American Board of Surgery In-Training Exam Performance Predicted by Question Bank Use While Unassociated With Other Learning Strategies.

INTRODUCTION: There is no consensus regarding optimal curricula to teach cognitive elements of general surgery. The American Board of Surgery In-Training Exam (ABSITE) aims to measure trainees' progress in attaining this knowledge. Resources like question banks (QBs), Surgical Council on Resident Education (SCORE) curriculum, and didactic conferences have mixed findings related to ABSITE performance and are often evaluated in isolation. This study characterized relationships between multiple learning methods and ABSITE performance to elucidate the relative educational value of learning strategies. METHODS: Use and score of QB, SCORE use, didactic conference attendance, and ABSITE percentile score were collected at an academic general surgery residency program from 2017 to 2022. QB data were available in the years 2017-2018 and 2021-2022 during institutional subscription to the same platform. Given differences in risk of qualifying exam failure, groups of ≤30th and >30th percentile were analyzed. Linear quantile mixed regressions and generalized linear mixed models determined factors associated with ABSITE performance. RESULTS: Linear quantile mixed regressions revealed a relationship between ABSITE performance and QB questions completed (1.5 percentile per 100 questions, P < 0.001) and QB score (1.2 percentile per 1% score, P < 0.001), but not with SCORE use and didactic attendance. Performers >30th percentile had a significantly higher QB score. CONCLUSIONS: Use and score of QB had a significant relationship with ABSITE performance, while SCORE use and didactic attendance did not. Performers >30th percentile completed a median 1094 QB questions annually with a score of 65%. Results emphasize success of QB use as an active learning strategy, while passive learning methods warrant further evaluation.

The Impact of Simulation Training on Operative Performance in General Surgery: Lessons Learned from a Prospective Randomized Trial.

BACKGROUND: Practice in the simulated environment can improve surgical skills. However, the transfer of open complex surgical skills to the operating room is unclear. This study evaluated the effect of resident operative performance following a simulation experience on a hand-sewn small bowel anastomosis and determined the impact of utilizing proficiency-based training. METHODS: Nine categorical interns performed a hand-sewn small bowel anastomosis in the operating room prior to (pre-test) and following (post-test) a 3-h simulation training session with an assessment at the end. Participants were randomly assigned to 1of 2 simulation training groups: proficiency-based or standard. Operative performance was videotaped. 2 independent, blinded faculty surgeons assessed performances by a global rating scale. Pre- and post-confidence levels were obtained on a 5-point Likert scale. RESULTS: Overall, pre-test and post-test operative performance was similar (3 [IQR, 2.5 -3.5] versus 3 [IQR, 3 -3], P = 0.59). Furthermore, no difference was observed in the post-test performance with proficiency-based or standard training (3 [IQR, 3 -3] versus 3 [IQR, 3 -3], P = 0.73). Self-reported confidence with the skills, however, significantly improved (median 1 versus 4, P = 0.007). CONCLUSIONS: In this prospective, randomized study, we did not observe an improvement in operative performance following simulation instruction and assessment, with both training groups. Overcoming barriers to skills transfer will be paramount in the future to optimize simulation training in general surgery. These findings highlight the importance of continued study for the ideal conditions and timing of technical skills training.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Current trends in medical education affecting allergy and immunology physicians and learners.

OBJECTIVE: To review current and relevant trends in medical education, undergraduate medical education, graduate medical education, and continuing medical education for the allergy and clinical immunology (A/I) community. DATA SOURCES: English-only published literature from the past 5 years were obtained by means of a PubMed search and Google Scholar searches in addition to pertinent review articles and relevant textbooks as selected by the authors. STUDY SELECTIONS: A total of 62 articles were selected for their relevance to the article's objective. Older references regarding medical education trends were included when they were felt to be essential. RESULTS: Competency-based medical education is the contextual framework for curriculum, instruction, and assessment. Current trends influencing competency-based medical education are the following: e-learning; interprofessional education; simulation-based medical education; diversity, inclusion, and equity; and mentoring. This review clarifies terminology and offers examples of the potential impact of these trends within the A/I educational community. The development of knowledge and skills related to these topics can be achieved through formal faculty development, mentoring, and self-directed, asynchronous instruction. CONCLUSION: Medical education continues to evolve as health care adapts to meet the changing needs of the health care system and our patients. The A/I physicians should be aware of current trends because these trends impact their roles as instructors and lifelong learners.

An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S.

Issue: As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

Registry-Based Trainee Assessments: Leveraging a Quality Collaborative for Surgical Education.

INTRODUCTION: We present our experience developing and embedding a registry-based module for resident feedback. METHODS: At our institution, entering operative data into the institutional quality collaborative registry is standard practice. In February 2019, a surgical education module was embedded into the registry to capture procedure-specific resident operative assessments. Faculty engagement with the sugical education module was assessed during its first year in existence (February 2019-February 2020). RESULTS: In total, 1074 of 1269 (85%) operative assessments were completed by 27 faculty via the surgical education registry module. Median faculty engagement rate with the module following resident-assisted procedures was 91% [IQR 76%-100%]. Residents received a median of 7 operative assessments [IQR 2-19] over the study period. CONCLUSION: By embedding a surgical education module into an existing surgical quality collaborative registry, procedure-specific operative assessments can be routinely captured.

Effect modification of resident autonomy and seniority on perioperative outcomes in laparoscopic cholecystectomy.

BACKGROUND: Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited. METHODS: Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time. RESULTS: Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64-9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p < 0.001, 95% CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p = 0.069, 95% CI 0.99-1.41). CONCLUSION: While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.

Digital Professionalism in Patient Care: A Case-Based Survey of Surgery Faculty and Trainees.

BACKGROUND: Use of digital devices have become ubiquitous in healthcare and can create professionalism issues. This study presents opinions of faculty, residents, and medical students to inform policy on the appropriate use of digital devices in the patient care setting. MATERIALS AND METHODS: A survey was administered from September 2018 to October 2018 to faculty and residents within the general surgery department at a large academic medical center and all fourth-year medical students at an affiliated university. The survey included direct statements and case-based scenarios on similar themes to triangulate responses. RESULTS: There were 114 participants in the survey-50 faculty, 26 residents, and 38 medical students. Digital device utilization was equivalent among all groups, and all participants use a smartphone. Digital devices were most frequently used during rounds and clinical conferences. Overall, digital device use was found more appropriate when seen in the case-based format rather than as a direct statement. Furthermore, use of these devices was seen as most appropriate when the provider explained its use or left the room to use the device. CONCLUSIONS: Digital devices are used by faculty and trainees at similar rates for parallel purposes, and the benefits for patient-related care are evident. However, the use of digital devices in the presence of patients should be minimized and always preceded by an explanation. These findings can inform institutional policy when creating guidelines on the professional use of these devices in the patient care setting.

Multidisciplinary Simulation Training Improves Surgical Resident Comfort With Airway Management.

BACKGROUND: Airway management is an essential element of surgical training, but with fewer procedures performed during residency, simulation is crucial to fill educational gaps. We evaluated the effect of a multidisciplinary airway simulation on the comfort of general surgery residents in managing airways. MATERIALS AND METHODS: All residents PGY 2-5 at a large academic general surgery residency program participated in a multidisciplinary airway management simulation. Precourse surveys evaluated self-perception of skills in three areas of airway management: surgical airway, basic ventilator strategies, and endotracheal intubation. Simulation consisted of didactic and procedural components and used high- and low-fidelity models including silicon airways, ventilators, porcine trachea, and airway adjuncts. Instruction was provided by anesthesia and otolaryngology faculty. Postcourse assessment was performed with a four-level Likert questionnaire. Results were analyzed using paired t-tests. RESULTS: Of the 19 residents surveyed, 37% of residents had 1-5 h and 32% had 5-10 h of prior airway instruction. Significant increases in mean comfort were observed across all three studied areas. Residents reported increased comfort performing a surgical airway (1.16 versus 1.95), P < 0.0001, and troubleshooting ventilator issues (1.59 versus 2.16), P < 0.0001. Comfort regarding overall airway management including endotracheal intubation demonstrated similar improvement (1.84 versus 2.32), P = 0.02. Subgroup analysis by PGY level showed the greatest impact on comfort level in junior residents. CONCLUSIONS: Multidisciplinary airway simulation can be effectively implemented in a general surgery training program and positively affect trainee comfort with these techniques, particularly among junior residents.

The Right Way to Teach Lefties - Exploring the Experiences of Left-Handed Trainees and Surgeons.

OBJECTIVE: This study describes the educational experiences of left-handed (LH) surgeons and provides recommendations for educating LH trainees, who face challenges due to their handedness. DESIGN, SETTING, AND PARTICIPANTS: A mixed methods analysis was performed. Semi-structured interviews were conducted with LH trainees, LH attendings, and right-handed (RH) attendings representing 4 hospitals within a large academic hospital system. Questions were curated from current literature to explore the educational experiences of LH trainees. Inductive and iterative coding techniques were employed to manually generate themes. Laterality questionnaires for skills in daily life and surgery were collected and analyzed. RESULTS: Laterality questionnaires demonstrate that LH trainees and surgeons are more mixed-handed and use their nondominant hand to a greater extent in surgery compared to daily life than RH attendings. Key themes were identified in the dimension of learning, including that initial decisions for which hand to use remain fixed throughout career, LH learning is largely self-directed, forced conformation to RH norms and microaggressions are common, LH instruments are rarely practical, and LH surgeons are advantaged with situational ambidexterity. Key themes related to teaching include that communication regarding handedness is lacking, RH surgeons are often unaware of/resistant to a LH approach, the onus is on the trainee to suggest accommodations to use their left hand, and attendings rarely effectively mentor LH learners in using their left hand. CONCLUSIONS: Left-handed surgeons face challenges in an environment designed for RH individuals, represented by themes regarding learning and teaching experiences of LH surgeons told by themselves and their teachers. Recommendations were created for LH trainees in learning, all attendings in teaching, LH attendings in their opportunity to mentor, and surgical societies in supporting LH trainees. Development of resources for LH trainees could fill a substantial gap. Exploration of how LH surgeons evolve situational ambidexterity could benefit all surgeons.

Female Representation at the Association of Program Directors in Surgery Annual Meeting: Moving Towards Gender Equality.

OBJECTIVE: This study aims to evaluate the state and changes over time of female representation in Association of Program Directors in Surgery (APDS) leadership and annual meeting presenters and session leaders. DESIGN, SETTING, AND PARTICIPANTS: APDS conference programs from 2013 to 2022 were reviewed to identify society leadership and meeting presenters and session leaders. Verified online profiles were used to gather professional role and reported gender. Descriptive statistics and t-tests compared female representation in the first half (2013-2017, prior) and second half of data (2018-2022, current). RESULTS: Leadership of APDS was an average 22% women, increasing from 13% in 2013 to 37% in 2022, and significantly increased from prior to current period (p = 0.0004). Conference presenters and session leaders were 42% women overall, increasing from 30% in 2013 to 52% in 2022. An average 33% staff surgeons, 54% trainees, 64% education scientists, and 51% medical student participants were female. Staff were 44% female in 2022 from 24% in 2013, significantly increased from prior to current period (p = 0.021). Comparing prior and current period cohorts, female presenters for paper sessions increased from 38% to 55% (p = 0.011), moderators from 15% to 39% (p = 0.046), and last author listed on presentation sessions from 18% to 32% (p = 0.010), while panelists, workshop directors, and presenters at all sessions increased without statistical significance. Female poster presenters decreased over time. CONCLUSIONS: Female representation at APDS meetings has increased over time. Women are well represented compared to the 2022 member population of 36% women. While positions typically held by more senior members, such as leadership, panelists, moderators, and last authors remain lower than other roles, increases over time are encouraging. APDS female representation compares favorably to many other surgical societies. Translation of successful practices regarding gender representation utilized by APDS to other surgical organizations could expedite progress toward gender parity in the field.

The Patient's Voice in Assessing Resident Communication Skills.

OBJECTIVE: To generate validity evidence for using patient-reported satisfaction ratings of residents' communication skills to determine progress along the Interpersonal and Communication Skills (ICS) Milestones. DESIGN: A single-institution, retrospective study analyzed a CAHPS Clinician and Group Survey (CG-CAHPS) database which collects inpatients' ratings of residents' communication skills using 6 questions on a scale of 1 (very poor) to 5 (very good). CG-CAHPS results for each resident were averaged for each question as well as across the 6 questions. The averaged ratings were compared between low and high performer groups. SETTING: A large, academic, mid-western General Surgery residency program. PARTICIPANTS: General Surgery residents with 3 or more survey responses from July 2020 to June 2021 were included. Residents were dichotomized into low or high performer groups based on their end-of-year ICS1 sub-competency milestone within their post-graduate year (PGY) cohort. RESULTS: 543 CG-CAHPS responses across 44 residents were analyzed with a median of 9 (Interquartile range 6, 17) responses per resident. When residents were compared based on PGY, ratings for the question "resident's knowledge about your medical care of condition" demonstrated statistically significant differences with PGY5s receiving the lowest score (p = 0.05). PGY5s received the lowest averaged ratings across all questions (p = 0.08, η2 = 0.10). When residents were dichotomized into low (n = 21) and high performer groups (n = 23) based on ICS1 milestones, statistically significant differences were noted in ratings for the questions "concern the resident showed for your questions or worries" (4.81 vs. 5, p = 0.047) and "courtesy and respect of the resident" (4.75 vs. 5, p = 0.046). CONCLUSIONS: Analysis of patient ratings of surgery residents' communication skills demonstrated concordant findings between ICS1 milestone and 2 domains of CG-CAHPS responses. When low and high performer groups were compared, CG-CAHPS responses demonstrated a similar pattern. These findings provide validity evidence for CG-CAHPS data as a source of information for ICS1 sub-competency assessment.

Operative teaching takes "GUTS": Impact of Educational Time Out on trainee's cognitive load.

BACKGROUND: Educational Time Out (ETO) incorporates intraoperative goal setting, task delineation, and debriefing. ETO has been previously reported to generate positive learning experiences for residents. This study aimed to study the impact of ETO on surgery residents' cognitive load. METHODS: A cross-over study design utilized the ETO arm during the first half of the rotation followed by no ETO for the second half. Surgery residents completed a modified NASA Task Load Index (NASA TLX) questionnaire following each operative case to report their cognitive load. RESULTS: 141 modified NASA TLX questionnaire responses were obtained where ETO occurred in 73 responses and no ETO in 68 responses. Residents reported a higher performance (p = 0.004) and a lower frustration (p = 0.018) component scores when ETO occurred. CONCLUSIONS: This study identified improved cognitive load on the modified NASA TLX instrument with higher performance and lower frustration scores associated with trainees who underwent preoperative goal setting with an ETO using the GUTS method.

Digital Professionalism in Patient Care: A Case Based Survey of Patients.

OBJECTIVE: The objective of this study was to obtain the perception of patients on the use of portable digital media devices by providers during patient care and compare the findings to a previous study that examined providers' perceptions on the use of these devices. DESIGN: This was a cross-sectional survey study. SETTING: This study took place at a large tertiary referral center. PARTICIPANTS: Participants were identified via inpatient lists from general surgery services. RESULTS: Of those eligible to participate, 70% completed the questionnaire. While some situations were seen as less appropriate, the overall consensus from participants was that informing the patient of why the physician is using a digital media device made it more appropriate. CONCLUSION: Patients recognize digital device use in healthcare is appropriate and professional when discussed with them in advance. Overall, patients and providers are in agreement that portable digital technology can improve patient care and open communication about the use improves the provider-patient relationship. There is some risk to patient trust in using digital devices in their presence.

The Virtual Recruitment Onion: Peeling Back the Layers of the Interview Season During the COVID-era.

OBJECTIVE: We sought to characterize General Surgery residency program directors' (PDs) baseline perspective on how the COVID-19 mandated changes to the recruitment and interview processes impacted how the PDs evaluated and recruited the applicants. DESIGN: An anonymous cross-sectional questionnaire survey. SETTING: A large, mid-western academic general surgery residency program. PARTICIPANTS: 47 PDs of Accreditation Council for Graduate Medical Education (ACGME) accredited General Surgery residency programs. RESULTS: During the virtual-only interviews during the COVID-19 pandemic-era 2020-21 General Surgery residency application cycle, PDs shifted their focus to virtual outreach efforts and bolstered social media presences to recruit strong applicants. Also, our study found statistically significant changes to the increased value of letters of recommendation (LORs) for the PDs when assessing an applicant's commitment to surgery. These findings suggest that the necessity of adapting to the virtual-only interview format significantly altered how the PDs recruited and evaluated applicants for the General Surgery residency match. CONCLUSIONS: A complete replacement of the in-person interviews with virtual-only interviews may be challenging unless buy-in exists from key stakeholders in the surgical community. Our study highlights the PDs' hesitation in assessing candidates' commitment to surgery from virtual interviews alone. Incorporating virtual interviews as a part of the screening process for applicants may serve as an avenue to maximize the benefits of the virtual interview format. Furthermore, COVID-19 pandemic has normalized the growing social media presence of residency programs, adding to the changing landscape of recruiting and interviewing applicants for General Surgery residency match.

Managing Up: Approaching Mentoring From a Mentee's Perspective.

OBJECTIVE: Discuss the evolution of mentorship models in surgical training and how educating the surgical trainees with the concepts from "manage up" theory can empower them to maximize the benefits afforded by mentoring relationships. METHODS: "Manage up" theory is derived from the business world where the subordinate takes ownership of the mentoring relationship with their superior by assessing the strengths and weaknesses of both parties and applying that information in managing a productive relationship. DISCUSSION: Surgery residency programs implement a variety of structured and unstructured mentorship programs to promote mentoring relationships and to encourage professional development. Mentees in successful mentoring relationships demonstrate characteristics and skills that residency programs can promote through formal training. Components of "manage up" theory can be applied by surgical trainees in approaching their mentors and in managing their mentor-mentee relationships. CONCLUSIONS: The benefits gained from a successful mentoring relationship for both the mentor and the mentee depend on active roles played by both parties. Strong evidence supports the need for educating mentees through formal curricula to empower them to assume an active role in their mentoring relationships.

A Document Analysis of Nationally Available Faculty Assessment Forms of Resident Performance.

BACKGROUND: Written feedback by faculty of resident performance is valuable when it includes components based on assessment for learning. However, it is not clear how often assessment forms include these components for summative and formative feedback. OBJECTIVE: To analyze prompts used in forms for faculty assessment of resident performance, guided by best practices in survey research methodology, self-regulation theory, and competency-based assessment. METHODS: A document analysis, which is a qualitative approach used to analyze content and structure of texts, was completed on assessment forms nationally available in MedHub. Due to the number of forms available, only internal medicine and surgery specialties were included. A document summary form was created to analyze the assessments. The summary form guided researchers through the analysis. RESULTS: Forty-eight forms were reviewed, each from a unique residency program. All forms provided a textbox for comments, and 54% made this textbox required for assessment completion. Eighty-three percent of assessments placed the open textbox at the end of the form. One-third of forms contained a simple prompt, "Comments," for the narrative section. Fifteen percent of forms included a box to check if the information on the form had been discussed with the resident. Fifty percent of the assessments were unclear if they were meant to be formative or summative in nature. CONCLUSIONS: Our document analysis of assessment forms revealed they do not always follow best practices in survey design for narrative sections, nor do they universally address elements deemed important for promotion of self-regulation and competency-based assessment.

Beyond Medical Knowledge and Patient Care: A Program Director's Perspective for the Role of General Surgery Subinternships.

OBJECTIVE: Established primary goals of general surgery subinternships are improvement in patient care and medical knowledge. However, the secondary gains such as obtaining recommendation letters and forming relationships are apparent but poorly defined. We sought the opinion of general surgery program directors (PDs) on the secondary purposes of subinternships. Our aim is to aide mentors and students to optimize the subinternship experience relative to the residency application process. DESIGN: A survey was administered in July 2019. This questionnaire consisted of 11 items and was broken down into 3 sections: demographics, PD perspective on the secondary goals of a general surgery subinternship, and the role of general surgery subinternships on the students' residency application. SETTING: An online, national survey through the Association for Program Directors listserv. PARTICIPANTS: United States general surgery PDs affiliated with the Association for Program Directors listserv. RESULTS: Sixty-one PDs completed the survey from 42 (69%) academic and 14 (23%) community programs. The majority of PDs (n = 33, 54%) reported that assessment of a subintern's suitability for their residency was the most important secondary purpose. Furthermore, PDs (n = 24, 39%) valued a letter of recommendation from faculty the student worked with during a subinternship as the most important criteria in the interview selection process. Away rotations were perceived as of equal value to subinternships completed at the student's home institution. Overall, PD opinions were similar at academic and community programs. CONCLUSIONS: Our study suggests subinternships significantly impact a student's application to general surgery residency, clarifying a secondary role for these rotations. Subinternships are important for PDs to assess a student for ranking at their program. All students should pursue a letter of recommendation from subinternship faculty, when possible, as they can heavily influence the interview selection process. Away rotations should only be recommended for those students who need to strengthen their application.