Hemorrhage Control Training: Preparing Adolescents to Act at Home, at School, or in Public.

OBJECTIVES: Uncontrolled bleeding is the leading cause of preventable death after a traumatic event, and early intervention to control bleeding improves opportunities for survival. It is imperative to prepare for local and national disasters by increasing public knowledge on how to control bleeding, and this preparation should extend to both adults and children. The purpose of this study is to describe a training effort to teach basic hemorrhage control techniques to early adolescent children. METHODS: The trauma and emergency departments at a combined level I adult and level II pediatric trauma center piloted a training initiative with early adolescents (grades 6-8) focused on 2 skills: packing a wound and holding direct pressure, and applying a Combat Application Tourniquet. Students were evaluated on each skill and completed presurveys and postsurveys indicating their likelihood to use the skills. RESULTS: Of the 194 adolescents who participated in the trainings, 97% of the students could successfully pack a wound and hold pressure, and 97% of the students could apply a tourniquet. Before the training, 71% of the adolescents indicated that they would take action to assist a bleeding victim; this increased to 96% after the training. CONCLUSIONS: Results demonstrate that basic hemorrhage control skills can be effectively taught to adolescents as young as 6th grade (ages 11-12 years) in a small setting with age-appropriate content and hands-on opportunities to practice the skills and such training increases students' perceived willingness to take action to assist a bleeding victim.

Intraoperative Teaching and Evaluation in General Surgery.

The operating room continues to be the location where surgical residents develop both technical and nontechnical skills, ultimately culminating with them being capable of safe and independent practice. The process of intraoperative instruction is, by necessity, moving from an apprentice-based model where skills are acquired somewhat randomly through repeated exposure and evaluation is done in a global gestalt fashion. Modern surgical education demands that intraoperative instruction be intentional and that evaluation provides formative and summative feedback. This chapter describes some best practice approaches to intraoperative teaching and evaluation.

Trauma Response for Elderly Anticoagulated Patients: An Initiative to Reduce Trauma Resource Utilization in the Emergency Department.

BACKGROUND: Trauma centers are challenged to have appropriate criteria to identify injured patients needing a trauma activation; one population that is difficult to triage is injured elderly patients taking anticoagulation or antiplatelet (ACAP) medications with suspected head injury. OBJECTIVE: The study purpose was to evaluate a hospital initiative to improve the trauma triage response for this population. METHODS: A retrospective study at a Level I trauma center evaluated revised trauma response criteria. In Phase 1 (June 2017 to April 2018; n = 91), a limited activation occurred in the trauma bay for injured patients 55 years and older, taking ACAP medications with evidence of head injury. In Phase 2 (June 2018 to April 2019; n = 142), patients taking ACAP medications with evidence of head injury received a rapid emergency department (ED) response. Primary outcomes were timeliness of ED interventions and hospital admission rates. Differences between phases were assessed with Kruskal-Wallis tests. RESULTS: An ED rapid response significantly reduced trauma team involvement (100%-13%, p < .001). Compared with Phase 1, patients in Phase 2 were more frequently discharged from the ED (48% vs. 68%, p = .003), and ED disposition decision was made more quickly (147 vs. 120 min, p = .01). In Phase 2, time to ED disposition decision was longer for patients who required hospital admission (108 vs. 179 min, p < .001); however, there were no significant differences between phases in reversal intervention (6% vs. 11%, p = .39) or timeliness of reversal intervention (49 vs. 118 min, p = .51). CONCLUSION: The ED rapid response delivered safe, timely evaluation to injured elderly patients without overutilizing trauma team activations.

Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage.

BACKGROUND: Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS: This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS: 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS: Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.

Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life.

BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

Artificial neural networks can predict trauma volume and acuity regardless of center size and geography: A multicenter study.

BACKGROUND: Trauma has long been considered unpredictable. Artificial neural networks (ANN) have recently shown the ability to predict admission volume, acuity, and operative needs at a single trauma center with very high reliability. This model has not been tested in a multicenter model with differing climate and geography. We hypothesize that an ANN can accurately predict trauma admission volume, penetrating trauma admissions, and mean Injury Severity Score (ISS) with a high degree of reliability across multiple trauma centers. METHODS: Three years of admission data were collected from five geographically distinct US Level I trauma centers. Patients with incomplete data, pediatric patients, and primary thermal injuries were excluded. Daily number of traumas, number of penetrating cases, and mean ISS were tabulated from each center along with National Oceanic and Atmospheric Administration data from local airports. We trained a single two-layer feed-forward ANN on a random majority (70%) partitioning of data from all centers using Bayesian Regularization and minimizing mean squared error. Pearson's product-moment correlation coefficient was calculated for each partition, each trauma center, and for high- and low-volume days (>1 standard deviation above or below mean total number of traumas). RESULTS: There were 5,410 days included. There were 43,380 traumas, including 4,982 penetrating traumas. The mean ISS was 11.78 (SD = 6.12). On the training partition, we achieved R = 0.8733. On the testing partition (new data to the model), we achieved R = 0.8732, with a combined R = 0.8732. For high- and low-volume days, we achieved R = 0.8934 and R = 0.7963, respectively. CONCLUSION: An ANN successfully predicted trauma volumes and acuity across multiple trauma centers with very high levels of reliability. The correlation was highest during periods of peak volume. This can potentially provide a framework for determining resource allocation at both the trauma system level and the individual hospital level. LEVEL OF EVIDENCE: Care Management, level IV.

Not all head injured patients on antiplatelet drugs need platelets: Integrating platelet reactivity testing into platelet transfusion guidelines.

INTRODUCTION: Antiplatelet medication use continues to rise in an aging population, and these agents can have a deleterious effect for patients with traumatic intracranial hemorrhage (tICH). The purpose of the current investigation is to assess the safety and efficacy of using platelet reactivity testing (PRT) to direct platelet transfusion for tICH patients. PATIENTS AND METHODS: A Level I trauma center adopted a targeted platelet transfusion guideline using PRT to determine whether platelets were inhibited by an antiplatelet medication (aspirin or P2Y12 inhibitors). Non-inhibited patients were monitored without platelet transfusion, regardless of severity of the head injury. The guideline was analyzed retrospectively to evaluate patient outcomes during the study period (June 2014-December 2016). All patients sustained blunt tICH and received a PRT for known or suspected antiplatelet medication use. Differences were assessed with Kruskal-Wallis and Fisher's Exact tests. RESULTS: 166 patients met study inclusion criteria. PRT results indicated that 48 patients (29%) were not inhibited by an antiplatelet medication, and 92% of those patients (n = 44) were spared platelet transfusion. Seven percent (n = 11) of all patients had a clinically significant progression of the head bleed, but this did not differ by inhibition or transfusion status. Implementation of this guideline reduced platelet transfusions by an estimated 30-50% and associated healthcare costs by 42%. CONCLUSIONS: A targeted platelet transfusion guideline using PRT reduced platelet usage for patients with tICH. If appropriately tested, results suggest that not all tICH patients taking or suspected of taking antiplatelet drugs need platelet transfusion. Platelet reactivity testing can significantly reduce healthcare costs and resource usage.

Head CT before Transfer Does Not Decrease Time to Craniotomy for TBI Patients.

Rural trauma education emphasizes that radiologic imaging should be discouraged if it delays transfer to definitive care. With increased capacity for image sharing, however, radiography obtained at referring hospitals (RH) could help providers at trauma centers (TC) prepare for patients with traumatic brain injury. We evaluated whether a head CT prior to transfer accelerated time to neurosurgical intervention at the TC. The study was conducted at a combined adult Level I and pediatric Level II TC with a catchment area that includes rural hospitals within a 150 mile radius. The trauma registry was used to identify patients with traumatic brain injury who went to surgery for a neurosurgical procedure immediately after arrival at the TC. All patients were transferred in from a RH. Differences between groups were assessed using analysis of variance and chi-square. Fifty-six patients met study criteria during the study period (2010-2015). The majority (86%) of patients received head CT imaging at the RH, including a significant percentage of patients (18%) who presented with GCS ≤8. There was no statistically significant decrease in time to surgery when patients received imaging at the RH. CT imaging was associated with a delay in transfer that exceeded 90 minutes. Findings demonstrate that imaging at the RH delayed transfer to definitive care and did not improve time to neurosurgical intervention at the TC. Transfer to the TC should not be obstructed by imaging, especially for patients with severe TBI.

Efficient Hemorrhage Control Skills Training for Healthcare Employees.

BACKGROUND: Several national initiatives are aimed at training citizens to assist bleeding victims. The purpose of this study was to evaluate an effort to quickly and efficiently teach basic bleeding control techniques to a clinical and nonclinical workforce. STUDY DESIGN: The research study was conducted at 4 hospitals in a mid-sized metropolitan area. In spring 2017, the trauma department at a Level I trauma center set an ambitious goal to provide hands-on training to 1,000 employees during the course of 6 weeks. Trainings occurred in small groups and lasted approximately 6 to 10 minutes, during which time participants were taught and practiced 2 skills: packing a wound and holding direct pressure, and applying a stretch-wrap-and-tuck tourniquet. Participants completed pre- and post-surveys indicating their likelihood to use these skills. RESULTS: More than 1,000 individuals were trained, and there were survey data for 870 participants. More than 40% of participants worked in nonclinical roles and 29% had no first aid or medical training. After completing skills training, 98% of participants indicated that they would be likely to take action to assist a bleeding victim and that they could correctly apply direct pressure or a tourniquet to control severe bleeding. CONCLUSIONS: Results demonstrate that basic hemorrhage control skills can be taught to clinical and nonclinical people in brief, hands-on training. Efforts like this can be deployed across large workplace environments to prepare the maximum number of employees to take action to assist bleeding victims.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population.

BACKGROUND: Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury. OBJECTIVES: The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients. METHODS: A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests. RESULTS: More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle. CONCLUSION: Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.

Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition.

IMPORTANCE: Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear. OBJECTIVES: To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate. DESIGN, SETTING, AND PARTICIPANTS: This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses. MAIN OUTCOMES AND MEASURES: Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared. RESULTS: The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons." CONCLUSIONS AND RELEVANCE: The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment.

OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

Effective Hospital-Wide Education in Hemorrhage Control.

BACKGROUND: Uncontrolled hemorrhage is the leading cause of potentially preventable traumatic death. Bleeding victims must receive immediate medical attention to save lives, and the first opportunity to control bleeding after trauma often comes from bystanders. Educating the general public is important for improving outcomes for hemorrhaging victims, and it is imperative for all people, including those with no clinical training, to have the knowledge to respond until trained medical specialists arrive. STUDY DESIGN: An 8-minute educational module was deployed to all hospital employees and included information on the location and contents of hemorrhage control bags in the hospital and how to use the materials in the bags to respond to uncontrolled hemorrhage. A pre-post questionnaire was administered with the module to evaluate effectiveness. McNemar tests were used to compare the responses and evaluate effectiveness of the education. RESULTS: Eighty-four percent of eligible employees (n = 4,845) completed the module and all items on the questionnaires. Three-quarters of respondents provided direct or ancillary care to patients, and one-quarter worked in nonclinical roles. On average, 57% of questions were answered correctly in the pre-questionnaire and 98% were answered correctly in the post-questionnaire. The module was effective for all employees regardless of clinical training. CONCLUSIONS: There is currently no succinct hemorrhage control education available that can be deployed across a large workplace environment. Results demonstrate that the brief learning module was effective in educating all employees in the basics of hemorrhage control. The module could be deployed in clinical and nonclinical settings.

Surgical Resident Radiation Knowledge, Attitudes, Practices, and Exposures.

OBJECTIVE: To investigate the level of ionizing radiation exposure among surgical residents and to evaluate resident knowledge, attitudes, and practices regarding exposures. DESIGN: An observational study was conducted using radiation exposure data for surgical residents who wore film badge dosimeters. A cross-sectional survey was electronically administered at the end of the year, examining resident knowledge, attitudes, and practices concerning radiation exposures. SETTING: Community teaching hospital in the Midwest. PARTICIPANTS: Surgical residents who wore a badge for the full calendar year and completed study survey. Excluded were graduating chiefs and interns who only had 6 calendar months of data. RESULTS: A total of 14 surgical residents (100%) were engaged in 168 rotations during study year. Primarily-general surgery (n = 103, 61%), night float (n = 16, 10%), trauma (n = 15, 9%), and vascular (n = 13, 8%). Radiation exposures were greater than a null value during most rotations (i.e., general surgery and night float), with no exposure above occupational thresholds. Certain rotations, namely vascular and trauma, had episodic high exposures. When asked if protective efforts changed during higher-risk rotations, responses revealed they increased (64%) or did not change (36%). A low Cronbach alpha (α = 0.2634) demonstrated that precaution use was not universal and had varied rationale. Percentage of correct radiation knowledge questions was 62%. A multilevel model predicting exposure had a significant multiplicative cross-level interaction term (p < 0.0001) between resident-level exposure and rotation type. CONCLUSIONS: Radiation exposure levels for surgical residents have not been previously investigated. Data demonstrated that surgical residents were not at a greater risk than other medical personnel. However, the study demonstrated detectable radiation exposures that were statistically greater than a null value for the most common rotations. Stochastic and dose-response effects of radiation make any exposure a concern. Attempts to lessen exposures are worthwhile, with study results identifying a need for greater safety precaution education and adherence.

Understanding an inclusive trauma system through characterization of admissions at level IV centers.

BACKGROUND: Level IV trauma centers are an integral part of inclusive trauma systems, although sparse data exists for these facilities. METHODS: An observational study was conducted using a Midwestern state's inpatient data files to characterize level IV center patients. Injury and severity levels, injury mechanism and/or intent, and distances to nearest tertiary centers were determined. RESULTS: During the study year, 3,346 injured patients were admitted at level IV centers. The median distance to nearest tertiary center was 43 miles. Median patient age was 81 years, and primary injury mechanism was falls. Overall, 22% of patients had an isolated hip fracture. Of moderately injured patients, 64% had an isolated hip fracture, 8% nonisolated hip fractures, and 9% rib fractures without hip fracture. Overall, 30% of patients had a high severity of injury. CONCLUSIONS: A large number of patients were admitted to level IV trauma centers. Patients admitted tended to be elderly and have orthopedic fall injuries. Study results provide important implications for provider education, prevention efforts, need for orthopedic surgical capabilities, and necessity of capturing these data in registries.

Residency Surgical Training at an Independent Academic Medical Center.

Independent academic medical centers have been training surgeons for more than a century; this environment is distinct from university or military programs. There are several advantages to training at a community program, including a supportive learning environment with camaraderie between residents and faculty, early and broad operative experience, and improved graduate confidence. Community programs also face challenges, such as resident recruitment and faculty engagement. With the workforce needs for general surgeons, independent training programs will continue to play an integral role.

Program Factors That Influence American Board of Surgery In-Training Examination Performance: A Multi-Institutional Study.

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.

Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance.

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.

Factors and Influences That Determine the Choices of Surgery Residency Applicants.

OBJECTIVE: We sought to evaluate characteristics of residency applicants selected to interview at independent general surgery programs, identify residency information resources, assess if there is perceived bias toward university or independent programs, and determine what types of programs applicants prefer. STUDY DESIGN: An electronic survey was sent to applicants who were selected to interview at a participating independent program. Open-ended responses regarding reasons for program-type bias were submitted. Multivariable logistic regression models were estimated to identify applicant characteristics associated with program-type preference. SETTING: Independent general surgery residency programs. PARTICIPANTS: A total, of 1220 applicants were selected to interview at one of 33 independent programs. RESULTS: In total, 670 surveys were completed (55% response rate). Demographics of respondents were similar to the full invited population. Median United States Medical Licensing Examination Step 1 and Step 2 scores were between 230 to 239 and 240 to 249, respectively. Most applicants reported receiving general information about surgery residency programs and specific information about independent programs from residency program websites. 34% of respondents perceived an imbalanced representation of program types, with 96% of those reporting bias toward university programs. CONCLUSIONS: Applicants selected to interview at independent programs are competitive for general surgery training and primarily use residency program websites for information gathering. Bias is common toward university programs for a variety of perceived reasons. This information will be useful in applicant evaluation and selection, serve as a stimulus to update program websites, and challenge independent program directors to work to alleviate bias against their programs.