Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes.

OBJECTIVES: Nearly 80% of general surgery residents (GSR) pursue Fellowship training. We hypothesized that fellowships coexisting with general surgery residencies do not negatively impact GSR case volumes and that fellowship-bound residents (FBR) preferentially seek out cases in their chosen specialty ("early tracking"). METHODS: To test our hypotheses, we analyzed the Accreditation Council for Graduate Medical Education Surgical Operative Log data from 2009 American Board of Surgery qualifying examination applicants (N = 976). General surgery programs coexisted with 35 colorectal (CR), 97 vascular (Vasc), 80 minimally invasive (MIS), and 12 Endocrine (Endo) fellowships. We analyzed (1) operative cases for general surgery residency programs with and without coexisting Fellowships, comparing caseloads for FBR and all GSR and (2) operative cases of FBR in their chosen specialties compared to all other GSR. Group means were compared using ANOVA with significance set at P < 0.01. RESULTS: Coexisting fellowships had minimal impact on GSR caseloads. Endocrine fellowships actually enhanced case volumes for all residents. CR impact was neutral while MIS and vascular fellowships resulted in small declines. Endo, CR, and Vasc but not MIS FBR performed significantly more cases in their future specialties than their GSR counterparts, consistent with self-directed, prefellowship tracking. Tracking seems to be additive and FBR do not sacrifice other GSR cases. CONCLUSIONS: Our data establish that the impact of Fellowships on GSR caseloads is minimal. Our data confirm that FBR seek out cases in their future specialties ("early tracking").

General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

OBJECTIVE: To assess changes in general surgery workloads and practice patterns in the past decade. BACKGROUND: Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. METHODS: The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. RESULTS: GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. CONCLUSIONS: GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

Factors in fellowship selection: effect of services and fellows.

PURPOSE: General Surgery residents are increasingly pursuing fellowships. We examine whether perceived subspecialty content, dedicated services, and fellows impact fellowship choices. METHODS: Specialty content was assessed through a survey linking 228 operations to 9 content areas. The presence of dedicated services and fellows and the post-residency activities of graduates 1997-2006 were collected from 2 program directors. RESULTS: A total of 75% of residents (26 University of Mississippi, UM; 22 Vanderbilt University, VU) completed surveys. Five dedicated services and 2 fellowships at UM and VU were identical; VU had an additional 4 services and 3 fellowships. UM and VU residents similarly associated 184 operations (81%) with General Surgery. Agreement was not linked to services or fellows. A total of 44% of UM graduates and 68% of VU graduates pursued fellowships. The top choice at UM was Plastic/Hand (14%, versus 6% VU) and Oncology/Endocrine at VU (19%, versus 2% UM). Differences in specialties selected could not be linked consistently to dedicated services or fellows. CONCLUSION: Dedicated services and fellows appear to have little impact on fellowship specialty selection by chief residents. There may be a generic effect of dedicated services favoring fellowship versus no fellowship. Differential faculty mentoring skills may influence specific fellowship choices.

Laparoscopic bilateral adrenalectomy for occult ectopic ACTH syndrome.

INTRODUCTION: Ectopic adrenocorticotropic hormone (ACTH) production is responsible for approximately 15% of the cases of Cushing's syndrome. Bilateral adrenalectomy is the most effective treatment for ectopic ACTH syndrome due to occult or disseminated tumors, but the open approach carries substantial morbidity. In this paper, we review our experience with laparoscopic bilateral adrenalectomy for occult ectopic ACTH syndrome. MATERIALS AND METHODS: Adrenalectomies performed by the authors were identified and the outcomes of laparoscopic bilateral adrenalectomies for ectopic ACTH syndrome were examined. Bilateral adrenalectomies were performed sequentially in full lateral decubitus, with patient repositioning between the sides. RESULTS: From 2001 to 2006, the authors performed 16 adrenalectomies in 14 patients, with 11 performed laparoscopically. Two women with occult ectopic ACTH syndrome, refractory to medical management, underwent laparoscopic bilateral adrenalectomies. Operative times were 240 and 245 minutes, including repositioning. One patient underwent a simultaneous wedge liver biopsy for a right lobar lesion. There were no complications. Each patient resumed a regular diet on the first postoperative day. Inpatient hospital stays were 3 days each, mainly for steroid-replacement management. Final pathologic diagnoses were diffuse adrenocortical hyperplasia. Both patients noted a quick improvement in Cushing's syndrome symptoms and signs and were maintained on hydrocortisone and fludrocortisone replacement without incident for over 2 years. CONCLUSIONS: Laparoscopic bilateral adrenalectomy for ectopic ACTH syndrome refractory to medical management can be performed with low morbidity. Symptoms and signs of hypercortisolism rapidly improve postoperatively.

Assessing thrombosis risk in patients with idiopathic, diabetic, and postsurgical gastroparesis.

Patients with severe gastrointestinal motility disorders are often found to have intravenous access clots or deep venous thrombosis. It has previously been reported that many patients who have intravenous access thrombosis have concomitant thrombotic risk factors. In this study, the goal was to determine the underlying prevalence of hypercoagulable risk in a series of patients with documented gastroparesis. Investigators studied 62 consecutive patients (52 female; mean age, 42 y) who had symptoms of gastroparesis. All patients were evaluated for placement of a gastric neural stimulation device, or they had had one placed previously. Patients underwent a hematologic interview and standardized coagulation measures of thrombotic risk. Laboratory studies measured acquired elevations of Factor VII, Factor VIII, fibrinogen, lupus anticoagulant panel, antiphospholipid antibody panel, homocysteine (in the setting of kidney disease), and activated protein resistance. Investigators also measured congenital factors: Factor VIII (with C-reactive protein levels), antithrombin III, protein C, protein S (total and free), Factor II mutation, Factor V Leiden, methylenetetrahydrofolate reductase, and homocysteine. Fifty-five patients (89%) were found to have detectable hypercoagulable risk factors. Twenty-five of the 62 patients (40%) had a documented history of abnormal clotting, including deep venous thrombosis, intravenous access thrombosis, and pulmonary embolism. All patients with a previous history of thrombosis had detectable clotting abnormalities. Of 56 patients, 40 (71%) had hypercoagulability and did not have diabetes (P=.036), and 20 (36%) had hypercoagulability and no known history of infection. However, this value was not statistically significant when infection and hypercoagulability were compared (P=.408). A high prevalence of acquired and congenital hypercoagulable defects has been observed in patients with gastroparesis, which may predispose them to arterial and venous clots. This unique finding warrants consideration of coagulation evaluation in patients with severe gastroparesis, especially when these patients are placed in high-risk thrombophilic situations, such as hospitalization, prolonged intravenous access, and surgery.

Does academic intervention impact ABS qualifying examination results?

OBJECTIVES: To assess the impact of a focused academic support program on American Board of Surgery In-Training Examination (ABSITE) scores and Qualifying Examination (QE) outcomes. METHODS: A mandatory intervention program was begun in April 2001 for residents with ABSITE Total Test (TT) percentiles <31. Program elements included: 1) individual faculty mentoring and personal learning plan 2) QE videotape review sessions 3) Surgical Education and Self-Assessment Program (SESAP) 4) monthly rotation evaluations, and 5) quarterly status feedback. A free medical evaluation was offered. Mock orals participation, educational psychologist consultation, and voluntary followup mentoring were added later. Study data were reviewed for 2003-2005 Chief Residents including ABSITE scores, QE results, conference attendance, rotation Overall Performance ratings, and resident surgeon case volumes. Results were compared for the academic intervention (AI) and no intervention (NI) groups. RESULTS: Fifteen residents graduated during the study period. Eight residents completed nine interventions; seven returned to TT percentiles >30 (7/8, 88%). First post-intervention ABSITE gains were large compared to NI and national peer groups. Standard Score (SS) TT gains were maintained until residency completion by four AI residents. Median AI PGY-5 TT percentile was 32 and three scores were

Initial performance of a modified milestones global evaluation tool for semiannual evaluation of residents by faculty.

OBJECTIVES: To determine whether faculty could successfully evaluate residents using a competency-based modified Milestones global evaluation tool. DESIGN: A program's leadership team modified a draft Surgery Milestones Working Group summative global assessment instrument into a modified Milestones tool (MMT) for local use during faculty meetings devoted to semiannual resident review. Residents were scored on 15 items spanning all competencies using an 8-point graphic response scale; unstructured comments also were solicited. Arithmetic means were computed at the resident and postgraduate year cohort levels for items and competency item sets. Score ranges (highest minus lowest score) were calculated; variability was termed "low" (range <2.0 points), "moderate" (range = 2.0), or "high" (range >2.0). A subset of "low" was designated "small" (1.0-1.9). Trends were sought among item, competency, and total Milestones scores. MMT correlations with examination scores and multisource (360°) assessments were explored. The success of implementing MMT was judged using published criteria for educational assessment methods. SETTING: Fully accredited, independently sponsored residency. PARTICIPANTS: Program leaders and 22 faculty members (71% voluntary, mean 12y of experience). RESULTS: Twenty-six residents were assessed, yielding 7 to 13 evaluations for MMT per categorical resident and 3 to 6 per preliminary trainee. Scores spanned the entire response scale. All MMT evaluations included narrative comments. Individual resident score variability was low (96% within competencies and 92% across competencies). Subset analysis showed that small variations were common (35% within competencies and 54% across competencies). Postgraduate year cohort variability was higher (61% moderate or high within competencies and 50% across competencies). Cohort scores at the item, competency, and total score levels exhibited rising trajectories, suggesting MMT construct validity. MMT scores did not demonstrate concurrent validity, correlating poorly with other metrics. The MMT met multiple criteria for good assessment. CONCLUSIONS: A modified Milestones global evaluation tool can be successfully adopted for semiannual assessments of resident performance by volunteer faculty members.

Duty hours, quality of care, and patient safety: general surgery resident perceptions.

BACKGROUND: The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce. STUDY DESIGN: A previously piloted survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). First postgraduate year (PGY1) and PGY2 trainees took the Junior examination (IJE); PGY3 and above took the Senior examination (ISE). Residency type, size, and location were linked to examinees using program codes. Five survey items queried all residents about the impact of further hour limits on care quality; online test residents answered 7 more items probing medical error sources. Data were analyzed using factorial ANOVA for association with sex, PGY level, and program demographics. RESULTS: There were 6,161 categorical surgery residents who took the ABSITE: 60% men, 60% ISE, and two-thirds in university programs. Paper (n = 5,079) and online (n = 1,082) examinees were similar. Item response rates ranged from 91% to 98%. Few (<25%) perceived that stricter hour limits would improve care quality to a large or maximal extent. IJE plus West and Northeast residents significantly more often favored fewer hours. Factors perceived as contributing to medical errors usually or always by ≥ 15% of residents were incomplete handoffs, inexperience or lack of knowledge, insufficient ancillary personnel, and excessive workload. CONCLUSIONS: Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.

Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.

PURPOSE: To assess internal medicine (IM) and surgery program directors' views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations. METHOD: In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes. RESULTS: Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents' relationships (P < .001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease. CONCLUSIONS: IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.

Sleep, supervision, education, and service: views of junior and senior residents.

OBJECTIVES: To assess sleep time and views about faculty supervision and educational activities of residents training only under 2003 duty hours standards. DESIGN: A survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). Twelve items explored sleep patterns, supervision, and educational activity times. Survey response relationships to gender, resident level, and program variables were explored through factorial analysis of variance and effect size testing. Alpha was set to <0.001, and effect size (omega-squared) significance was set at ≥1% of variance explained to limit statistically significant but practically unimportant results. Survey participation was voluntary, and responses were processed separately from ABSITE scoring. SETTING: General surgery residencies. PARTICIPANTS: A total of 6161 categorical surgery residents: 2545 first postgraduate year (PGY1) and second postgraduate year (PGY2) trainees took the junior examination (IJE), and 3616 third postgraduate year (PGY3) and above residents took the senior examination (ISE). RESULTS: Response rates were ≥95%. Sleep during extended call was significantly less for IJE residents, but IJE residents' sleep mirrored ISE residents' sleep on night float, day assignments, and days off. Faculty supervision was judged Adequate or better by more than 90% of both groups. IJE residents significantly more often rated operative caseloads and operating time as inadequate; caseloads and operating room (OR) time also linked significantly to program type. IJE residents reported significantly higher inpatient, but not outpatient, time. Most IJE and ISE residents agreed that care continuity opportunities were Adequate and judged workloads as Adequate or better. Although many IJE and ISE residents rated educational time as Adequate or better, 25% of each group scored it as Insufficient or worse. CONCLUSIONS: Resident discretionary time is not devoted primarily to sleep. Residents consider increased faculty supervision unnecessary. IJE residents believe their time could be better apportioned across educational settings. Decreased workloads and increased educational time are desired by substantial minorities of IJE and ISE residents, arguing for further interventions to preserve education over service.

"Do one, teach one" the new paradigm in general surgery residency training.

OBJECTIVE: There is literature examining the total number of procedures performed by surgery residents before and after duty hour restrictions (DHR). There is insufficient literature addressing the effect of DHR on the number of procedures in which residents directly participate as an assistant, rather than as the primary operating surgeon. METHODS: The operative experience of general surgery residents completing training at the University of Mississippi Medical Center from 2002 to 2008 was retrospectively examined. Data collected included all procedures entered into the General Surgery Operative Log of the American Council on Graduate Medical Education web site in each of the following categories: Surgeon Chief (SC), Surgeon Junior (SJ), Teaching Assistant (TA), and First Assistant (FA). RESULTS: A total of 31 residents completed the program during the study period. Linear regression analysis revealed a significant decrease in the total number of operative procedures (p < 0.05, slope = -55.23, r = -0.99) and the number of procedures reported as FA (p < 0.05, slope = -75, r = -0.89) over the 7-year period. The number of procedures in which residents functioned as the primary surgeon (SJ and SC) or TA remained constant. CONCLUSIONS: Since the implementation of DHR at our institution, the number of procedures in which residents participate as a FA has declined. A surgeon is the sum of his or her cumulative operative experience, whether as the operating surgeon or assistant surgeon; one must conclude that the surgical residents' total operative experience at our institution has declined since the inception of the DHR.

Program directors' views on general surgery resident travel for transplant rotations.

BACKGROUND: Some program directors in surgery (PDs) must maintain transplant rotations at nonintegrated (away) hospitals. This study investigated the opinions of PDs related to resident travel for transplant surgery experience. METHODS: An Internet-based survey was e-mailed to 251 PDs in the United States. RESULTS: Altogether, 131 PDs (52%) responded. Of those, 66% have a transplant service at integrated hospitals. Small majorities of PDs believed transplant rotations offer a good educational experience (59%) and comply with duty hours (71%). Few PDs believed transplant rotations provide excellent operative experience (47%) and mandate service over education (38%). PDs leading community-affiliated and smaller programs employed away rotations more commonly. Affected PDs used commuting (48%) and purchased temporary housing (52%). Most believed travel is a poor aspect of the experience (78%) and transplant rotations should become an optional component of residency training (60%). PDs using away hospitals more often believed this content area should be eliminated. CONCLUSIONS: Although away transplant rotations minimally impact opinions of PDs related to select educational issues, most PDs challenge the existing paradigm of transplant surgery as essential content.

Nondesignated preliminary residents in general surgery: 25-year outcomes.

BACKGROUND: This study assesses the outcomes of nondesignated preliminary (NDP) residents in general surgery (GS) at an independent, nonuniversity training program. METHODS: Records of all NDP residents from 1984-1985 through 2008-2009 were reviewed, and residents' careers were followed. Designated preliminary and categorical residents were excluded. RESULTS: Sixty-two residents completed the NDP year. Three of these residents also completed a second postgraduate NDP year. A total of 60 NDPs (97%) continued in accredited postgraduate programs. Forty-eight graduates (77%) pursued surgery-associated careers: 26 (42%) in GS and 22 (35%) in other surgery-related specialties. Eleven of the 26 NDPs who entered GS (42%) became categorical residents in our program. All NDP GS graduates are board certified, board eligible, or are residents in training. CONCLUSIONS: After a preliminary year in GS, NDPs continued in postgraduate medical education followed by board certification, usually in GS or surgery-related specialties. NDPs often obtain categorical positions in the parent GS program.

Motivations to pursue fellowships are gender neutral.

OBJECTIVE: To determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics. DESIGN: Prospective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships. SETTING: General surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process. PARTICIPANTS: All 1034 first-time applicants. MAIN OUTCOME MEASURES: chi(2) tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making. RESULTS: The fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender. CONCLUSIONS: The ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.

Retrospective evaluation of residents' American Board of Surgery In-Service Training Examination (ABSITE) scores as a tool to evaluate changes made in a basic science curriculum.

OBJECTIVE: To evaluate the effectiveness of a new basic science curriculum at a university-affiliated general surgery residency program. DESIGN: A retrospective evaluation of general surgery residents' American Board of Surgery (ABS) In-Training Examination (ABSITE) scores before and after the implementation of a new basic science curriculum. SETTING: Not-for-profit tertiary referral center with a university-affiliated Accreditation Council for Graduate Medical Education (ACGME) accredited community general surgery residency program. PARTICIPANTS: Postgraduate year (PGY) 1 through 5 general surgical residents. RESULTS: The total questions answered correctly (percent correct) in the main 3 categories improved after implementation of the new curriculum for PGY 1 (total test: 70 +/- 7 vs 60 +/- 9, p < 0.05; clinical science: 71 +/- 10 vs 59 +/- 9, p < 0.05; and basic science: 69 +/- 7 vs 60 +/- 10, p = 0.0003) and for PGY 2 residents (total test: 74 +/- 5 vs 66 +/- 7, p < 0.05; clinical science: 74 +/- 7 vs 66 +/- 8, p = 0.003; and basic science: 74 +/- 5 vs 66 +/- 8, p < 0.05). With the exception of the percentage of clinical questions answered correctly for the PGY 4 level, there was no statistically significant worsening of scores in any other subcategories for any other PGY levels (3 through 5) after implementation of the new program. Before the institution of the new curriculum, 24% (26/110) of residents scored below the 35th percentile, and after the institution of the new curriculum, this number decreased to 12% (12/98), p = 0.006. The first-time passage rate on the ABS Qualifying Examination was unchanged in the period before and after the implementation of the new curriculum (89% vs 86%; p = 0.08). When comparing the bimonthly quizzes with the ABSITE, the correlation coefficient was 0.34. CONCLUSION: After the implementation of a new basic science curriculum organized and directed by the faculty, there were statistically significant improvements of PGY 1 and 2 residents' ABSITE scores.