Teaching Before, During, and After a Surgical Resuscitation.

Teaching during a surgical resuscitation can be difficult due to the infrequency of these events. Furthermore, when these events do occur, the trainee can experience cognitive overload and an overwhelming amount of stress, thereby impairing the learning process. The emergent nature of these scenarios can make it difficult for the surgical educator to adequately teach. Repeated exposure through simulation, role play, and "war games" are great adjuncts to teaching and preparation before crisis. However, surgical educators can further enhance the knowledge of their trainees during these scenarios by using tactics such as talking out loud, targeted teaching, and debriefing.

Open in Case of SOAP Emergency: Preparation for and Recovery after Failing to Match.

Failing to secure an internship is an extremely stressful event. In this manuscript we describe a process to prepare students for success, should they fail to match. This process involves an assessment of individual vulnerability, implementing mitigation strategies, developing a comprehensive plan in the event of failing to match, that is executed if the student needs to enter the Supplemental Offer Acceptance Program (SOAP) or the "scramble".

Visual Misrepresentations: The Lack of Skin Tone and Sex Equity in General Surgical Textbooks.

OBJECTIVE: Lack of racial and ethnic diversity in educational material contributes to health disparities. This study sought to determine if images of skin color and sex in general surgery textbooks were reflective of the U.S. DESIGN: All human figures with discernable sex characteristics and/or skin tone were evaluated independently by 4 coders. Each image was categorized as male or female. Skin tone in each image was categorized using the Massey- Martin skin color scale. This data was compared to 2020 U.S. Census Data. SETTING: U.S. Medical School. PARTICIPANTS: Not applicable. RESULTS: A total of 1179 images were evaluated for skin tone alone; 293 images for sex alone. 650 images depicted characteristics of both sex and skin tone. Interrater reliability was 0.78 for skin tone and 0.91 for sex. While the U.S. population is 59.3% white, 29.5% non-black persons of color and 13.6% black, in surgical textbooks, 90.7% of images were white, 6.5% were non-black persons of color, and 2.8% were black. Distribution of skin tone for all textbooks were significantly different. (p < 0.001) compared to the U.S. POPULATION: The U.S. population is 49.5% male and 50.5% female. When images of sex specific genitalia and breasts are excluded, surgical textbook images are 62.9% male and 37.1% female. Only 1 textbook had a distribution of sex that was similar to the U.S. CONCLUSIONS: Despite increasing diversity in the U.S. population there is a lack of skin tone and sex diversity in traditional surgical textbooks.

A Primer on General Surgery Applicants Who Have Graduated From Indian Medical Schools.

Background: Graduates of Indian medical schools account for the greatest proportion of non-US born international medical graduates applying to general surgery residency programs.Purpose: Provide information to facilitate fair and holistic review of applicants from Indian medical schools.Research Design: Comprehensive review of the Indian medical education system, including history, regulatory agencies, medical school admission, curriculum, cultural differences, immigration issues, and outcomes after residency.Results: The Indian medical education system is one of the world's oldest. The number of medical schools and graduates continues to increase. Medical school admission criteria are variable. Recent regulatory changes have improved the quality of applicants entering the US. Emphasis on academic performance over volunteerism as well as communication styles differ from US graduates. The success of graduates during and after residency is well documented.Conclusions: Understanding the differences in the US and Indian medical education systems will provide a basis for the fair evaluation of applicants.

The COVID-19 Patient in the Surgical Intensive Care Unit.

COVID-19 continues to rampage around the world. Noncritical care-trained physicians may be deployed into the intensive care unit to manage these complex patients. Although COVID-19 is primarily a respiratory disease, it is also associated with significant pathology in the brain, heart, vasculature, lungs, gastrointestinal tract, and kidneys. This article provides an overview of COVID-19 using an organ-based, systematic approach.

The Biology and Psychology of Surgical Learning.

Surgical education requires proficiency with multiple types of learning to create capable surgeons. This article reviews a conceptual framework of learning that starts with the biological basis of learning and how neural networks encode memory. We then focus on how information can be absorbed, organized, and recalled, discussing concepts such as cognitive load, knowledge retrieval, and adult learning. Influences on memory and learning such as stress, sleep, and unconscious bias are explored. This overview of the biological and psychological aspects to learning provides a foundation for the articles to follow.

Promoting Access of Osteopathic Medical Students to Surgical Residency Training Programs.

The COVID-19 pandemic has uncovered disparities for allopathic and osteopathic surgical applicants for the upcoming 2021 residency application cycle. It has provided an opportunity for change to the current paradigm in surgical resident selection. This study seeks to quantify the disproportionality of opportunities between allopathic and osteopathic students and provides solutions to level the playing field for all applicants.

Surgical Trainees' Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal.

BACKGROUND: Surgeon educators express concern about trainees' sense of patient ownership. We aimed to compare resident and faculty perceptions on residents' sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics. METHODS: An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at seven academic surgery residencies across the United States. We modified an established psychological ownership scale to measure patient ownership among surgical trainees. RESULTS: Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 78.0% of faculty agreed that residents took personal responsibility for patient outcomes, but only 26.4% thought residents felt a similar or higher degree of patient ownership compared with themselves. Faculty underestimated the proportion of residents that routinely checked on their patients when off-duty (36.8 versus 92.6%, P < 0.001). Higher means on the patient ownership scale correlated with female sex (5.9 versus. 5.5 for males, P = 0.009), advanced post graduate year level (5.3, 5.5, 5.7, 5.8, 6.1, for post graduate year 1-5, respectively, P = 0.02), and the sense that patient outcomes affected the resident respondent's mood (5.8 versus 4.8 for those whose mood was not affected, P < 0.001). In addition, trainees who perceived better resident camaraderie (P = 0.004), faculty mentorship (P < 0.001), and that their program provided appropriate autonomy (P = 0.03) felt greater responsibility for patient outcomes. CONCLUSIONS: Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents' sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.

Now Arriving: Surgical Trainees From Generation Z.

OBJECTIVE: To provide an overview of the Generation Z, compare and contrast Generation Z with previous generations, and present information on how to best educate members of Generation Z. DESIGN: Literature review. SETTING: Not applicable. PARTICIPANTS: Not applicable. RESULTS: Historical events and societal trends as well as changes in parenting style has resulted in unique characteristics for Generation Z. The most significant influence on this generation has been the wide-spread use of the smart phone. While this device has great educational potential, it also presents a real risk with digital foot prints influencing residency selection and evolution of mental health problems. CONCLUSIONS: The characteristics of Generation Z such accountability, emphasis on achievement and dedication to long-term goals makes them different from previous generations.

Rapid Reversal of Novel Anticoagulant and Antiplatelet Medications in General Surgery Emergencies.

The reversal of the new class of nonvitamin K antagonist oral anticoagulants (NOACs) is challenging in the emergent perioperative setting. This summary focuses on the reversal of NOACs, determining the emergent nature (risk analysis), and other considerations in reversal.

Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method.

OBJECTIVE: Faculty teaching skills are critical for effective surgical education, however, which skills are most important to be taught in a faculty development program have not been well defined. The objective of this study was to identify priorities for faculty development as perceived by surgical educators. DESIGN: We used a modified Delphi methodology to assess faculty perceptions of the value of faculty development activities, best learning modalities, as well as barriers and priorities for faculty development. An expert panel developed the initial survey and distributed it to the membership of the Association of Program Directors in Surgery. Responses were reviewed by the expert panel and condensed to 3 key questions that were redistributed to the survey participants for final ranking. PARTICIPANTS: Seven experts reviewed responses to 8 questions by 110 participants. 35 participants determined the final ranking responses to 3 key questions. RESULTS: The top three priorities for faculty development were: 1) Resident assessment/evaluation and feedback 2) Coaching for faculty teaching, and 3) Improving intraoperative teaching skills. The top 3 learning modalities were: 1) Coaching 2) Interactive small group sessions, and 3) Video-based education. Barriers to implementing faculty development included time limitations, clinical workload, faculty interest, and financial support. CONCLUSIONS: Faculty development programs should focus on resident assessment methods, intraoperative and general faculty teaching skills using a combination of coaching, small group didactic and video-based education. Concerted efforts to recognize and financially reward the value of teaching and faculty development is required to support these endeavors and improve the learning environment for both residents and faculty.

The Cost of Compliance: The Financial Burden of Fulfilling Accreditation Council for Graduate Medical Education and American Board of Surgery Requirements.

OBJECTIVE: There has been a significant increase in the number of regulatory requirements for general surgery graduate medical education (GME) programs over the last 20 years from the governing bodies of the American Board of Surgery (ABS) and the Accreditation Council of Graduate Medical Education (ACGME). We endeavored to calculate the cost to general surgery GME programs of regulatory requirements. DESIGN: We examined the requirements for General Surgery ABS Certification as well as the 2017 ACGME Program Requirements in General Surgery for all mandates that require funding by the surgery program to achieve. The requirements requiring funding include certification in Advanced Cardiac Life Support, Advanced Trauma Life Support, Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery; access to medical references; simulation capability, program director protected time (30%); program coordinator salary (Association for Hospital Medical Education reported mean); and faculty time devoted to morbidity and mortality conference, journal club, Clinical Competency Committee, and Program Evaluation Committee. We then identified the cost of each mandate based on the average program in the United States of 5 residents per year in 5 clinical years. RESULTS: Total cost for the average program per year as the result of ABS or ACGME mandate equaled a minimum of $227,043. The ABS associated costs are $8900 per year. The ACGME associated costs are $218,143. The cost of program director and faculty time to meet the minimum ACGME requirements equaled $159,600. CONCLUSIONS: The most significant cost associated with mandates set forth by the ABS and ACGME are program director and faculty time devoted to resident education and evaluation. Recognition of this cost burden by institutions and policymakers for the allocation of funds is important to maintain strong general surgery GME programs.

The Fundamentals of Resident Dismissal.

Residents have the rights and responsibilities of both students and employees. Dismissal of a resident from a training program is traumatic and has lasting repercussions for the program director, the faculty, the dismissed resident, and the residency. A review of English language literature was performed using PUBMED and OVID databases, using the search terms, resident dismissal, resident termination, student dismissal, student and resident evaluation, legal aspects of education, and remediation. The references of each publication were also reviewed to identify additional appropriate citations. If the Just Cause threshold has been met, educators have the absolute discretion to evaluate academic and clinical performance. Legal opinion has stated that it is not necessary to wait until a patient is harmed to dismiss a resident. Evaluations should be standard and robust. Negative evaluations are not defamatory as the resident gave consent to be evaluated. Provided departmental and institutional polices have been followed, a resident can be dismissed without a formal hearing. Residencies are entitled to modify academic requirements and dismissal is not considered a breach of contract. Although there is anxiety regarding resident dismissal, the courts have uniformly supported faculty having this role. When indicated, failure to dismiss a resident also places the program director and the faculty at risk for educational malpractice.

"I got it on Ebay!": cost-effective approach to surgical skills laboratories.

BACKGROUND: Surgical education is witnessing a surge in the use of simulation. However, implementation of simulation is often cost-prohibitive. Online shopping offers a low budget alternative. The aim of this study was to implement cost-effective skills laboratories and analyze online versus manufacturers' prices to evaluate for savings. MATERIALS AND METHODS: Four skills laboratories were designed for the surgery clerkship from July 2014 to June 2015. Skills laboratories were implemented using hand-built simulation and instruments purchased online. Trademarked simulation was priced online and instruments priced from a manufacturer. Costs were compiled, and a descriptive cost analysis of online and manufacturers' prices was performed. Learners rated their level of satisfaction for all educational activities, and levels of satisfaction were compared. RESULTS: A total of 119 third-year medical students participated. Supply lists and costs were compiled for each laboratory. A descriptive cost analysis of online and manufacturers' prices showed online prices were substantially lower than manufacturers, with a per laboratory savings of: $1779.26 (suturing), $1752.52 (chest tube), $2448.52 (anastomosis), and $1891.64 (laparoscopic), resulting in a year 1 savings of $47,285. Mean student satisfaction scores for the skills laboratories were 4.32, with statistical significance compared to live lectures at 2.96 (P < 0.05) and small group activities at 3.67 (P < 0.05). CONCLUSIONS: A cost-effective approach for implementation of skills laboratories showed substantial savings. By using hand-built simulation boxes and online resources to purchase surgical equipment, surgical educators overcome financial obstacles limiting the use of simulation and provide learning opportunities that medical students perceive as beneficial.

The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care.

OBJECTIVE: To decipher if patient attitudes toward resident participation in their surgical care can be improved with patient education regarding resident roles, education, and responsibilities. DESIGN: An anonymous questionnaire was created and distributed in outpatient surgery clinics that had residents involved with patient care. In total, 3 groups of patients were surveyed, a control group and 2 intervention groups. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents. The first pamphlet used an analogy-based explanation. The second pamphlet used literature citations and statistics. SETTING: Keesler Medical Center, Keesler AFB, MS. University of Texas Health Science Center at San Antonio, San Antonio, TX. PARTICIPANTS: A total of 454 responses were collected and analyzed-211 in the control group, 118 in the analogy pamphlet group, and 125 in the statistics pamphlet group. RESULTS: Patients had favorable views of residents assisting with their surgical procedures, and the majority felt that outcomes were the same or better regardless of whether they read an informational pamphlet. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care. Further, 52% of patients in the control group agreed or strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% of the patients who read the analogy pamphlet and statistics pamphlet, respectively (p = 0.05). When we combined the 2 intervention groups compared to the control group, this significant difference persisted (p = 0.02). CONCLUSION: Most patients welcome resident participation in their surgical care, but they expect to be asked permission for resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently.