with ACGME policy and serve <6 years. HT programs had lower mean pass rates on ABS certifying exam than LT programs (76% vs 83%, p < 0.01), but not qualifying exam (88% vs 88%). HT programs are less likely to meet the current 65% pass rate standard (82% vs 93%, p < 0.05). CONCLUSIONS: (1) An estimated 40% of general surgery PDs had tenures of <6 years. (2) Greater PD turnover is associated with lower ABS pass rates among general surgery graduates.

If You Build It, Will They Come? Candidate Completion of Preinterview Screening Assessments.

INTRODUCTION: Residency applicant screening practices are inefficient and costly. However, programs may not consider using alternative assessments for fear that candidates will be "turned off" by additional hurdles in the application process. This study explores the relationship between candidate completion of preinterview screening assessments, applicant examination scores, and program factors. METHODS: Applicants to any of 7 general surgery residency programs were invited to take a preinterview online assessment. Program characteristics and applicant United States Medical Licensing Exams scores were considered in relation to each program's assessment completion rate. RESULTS: A total of 2960 applicants were invited to take the assessment and 97% (2870/2960) completed it. Program completion rates ranged from 95% to 98%. There was no correlation between program characteristics and applicant completion rates. Candidates who did not complete the assessment had significantly lower United States Medical Licensing Exams scores. CONCLUSIONS: Incorporating preinterview assessments to objectively measure candidate competencies and fit will not detract applicants from a general surgery program.

An Online System to Help With Mock Oral Examination Administration.

OBJECTIVE: Describe an online system used to collect data, compute statistics, and provide reports for mock oral examinations. DESIGN: Forty general surgery residents, program directors, and faculty serving as examiners completed a survey regarding their experiences with the online mock oral examination system. SETTING: General surgery residency programs and national surgical conferences. PARTICIPANTS: General surgery residents, program directors, and faculty. RESULTS: System users had very positive attitudes toward the online system in terms of usability and reporting functions. CONCLUSIONS: The mock oral exam management online system is a useful tool that eases the burden of managing a mock oral exam session.

Video-Based Patient Education Improves Patient Attitudes Toward Resident Participation in Outpatient Surgical Care.

OBJECTIVE: Decipher if patient attitudes toward resident participation in surgical care can be improved with patient education using a video-based modality. DESIGN: A survey using a 5-pt Likert scale was created, piloted, and distributed in general and colorectal surgery outpatient clinics that had residents involved with patient care at 2 facilities, both with control and intervention groups. The intervention group viewed a short video (∼4 min) explaining the role, education, and responsibilities of medical students, residents, and attending surgeons prior to answering the survey. SETTING: General and colorectal surgery outpatient clinics at the University of Texas Health San Antonio, Texas. PARTICIPANTS: A total of 383 responses were collected, all clinic patients were eligible. RESULTS: The majority of patients (82%) welcomed resident participation in their health care. Eighteen percent of patients did not expect residents to be involved in their care. Patients had favorable views of residents participating during their surgical procedures with 77% responding "agree" or "strongly agree" to a senior resident assisting with a complicated procedure. Patients who viewed the video versus control were less concerned with how much of the procedure the resident would perform (76% vs 86%, p = 0.010). Patients who viewed the video felt less inconvenienced (p = 0.004). CONCLUSIONS: The majority of patients are welcoming to resident participation in their surgical care but only 54% were expecting resident involvement at their clinic visit. Early explanation with an educational video of resident roles, education, and responsibilities may help bridge the gap and improve patient experience.

The Cost of Compliance: The Financial Burden of Fulfilling Accreditation Council for Graduate Medical Education and American Board of Surgery Requirements.

OBJECTIVE: There has been a significant increase in the number of regulatory requirements for general surgery graduate medical education (GME) programs over the last 20 years from the governing bodies of the American Board of Surgery (ABS) and the Accreditation Council of Graduate Medical Education (ACGME). We endeavored to calculate the cost to general surgery GME programs of regulatory requirements. DESIGN: We examined the requirements for General Surgery ABS Certification as well as the 2017 ACGME Program Requirements in General Surgery for all mandates that require funding by the surgery program to achieve. The requirements requiring funding include certification in Advanced Cardiac Life Support, Advanced Trauma Life Support, Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery; access to medical references; simulation capability, program director protected time (30%); program coordinator salary (Association for Hospital Medical Education reported mean); and faculty time devoted to morbidity and mortality conference, journal club, Clinical Competency Committee, and Program Evaluation Committee. We then identified the cost of each mandate based on the average program in the United States of 5 residents per year in 5 clinical years. RESULTS: Total cost for the average program per year as the result of ABS or ACGME mandate equaled a minimum of $227,043. The ABS associated costs are $8900 per year. The ACGME associated costs are $218,143. The cost of program director and faculty time to meet the minimum ACGME requirements equaled $159,600. CONCLUSIONS: The most significant cost associated with mandates set forth by the ABS and ACGME are program director and faculty time devoted to resident education and evaluation. Recognition of this cost burden by institutions and policymakers for the allocation of funds is important to maintain strong general surgery GME programs.

Proficiency-based preparation significantly improves FES certification performance.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) certification has recently been mandated by the American Board of Surgery but best methods for preparing for the exam are lacking. Our previous work demonstrated a 40% pass rate for PGY5 residents in our program. The purpose of this study was to determine the effectiveness of a proficiency-based skills and cognitive curriculum for FES certification. METHODS: Residents who agreed to participate (n = 15) underwent an orientation session, followed by skills pre-testing using three previously described models (Trus, Operation targeting task, and Kyoto) as well as the actual FES skills exam (vouchers provided by the FES committee). Participants then trained to proficiency on all three models for the skills curriculum and completed the FES online didactic material for the cognitive curriculum. Finally, participants post-tested on the models and took the actual FES certification exam. Values are mean ± SD; p < 0.05 was considered significant. RESULTS: Of 15 residents who participated, 8 (53%) passed the FES skills exam at baseline. Participants required 2.7 ± 1.3 h to achieve proficiency on the models and approximately 3 h to complete the cognitive curriculum. At post-test, 14 (93%, vs. pre-test 53%, p = 0.041) passed the FES skills exam. 14 (93%) passed the FES cognitive exam and 13/15 (87%) passed both the skills and cognitive exam and achieved FES certification. CONCLUSIONS: Our traditional clinical endoscopy curricula were not sufficient for senior residents to pass the FES exam. Implementation of a proficiency-based flexible endoscopy curriculum using bench-top models and the FES online materials was feasible and effective for the majority of learners. Importantly, with a modest amount of additional training, 87% of our trainees were able to pass the FES examination, which represents a significant improvement for our program. We expect that additional refinements of this curriculum may yield even better results for preparing future residents for the FES examination.