Surgical Trainee Performance and Alignment With Surgical Program Director Expectations.

OBJECTIVE: To examine the alignment between graduating surgical trainee operative performance and a prior survey of surgical program director expectations. BACKGROUND: Surgical trainee operative training is expected to prepare residents to independently perform clinically important surgical procedures. METHODS: We conducted a cross-sectional observational study of US general surgery residents' rated operative performance for Core general surgery procedures. Residents' expected performance on those procedures at the time of graduation was compared to the current list of Core general surgery procedures ranked by their importance for clinical practice, as assessed via a previous national survey of general surgery program directors. We also examined the frequency of individual procedures logged by residents over the course of their training. RESULTS: Operative performance ratings for 29,885 procedures performed by 1861 surgical residents in 54 general surgery programs were analyzed. For each Core general surgery procedure, adjusted mean probability of a graduating resident being deemed practice-ready ranged from 0.59 to 0.99 (mean 0.90, standard deviation 0.08). There was weak correlation between the readiness of trainees to independently perform a procedure at the time of graduation and that procedure's historical importance to clinical practice ( p = 0.22, 95% confidence interval 0.01-0.41, P = 0.06). Residents also continue to have limited opportunities to learn many procedures that are important for clinical practice. CONCLUSION: The operative performance of graduating general surgery residents may not be well aligned with surgical program director expectations.

Striving for work-life balance: effect of marriage and children on the experience of 4402 US general surgery residents.

OBJECTIVE: To determine how marital status and having children impact US general surgical residents' attitudes toward training and personal life. BACKGROUND: There is a paucity of research describing how family and children affect the experience of general surgery residents. METHODS: Cross-sectional survey involving all US categorical general surgery residents. Responses were evaluated by resident/program characteristics. Statistical analysis included the χ test and hierarchical logistic regression modeling. RESULTS: A total of 4402 residents were included (82.4% response rate) and categorized as married, single, or other (separated/divorced/widowed). Men were more likely to be married (57.8% vs 37.9%, P < 0.001) and have children (31.5% vs 12.0%, P < 0.001). Married residents were most likely to look forward to work (P < 0.001), and report happiness at work (P < 0.001) and a good program fit (P < 0.001). "Other" residents most frequently felt that work hours caused strain on family life (P < 0.001). Residents with children more frequently looked forward to work (P = 0.001), were happy at work (P = 0.001), and reported a good program fit (P = 0.034), but had strain on family life (P < 0.001), and worried about future finances (P = 0.005). On hierarchical logistic regression modeling, having children was predictive of a resident looking forward to work [odds ratio (OR): 1.22, P = 0.035], yet feeling that work caused family strain (OR: 1.66, P < 0.001); being single was associated with less strain (OR: 0.72, P < 0.001). The female gender was negatively associated with looking forward to work (OR: 0.81, P = 0.007). CONCLUSIONS: Residents who were married or parents reported greater satisfaction and work-life conflict. The complex effects of family on surgical residents should inform programs to target support mechanisms for their trainees.

Discrepancies in training satisfaction and program completion among 2662 categorical and preliminary general surgery residents.

OBJECTIVE: To compare training experiences of postgraduate year (PGY)-1 and PGY-2 categorical and nondesignated preliminary (NDP) residents and examine NDP educational outcomes. BACKGROUND: There is a paucity of research describing the professional attitudes of NDP surgical trainees. METHODS: Analysis of the 2009 National Study of Expectations and Attitudes of Residents in Surgery survey and American Board of Surgery 2009 to 2011 Resident Rosters. Chi-square and hierarchical logistic regression modeling were employed. RESULTS: A total of 1428 PGY-1s (528 NDPs) and 1234 PGY-2s (189 NDPs) were included. Among PGY-1s, NDPs reported lower program satisfaction than categorical residents (84.2% vs 89.2%, P = .007), and less collegiality with coresidents (P = 0.001). NDPs were less satisfied with their operative experience (P = 0.002) and less frequently enjoyed operating (P < 0.001). NDPs more frequently reported that "the personal cost of surgical training is not worth it" (11.2% vs 3.7%, P < 0.001) and were less frequently committed to completing their surgical training (P < 0.001). Among PGY-2s, NDPs expressed a lower program fit (P = 0.008) and commitment to program completion (P = 0.037). Of 1102 NDP PGY-1s and PGY-2s on the 2009 American Board of Surgery Resident Roster, 347 achieved categorical status by 2011 (31.5%), including 237 National Study of Expectations and Attitudes of Residents in Surgery respondents (34.3%). Marked response differences were found between NDPs who ultimately did and did not achieve categorical status. In hierarchical logistic regression modeling, older age [30-34 years, odds ratio (OR): 0.54; ≥35 years, OR: 0.28), and race/ethnicity (black, OR: 0.28; Hispanic, OR: 0.50) were negatively associated with an NDP attaining categorical status. CONCLUSIONS: The residency experience for NDPs appears less rewarding than for categorical residents. NDPs report less robust operative experience and overall support. Ultimately, only one third of NDPs become categorical surgery residents.

Race and surgical residency: results from a national survey of 4339 US general surgery residents.

OBJECTIVE: To determine how race influences US general surgery residents' experiences during residency training. BACKGROUND: Minorities are underrepresented in medicine, particularly surgery, with no large-scale studies investigating their training experiences. METHODS: Cross-sectional national survey administered after the 2008 American Board of Surgery In-Training Examination to all categorical general surgery residents. Demographic characteristics and survey responses with respect to race were evaluated using the χ test and hierarchical logistic regression modeling. RESULTS: A total of 4339 residents were included: 61.9% whites, 18.5% Asians, 8.5% Hispanics, 5.3% Blacks, and 5.8% Others. Minorities differed from whites in sex proportion, marital status, number of children, geographic location, type of residency program, and 24 survey items (all Ps < 0.05). Compared with white residents, Black, Asian, and Other residents were less likely to feel they fit in at their programs (86.2% vs 73.9%, 83.3%, and 81.2%, respectively; P < 0.001). Black and Asian residents were more likely to report that attendings would think worse of them if they asked for help (13.5% vs 20.4% and 18.4%, respectively; P = 0.002), and Black residents were less likely to feel they could count on their peers for help (85.2% vs 77.2%; P = 0.017). On hierarchical logistic regression modeling, Blacks were least likely to fit in at their programs (odds ratio = 0.6; P = 0.004), and all minorities were more likely to feel that there was a need for additional specialty training (odds ratio = 1.4 Blacks and Hispanics, 1.9 Asians, and 2.1 Others; all Ps ≤ 0.05). CONCLUSIONS: Minority residents report less positively on program fit and relationships with faculty and peers. Future studies should focus on examining residency interventions to improve support and integration of minority residents.

National curricula, certification and credentialing.

The education, certification, and credentialing of surgeons is undergoing change brought about by public expectations and by reform within the profession. In the United States, there is a clear trend towards standardization of education, as exemplified by the Surgical Council on Resident Education (SCORE) curriculum. There is an emerging effort to tie certification closely to the national curriculum. Finally, there is clarity emerging from the curriculum development process about the expected operative skills of graduating surgical trainees, and this will ultimately drive the process by which surgeons are credentialed by their hospitals or surgical centers. This period of change is being accompanied by a demand for more assessment of trainees and for outcomes-based training and residency program accreditation.

A national study of attrition in general surgery training: which residents leave and where do they go?

OBJECTIVE(S): Implementation of the 80-hour mandate was expected to reduce attrition from general surgery (GS) residency. This is the first quantitative report from a national prospective study of resident/program characteristics associated with attrition. METHODS: Analysis included all categorical GS residents entered on American Board of Surgery residency rosters in 2007 to 2008. Cases of attrition were identified by program report, individually confirmed, and linked to demographic data from the National Study of Expectations and Attitudes of Residents in Surgery administered January 2008. RESULTS: All surgical categorical GS residents active on the 2007-2008 resident rosters (N = 6,303) were analyzed for attrition. Complete National Study of Expectations and Attitudes of Residents in Surgery demographic information was available for 3959; the total and survey groups were similar with regard to important characteristics. About 3% of US categorical residents resigned in 2007 to 2008, and 0.4% had contracts terminated. Across all years (including research), there was a 19.5% cumulative risk of resignation. Attrition was highest in PGY-1 (5.9%), PGY-2 (4.3%), and research year(s) (3.9%). Women were no more likely to leave programs than men (2.1% vs. 1.9%). Of several program/resident variables examined, postgraduate year-level was the only independent predictor of attrition in multivariate analysis. Residents who left GS whose plans were known most often pursued nonsurgical residencies (62%), particularly anesthesiology (21%) and radiology (11%). Only 13% left for surgical specialties. CONCLUSIONS: Attrition rates are high despite mandated work hour reductions; 1 in 5 GS categorical residents resigns, and most pursue nonsurgical careers. Demographic factors, aside from postgraduate year do not appear predictive. Residents are at risk for attrition early in training and during research, and this could afford educators a target for intervention.

Operative experience of residents in US general surgery programs: a gap between expectation and experience.

OBJECTIVE: The purpose of the study was to identify a group of operations which general surgery residency program directors believed residents should be competent to perform by the end of 5 years of training and then ascertain actual resident experience with these procedures during their training. SUMMARY BACKGROUND DATA: There is concern about the adequacy of training of general surgeons in the United States. The American Board of Surgery and the Association of Program Directors in Surgery undertook a study to determine what operative procedures residency program directors consider to be essential to the practice of general surgery and then we measured the actual operative experience of graduating residents in those procedures, as reported to the Residency Review Committee for Surgery (RRC). METHODS: An electronic survey was sent to residency program directors at the 254 general surgery programs in the US accredited by the RRC as of spring 2006. The program directors were presented with a list of 300 types of operations. Program directors graded the 300 procedures "A," "B," or "C" using the following criteria: A--graduating general surgery residents should be competent to perform the procedure independently; B--graduating residents should be familiar with the procedure, but not necessarily competent to perform it; and C--graduating residents neither need to be familiar with nor competent to perform the procedure. After ballots were tallied, the actual resident operative experience reported to the RRC by all residents finishing general surgery training in June 2005 was reviewed. RESULTS: One hundred twenty-one of the 300 operations were considered A level procedures by a majority of program directors (PDs). Graduating 2005 US residents (n = 1022) performed only 18 of the 121 A procedures, an average of more than 10 times during residency; 83 of 121 procedures were performed on an average less than 5 times and 31 procedures less than once. For 63 of the 121 procedures, the mode (most commonly reported) experience was 0. In addition, there was significant variation between residents in operative experience for specific procedures. In virtually all cases, the mean reported experience exceeded the mode, suggesting that the mean is a poor measure of typical experience. CONCLUSIONS: These data pose important problems for surgical educators. Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations. Finally, the large variations in experience between individuals in our residency system need to be explored, understood, and remedied.

Surgical education in the internet era.

Technological advancements, along with economic and political issues, have resulted in major changes in surgical education. The development of high fidelity simulators and the widespread availability of the Internet have allowed learning to be shifted away from the operating room. Furthermore, the Internet provides an opportunity for surgical educators to standardize general surgery training and assessment and to develop collaborations nationally and globally. This paper highlights presentations about the challenges as well as the rewards of surgical education in the age of the Internet from the 2009 Academic Surgical Congress.

Overexpression of 5-lipoxygenase in colon polyps and cancer and the effect of 5-LOX inhibitors in vitro and in a murine model.

PURPOSE: Arachidonic acid metabolism via the cyclooxygenase (COX) and 5-lipoxygenase (5-LOX) pathways modulates cell growth and apoptosis. Many studies have examined the effects of COX inhibitors on human colorectal cancer, but the role of 5-LOX in colonic cancer development has not been well studied. The purpose of this study was to evaluate the expression of 5-LOX in colonic polyps and cancer and the effect of 5-LOX inhibition on colon cancer cell proliferation. EXPERIMENTAL DESIGN: Colonic polyps, cancer, and normal mucosa were evaluated for 5-LOX expression by immunohistochemistry. Reverse transcription-PCR was used to establish 5-LOX expression in colon cancer cells. Thymidine incorporation and cell counts were used to determine the effect of the nonspecific LOX inhibitor Nordihydroguaiaretic Acid and the 5-LOX inhibitor Rev5901 on DNA synthesis. A heterotopic xenograft model in athymic mice using HT29 and LoVo human colon cancer cells was used to evaluate the effect of the 5-LOX inhibitor zileuton on tumor growth. RESULTS: 5-LOX is overexpressed in adenomatous polyps and cancer compared with that of normal colonic mucosa. LOX inhibition and 5-LOX inhibition decreased DNA synthesis in a concentration- and time-dependent manner in the Lovo cell line (P < 0.05). Inhibition of 5-LOX in an in vivo colon cancer xenograft model inhibited tumor growth compared with that of controls (P < 0.05). CONCLUSIONS: This study showed that 5-LOX is up-regulated in adenomatous colon polyps and cancer compared with normal colonic mucosa. The blockade of 5-LOX inhibits colon cancer cell proliferation both in vitro and in vivo and may prove a beneficial chemopreventive therapy in colon cancer.

Attitudes, training experiences, and professional expectations of US general surgery residents: a national survey.

CONTEXT: General surgery residency programs are facing multiple pressures, including attracting and retaining residents. Despite the importance of resident perspectives in designing effective responses to these pressures, understanding of residents' views is limited. OBJECTIVE: To profile US general surgery residents; characterize resident attitudes, experiences, and expectations regarding training; and examine differences by sex and training year. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of all general surgery residents completing a survey in January 2008 following administration of the American Board of Surgery In-Training Examination. MAIN OUTCOME MEASURES: Resident satisfaction; perceived supports, strains and concern; career motivations; and professional expectations. RESULTS: Of 5345 categorical general surgery residents, 4402 (82.4%) responded, representing 248 of 249 surgical residency programs. Most respondents expressed satisfaction with training (3686 [85.2%]; 95% confidence interval [CI], 84.1%-86.3%) and supportive peer relationships (3433 [84.2%]; 95% CI, 83.1%-85.3%). However, residents also reported unmet needs and apprehensions about training and careers. Worry that they will not feel confident performing procedures independently was reported by 1185 (27.5%; 95% CI, 26.2%-28.8%), while 2681 (63.8%; 95% CI, 62.4%-65.3%) reported that they must complete specialty training to be competitive. Perceptions of program support differ, with men more likely than women to report that their program provides support (2188 [74.5%] vs 895 [65.6%]; P < .001), and that they can turn to faculty when having difficulties (2193 [74.5%] vs 901 [66.4%]; P < .001). Reports of having considered leaving training in the prior year differed significantly across years (P < .001), highest in postgraduate year 2 (19.2%) and lowest in postgraduate year 5 (7.2%). CONCLUSIONS: General surgery residents' attitudes, experiences, and expectations regarding training reflect both high levels of satisfaction and sources of strain. These factors vary by sex and training year.

Treatment of chronic pancreatitis with endotherapy or surgery: critical review of randomized control trials.

The goal of this Society for Surgery of the Alimentary Tract postgraduate course was to review critically the highest level of published evidence focused on treating the disabling chronic abdominal pain due to chronic pancreatitis. Just eight randomized controlled trials (RCTs) have been reported since 1995. All are from Europe. These eight RCTs utilized 380 patients to compare a diverse variety of surgical resections, surgical drainage vs. endotherapy (trans-ampullary pancreatic stents for drainage), or endotherapy with or without shock wave lithotripsy. Therefore, these trials contained a paucity of patients for each treatment compared. Heterogeneity was evident after analysis of the study designs because they used a diverse set of inclusion and exclusion criteria usually not based on objective criteria such as ductal anatomy. All but one had short follow-up. Because of the lack of homogeneity for these study designs that were somewhat underpowered, the RCTs on the treatment of chronic pancreatitis to relieve disabling abdominal pain must be read carefully. In addition to RCTs, the case series still remains a valuable part of our literature.

Measuring Competence in Surgical Training through Assessment of Surgical Entrustable Professional Activities.

OBJECTIVE: To assess competency in surgical residents with bundled assessments using a surgical entrustable professional activity (SEPA) framework. DESIGN: A pilot study was conducted using a combination of validated assessment tools (multiple choice exam (MCE) questions from the Surgical Council on Resident Education [SCORE], the Clinical Assessment and Management Examination - Outpatient (CAMEO) form, the Virtual Surgical Patient (VSP) website, and a procedure-specific Operative Performance Rating System [OPRS]) to determine competency in surgical residents in the treatment of breast cancer and gallbladder disease, respectively. SETTING: A large academic institution with a surgical training program in the Mid West of the United States. PARTICIPANTS: A total of 10 categorical surgical residents were invited to participate. Five completed the breast surgical EPA (SEPA) and 5 different residents completed the gallbladder SEPA. RESULTS: In terms of performance on the assessments, for the breast SEPA, scores did not appear to be related to PGY level, and residents' performance in general was the least strong on the MCE and the VSP case. The gallbladder SEPA showed a more expected pattern, distinguishing between junior and senior residents. As expected, all junior residents were required to remediate the OPRS assessment, while the senior residents passed. For the OPRS, senior level residents consistently were rated as "excellent" in terms of operative flow (5/5), while junior residents were all given a score of "good" (3/5). CONCLUSIONS: Assessing competence among surgical residents has been a discussion for several years. Varying methods of assessing competence have been proposed, but surgical competence is presently defined in a very general way through both the ACGME and American Board of Surgery (ABS). Using a SEPA format, as proposed, we could ensure specific understanding of each graduating resident's ability. These results show that the SEPA may be a valid tool for defining and capturing multiple areas of competence that are associated with different disease processes.

On the role of transforming growth factor-beta in the growth inhibitory effects of retinoic acid in human pancreatic cancer cells.

BACKGROUND: Retinoids are potent growth inhibitory and differentiating agents in a variety of cancer cell types. We have shown that retinoids induce growth arrest in all pancreatic cancer cell lines studied, regardless of their p53 and differentiation status. However, the mechanism of growth inhibition is not known. Since TGF-beta2 is markedly induced by retinoids in other cancers and mediates MUC4 expression in pancreatic cancer cells, we investigated the role of TGF-beta in retinoic acid-mediated growth inhibition in pancreatic cancer cells. RESULTS: Retinoic acid markedly inhibited proliferation of two cell lines (Capan-2 and Hs766T) in a concentration and time-dependent manner. Retinoic acid increased TGF-beta2 mRNA content and secretion of the active and latent forms of TGF-beta2 (measured by ELISA and bioassay). The concentrations of active and TGF-beta2 secreted in response to 0.1 - 10 muM retinoic acid were between 1-5 pM. TGF-beta2 concentrations within this range also inhibited proliferation. A TGF-beta neutralizing antibody blocked the growth inhibitory effects of retinoic acid in Capan-2 cells and partially inhibitory the effects in Hs766T cells. CONCLUSION: These findings indicate that TGF-beta can cause growth inhibition of pancreatic cancer cells, in a p53-independent manner. Furthermore, it demonstrates the fundamental role of TGF-beta in growth inhibition in response to retinoic acid treatment is preserved in vitro.

Duodenum-preserving head resection for chronic pancreatitis: an institutional experience and national survey of usage.

BACKGROUND: Duodenum-preserving pancreatic head resections (DPPHRs) have been shown in European randomized clinical trials to be superior to pancreaticoduodenectomy for chronic pancreatitis, but DPPHR procedures have been slow to be adopted in the United States. METHODS: To assess national attitudes of surgeons toward DPPHR, a web-based survey was administered to the U.S. members of the Pancreas Club, which is a national organization of pancreatic surgeons. We also performed a retrospective review of 21 DPPHRs, performed by the senior author, for chronic pancreatitis between January 2000 and March 2005. RESULTS: The web-based national survey was completed by 64 of 118 members of the Pancreas Club (54.24%). Of the 59 surgeons who perform operations for chronic pancreatitis, 34 had performed a DPPHR at least once. Only 23 U.S. surgeons continue to perform these procedures. Most surgeons who are not performing DPPHRs responded that, despite the published literature, existing procedures such as the Whipple and Puestow were better procedures. In our clinical series, 12 men and 9 women with a mean age of 48.2 +/- 9.6 years underwent DPPHR. The median length of stay was 9 days with 6 patients (28%) who had complications in the postoperative period. Ten of 20 potentially evaluable patients completed a visual analog pain scale and EORTC C-30 quality-of-life questionnaire. Pancreatic functioning approached the normal range in all domains. As compared with a general population of patients with chronic pancreatitis, significant improvement occurred in pancreatic-related pain and digestive function. Self-reported pain was significantly better after operation than before operation. CONCLUSIONS: DPPHR provides excellent functional results with relatively low postoperative morbidity and duration of stay. These procedures are underused in the United States, with very few surgeons who use, teach them, or report their results.

Surgical council on resident education: a new organization devoted to graduate surgical education.

The Surgical Council on Resident Education (SCORE) is a voluntary consortium of six organizations with responsibility for resident education in surgery and an interest in improving the training of surgeons. The founding organizations are the American Board of Surgery (ABS), the American College of Surgeons (ACS), the American Surgical Association (ASA), the Association of Program Directors in Surgery (APDS), the Association for Surgical Education (ASE), and the Residency Review Committee for Surgery of the Accreditation Council on Graduate Medical Education (RRC-S). SCORE emerged from a concerted desire to strengthen the graduate education of surgeons and to assure the competence of surgical trainees in the US. SCORE has a unique ability to foster change in resident education because it brings together the major regulatory organizations (ABS and RRC-S), the major professional organization in surgery (ACS), the senior academic organization in surgery (ASA), and the major surgical education organizations (APDS and ASE). SCORE envisions an ambitious agenda. At its meeting in Philadelphia on November 20, 2006, it began developing a standardized curriculum in general surgery to span the period from medical school to practice, and it defined the scope of the curriculum. It approved continued work of building a national Web site to deliver educational content to general surgery residents and to assist program directors. It endorsed continued development of a basic surgery curriculum for all first-year surgery residents and development of a comprehensive technical skills curriculum for all levels of general surgery training, both of which have been initiated by the ACS. In the future, SCORE plans to examine issues such as the assessment of technical competency, the role of simulation in surgical education, the teaching and assessment of professional behaviors, the practicing surgeon's view of the adequacy of residency training, faculty development, and the attrition of residents from surgery residencies. Members of SCORE intend to investigate best practices in surgical education in other countries. SCORE hopes to take a leadership position in improving the quality of surgical education and surgery in the US.

Implementation and evaluation of a new surgical residency model.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) duty-hour requirements prompted program directors to rethink the organizational structure of their residency programs. Many surgical educators have expressed concerns that duty-hour restrictions would negatively affect quality of resident education. This article summarizes evaluation research results collected to study the impact of our reengineered residency program designed to preserve important educational activities while meeting duty-hour accreditation requirements. STUDY DESIGN: The traditional residency structure was redesigned to include a mixture of apprenticeship, small team, and night-float models. Impact evaluation data were collected using operative case logs, standardized test scores, quality assurance data, resident perception surveys, a faculty survey, and process evaluation measures. RESULTS: PGY1s and PGY2s enjoyed a substantial increase in operative cases. Operative cases increased overall and no resident has failed to meet ACGME volume or distribution requirements. American Board of Surgery In-Training Examination performance improved for PGY1s and PGY2s. Patient outcomes measures, including monthly mortality and number of and charges for admissions, showed no changes. Anonymously completed rotation evaluation forms showed stable or improved resident perceptions of case load, continuity, operating room teaching, appropriate level of faculty involvement and supervision, encouragement to attend conferences, and general assessment of the learning environment. A quality-of-life survey completed by residents before and after implementation of the new program structure showed substantial improvements. Faculty surveys showed perceived increases in work hours and job dissatisfaction. New physician assistant and nurse positions directly attributed to duty-hour restrictions amounted to about 0.2 full-time equivalent per resident. CONCLUSIONS: Duty-hour restrictions produce new challenges and might require additional resources but need not cause a deterioration of surgical residents' educational experience.

National efforts to reform residency education in surgery.

Major changes in surgical practice and myriad external mandates have affected residency education in surgery. The traditional surgery residency education and training model has come under scrutiny, and calls for major reform of this model have been made by a variety of stakeholders. The American Surgical Association appointed a Blue Ribbon Committee in 2002 to consider the recent changes in surgical practice and surgical education and propose solutions that would ensure a well-educated and well-trained surgical workforce for the future. This committee included representatives from the American Surgical Association, the American College of Surgeons, the American Board of Surgery, and the Residency Review Committee for Surgery. The committee made several far-reaching recommendations relating to residency education in surgery. After the Blue Ribbon Committee completed its task in 2004, representatives from the aforementioned four organizations, the Association of Program Directors in Surgery, and the Association for Surgical Education created a national consortium called the Surgical Council on Resident Education (SCORE). This consortium is pursuing efforts to reform residency education in surgery and implement several key recommendations of the Blue Ribbon Committee. The principal area of focus of SCORE is the development of a national curriculum for surgery residency education and training. Other activities of SCORE include the development of a Web site to support surgery residency education and pursuit of international collaboration. SCORE's efforts will be key to offering surgery residents the best educational experiences, preparing residents for future practice, and supporting delivery of surgical care of the highest quality. The authors examine the current state of residency education in surgery and explore efforts underway to reform this educational model.

Graduate medical education in surgery in the United States.

Each year, approximately 1000 graduating medical students enter 5-year residency programs in general surgery. Their salaries are funded by the federal government. Following 5 years of general surgery training, approximately 70% of graduates enroll in a specialty fellowship. Surgery training currently faces a number of challenges, including the diminishing attractiveness of surgery as a career, attrition from residency programs, mandated work hour limits, extensive service requirements in the hospital environment, increasing specialization, and changing patient expectations about the role of residents in their care, among others. In the face of these challenges, the profession is beginning to respond to the need for positive change in the process of training surgeons.

5-Lipoxygenase, a marker for early pancreatic intraepithelial neoplastic lesions.

Pancreatic cancer has an abysmal prognosis because of late diagnosis. Therefore, it is important to identify risk factors if we are to be able to prevent and detect this cancer in an early, noninvasive stage. Pancreatic intraepithelial neoplasias (PanIN) are the precursor lesions which could be an ideal target for chemoprevention. This study shows up-regulation of 5-lipoxygenase (5-LOX) in all grades of human PanINs and early lesions of pancreatic cancer in two different animal models (EL-Kras mice and N-nitrosobis(2-oxopropyl)amine-treated hamsters) by immunohistochemistry. The results were consistent in all tissues examined, including seven chronic pancreatitis patients, four pancreatic cancer patients, one multiorgan donor, nine EL-Kras mice, and three N-nitrosobis(2-oxopropyl)amine-treated hamsters, all with PanINs. Overexpression of 5-LOX in NIH3T3 cells resulted in greater sensitivity of these cells to the growth inhibitory effects of the 5-LOX inhibitor Rev5901. These findings provide evidence that 5-LOX plays a key role in the development of pancreatic cancer. Furthermore, the lipoxygenase pathway may be a target for the prevention of this devastating disease.

Apigenin inhibits pancreatic cancer cell proliferation through G2/M cell cycle arrest.

BACKGROUND: Many chemotherapeutic agents have been used to treat pancreatic cancer without success. Apigenin, a naturally occurring flavonoid, has been shown to inhibit growth in some cancer cell lines but has not been studied in pancreatic cancer. We hypothesized that apigenin would inhibit pancreatic cancer cell growth in vitro. RESULTS: Apigenin caused both time- and concentration-dependent inhibition of DNA synthesis and cell proliferation in four pancreatic cancer cell lines. Apigenin induced G2/M phase cell cycle arrest. Apigenin reduced levels of cyclin A, cyclin B, phosphorylated forms of cdc2 and cdc25, which are all proteins required for G2/M transition. CONCLUSION: Apigenin inhibits growth of pancreatic cancer cells through suppression of cyclin B-associated cdc2 activity and G2/M arrest, and may be a valuable drug for the treatment or prevention of pancreatic cancer.