International Medical Graduates are Comparable to American Medical Graduates as General Surgery Interns.

BACKGROUND: International medical graduates (IMGs) are often relegated to preliminary positions in general surgery (GS) owing to uncertainties about the candidate's performance in the American healthcare setting. We aimed to determine the comparative performance of IMGs and American medical graduates (AMGs) at baseline and assess these trends over the course of their GS internship. METHODS: Evaluations of all IMG preliminary and AMG categorical interns from 2013 to 2017 at our GS residency program were obtained from three faculty members to score overall performance, technical skills, interpersonal communication, and medical knowledge on a 10-point Likert scale. Scores on the American Board of Surgery In-Training Exam, an in-house preparation test, United States Medical Licensing Exam, and performance during the biannual multistation objective assessments were compared between the two resident groups. RESULTS: Seventy-two interns (28 [39%] AMG categorical and 44 [61%] IMG preliminary) met inclusion criteria. The AMG group had significantly higher median Step 1 and Step 2 scores compared with our IMG group (243 versus 231, P = 0.002, and 250 versus 246, P = 0.03, respectively).Although in-house preparation test scores were higher among IMGs (median [interquartile range] of 36 [33-40] among AMGs and 38 [34-45] among IMGs; P = 0.002), there were no statistically significant differences between the American Board of Surgery In-Training Exam scores of the two groups. The median scores for the four faculty evaluation components were similar between the AMG (7, 8, 7, 7) and IMG resident groups (7, 7, 7, 7; P = nonsignificant). IMGs scored significantly higher in both biannual multistation objective assessments than AMGs (median [interquartile range] July: 59 [47-91] versus 55 [37-62], P = 0.005; January: 103 [86-116] versus 91 [87-104], P = 0.03). CONCLUSIONS: It is reassuring to confirm that no matter where they are from, great candidates can perform well as surgical interns in a GS training program.

Outcomes After the Implementation of Practice Management Guidelines for the Treatment of Cardiovascular Implantable Device Pocket Infections.

BACKGROUND: Treatment of cardiovascular implantable device pocket infections (CIDPIs) requires a multimodal approach that includes antimicrobials, device explantation, and local wound care. Our institution implemented a practice management guideline (PMG) to standardize the care of CIDPIs and engage our acute care surgeons in 2013. Our PMG includes wound culture, complete capsulectomy, pulse lavage, and the placement of a negative pressure wound therapy appliance at the time of device extraction. Forty-eight hours later, wounds are irrigated and closed in a delayed primary fashion over drains. Our objective was to compare the outcomes of patients who underwent device extraction before and after the implementation of the PMG for the treatment of CIDPIs. METHODS: An IRB-approved retrospective review of 155 patients at our institution from 2012 to 2015 who underwent device explantation. Evaluated outcomes measured included days from device explant to wound closure, and postoperative complications. Outcomes data were analyzed before (pre-PMG) and after (post-PMG) enactment of the PMG. RESULTS: Fifty-eight patients (42 males; mean age 68 years) were managed prior to PMG implementation; 97 (72 males; mean age 67) were managed after. Mean days from device explantation to wound closure were compared (pre-PMG 6 ± 3.5 and post-PMG 2.8 ± 1.8), and time to closure was reduced by 3-d post-PMG implementation (P < 0.05). No increase in surgical site infection, hematoma, or unplanned return to operating room was demonstrated between groups (P < 0.05). CONCLUSIONS: The implementation of a PMG for the management of CIDPIs is effective in reducing the number of days to pocket wound closure; acute care surgeons are well equipped to participate in this practice and improve patient outcomes.

Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications.

INTRODUCTION: Although seemingly straightforward, tube thoracostomy (TT) has been associated with complication rates as high as 30 %. A lack of a standardized nomenclature for reporting TT complications makes comparison and evaluation of reports impossible. We aim to develop a classification method in order to standardize the reporting of complications of TT and identify all reported complications of TT and time course in which they occurred to validate the reporting method. METHODS: A systematic search of MEDLINE, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews from each databases inception through November 5, 2013 was conducted. Original articles written in the English language reporting TT complications were searched. This review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Duplicate reviewers abstracted case reports for inclusion. Cases were then sorted into one of the five complication categories by two reviewers, and in case of disagreements, settled by a third reviewer. RESULTS: Of 751 papers reporting TT complications, 124 case reports were included for analysis. From these reports, five main categories of TT complications were identified: insertional (n = 65); positional (n = 36); removal (n = 11); infective and immunologic (n = 7); and instructional, educational, or equipment related (n = 5). Placement of TT has occurred in nearly every soft tissue and vascular structure in the thoracic cavity and intra-abdominal organs. CONCLUSION: Our classification method provides further clarity and systematic standardization for reporting TT complications.

Low tissue oxygen saturation is associated with requirements for transfusion in the rural trauma population.

BACKGROUND: Tissue O2 saturation (StO2) is a measure of tissue perfusion and should decrease during active hemorrhage. An initial StO2 value upon trauma center arrival measured concurrently with or prior to vitals, may predict hemorrhagic shock, requiring early blood product transfusion. Our aim was to identify the early StO2 threshold associated with a greater volume of packed red blood cell (PRBC) transfusion 24 h after injury. METHODS: All highest tier triage trauma patients from January 2011 to July 2012 were included in this study. The initial StO2 value upon arrival was used for comparison. RESULTS: A total of 632 patients were considered, 74% of them male with a mean age of 46 years. Initial StO2 values were available for 325 patients. An StO2 value of 65% was determined as the cutoff due to the marked increase in PRBC consumption in 24 h. There were 23 patients (7%) with an StO2 reading <65% compared to 302 patients with values ≥65%. Both groups had similar systolic blood pressure (118 vs. 126) and heart rate (99 vs. 95) in the trauma bay. In addition, there was no difference in the initial hemoglobin, pH, or base deficit. An early StO2 value <65% also led to a greater number of PRBC transfused in 24 h (6.4 vs. 1.7). Regression analysis demonstrated that an StO2 <65% was the only variable associated with a higher PRBC transfusion volume in 24 h (p = 0.01). CONCLUSIONS: An StO2 value <65% correlates with greater requirement for PRBC transfusion 24 h after injury. This suggests that StO2 can be used as an early marker of hemorrhage which may be superior to traditional vital signs in the trauma population.

Expanded Access to Video-Based Laparoscopic Skills Assessments: Ease, Reliability, and Accuracy.

OBJECTIVE: Video-based performance assessments provide essential feedback to surgical residents, but in-person and remote video-based assessment by trained proctors incurs significant cost. We aimed to determine the reliability, accuracy, and difficulty of untrained attending staff surgeon raters completing video-based assessments of a basic laparoscopic skill. Secondarily, we aimed to compare reliability and accuracy between 2 different types of assessment tools. DESIGN: An anonymous survey was distributed electronically to surgical attendings via a national organizational listserv. Survey items included demographics, rating of video-based assessment experience (1 = have never completed video-based assessments, 5 = often complete video-based assessments), and rating of favorability toward video-based and in-person assessments (0 = not favorable, 100 = favorable). Participants watched 2 laparoscopic peg transfer performances, then rated each performance using an Objective Structured Assessment of Technical Skill (OSATS) form and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS). Participants then rated assessment completion ease (1 = Very Easy, 5 = Very Difficult). SETTING: National survey of practicing surgeons. PARTICIPANTS: Sixty-one surgery attendings with experience in laparoscopic surgery from 10 institutions participated as untrained raters. Six experienced laparoscopic skills proctors participated as expert raters. RESULTS: Inter-rater reliability was substantial for both OSATS (k = 0.75) and MISTELS (k = 0.85). MISTELS accuracy was significantly higher than that of OSATS (κ: MISTELS = 0.18, 95%CI = [0.06,0.29]; OSATS = 0.02, 95%CI = [-0.01,0.04]). While participants were inexperienced with completing video-based assessments (median = 1/5), they perceived video-based assessments favorably (mean = 73.4) and felt assessment completion was "Easy" on average. CONCLUSIONS: We demonstrate that faculty raters untrained in simulation-based assessments can successfully complete video-based assessments of basic laparoscopic skills with substantial inter-rater reliability without marked difficulty. These findings suggest an opportunity to increase access to feedback for trainees using video-based assessment of fundamental skills in laparoscopic surgery.

Understanding Team Dynamics and Culture of Safety Using Video Reflexive Ethnography during Real-Time Emergent Intubation.

Rationale: Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations, preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. Objectives: To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department and intensive care unit and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. Methods: Video-reflexive ethnography involves in situ video recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the emergency department and intensive care unit at Mayo Clinic Rochester, and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. Results: Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n = 23), respiratory therapists (n = 16), pharmacists (n = 7), advanced practitioners (n = 5), and physicians (n = 26). In video-reflexive discussions, major safety gaps were identified and several solutions were proposed related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. Conclusions: The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself.

Assessing the stops framework for coping with intraoperative errors: Evidence of efficacy, hints of hubris, and a bridge to abridging burnout.

BACKGROUND: Answering calls in the literature, we developed and introduced an evidence-based tool for surgeons facing errors in the operating room: the STOPS framework (stop, talk to you team, obtain help, plan, succeed). The purpose of this research was to assess the impact of presenting this psychological tool on resident coping in the operating room and the related outcome of burnout while examining sex differences. METHODS: In a natural experiment, general surgery residents were invited to attend 2 separate educational conferences regarding coping with errors in the operating room. Three months later, all residents were asked to fill out a survey assessing their coping in the operating room, level of burnout, and demographics. We assessed the impact of the educational intervention by comparing those who attended the coping conferences with those who did not attend. RESULTS: Thirty-five residents responded to the survey (65% response rate, 54% female respondents, 49% junior residents). Our hypothesized moderated mediation model was supported. Sex was found to moderate the impact of the STOPS framework-female residents who attended the coping educational conference reported higher coping self-efficacy, whereas attendance had no statistically significant impact on male levels of coping self-efficacy. In turn, higher coping self-efficacy was associated with lower levels of burnout. CONCLUSION: Our results suggest that there is evidence of efficacy in this instruction-female residents presented this material report higher levels of coping in the operating room compared to those who did not receive the framework. Further, increase in coping ability was associated with reduced levels of burnout for both genders.

Ketamine for Primary Analgosedation in Critically Ill Surgery and Trauma Patients Requiring Mechanical Ventilation.

OBJECTIVES: Evaluate effectiveness and safety outcomes associated with the use of ketamine for primary analgosedation in the surgical/trauma ICU setting. DESIGN: Retrospective cohort study. SETTING: Academic medical center in Minnesota. PATIENTS: Patients admitted to the surgical ICU between 2015 and 2019 requiring mechanical ventilation and meeting one of three definitions for ketamine primary analgosedation were included: 1) no concomitant opioid infusion, 2) ketamine monotherapy for greater than or equal to 6 hours with subsequent opioid infusion, or 3) ketamine initiated concomitantly or within 4 hours of opioid and total opioid duration less than 4 hours. INTERVENTIONS: None. MEASUREMENTS: Use of ketamine, analgesics, and sedatives were evaluated. Pain, sedation, and delirium assessments immediately before and during ketamine infusion were collected and compared with reported goals. Concomitant analgesics, sedatives, and psychotropics were recorded. Reported failures due to ineffectiveness and toxicity were collected. MAIN RESULTS: Of 164 included patients, 88% never received a concomitant opioid infusion (primary analgosedation definition 1), 12% met alternative criteria for primary analgosedation (definitions 2 and 3). A majority, 68%, were surgical admissions and mean Acute Physiology and Chronic Health Evaluation III score was 90 (± 30). Median mechanical ventilation duration was 2.5 days (1.1-4.5) and ICU length of stay of 4.9 days (3-8). The median ketamine infusion dose and duration were 0.18 mg/kg/hr (0.1-0.3) and 30 hours (15.1-51.8). Concomitant infusions of propofol and dexmedetomidine were administered in 49% and 29% of patients, respectively. During ketamine infusion, the median percent of total pain scores at goal was 62% (33-96%), while 64% (37-91%) of Richmond Agitation Sedation Scale scores were at goal, and 47% of patients were Confusion Assessment Method-ICU positive during the ketamine infusion. Hallucinations were documented in 14% of patients and ketamine failure occurred in 11% of patients. CONCLUSIONS: Ketamine may be an effective primary analgosedation option in intubated surgical ICU patients, but prospective randomized studies are needed to evaluate this strategy.

Implementation of a Brief Evidence-Based Intraoperative Coping Curriculum.

BACKGROUND AND RATIONALE: Recent research has called for further resident training in coping with errors and adverse events in the operating room. To the best of our knowledge, there currently exists no evidence-based curriculum or training on this topic. MATERIALS AND METHODS: Synthesizing three prior studies on how experienced surgeons react to errors and adverse events, we developed the STOPS framework for handling surgical errors and adverse events (Stop, Talk to your team, Obtain help, Plan, Succeed). This material was presented to residents in two teaching sessions. RESULTS AND CONCLUSION: In this paper, we describe the presentation of, and the uniformly positive resident reaction to, the STOPS framework: an empirically based psychological tool for surgeons who experience operative errors or adverse events.

Systematic Review of Procedural Skill Simulation in Health Care in Low- and Middle-Income Countries.

ABSTRACT: Low- and middle-income countries (LMICs) have adopted procedural skill simulation, with researchers increasingly investigating simulation efforts in resource-strained settings. We aim to summarize the current state of procedural skill simulation research in LMICs focusing on methodology, clinical area, types of outcomes and cost, cost-effectiveness, and overall sustainability. We performed a comprehensive literature review of original articles that assessed procedural skill simulation from database inception until April 2022.From 5371 screened articles, 262 were included in this review. All included studies were in English. Most studies were observational cohort studies (72.9%) and focused on obstetrics and neonatal medicine (32.4%). Most measured outcome was the process of task performance (56.5%). Several studies mentioned cost (38.9%) or sustainability (29.8%). However, few articles included actual monetary cost information (11.1%); only 1 article assessed cost-effectiveness. Based on our review, future research of procedural skill simulation in LMICS should focus on more rigorous research, cost assessments, and on less studied areas.

The good, the bad, and the ugly: Operative staff perspectives of surgeon coping with intraoperative errors.

BACKGROUND: Intraoperative errors are inevitable, and how surgeons respond impacts patient outcomes. Although previous research has queried surgeons on their responses to errors, no research to our knowledge has considered how surgeons respond to operative errors from a contemporary first-hand source: the operating room staff. This study evaluated how surgeons react to intraoperative errors and the effectiveness of employed strategies as witnessed by operating room staff. METHODS: A survey was distributed to operating room staff at 4 academic hospitals. Items included multiple-choice and open-ended questions assessing surgeon behaviors observed after intraoperative error. Participants reported the perceived effectiveness of the surgeon's actions. RESULTS: Of 294 respondents, 234 (79.6%) reported being in the operating room when an error or adverse event occurred. Strategies positively associated with effective surgeon coping included the surgeon telling the team about the event and announcing a plan. Themes emerged regarding the importance of the surgeon remaining calm, communicating, and not blaming others for the error. Evidence of poor coping also emerged: "Yelling, feet stomping and throwing objects onto the field. [The surgeon] cannot articulate needs well because of anger." CONCLUSION: These data from operating room staff corroborates previous research presenting a framework for effective coping while shedding light on new, often poor, behaviors that have not emerged in prior research. Surgical trainees will benefit from the now-enhanced empirical foundation on which coping curricula and interventions can be built.

Simulation as Soothsayer: Simulated Surgical Skills MMIs During Residency Interviews are Associated With First Year Residency Performance.

OBJECTIVE: The main consideration during residency recruitment is identifying applicants who will succeed during residency. However, few studies have identified applicant characteristics that are associated with competency development during residency, such as the Accreditation Council for Graduate Medical Education milestones. As mini multiple interviews (MMIs) can be used to assess various competencies, we aimed to determine if simulated surgical skills MMI scores during a general surgery residency interview were associated with Accreditation Council for Graduate Medical Education milestone ratings at the conclusion of intern year. DESIGN: Retrospective cohort study. Interns' Step 1 and 2 clinical knowledge (CK) scores, interview day simulated surgical skills MMI overall score, traditional faculty interview scores, average overall milestone ratings in the spring of residency, and intern American Board of Surgery In-Training Examination (ABSITE) percentile scores were gathered. Two multiple linear regression were performed analyzing the association between Step 1, Step 2 CK, MMI, and traditional faculty interview scores with (1) average overall milestone rating and (2) ABSITE percentile scores, controlling for categorical/preliminary intern classification. SETTING: One academic medical center PARTICIPANTS: General surgery interns matriculating in 2020-2021 RESULTS: Nineteen interns were included. Multiple linear regression revealed that higher overall simulated surgical skills MMI score was associated with higher average milestone ratings (ß = .45, p = 0.03) and higher ABSITE score (ß = .43, p = 0.02) while neither Step 1, Step 2 CK, nor faculty interview scores were significantly associated with average milestone ratings. CONCLUSIONS: Surgical residency programs invest a tremendous amount of effort into training residents, thus metrics for predicting applicants that will succeed are needed. Higher scores on a simulated surgical skills MMIs are associated with higher milestone ratings 1 year into residency and higher intern ABSITE percentiles. These results indicate a noteworthy method, simulated surgical skills MMIs, as an additional metric that may select residents that will have early success in residency.

Impact of the COVID-19 Pandemic on Resident Physician Clinical and Educational Work Hours at a Large Sponsoring Institution.

BACKGROUND: The COVID-19 pandemic affected graduate medical education (GME) by decreasing elective procedures and disrupting didactic learning activities in 2020. Editorials have hypothesized that resident physicians worked fewer hours, therefore losing valuable experience, but we are not aware of studies that have objectively assessed changes in hours worked. OBJECTIVE: This study aims to identify differences secondary to the COVID-19 pandemic in resident work hours across all specialties at 3 geographically dispersed, integrated academic hospitals in a large sponsoring institution. METHODS: We obtained de-identified work hour data from all residency programs at Mayo Clinic in Arizona, Florida, and Minnesota. Resident work hours were compared between 2020 and 2019 from March to May. RESULTS: Work hours for 1149 and 1118 residents during the pandemic and control periods respectively were compared. Decreases in resident work hours were seen, with the largest decrease demonstrated in April 2020 when 19 of 43 programs demonstrated significantly decreased work hours. Residents worked more hours from home in April 2020 compared to the previous year (Arizona: mean 1 hour in 2019 vs 5.2 hours in 2020, P<.001; Florida: mean 0.7 hour in 2019 vs 6.5 hours in 2020, P<.001; Minnesota: mean 0.8 hour in 2019 vs 10.2 hours in 2020, P<.001). CONCLUSIONS: The COVID-19 pandemic was associated with a decrease in work hours in some, but not all, specialties. The decrease in on-site work was only partially offset by an increased number of hours worked from home.

LEGO®-based communication assessment in virtual general surgery residency interviews.

Purpose: Effective communication skills are a critical quality and skill that is highly sought after for surgeons which largely impacts patient outcomes. Residency programs design their interview processes to select the best candidates. LEGO®-based activities have been frequently used to enhance communication skills and team building. This study investigates the effectiveness and reliability of a novel LEGO®-based communication assessment in interviews for surgical residencies and the feasibility of implementing it in a virtual setting. Methods: This study conducted a retrospective analysis of a LEGO®-based communication assessment at the program's 2020/2021 residency interviews. Each applicant was assessed on a different model. The total scores were analyzed for consistency among raters and correlated to faculty interviews. Furthermore, the impact of the assessment structure, scoring criteria, and range of models' difficulties on the total scores were explored. Results: A total of 54 categorical and 55 preliminary applicants interviewed on 2 days. The assessment on different models and had no impact on applicants' total scores for either categorical and preliminary groups (p = 0.791 and 0.709, respectively). The communication components of the assessment showed high consistency between the raters. The two applicant groups displayed a statistically significant difference (p = 0.004) in the communication evaluation and model accuracy components. Total scores did not correlate with the faculty interviews of standardized questions in either group. Conclusion: This novel LEGO®-based communication assessment showed high reliability and promising results as a tool to assess communication and problem solving for residency interviews that can be readily implemented in a virtual setting. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00021-4.

New Heuristics to Stratify Applicants: Predictors of General Surgery Residency Applicant Step 1 Scores.

OBJECTIVE: In 2022, United States Medical Licensing Examination (USMLE) Step 1 scores will become pass/fail. This may be problematic, as residency programs heavily rely on USMLE Step 1 scores as a metric when determining interview invitations. This study aimed to assess candidate application metrics associated with USMLE Step 1 scores to offer programs new cues for stratifying applicants. DESIGN: Retrospective cohort study analyzing interviewed applicants to one general surgery residency program in 2019 and 2020. Applicant data analyzed included USMLE Step 1 scores, number of publications, clerkship scores, letter of recommendation scores (out of 2, scored by 0.25 interval), interview overall score (out of 5, scored by integer level), and standardized question score (out of 10). Each year, applicant's answers to one standardized behavioral question during their interview were scored by interviewers. SETTING: Tertiary medical center, academic general surgery residency program. PARTICIPANTS: Interviewed applicants at one general surgery residency program whose applications contained complete demographic information (203 out of 247). RESULTS: Multiple Linear Regression revealed that higher surgical clerkship (ß = 0.19, p = 0.006) and higher standardized interview question (ß = 0.32, p < 0.001) scores were positively associated with applicant USMLE Step 1 score (F[7, 195] = 6.61, p < 0.001, R2 = 0.19). Letter of recommendation score, number of peer reviewed publications, gender, race, and applicant type (preliminary/categorical) were not associated with USMLE Step 1 scores. CONCLUSIONS: With USMLE Step 1 scores transitioning to pass/fail, surgical residency programs need new selection heuristics. Surgery clerkship scores and standardized behavioral questions answered by applicants prior to the interview could provide a holistic view of applicants and help programs better stratify candidates without USMLE Step 1 scores.

Video feedback with error-focused or correct-focused examples in surgical skills distance learning: A randomized trial.

BACKGROUND: Although it seems natural that surgical trainees would learn from demonstrations of a correct performance, evidence outside of surgical education has suggested that error-focused examples may promote error detection and improved procedural task performance. We hypothesized that feedback through error-focused videos would improve procedural learning more than correct-focused videos. METHODS: We conducted a randomized controlled trial of video feedback comparing error-focused versus correct-focused examples. The participants were interviewees at our general surgery residency program in December 2020. All of the interviewees performed suturing and knot tying tasks on their interview day (baseline), with 70 common errors identified. For each error, we created an instructional feedback video in two formats: one video demonstrating the error and another demonstrating correct performance. The study participants received feedback videos based on baseline performance errors, with the format randomly assigned. Two blinded raters assessed the baseline and postintervention performances. RESULTS: Thirty-seven interviewees enrolled and 17 submitted postintervention videos. The postintervention mean performance scores were significantly higher (P = .02) in the error-focused than the correct-focused example group (suturing [maximum score 18]: 16.9 vs 13.9 [difference 2.9; 95% CI 0.7, 5.1]; knot-tying [maximum score 24]: 21.6 vs 17.8 [difference 3.8; 95% CI 0.5, 7.0]). We found no between-group differences in performance time ([error-focused versus correct-focused] suturing: 246 vs 256 s; knot-tying: 170 vs 138 s; P = .08). Mean satisfaction with feedback was similar between groups (error-focused: mean = 5.3 versus correct-focused: mean = 5.2, out of 7; P = .95). CONCLUSION: Feedback that highlights errors is associated with better learning of surgical skills than feedback demonstrating correct performance, confirming our hypothesis.

Video Commentary & Machine Learning: Tell Me What You See, I Tell You Who You Are.

BACKGROUND & OBJECTIVE: Teaching and assessment of complex problem solving are a challenge for medical education. Integrating Machine Learning (ML) into medical education has the potential to revolutionize teaching and assessment of these problem-solving processes. In order to demonstrate possible applications of ML to education, we sought to apply ML in the context of a structured Video Commentary (VC) assessment, using ML to predict residents' training level. SETTING: A secondary analysis of multi-institutional, IRB approved study. Participants had completed the VC assessment consisting of 13 short (20-40 seconds) operative video clips. They were scored in real-time using an extensive checklist by an experienced proctor in the assessment. A ML model was developed using TensorFlow and Keras. The individual scores of the 13 video clips from the VC assessment were used as the inputs for the ML model as well as for regression analysis. PARTICIPANTS: A total of 81 surgical residents of all postgraduate years (PGY) 1-5 from 7 institutions constituted the study sample. RESULTS: Scores from individual VC clips were strongly positively correlated with PGY level (p = 0.001). Some video clips were identified to be strongly correlated with a higher total score on the assessment; others had significant influence when used to predict trainees' PGY levels. Using a supervised machine learning model to predict trainees' PGY resulted in a 40% improvement over traditional statistical analysis. CONCLUSIONS: Performing better in a few select video clips was key to obtaining a higher total score but not necessarily foretelling of a higher PGY level. The use of the total score as a sole measure may fail to detect deeper relationships. Our ML model is a promising tool in gauging learners' levels on an assessment as extensive as VC. The model managed to approximate residents' PGY levels with a lower MAE than using traditional statistics. Further investigations with larger datasets are needed.

Association of scooter-related injury and hospitalization with electronic scooter sharing systems in the United States.

INTRODUCTION: We used interrupted time series (ITS) analysis to determine whether e-scooter shares' introduction in September 2017 increased serious scooter-related injury across the United States. METHODS: Using the National Electronic Injury Surveillance System, we queried emergency department visits involving motorized scooter-related injuries from January 2010-December 2019. Cases originating where e-scooter shares launched between September 1, 2017-December 1, 2019 (intervention period) were considered exposed. The first month of launch (September 2017) was chosen as the time point for pre- and post-intervention analysis. The primary outcome was change in hospitalizations following scooter injury in association with the month/year launch. RESULTS: This analysis includes 2754 unweighted encounters, representing 102614 estimated injuries involving motorized scooters nationwide. Hospitals within 20 miles of e-scooter shares also experienced a significant monthly increase of 0.24 scooter-related injury hospitalizations/1000 product-related injury hospitalizations ([0.17,0.31]) compared to a non-significant change in hospitalizations of 0.02 [-0.05,0.09] for control hospitals. CONCLUSION: An increase in serious motorized scooter injuries coincides with e-scooter shares' introduction in the US. Future works should explore effective polices to improve public safety.

Course Design and Learning Outcomes of a Practical Online Ergonomics Course for Surgical Residents.

OBJECTIVE: Course content was designed and the learning outcomes assessed for an online ergonomics course for surgical residents. This course could fulfill an optional Surgical Council on Resident Education (SCORE) curriculum on Surgical Ergonomics. DESIGN: The online course included five 5-minute modules within the residents' learning system, each ending with an ungraded knowledge question, and a final 5-question multiple-choice retention quiz that allowed infinite attempts. The course was designed by ergonomists and surgeons at a quaternary academic hospital system. Participants were given two weeks to complete the modules. An electronic survey with questions assessing ergonomics knowledge and understanding on a 5-point Likert scale (strongly disagree - strongly agree) was distributed both before and after the course. The post-course survey included three additional questions to elicit feedback regarding learning experience and course design. Descriptive statistics and nonparametric paired comparisons were used to evaluate learning outcomes. SETTING: General surgery residency program at an academic medical center in the U.S. PARTICIPANTS: Twenty-two general surgery post graduate year 1 residents (PGY1s) were recruited to participate and completed the pre-course survey. Eight out of the 22 participants (36%) completed the online course and quiz; seven (32%) completed the course, quiz, and the post-course survey. RESULTS: Participants had high pre-course awareness of the importance of surgical ergonomics, benefits of work-related musculoskeletal disorder (WMSD) prevention, as well as awkward intraoperative postures being an WMSD risk factor. Participants' confidence increased significantly from pre- to post-course in ability to assess risk (p = 0.021), but not in ability or willingness to mitigate risky surgical postures. Participants who completed the quiz answered a median of 4 (IQR: [4, 5]) questions correctly. All participants indicated that they would recommend this course to other residents. CONCLUSIONS: These short practical ergonomics online learning modules increased surgical residents' confidence in assessing surgical WMSD risks.