Management of Incidental Thyroid Nodules.

Thyroid nodules are widely prevalent, and often discovered incidentally. Malignancy rates are low for incidental thyroid nodules, and overall outcomes are favorable regardless of diagnosis. Patients with thyroid nodules should be evaluated with TSH levels followed by ultrasound of the thyroid and cervical lymph nodes. It is important to recognize sonographic features suspicious for thyroid malignancy and obtain biopsies when indicated according to major society guidelines. The Bethesda System for Reporting Thyroid Cytopathology along with molecular testing can help guide management decisions regarding thyroid nodules. Surgical resection and other emerging technologies are safe and effective for the treatment of thyroid nodules needing intervention.

Physician-Targeted Interventions Reduce Surgical Expense and Improve Value-Driven Health Outcomes.

INTRODUCTION: Increasing health-care costs in the United States have not translated to superior outcomes in comparison to other developed countries. The implementation of physician-targeted interventions to reduce costs may improve value-driven health outcomes. This study aimed to evaluate the effectiveness of physician-targeted interventions to reduce surgical expenses and improve care for patients undergoing total thyroidectomies. METHODS: Two separate face-to-face interventions with individual surgeons focusing on surgical expenses associated with thyroidectomy were implemented in two surgical services (endocrine surgery and otolaryngology) by the surgical chair of each service in Jun 2016. The preintervention period was from Dec 2014 to Jun 2016 (19 mo, 352 operations). The postintervention period was from July 2016 to January 2018 (19 mo, 360 operations). Descriptive statistics were utilized, and differences-in-differences were conducted to compare the pre and postintervention outcomes including cost metrics (total costs, fixed costs, and variable costs per thyroidectomy) and clinical outcomes (30-d readmission rate, days to readmission, and total length of stay). RESULTS: Patient demographics and characteristics were comparable across pre- and post-intervention periods. Post-intervention, both costs and clinical outcomes demonstrated improvement or stability. Compared to otolaryngology, endocrine surgery achieved additional savings per surgery post-intervention: mean total costs by $607.84 (SD: 9.76; P < 0.0001), mean fixed costs by $220.21 (SD: 5.64; P < 0.0001), and mean variable costs by $387.82 (SD: 4.75; P < 0.0001). CONCLUSIONS: Physician-targeted interventions can be an effective tool for reducing cost and improving health outcomes. The effectiveness of interventions may differ based on specialty training. Future implementations should standardize these interventions for a critical evaluation of their impact on hospital costs and patient outcomes.

Assessment of lesbian, gay, bisexual, transgender, and questioning experiences within a large southeast training program.

The USA has become increasingly diverse resulting in greater strides to improve workforce diversity and inclusivity. The objective of this study is to compare the experiences of trainees in Graduate Medical Education who identify as Lesbian, Gay, Bisexual, Transgender or Questioning (LGBTQ) to the experiences of non-LGBTQ trainees within the medical workplace. We conducted a cross-sectional, exploratory survey from 1 December 2020 to 14 January 2021 at a single, large teaching institution. We collected data anonymously and stored it in a REDCap database. We excluded surveys in which trainees did not respond to sexual orientation. We used contingency tables and Fisher's exact test to identify outcomes associated with sexual orientation and gender identity particularly with regard to professionalism, well-being, and satisfaction with training. We distributed the survey to 840 trainees. 730 trainees were included (23 (3.2%) LGBTQ and 707 (96%) Straight). LGBTQ trainees were more likely to experience offensive remarks based on race/ethnicity (p = 0.03) and sexual orientation (p = 0.01). Secondary analysis based on race found that Blacks and Other were more likely to report differences based on professionalism and satisfaction with their training program. There was no difference seen among LGBTQ trainees based on race. We found trainees who identified as LGBTQ were more likely to experience discrimination/microaggressions. Also, racial and ethnic groups that are underrepresented in medicine were more likely to encounter discrimination and dissatisfaction with their training. More efforts are needed in academics to promote safe and supportive LGBTQ and minority training experiences.

Survival After Adrenalectomy for Metastatic Lung Cancer.

BACKGROUND: Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases. Although clinical use of adrenal metastasectomy has expanded, indications remain poorly defined. The aim of this study was to evaluate the clinical benefit of adrenal metastasectomy for all lung cancer subtypes. PATIENTS AND METHODS: We performed a retrospective cohort study of patients who underwent adrenal metastasectomy for metastatic lung cancer at six institutions between 2001 and 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Cox proportional hazards regressions and Kaplan-Meier survival analysis were performed. RESULTS: For 122 patients, the mean age was 60.5 years and 49.2% were female. Median time to detection of the metastasis was 11 months, and 41.8% were ipsilateral to the primary lung cancer. Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%). Factors associated with longer DFS included primary tumor resection [hazard ratio (HR): 0.001; p = 0.005], longer time to adrenal metastasis (HR: 0.94; p = 0.005), and ipsilateral metastases (HR: 0.13; p = 0.004). Shorter DFS corresponded with older age (HR: 1.11; p = 0.01), R1 resection (HR: 8.94; p = 0.01), adjuvant radiation (HR: 9.45; p = 0.02), and open adrenal metastasectomy (HR: 10.0; p = 0.03). Median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). Longer OS was associated with ipsilateral metastasis (HR: 0.55; p = 0.02) and adjuvant chemotherapy (HR: 0.35; p = 0.02). Shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52; p = 0.007), small cell histology (HR: 15.0; p = 0.04), and lung radiation (HR: 3.37; p = 0.002). DISCUSSION: Durable survival was observed in patients undergoing adrenal metastasectomy and should be considered for isolated adrenal metastases of NSCLC. Small cell histology and extra-adrenal metastases are relative contraindications to adrenal metastasectomy.

Adrenalectomy for Secondary Malignancy: Patients, Outcomes, and Indications.

OBJECTIVE: The goal of this study was to examine a multi-institutional experience with adrenal metastases to describe survival outcomes and identify subpopulations who benefit from adrenal metastasectomy. BACKGROUND: Adrenalectomy for metastatic disease is well-described, although indications and outcomes are incompletely defined. METHODS: A retrospective cohort study was performed of patients undergoing adrenalectomy for secondary malignancy (2002-2015) at 6 institutions. The primary outcomes were disease free survival (DFS) and overall survival (OS). Analysis methods included Kaplan-Meier and Cox proportional hazards. RESULTS: Of 269 patients, mean age was 60.1 years; 50% were male. The most common primary malignancies were lung (n = 125, 47%), renal cell (n = 38, 14%), melanoma (n = 33, 12%), sarcoma (n = 18, 7%), and colorectal (n = 12, 5%). The median time to detection of adrenal metastasis after initial diagnosis of the primary tumor was 17 months (interquartile range: 6-41). Post-adrenalectomy, the median DFS was 18 months (1-year DFS: 54%, 5-year DFS: 31%). On multivariable analysis, lung primary was associated with longer DFS [hazard ratio (HR): 0.49, P = 0.008). Extra-adrenal oligometastatic disease at initial presentation (HR: 1.84, P = 0.016), larger tumor size (HR: 1.07, P = 0.013), chemotherapy as treatment of the primary tumor (HR: 2.07 P = 0.027) and adjuvant chemotherapy (HR: 1.95, P = 0.009) were associated with shorter DFS. Median OS was 53 months (1-year OS: 83%, 5-year OS: 43%). On multivariable analysis, extra-adrenal oligometastatic disease at adrenalectomy (HR: 1.74, P = 0.031), and incomplete resection of adrenal metastasis (R1 margins; HR: 1.62, P = 0.034; R2 margins; HR: 5.45, P = 0.002) were associated with shorter OS. CONCLUSIONS: Durable survival is observed in patients undergoing adrenal metastasectomy and should be considered for subjects with isolated adrenal metastases.

Single Gland, Ectopic Location: Adenomas are Common Causes of Primary Hyperparathyroidism in Children and Adolescents.

BACKGROUND: Primary hyperparathyroidism (PHPT) in children and adolescents is uncommon. Data-driven guidelines for management in pediatric patients are limited. METHODS: We performed a retrospective cohort analysis of all patients (1997-2017) with PHPT ≤ 21 years of age who underwent parathyroidectomy at three institutions. Clinical and demographic variables were analyzed. Primary operative outcome was cure (normocalcemia > 6 months after surgery); secondary outcome was operative success (intraoperative parathyroid hormone decrease of ≥ 50%). RESULTS: We identified 86 patients with a median age of 17 years (IQR: 14, 19); 64% (n = 55) were female. The mean preoperative serum calcium was 11.7 mg/dL, median parathyroid hormone (PTH) was 110 pg/mL, and median urine calcium was 4.1 mg/kg/24 h. Preoperatively, sestamibi scan localized in 41/71 patients (58%); neck ultrasound localized in 19/44 (43%). The most common pathology at surgery was a single ectopic parathyroid adenoma in 71% (n = 61). A high incidence of ectopic adenomas (25%, n = 22) was observed, most commonly intrathymic (n = 13), followed by tracheoesophageal groove (n = 5), carotid sheath (n = 2), and intrathyroidal (n = 2). Of 56 patients with retrievable data > 6 months postoperatively, cure was achieved in 55 of 56 patients (98%). One patient who presented to us with parathyromatosis require subsequent reoperation. CONCLUSION: In this multi-institutional series of PHPT in children and adolescents, the majority were sporadic PHPT and were due to a single adenoma. We observed a high incidence of ectopic parathyroid adenomas, most commonly intrathymic. Given the high risk for ectopic adenoma in pediatric patients, parathyroid surgery in children and adolescents should be performed by experienced surgeons.

Gender and Racial Disparities in Survival After Surgery Among Papillary and Patients With Follicular Thyroid Cancer: A 45-Year Experience.

BACKGROUND: Demographic disparities have been described for survival after thyroid cancer surgery using national registries and databases. At the institution level, we hypothesized that assessing survival after thyroid cancer surgery in a long-term cohort with diverse gender and racial groups would reveal disparities in survival. METHODS: We examined medical records of patients with papillary or follicular thyroid cancer undergoing thyroidectomy, lobectomy, and other surgical procedures from 1971 to 2016 at a tertiary referral center. We obtained information on demographics, cancer stage, procedure, and radioactive iodine (RAI). We measured survival using Kaplan-Meier estimates and Cox proportional hazards models. RESULTS: A total of 1440 (91%) patients with papillary cancer and 144 (9%) patients with follicular thyroid cancer underwent total thyroidectomy (1297, 82%), lobectomy (261, 16.5%), and other surgical procedures (26, 1.5%). Most patients (1131, 71%) were woman, and 909 (57%) were older than 45 years. Race/ethnicity included 805 (51%) white, 161 (10%) African Americans, and 618 (39%) other race/ethnicities. Both 10- and 20-year survival rates in nonwhite males were worse compared with nonwhite females (P < .0001). After controlling for age, cancer type, stage, surgical procedure, RAI, and year of surgery, nonwhite males had a higher mortality risk compared with nonwhite females (P = .0376, confidence interval (CI): 1.03-2.43), white males (P < .0001, CI: 1.88-6.54), and white females (P < .0001, CI: 3.31-9.90). CONCLUSIONS: Our diverse cohort demonstrates significant gender and racial disparities in survival after thyroid cancer surgery. To improve health outcomes and reduce health disparities among nonwhite males, interventions and long-term care management should target potentially modifiable causes of worse outcomes in this group.

Effect of Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP) on Malignancy Rates in Thyroid Nodules: How to Counsel Patients on Extent of Surgery.

PURPOSE: To investigate the impact of the nomenclature change to "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) on reported malignancy rates following thyroidectomy. METHODS: Retrospective cohort study of patients with thyroid nodules sampled preoperatively with fine-needle aspiration (FNA) and subsequently removed at one tertiary-care hospital from 4/2016 to 2/2017. Surgical procedure, anatomic pathology, thyroid cytopathology classification, and demographic characteristics were recorded. RESULTS: Thyroidectomy was performed in 353 patients. Twenty-six patients (7.3%) had NIFTP on anatomic pathology. Preoperative FNA demonstrated atypia of undetermined significance (AUS/Bethesda III) in 13 (50%), suspicious for malignancy (SUS/Bethesda V) in 6 (23%), suspicious for follicular neoplasm (SFN/Bethesda IV) in 4 (15%), benign/Bethesda I in 2 (8%), and malignant/Bethesda VI in 1 (4%). Invasive malignancy rates across cytologic categories changed as follows: benign (n = 74) from 4 to 1%, AUS (n = 85) from 33 to 18% (p < 0.05), SFN (n = 58) from 29 to 22%, SUS (n = 33) from 91 to 73% (p < 0.05), and malignant (n = 99) from 99 to 98%. Overall decrease in invasive malignancy was 7.3% for the entire population and 13.1% for indeterminate preoperative FNA cytology (Bethesda III-V). Among 26 NIFTP patients, 17 had thyroid lobectomy (TL) and 9 underwent total thyroidectomy (TT). Eight of the nine patients with TT could have been definitively treated with TL, an 89% decrease. CONCLUSIONS: The NIFTP nomenclature change led to an overall decrease in the malignancy rate at our institution, especially for Bethesda III-V categories. Patients may be counseled toward more conservative surgical options if NIFTP is in the differential.

Is Frozen-Section Analysis During Thyroid Operation Useful in the Era of Molecular Testing?

BACKGROUND: With the increased use of molecular testing of thyroid fine-needle biopsies, the frequency and extent of thyroid resection for thyroid nodules has changed. Although the role of frozen-section analysis of the thyroid has been reduced markedly in recent years, many surgeons still routinely use it intraoperatively. We sought to determine the utility of frozen section during thyroidectomy in the era of molecular testing. STUDY DESIGN: We reviewed 236 consecutive patients who had thyroidectomy with intraoperative frozen-section analysis at our institution between November 2015 and October 2017. We re-reviewed the preoperative diagnosis, frozen-section diagnosis, final pathology, and whether operative management changed from the initial plan based on frozen section. RESULTS: Mean age of the patients was 55.6 ± 14.1 years, and 83% were female. Of the 236 patients, frozen section did not change the intraoperative management in 225 (95%). Of the 11 patients whose thyroid operation was modified, the operation was either too much or not enough in 6 patients. In only 5 (2.1%) patients, frozen-section analysis correctly changed the extent of thyroidectomy. CONCLUSIONS: Thyroid frozen-section analysis adds cost and time to thyroid operations without notable benefit. In our cohort, only 2.1% of frozen sections accurately changed intraoperative management. We recommend against its routine use.

Hyperthyroidism is Underdiagnosed and Undertreated in 3336 Patients: An Opportunity for Improvement and Intervention.

OBJECTIVE: The aim of this study was to determine the prevalence of undiagnosed and untreated hyperthyroidism among patients with suppressed thyroid-stimulating hormone (TSH). BACKGROUND: Hyperthyroidism can significantly diminish patient quality of life and increase the financial burden on patients and health systems. We hypothesized that many patients with hyperthyroidism remain undiagnosed because physicians fail to recognize and evaluate suppressed TSH as the first indication of disease. METHODS: We reviewed administrative data on 174011 patients with TSH measured at a tertiary referral center between 2011 and 2017 to identify individuals with hyperthyroidism (TSH <0.05 mU/L) and their subsequent outcomes: evaluation (measurement of T4, T3, radioactive iodine (RAI) uptake scan, thyroid-stimulating immunoglobulin, thyroid peroxidase antibodies) diagnosis, referral and treatment. We used Kaplan-Meier methods and multivariable time-related parametric hazard modeling to measure our outcomes. RESULTS: We found 3336 patients with hyperthyroidism. The mean age of our cohort was 52 ±â€Š17 years, with 79% females and 59% whites. Only 1088 patients (33%) received any appropriate evaluation and hyperthyroidism remained undiagnosed in 37% of patients who had the appropriate workup. Among those diagnosed with hyperthyroidism, only 21% were referred for surgery and 34% received RAI. Predictors for hyperthyroidism diagnosis include lower TSH (0.01u/L), younger age, African-American race, private commercial insurance, being seen in an outpatient setting, absence of medical comorbidities, presentation with ophthalmopathy, or weight loss. CONCLUSIONS: Hyperthyroidism is frequently unrecognized and untreated, which can lead to adverse outcomes and increased costs. Improved systems for detection and treatment of hyperthyroidism are needed to address this gap in care.

Reducing cost and improving operating room efficiency: examination of surgical instrument processing.

BACKGROUND: Operating room efficiency can be compromised because of surgical instrument processing delays. We observed that many instruments in a standardized tray were not routinely used during thyroid and parathyroid surgery at our institution. Our objective was to create a streamlined instrument tray to optimize operative efficiency and cost. MATERIALS AND METHODS: Head and neck surgical instrument trays were evaluated by operating room team leaders. Instruments were identified as either necessary or unnecessary based on use during thyroidectomies and parathyroidectomies. The operating room preparation time, tray weights, number of trays, and number of instruments were recorded for the original and new surgical trays. Cost savings were calculated using estimated reprocessing cost of $0.51 per instrument. RESULTS: Three of 13 head and neck trays were converted to thyroidectomy and parathyroidectomy trays. The starting head and neck surgical set was reduced from two trays with 98 total instruments to one tray with 36 instruments. Tray weight decreased from 27 pounds to 10 pounds. Tray preparation time decreased from 8 min to 3 min. The new tray saved $31.62 ($49.98 to $18.36) per operation in reprocessing costs. Projected annual savings with hospitalwide implementation is over $28,000.00 for instrument processing alone. Unmeasured hospital savings include decreased instrument wear and replacement frequency, quicker operating room setup, and decreased decontamination costs. CONCLUSIONS: Optimizing surgical trays can reduce cost, physical strain, preparation time, decontamination time, and processing times, and streamlining trays is an effective strategy for hospitals to reduce costs and increase operating room efficiency.

Impact of near-peer teaching rounds on student satisfaction in the basic surgical clerkship.

BACKGROUND: Teaching rounds are rarely featured in the surgery clerkship. Senior students interested in surgery are suited to precept teaching rounds. Near-peer teaching can provide benefits to both learners and preceptors. METHODS: Near-peer teaching rounds consisted of senior student-precetors leading groups of 3 clerkship students on teaching rounds once during the clerkship. We prospectively surveyed student satisfaction before and after instituting near-peer teaching rounds. We retrospectively gathered qualitative narratives from student-preceptors. RESULTS: The survey response rate was 93% before near-peer teaching rounds were instituted and 85% after. Satisfaction with the learning environment and the quality and amount of small-group teaching were significantly higher after the institution of near-peer teaching rounds (P ≤ .001 for all 3). Satisfaction with the overall clerkship and baseline interest in surgery were not significantly different. Student-preceptors reported gaining valuable experience for future roles in academia as residents and attending surgeons. CONCLUSIONS: Student satisfaction with small-group teaching and the learning environment increased after the institution of near-peer teaching rounds in the surgery clerkship. Student-preceptors gained early experience for careers in academic surgery.

Graduating Students' and Surgery Program Directors' Views of the Association of American Medical Colleges Core Entrustable Professional Activities for Entering Residency: Where are the Gaps?

OBJECTIVE: Residency program directors have increasingly expressed concern about the preparedness of some medical school graduates for residency training. The Association of American Medical Colleges recently defined 13 core entrustable professional activities (EPAs) for entering residency that residents should be able to perform without direct supervision on the first day of training. It is not known how students' perception of their competency with these activities compares with that of surgery program directors'. DESIGN: Cross-sectional survey. SETTING: All surgery training programs in the United States. PARTICIPANTS: All program directors (PDs) in the Association of Program Directors in Surgery (APDS) database (n = 222) were invited to participate in an electronic survey, and 119 complete responses were received (53.6%). Among the respondents, 83% were men and 35.2% represented community hospital programs. PDs' responses were compared with questions asking students to rate their confidence in performance of each EPA from the Association of American Medical Colleges Graduation Questionnaire (95% response). RESULTS: PDs rated their confidence in residents' performance without direct supervision for every EPA significantly lower when compared with the rating by graduating students. Although PDs' ratings continued to be lower than students' ratings, PDs from academic programs (those associated with a medical school) gave higher ratings than those from community programs. PDs generally ranked all 13 EPAs as important to being a trustworthy physician. PDs from programs without preliminary residents gave higher ratings for confidence with EPA performance as compared with PDs with preliminary residents. Among PDs with preliminary residents, there were equal numbers of those who agreed and those who disagreed that there are no identifiable differences between categorical and preliminary residents (42.7% and 41.8%, respectively). CONCLUSIONS: A large gap exists between confidence in performance of the 13 core EPAs for entering residency without direct supervision for graduating medical students and surgery program directors. Both the groups identified several key areas for improvement that may be addressed by medical school curricular interventions or expanding surgical boot camps in hopes to improve resident performance and patient safety.

A blended online curriculum in the basic surgery clerkship: a pilot study.

BACKGROUND: A "lectures plus clinical experiences" curriculum for surgical clerkships has significant faculty demand. A less faculty-intense blended online curriculum (BOC) could provide similar/improved academic performance compared with traditional curricula (TCs). METHODS: Following an initial pilot study, students in the surgery clerkship at Johns Hopkins during 2013 to 2014 experienced a BOC (n = 129). Students the preceding year (2012 to 2013) experienced the TC (n = 108). Performance and satisfaction were compared between groups using clinical evaluations, National Board of Medical Examiners examination scores, and clerkship evaluations. RESULTS: No significant differences in academic performance between BOC and TC students were observed on National Board of Medical Examiners examination or clinical evaluation scores. After multivariable adjustment, student year was the only significant predictor of student performance. Clerkship teaching ratings were higher for BOC students than TC students (4.25/5 vs 3.98/5, P = .03). CONCLUSIONS: BOC incorporation in the basic surgery clerkship resulted in noninferior academic outcomes and significantly improved student satisfaction.

Lower vitamin D levels in surgical hyperparathyroidism versus thyroid patients.

Low vitamin D levels have been shown to be associated with primary hyperparathyroidism, but it is unclear whether vitamin D deficiency may be an etiologic factor in the development of primary hyperparathyroidism. To investigate this, we compared preoperative vitamin D levels of patients undergoing surgery for primary hyperparathyroidism with those of patients undergoing surgery for benign thyroid disease. With Institutional Review Board approval, data were collected prospectively on patients undergoing parathyroidectomy or thyroidectomy by one surgeon between March 2006 and July 2011. Patients were excluded if they underwent simultaneous thyroid and parathyroid surgery, had secondary or tertiary hyperparathyroidism, if no preoperative vitamin D level was measured, or if they took vitamin D supplements. Inclusion criteria were met by 219 patients who underwent parathyroidectomy and 186 patients who underwent thyroid surgery. Patient age, sex, race, and preoperative vitamin D levels (vitamin D 25-OH; normal, 32 to 100 pg/mL) were collected. Statistical analysis was performed using linear regression. Vitamin D levels were significantly lower in the parathyroid group compared with the thyroid group (23.8 vs 28.5 pg/mL; P < 0.001). This difference was also observed after adjustment for age, sex, and race with a mean difference of 4.87 pg/mL (P < 0.001). Statistically significant associations between lower vitamin D levels and patients younger than 50 years (P = 0.048), male sex (P = 0.03), and nonwhite race were identified (P < 0.001). Patients with primary hyperparathyroidism are more likely to have lower vitamin D levels than a control surgical population. Further study is needed to determine whether low vitamin D levels may be an etiologic factor associated with the development of hyperparathyroidism.

Duty hours and perceived competence in surgery: are interns ready?

BACKGROUND: A fundamental shift in the structure of many surgical training programs has occurred after the July 2011 rule changes. Our intern didactic program was intensified in 2011 with targeted lectures, laboratories, and clinical cases as well as direct supervision until competency was achieved for basic clinical problems. We sought to compare interns' perceived preparedness throughout and at the end of the academic years before and after July 2011. MATERIALS AND METHODS: Intern perceptions of preparedness to manage common clinical scenarios and perform procedures in general surgery were serially surveyed in academic years ending in 2011 and 2012 based on the Residency Review Committee supervision guidelines. RESULTS: Interns felt less prepared across all measured domains from 2011-2012. Interns felt significantly less prepared to manage hypotension (3.00/4 points to 2.67/4 points; P=0.04), place a tube thoracostomy (2.45/4 points to 1.92/4 points; P=0.04), or perform an inguinal hernia repair (1.91/4 points to 0.92/4 points; P=0.01) without supervision. Interns were also significantly less likely to agree that they were able to gain clinical skills based on experience (4.31/5 points versus 4.15/5 points; P=0.02). Longitudinal analysis throughout internship demonstrated improved preparedness to manage common clinical problems and perform procedures between the second and the fifth months of internship. CONCLUSIONS: First-year residents after July 2011 felt less prepared in the topics surveyed than those before July 2011. Interns made the greatest gains in preparedness between months 2 and 5, suggesting that despite planned interventions, no substitute currently exists for actual clinical experience. Planned educational interventions to improve intern preparedness are also indicated.

Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after July 2011.

OBJECTIVES: Resident duty-hour regulatory changes in July 2011 led to dramatic modifications in the structure of many surgical training programs in the United States. These changes were hypothesized to have effects on the quality of life and education of residents, and the patient care they deliver. Our study aims to measure changes in these domains among junior and senior residents before and after implementation of the latest regulations. DESIGN: Longitudinal cohort study comparing objective and subjective metrics of education, patient care, and quality of life among all surgical residents at one institution. SETTING: Tertiary academic medical center. PARTICIPANTS: All residents in the Department of Surgery over 2 years (n = 97) were included. The included electronic survey had 30 and 36 responses in 2011 and 2012, respectively (overall 68% response rate). RESULTS: Operative cases increased for residents at all postgraduate year levels. No significant differences in in-training examination scores were observed. Comparison of subjective data from the program evaluation and developed survey revealed a significant decrease in perception of resident clinical skill development (4.31/5 in 2011 to 4.15/5 in 2012, p = 0.02). Residents reported decreased quality of operative experiences (83% to 59%, p = 0.04), and less independence evaluating patient problems (90% to 61%, p < 0.01). Levels of burnout were high in the entire group, but decreased significantly over the study period (93% and 75% in 2011 and 2012, respectively, p = 0.05), with the largest difference seen in individuals with "high burnout" (43% and 11%, in 2011 and 2012, respectively, p < 0.01). Residents met criteria for "sleepiness" before and after the 16-hour rule implementation (68% and 67%, in 2011 and 2012, respectively, p = 0.92). CONCLUSIONS: Following the July 2011 duty-hour changes, surgical residents report a negative effect on their education, with decreased clinical skill progression and perceptions of operative experience quality and patient care independence. Improvements in quality of life metrics, including burnout, were observed.

Medical student subinternships in surgery: characterization and needs assessment.

BACKGROUND: Medical students commonly enroll in courses known as "subinternships" before residency application. This study investigated the experiences and needs of students completing subinternships in surgery. METHODS: Electronic surveys were sent to medical students applying to the surgery residency program at our institution and to medical student clerkship directors for distribution nationally. Approximately 700 surveys were distributed with 275 completed (39%). RESULTS: Sixty-one percent of respondents indicated subinternships influenced specialty choice, and 82% of this group applied in general surgery. General surgery applicants rated mentorship (93%) and clerkship experience (92%) as important factors for specialty choice. Technical skills education was rated as beneficial by 89% of respondents, but formal laboratories were included only in 21% of courses. Only 49% received course objectives, and less than 10% were given a reading schedule. CONCLUSIONS: Opportunity exists to define a curriculum for surgical subinternships in order to address student needs for specific didactics for residency preparation and technical skill enhancement.