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.

Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

OBJECTIVE: To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon. BACKGROUND: Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons. METHODS: We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days. RESULTS: We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01). CONCLUSION: Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

Characterizing tissue perfusion after lower extremity intervention using two-dimensional color-coded digital subtraction angiography.

OBJECTIVE: Digital subtraction angiography (DSA) of the peripheral arterial vasculature provides lumenographic information but only a qualitative assessment of blood flow. The ability to quantify adequate tissue perfusion of the lower extremities would enable real-time perfusion assessment during DSA of patients with peripheral arterial disease (PAD). In this study, we used a novel real-time imaging software to delineate tissue perfusion parameters in the foot in PAD patients. METHODS: Between March 2015 and June 2016, patients (N = 31) underwent lower extremity angiography using a two-dimensional perfusion (2DP) imaging protocol (Philips Healthcare, Andover, Mass). Of the 31 enrolled patients, 16 patients received preintervention and postintervention DSA images (18 angiograms), while contrast agent injection settings and the position of the foot, catheter, and C-arm were kept constant. The region of interest for perfusion measurements was taken at the level of the medial malleolus. Perfusion parameters included arrival time (AT) of contrast material, wash-in rate (WIR), time to peak (TTP) contrast intensity, and area under the curve (AUC). RESULTS: Patients (mean age, 67 years; male, 61%) undergoing 2DP had limbs classified as Rutherford class 3 (n = 9 limbs), class 4 (n = 11), and class 5 (n = 14) ischemia with a mean ankle-brachial index of 0.63. For the whole cohort, median (interquartile range) AT measured 5.20 (3.10-7.25) seconds; WIR, 61.95 (43.53-86.43) signal intensity (SI)/s; TTP, 3.80 (2.88-4.50) seconds; peak intensity, 725.00 (613.75-1138.00) SI; and AUC, 12,084.00 (6742.80-17,059.70) SI*s. A subset of patients had 2DP performed before and after intervention (n = 18 cases). A detectable improvement in SI and two-dimensional flow parameters was seen after intervention. Average AT of contrast material to the region of interest shortened after intervention with percentage decrease of 30.1% ± 49.1%, corresponding decrease in TTP of 17.6% ± 24.7%, increase in WIR of 68.8% ± 94.2% and in AUC of 10.5% ± 37.6%, decrease in mean transit time of 18.7% ± 28.1%, and increase in peak of 34.4% ± 42.2%. CONCLUSIONS: The 2DP imaging allows measurement of blood flow in real time as an adjunct to DSA. The AT may be the most sensitive marker of perfusion change in the lower extremity. Quantitative thresholds based on 2DP hold promise for immediate treatment effectiveness assessment in patients with PAD.

Simulation of carotid artery stenting reduces training procedure and fluoroscopy times.

OBJECTIVE: Outcomes from carotid artery stenting (CAS) are related to experience and technical expertise of the operator. Simulation of CAS may enhance clinical proficiency. We interrogated the impact of endovascular simulation of CAS procedures in operators who are at various stages of training. METHODS: Twelve trainees (students [n = 4]; junior surgery residents, postgraduate year [PGY] 1-3 [n = 4]; and senior surgery residents or fellows, PGY 4-7 [n = 4]) were apprised of characteristics of an endovascular simulator and CAS procedures. This was followed by four independent sessions that were assessed for objective measures including procedure and fluoroscopy times and contrast agent use. A qualitative analysis grading steps of CAS by two observers using a Likert scale was performed. One-way analysis of variance and paired t-tests were employed for data analysis. RESULTS: For all participants (n = 12), procedure times (mean, 920 ± 279 seconds for the first session vs 454 ± 156 seconds for the fourth session; P < .01; confidence interval [CI], 315-621) and fluoroscopy cumulative times (mean, 421 ± 230 seconds for the first session vs 222 ± 102 seconds for the fourth session; P < .01; CI, 78-285) decreased with progression of cases. Students and PGY 1-3 residents decreased their procedure times significantly in comparison of initial and final sessions (P < .05 and P < .01, respectively). For all groups, fluoroscopy cumulative times were reduced, and this decrement was significant in the PGY 1-3 cohort (mean, 444 ± 8 seconds for the first session vs 265 ± 51 seconds for the fourth session; P < .01; CI, 81-276). Initial CAS procedure times were significantly different between groups (P < .05), but this was observed to resolve by the final case at study completion. Qualitatively, the Likert scores of students and PGY 1-3 residents significantly improved with case repetition, specifically in the following steps: (1) cannulation of common carotid artery and (2) sizing and deployment of embolic protection device. Senior operators (PGY 4-7) demonstrated consistently better performance overall with minimal change in scoring with case repetition. CONCLUSIONS: Practice leads to improvements in endovascular simulator procedure and fluoroscopy times, especially for more novice trainees. Initial operator performance gaps can be approximated with a few sessions to expected proficiency. Incorporation of endovascular simulators in residency training may assist in shortening the learning curve in rarer endovascular procedures.

Endothelial Function Is Preserved in Veins Harvested by Either Endoscopic or Surgical Techniques.

BACKGROUND: Endoscopic vein harvest for lower extremity arterial bypass grafting has been questioned due to concern for endothelial damage during procurement. We sought to compare nitric oxide (NO)-mediated endothelial-dependent relaxation (EDR) in vein segments harvested using open surgical techniques (OH) versus endoscopic vein harvest (EH) techniques. METHODS: Saphenous vein segments were harvested for lower extremity bypass, and a single, minimally handled section of saphenous vein, free of branches, was taken from the end of the graft. Four 4-mm venous ring segments were then cut and mounted on force transducers. Segments were mounted in 37° oxygenated Krebs-Henseleit solution and maximally contracted using KCl. Individual ring segments that did not react to KCl were excluded from the study. Norepinephrine (NE) was used to achieve submaximal contraction. EDR was determined using increasing concentrations of bradykinin (BDK). Endothelial-independent relaxation (EIR) was confirmed using sodium nitroprusside. Two-way analysis of variance (ANOVA) was used to analyze differences between harvest techniques across BDK concentration and a Student's t-test was used to analyze single comparisons. RESULTS: Vein segments harvested from patients (n = 13) led to 28 viable rings that exhibited a positive reaction to KCl (11 rings; 5 patients EH vs. 17 rings; 8 patients OH). Both vein groups achieved moderate relaxation to maximal BDK concentration, [10-6 M]; (49.5% EH vs. 40.55% OH, P = 0.270). Analysis by 2-way ANOVA for mean % relaxation for BDK concentration [10-11-10-6 M] showed improved EDR in EH samples compared with OH (P = 0.029). Mean nitrite/nitrate (NO(x)) tissue bath concentration measurements post-BDK were 139.8 nM (EH) vs. 97.2 nM (OH; P = 0.264). Histology and positive factor VIII immunohistochemistry staining provided evidence for the presence of intact endothelium in our sample segments. EIR was preserved and was similar in the two groups. CONCLUSIONS: Endothelial function is preserved when utilizing endoscopic harvesting techniques. The advantages of minimally invasive vein procurement for lower extremity bypass can be obtained without concern for damaging venous endothelium.

Comparative occupational radiation exposure between fixed and mobile imaging systems.

OBJECTIVE: Endovascular intervention exposes surgical staff to scattered radiation, which varies according to procedure and imaging equipment. The purpose of this study was to determine differences in occupational exposure between procedures performed with fixed imaging (FI) in an endovascular suite compared with conventional mobile imaging (MI) in a standard operating room. METHODS: A series of 116 endovascular cases were performed over a 4-month interval in a dedicated endovascular suite with FI and conventional operating room with MI. All cases were performed at a single institution and radiation dose was recorded using real-time dosimetry badges from Unfors RaySafe (Hopkinton, Mass). A dosimeter was mounted in each room to establish a radiation baseline. Staff dose was recorded using individual badges worn on the torso lead. Total mean air kerma (Kar; mGy, patient dose) and mean case dose (mSv, scattered radiation) were compared between rooms and across all staff positions for cases of varying complexity. Statistical analyses for all continuous variables were performed using t test and analysis of variance where appropriate. RESULTS: A total of 43 cases with MI and 73 cases with FI were performed by four vascular surgeons. Total mean Kar, and case dose were significantly higher with FI compared with MI. (mean ± standard error of the mean, 523 ± 49 mGy vs 98 ± 19 mGy; P < .00001; 0.77 ± 0.03 mSv vs 0.16 ± 0.08 mSv, P < .00001). Exposure for the primary surgeon and assistant was significantly higher with FI compared with MI. Mean exposure for all cases using either imaging modality, was significantly higher for the primary surgeon and assistant than for support staff (ie, nurse, radiology technologist) beyond 6 feet from the X-ray source, indicated according to one-way analysis of variance (MI: P < .00001; FI: P < .00001). Support staff exposure was negligible and did not differ between FI and MI. Room dose stratified according to case complexity (Kar) showed statistically significantly higher scattered radiation in FI vs MI across all quartiles. CONCLUSIONS: The scattered radiation is several-fold higher with FI than MI across all levels of case complexity. Radiation exposure decreases with distance from the radiation source, and is negligible outside of a 6-foot radius. Modern endovascular suites allow high-fidelity imaging, yet additional strategies to minimize exposure and occupational risk are needed.

Endovascular aneurysm repair simulation can lead to decreased fluoroscopy time and accurately delineate the proximal seal zone.

BACKGROUND: The use of simulators for endovascular aneurysm repair (EVAR) is not widespread. We examined whether simulation could improve procedural variables, including operative time and optimizing proximal seal. For the latter, we compared suprarenal vs infrarenal fixation endografts, right femoral vs left femoral main body access, and increasing angulation of the proximal aortic neck. METHODS: Computed tomography angiography was obtained from 18 patients who underwent EVAR at a single institution. Patient cases were uploaded to the ANGIO Mentor endovascular simulator (Simbionix, Cleveland, Ohio) allowing for three-dimensional reconstruction and adapted for simulation with suprarenal fixation (Endurant II; Medtronic Inc, Minneapolis, Minn) and infrarenal fixation (C3; W. L. Gore & Associates Inc, Newark, Del) deployment systems. Three EVAR novices and three experienced surgeons performed 18 cases from each side with each device in randomized order (n = 72 simulations/participant). The cases were stratified into three groups according to the degree of infrarenal angulation: 0° to 20°, 21° to 40°, and 41° to 66°. Statistical analysis used paired t-test and one-way analysis of variance. RESULTS: Mean fluoroscopy time for participants decreased by 48.6% (P < .0001), and total procedure time decreased by 33.8% (P < .0001) when initial cases were compared with final cases. When stent deployment accuracy was evaluated across all cases, seal zone coverage in highly angulated aortic necks was significantly decreased. The infrarenal device resulted in mean aortic neck zone coverage of 91.9%, 89.4%, and 75.4% (P < .0001 by one-way analysis of variance), whereas the suprarenal device yielded 92.9%, 88.7%, and 71.5% (P < .0001) for the 0° to 20°, 21° to 40°, and 41° to 66° cases, respectively. Suprarenal fixation did not increase seal zone coverage. The side of femoral access for the main body did not influence proximal seal zone coverage regardless of infrarenal angulation. CONCLUSIONS: Simulation of EVAR leads to decreased fluoroscopy times for novice and experienced operators. Side of femoral access did not affect precision of proximal endograft landing. The angulated aortic neck leads to decreased proximal seal zone coverage regardless of infrarenal or suprarenal fixation devices.

Dextran or Saline Can Replace Contrast for Intravascular Optical Coherence Tomography in Lower Extremity Arteries.

PURPOSE: To examine the hypothesis that alternative flush media could be used for lower extremity optical coherence tomography (OCT) imaging in long lesions that would normally require excessive use of contrast. METHODS: The OPTical Imaging Measurement of Intravascular Solution Efficacy (OPTIMISE) trial was a single-center, prospective study (ClinicalTrials.gov identifier NCT01743872) that enrolled 23 patients (mean age 68±11 years; 14 men) undergoing endovascular intervention involving the superficial femoral artery. Four flush media (heparinized saline, dextran, carbon dioxide, and contrast) were used in succession in random order for each image pullback. Quality was defined as ≥270° visualization of vessel wall layers from each axial image. Mean proportions (± standard deviation) of image quality for each flush medium were assessed using 1-way analysis of variance and are reported with the 95% confidence intervals (CI). RESULTS: Four OCT catheters failed, leaving 19 patients who completed the OCT imaging protocol; from this cohort, 51 highest quality runs were selected for analysis. Average vessel diameter was 3.99±1.01 mm. OCT imaging allowed 10- to 15-µm resolution of the lumen border, with diminishing quality as vessel diameter increased. Plaque characterization revealed fibrotic lesions. Mean proportions of image quality were dextran 87.2%±12% (95% CI 0.81 to 0.94), heparinized saline 74.3%±24.8% (95% CI 0.66 to 0.93), contrast 70.1%±30.5% (95% CI 0.52 to 0.88), and carbon dioxide 10.0%±10.4% (95% CI 0.00 to 0.26). Dextran, saline, and contrast provided better quality than carbon dioxide (p<0.001). CONCLUSION: OCT is feasible in peripheral vessels <5 mm in diameter. Dextran or saline flush media can allow lesion characterization, avoiding iodinated contrast. Carbon dioxide is inadequate for peripheral OCT imaging. Axial imaging may aid in enhancing durability of peripheral endovascular interventions.

Prevalence of Bovine Aortic Arch Configuration in Adult Patients with and without Thoracic Aortic Pathology.

BACKGROUND: Bovine aortic arch (BA) occurs in approximately 15-35% of the US population and is regarded as a clinically insignificant, normal variant. The aim of this study was to assess the prevalence of types I (type I bovine arch [T1BA], common origin of innominate and/or left common carotid artery) and II (type II bovine arch [T2BA], left common carotid originating from innominate) bovine arch in patients with and without thoracic aortic pathology. METHODS: We retrospectively reviewed all serial computed tomography images (n = 817) performed at our institution over 4 months to determine the overall prevalence of BA. Thoracic aorta and/or arch vessels were visualized, with images read by certified radiologists. A separate analysis compared a series of 156 consecutive patients with thoracic pathology (dissection or aneurysm ≥ 4.0 cm), from a 25-month period, with 757 control patients without pathology from the original sample. Statistical analysis included a chi-squared contingency table. RESULTS: Analysis revealed a bovine arch prevalence of 31.1% (n = 254), including 14.9% T1BA and 16.2% T2BA. Patients with thoracic aortopathy (n = 156) had aortic dissection (n = 26) or aneurysm (n = 130). These patients were older and had an increased prevalence of hypertension, hyperlipidemia, and aortic calcification. In addition, there was increased prevalence of T2BA in the pathology group (23.7%) compared with controls (15.9%; P = 0.03). T1BA was not significantly different between groups (11.5% vs. 14.9%; P = 0.59). When thoracic disease was stratified by pathology type, T2BA occurred more frequently in patients with thoracic aortic aneurysm (24.6% vs. 15.9%; P = 0.04). BA trended upward, in patients with thoracic aortic dissection (42.3% vs. 30.8%; P = 0.28). CONCLUSIONS: Our analyses revealed a prevalence of bovine arch of 31% in our patient population. BA occurred more frequently in patients with thoracic aortopathy than controls. Therefore, patients with BA may be associated with higher levels of thoracic aortic pathology and may benefit from increased clinical vigilance.

Upper Extremity Steal Syndrome Is Associated with Atherosclerotic Burden and Access Configuration.

BACKGROUND: Clinically significant steal syndrome occurs in a subset of dialysis patients with arteriovenous (AV) access. Factors associated with steal are poorly understood. Severe symptoms require access revision or sacrifice, potentially jeopardizing access options. Our objective was to review our dialysis access experience to identify factors associated with significant steal syndrome. METHODS: We reviewed all adult patients undergoing their first permanent upper extremity access, AV fistula (AVF) or AV graft (AVG), between January 2008 and July 2011 at a single center. Medical, demographic, and access characteristics were collected from our electronic medical record and a local dialysis center's database. Patients who required correction of steal syndrome were compared with the larger access cohort. Statistical analysis included Fisher's exact test and χ(2) for noncontinuous variables and unpaired t-test for continuous variables. RESULTS: Of the 303 patients, 15 required correction for steal syndrome (8 of 232 AVF and 7 of 71 AVG). Eight were ligated; 2 were initially banded, then ligated; and 5 underwent distal revascularization with interval ligation. Coronary artery disease was more prevalent in steal syndrome patients (66.7% vs. 25%, P = 0.001); the same was found with peripheral arterial disease (40% vs. 13.8%, P = 0.02). Furthermore, more patients with steal syndrome were on clopidogrel for cardiovascular reasons (40% vs. 9%, P = 0.002). Steal syndrome only developed with AVF and AVG using brachial artery inflow. No cases of steal syndrome arose from radial/ulnar inflow (P = 0.03). All AVG with steal syndrome had a straight configuration; no looped AVG developed steal (P = 0.02). Other patient characteristics such as age, sex, race, hypertension, diabetes mellitus, congestive heart failure, cerebrovascular accident, cause of end-stage renal disease, and other medication history were not different between groups. CONCLUSIONS: Clinically significant steal syndrome is associated with disease in coronary and peripheral arterial beds. In addition, the use of brachial artery inflow and straight AVG configuration is associated with steal syndrome. Consideration should be given to construction of access using smaller forearm arteries and looped AVG configuration in patients with high risk for steal. In addition, such patients may require more vigilant monitoring for development of steal after access construction.

Elevated Peak Systolic Velocity and Velocity Ratio from Duplex Ultrasound are Associated with Hemodynamically Significant Lesions in Arteriovenous Access.

BACKGROUND: Duplex ultrasound (DUS) is reliably used to detect lesions in the peripheral and carotid arterial beds and venous system. Although commonly used in clinical practice, duplex criteria to define lesions in arteriovenous access are not well characterized. This study will define the optimal Doppler-derived peak systolic velocity (PSV) and velocity ratio (VR) to identify >50% lesions in arteriovenous fistulas (AVF) and arteriovenous grafts (AVG). METHODS: This retrospective analysis includes patients with both DUS and fistulogram within 30 days. DUS-derived PSV and VR were recorded for 3 segments of each access and compared with fistulograms of the same 3 segments of each AV access. Receiver operating characteristic (ROC) was used to determine the optimal DUS criteria for diagnosis of >50% stenosis. RESULTS: Fifty pairs of imaging in 40 patients were available for analysis. Mean PSV and VR for segments with greater than 50% stenosis were significantly greater than those without; mean PSV of 480 cm/sec vs. 297 cm/sec (P < 0.001) and mean VR of 3.81 vs. 2.09 (P < 0.001). The ROC analysis demonstrated an optimal PSV of 404 and VR of 2.2 to diagnose >50% stenosis with area under the curve of 0.825 and 0.821 for PSV and VR, respectively. PSV of 500 had sensitivity (Se) of 0.60, specificity (Sp) of 0.86, positive predictive value (PPV) of 0.72, and negative predictive value (NPV) of 0.78. VR of 3.0 had Se of 0.52, Sp of 0.91, PPV of 0.77, and NPV of 0.75. CONCLUSIONS: DUS-derived PSV of 400 cm/sec and VR of 2.25 have good discrimination to predict greater than 50% stenosis in AVFs and AVGs. Given the broad range of velocities in AV accesses, a threshold of PSV greater than 500 cm/sec and VR greater than 3.0, will reliably identify graft-threatening lesions. Se and Sp of PSV 500 are 0.596 and 0.854, respectively. Se and Sp for VR 3.0 are 0.519 and 0.894, respectively.

The end stage of dialysis access: femoral graft or HeRO vascular access device.

BACKGROUND: Maintaining and establishing vascular access in end-stage renal disease (ESRD) patients is complicated when they are poor candidates for traditional upper extremity access. Our objective was to compare our experience with 2 alternative dialysis accesses, the femoral arteriovenous graft (fAVG) and the Hemodialysis Reliable Outflow (HeRO), in patients with limited remaining options. METHODS: A single institution, retrospective review of ESRD patients with fAVG or HeRO placed between May 2009 and February 2013 was performed. Adult patients were selected by reviewing all arteriovenous grafts placed at a single institution. Patient demographics, medical history, access characteristics, and outcomes were recorded from both institutional and dialysis center databases. Data were evaluated using Fisher's exact test, unpaired t-test for continuous variables, log-rank test, and univariate analysis. RESULTS: A total of 56 accesses in 43 unique patients met these criteria: 35 fAVG and 21 HeRO; with 1 HeRO patient lost immediately to follow-up. Clinical variables were similar except the HeRO group had more diabetic patients (60% HeRO, 22.9% fAVG; P = 0.01). The average number of years on hemodialysis was 7.0 ± 1.0 for fAVG and 5.7 ± 0.9 for HeRO (P = 0.41). Primary patency was 40.5%, 18.7%, and 14.9% for fAVG and 29.0%, 29.0%, and 0% for HeRO at 6 months, 12 months, and 2 years (P = 0.67), respectively. Assisted primary patency was also similar, with 43.8%, 29.4%, and 13.8% for fAVG and 34.8%, 34.8%, and 17.4% for HeRO at 6 months, 12 months, and 2 years (P = 0.81), respectively. Secondary patency was 62.6%, 50.6%, 19.3% for fAVG and 68.0%, 53.5%, 38.3% for HeRO at 6 months, 12 months, and 2 years (P = 0.69), respectively. Average number of interventions to maintain patency for fAVG was 1.1 ± 1.47 and 1.65 ± 2.52 for HeRO (P = 0.35). Infectious complications occurred in 29% of fAVG and 15% of HeRO (P = 0.33). CONCLUSIONS: Patients who received either fAVG or HeRO experience poor access patency. ESRD patients who receive either of these procedures appear to be at the end stage of available access options.

Evaluating Educational Outcomes Using Patient Outcomes of New Surgeons Performing Partial Colectomy Compared to Cholecystectomy.

PURPOSE: Despite ongoing efforts to improve surgical education, surgical residents face gaps in their training. However, it is unknown if differences in the training of surgeons are reflected in the patient outcomes of those surgeons once they enter practice. This study aimed to compare the patient outcomes among new surgeons performing partial colectomy-a common procedure for which training is limited-and cholecystectomy-a common procedure for which training is robust. METHOD: The authors retrospectively analyzed all adult Medicare claims data for patients undergoing inpatient partial colectomy and inpatient cholecystectomy between 2007 and 2018. Generalized additive mixed models were used to investigate the associations between surgeon years in practice and risk-adjusted rates of 30-day serious complications and death for patients undergoing partial colectomy and cholecystectomy. RESULTS: A total of 14,449 surgeons at 4,011 hospitals performed 340,114 partial colectomy and 355,923 cholecystectomy inpatient operations during the study period. Patients undergoing a partial colectomy by a surgeon in their 1st vs 15th year of practice had higher rates of serious complications (5.22% [95% CI, 4.85%-5.60%] vs 4.37% [95% CI, 4.22%-4.52%]; P < .01) and death (3.05% [95% CI, 2.92%-3.17%] vs 2.83% [95% CI, 2.75%-2.91%]; P < .01). Patients undergoing a cholecystectomy by a surgeon in their 1st vs 15th year of practice had similar rates of 30-day serious complications (4.11% vs 3.89%; P = .11) and death (1.71% vs 1.70%; P = .93). CONCLUSIONS: Patients undergoing partial colectomy faced a higher risk of serious complications and death when the operation was performed by a new surgeon compared to an experienced surgeon. Conversely, patient outcomes following cholecystectomy were similar for new and experienced surgeons. More attention to partial colectomy during residency training may benefit patients.

Association of Surgical Resident Competency Ratings With Patient Outcomes.

PURPOSE: Accurate assessment of clinical performance is essential to ensure graduating residents are competent for unsupervised practice. The Accreditation Council for Graduate Medical Education milestones framework is the most widely used competency-based framework in the United States. However, the relationship between residents' milestones competency ratings and their subsequent early career clinical outcomes has not been established. It is important to examine the association between milestones competency ratings of U.S. general surgical residents and those surgeons' patient outcomes in early career practice. METHOD: A retrospective, cross-sectional study was conducted using a sample of national Medicare claims for 23 common, high-risk inpatient general surgical procedures performed between July 1, 2015, and November 30, 2018 (n = 12,400 cases) by nonfellowship-trained U.S. general surgeons. Milestone ratings collected during those surgeons' last year of residency (n = 701 residents) were compared with their risk-adjusted rates of mortality, any complication, or severe complication within 30 days of index operation during their first 2 years of practice. RESULTS: There were no associations between mean milestone competency ratings of graduating general surgery residents and their subsequent early career patient outcomes, including any complication (23% proficient vs 22% not yet proficient; relative risk [RR], 0.97, [95% CI, 0.88-1.08]); severe complication (9% vs 9%, respectively; RR, 1.01, [95% CI, 0.86-1.19]); and mortality (5% vs 5%; RR, 1.07, [95% CI, 0.88-1.30]). Secondary analyses yielded no associations between patient outcomes and milestone ratings specific to technical performance, or between patient outcomes and composites of operative performance, professionalism, or leadership milestones ratings ( P ranged .32-.97). CONCLUSIONS: Milestone ratings of graduating general surgery residents were not associated with the patient outcomes of those surgeons when they performed common, higher-risk procedures in a Medicare population. Efforts to improve how milestones ratings are generated might strengthen their association with early career outcomes.

Pragmatic Mentoring Strategies for the Busy Surgeon Scientist.

OBJECTIVE: The value of research mentorship in academic medicine is well-recognized, yet there is little practical advice for how to develop and sustain effective mentoring partnerships. Gaining research skill and mentorship is particularly critical to success in academic surgery, yet surgeon scientists are challenged in their mentorship efforts by time constraints and lack of education on how to mentor. To address this gap, this study explored the strategies that award-winning faculty mentors utilize in collaborating with their medical student mentees in research. DESIGN, SETTING, AND PARTICIPANTS: For this qualitative study, the authors invited physician recipients of an institution-wide mentorship award to participate in individual, semi-structured interviews during July and August 2018. Following interview transcription, the authors independently coded the text and collaboratively identified common mentoring strategies and practices via a process of thematic analysis. RESULTS: Nine physician mentors, representing a mix of genders, medical specialties and types of research (basic science, clinical, translational, and health services), participated in interviews. The authors identified 12 strategies and practices from the interview transcripts that fell into 5 categories: Initiating the partnership; Determining the research focus; Providing project oversight; Developing mentee research competence; and Supporting mentee self-efficacy. CONCLUSION: Award-winning mentors employ a number of shared strategies when mentoring medical trainees in research. These strategies can serve as a guide for academic surgeons who wish to improve their research mentoring skills.

Representativeness of Workplace-Based Operative Performance Assessments for Resident Operative Experience.

OBJECTIVE: Workplace-based assessment is increasingly prevalent in surgical education, especially for assessing operative skill. With current implementations, not all observed clinical performances are assessed, in part because trainees often have discretion about when they seek assessment. As a result, these samples of observed operative performances may not be representative of the full breadth of experience of surgical trainees. Therefore, analyses of these samples may be biased. We aimed to benchmark patterns of procedures logged in the SIMPL operative performance assessment system against records of trainee experience in Accreditation Council for Graduate Medical Education (ACGME) case logs. DESIGN: We analyzed SIMPL longitudinal intraoperative performance assessments from categorical trainees in US general surgery residency programs. We compared overall patterns of how procedures are logged in SIMPL and in ACGME case logs using a Pearson correlation, and we examined differences in how individual procedures are logged in each system using Fisher's exact test. RESULTS: Total procedure frequency from the SIMPL dataset was strongly correlated with total procedure frequency from ACGME case logs (r = 0.86, 95% CI 0.80-0.90). A subset of these procedures (10 of 116 procedures) was logged more frequently in the SIMPL dataset. These 10 procedures accounted for 56% of SIMPL observations and 30% of ACGME logged cases. Case complexity was comparable for assessments initiated by residents and faculty. CONCLUSIONS: Samples of intraoperative performance ratings gathered using the SIMPL application largely resemble ACGME case logs. There is no evidence to indicate that residents preferentially select fewer complex cases for assessment.

How Do Programs Measure Resident Performance? A Multi-Institutional Inventory of General Surgery Assessments.

OBJECTIVE: To perform an inventory of assessment tools in use at surgical residency programs and their alignment with the Milestone Competencies. DESIGN: We conducted an inventory of all assessment tools from a sample of general surgery training programs participating in a multi-center study of resident operative development in the United States. Each instrument was categorized using a data extraction tool designed to identify criteria for effective assessment in competency based education and according to which Milestone Competency was being evaluated. Tabulations of each category were then analyzed using descriptive statistics. Interviews with program directors and assessment coordinators were conducted to understand each instrument's intended use within each program. SETTING: Multi-institutional review of general surgery assessment programs. PARTICIPANTS: We identified assessment tools used by 10 general surgery programs during the 2019 to 2020 academic year. Programs were selected from a cohort already participating in a separate research study of resident operative development in the United States. RESULTS: We identified 42 unique assessment tools used. Each program used an average of 7.2 (range 4-13) unique assessment instruments to measure performance, of which only 5 (11.9%) were used by at least 1 other program in our sample. Of all assessments, 59.5% were used monthly or less frequently. The majority (66.7%) of instruments were retrospective global assessments, rather than discrete observed performances. There were 4 (9.5%) instruments with established reliability or validity evidence. Across programs there was also significant variation in the volume of assessment used to evaluate residents, with the median total number of evaluations/trainee across all Milestone Competencies being 217 (IQR 78) per year. Patient care was the most frequently evaluated Milestone Competency. CONCLUSIONS: General surgical assessment systems predominantly employ non-standardized global assessment tools that lack reliability or validity evidence. This variability makes it challenging to interpret and compare competency standards across programs. A standardized assessment toolkit with established reliability and validity evidence would allow training programs to measure the competence of their trainees more uniformly and understand where improvements in our training system can be made.

Novel method to link surgical trainee performance data to patient outcomes.

BACKGROUND: A significant roadblock in surgical education research has been the inability to compare trainee performance to the outcomes of those surgeons after they enter independent practice. We describe the feasibility of an innovative method to link trainee performance data with patient outcomes. METHODS: We extracted surgeon NPI numbers from Medicare claims data for common general surgery procedures between 2007 and 2017. Next, American Board of Surgery (ABS) trainee performance data was cross-referenced with additional resources to supplement NPI data. The patient and trainee datasets were linked using NPI number and a linkage rate was calculated. RESULTS: We identified 12,952 unique surgeons in the Medicare file. Medicare surgeons were matched with ABS records by NPI number, with 96.2% (n = 12,460) of surgeons linked successfully. CONCLUSIONS: We demonstrated a novel process to link patient outcomes to trainee performance. This innovation can enable future research investigating the relationship between surgical trainee performance and patient outcomes in independent practice.