Piloting a National Curricular Resource for the Transition to Surgical Residency: Characteristics of Participating Schools and Their Students.

OBJECTIVE: To determine the extent to which U.S. Liaison Committee of Medical Education (LCME)-accredited medical schools chose to participate in piloting a national curricular resource, the American College of Surgeons/Association of Program Directors in Surgery/Association of Surgical Education Resident Prep Curriculum ("ACS-surgery-prep curriculum"), and implications of such participation for student access nationally to this resource. DESIGN: We examined the significance of school-level differences in ACS-surgery-prep curriculum pilot participation and student-level differences in curriculum access based on medical school attended in bivariate analysis. SETTING: U.S. medical schools choosing to participate in the ACS-surgery-prep curriculum through 2021. Students graduating from U.S. LCME-accredited medical schools in 2020-2021 were invited to complete the Association of American Medical Colleges 2021 Graduation Questionnaire (GQ). PARTICIPANTS: Our study included data for 2569 students intending surgery specialties (16% of 16,353 2021 GQ respondents) from ACS-surgery-prep curriculum pilot and non-pilot schools. RESULTS: Of 148 medical schools attended by 2021 GQ respondents, 93 (63%) were identified as ACS-surgery-prep curriculum pilot schools. Pilot participation varied by school region, community-based designation, and research intensity (each p < 0.05) but not by ownership or transition to residency (TTR) course requirements (each p > 0.05). Of 2569 GQ respondents nationally intending surgery specialties, 1697 (66%) attended an ACS-surgery-prep curriculum pilot school; this proportion did not vary by gender or race/ethnicity (each p > 0.05) but varied by students' school TTR course requirements (p < 0.001). Findings were similar among the 1059 students intending general surgery specialties specifically (41% of all 2569 students intending surgery specialties). CONCLUSIONS: Many U.S. LCME-accredited medical schools piloted this national TTR surgery curriculum. School-level characteristics associated with pilot participation can inform outreach efforts to encourage the participation of interested schools in piloting this TTR resource. With this curriculum distribution model, we observed no gender or racial/ethnic disparities in curriculum access nationally among students intending surgery specialties.

The American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA): Validity Evidence From a Three-Year National Study.

OBJECTIVE: To gather validity evidence supporting the use and interpretation of scores from the American College of Surgeons Entering Resident Readiness Assessment (ACS ERRA) Program. SUMMARY AND BACKGROUND DATA: ACS ERRA is an online formative assessment program developed to assess entering surgery residents' ability to make critical clinical decisions, and includes 12 clinical areas and 20 topics identified by a national panel of surgeon educators and residency program directors. METHODS: Data from 3 national testing administrations of ACS ERRA (2018-2020) were used to gather validity evidence regarding content, response process, internal structure (reliability), relations to other variables, and consequences. RESULTS: Over the 3 administrations, 1975 surgery residents participated from 125 distinct residency programs. Overall scores [Mean = 64% (SD = 7%)] remained consistent across the 3 years ( P = 0.670). There were no significant differences among resident characteristics (gender, age, international medical graduate status). The mean case discrimination index was 0.54 [SD = 0.15]. Kappa inter-rater reliability for scoring was 0.87; the overall test score reliability (G-coefficient) was 0.86 (Ф-coefficient = 0.83). Residents who completed residency readiness programs had higher ACS ERRA scores (66% versus 63%, Cohen's d = 0.23, P < 0.001). On average, 15% of decisions made (21/140 per test) involved potentially harmful actions. Variability in scores from graduating medical schools (7%) carried over twice as much weight than from matched residency programs (3%). CONCLUSIONS: ACS ERRA scores provide valuable information to entering surgery residents and surgery program directors to aid in development of individual and group learning plans.

American College of Surgeons Objective Assessment of Skills in Surgery (ACS OASIS): A Formative Assessment of Junior Residents' Technical Skills.

OBJECTIVE: The objective assessment of technical skills of junior residents is essential in implementing competency-based training and providing specific feedback regarding areas for improvement. An innovative assessment that can be easily implemented by training programs nationwide has been developed by expert surgeon educators under the aegis of the American College of Surgeons (ACS) Division of Education. This assessment, ACS Objective Assessment of Skills in Surgery (ACS OASIS) uses eight stations to address technical skills important for junior residents within the domains of laparoscopic appendectomy, excision of lipoma, central line placement, laparoscopic cholecystectomy, trocar placement, exploratory laparotomy, repair of enterotomy, and tube thoracostomy. The purpose of this study was to implement ACS OASIS at a number of sites to study its psychometric rigor. DESIGN: The ACS OASIS was pre-piloted at two programs to establish feasibility and to gather information regarding implementation. Each skills station was 12 minutes long, and the faculty completed a checklist with 5 to 15 items, and a global assessment scale. The study was then repeated at three pilot sites and included 29 junior residents who were assessed by a total of 44 faculty. Psychometric data for the stations and checklists were collected and analyzed. SETTING: The pre-pilot sites were Geisinger and University of Tennessee Knoxville.Data were gathered from pilot sites that included Wellspan Health, Duke University, and University of California Los Angeles. RESULTS: The mean checklist score for all learners was 76% (IQR of 66%-85%). The average global rating was 3.36 on a 5-point scale with a standard deviation of 0.56. The overall cut score derived using the borderline group method was at 68% with 34% of performances requiring remediation. Using this criterion, the average number of stations that were completed by each learner without need for remediation was five.The station discrimination index ranged from 0.27 to 0.65 (all above the threshold of 0.25), demonstrating solid psychometric characteristics at the station level. The internal-consistency reliability was 0.76 with SEM of 5.8%. The inter-rater reliability (intraclass correlation) was high at 0.73 with general agreement of 79% between the two raters. The station discrimination was at 0.45 (range of 0.27 to 0.65) indicating a high level of differentiation between high and low performers. Using the generalizability theory, the G-coefficient reliability was at 0.72 with the reliability projection flattening after 8 stations. Overall, 75% to 82% the faculty and learners rated ACS OASIS as realistic and beneficial. CONCLUSIONS: ACS OASIS is a psychometrically sound technical skills assessment tool that can provide useful information for feedback to junior residents and support efforts to remediate gaps in performance.

Resident Readiness for Senior Level Decision Making: Identifying the Domains for Formative Assessment and Feedback.

OBJECTIVE: To establish expert consensus regarding the domains and topics for senior surgery residents (PGY-4) to make critical decisions and assume senior-level responsibilities, and to develop the formative American College of Surgeons Senior Resident Readiness Assessment (ACS SRRA) Program. DESIGN: The American College of Surgeons (ACS) education leadership team conducted a focus group with surgical experts to identify the content for an assessment tool to evaluate senior residents' readiness for their increased levels of responsibility. After the focus group, national experts were recruited to develop consensus on the topics through three rounds of surveys using Delphi methodology. The Delphi participants rated topics using Likert-type scales and their comments were incorporated into subsequent rounds. Consensus was defined as ≥ 80% agreement with internal-consistency reliability (Cronbach's alpha) ≥ 0.8. In a stepwise fashion, topics that did not achieve consensus for inclusion were removed from subsequent survey rounds. SETTING: The surveys were administered via an online questionnaire. PARTICIPANTS: Twelve program directors and assistant program directors made up the focus group. The 39 Delphi participants represented seven different surgical subspecialties and were from diverse practice settings. The median length of experience in general surgery resident education was 20 years (IQR 14.3-30.0) with 64% of the experts being either current or past general surgery residency program directors. RESULTS: The response rate was 100% and Cronbach's alpha was ≥ 0.9 for each round. The Delphi participants contributed a large number of comments. Of the 201 topics that were evaluated initially, 120 topics in 25 core clinical areas were included to create the final domains of ACS SRRA. CONCLUSIONS: National consensus on the domain of the ACS SRRA has been achieved via the modified Delphi method among expert surgeon educators. ACS SRRA will identify clinical topics and areas in which each senior resident needs improvement and provide data to residents and residency programs to develop individualized learning plans. This would help in preparing the senior residents to assume their responsibilities and support their readiness for future fellowship training or surgical practice.

Defining the need for faculty development in assessment.

BACKGROUND: High-quality workplace-based assessments are essential for competency-based surgical education. We explored education leaders' perceptions regarding faculty competence in assessment. METHODS: Surgical education leaders were surveyed regarding which areas faculty needed improvement, and knowledge of assessment tools. Respondents were queried on specific skills regarding (a)importance in resident/medical student education (b)competence of faculty in assessment and feedback. RESULTS: Surveys (n = 636) were emailed, 103 responded most faculty needed improvement in: verbal (86%) and written (83%) feedback, assessing operative skill (49%) and preparation for procedures (50%). Cholecystectomy, trauma laparotomy, inguinal herniorrhaphy were "very-extremely important" in resident education (99%), but 21-24% thought faculty "moderately to not-at-all" competent in assessment. This gap was larger for non-technical skills. Regarding assessment tools, 56% used OSATS, 49% Zwisch; most were unfamiliar with all non-technical tools. SUMMARY: These data demonstrate a significant perceived gap in competence of faculty in assessment and feedback, and unfamiliarity with assessment tools. This can inform faculty development to support competency-based surgical education.

Lived Experiences of Surgical Residents During the COVID-19 Pandemic: A Qualitative Assessment.

OBJECTIVE: As the COVID-19 pandemic dynamically changes our society, it is important to consider how the pandemic has affected the training and wellness of surgical residents. Using a qualitative study of national focus groups with general surgery residents, we aim to identify common themes surrounding their personal, clinical, and educational experiences that could be used to inform practice and policy for future pandemics and disasters. DESIGN: Six 90-minute focus groups were conducted by a trained qualitative researcher who elicited responses on six predetermined topics. De-identified transcripts and audio recordings were later analyzed by two independent researchers who organized responses to each topic into themes. SETTING: Focus groups were conducted virtually and anonymously. PARTICIPANTS: General surgery residents were recruited from across the country. Demographic information of potential participants was coded, and subjects were randomly selected to ensure a diverse group of participants. RESULTS: The impact of the COVID-19 pandemic on residents' clinical, educational, and personal experiences varied depending on the institutional response of the program and the burden of COVID-19 cases geographically. Many successes were identified: the use of telehealth and virtual didactics, an increased sense of camaraderie amongst residents, and flexibility in scheduling. Many challenges were also identified: uncertainty at work regarding personal protective equipment and scheduling, decreased case volume and educational opportunities, and emotional trauma and burnout associated with the pandemic. CONCLUSIONS: These data gathered from our qualitative study highlight a clear, urgent need for thoughtful institutional planning and policies for the remainder of this and future pandemics. Residency programs must ensure a balanced training program for surgical residents as they attempt to master the skills of their craft while also serving as employed health care providers in a pandemic. Furthermore, a focus on wellness, in addition to clinical competency and education, is vital to resident resilience and success in a pandemic setting.

Gathering Validity Evidence to Adapt the Non-technical Skills for Surgeons (NOTSS) Assessment Tool to the United States Context.

BACKGROUND: Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context. STUDY DESIGN: A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion. RESULTS: A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected. CONCLUSIONS: A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S.

The American College of Surgeons Entering Resident Readiness Assessment Program: Development and National Pilot Testing Results.

OBJECTIVE: To assess the readiness of entering residents for clinical responsibilities, the American College of Surgeons (ACS) Division of Education developed the "Entering Resident Readiness Assessment" (ACS-ERRA) Program. SUMMARY BACKGROUND: ACS-ERRA is an online formative assessment that uses a key features approach to measure clinical decision-making skills and focuses on cases encountered at the beginning of residency. Results can be used to develop learning plans to address areas that may need reinforcement. METHODS: A national panel of 16 content experts, 3 medical educators, and a psychometrician developed 98 short, key features cases. Each case required medical knowledge to be applied appropriately at challenging decision points during case management. Four pilot testing studies were conducted sequentially to gather validity evidence. RESULTS: Residents from programs across the United States participated in the studies (n = 58, 20, 87, 154, respectively). Results from the pilot studies enabled improvements after each pilot test. For the psychometric pilot (final pilot test), 2 parallel test forms of the ACS-ERRA were administered, each containing 40 cases, resulting in overall mean testing time of 2 hours 2 minutes (SD = 43 min). The mean test score was 61% (SD = 9%) and the G-coefficient reliability was 0.90. CONCLUSIONS: Results can be used to identify strengths and weaknesses in residents' decision-making skills and yield valuable information to create individualized learning plans. The data can also support efforts directed at the transition into residency training and inform discussions about levels of supervision. In addition, surgery program directors can use the aggregate test results to make curricular changes.

Needs Assessment for an American College of Surgeons Certificate in Applied Surgical Education Leadership (CASEL).

OBJECTIVE: Surgeon educators in departments of surgery play key roles in leading and advancing surgical education. Their activities include ensuring sound curricula and evaluation systems, monitoring education resources, overseeing faculty development, and providing mentorship. For more than 25 years, the American College of Surgeons (ACS) has offered a comprehensive "Surgeons as Educators" (SAE) course to address fundamental topics in surgical education. This study aims to identify future career needs of SAE graduates to inform the development of an American College of Surgeons Certificate in Applied Surgical Education Leadership program. DESIGN: An IRB exempt, anonymous electronic survey was developed to determine educational roles, career aspirations, and needs of SAE Graduates. SETTING AND PARTICIPANTS: Participants included all 763 1993-2016 SAE graduates. RESULTS: One hundred and thirty-five responses were received from 600 (22.5%) graduates with valid email addresses. Sixty (45%) respondents completed the SAE Course > 5 years prior to the study (M5YRS) and 75 (55%) within the last 5 years (L5YRS). L5YRS respondents were less likely to be full professors (8% vs. 44%) or to serve as program directors (32% vs. 57%), and more likely to be associate program directors (25% vs. 17%) or clerkship directors (40% vs. 18%). High percentages of both L5YRS and M5YRS reported not pursuing additional educational opportunities post-SAE due to time and fiscal constraints. One-fifth of respondents were unaware of additional opportunities and 19% of M5YRS versus 6% of L5YRS stated that existing programs did not meet their needs. Overall improving skills as educational leaders, developing faculty development programs, and conducting educational research were noted as priorities for future development. Differences were observed between the L5YRS and M5YRS groups. The dominant preferences for course format were full-time face-to-face (41%) or a combination of full-time face-to-face with online modules (24%). The most important considerations in deciding to pursue a certificate course were course content, and interest in advancing career and time constraints. CONCLUSIONS: An SAE graduate survey has confirmed the need for additional formal training in surgical education leadership in order to permit surgeon educators meet the demands of the changing landscape of surgical education. The needs of early career faculty may differ from those of more senior surgeon educators.

American College of Surgeons/Association for Surgical Education medical student simulation-based surgical skills curriculum needs assessment.

BACKGROUND: Simulation can enhance learning effectiveness, efficiency, and patient safety and is engaging for learners. METHODS: A survey was conducted of surgical clerkship directors nationally and medical students at 5 medical schools to rank and stratify simulation-based educational topics. Students applying to surgery were compared with others using Wilcoxon's rank-sum tests. RESULTS: Seventy-three of 163 clerkship directors (45%) and 231 of 872 students (26.5%) completed the survey. Of students, 28.6% were applying for surgical residency training. Clerkship directors and students generally agreed on the importance and timing of specific educational topics. Clerkship directors tended to rank basic skills, such as examination skills, higher than medical students. Students ranked procedural skills, such as lumbar puncture, more highly than clerkship directors. CONCLUSIONS: Surgery clerkship directors and 4th-year medical students agree substantially about the content of a simulation-based curriculum, although 4th-year medical students recommended that some topics be taught earlier than the clerkship directors recommended. Students planning to apply to surgical residencies did not differ significantly in their scoring from students pursuing nonsurgical specialties.

Multi-institutional validation of a web-based core competency assessment system.

OBJECTIVE: The Association of Program Directors in Surgery and the Division of Education of the American College of Surgeons developed and implemented a web-based system for end-of-rotation faculty assessment of ACGME core competencies of residents. This study assesses its reliability and validity across multiple programs. METHODS: Each assessment included ratings (1-5 scale) on 23 items reflecting the 6 core competencies. A total of 4241 end-of-rotation assessments were completed for 332 general surgery residents (> or =5 evaluations each) at 5 sites during the 2004-2005 and 2005-2006 academic years. The mean rating for each resident on each item was computed for each academic year. The mean rating of items representing each competency was computed for each resident. Additional data included USMLE and ABSITE scores, PGY, and status in program (categorical, designated preliminary, and undesignated preliminary). RESULTS: Coefficient alpha was greater than 0.90 for each competency score. Mean ratings for each competency increased significantly (p < 0.01) as a function of PGY. Mean ratings for professionalism and interpersonal/communication skills (IPC) were significantly higher than all other competencies at all PGY levels. Competency ratings of PGY 1 residents correlated significantly with USMLE Step I, ranging from (r = 0.26, p < 0.01) for Professionalism to (r = 0.41, p < 0.001) for Systems-Based Practice. Ratings of Knowledge (r = 0.31, p < 0.01), Practice-Based Learning & Improvement (PBLI; r = 0.22, p < 0.05), and Systems-Based Practice (r = 0.20, p < 0.05) correlated significantly with 2005 ABSITE Total Percentile. Ratings of all competencies correlated significantly with the 2006 ABSITE Total Percentile Score (range: r = 0.20, p < 0.05 for professionalism to r = 0.35, p < 0.001 for knowledge). Categorical and designated preliminary residents received significantly higher ratings (p < 0.05) than nondesignated preliminaries for knowledge, patient care, PBLI, and systems-based practice only. CONCLUSIONS: Faculty ratings of core competencies are internally consistent. The pattern of statistically significant correlations between competency ratings and USMLE and ABSITE scores supports the postdictive and concurrent validity, respectively, of faculty perceptions of resident knowledge. The pattern of increased ratings as a function of PGY supports the construct validity of faculty ratings of resident core competencies.