A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural Dexterity Training for Surgeons (PACTS) Trial.

OBJECTIVES: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs. BACKGROUND: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown. METHODS: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences. RESULTS: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199). CONCLUSIONS: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

EQIP's First Year: A Step Closer to Higher Quality in Surgical Education.

OBJECTIVE: To describe the first year of the Educational Quality Improvement Program (EQIP) DESIGN: The Educational Quality Improvement Program (EQIP) was formed by the Association of Program Directors in Surgery (APDS) in 2018 as a continuous educational quality improvement program. Over 18 months, thirteen discrete goals for the establishment of EQIP were refined and executed through a collaborative effort involving leaders in surgical education. Alpha and beta pilots were conducted to refine the data queries and collection processes. A highly-secure, doubly-deidentified database was created for the ingestion of resident and program data. SETTING & PARTICIPANTS: 36 surgical training programs with 1264 trainees and 1500 faculty members were included in the dataset. 51,516 ERAS applications to programs were also included. Uni- and multi-variable analysis was then conducted. RESULTS: EQIP was successfully deployed within the timeline described in 2020. Data from the ACGME, ABS, and ERAS were merged with manually entered data by programs and successfully ingested into the EQIP database. Interactive dashboards have been constructed for use by programs to compare to the national cohort. Risk-adjusted multivariable analysis suggests that increased time in a technical skills lab was associated with increased success on the ABS's Qualifying Examination, alone. Increased time in a technical skills lab and the presence of a formal teaching curriculum were associated with increased success on both the ABS's Qualifying and Certifying Examination. Program type may be of some consequence in predicting success on the Qualifying Examination. CONCLUSIONS: The APDS has proved the concept that a highly secure database for the purpose of continuous risk-adjusted quality improvement in surgical education can be successfully deployed. EQIP will continue to improve and hopes to include an increasing number of programs as the barriers to participation are overcome.

The APDS General Surgery Education Quality Improvement Program (EQIP).

BACKGROUND: Although the ACGME has called for outcomes-based evaluation of residency programs, few metrics or benchmarks exist connecting educational processes with resident educational outcomes. To address this deficiency, a national Education Quality Improvement Program (EQIP) for General Surgery training is proposed. METHODS: We describe the initial efforts to create this platform. In addition, a national survey was administered to 330 Program Directors to assess their interest in and concerns about a continuous educational quality improvement project. RESULTS: We demonstrate that through a collaborative process and the support of the Association of Program Directors in Surgery (APDS), we were able to develop the groundwork for a national surgical educational improvement project, now called EQIP. The survey response rate was 45.8% (152 of 332 programs) representing a mix of university (55.3%), university-affiliated (18.4%), independent (24.3%), and military (2.0%) programs. Most respondents (66.2%) had not previously heard of EQIP. Most respondents (69.7%) believe that educational outcomes can be measured. The majority of respondents indicated they believed EQIP could be successful (57%). Only 2.3% thought EQIP would not be successful. Almost all programs (98.7%) expressed a willingness to participate, although 19.1% did not believe that they had adequate resources to participate. CONCLUSION: The APDS EQIP platform holds promise as a useful and achievable method to obtain educational outcomes data. These data can be used as a basis for continuous surgical educational quality improvement. General Surgery Program Directors have expressed enthusiasm for EQIP and are willing to participate in the program examining outcomes of General Surgery training programs, with an ultimate goal of improving overall residency training.

Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs.

OBJECTIVE: Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs. DESIGN: After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics. SETTING: An anonymous electronic survey was distributed to interested programs in early 2019. PARTICIPANTS: US General Surgery trainees and attending surgeons. RESULTS: A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection. CONCLUSIONS: Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning.

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills.

PURPOSE: Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills. METHODS: Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16. RESULTS: A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05). CONCLUSIONS: At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.

Ad astra per aspera (Through Hardships to the Stars): Lessons Learned from the First National Virtual APDS Meeting, 2020.

OBJECTIVE: After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting. DESIGN: APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking. SETTING: The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming. PARTICIPANTS: There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally. RESULTS: There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance. CONCLUSIONS: A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.

The Resident Outcome Project: Increased Academic Productivity Associated with a Formal Clinical Research Curriculum.

PURPOSE: A formal 2-year clinical research project in conjunction with a system-based practice and practice-based learning and improvement curriculum was initiated for all residents in our program. Within the structure of this formal clinical research curriculum, residents are required to develop a research hypothesis, develop an appropriate study design, collect and analyze data, and present a completed project. METHODS: At the end of the PGY1 year, residents select a project with an emphasis on quality improvement or clinical outcomes. The first 6 months of the 2-year program are dedicated to the identification of a faculty mentor and submission of a formal proposal to both the departmental education committee and to the institutional IRB. Over the following 12 months, residents meet monthly for required group research meetings. The final 6 months are focused on data analysis and project completion. RESULTS: Seventy-five residents have successfully completed the clinical research program since it was initiated in 2002. Completed projects led to abstracts accepted at 33 national or regional meetings and 11 peer reviewed publications to date. In addition, 3 major hospital wide quality improvement measures were initiated based on project findings. Following the first peer reviewed publication associated with these research projects in 2006, there have been significant increases in not only the number of accepted abstracts from these resident projects (3/18 [17%] vs 30/57 [53%], p = 0.008) but also the total number of all accepted resident clinical research (mean accepted abstracts per year 7.9 vs 1.0, p = 0.009 and mean peer reviewed publications per year 6.8 vs 2.0, p = 0.003.) DISCUSSION: Increased academic productivity was observed after a formal resident clinical research program was initiated in our program. Resident research efforts extended beyond the specific initial outcome projects as skills gained allowed for future independent clinical research.

"Tweet"-format reflective writing: A hidden needs assessment?

BACKGROUND: Medical student reflection is integral for professional development. Preliminary findings suggest that short-format writing promotes reflection and identifies impactful experiences. We sought to determine whether reflective writing could be used as a clerkship needs assessment. METHODS: During their surgical clerkship, medical students submitted "tweet"-format reflections and completed a standardized evaluation. "Tweet" content was analyzed using modified grounded theory methods and coded by valence, content, and reflection. Sub-coding was conducted to compare feedback between "tweets" and evaluations. RESULTS: We analyzed 286 reflections and 214 evaluation comments; 176 "tweets" were reflective (62%). "Tweets" commented on "patient interaction" (53%), "educational experience" (38%), "physician interaction" (26%), and "career decisions" (10%). A significant difference was observed between "tweets" and evaluations with regard to the number that provided feedback on experiences with "critically ill or dying patients." CONCLUSIONS: Reflections provided real-time reactions to impactful clerkship events, notably those involving critically ill or dying patients. This focus on illness may represent an unmet need for discussions related to end of life care. Overall, reflections provided more actionable feedback compared to evaluations.

"Tweet"-Format Writing Is an Effective Tool for Medical Student Reflection.

OBJECTIVE: Reflective writing during medical education allows for professional growth through retrospective analysis of experiential knowledge. However, these writing assignments can pose a challenge to millennial medical students who are more likely to assimilate knowledge through the use of innovative technology and who prefer their data in a concise format. Here, we present a novel, tweet-style reflective writing assignment to better engage the unique skill set of today's medical students. We analyzed the written content partway through the year to determine whether or not the format retains the impact of longer, more structured reflective writing assignments. DESIGN: Surgical clerkship students were required to reflect on 3 distinct experiences through a 140-character written reflection, or tweet. Students were able to submit these assignments at any point during their rotation through a platform available on their smartphone or computer. There were no specifications with regard to content. These reflections were analyzed using modified grounded theory methods. Each tweet was analyzed by 2 individuals to ensure intercoder reliability. Codes were created a priori with respect to positive and negative domains, and type of experience. STETTING: Department of Surgery, Warren Alpert School of Medicine, Brown University, Third Year Medical Student Surgical Clerkship. PARTICIPANTS: Third year medical students at the Warren Alpert School of Medicine, Brown University. Fifty-six medical students were included in this study. RESULTS: During the first 4 blocks of the 2016-2017 academic year, 56 students rotated through the third year surgical clerkship. One hundred and sixty-eight tweets were collected and coded. Sixty-nine tweets (42%) had a positive valence. Students reflected on the following experiences: patient interaction (54%), surgical education (34%), physician/resident interaction (27%), and career decisions (11%). Overall, 87 (52%) tweets were reflective. Many tweets included emotional reactions to specific experiences. CONCLUSIONS: Using tweet-style reflective writing, students identified and reacted to multiple salient experiences from their surgical clerkship. They reflected on both positive and negative emotions, mostly related to personal interactions with patients, but also associated with their education, their team, and their future career. Based on early analysis of the data, we believe that short format writing can be an effective format for reflection.

Trauma morning report is the ideal environment to teach and evaluate resident communication and sign-outs in the 80 hour work week.

BACKGROUND: The 80h work week has raised concerns that complications may increase due to multiple sign-outs or poor communication. Trauma Surgery manages complex trauma and acute care surgical patients with rapidly changing physiology, clinical demands and a large volume of data that must be communicated to render safe, effective patient care. Trauma Morning Report format may offer the ideal situation to study and teach sign-outs and resident communication. MATERIALS AND METHODS: Surgery Residents were assessed on a 1-5 scale for their ability to communicate to their fellow residents. This consisted of 10 critical points of the presentation, treatment and workup from the previous night's trauma admissions. Scores were grouped into three areas. Each area was scored out of 15. Area 1 consisted of Initial patient presentation. Area 2 consisted of events in the trauma bay. Area 3 assessed clarity of language and ability to communicate to their fellow residents. The residents were assessed for inclusion of pertinent positive and negative findings, as well as overall clarity of communication. In phase 1, residents were unaware of the evaluation process. Phase 2 followed a series of resident education session about effective communication, sign-out techniques and delineation of evaluation criteria. Phase 3 was a resident-blinded phase which evaluated the sustainability of the improvements in resident communication. RESULTS: 50 patient presentations in phase 1, 200 in phase 2, and 50 presentations in phase 3 were evaluated. Comparisons were made between the Phase 1 and Phase 2 evaluations. Area 1 (initial events) improved from 6.18 to 12.4 out of 15 (p<0.0001). Area 2 (events in the trauma bay) improved from 9.78 to 16.53 (p<0.0077). Area 3 (communication and language) improved from 8.36 to 12.22 out of 15 (P<0.001). Phase 2 to Phase 3 evaluations were similar, showing no deterioration of skills. CONCLUSIONS: Trauma Surgery manages complex surgical patients, with rapidly changing physiologic and clinical demands. Trauma Morning Report, with diverse attendance including surgical attendings and residents in various training years, is the ideal venue for real-time teaching and evaluation of sign-outs and reinforcing good communication skills in residents.

Teaching leadership in trauma resuscitation: Immediate feedback from a real-time, competency-based evaluation tool shows long-term improvement in resident performance.

BACKGROUND: Limited data exist on how to develop resident leadership and communication skills during actual trauma resuscitations. METHODS: An evaluation tool was developed to grade senior resident performance as the team leader during full-trauma-team activations. Thirty actions that demonstrated the Accreditation Council for Graduate Medical Education core competencies were graded on a Likert scale of 1 (poor) to 5 (exceptional). These actions were grouped by their respective core competencies on 5 × 7-inch index cards. In Phase 1, baseline performance scores were obtained. In Phase 2, trauma-focused communication in-services were conducted early in the academic year, and immediate, personalized feedback sessions were performed after resuscitations based on the evaluation tool. In Phase 3, residents received only evaluation-based feedback following resuscitations. RESULTS: In Phase 1 (October 2009 to April 2010), 27 evaluations were performed on 10 residents. In Phase 2 (April 2010 to October 2010), 28 evaluations were performed on nine residents. In Phase 3 (October 2010 to January 2012), 44 evaluations were performed on 13 residents. Total scores improved significantly between Phases 1 and 2 (p = 0.003) and remained elevated throughout Phase 3. When analyzing performance by competency, significant improvement between Phases 1 and 2 (p < 0.05) was seen in all competencies (patient care, knowledge, system-based practice, practice-based learning) with the exception of "communication and professionalism" (p = 0.56). Statistically similar scores were observed between Phases 2 and 3 in all competencies with the exception of "medical knowledge," which showed ongoing significant improvement (p = 0.003). CONCLUSIONS: Directed resident feedback sessions utilizing data from a real-time, competency-based evaluation tool have allowed us to improve our residents' abilities to lead trauma resuscitations over a 30-month period. Given pressures to maximize clinical educational opportunities among work-hour constraints, such a model may help decrease the need for costly simulation-based training. LEVEL OF EVIDENCE: Therapeutic study, level III.

An early surgical training module for compartment pressure measurement.

BACKGROUND: We test a novel simulated teaching module's ability to educate junior residents in the assessment of compartment syndrome (CS) and compartment pressure measurement (CPM). METHODS: Twenty-two postgraduate year 1 and postgraduate year 2 surgical residents received a 2-hour didactic and practical teaching module on CS assessment and CPM using a simulated model. A structured teaching session by a postgraduate year 5 surgical resident was assessed by carefully constructed pretest, post-test, and delayed retention tests and a practical testing session by 2 board-certified general surgeons. RESULTS: Analysis of variance demonstrated significant difference between pretest (6.1/10), post-test (7.9/10), and retention test (8.2/10) scores [F (2,49) = 9.24, P < .01], with no difference in post-test to retention test comparison (P = .90). Mean CPM scores were 8.5/10 for preparation, 9.0/10 for performance, and 8.5/10 for management components, which did not differ [F (2,57) = .46, P = .63]. CONCLUSIONS: We demonstrate an efficient simulated CS and CPM teaching module for the education of junior surgical residents using a synthetic model.

American College of Surgeons National Surgical Quality Improvement Program as a quality-measurement tool for advanced cancer patients.

BACKGROUND: Multiple studies have shown the significantly increased post-operative morbidity and mortality of patients undergoing palliative operations. It has been proposed by some authors that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database can be used reliably to develop risk-calculators or as an aid for clinical decision-making in advanced cancer patients. ACS-NSQIP is a population-based database that by design only captures outcomes data for the first 30-day following an operation. We considered the suitability of these data as a tool for decision-making in the advanced cancer patient. METHODS: Six-year retrospective review of a single institution's ACS-NSQIP database for cases identified as "Disseminated Cancer". Procedures performed with palliative intent were identified and analyzed. RESULTS: Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having "Disseminated Cancer". Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the "Disseminated Cancer" group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72). CONCLUSIONS: Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.

What Shape is Your Resident in? Using a Radar Plot to Guide a Milestone Clinical Competency Discussion.

OBJECTIVE: One of the challenges for program directors (PDs) is to sort and weight the tidal wave of assessments that training programs create in the modern Milestone era. We evaluated whether the use of a radar plot (RP) would be helpful in sorting data and providing a graphic representation of each resident's progress. DESIGN: Using at least 2 different types of assessments for each of the 16 surgical Milestones, the data were ranked and weighted by a predetermined method embedded in a computerized workbook (Excel). This process created a unique 16-spoked RP for each resident (Fig. below). The RP allowed the faculty to see areas of weakness (shown by concavity) and allowed an overall grade calculated as a ratio of the area of the smooth outer circle (faculty expectations, triangles) and the resident's unique radar shape (resident performance, squares). To help us validate our new tool, we looked at whether residents with recent remedial issues "looked" different from residents without remedial issues. RESULTS: Of our 30 categorical residents, 8 had significant areas of concavities, suggesting possible areas of improvement. Of these 8 residents, 4 had been on a remediation program in the last 18 months. The average ratio of performance/expectations was 0.709. The 4 residents on recent remediation had a ratio of 0.616 when compared with 0.723 for the residents without remedial issues (p < 0.009). CONCLUSIONS: Many exciting challenges await PDs, as we evolve to a competency-based evaluation system. The use of an evaluation summary tool using RPs may aid PDs in leading clinical competency discussions and in monitoring a resident's progress over time.

A multicenter study of preventable contact burns from glass fronted gas fireplaces.

Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

Assessment of surgical residents in a vascular anastomosis laboratory.

BACKGROUND: We designed a simple, low-cost workshop to teach surgical residents the basic skills of vascular anastomosis. We studied our ability to identify objective procedural and end-product metrics that could be used to measure improvement in vascular anastomotic skill before and after training. MATERIALS AND METHODS: Ten postgraduate year 2 residents without previous vascular surgery experience and four attending surgeons (expert) performed end-to-side anastomosis using a synthetic graft. The residents were taught the basic skills of vascular anastomosis during three didactic workshops. The objective metrics included volume leakage after saline perfusion (leak) and the time needed to complete the anastomosis. Penalty points were assigned for broken sutures, air knots, locking sutures, and failure to maintain an outside-in to inside-out technique. The leak, time, and penalties before and after training were compared. RESULTS: The mean leak was 70.4 ± 13.7 mL and the mean completion time was 18.7 ± 3 min for the pretraining group versus 45.3 ± 10.6 mL (P < 0.01) and 8.5 ± 1 min (P < 0.001), respectively, for the attending group. After training, significant improvement was seen in resident leak (46.7 ± 6.8 mL; P < 0.001) and completion time (14.4 ± 3 min; P < 0.01). Leak was similar between the post-training and expert groups (46.7 ± 6.8 mL and 45.3 ± 10.6 mL, respectively; P = 0.77); however, a significant difference for the completion time remained (14.4 ± 3.0 min and 8.5 ± 1 min, respectively; P < 0.01). The mean number of technical errors improved from 2.7 in the pretraining group to zero for the post-training group after completing the workshop. CONCLUSIONS: We have reported an easy to implement workshop for teaching surgical residents the basic skills of performing vascular anastomosis.

The reflective statement: a new tool to assess resident learning.

PURPOSE: Continued assessment and redesign of the curriculum is essential for optimal surgical education. For the last 3 y, we have asked the residents to reflect on the previous week and describe "the best thing" they learned. We hypothesize that this statement could be used to assess the weaknesses or strengths of our curriculum. METHODS: Starting in 2007, residents filled out surveys approximately 4 times/y at the start of a mandatory conference. They were asked to describe the "best thing" they learned that week, where it was learned, and who taught it. Residents were not asked to classify the item learned by core competency (communication, knowledge, patient care, practice-based learning, professionalism, and systems-based practice). This categorization into core competencies was done as part of our study design. Attending, fellow, resident, or other were used as groups designating who taught each item. Where the item was learned was fit into either clinic, conference, operating room (OR), wards, or self. The impact of postgraduate year (PGY) level on learning was also assessed. χ(2) analysis was used to compare groups. RESULTS: During the study period, 304 surveys were completed and returned by 65 residents. The majority of responses came from PGY 1 residents (134, 43%). Patient care and knowledge were the most common core competencies learned. As PGY level increased, learning of professionalism (P = 0.035) increased. A majority of learning was experiential (wards and OR, P < 0.0125). Self-learning and learning in clinic was a minor component of learning (P < 0.0125). Learning on wards (P < 0.001) decreased as residents progressed and learning from the OR (P = 0.002) had the opposite trend. CONCLUSIONS: Patient care and knowledge are the most frequently cited competencies learned by the residents. Self-learning is not a significant source of learning, and the majority of the learning is experiential. It is not known if this was a sign that there was a lack of self-directed learning or that self-directed learning was not an efficient method of learning. In addition, each PGY level learns differently (teacher and location of learning), perhaps reflecting the different needs and/or structure of each PGY. We believe the reflective statement has been and will be a useful tool to assess our curriculum.

Leukocyte-depleted blood transfusion is associated with decreased survival in resected early-stage lung cancer.

OBJECTIVES: Blood transfusion has been shown to have deleterious effect on lung cancer survival, but little data are available that assess whether leukocyte-depleted (LD) blood has a similar adverse effect. Our institution has been using LD red cells since 2001. We sought to determine whether LD blood has an effect on survival after resection of early-stage lung cancer. METHODS: From a prospective database, we evaluated all patients with pathologic stage I non-small cell lung cancer. Patients receiving LD blood were compared with those receiving no transfusion. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis by Cox regression was used to identify independent risk factors affecting survival. RESULTS: From 2001 to 2009, 361 patients were evaluated; 63 received LD red cell cell transfusion and 298 received no transfusion. Median follow-up was 48 months. Disease-free survival (P < .001) and overall survival (P < .001) were worse in patients receiving LD blood. Stratifying for stage, disease-free survival continued to be worse with transfusion for stage IA (P = .002) and IB (P = .002). Similarly, overall survival continued to be worse with transfusion for stage IA (P < .001) and IB (P < .001). For disease-free and overall survival, univariate analysis revealed increased age, male gender, anemia, transfusion, and higher stage to be adverse factors, with transfusion and higher stage continuing to be significant adverse factors after multivariate analysis. CONCLUSIONS: Our data suggest that transfusion of LD blood is associated with a worse disease-free and overall survival in patients with resected stage I non-small cell lung cancer.