Rapid development of squamous cell carcinoma at a split-thickness skin graft donor site.

The development of a Marjolin ulcer at the site of a split-thickness skin graft donor site is exceptionally rare. Here we describe the rapid development of squamous cell carcinoma at a split-thickness skin graft donor site in the setting of severe burn. We present a case of a 52-year-old male with no past medical history who presented with a 24% total body surface area burn caused by a flash flame. Four months after his initial excision and grafting, he presented for revision of a burn scar with an additional complaint of a rapidly developing skin lesion at his donor site, which arose over 2 weeks. The lesion was excised en bloc and found to be invasive squamous cell carcinoma. There are 5 previous cases of squamous cell carcinoma development at the site of split-thickness skin harvest in the setting of severe burn. While the typical Marjolin ulcer has a latency period of up to 30 years, lesions that arise in split-thickness skin graft donor sites appear to have a rapid onset of weeks to months. Squamous cell carcinoma at the site of split-thickness skin grafting is an uncommon but important sequelae of burn care.

Burnout in Surgical Residents of Underrepresented in Medicine Backgrounds: Key Influencing Factors and Possible Solutions.

INTRODUCTION: Alarming rates of burnout in surgical training pose a concern due to its deleterious effects on both patients and providers. Datum remains lacking on rates of burnout in surgical residents based on race and ethnicity. This study aims to document the frequency of burnout in surgical residents of racially underrepresented backgrounds and elucidate contributing factors. METHODS: A 35-question anonymized survey was distributed to general surgery residents from 23 programs between August 2018 and May 2019. This survey was designed from the validated Maslach Burnout Inventory, and included additional questions assessing participant demographics, educational, and social backgrounds. Responses were analyzed utilizing chi-square tests and Wilcoxon rank sum tests. There was also a free response portion of the survey which was evaluated using thematic analysis. RESULTS: We received 243 responses from 23 general surgery programs yielding a 9% (23/246) program response rate and 26% (243/935) response rate by surgical residents. One hundred and eighty-five participants (76%) identified as nonunderrepresented in medicine and 58 (24%) of participants identified as underrepresented in medicine. Fifty-three percent were male and 47% female. Overall, sixty-six percent of all surgical residents (n = 161) endorsed burnout with racially underrepresented residents reporting higher rates of burnout at 76% compared to 63% in their nonunderrepresented counterparts (P = 0.07). CONCLUSIONS: Although the generalizability of these results is limited, higher rates of reported burnout in racially underrepresented trainees noted in our study illuminates the need for continual dialogue on potential influencing factors and mitigation strategies.

Impact of Alcohol and Methamphetamine Use on Burn Resuscitation.

Mortality associated with burn injuries is declining with improved critical care. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single-center studies; however, has not been studied since implementation of computerized decision support for resuscitation. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours. A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ± 2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ± 2.49 cc/kg/TBSA, and patients with neither received a mean of 4.33 ± 1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements. In the first 6 hours patients with alcohol use had significantly higher urinary output (UO) in comparison to patients with methamphetamine use which had similar output to patients negative for both substances. This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly greater fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased UO as a cause for their increased fluid requirements.

Virtual Mentoring: A Novel Approach to Facilitate Medical Student Applications to General Surgery Residency.

OBJECTIVE: The COVID-19 pandemic rapidly altered the landscape of medical education, particularly disrupting the residency application process and highlighting the need for structured mentorship programs. This prompted our institution to develop a virtual mentoring program to provide tailored, one-on-one mentoring to medical students applying to general surgery residency. The aim of this study was to examine general surgery applicant perception of a pilot virtual mentoring curriculum. DESIGN: The mentorship program included student-tailored mentoring and advising in 5 domains: resume editing, personal statement composition, requesting letters of recommendation, interview skills, and residency program ranking. Electronic surveys were administered following ERAS application submission to participating applicants. The surveys were distributed and collected via a REDCap database. RESULTS: Eighteen out of 19 participants completed the survey. Confidence in a competitive resume (p = 0.006), interview skills (p < 0.001), obtaining letters of recommendation (p = 0.002), personal statement drafting (p < 0.001), and ranking residency programs (p < 0.001) were all significantly improved following completion of the program. Overall utility of the curriculum and likelihood to participate again and recommend the program to others was rated a median 5/5 on the Likert scale (5 [IQR 4-5]). Confidence in the matching carried a premedian 66.5 (50-65) and a postmedian 84 (75-91) (p = 0.004). CONCLUSION: Following the completion of the virtual mentoring program, participants were found to be more confident in all 5 targeted domains. In addition, they were more confident in their overall ability to match. General Surgery applicants find tailored virtual mentoring programs to be a useful tool allowing for continued program development and expansion.

Survival after multiple episodes of cardiac arrest.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital. OBJECTIVES: The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events. METHODS: We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality. RESULTS: There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p<.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p<.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p<.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01). CONCLUSION: Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.

The Battle of the Titans-Comparing Resuscitation Between Five Major Burn Centers Using the Burn Navigator.

The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9-25]), or total body surface area (TBSA) (34 [25.8-47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.

Educational Experience Impacts Wellness More than Hours Worked.

OBJECTIVE: The Accreditation Council for Graduate Medical Education has focused its interests on resident wellbeing and the clinical work environment in recent years. Concerns regarding both duty hours as well as service obligations versus education resulted in programs nationwide receiving citations, including ours. This study aimed to evaluate the impact of those 2 factors on surgical residents' general wellbeing, hypothesizing that service obligations would be a stronger predictor. DESIGN: We have previously reported on the use of a "Fuel Gauge" tool developed at our institution for monitoring resident wellbeing. We performed a retrospective comparison of prospectively collected cross-sectional survey data comparing the Fuel Gauge to a bimonthly "Service Versus Education" (SVE) report. This report used similar scaling and allowed residents to provide feedback on the balance of the educational quality of their current rotation in comparison to their perception of service obligation. Pearson's correlation was then used to compare those scores with duty hour logs to determine if a relationship could be identified between the 3 measurements. SETTING: Academic institution of the University of Texas Southwestern in Dallas, Texas. PARTICIPANTS: Active general surgery residents (n = 73). RESULTS: During the study period, 73 residents filled out both a Fuel Gauge assessment and a SVE assessment at least once, with 273 complete data points available for analysis. Our program's Fuel Gauge median was 4, and our program's median SVE score was 4. Fuel Gauge assessment scores demonstrated a moderate positive correlation with SVE (r = 0.65, p < 0.001), while only a weakly negative association with increasing hours worked (r = -0.15, p = 0.015). SVE also demonstrated a weak negative correlation with hours logged (r = -0.225, p = 0.001). CONCLUSIONS: While the Accreditation Council for Graduate Medical Education recognizes that multiple factors contribute to resident wellbeing issues, early efforts were focused on limiting excessive duty hours. Examining our institutional data regarding the previously understudied factor of SVE, we indeed found a stronger correlation with resident perception of low educational value rather than excessive work hours contributing to lower Fuel Gauge scores. These data, if verified, should guide program directors in identifying other institutional factors that may more strongly contribute to their own culture of resident wellness.

Assessing Videoconference Etiquette in Academia: Determining Positive and Negative Associations With Online Interactions.

INTRODUCTION: The lack of guidelines for videoconferencing etiquette elucidated frustrations during the COVID-19 pandemic. The authors aimed to assess the perceptions of faculty educators and residents regarding videoconferencing etiquette. METHODS: In 2021, a survey assessing perceptions regarding the formality of various meeting types and the importance of various videoconferencing etiquette practices (Likert scale of 1-5) was created and disseminated to all faculty educators and residents at a single institution. Responses of faculty versus residents were analyzed in general and by procedural and mixed/nonprocedural subspecialties. RESULTS: The faculty response rate was 53.5% (38/71). The resident response rate was 7.3% (115/1569). A total of 19 departments were represented. Faculty respondents reported having significantly more hours of weekly formal meetings than residents, 4 (3-10) versus 2 (1-4) h (P < 0.05), and no difference in informal meeting hours, with 3 (2-6) versus 3 (1.6-5) h (P = 0.210). Faculty and residents concurred on the formality of all meeting types except for didactics, which residents regarded more frequently as informal (80.9% versus 57.9%; P < 0.01). Faculty rated wearing professional attire and keeping one's video on as mattering more, and that videoconferencing from bed was more inappropriate (P < 0.05). Furthermore, faculty and residents in mixed/nonprocedural specialties had more significantly discordant perceptions between them than did those in procedural specialties. CONCLUSIONS: The data demonstrated that faculty educators and residents have differing perceptions regarding the formality of meeting types and etiquette practices. These should be addressed to prevent future frustrations and improve engagement in ongoing virtual conferencing education.

Laparoscopic Ambidexterity in Left-Handed Trainees.

INTRODUCTION: There is a paucity of objective data about the advantages or disadvantages of handedness in surgery. Given the need for ambidexterity in laparoscopic surgery, our study aimed to identify the patterns in handedness and performance on basic laparoscopic tasks. METHODS: A retrospective analysis of intern laparoscopic performance on bimanual tasks was assessed for delta time (differences in task time between the dominant and nondominant hand) between left-hand and right-hand dominant interns. RESULTS: Data were analyzed for 16 residents. 25% were left-handed dominant (4/16) and 75% were right-handed dominant (12/16). Of the left-handed surgeons, 75% (3/4) operated primarily with their right hand. There was a significant difference between the time to task completion in Task 2 of left-handed and right-handed residents with median (IQR) time 94 s (90.25-97) and 127 s (104.25-128.5), respectively (P value = 0.02). No significant difference was seen between left-handed and right-handed residents on Task 1 (50 s versus 49 s) and Task 3 (51 s versus 59.5 s). In all three tasks, however, left-handed dominant residents had smaller variability (IQR 4.5-8 s versus 7-24.25 s) and significantly shorter delta times. CONCLUSIONS: Although true ambidexterity is rare, the ability to be facile with both hands is crucial for laparoscopic surgery. Our data show that variability in performance between the dominant hand and nondominant hand was remarkably smaller for left-hand dominant residents. This remains true despite the majority learning to operate with their nondominant hand. These data demonstrate a possible advantage to being left-hand dominant and may lead to further insights into variations of skill acquisition and improved curriculum development.

Creating a Proficiency-based Remote Laparoscopic Skills Curriculum for the COVID-19 Era.

OBJECTIVE: Social distancing restrictions due to COVID-19 challenged our ability to educate incoming surgery interns who depend on early simulation training for basic skill acquisition. This study aimed to create a proficiency-based laparoscopic skills curriculum using remote learning. DESIGN: Content experts designed 5 surgical tasks to address hand-eye coordination, depth perception, and precision cutting. A scoring formula was used to measure performance: cutoff time - completion time - (K × errors) = score; the constant K was determined for each task. As a benchmark for proficiency, a fellowship-trained laparoscopic surgeon performed 3 consecutive repetitions of each task; proficiency was defined as the surgeon's mean score minus 2 standard deviations. To train remotely, PGY1 surgery residents (n = 29) were each issued a donated portable laparoscopic training box, task explanations, and score sheets. Remote training included submitting a pre-test video, self-training to proficiency, and submitting a post-test video. Construct validity (expert vs. trainee pre-tests) and skill acquisition (trainee pre-tests vs. post-tests) were compared using a Wilcoxon test (median [IQR] reported). SETTING: The University of Texas Southwestern Medical Center in Dallas, Texas PARTICIPANTS: Surgery interns RESULTS: Expert and trainee pre-test performance was significantly different for all tasks, supporting construct validity. One trainee was proficient at pre-test. After 1 month of self-training, 7 additional residents achieved proficiency on all 5 tasks after 2-18 repetitions; trainee post-test scores were significantly improved versus pre-test on all tasks (p = 0.01). CONCLUSIONS: This proficiency-based curriculum demonstrated construct validity, was feasible as a remote teaching option, and resulted in significant skill acquisition. The remote format, including video-based performance assessment, facilitates effective at-home learning and may allow additional innovations such as video-based coaching for more advanced curricula.

How We Did It: Implementing a Trainee-Focused Surgical Research Curriculum and Infrastructure.

OBJECTIVE: To describe the implementation of a department-wide research curriculum and infrastructure created to promote academic collaboration and productivity, particularly amongst trainees and junior investigators involved in basic, translational, clinical, quality, or education research. DESIGN: Description of UT Southwestern Medical Center's (UTSW) surgical research resources and infrastructure and the development of a didactic curriculum focused on research methods, writing skills, and optimizing academic time and effort. SETTING: The collaboration was initiated by UTSW Department of Surgery residents who were on dedicated research time (DRT) and grew to include trainees and faculty at all levels of the institution. Guest lecturers from institutions around the country were incorporated via virtual meeting platforms. PARTICIPANTS: Medical students, residents, and clinical and research faculty from the Department of Surgery were invited to attend research meetings, didactics, and the guest-lecture series. Additionally, all groups were given access to shared resources and encouraged to share their own work. RESULTS: A robust set of resources including data analysis tools, manuscript and grant writing templates, funding opportunities, and a comprehensive list of surgical conferences was created and made accessible to UTSW Surgery team members. Moreover, a curriculum of lectures covering a broad variety of topics for all types of research was created and has thus far reached an audience of over 40 UTSW Surgery trainees and staff. CONCLUSIONS: A comprehensive set of lectures and resources targeted toward facilitating surgical research was designed and implemented at one of the largest surgical training programs in the country. This effort represents a low-cost, feasible, and accessible way to improve academic productivity and enhance the training of surgeon-scientists and can serve as a blueprint for other institutions around the country.

The Impact of COVID-19 on Surgical Education.

BACKGROUND: At the onset of social distancing, our general surgery residency transitioned its educational curriculum to an entirely virtual format with no gaps in conference offerings. The aim of this study is to examine the feasibility of our evolution to a virtual format and report program attitudes toward the changes. METHODS: On March 15, 2020, due to the coronavirus disease (COVID-19) our institution restricted mass gatherings. We immediately transitioned all lectures to a virtual platform. The cancellation of elective surgeries in April 2020 then created the need for augmented resident education opportunities. We responded by creating additional lectures and implementing a daily conference itinerary. To evaluate the success of the changes and inform the development of future curriculum, we surveyed residents and faculty regarding the changes. Classes and faculty answers were compared for perception of value of the online format. RESULTS: Pre-COVID-19, residency-wide educational offerings were concentrated to one half-day per week. Once restrictions were in place, our educational opportunities were expanded to a daily schedule and averaged 16.5 hours/week during April. Overall, 41/63 residents and 25/94 faculty completed the survey. The majority of residents reported an increased ability (56%) or similar ability (34.1%) to attend virtual conferences while 9.9% indicated a decrease. Faculty responses indicated similar effects (64% increased, 32% similar, 4% decreased). PGY-1 residents rated the changes negatively compared to other trainees and faculty. PGY-2 residents reported neutral views and all other trainees and faculty believed the changes positively affected educational value. Comments from PGY1 and 2 residents revealed they could not focus on virtual conferences as it was not "protected time" in a classroom and that they felt responsible for patient care during virtual lectures. A majority of both residents (61%) and faculty (84%) reported they would prefer to continue virtual conferences in the future. CONCLUSIONS: The necessity for adapting our academic offerings during the COVID-19 era has afforded our program the opportunity to recognize the feasibility of virtual platforms and expand our educational offerings. The majority of participants report stable to improved attendance and educational value. Virtual lectures should still be considered protected time in order to maximize the experience for junior residents.

Trainee Reliance on Public Service Loan Forgiveness.

OBJECTIVE: The Public Service Loan Forgiveness (PSLF) program is an option to trainees to help alleviate federal education debt. The prevalence of PSLF utilization and how this may impact career decisions of trainees is unknown. The purpose of this study was to understand the prevalence, impact, and understanding of PSLF participation on trainees. DESIGN: IRB-approved anonymous survey asking study subjects to report demographics, financial status, and reliance on PSLF. In addition, study subjects were asked to report their participation in PSLF, the possible impact of PSLF participation on career decisions, and to identify the qualifications needed to complete PSLF. SETTING: Online anonymous survey. PARTICIPANTS: The survey was offered to all physician trainees in all specialties at the University of Texas, Southwestern, University of Wisconsin, Madison, and University of Michigan, Ann Arbor. RESULTS: There were 934 respondents, yielding a 37.6% response rate. A total of 416/934 (44.5%) respondents were actively or planning on participating in the PSLF program with 175/934 (18.7%) belonging to a surgical specialty. Those belonging to a surgical specialty were more likely to be PSLF participants compared to medical specialties (53.1% versus 42.6%, p = 0.01). For those participating in PSLF, 82/416 (19.7%) stated this participation impacted career decisions. A total of 275/934 (29.4%) respondents obtained and 437/934 (46.8%) wanted to receive formal training/lectures in regards to the PSLF program. Of those actively or planning on participating in the PSLF program, only 58/416 (13.9%) were able to correctly identify all of the qualifications/criteria to complete the program. CONCLUSIONS: A large proportion of trainees rely on the PSLF program for education loan forgiveness with approximately 20% reporting participation impacted career decisions. Additionally, the majority may not fully understand PSLF criteria. Programs should strongly consider providing a formal education regarding PSLF to their trainees.

The Relationship Between Surgeon Faculty Emotional Intelligence and Medical Student Evaluations.

OBJECTIVE: We sought to measure the emotional intelligence (EI) of surgical faculty and the relationship between faculty EI and medical student (MS) evaluations of faculty. DESIGN: Faculty completed the Emotional Intelligence Appraisal. Aggregate, anonymous MS evaluations were collected from the Program Director's office. Parametric and nonparametric tests were used for analysis. SETTING: This study was first performed in a single surgical division at 1 center which informed an expanded study including the entire General Surgery Department at a single academic institution. PARTICIPANTS: A pilot study was conducted in 1 surgical division which was then expanded to all clinical faculty in the Department of Surgery. All clinical faculty in the Department of Surgery were eligible for enrollment. RESULTS: Pilot study faculty EI scores were positively correlated with MS evaluations (r = 0.92, p < 0.001). The follow-up study enrolled 41 surgeons with a median age of 48 (inter-quartile range 12). The sample was mostly white (70.7%). Mean EI for the group was 76 (standard deviation ± 7.8). Total faculty EI scores were not significantly correlated with MS evaluations (r = 0.30, p = 0.06). CONCLUSIONS: MS evaluations of surgeon faculty were not related to EI in the larger sample. However, EI did correlate to MS evaluations in 2 surgical specialties. Further exploration into the utility of EI training in surgical departments should be conducted to determine the true value of such endeavors.

Faculty Emotional Intelligence Matters for Resident Education.

OBJECTIVE: This study aimed to determine the emotional intelligence (EI) of surgical faculty and evaluate its relationship with resident evaluations of faculty behaviors. DESIGN: This study retrospectively collected faculty EI scores as well as general surgery resident evaluations of faculty. Parametric and nonparametric tests were used for statistical analysis. SETTING: The study was conducted at the University of Texas Southwestern in the Department of Surgery in Dallas, Texas. This is an academic, tertiary care center. PARTICIPANTS: Surgical faculty members at a single institution in 2018 completed the Emotional Intelligence Appraisal, a 28-item, electronic assessment with possible scores ranging from zero to 100. Aggregate, anonymous resident evaluations of faculty members were collected from the program director's office. Faculty with fewer than 8 resident evaluations were excluded. RESULTS: In total, 59 faculty members participated (89%). The sample was mostly white (69.2%), male (63.5%), with an average of 47 ± 10 years of age, 12.2 ± 10 years in practice, and 44 ± 24 evaluations per faculty member. The group's mean EI score was 76 ± 7.7. Faculty EI scores were found to have a moderate, positive correlation with resident rotational evaluations of faculty (r(51) = 0.52, p < 0.001). Faculty EI scores did not significantly correlate with resident evaluations of faculty intraoperative behaviors. CONCLUSIONS: The results of this study suggest that a majority of our faculty are competent with regard to EI. Furthermore, faculty EI is an important factor in the clinical learning environment and correlates with resident rotational evaluations of teaching behaviors.

Virtual Interviews in the Era of COVID-19: A Primer for Applicants.

PROBLEM: The COVID-19 pandemic is an evolving crisis with widespread impact upon our medical system, including senior trainee travel for fellowship interviews. Numerous institutions have conscientiously deferred in-person interviews or virtual formats. Given the competitive nature of fellowship interviews, candidates may express concern that they are at a disadvantage in engaging in online meetings versus live, on-site interviews, and similarly may feel ill prepared to perform optimally during online interviews. APPROACH: We draw upon our experience with online interview platforms in this guide for fellowship candidates who are rapidly adapting to new technology and styles associated with videoconference interviews so that they can best promote themselves for competitive positions.

Comparison of Appendectomy for Perforated Appendicitis With and Without Abscess: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: Outcomes of appendectomy stratified by type of complicated appendicitis (CA) features are poorly researched, and the evidence to guide operative versus nonoperative management for CA is lacking. This study aimed to determine laparoscopic-to-open conversion risk, postoperative abscess risk, unplanned readmission risk, and length of hospital stay (LOS) associated with appendectomy in patients with perforated appendicitis without abscess (PA) and perforated appendicitis with abscess (PAWA) compared with a control cohort of nonperforated appendicitis (NPA). METHODS: The 2016-2017 National Surgical Quality Improvement Program Appendectomy-targeted database identified 12,537 (76.1%) patients with NPA, 2142 (13.0%) patients with PA, and 1799 (10.9%) patients with PAWA. Chi-squared analysis and analysis of variance were used to compare categorical and continuous variables. Binary logistic and linear regression models were used to compare risk-adjusted outcomes. RESULTS: Compared with NPA, PA and PAWA had higher rates of conversion (0.8% versus 4.9% and 6.5%, respectively; P < 0.001), postoperative abscess requiring intervention (0.6% versus 4.8% and 7.0%, respectively; P < 0.001), readmission (2.8% versus 7.7% and 7.6%, respectively; P < 0.001), and longer median LOS (1 day versus 2 days and 2 days, respectively; P < 0.001). PA and PAWA were associated with increased odds of postoperative abscess (odds ratio [OR]: 7.18, 95% confidence interval [CI]: 5.2-9.8 and OR: 9.94, 95% CI: 7.3-13.5, respectively), readmission (OR: 2.70, 95% CI: 2.1-3.3 and OR: 2.66, 95% CI: 2.2-3.3, respectively), and conversion (OR: 5.51, 95% CI: 4.0-7.5 and OR: 7.43, 95% CI: 5.5-10.1, respectively). PA was associated with an increased LOS of 1.7 days and PAWA with 1.9 days of LOS (95% CI: 1.5-1.8 and 1.7-2.1, respectively). CONCLUSIONS: Individual features of CA were independently associated with outcomes. Further research is needed to determine if surgical management is superior to nonoperative management for CA.

Are you better off than you were 4 years ago? Measuring the impact of the ABS flexible endoscopy curriculum.

INTRODUCTION: In 2014, the ABS introduced the Flexible Endoscopy Curriculum (FEC). The FEC did not alter the minimum defined category case volumes for endoscopy; however, it did introduce specific cognitive and technical milestones for endoscopy training. It also mandated that residents pass the Fundamentals of Endoscopic Skills (FES) exam to qualify for board certification. Although significant research has been published regarding residents' success on the FES exam, very little is known regarding how the FEC has changed the way general surgery programs train their residents in surgical endoscopy. The aim of this study was to quantify changes in flexible endoscopy education at a large academic program in the 4 years since the FEC was published. METHODS: We classified the impact of FEC into four categories: (a) case volume or distribution, (b) clinical rotations, (c) required didactics or simulation exercises, and (d) FES pass rates. For category (a), we reviewed current and historical case logs for all categorical residents from 2013 to 2018. Mann-Whitney U tests were used to compare endoscopy volumes for each PGY level in 2013-2014 to the respective PGY level in 2017-2018 with p < 0.05 considered significant. For categories (b)-(d), we gathered historical records from the residency coordinator and endoscopy rotation director. RESULTS: Complete data were available for 57 residents in the 2013-2014 academic year and 56 residents in the 2017-2018 academic year. Median total endoscopies performed by PGY2, PGY3, and PGY5 residents all significantly increased during the FEC rollout. Our program's focus on endoscopy also expanded with absolute increases in endoscopy rotations, didactics, and simulation exercises. These changes translated into significantly increased pass rates on the FES exam from 40 to 100%. CONCLUSIONS: Implementation of the FEC at a large academic program led to measurable improvements in clinical experience, program structure, educational programing, and performance on high-stakes assessments.

The Fuel Gauge: A Simple Tool for Assessing General Surgery Resident Well-Being.

OBJECTIVE: Resident well-being is an increasingly relevant issue in medical education; however, there is no consensus on how to best measure well-being. The "fuel gauge," is a simple, easy-to-use tool developed to measure resident well-being and previously applied in an Internal Medicine Residency Program at our institution. The current study sought to evaluate its acceptability and usefulness in a surgery program. DESIGN: Weekly fuel gauge data was retrospectively collected from August 2017 through December 2018 along with resident Postgraduate Year designations. SETTING: This study was conducted at a single, large general surgery residency program that rotates through a variety of hospitals, including a University hospital, a large county hospital, a Veterans Affairs hospital, and a freestanding Children's hospital. PARTICIPANTS: Categorical general surgery residents at every level of training as well as preliminary interns and off service intern rotators from urology, oral and maxillofacial surgery, and otolaryngology were eligible for the study. Fuel gauge submissions which did not denote a score were excluded from analysis. RESULTS: Out of 130 residents, 103 (79.2%) completed at least 1 fuel gauge assessment with a weekly mean response rate of 41.5%. Low scores were submitted by 39.8% of resident participants. Narrative feedback was provided in 6.2% of submissions with increased length associated with decreased fuel gauge score. CONCLUSIONS: The fuel gauge was well accepted by a large general surgery program with no decline in participation rates over the study period. The tool provided residents with a direct line of communication with their program's administration, and a feasible way for the program director's office to monitor and identify residents who were struggling with regard to their well-being.