The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents' self-efficacy.

BACKGROUND: Implementation of the Fundamentals of Laparoscopic Surgery (FLS) by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for educational structure for laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy (SE) with laparoscopic procedures. METHODS: We conducted a national survey, linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9275 residents from 325 US General Surgery Training Programs participated. The online survey included multimodal questions that analyzed whether participants felt they could perform the most commonly-logged laparoscopic operations among residents [Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), Laparoscopic Right Hemicolectomy (LRH), Diagnostic Laparoscopy (DL)] without faculty assistance. This used a 5-point scaled assessment, ranging from "not able to" to "definitely able to." Multivariate analyses determined if completion of FLS made a difference for resident self-efficacy, stratified by post-graduate year (PGY). RESULTS: At the time of the survey, 2300 reported completion of FLS. The percentage of FLS completion increased from PGY1 to PGY5 (4.2% n = 59 vs 85.8% n = 893). PGY1 residents who completed FLS, from 48 diverse institutions, demonstrated the most significant increases in SE (p < 0.05) with significantly higher perceived self-efficacy in LA (p = 0.001) and LRH (p = 0.012). PGY2 and PGY3 residents indicated increased SE in DL (p = 0.037, p = 0.015, respectively), based on FLS completion. These FLS effects were less evident in the more senior classes. CONCLUSIONS: Completion of FLS arguably has the greatest benefits for more junior residents, as it establishes a foundation of laparoscopic knowledge and skill, upon which further residency training can build. Successful completion of the curriculum and assessment offered by the Fundamentals of Laparoscopic Surgery leads to greater sense of ability in early trainees.

Diversity, Equity, and Inclusion: A Current Analysis of General Surgery Residency Programs.

BACKGROUND: Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally. MATERIALS AND METHODS: General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses. RESULTS: A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05). DISCUSSION: In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.

Individual and Institutional Factors Associated with PGY5 General Surgery Resident Self-Efficacy: A National Survey.

BACKGROUND: Variability in post-graduate year 5 (PGY5) residents' operative self-efficacy exists; yet the causes of variability have not been explored. Our study aims to determine resident-related and program-dependent factors associated with residents' perceptions of self-efficacy. STUDY DESIGN: Following the 2020 American Board of Surgery In-Training Examination, a national survey of self-efficacy in 10 of the most commonly performed Accreditation Council for Graduate Medical Education case-log procedures was completed. RESULTS: A total of 1,145 PGY5 residents completed the survey (response rate 83.8%), representing 296 surgical residency programs. Female sex (odds ratio [OR] 0.46 to 0.67; 95% CI 0.30 to 0.95; p < 0.05) was associated with decreased self-efficacy for 6 procedures. Residents from institutions with emphasis on autonomy were more likely to report higher self-efficacy for 8 of 10 procedures (OR 1.39 to 3.03; 95% CI 1.03 to 4.51; p < 0.05). In addition, increased socialization among residents and faculty also correlated with increased self-efficacy in 3 of 10 procedures (OR 1.41 to 2.37; 95% CI 1.03 to 4.69; p < 0.05). Procedures performed with higher levels of resident responsibility, based on Graduated Levels of Resident Responsibility (GLRR) and Teaching Assistant (TA) scores, were correlated with higher self-efficacy (p < 0.001). CONCLUSION: Ensuring that residents receive ample opportunities for GLRR and TA experiences, while implementing programmatic support for resident-dependent factors, may be crucial for building self-efficacy in PGY5 residents. Institutional support of resident "autonomy" and increasing methods of socialization may provide a means of building trust and improving perceptions of self-efficacy. In addition, reevaluating institutional policies that limit opportunities for graduated levels of responsibility, while maintaining patient safety, may lead to increased self-efficacy.

Defining the Deficit in US Surgical Training: The Trainee's Perspective.

BACKGROUND: Self-efficacy is the personal judgment of how well one can successfully complete a task. The goal of this study was to assess self-efficacy of PGY5 residents for common general surgery operations. We hypothesized there are deficits in self-efficacy of PGY5 residents, and self-efficacy of a given operation correlates with experience performing the operation without attending assistance (independently) and teaching the operation from start to finish. METHODS: A survey was linked to the 2020 American Board of Surgery In-Training Examination. From the ACGME case log's 15 most commonly performed surgeon-chief operations and AHRQ's 15 most common operations, 10 operations were selected. Residents evaluated their ability to perform these operations independently using a 5-point self-efficacy scale. Residents were asked whether they had experience performing these operations independently or teaching the operation from start to finish. Descriptive statistics and Pearson correlation were used to examine the relationship between self-efficacy and operative experience. RESULTS: In all, 1,145 of 1,367 PGY5 residents (84%) responded. Highest self-efficacy was in performing wide-local excision (90.24%) and lowest was in performing open thyroidectomy (19.58%). Eighty-eight (7.7%) reported self-efficacy in all procedures. Statistically significant positive correlations were identified between experience and self-efficacy for cases performed without assistance (r = 0.98, p < 0.01) and cases taught (r = 0.91, p < 0.01). CONCLUSIONS: With 5 months left in training, 92.3% of residents report deficits in preparation for practice, as defined by self-efficacy to complete common procedures independently. Resident self-efficacy increased in direct relation to performed cases and cases taught.

American Board of Surgery Entrustable Professional Activities (EPAs): Assessing Graduating Residents' Perception of Preoperative Entrustment.

OBJECTIVE: To determine if graduating surgical residents are achieving entrustment of surgical entrustable professional activities (EPAs). We hypothesize that postgraduate year 5 (PGY5) residents are achieving evaluation and management entrustment in the selected EPAs. DESIGN: In January 2020, surgical residents completed a survey following the American Board of Surgery In-Training Examination (ABSITE) to measure their levels of entrustment in 4 of the 5 ABS-selected EPAs. A Resident Entrustability Index (REI) score was developed to ascertain PGY5 residents' levels of entrustment (range 1-5). Residents indicated how often their assessments and operative plans were modified in the prior 6 months for each EPA (1=Always, 2=Frequently, 3=Occasionally, 4=Rarely, 5=Never). An independent clinical decision-making score (ICDM) was developed with subsequent evaluation of its relationships to intrinsic, resident-related and extrinsic, program-dependent factors. SETTING: A national post-ABSITE survey. PARTICIPANTS: All general surgery residents participating in ABSITE were invited to participate. Of the 1367 PGY5 residents that completed the survey, 1049 residents (76.7%) responded to the surgical EPA items. RESULTS: Residents achieved an average REI of 4, indicating rare modification of assessments and operative plans for the 4 EPAs assessed. Complete entrustment was reported for inguinal hernias and penetrating abdominal trauma (Median REI = 5, IQR 4, 5) indicating assessments and operative plans were never modified. Lack of entrustment (REI ≤3) was reported by a minority of residents (ranging from 8.6% for operative plan of right lower quadrant pathology to 12.8% for operative plan of blunt abdominal trauma). Significant resident-related and program-dependent factors associated with achievement of expected ICDM was socializing with a co-resident (p = 0.001), while training in one's hometown (p < 0.001) and policies that mandate attendings be scrubbed in (p = 0.022) were associated with decreased achievement of expected ICDM. Overall, 89.2% and 90.3% of PGY5 residents are attaining appropriate levels of entrustment and ICDM abilities, respectively, within 6 months of graduating. CONCLUSIONS: Of the EPAs evaluated, PGY5 residents are achieving appropriate levels of entrustment in evaluation and management. Although this is the case for a vast majority of PGY5 residents, there is still work to be done to ensure that all PGY5 residents are attaining entrustment prior to graduation. Our study also provides content validity for the surgical EPAs in assessing levels of entrustment in PGY5 residents.

Creutzfeldt-Jakob Disease: In-hospital demographics report of national data in the United States from 2016 and review of a rapidly-progressive case.

BACKGROUND: This report highlights a rapidly progressive case of Creutzfeldt-Jakob Disease (CJD) whose time from symptom onset to death spanned less than two months. We also explore the most recently available in-patient demographics data for discharges with CJD in the United States. METHODS: We reviewed a CJD case and systematically analyzed a retrospective cohort of CJD discharges using the Healthcare Cost and Utilization Project (HCUP) to evaluate the existing national data on the status of CJD demographics and dispositions in the United States in 2016. RESULTS: An estimated total of 710 hospital discharges with a diagnosis of CJD were seen across the United States in 2016. According to HCUP, the average age of patients was 66.15 ±â€¯11.54 years with 48.6 % female. Average time to intubation from admission to hospital was 4.71 ±â€¯7.32 days with a rate of intubation of 6.34 %. The mean hospital cost was $19,901.25 ± $18,743.48. The rate of in-hospital mortality was 8.45 %. No significant geographical differences were noted (p = 0.49). No significant differences were seen among incidence in specific ethnic groups (p = 0.33) or income quartiles (p = 0.90). CONCLUSIONS: Our data shows that the incidence of CJD in 2016 appears to be equally distributed among individuals in the United States by demographic categories. Additionally, our case-study from 2019 illustrates an important example for diagnosing a rapidly-progressing case of CJD.

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

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