National Profile of the ACGME Milestones 1.0 and 2.0 within General Surgery: A Seven-Year National Study from 2014 to 2021.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) introduced General Surgery Milestones 1.0 in 2014 and Milestones 2.0 in 2020 as steps toward competency-based training. Analysis will inform residency programs on curriculum development, assessment, feedback, and faculty development. This study describes the distributions and trends for Milestones 1.0 and 2.0 ratings and proportion of residents not achieving the level 4.0 graduation target. METHODS: A deidentified dataset of milestone ratings for all ACGME-accredited General Surgery residency programs in the United States was used. Medians and interquartile ranges (IQR) were reported for milestone ratings at each PGY level. Percentages of PGY-5s receiving final year ratings of less than 4.0 were calculated. Wilcoxon rank sum tests were used to compare 1.0 and 2.0 median ratings. Kruskal-Wallis and Bonferroni post-hoc tests were used to compare median ratings across time periods and PGY levels. Chi-squared tests were used to compare the proportion of level 4.0 nonachievement under both systems. RESULTS: Milestones 1.0 data consisted of 13,866 residents and Milestones 2.0 data consisted of 7,633 residents. For 1.0 and 2.0, all competency domain median ratings were higher for subsequent years of training. Milestones 2.0 had significantly higher median ratings at all PGY levels for all competency domains except Medical Knowledge. Percentages of PGY-5 residents not achieving the graduation target in Milestones 1.0 ranged from 27% to 42% and in 2.0 from 5% to 13%. For Milestones 1.0, all subcompetencies showed an increased number of residents achieving the graduation target from 2014 to 2019. CONCLUSIONS: This study of General Surgery Milestones 1.0 and 2.0 data uncovered significant increases in average ratings and significantly fewer residents not achieving the graduation target under the 2.0 system. We hypothesize that these findings may be related more to rating bias given the change in rating scales, rather than a true increase in resident ability.

Hiatal hernia reporting: time to remove subjectivity?

INTRODUCTION: The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies. METHODS AND PROCEDURES: Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements. RESULTS: Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R2 = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R2 = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R2 = 0.0143, p = 0.366), endoscopic subjective size estimates (R2 = 0.0481, p = 0.0986), or the manometry measurements (R2 = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227). CONCLUSIONS: Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.

Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment.

Introduction: Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods: With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results: Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion: The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.

Trend of minimally invasive and open surgery experience of general surgery residents: Accreditation Council for Graduate Medical Education general surgery case log in Thailand.

Purpose: Minimally invasive surgery (MIS) offers patients several benefits, such as smaller incisions, and fast recovery times. General surgery residents should be trained in both open and MIS. We aimed to examine the trends of minimally invasive and open procedures performed by general surgery residents in Thailand. Methods: A retrospective review of the Royal College of Surgeons of Thailand and Accreditation Council for Graduate Medical Education general surgery case logs from 2007 to 2018 was performed for common open and laparoscopic general surgery operations. The data were grouped by three time periods, which were 2007-2010, 2011-2014, and 2015-2018, and analyzed to explore changes in the operative trends. Results: For Thai residents, the mean number of laparoscopic operations per person per year increased from 5.97 to 9.36 (56.78% increase) and open increased from 20.02 to 27.16 (35.67% increase). There was a significant increase in the average number of minimally invasive procedures performed among cholecystectomy (5.83, 6.57, 8.10; p < 0.001) and inguinal hernia repair (0.33, 0.35, 0.66; p < 0.001). Compared to general surgery residents in the United States, Thai residents had more experience with open appendectomy, but significantly less experience with all other operations/procedures. Conclusion: The number of open and minimally invasive procedures performed or assisted by Thai general surgery residents has slowly increased, but generally lags behind residents in the United States. The Thai education program must be updated to improve residents' technical skills in open and laparoscopic surgery to remain competitive with their global partners.

Multidisciplinary perceptions on robotic surgical training: the robot is a stimulus for surgical education change.

BACKGROUND: It is unclear how to best establish successful robotic training programs or if subspecialty robotic program principles can be adapted for general surgery practice. The objective of this study is to understand the perspectives of high-volume robotic surgical educators on best practices in robotic surgery training and to provide recommendations transferable across surgical disciplines. METHODS: This multi-institutional qualitative analysis involved semi-structured interviews with high-volume robotic educators from academic general surgery (AGS), community general surgery (CGS), urology (URO), and gynecology (GYN). Purposeful sampling and snowballing ensured high-volume status and geographically balanced representation across four strata. Interviews were transcribed, deidentified, and independently, inductively coded. A codebook was developed and refined using constant comparative method until interrater reliability kappa reached 0.95. A qualitative thematic, framework analysis was completed. RESULTS: Thirty-four interviews were completed: AGS (n = 9), CGS (n = 8), URO (n = 9), and GYN (n = 8) resulting in 40 codes and four themes. Theme 1: intangibles of culture, resident engagement, and faculty and administrative buy-in are as important as tangibles of robot and simulator access, online modules, and case volumes. Theme 2: robotic OR integration stresses the trainee-autonomy versus patient-safety balance. Theme 3: trainees acquire robotic skills along individual learning curves; benchmark assessments track progress. Theme 4: AGS can learn from URO and GYN through multidisciplinary collaboration but must balance pre-existing training program use with context-specific curricular needs. CONCLUSIONS: Robotic surgical experts emphasize the importance of universal training paradigms, such as a strong educational culture that balances autonomy and patient safety, collaboration between disciplines, and routine assessments for continuous growth. Often, introduction and acceptance of the robot serves as a stimulus to discuss broader surgical education change.

The Big Sibling program: Impact of a medical student-resident mentorship program during the surgery clerkship.

BACKGROUND: We created a Big Sibling mentorship program for medical students and studied the program effects. METHODS: Between July 2019 to December 2020, students completing their surgery clerkship were paired with a Big Sibling surgical research resident. Participation in and perceptions of the program were assessed by survey. RESULTS: 81 medical students and 25 residents participated with a 79% and 95% survey response rate, respectively. The most valuable topics discussed included ward skills, personal development and career advising. Students who interacted >2 times with their Big Sibling were more likely to perceive the operating room as a positive learning environment, view attendings as role models, and receive mentoring and feedback from residents and attendings (p = 0.03, 0.02, 0.01 respectively). 78% of residents thought the program was a positive experience and no residents found it burdensome. CONCLUSION: The Big Siblings program enhances the surgery clerkship learning environment. Students who engaged with their Big Sibling had a more positive view of the clerkship and the mentorship provided by residents and attendings.

Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery.

OBJECTIVE: To investigate inpatient satisfaction with surgical resident care. BACKGROUND: Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed. METHODS: English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method. RESULTS: Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons. CONCLUSIONS: Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.

Effective Senior Surgical Residents as Defined by Their Peers: A Qualitative Content Analysis of Nontechnical Skills Development.

OBJECTIVE: This study aims to define an effective senior resident and understand the process of leadership and nontechnical skill development in the transition from junior to senior surgery resident. SUMMARY BACKGROUND: General surgery residents are responsible for patient care, technically demanding operations, and diverse care team management. However, leadership skill development for the transition from junior to senior resident roles is often overlooked. METHODS: We conducted 15 semi-structured focus groups with surgery residents from an urban, academic institution. Focus group transcripts were inductively coded. Using content analysis and constant comparative methodology, primary codes were refined into categories and organized into higher-level themes. RESULTS: Thirty-three general surgery residents completed fifteen focus groups. Six themes were identified. Three themes describe the process of becoming an effective senior resident: how to define a senior resident's scope of practice, the transition process, and the importance of personal investment. Three themes were identified regarding effective seniors: ideal traits, teachable skills, and the team and patient impact. CONCLUSIONS: Surgery residents define an effective senior resident as the team member with the highest level of experience who manages the big picture of patient care. The transition is improved by personal engagement and acknowledgement of the transition. Ideal traits of effective seniors, including emotional intelligence and inherent personality traits, allow a resident to more naturally assume this role; however, teachable skills, such as communication, expectation setting and competence, can be taught to improve one's effectiveness. The actions of a senior resident impact the team and patient care, underscoring the importance of understanding this role.

Utilizing co-curricular learning tools to foster leadership development in graduate and professional schools: Examples and lessons learned.

Faculty have an implicit expectation that their graduate and professional students will become leaders in their respective fields; however, there is a lack of formalized co-curricular education to prepare them to assume leadership. This article provides two examples of co-curricular leadership education programs as inspiration for others to develop and navigate the challenges of delivering programming.

Impact of Rater Training on Residents Technical Skill Assessments: A Randomized Trial.

OBJECTIVE: The ACS/APDS Resident Skills Curriculum's Objective Structured Assessment of Technical Skills (OSATS) consists of task-specific checklists and a global rating scale (GRS) completed by raters. Prior work demonstrated a need for rater training. This study evaluates the impact of a rater-training curriculum on scoring discrimination, consistency, and validity for handsewn bowel anastomosis (HBA) and vascular anastomosis (VA). DESIGN/ METHODS: A rater training video model was developed, which included a GRS orientation and anchoring performances representing the range of potential scores. Faculty raters were randomized to rater training or no rater training and were asked to score videos of resident HBA/VA. Consensus scores were assigned to each video using a modified Delphi process (Gold Score). Trained and untrained scores were analyzed for discrimination and score spread and compared to the Gold Score for relative agreement. RESULTS: Eight general and eight vascular surgery faculty were randomized to score 24 HBA/VA videos. Rater training increased rater discrimination and decreased rating scale shrinkage for both VA (mean trained score: 2.83, variance 1.88; mean untrained score: 3.1, variance 1.14, p = 0.007) and HBA (mean trained score: 3.52, variance 1.44; mean untrained score: 3.42, variance 0.96, p = 0.033). On validity analyses, a comparison between each rater group vs Gold Score revealed a moderate training impact for VA, trained κ=0.65 vs untrained κ=0.57 and no impact for HBA, R1 κ = 0.71 vs R2 κ = 0.73. CONCLUSION: A rater-training curriculum improved raters' ability to differentiate performance levels and use a wider range of the scoring scale. However, despite rater training, there was persistent disagreement between faculty GRS scores with no groups reaching the agreement threshold for formative assessment. If technical skill exams are incorporated into high stakes assessments, consensus ratings via a standard setting process are likely a more valid option than individual faculty ratings.

Interprofessional Trauma Team Training: Leveraging Each Specialties' Expertise to Teach Procedural-Based Skills.

OBJECTIVE: The goal of this study was to utilize interprofessional trauma team training to teach procedural-based skills, teamwork, and assess the impact on the procedural comfort and interprofessional collaboration. DESIGN: Interdisciplinary skills sessions were created to focus on chest tube placement and advanced ultrasound techniques. Chest tube sessions were taught by senior general surgery (GS) residents and faculty. Ultrasound sessions were taught by emergency medicine (EM) fellows and faculty. Mock trauma simulations for EM and GS residents and EM nurses, were developed to also focus on improving interprofessional trauma-bay collaboration. Sessions were held throughout the year for 2 consecutive academic years. After completing skills sessions and trauma scenarios, participants were surveyed on skill comfort, session utility, and willingness to collaborate with the other specialty. Likert scale responses were analyzed by specialty cohort and in aggregate. Free-text feedback responses were analyzed for common themes. SETTING: Large, tertiary, urban academic medical center PARTICIPANTS: Forty seven EM residents and 32 GS residents completed instructional chest tube and ultrasound simulations, respectively. Twenty two EM residents, 24 GS residents, and 29 EM nurses participated in interprofessional trauma simulations. RESULTS: For chest tube placement: 71% of EM residents reported feeling uncomfortable with the procedure prior to the session, with 100% reporting improved confidence afterwards. Seventy percent stated the model was realistic. One hundred percent thought it improved their procedural skills. All participants thought it was worthwhile, should be offered again in future years, and planned to incorporate what they learned in their future practice. For the ultrasound sessions: 61% of GS residents felt uncomfortable with the Focused Assessment with Sonography in Trauma prior to the simulation. Ninety four percent reported the improved skill and confidence, and felt the model was realistic. All participants felt sessions were worthwhile, should be offered again, and planned to incorporate what they learned in their future practice. For trauma simulations: 97% of participants felt scenarios were realistic and clinically relevant and planned to incorporate lessons learned in their future clinical practice. All participants thought participation was worthwhile. Ninety seven percent thought it improved their confidence with trauma clinical management and 56% reported it improved their skills. Many participants reported they appreciated learning from the other specialty's perspective, with greater than 95% of all participants reporting improved comfort and willingness to collaborate across disciplines when caring for future trauma patients. All participants requested the simulation sessions continue in future academic years. CONCLUSION: Interprofessional trauma simulation sessions can harness the unique skill sets of different disciplines to teach procedural-based skills and improve interprofessional collaboration within the trauma bay.

Psychological safety between pediatric residents and nurses and the impact of an interdisciplinary simulation curriculum.

BACKGROUND: Effective teamwork in interdisciplinary healthcare teams is necessary for patient safety. Psychological safety is a key component of effective teamwork. The baseline psychological safety on pediatric inpatient healthcare teams is unknown. The purpose of this study is to determine the baseline psychological safety between pediatric nurses and residents and examine the impact of an interdisciplinary nighttime simulation curriculum. METHODS: A convergent, multistage mixed methods approach was used. An interprofessional simulation curriculum was implemented fall 2020 to spring 2021. Qualitative focus group data and quantitative survey data on team psychological safety were collected and compared, both pre- and post-intervention and across nurses and residents. Thematic analysis of the qualitative data was conducted, and themes integrated with survey findings. RESULTS: Data were collected from 30 nurses and 37 residents pre-intervention and 32 and 38 post-intervention, respectively. Residents and nurses negatively rated psychological safety (pre-intervention mean = 3.40 [SD = 0.72]; post-intervention mean = 3.35 [SD = 0.81]). At both times psychological safety was rated significantly lower for residents (pre-intervention mean = 3.11 [SD = 0.76], post-intervention mean = 2.98 [SD = 0.84]) than nurses (pre-intervention mean = 3.76 [SD = 0.45], post-intervention mean = 3.79 [SD = 0.50]), all P < .001. Qualitative analysis identified six integrated themes: (1) influence of existing relationships on future interactions, (2) unsatisfactory manner and frequency of communication, (3) unsatisfactory resolution of disagreements (4) overwhelming resident workload impairs collaboration, (5) interpersonal disrespect disrupts teamwork, and (6) interprofessional simulation was useful but not sufficient for culture improvement. CONCLUSION: Resident-nurse team psychological safety ratings were not positive. While interprofessional simulation curriculum shows promise, additional efforts are needed to improve psychological safety among residents and nurses.

Gaps in Practice Management Skills After Training: A Qualitative Needs Assessment of Early Career Surgeons.

PURPOSE: Shifts in American healthcare delivery mechanisms pose significant hurdles to new physicians. Surgeons are particularly susceptible to these changes, but surgical residency educational efforts primarily focus on technical and clinical training to the exclusion of business and management practices. This study conducted a needs assessment of perceived gaps in practice management skills among early career surgeons to guide future training curricula. METHODS: This study was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify early career (<5 years following fellowship completion) surgeons across the United States. A semi-structured interview guide was created from interviews with surgical administrators and physician administrative curricula. Transcripts were de-identified and analyzed using a constructivist grounded theory approach. RESULTS: Ten surgeons from 6 specialties and 6 institutions were interviewed along with 3 surgeon administrators. Three major domains of need were identified: (1) fundamentals of procedural coding, clinical billing, & compliance, (2) finding/building a practice, and (3) navigating organizational challenges. First, surgeons thought trainees would benefit from a better understanding of reimbursement schema and the basics of health policy. They also thought that more exposure to malpractice litigation, especially for handling case review or expert witness requests, would be helpful for discerning how to handle such issues early in their career. In addition, early career surgeons expressed a desire to have dedicated mentorship time, a primer on evaluating job offers with simulated contract negotiation, and guidance regarding administrative roles. Finally, surgeons requested training in change management techniques, care pathway construction, and the basics of staffing decisions. CONCLUSIONS: There are significant practice management gaps in surgical training which may be amenable to targeted educational efforts during a residency or fellowship program. Future research will test the generalizability of these findings as well as build curricula that adequately meet these needs.

Virtual Simulation of Intra-operative Decision-Making for Open Abdominal Aortic Aneurysm Repair: A Mixed Methods Analysis.

OBJECTIVE: To create and pilot test a novel open abdominal aortic aneurysm (AAA) repair virtual simulation focused on intraoperative decision-making. To identify if the simulation replicated real-time intra-operative decision-making and discover how learners' respond to this type of simulation. DESIGN: An explanatory sequential mixed methods study. We developed a step-by-step outline of major intra-operative decision points within a standard open AAA repair. Perioperative and intraoperative decision-making trees were developed and coded into an online virtual simulation. The simulation was piloted. Quantitative data was collected from the simulation platform. We then performed a qualitative thematic analysis on feedback from interviewed participants. SETTING: Four academic general and vascular surgical training programs across the US. PARTICIPANTS: Seventeen vascular and general surgery trainees and 6 vascular surgery faculty. RESULTS: Participants spent on average 27 minutes (range: 8-45 minutes) interacting with the interface. 93% of participants reported feeling they were making real intraoperative decisions. 85% said it added to their knowledge base. 96% requested additional simulations. 22 interviews were completed: 241 primary codes were collapsed into 21 parent codes, and 6 emerging themes identified. Themes included the benefit of how (1) "Virtual Learning Could Standardize the Training Experience"; how (2) "Dealing with the Unexpected" as a trainee is an important part of surgical education growth, and that this (3) "Choose Your Own Adventure" virtual format simulates this intraoperative growth experience. Participants requested a (4) "Looping Feature Feedback Diagram" for future simulation iterations and highlighted that (5) "Fancier is Not Necessarily More Educational." Finally, many trainees wondered about (6) "The Attending Impact" from the simulation: if faculty would notice a difference between trainees who did vs did not utilize the simulation for case preparation. CONCLUSIONS: Operative simulation training should focus on both technical skills and intra-operative decision-making, particularly "dealing with the unexpected." The learners' responses indicate that a low-fidelity, scalable, virtual platform can effectively deliver knowledge and allow for intra-operative decision-making practice in a remote learning environment.

Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training.

BACKGROUND: Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum. METHODS: Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA. RESULTS: Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion. CONCLUSION: A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.

Finding my people: Effects of student identity and vulnerability to Stereotype Threat on sense of belonging in surgery.

BACKGROUND: Diversity in surgery lags behind the medical student population. We documented first-year medical students' vulnerability to stereotype threat (VST) and its impact on a sense of belonging in surgery. METHODS: All first-year medical students at a single academic institution were surveyed. Demographics, VST, anticipated clerkship experience, and sense of belonging were assessed. RESULTS: 44% of students were vulnerable to ST in upcoming clerkships, with the majority worried about surgical clerkships. More student from races/ethnicities underrepresented in medicine (URM; 74%) and sexual minorities (62%) were vulnerable than white (30%) and heterosexual (38%) students respectively (p = 0.001 and p = 0.017). Knowing a surgeon with a shared identity would enhance belonging for most students (84%). VST was higher for those who do not anticipate working with (p < 0.001) or do not know a surgeon (p = 0.0001) who shares their identity. CONCLUSION: VST significantly influences a student's sense of belonging in surgery. More research is needed to promote inclusivity in surgery.

A multisite study of medical student perspectives on the core surgical clerkship.

BACKGROUND: The surgical clerkship is the primary surgical learning experience for medical students. This study aims to understand student perspectives on the surgery clerkship both before and after the core surgical rotation. METHODS: Medical students at 4 academic hospitals completed pre and postclerkship surveys that included open-ended questions regarding (1) student learning goals and concerns and (2) how surgical clerkship learning could be enhanced. Thematic analysis was performed, and interrater reliability was calculated. RESULTS: Ninety-one percent of students completed both a pre and postclerkship survey (n =162 of 179), generating 320 preclerkship and 270 postclerkship responses. Mean kappa coefficients were 0.83 and 0.82 for pre and postclerkship primary themes, respectively. Thematic analysis identified 5 broad themes: (1) core learning expectations, (2) understanding surgical careers, culture, and work, (3) inhabiting the role of a surgeon, (4) inclusion in the surgical team, and (5) the unique role of the medical student on clinical clerkships. Based on these themes, we propose a learner-centered model of a successful surgical clerkship that satisfies discrete student learning and goals and career objectives while ameliorating the challenges of high-stakes clinical surgical environments such as the operating room. CONCLUSION: Understanding student perspectives on the surgery clerkship, including preclerkship motivations and concerns and postclerkship reflections on surgical learning, revealed potential targets of intervention to improve the surgery clerkship. Future investigation may elucidate whether the proposed model of the elements of a successful surgery clerkship learning facilitates improvement of the surgical learning environment and enhanced surgical learning.

Simulation versus reality: what can interprofessional simulation teach us about team dynamics in the trauma bay?

Purpose: Surgical consultation and the joint management of trauma patients is a common scenario in the emergency department. The goal of this study was to utilize interprofessional trauma team training to understand the role of simulation and its impact on the overall culture of trauma-related care. Methods: Interdisciplinary trauma simulation scenarios were completed by 12 groups of emergency medicine residents, general surgery residents, and emergency medicine nurses across two academic years. Following each simulation, a debriefing session was held to reflect on the scenario, focusing on team interactions. Debriefing sessions were audio-recorded, transcribed, deidentified, and independently, inductively coded by two members of the research team. Using the constant comparative method, a codebook was developed and refined until interrater reliability was confirmed with a kappa of > 0.9. Codes were organized into higher level themes. Results: There were 72 participants, including 23 general surgery residents, 19 emergency medicine residents, and 30 emergency medicine nurses. 214 primary codes were collapsed into 29 coding categories, with 6 emerging themes. Pre-trauma bay impact describes how interactions prior to the trauma scenario can impact how team members communicate, trust one another, and ultimately care for the patient. Role and team identity explores the importance of one knowing their individual role in the trauma bay and how it impacts overall team identity. Resource allocation describes the balance of having appropriate resources to efficiently care for patients while not negatively impacting crowd control or role identity. Impact of the simulation experience highlights the impact of the lower stakes simulation scenario on learning and reflection as well as concerns with simulation fidelity. Trauma leader traits and actions outlines inherent traits and learned actions of trauma leaders that impact how the trauma scenario unfolds. Interprofessional team performance describes the overall performance of the trauma team, including but not limited to the type of communication used, teamwork behaviors, and transition of care of the patient. Conclusions: Interdisciplinary trauma simulations and structured debriefing sessions provide insights into team dynamics and interprofessional relationships. Simulations and debriefing sessions can promote understanding, respect, and familiarity of team members' roles; recognition of key characteristics of high functioning leaders and teams; and discovery of conflict mitigating strategies for future interdisciplinary team improvement. Simulation sessions allow implementation of quality improvement measures and communication and leadership strategy practice in a safe, collaborative learning environment. The lessons learned from these sessions can encourage participants to reexamine how they interact and function as a team within the real-life trauma bay.

Eyes of the Beholders: First-year medical students' perceptions of surgeons and the field of surgery.

BACKGROUND: Medical students have negative perceptions of surgery prior to their clerkships. To explore possible explanations, we examined the association between these perceptions, individual identity and vulnerability to stereotype threat (ST). METHODS: All first-year medical students at a single school received an electronic survey which assessed identity groups, vulnerability to ST and perceptions of surgeons/surgery. Multi-method analyses examined these associations. RESULTS: Women held more negative than positive views about the field of surgery (p = 0.007) but not surgeons. Students vulnerable to ST had negative views about both surgeons (p < 0.0001) and surgery (p = 0.007). They were also less interested in pursuing a surgical career compared to non-vulnerable students (56% vs. 80% p = 0.03). CONCLUSION: For some students, negative views of surgeons and surgery appear to be associated with individual identity and ST. Future research should aim to confirm these findings and identify strategies to develop positive perceptions for these populations.