The characteristics and outcomes of trauma admissions to an adult general surgery ward in a tertiary teaching hospital.

BACKGROUND: Traumatic injuries are proportionally higher in low- and middle-income countries (LMICs) than high-income counties. Data on trauma epidemiology and patients' outcomes are limited in LMICs. METHODS: A retrospective review of medical records was performed for trauma admissions to the Princess Marina Hospital general surgical (GS) wards from August 2017 to July 2018. Data on demographics, mechanisms of injury, body parts injured, Revised Trauma Score, surgical procedures, hospital stay, and outcomes were analysed. RESULTS: During the study period, 2610 patients were admitted to GS wards, 1307 were emergency admissions. Trauma contributed 22.1% (576) of the total and 44.1% of the emergency admissions. Among the trauma admissions, 79.3% (457) were male. The median[interquartile range(IQR)](range) age in years was 30[24-40](13-97). The main mechanisms of injury were interpersonal violence (IPV), 53.1% and road traffic crashes (RTCs), 23.1%. More females than males suffered animal bites (5.9% vs. 0.9%), and burns (8.4% vs. 4.2%), while more males than females were affected by IPV (57.8% vs. 35.3%) and self-harm (5.5% vs. 3.4%). Multiple body parts were injured in 6.6%, mainly by RTCs. Interpersonal violence (IPV) and RTCs resulted in significant numbers of head and neck injuries, 57.3% and 22.2% respectively. More females than males had multiple body-parts injury 34.5% vs. 18.5%. Revised Trauma Score (RTS) of ≤11 was recorded in IPV, 38.4% and RTCs, 33.6%. Surgical procedures were performed on 44.4% patients. The most common surgical procedures were laparotomy (27.8%), insertion of chest tube (27.8%), and craniotomy/burr hole(25.1%). Complications were recorded in 10.1% of the patients(58) including 39 deaths, 6.8% of the 576. CONCLUSION: Trauma contributed significantly to the total GS and emergency admissions. The most common mechanism of injury was IPV with head and neck the most frequently injured body part. Further studies on IPV and trauma admissions involving paediatric and orthopaedic patients are warranted.

Developing Research Potential and Building Partnerships: A Report of the Fundamentals of Surgical Research Course at the College of Surgeons of East, Central, and Southern Africa.

BACKGROUND: Approximately a decade after the inaugural Fundamentals of Surgical Research Course (FSRC) at the West African College of Surgeons meeting (2008), the Association for Academic Surgery expanded the course offering to the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA). After the second annual offering of the course in 2019, participants were surveyed to assess the impact of the course. METHODS: A survey was distributed to the attendees of the 2019 second COSECSA FSRC course, held in December 2019 in Kampala, Uganda. Approximately 80 people attended at least a portion of the full-day course. Forty-nine participants completed the voluntary survey questionnaire distributed to assess each session of the course at course completion. RESULTS: Ten different countries were represented among the attendees. Of the 49 evaluations, 35 respondents were male and six were female. Eight respondents did not identify a gender. Surgical residents comprised 19 of the 49 attendees, and one of the 49 attendees was a medical student. Thirty-five respondents indicated that their views of surgical research had changed after attending the course. CONCLUSIONS: The second annual FSRC at COSECSA confirmed significant interest in building research skills and partnerships in sub-Saharan Africa. A wide variety of learners attended the course, and a majority of the sessions received overwhelmingly positive feedback. Multiple conference attendees expressed interest in serving as faculty for the course moving forward, highlighting a viable path for sustainability as the Association for Academic Surgery develops an international research education platform.

Ethics as a Non-technical Skill for Surgical Education in Sub-Saharan Africa.

BACKGROUND: In recent years, surgical education has increased its focus on the non-technical skills such as communication and interpersonal relationships while continuing to strive for technical excellence of procedures and patient care. An awareness of the ethical aspects of surgical practice that involve non-technical skills and judgment is of vital concern to surgical educators and encompasses disparate issues ranging from adequate supervision of trainees to surgical care access. METHODS: This bibliographical research effort seeks to report on ethical challenges from a sub-Saharan Africa (SSA) perspective as found in the peer-reviewed literature employing African Journals Online, Bioline, and other sources with African information as well as PubMed and PubMed Central. The principles of autonomy, non-maleficence, beneficence, and justice offer a framework for a study of issues including: access to care (socioeconomic issues and distance from health facilities); resource utilization and decision making based on availability and cost of resources, including ICU and terminal extubation; informed consent (both communication about reasonable expectations post-procedure and research participation); research ethics, including local projects and international collaboration; quality and safety including supervision of less experienced professionals; and those religious and cultural issues that may affect any ethical decision making. The religious and cultural environment receives attention because beliefs and traditions affect medical choices ranging from acceptance of procedures, amputations, to end-of-life decisions. RESULTS AND CONCLUSIONS: Ethics awareness and ethics education should be a vital component of non-technical skills training in surgical education and medical practice in SSA for trainees. Continuing professional development of faculty should include an awareness of ethical issues.

Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up.

BACKGROUND: African surgical workforce needs are significant, with largest disparities existing in rural settings. Pan-African Academy of Christian Surgeons (PAACS), a primarily rural-based general surgery training program, has published successes in producing rural African surgeons; however, long-term follow-up data are unreported. The goal of our study was to define characteristics of PAACS alumni surgeons working in rural hospitals, documenting successes and illuminating strategies for trainee recruitment and retention. METHOD: PAACS' twenty-year surgery residency database was reviewed for 12 programs throughout Africa regarding trainee demographics and graduate outcomes. Characteristics of PAACS' graduate surgeons were further analyzed with a 42-question survey. RESULTS: Among active PAACS graduates, 100% practice in Africa and 79% within their home country. PAACS graduates had 51% short-term and 35% long-term (beyond 5 years) rural retention rate (less than 50,000 population). CONCLUSION: Our study shows that PAACS general surgery training program has a high retention rate of African surgeons in rural settings compared to all programs reported to date, highlighting a multifaceted, rural-focused approach that could be emulated by surgical training programs worldwide.

Global surgery opportunities for U.S. surgical residents: an interim report.

INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery developed guidelines that allowed time spent and cases performed outside of the United States by surgical residents from ACGME-accredited training programs to be applied toward program completion. We hypothesized that the number of programs with global surgical rotations would have increased after that important development. We also sought to determine the characteristics that led to sustainment of such programs. METHODS: An Institutional Review Board-approved electronic survey was sent to all 253 program directors of ACGME-approved general surgery residencies requesting information on international rotations available to residents. Responses were requested from program directors with extant rotations. Survey questions focused on locations, funding, nature of the rotations, faculty involvement, keys to success, and the barriers to overcome during program development and sustainment. RESULTS: The survey reported 34 surgery residency programs offering global surgery rotations, up from 23 just 5 years previously. Of these reporting programs, 25 have been approved by the ACGME. Most rotations occur in the postgraduate year 3 or 4 and are primarily clinical rotations. Africa is the main destination. Resident supervision is provided by a mixture of host and home surgeons. A dedicated faculty is considered to be the most important element for success while funding remains a major impediment. CONCLUSIONS: The interest in global surgery continues to increase, and general surgical programs will strive to meet the expectations of residents looking for international exposure. Collaboration could facilitate resident opportunities and potentially be more cost-effective.

The role of a preliminary PGY-3 in general surgery training.

INTRODUCTION: Even before the preliminary postgraduate year (PGY)-3 was eliminated from surgical residency, it had become increasingly difficult to fill general surgery PGY-4 vacancies. This ongoing need prompted the Association of Program Directors in Surgery (APDS) leadership to form a task force to study the possibility of requesting the restoration of the preliminary PGY-3 to Accreditation Council for Graduate Medical Education-approved general surgery residency programs. METHODS: The task force conducted a 10-year review of the APDS list serve to ascertain the number of advertised PGY-4 open positions. Following the review of the list serve, the task force sent IRB-approved electronic REDCap surveys to 249 program directors (PDs) in general surgery. RESULTS: The list serve review revealed more than 230 requests for fourth-year residents, a number that most likely underestimates the need, as such, vacancies are not always advertised through the APDS. A total of 119 PDs (~48%) responded. In the last 10 years, these 119 programs needed an average of 2 PGY-4 residents (range: 0-8), filled 1.3 positions (range: 0-7), and left a position unfilled 1.3 times (range: 0-7). Methods for finding PGY-4 residents included making personal contacts with other PDs (52), posting on the APDS Topica List Serve (47), and using the APDS Web site for interested candidates on residency and fellowship job listings (52). Reasons for needing a PGY-4 resident included residents leaving the program (82), extra laboratory years (39), remediation (31), and approved program expansion (21), as well as other issues. Satisfaction scores for the added PGY-4 residents were more negative (43) than positive (30). Problems ranged from lack of preparation to professionalism. When queried as to an optimal number of preliminary residents needed nationally at the PGY-3 level, responses varied from 0 to 50 (34 suggested 10). CONCLUSIONS: The survey of PDs supports the need for the reintroduction of a limited number of Accreditation Council for Graduate Medical Education-approved preliminary PGY-3 positions in general surgery residency programs.

Does intentional support of degree programs in general surgery residency affect research productivity or pursuit of academic surgery?

OBJECTIVE: Many residents supplement general surgery training with years of dedicated research, and an increasing number at our institution pursue additional degrees. We sought to determine whether it was worth the financial cost for residency programs to support degrees. DESIGN: We reviewed graduating chief residents (n = 69) in general surgery at Vanderbilt University from 2001 to 2010 and collected the data including research time and additional degrees obtained. We then compared this information with the following parameters: (1) total papers, (2) first-author papers, (3) Journal Citation Reports impact factors of journals in which papers were published, and (4) first job after residency or fellowship training. SETTING: The general surgery resident training program at Vanderbilt University is an academic program, approved to finish training 7 chief residents yearly during the time period studied. PARTICIPANTS: Chief residents in general surgery at Vanderbilt who finished their training 2001 through 2010. RESULTS: We found that completion of a degree during residency was significantly associated with more total and first-author publications as compared with those by residents with only dedicated research time (p = 0.001 and p = 0.017). Residents completing a degree also produced publications of a higher caliber and level of authorship as determined by an adjusted resident impact factor score as compared with those by residents with laboratory research time only (p = 0.005). Degree completion also was significantly correlated with a first job in academia if compared to those with dedicated research time only (p = 0.046). CONCLUSIONS: Our data support the utility of degree completion when economically feasible and use of dedicated research time as an effective way to significantly increase research productivity and retain graduates in academic surgery. Aggregating data from other academic surgery programs would allow us to further determine association of funding of additional degrees as a means to encourage academic productivity and retention.

Achievement in surgical residency: are objective measures of performance associated with awards received in final years of training?

OBJECTIVE: For the past 15 years at our institution's general surgery residency program, 3 of the senior residents have been chosen to be awarded either (1) Best Resident in Research, (2) Best Resident in Teaching, or (3) Best Resident Overall. Considering that these awards serve as data representing outstanding performance as surgical residents, the objective of this study was to determine the association between receiving one of these awards and objective measures of performance. METHODS: Individual files were reviewed for the 103 residents who graduated from our institution's general surgery program from 1994 to 2010. These data were studied as a whole, and then divided into an award-winning group and a non-award winning group and subsequently compared across several objective parameters, including The United States Medical Licensing Examination (USMLE) scores, American Board of Surgery In-Training Examination (ABSITE) scores, first-time American Board of Surgery Certifying and Qualifying Examination pass rates, Alpha Omega Alpha membership status, and number of research years, using a logistic regression model. RESULTS: Overall, 103 residents completed their general surgery residency training at our institution from 1994 to 2010, and of these residents, 16 (16%) received the Best Resident in Research award, 15 (16%) received the Best Resident in Teaching award, and 17 (17%) received the Best Resident Overall award in their final years of training. Compared with those who did not receive an award, a hypothesis-based one-tailed test revealed that award winners had a significantly lower median USMLE Step 1 scores (p = 0.04) and marginally lower median USMLE Step 2 scores (p = 0.05). Alpha Omega Alpha membership status, median ABSITE percent correct overall, first-time American Board of Surgery examination pass rates, and number of research years during residency were not significantly different between the 2 groups. CONCLUSION: Many factors contribute to success during general surgery residency. Our study showed that higher USMLE and ABSITE scores were not associated with receiving top awards in final years of training at one institution over 15 years.

The role of the nonphysician educator in general surgery residency training: from outcome project and duty-hours restrictions to the next accreditation system and milestones.

OBJECTIVE: In 2002 and 2003 the ACGME Outcome Project (assessing residents based on competencies) and duty-hours restrictions were implemented. One strategy for assisting PDs in the increased workload was to hire nonphysician educators with training and experience in curriculum design, teaching techniques, adult learning theories, and research methods. This study sought to document prevalence and responsibilities of nonphysician educators. METHODS: IRB approval was received for a two-part study. All 247 general surgery PDs were e-mailed the question, "Do you have a nonphysician educator as a member of your surgery education office?" Those who replied "yes" or volunteered "not currently but in the past" were e-mailed a link to an electronic survey concerning the role of the nonphysician educator. SETTING: Residency training programs in general surgery. PARTICIPANTS: General surgery program directors. RESULTS: Of the 126 PDs who responded to the initial query, 37 said "yes" and 4 replied "not currently but in the past". Thirty-two PDs of the initial 41 respondents completed the survey. Significant findings included: 65% were hired in the last 6 years; faculty rank is held by 69%; and curriculum development was the most common responsibility but teaching, research, and administrative duties were often listed. PDs perceived that faculty, residents, and medical students had mostly positive attitudes towards nonphysician educators. CONCLUSIONS: The overall results seem to support the notion that nonphysician educators serve as vital members of the team.

Teaching in the operating room: results of a national survey.

BACKGROUND: With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education. METHODS: A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs. RESULTS: A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time. CONCLUSIONS: This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations.

Elective global surgery rotations for residents: a call for cooperation and consortium.

BACKGROUND: International elective experiences are becoming an increasingly important component of American general surgery education. In 2011, the Residency Review Committee (RRC) approved these electives for credit toward graduation requirements. Previous surveys of general surgery program directors have established strong interest in these electives but have not assessed the feasibility of creating a national and international database aimed at educational standardization. The present study was designed to gain in-depth information from program directors about features of existing international electives at their institution and to ascertain interest in national collaboration. METHODS: This cross-sectional study of 253 United States general surgery program directors was conducted using a web-based questionnaire program. RESULTS: Of the program directors who responded to the survey, twelve percent had a formal international elective in place at their institution, though 80% of these did not have a formal associated curriculum for the rotation. Sixty percent of respondents reported that informal international electives existed for their residents. The location, length, and characteristics of these electives varied widely. Sixty-eight percent of program directors would like to participate in a national and international database designed to facilitate standardization of electives and educational exchange. CONCLUSIONS: In a world of increasing globalization, international electives are more important than ever to the education of surgery residents. However, a need for standardization of these electives exists. The creation of an educational consortium and database of international electives could improve the academic value of these electives, as well as provide increased opportunities for twinning and bidirectional exchange.

Spiritual dimensions of surgical palliative care.

The spiritual dimensions of surgical palliative care encompass recognition of mortality (physician and patient); knowledge of moral and ethical dilemmas of medical decision making; respect for each individual and for all belief systems; responsibility to remain physically and psychologically present for the patient and family; and knowledge of when chaplains, palliative care professionals, or social workers should be consulted. Certain aspects of surgical palliative care distinguish it from palliative care in other medical disciplines such as the 2 definitions (palliative procedure and palliative care), treating a disproportionate share of patients who suffer unforeseen tragic events, and the surgical system.

National efforts to reform residency education in surgery.

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