Development and Assessment of Machine Learning Models for Individualized Risk Assessment of Mastectomy Skin Flap Necrosis.

OBJECTIVE: To develop, validate, and evaluate ML algorithms for predicting MSFN. BACKGROUND: MSFN is a devastating complication that causes significant distress to patients and physicians by prolonging recovery time, compromising surgical outcomes, and delaying adjuvant therapy. METHODS: We conducted comprehensive review of all consecutive patients who underwent mastectomy and immediate implant-based reconstruction from January 2018 to December 2019. Nine supervised ML algorithms were developed to predict MSFN. Patient data were partitioned into training (80%) and testing (20%) sets. RESULTS: We identified 694 mastectomies with immediate implant-based reconstruction in 481 patients. The patients had a mean age of 50 ± 11.5 years, years, a mean body mass index of 26.7 ± 4.8 kg/m 2 , and a median follow-up time of 16.1 (range, 11.9-23.2) months. MSFN developed in 6% (n = 40) of patients. The random forest model demonstrated the best discriminatory performance (area under curve, 0.70), achieved a mean accuracy of 89% (95% confidence interval, 83-94), and identified 10 predictors of MSFN. Decision curve analysis demonstrated that ML models have a superior net benefit regardless of the probability threshold. Higher body mass index, older age, hypertension, subpectoral device placement, nipple-sparing mastectomy, axillary nodal dissection, and no acellular dermal matrix use were all independently associated with a higher risk of MSFN. CONCLUSIONS: ML algorithms trained on readily available perioperative clinical data can accurately predict the occurrence of MSFN and aid in individualized patient counseling, preoperative optimization, and surgical planning to reduce the risk of this devastating complication.

The Use of Machine Learning for Predicting Complications of Free-Flap Head and Neck Reconstruction.

BACKGROUND: Machine learning has been increasingly used for surgical outcome prediction, yet applications in head and neck reconstruction are not well-described. In this study, we developed and evaluated the performance of ML algorithms in predicting postoperative complications in head and neck free-flap reconstruction. METHODS: We conducted a comprehensive review of patients who underwent microvascular head and neck reconstruction between January 2005 and December 2018. Data were used to develop and evaluate nine supervised ML algorithms in predicting overall complications, major recipient-site complication, and total flap loss. RESULTS: We identified 4000 patients who met inclusion criteria. Overall, 33.7% of patients experienced a complication, 26.5% experienced a major recipient-site complication, and 1.7% suffered total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = 0.61, sensitivity = 0.60). Regularized regression had the best performance for predicting major recipient-site complications (AUROC = 0.68, sensitivity = 0.66), and decision trees were the best predictors of total flap loss (AUROC = 0.66, sensitivity = 0.50). CONCLUSIONS: ML accurately identified patients at risk of experiencing postsurgical complications, including total flap loss. Predictions from ML models may provide insight in the perioperative setting and facilitate shared decision making.

Outcomes of Complex Abdominal Wall Reconstruction with Biologic Mesh in Patients with 8 Years of Follow-Up.

BACKGROUND: While many studies evaluated outcomes of abdominal wall reconstruction with biologic mesh, long-term data is lacking. In this study, we sought to analyze the outcomes of complex AWR with biologic mesh in a robust cohort of patients with a mean follow up of 8 years. METHODS: We conducted a longitudinal study of AWR patients from 2005 to 2019. Hernia recurrence was the primary outcome, and surgical site occurrence was the secondary outcome. Predictive/protective factors were identified using a Cox proportional hazards regression models. RESULTS: We identified 109 consecutive patients who met the inclusion criteria. Patient's mean (± SD) age was 57.5 ± 11.8 years, mean body mass index was 30.7 ± 7.2 kg/m2, and mean follow-up time was 96.2 ± 15.9 months. Fifty-six percent had clean defects, 34% had clean-contaminated defects, and 10% had contaminated/infected defects. Patients had a mean defect size of 261 ± 199.6 cm2 and mean mesh size of 391.3 ± 160.2 cm2. Nineteen patients (17.4%) developed HR at the final follow-up date. Obesity was independently associated with a four-fold higher risk of HR (hazard ratio, 3.98; 95%CI, 1.34 to 14.60, p = 0.02). SSOs were identified in 24.8% of patients. A prior hernia repair was associated with a three-fold higher risk of SSOs (Odds ratio, 3.13; 95%CI, 1.10 to 8.94, p = 0.03). No patient developed mesh infection. CONCLUSION: These longitudinal data demonstrate that complex AWR with biologic mesh provides long-term durable outcomes with acceptable HR and SSO rates despite high contamination levels, patients complexity, and large defect size.

The combined profunda artery perforator-gracilis flap for immediate facial reanimation and resurfacing of the radical parotidectomy defect.

BACKGROUND: A radical parotidectomy with facial nerve sacrifice results in facial nerve paralysis as well as a volume and often cutaneous defect. Prior experience with nerve grafting and static suspension has yielded suboptimal results. The present report aims to examine the feasibility and outcomes of a combined free gracilis and profunda artery perforator (PAP) flap from a single donor site can reconstruct these extensive defects and potentially restore dynamic facial reanimation even in the setting of adjuvant radiation. PATIENTS AND METHODS: A retrospective review of 10 patients (6 males and 4 females) was performed from 2016 to 2020 that underwent a combined PAP-gracilis reconstruction of a radical parotidectomy defect. All patients (mean age: 71.3 years; range: 52-83 years) received adjuvant radiation. A chimeric PAP-gracilis flap requiring a single microvascular anastomosis was performed in three patients while the remaining patients underwent a double free flap reconstruction. RESULTS: The gracilis flap was innervated using the facial nerve stump, spinal accessory and massecteric nerve in three patients each. One patient's gracilis was innervated using the hypoglossal nerve. Three patients also underwent nerve grafting of the facial nerve. One patient was taken back to the operating room for a hematoma in the recipient site and there were not flap losses of either the PAP or gracilis flap. Two patients had delayed wound healing of the donor site that healed with conservative management. Average follow-up was 11.1 months (range: 8.1-19.5 months). Six patients were able to achieve dynamic animation while the others obtained a static reconstruction and did not have issues with drooling, eating, or speaking. CONCLUSIONS: Immediate functional muscle transfer can potentially restore dynamic facial reanimation even following radiation. Combining reconstruction using a PAP-gracilis flap addresses the soft tissue deficit and facial paralysis using a single donor site in a single operation.

Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation.

BACKGROUND: Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. METHODS: We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. RESULTS: We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). CONCLUSION: Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

ChatGPT Is Equivalent to First-Year Plastic Surgery Residents: Evaluation of ChatGPT on the Plastic Surgery In-Service Examination.

BACKGROUND: ChatGPT is an artificial intelligence language model developed and released by OpenAI (San Francisco, CA) in late 2022. OBJECTIVES: The aim of this study was to evaluate the performance of ChatGPT on the Plastic Surgery In-Service Examination and to compare it to residents' performance nationally. METHODS: The Plastic Surgery In-Service Examinations from 2018 to 2022 were used as a question source. For each question, the stem and all multiple-choice options were imported into ChatGPT. The 2022 examination was used to compare the performance of ChatGPT to plastic surgery residents nationally. RESULTS: In total, 1129 questions were included in the final analysis and ChatGPT answered 630 (55.8%) of these correctly. ChatGPT scored the highest on the 2021 exam (60.1%) and on the comprehensive section (58.7%). There were no significant differences regarding questions answered correctly among exam years or among the different exam sections. ChatGPT answered 57% of questions correctly on the 2022 exam. When compared to the performance of plastic surgery residents in 2022, ChatGPT would rank in the 49th percentile for first-year integrated plastic surgery residents, 13th percentile for second-year residents, 5th percentile for third- and fourth-year residents, and 0th percentile for fifth- and sixth-year residents. CONCLUSIONS: ChatGPT performs at the level of a first-year resident on the Plastic Surgery In-Service Examination. However, it performed poorly when compared with residents in more advanced years of training. Although ChatGPT has many undeniable benefits and potential uses in the field of healthcare and medical education, it will require additional research to assess its efficacy.

Impact of Obesity on Outcomes of Prepectoral vs Subpectoral Implant-Based Breast Reconstruction.

BACKGROUND: The impact of obesity on outcomes of prepectoral vs subpectoral implant-based reconstruction (IBR) is not well-established. OBJECTIVES: The goal of this study was to assess the surgical and patient-reported outcomes of prepectoral vs subpectoral IBR. The authors hypothesized that obese patients would have similar outcomes regardless of device plane. METHODS: We conducted a retrospective review of obese patients who underwent 2-stage IBR from January 2017 to December 2019. The primary endpoint was the occurrence of any breast-related complication; the secondary endpoint was device explantation. RESULTS: The authors identified a total of 284 reconstructions (184 prepectoral, 100 subpectoral) in 209 patients. Subpectoral reconstruction demonstrated higher rates of overall complications (50% vs 37%, P = .047) and device explantation (25% vs 12.5%, P = .008) than prepectoral reconstruction. In multivariable regression, subpectoral reconstruction was associated with higher risk of infection (hazard ratio [HR], 1.65; P = .022) and device explantation (HR, 1.97; P = .034). Subgroup analyses demonstrated significantly higher rates of complications and explantation in the subpectoral group in those with a body mass index (BMI) ≥ 35 and BMI ≥40. The authors found no significant differences in mean scores for satisfaction with the breast (41.57 ± 13.19 vs 45.50 ± 11.91, P = .469), psychosocial well-being (39.43 ± 11.23 vs 39.30 ± 12.49, P = .915), and sexual well-being (17.17 ± 7.83 vs 17.0 ± 9.03, P = .931) between subpectoral and prepectoral reconstruction. CONCLUSIONS: Prepectoral reconstruction was associated with significantly decreased overall complications, infections, and device explantation in obese patients compared with subpectoral reconstruction. Prepectoral reconstruction provides superior outcomes to subpectoral reconstruction with comparable patient-reported outcomes.

Acellular Dermal Matrix Provides Durable Long-Term Outcomes in Abdominal Wall Reconstruction: A Study of Patients with Over 60 Months of Follow-up.

BACKGROUND: Ventral hernia repair (VHR) is one of the most commonly performed procedures in the United States, but studies assessing the long-term outcomes of VHR using biologic mesh are scarce. OBJECTIVE: We sought to determine the rates of hernia recurrence (HR) and surgical site occurrences (SSOs) in a large cohort of patients who underwent AWR with biologic mesh. METHODS: We conducted a retrospective cohort study of patients who underwent AWR using either porcine ADM (PADM) or bovine ADM (BADM) from 2005 to 2019. We analyzed the full cohort and a subset of our population with minimum long-term follow-up (LTF) of 5 years. The primary outcome measure was HR. Secondary outcomes were SSOs. RESULTS: We identified a total of 725 AWRs (49.5% PADM, 50.5% BADM). Mean age was 69 ± 11.5 years and mean body mass index was 31 ± 7 kg/m 2 . Forty-two percent of the defects were clean at the time of AWR, 44% were clean-contaminated, and 14% were contaminated/infected. Mean defect size was 180 ± 174 cm 2 , mean mesh size was 414 ± 203 cm 2 . Hernia recurred in 93 patients (13%), with cumulative HR rates of 4.9%, 13.5%, 17.3%, and 18.8% at 1, 3, 5, and 7 years, respectively. There were no differences in HR ( P = 0.83) and SSO ( P = 0.87) between the 2 mesh types. SSOs were identified in 27% of patients. In our LTF group (n = 162), the HR rate was 16%. Obesity, bridged repair, and concurrent stoma presence/creation were independent predictors of HR; component separation was protective against HR. CONCLUSIONS: Despite its use in complex AWR, ADM provides durable long-term outcomes with relatively low recurrence rates.

Impact of Body Mass Index on Surgical Outcomes in Oncologic Microvascular Head and Neck Reconstruction.

BACKGROUND: Despite increasing recognition, obesity continues to represent a major health issue for millions of people in the USA and worldwide. There is a paucity in the literature regarding the effect of body mass index (BMI) on microsurgical head and neck reconstruction. The present study hypothesized that high BMI is predictive of postoperative recipient- and donor-site complications with longer operative times. PATIENTS AND METHODS: Retrospective review of patients who underwent free flap surgery for head and neck reconstruction was performed between January 2005 and December 2018. Patients were categorized into four groups based on BMI: < 20 kg/m2, 20-30 kg/m2, 30-40 kg/m2, and ≥ 40 kg/m2. Patient characteristics and surgical outcomes were compared between the four groups. RESULTS: Overall, 4000 free flap surgeries were included in the present study, performed on 3753 patients, of whom 9.9% had a BMI < 20 kg/m2, 64.9% had a BMI between 20 and 30 kg/m2, 21.6% had a BMI between 30 and 40 kg/m2, and 3.6% had a BMI ≥ 40 kg/m2. After adjusting for potential confounders, multivariate analysis showed no association between BMI and any complication, major recipient complications, or total flap loss. However, multivariate linear regression model showed BMI 30-40 kg/m2 and BMI ≥ 40 kg/m2 to be independently associated with longer operative times compared with BMI < 20 kg/m2. CONCLUSION: Obesity and high BMI increase operative times; however, with meticulous surgical technique and diligent postoperative care, microvascular head and neck reconstructions can be performed safely and reliably in the majority of patients regardless of BMI with similar overall, recipient-site, and donor-site complications.

The Experience of Virtual Interviews in Resident Selection: A Survey of Program Directors in Surgery.

BACKGROUND: MATCH 2021 was short of the classic "in-person" component. Herein, we assess the impact of virtual interviews (VIs) on resident selection, from the perspectives of program directors (PDs) across all surgical specialties. MATERIALS AND METHODS: We conducted a cross-sectional survey-based study of ACGME-accredited US residency program directors (PDs) of all surgical specialties. The survey was designed based on a review of relevant literature and inquired about the strengths, limitations, and overall utility of VIs. RESULTS: A total of 365 PDs responded to our survey. Almost all respondents (90%) found VIs to be less expensive than in-person interviews, while only 34% agree that VIs were less time-consuming. Only a median of 5% of interviews was complicated by technical difficulties. Most PDs found it more challenging to assess applicants' fit (75%), personality and communication skills (71%), and commitment to specialty (60%). Only 14% found VIs to be overall better for assessing residency applicants. In future cycles, most PDs are planning to host both virtual and in-person interviews (57%), while 35% and 8% will host exclusive in-person and virtual interviews, respectively. CONCLUSIONS: VIs are a novel way of dealing with the restrictions imposed by COVID-19. Despite their cost and time benefit, they present particular challenges in evaluating residency applicants. A combination of both virtual and in-person interviews will likely be implemented in the coming cycles.

Outcomes and technical modifications of vascularized lymph node transplantation from the lateral thoracic region for treatment of lymphedema.

BACKGROUND AND OBJECTIVES: This study evaluates clinical outcomes of vascularized lymph node transplantation (VLNT) from the lateral thoracic region and technical modifications. METHODS: Consecutive patients that underwent lateral thoracic VLNT to treat extremity lymphedema were included. Demographic and treatment data were recorded, and outcomes data including limb volume, LDex score, and Lymphedema Life Impact Scale (LLIS), QuickDASH, and LEFS questionnaires, were collected prospectively. Consecutive patients that underwent single-photon emission computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (RLM) were analyzed to characterize the physiological drainage of the normal upper extremity. RESULTS: A consecutive series of 32 flaps were included. At 24 months postoperatively mean reduction in limb volume excess was 47.2% (±11.6; p = 0.0085), LDex score was 63.1% (±8.5; p < 0.001), and LLIS score was 65.1% (±7.4; p < 0.001). Preoperatively 14/31 patients (45.2%) reported cellulitis, and postoperatively there were no episodes at up to 24 months (p < 0.001). No patient developed donor extremity lymphedema at mean 18.6 (±8.3) months follow-up. SPECT/CT-RLM of 182 normal axillae demonstrated that the sentinel lymph node(s) of the upper extremity was consistently anatomically located in the upper outer quadrant of the axilla (97%). CONCLUSIONS: VLNT from the lateral thoracic region is effective and versatile for the treatment of lymphedema with a low donor site complication rate.

Master's Degrees Among Academic Plastic Surgeons and Plastic Surgery Residents: What Are the Trends?

BACKGROUND: As more plastic surgery clinicians pursue advanced degrees and strive to become stronger physician-scientists, an objective understanding of how such degrees influence careers becomes important. We hypothesized that having a master's degree is associated with higher scholarly activity, research funding, academic progression, and leadership appointments. METHODS: Accreditation Council for Graduate Medical Education-accredited integrated plastic surgery residency program Web sites were queried to create a data set of current academic plastic surgeons (APSs) and plastic surgery residents (PSRs). Scholarly metrics such as publications, citations, and H-indices were extracted from the Scopus database. National Institutes of Health and Plastic Surgery Foundation funding information was collected through their respective Web sites. RESULTS: Our cohort comprised 799 APSs and 922 PSRs, of whom 8% and 7.4%, respectively, had at least one master's degree. Academic plastic surgeons with master's of public health degrees had a significantly higher median number of publications and citations than APSs without a master's of public health. There was no association between any master's degree and academic rank or being a department chairman or program director. Academic plastic surgeons with master of science degrees were more likely to receive National Institutes of Health grants. Among PSRs, master's of science graduates had a higher median number of publications. Other master's degrees did not significantly influence scholarly productivity or funding. CONCLUSIONS: Certain master's degrees had an impact on scholarly productivity, with no significant effect on academic rank or leadership positions. The value of master's degrees in programs focusing on healthcare management, leadership skills, and business acumen likely extends beyond the scope of this study.

Addressing Surgical Care Disparities: Residents' Involvement in Global Mission Trips.

ABSTRACT: Humanitarian mission trips have been organized by several residency programs and organizations to cater to surgical care in underdeveloped countries. While there is cross-talk on the existence of such opportunities, there is a paucity of guidance to residents on participation in such trips, their benefits, and the myriad of intangibles to consider while planning to pursue such opportunities. Through this article, the authors highlight the background and utility of humanitarian surgical missions and summarize the clinical and surgical experiences that these trips offer for residents choosing to embark on these altruistic journeys.

Seminal Studies in Facial Reanimation Surgery: Consensus and Controversies in the Top 50 Most Cited Articles.

ABSTRACT: Facial paralysis can impair one's ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist.Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.

Alternative Strategies for Evaluating General Surgery Residency Applicants and an Interview Limit for MATCH 2021: An Impending Necessity.

The COVID-19 pandemic has posed unique challenges for evaluating general surgery residency applicants to MATCH 2021. In the absence of away rotations, programs are likely to afford greater importance to objective data to stratify the applicant pool and medical students are likely to experience difficulty in thoroughly assessing each program. Virtual rotations, meet-and-greet events conducted before the application submission deadline, personality testing before extending interviews, standardized letters of recommendation, and skills testing can serve as valuable adjuncts for determining the best applicant-program fit. Finally, an interview limit which sets the bar for the maximum number of accepted interviews per applicant per specialty can offer a level playing field in the absence of time and cost limitations associated with travel.

Financial Toxicity Following Surgical Treatment for Breast Cancer: A Cross-sectional Pilot Study.

BACKGROUND: Despite growing national attention, there is limited understanding of the patient- and treatment-level characteristics related to treatment cost-associated distress ("financial toxicity") in breast cancer patients. Our aim is to identify risk factors for financial toxicity amongst breast cancer patients undergoing surgical treatment. METHODS: This is a single-institution cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 and June 2019. Financial toxicity was measured via the 11-item comprehensive score for financial toxicity (COST) instrument. Responses were linked with data on patient demographics and clinical history abstracted from the corresponding medical record. Multivariate regression was used to identify patient- and treatment-level factors associated with worsening financial toxicity. Secondary outcome measures included self-reported coping strategies for high treatment costs. RESULTS: A total of 571 patients were included; overall, these individuals were mostly white (76.0%), in-state residents (72.3%), and married (73.0%). Following multivariate analysis, lower financial distress was associated with the use of supplemental insurance, increasing annual household income, and a higher credit score (score > 740). Conversely, work reduction or cessation, increased out-of-pocket spending, advanced tumor stage, and being employed at the time of diagnosis were associated with increased financial distress. Patients with higher reported financial distress were more likely to decrease their spending on food, clothing, and leisure activities. CONCLUSIONS: Financial toxicity was associated with baseline demographic, disease, and treatment characteristics in our cohort of insured patients. These characteristics may be critical opportunities for interventions related to financial navigation along the treatment continuum.

Sentinel Lymph Node Removal After Neoadjuvant Chemotherapy in Clinically Node-Negative Patients: When to Stop?

BACKGROUND: The maximum number of sentinel lymph nodes (SLN) to be resected to accurately stage the axilla in patients undergoing neoadjuvant chemotherapy (NAC) for the treatment of clinically node-negative (cN0) breast cancer has not been determined. We sought to determine the sequence of removal of the positive SLNs in this patient population. METHODS: All patients aged ≥ 18 years diagnosed with cN0 invasive breast cancer who received NAC and underwent SLN surgery at Mayo Clinic Rochester between September 2008 and September 2018 were identified. Univariate analysis was performed to compare factors associated with positive nodes and where the first positive node was in the sequence of removal of the SLNs. RESULTS: We identified 446 cancers among 440 patients with a median age of 51 (IQR: 43, 61) years. At surgery, 381 (85.4%) cancers were pathologically node (ypN) negative and 65 (14.6%) were pN + . The number of nodes removed was similar for both patients with ypN0 and ypN + disease, with a median number of SLNs removed of 2.0 (IQR: 2.0, 3.0). Of all patients with a positive node, the first positive node was most commonly the 1st node removed (75.4%), and was identified by the 3rd SLN removed in all cases. CONCLUSIONS: Among cN0 patients treated with NAC, if a positive SLN is present, it is most commonly identified as the 1st sentinel node removed by the surgeon, and was identified by the 3rd sentinel node in our series. This suggests that once 3 SLNs have been resected, removal of additional sentinel lymph nodes does not add diagnostic value.

Virtual Rotations During COVID-19: An Opportunity for Enhancing Diversity.

The COVID-19 pandemic has presented unique challenges to medical education. With the lack of in-person away rotations for the 2020-2021 residency application cycle, virtual rotations have surfaced as an alternative. The virtual rotations that the authors participated in allowed for active participation in various resident educational activities such as journal club, grand rounds, and morning conferences. One critical aspect of virtual rotations was the one-on-one meetings with the program leadership. In addition to a virtual tour of the hospital and campus, many programs offered virtual social hours with the residents to converse about the program, the city, and the match process. A few programs even allowed applicants to attend virtually live-streamed surgeries. These rotations offer students, especially those without a corresponding home program, an invaluable opportunity to express their interest in a particular program and gain foundational knowledge about the specialty. Virtual rotations also provide underrepresented minorities and international medical graduates with clinical exposure, mentorship, and networking opportunities, mitigating some of the challenges presented by COVID-19.

Termination of the USMLE Step 2 CS: Perspectives of Surgical Residents with Diverse Medical Backgrounds.

As the decision to permanently suspend the USMLE Step 2 Clinical Skills exam resonates across the medical education landscape, it has different implications for the graduates of American allopathic (US-MD), osteopathic (DO) medical schools and international medical graduates (IMGs). Through this perspective, we as authors who represent each of these three diverse cohorts highlight the changes that resulted from the COVID-19 pandemic and delve into the multitude of ramifications that could ensue as a result of this decision. Our propositions are geared towards a standardized objective structured clinical examination for evaluating US-MDs and DOs, and a call for novel evaluation strategies to assure the minimum clinical standards of IMGs.

International Medical Graduates are Comparable to American Medical Graduates as General Surgery Interns.

BACKGROUND: International medical graduates (IMGs) are often relegated to preliminary positions in general surgery (GS) owing to uncertainties about the candidate's performance in the American healthcare setting. We aimed to determine the comparative performance of IMGs and American medical graduates (AMGs) at baseline and assess these trends over the course of their GS internship. METHODS: Evaluations of all IMG preliminary and AMG categorical interns from 2013 to 2017 at our GS residency program were obtained from three faculty members to score overall performance, technical skills, interpersonal communication, and medical knowledge on a 10-point Likert scale. Scores on the American Board of Surgery In-Training Exam, an in-house preparation test, United States Medical Licensing Exam, and performance during the biannual multistation objective assessments were compared between the two resident groups. RESULTS: Seventy-two interns (28 [39%] AMG categorical and 44 [61%] IMG preliminary) met inclusion criteria. The AMG group had significantly higher median Step 1 and Step 2 scores compared with our IMG group (243 versus 231, P = 0.002, and 250 versus 246, P = 0.03, respectively).Although in-house preparation test scores were higher among IMGs (median [interquartile range] of 36 [33-40] among AMGs and 38 [34-45] among IMGs; P = 0.002), there were no statistically significant differences between the American Board of Surgery In-Training Exam scores of the two groups. The median scores for the four faculty evaluation components were similar between the AMG (7, 8, 7, 7) and IMG resident groups (7, 7, 7, 7; P = nonsignificant). IMGs scored significantly higher in both biannual multistation objective assessments than AMGs (median [interquartile range] July: 59 [47-91] versus 55 [37-62], P = 0.005; January: 103 [86-116] versus 91 [87-104], P = 0.03). CONCLUSIONS: It is reassuring to confirm that no matter where they are from, great candidates can perform well as surgical interns in a GS training program.