A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment.

OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

Mediastinal Paraganglioma.

Paragangliomas of the mediastinum are rare, with only approximately 150 cases reported in the literature. Surgical excision is the treatment of choice; however, these tumors often lie near critical vascular structures. Here we present the case of a patient with a mediastinal paraganglioma discovered during a diagnostic procedure.

Evaluating Surgical Residents Quickly and Easily Against the Milestones Using Electronic Formative Feedback.

OBJECTIVE: This study was conducted to assess the effectiveness of a newly implemented electronic web-based review system created at our institution for evaluating resident performance relative to established milestones. DESIGN: Retrospective review of data collected from a survey of general surgery faculty and residents. SETTING: Tertiary care teaching hospital system and independent academic medical center. PARTICIPANTS: A total of 12 general surgery faculty and 17 general surgery residents participated in this study. The survey queried the level of satisfaction before and after the adoption of QuickNotes using several statements scored on a 5-point scale, with 1 being the lowest rating as "not satisfied," and 5 being the highest rating as "completely satisfied." RESULTS: The weighted average improvements from pre- to post-QuickNotes implementation for the faculty responding to the survey ranged from 10% to 40%; weighted average improvements for the residents responding to the survey ranged from 5% to 73%. For the survey of faculty, both sets of weighted averages tended to be higher than the weighted average for the resident's survey responses. The highest rated topic was the faculty's level of satisfaction with the "frequency to provide feedback" with a post-QuickNotes implementation weighted average of 4.25, closely followed by the residents' level of satisfaction with the "evaluation includes positive feedback" with a post-QuickNotes implementation weighted average of 4.24. The most notable increases in weighted averages from preimplementation to postimplementation were noted for "overall satisfaction" (20% increase for faculty, 37% for residents), "reflects actual criteria that matter" (36% increase for faculty, 73% for residents), faculty "opportunity for follow-up" (increase of 40%), resident "reflects overall trends" (increase of 37%), and resident "provides new information about my performance" (increase of 37%). CONCLUSIONS: Our institutional adoption of QuickNotes into the resident evaluation process has been associated with an overall increased level of satisfaction in the evaluation process by both faculty and residents. The design of QuickNotes facilitates its integration into the resident training environment, as it is web based, easy to use, and has no additional cost over the standard New Innovations subscription. Although it is designed to capture snapshots of trainee behavior and performance, monthly reports through QuickNotes can be used effectively in conjunction with the more traditional end-of-rotation evaluations to show trends, identify areas of strength that should be reinforced, demonstrate areas needing improvement, allow for a more tailored individual education plan to be developed, and permit a more accurate determination of milestone progression.

Neoadjuvant Gemcitabine Chemotherapy followed by Concurrent IMRT Simultaneous Boost Achieves High R0 Resection in Borderline Resectable Pancreatic Cancer Patients.

BACKGROUND: To study the feasibility of down stage the borderline resectable pancreatic cancer (BRPC) to resectable disease, we reported our institutional results using an intensity-modulated radiation therapy (IMRT) simultaneous integrated boost (SIB) dose escalation approach to improve R0 resectability. METHODS: We reviewed our past 7 years of experience of using neoadjuvant induction chemotherapy with Gemcitabine followed by concurrent chemoradiaiton for BRPC. During the concurrent, chemo was 5-FU and radiation were IMRT with SIB technique to target the key areas with dose escalation to 5600 in 28 fractions. The key areas were defined by PET positive area. This was followed by restaging imaging to rule out distant metastases before resection. RESULTS: 25 finished dose escalation protocol. 2 of the 25 cases developed distant metastases, 23 (92%) patients without distant metastases underwent pancreatectomy. Among the those received pancreatectomy, 22 (95%) achieved negative margin (R0). The gastrointestinal toxicity > grade 2 was 8% and there was no grade 4 toxicity. CONCLUSION: Neoadjuvant Gemcitabine-based induction chemotherapy followed by 5-FU-based IMRT-SIB is a feasible option in improving the likelihood of R0 resection rate in BRPC without compromising the organs at risk for toxicity.

Invasion vs insurgency: US Navy/Marine Corps forward surgical care during Operation Iraqi Freedom.

HYPOTHESIS: The transition from maneuver warfare to insurgency warfare has changed the mechanism and severity of combat wounds treated by US Marine Corps forward surgical units in Iraq. DESIGN: Case series comparison. SETTING: Forward Resuscitative Surgical System units in Iraq. PATIENTS: Three hundred thirty-eight casualties treated during the invasion of Iraq in 2003 (Operation Iraqi Freedom I [OIF I]) and 895 casualties treated between March 2004 and February 2005 (OIF II). INTERVENTIONS: Definitive and damage control procedures for acute combat casualties. MAIN OUTCOME MEASURES: Mechanism of injury, procedures performed, time to presentation, and killed in action (KIA) and died of wounds (DOW) rates. RESULTS: More major injuries occurred per patient (2.4 vs 1.6) during OIF II. There were more casualties with fragment wounds (61% vs 48%; P = .03) and a trend toward fewer gunshot wounds (33% vs 43%; P = .15) during OIF II. More damage control laparotomies (P = .04) and more soft tissue debridements (P < .001) were performed during OIF II. The median time to presentation for critically injured US casualties during OIF I and OIF II were 30 and 59 minutes, respectively. The KIA rate increased from 13.5% to 20.2% and the DOW rate increased from 0.88% to 5.5% for US personnel in the First Marine Expeditionary Force area of responsibility. CONCLUSIONS: The transition from maneuver to insurgency warfare has changed the type and severity of casualties treated by US Marine Corps forward surgical units in Iraq. Improvised explosive devices, severity and number of injuries per casualty, longer transport times, and higher KIA and DOW rates represent major differences between periods. Further data collection is necessary to determine the association between transport times and mortality rates.

The U.S. Navy's forward resuscitative surgery system during Operation Iraqi Freedom.

The forward resuscitative surgery system (FRSS) is the Navy's most forward-deployed echelon II medical unit. Between March and August 2003, six FRSS teams were deployed in support of Operation Iraqi Freedom (OIF). During the combat phase of OIF (March 21 to May 1, 2003), a total of 34 Marine Corps and 62 Iraqi patients underwent treatment at a FRSS. FRSS teams were assigned two distinct missions; "forward" FRSS teams operated with combat service support elements in direct support of regimental combat teams, and "jump" FRSS teams served as a forward element of a surgical company. This article presents the experiences of the FRSS teams in OIF, including a discussion of time to presentation from wounding, time to operation, time to evacuation, and lessons learned from the deployment of the FRSS.

Initial experience of US Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom.

HYPOTHESIS: Modern US Marine Corps (USMC) combat tactics are dynamic and nonlinear. While effective strategically, this can prolong the time it takes to transport the wounded to surgical capability, potentially worsening outcomes. To offset this, the USMC developed the Forward Resuscitative Surgical System (FRSS). By operating in close proximity to active combat units, these small, rapidly mobile trauma surgical teams can decrease the interval between wounding and arrival at surgical intervention with resultant improvement in outcomes. DESIGN: Case series. SETTING: Echelon 2 surgical units during the invasion phase of Operation Iraqi Freedom. PATIENTS: Ninety combat casualties, consisting of 30 USMC and 60 Iraqi patients, were treated in the FRSS between March 21 and April 22, 2003. INTERVENTIONS: Tactical surgical intervention consisting of selectively applied damage control or definitive trauma surgical procedures. MAIN OUTCOME MEASURES: Time to surgical intervention and outcome following treatment in the FRSS. RESULTS: Ninety combat casualties with 170 injuries required 149 procedures by 6 FRSS teams. The USMC patients were received within a median of 1 hour of wounding with the critically injured being received within a median of 30 minutes. Fifty-three USMC personnel were killed in action and 3 died of wounds for a killed in action rate of 13.5% and a died of wounds rate of 0.8% during the invasion phase of Operation Iraqi Freedom. All Marines treated in the FRSS survived. CONCLUSION: The use of the FRSS in close proximity to the point of engagement during the initial, dynamic combat phase of Operation Iraqi Freedom prevented delays in surgical intervention of USMC combat casualties with resultant beneficial effects on patient outcomes.