RESUMEN
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
Asunto(s)
Periodo Perioperatorio/métodos , Complicaciones Posoperatorias/cirugía , Accidente Cerebrovascular/etiología , American Heart Association , Femenino , Humanos , Masculino , Enfermedades del Sistema Nervioso , Factores de Riesgo , Accidente Cerebrovascular/fisiopatología , Estados UnidosAsunto(s)
Enfermedades Cardiovasculares/epidemiología , Sistema Cardiovascular/fisiopatología , Cirugía General , Manejo de Atención al Paciente/métodos , Atención Perioperativa/métodos , American Heart Association , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/prevención & control , Humanos , Monitoreo Fisiológico , Manejo del Dolor , Factores de Riesgo , Estados UnidosAsunto(s)
Cardiología/normas , Enfermedades Cardiovasculares/diagnóstico , Manejo del Dolor/normas , Atención Perioperativa/normas , American Heart Association , Cardiología/organización & administración , Enfermedades Cardiovasculares/cirugía , Humanos , Manejo del Dolor/métodos , Procedimientos Quirúrgicos Operativos/normas , Estados UnidosAsunto(s)
Cardiología/normas , Enfermedades Cardiovasculares/diagnóstico , Manejo del Dolor/normas , Atención Perioperativa/normas , American Heart Association , Cardiología/organización & administración , Enfermedades Cardiovasculares/cirugía , Humanos , Manejo del Dolor/métodos , Procedimientos Quirúrgicos Operativos/normas , Estados UnidosRESUMEN
BACKGROUND: The study explores how residents and faculty assess the ACGME's 16-h limit on intern shifts. METHODS: Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes. RESULTS: Few view the intern shift limit as a positive change. Views differ (P < 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected. CONCLUSIONS: The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty.
Asunto(s)
Actitud del Personal de Salud , Cirugía General/educación , Internado y Residencia/normas , Admisión y Programación de Personal/normas , Tolerancia al Trabajo Programado/psicología , Carga de Trabajo/normas , Docentes Médicos/psicología , Fatiga/etiología , Humanos , Internado y Residencia/métodos , Entrevistas como Asunto , Estudiantes de Medicina/psicología , Encuestas y Cuestionarios , Factores de Tiempo , Estados Unidos , Carga de Trabajo/psicologíaRESUMEN
BACKGROUND: Nurse Practitioners and Physician Assistants - called non-physician practitioners or NPPs - are common, but little is known about their educational promise and problems. METHODS: General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. RESULTS: NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. CONCLUSIONS: NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes.
Asunto(s)
Docentes Médicos/organización & administración , Cirugía General/educación , Internado y Residencia/métodos , Enfermeras Practicantes/organización & administración , Asistentes Médicos/organización & administración , Médicos/organización & administración , Actitud del Personal de Salud , Humanos , Internado y Residencia/organización & administración , Rol Profesional , Relaciones Profesional-Paciente , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVE: The objective is to use qualitative and quantitative analysis to develop a patient safety curriculum for surgical residents. DESIGN: A prospective study of surgical residents using both quantitative and qualitative methods to craft a patient safety curriculum. Both a survey and focus groups were held before and 4 months after delivery of the patient safety curriculum. SETTING: The University of New Mexico Hospital, a tertiary academic medical center. PARTICIPANTS: General surgery residents, postgraduate years 1 to 5 RESULTS: Qualitative and quantitative analysis revealed areas that required attention and thus helped to mold the curriculum. Qualitative analysis after delivery of the curriculum showed positive changes in attitudes and normative beliefs toward patient safety. Specifically, attitudes and approach to quality improvement and teamwork showed improvement. Survey analysis did not show any significant change in resident perception of the environment during the time frame of this study. CONCLUSIONS: Using qualitative analysis to uncover attitudinal barriers to a safe patient environment can help to enhance the relevance and content of a patient safety curriculum for general surgery residents.
Asunto(s)
Curriculum , Educación de Postgrado en Medicina , Cirugía General/educación , Internado y Residencia , Seguridad del Paciente , Actitud del Personal de Salud , Femenino , Grupos Focales , Humanos , Masculino , New Mexico , Estudios Prospectivos , Mejoramiento de la Calidad , Encuestas y CuestionariosAsunto(s)
Acreditación/normas , Procedimientos Quirúrgicos Robotizados/educación , Especialidades Quirúrgicas/normas , Consejos de Especialidades/normas , Cirujanos/educación , Humanos , Procedimientos Quirúrgicos Robotizados/normas , Procedimientos Quirúrgicos Robotizados/tendencias , Especialidades Quirúrgicas/organización & administración , Cirujanos/normas , Estados UnidosRESUMEN
PURPOSE: Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. METHOD: Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. RESULTS: A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. CONCLUSIONS: Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.
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Educación de Postgrado en Medicina , Cirugía General/educación , Profesionalismo , Estudiantes de Medicina/psicología , Tolerancia al Trabajo Programado/psicología , Carga de Trabajo/psicología , Humanos , Internado y Residencia , Pase de Guardia , Encuestas y Cuestionarios , Estados UnidosRESUMEN
IMPORTANCE: Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations. OBJECTIVES: To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS: An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide. MAIN OUTCOMES AND MEASURES: Scores from the 2014 ABSITE. RESULTS: A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance. CONCLUSIONS AND RELEVANCE: Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.
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Educación de Postgrado en Medicina/métodos , Evaluación Educacional/métodos , Cirugía General/educación , Hábitos , Internado y Residencia/métodos , Lectura , Sociedades Médicas , Adulto , Femenino , Humanos , Masculino , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVE: To determine the influence of program strategies, such as program directors' (PD) attitudes about the American Board of Surgery In-Training Examination (ABSITE) and approach to ABSITE preparation, on residents' ABSITE performance. DESIGN: A 17-item questionnaire was sent to PDs at surgical residency programs. The questions were designed to elicit information regarding the educational curriculum, remediation protocols, and opinions relating to the ABSITE. Main outcome measure was categorical resident ABSITE percentile scores from the January 2014 examination. Statistical analysis was performed using the Student t-test, analysis of variance, and linear regression as appropriate. SETTING: The study was carried out at general surgery residency programs across the country. PARTICIPANTS: In total, 15 general surgery residency PDs participated in the study. RESULTS: The PD response rate was 100%. All 460 resident ABSITE scores from the 15 programs were obtained. In total, 10 programs (67%) identified as university affiliated, 4 programs (27%) as independent academic, and 1 program (7%) as hybrid. The mean number of residents per program was 30.7 (range: 15-57). In total, 14 PDs (93%) indicated that an ABSITE review curriculum was in place and 13 PDs (87%) indicated they had a remediation protocol for residents with low ABSITE scores (with differing thresholds of <30th, <35th, and <40th percentile). The median overall ABSITE score for all residents was 61st percentile (interquartile range = 39.5). The mean ABSITE score for each program ranged from 39th to 75th percentile. Program factors associated with higher ABSITE scores included tracking resident reading throughout the year (median 63rd percentile with tracking vs 59th percentile without, p = 0.040) and the type of remediation (by PD: 77th percentile, by PD and faculty: 57th percentile, faculty only: 64th percentile, with Surgical Education and Self-Assessment Program (SESAP): 63rd percentile, outside review course: 43rd percentile; p < 0.001). Programs with a remediation protocol trended toward higher ABSITE scores compared with programs without remediation protocols (median 61st percentile vs 53rd percentile, p = 0.098). Factors not significantly associated with ABSITE performance included number of structured educational hours per week and frequency of ABSITE review sessions. CONCLUSIONS: Program factors appear to significantly influence ABSITE performance. Programs where the PD was actively involved in remediation mentorship and the tracking of resident reading achieved higher ABSITE percentile scores on the January 2014 examination. Counterintuitively, residents from programs with a lower ABSITE threshold for remediation performed better on the examination.
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Competencia Clínica , Cirugía General/educación , Internado y Residencia , Consejos de Especialidades , Estudios Transversales , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVES: To create a clinical competency committee (CCC) that (1) centers on the competency-based milestones, (2) is simple to implement, (3) creates competency expertise, and (4) guides remediation and coaching of residents who are not progressing in milestone performance evaluations. DESIGN: We created a CCC that meets monthly and at each meeting reviews a resident class for milestone performance, a competency (by a faculty competency champion), a resident rotation service, and any other resident or issue of concern. SETTING: University surgical residency program. PARTICIPANTS: The CCC members include the program director, associate program directors, director of surgical curriculum, competency champions, departmental chair, 2 at-large faculty members, and the administrative chief residents. RESULTS: Seven residents were placed on remediation (later renamed as coaching) during the academic year after falling behind on milestone progression in one or more competencies. An additional 4 residents voluntarily placed themselves on remediation for medical knowledge after receiving in-training examination scores that the residents (not the CCC membership) considered substandard. All but 2 of the remediated/coached residents successfully completed all area milestone performance but some chose to stay on the medical knowledge competency strategy. CONCLUSIONS: Monthly meetings of the CCC make milestone evaluation less burdensome. In addition, the expectations of the residents are clearer and more tangible. "Competency champions" who are familiar with the milestones allow effective coaching strategies and documentation of clear performance improvements in competencies for successful completion of residency training. Residents who do not reach appropriate milestone performance can then be placed in remediation for more formal performance evaluation. The function of our CCC has also allowed us opportunity to evaluate the required rotations to ensure that they offer experiences that help residents achieve competency performance necessary to be safe and effective surgeons upon completion of training.
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Educación Basada en Competencias/métodos , Cirugía General/educación , Internado y Residencia , Miembro de Comité , Curriculum , Evaluación Educacional , Docentes Médicos , Evaluación de Programas y Proyectos de SaludRESUMEN
IMPORTANCE: General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition. OBJECTIVE: To determine how often categorical general surgery residents seriously consider leaving residency. DESIGN, SETTING, AND PARTICIPANTS: At 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not. MAIN OUTCOMES AND MEASURES: Factors associated with the desire to leave residency. RESULTS: The survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the presence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, P = .04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; P = .03). CONCLUSIONS AND RELEVANCE: A majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.
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Cirugía General/educación , Reorganización del Personal/estadística & datos numéricos , Adulto , Femenino , Humanos , Internado y Residencia , Estilo de Vida , Masculino , Análisis Multivariante , Médicos/psicología , Médicos Mujeres/psicología , Médicos Mujeres/estadística & datos numéricosRESUMEN
BACKGROUND: the aim of this study was to explore professional values, value conflicts, and assessments of the Accreditation Council for Graduate Medical Education's duty-hour restrictions. METHODS: questionnaires distributed at 15 general surgery programs yielded a response rate of 82% (286 faculty members and 306 residents). Eighteen items were examined via mean differences, percentages in agreement, and significance tests. Follow-up interviews with 110 participants were explored for main themes. RESULTS: residents and faculty members differed slightly with respect to core values but substantially as to whether the restrictions conflict with core values or compromise care. The average resident-faculty member gap for those 13 items was 35 percentage points. Interview evidence indicates consensus over professional values, a gulf between individualistic and team orientations, frequent moral dilemmas, and concerns about the assumption of responsibility by residents and "real-world" training. CONCLUSIONS: the divide between residents and faculty members over conflicts between the restrictions, core values, and patient care poses a significant issue and represents a challenge in educating the next generation of surgeons.
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Ética Médica , Docentes Médicos , Cirugía General/ética , Internado y Residencia/ética , Atención al Paciente/ética , Admisión y Programación de Personal/ética , Actitud del Personal de Salud , Conflicto Psicológico , Femenino , Humanos , Masculino , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
Despite the significant growth in population in the United States since 1980 and societal and demographic factors such as an aging population, there has been no increase in the number of graduating general surgery residents each year, which has created a worsening shortage of general surgeons. Other factors, such as stricter duty hours requirements and an increase in the number and variety of procedures general surgeons must perform, have also contributed to this shortage. Yet, applicant demand for general surgery positions is currently strong and will increase as new medical schools are created and current medical schools expand class size. The authors of this commentary propose an expansion of the Accreditation Council for Graduate Medical Education-approved general surgery categorical resident positions as the necessary first step in addressing the current and projected shortage of general surgeons. Before this expansion of general surgery residencies can occur, impediments such as the availability of residency spots for both U.S. and international medical graduates, the availability of educational opportunities for residents in teaching hospitals, and inadequate financial resources, such as a lack of funding from the Centers for Medicare and Medicaid, must be overcome.
Asunto(s)
Cirugía General/educación , Internado y Residencia/estadística & datos numéricos , Médicos/provisión & distribución , Predicción , Médicos Graduados Extranjeros , Hospitales de Enseñanza , Humanos , Internado y Residencia/economía , Evaluación de Necesidades , Admisión y Programación de Personal/legislación & jurisprudencia , Estados UnidosRESUMEN
BACKGROUND: Some anticipated that the Accreditation Council for Graduate Medical Education duty hours restrictions would foster a team-focused "new professionalism" among residents. This study explores the prevalence and challenges of a new professionalism and whether they vary by program size. METHOD: Questionnaires distributed in 15 general surgery programs produced an 82% response rate (N = 306); 52 semistructured follow-up interviews were completed. Results include means, percentage who "agree or strongly agree," significance tests, and main themes from the interviews. RESULTS: A new professionalism is limited by residents' reluctance to pass work from day to night teams, unclear guidance regarding stay-or-go decisions during shift transitions, little educational emphasis on sign-outs, and the practice of long hours in the name of professionalism. Program size is largely unassociated with these beliefs and behaviors. CONCLUSIONS: A new professionalism represents a stalled revolution among surgical residents. The new professionalism's emphasis on teamwork requires additional attention to staffing and workload management.
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Educación de Postgrado en Medicina , Cirugía General/educación , Internado y Residencia , Práctica Profesional , Carga de Trabajo , Toma de Decisiones , Humanos , Entrevistas como Asunto , Admisión y Programación de Personal , Encuestas y Cuestionarios , Estados Unidos , Tolerancia al Trabajo ProgramadoAsunto(s)
Comités Consultivos , American Heart Association , Cardiología , Enfermedades Cardiovasculares , Atención Perioperativa , Humanos , Comités Consultivos/normas , Cardiología/métodos , Cardiología/normas , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/terapia , Manejo de la Enfermedad , Atención Perioperativa/métodos , Atención Perioperativa/normas , Estados UnidosRESUMEN
PURPOSE: We developed a system of resident-driven, evidence-based standardization of care in our trauma-surgical intensive care unit (TSICU). Our main purposes are to improve patient care and outcomes and to help the residents develop practical competency in practice-based learning and improvement and in systems-based practice. DEVELOPMENT OF THE ACTIVITY: Since October 2006, each rotating TSICU resident has chosen a topic to research the available evidence and has developed a guideline, which the resident then presents to the TSICU faculty and residents for discussion, amendments, and acceptance or reevaluation. EVALUATION COMPONENT: Evaluation of proposed guidelines is based on the quality of information presented in support of the recommendations. Ultimately, acceptance of a guideline requires consensus among the TSICU faculty. Immediate feedback is given to the presenting resident by the faculty. The residents evaluate the program via a Web-based evaluation tool. PROPOSED OUTCOME MEASURES: We have qualitative data from residents that indicate this experience is positive. We are developing a tool to use both qualitative and quantitative means to evaluate resident, faculty, and nursing staff satisfaction with the process. We will use our clinical database to evaluate whether improved patient outcomes have resulted from standardization of care. IMPLEMENTATION DATES AND EXPERIENCE TO DATE: We implemented this methodology in October 2006 and have thus far implemented 20 guidelines and 2 standardized order sets. CONCLUSION AND OR NEXT STEPS: We believe competency is achieved and demonstrated by actively participating in a process such as development of care guidelines. Researching and developing standardized guidelines for our TSICU seems to be an effective and practical way for residents to use multiple sources for practice-based learning and improvement. It also requires the resident to advocate for quality patient care and optimal patient care systems. We plan to use outcome and qualitative data to validate this method.