Internally versus externally trained residents and fellows hired as attendings at a large integrated healthcare system: a 20-year retrospective study.

BACKGROUND: There remains a question of whether graduates trained internally are different than those trained elsewhere. We examine the difference between physicians trained within our Graduate Medical Education (GME) programs versus physicians trained elsewhere. Our large integrated healthcare system is unique in addressing this objective due to its large physician labor hiring needs across different specialties of GME graduates. METHODS: A retrospective review was performed from Jan 2000 to August 2020 of Kaiser Permanente Southern California (KPSC) physicians hired: KPSC GME trained versus non-KPSC GME trained. We examined five variables: retention, leadership (current or historical), physician relations cases, member appraisal of physician and provider services survey (MAPPS) scores, and rate of board certification. Chi-square test of proportions was used for comparison, p < 0.05 was significant. RESULTS: From Jan 2000 to August 2020, 2940 residents and fellows graduated from KPSC GME programs, of which 1127 (38%) were hired on at KPSC as full time attendings. Across all five metrics (Retention 82% vs 76% (p = < 0.01), Leadership [current 13% vs 10% (p = < 0.01)or historical 17% vs 14% (p = 0.01)], Physician Relations 23% vs 26% (p = 0.04), MAPPS 75% vs 69% (p = < 0.01), and Board Certification 81% vs 74% (p = < 0.01)), KPSC outperformed non-KPSC GME-trained physicians to a statistically significant degree. CONCLUSIONS: We have shown that an internally sponsored GME program can represent an opportunity for recruitment of physicians that may have higher retention rates, higher probability of being physician leaders, decreased likelihood of physician relations issues, improved patient satisfaction, and increased rates of board certification.

Gallbladder Polyps: Real or Imagined?

The finding of gallbladder polyps on imaging studies prompts further workup. Imaging results are often discordant with final pathology. The goal of this study is to compare polypoid lesions of the gallbladder found on preoperative ultrasound (US) with final pathologic diagnosis after cholecystectomy to help guide clinical decision-making. A retrospective study was conducted identifying adult patients who were diagnosed with polyps via US and who underwent cholecystectomy from 2008 through 2015. Imaging data, final pathology, and demographics were manually reviewed. A total of 2290 cholecystectomy patients had US-based polyps. Of these, 1661 patients (73%) did not have polyps on final pathology; primarily, stones or sludge were identified. Adenomyosis was diagnosed in 61 patients (2.7%). A total of 556 patients (24.2%) had pathologic polypoid lesions with the following breakdown: 463 (20.2%) cholesterol polyps, 43 other benign polyps (1.8%), 40 adenomas (1.7%), and 10 adenocarcinomas (0.4%). All patients with adenocarcinoma were older than 40 years and 91 per cent had US findings of polyps >10 mm. Ultrasound alone is an unreliable method of detecting real gallbladder polyps. This large database study found a very low risk of cancer. Size on US and patient age should be considered in the selection of appropriate surgical candidates with sonographic "polyps."

Small Bowel Obstructions in a Virgin Abdomen: Is an Operation Mandatory?

Though conventionally not considered standard of care, nonoperative management of patients with small bowel obstruction (SBO) without previous abdominal operations, so called "virgin abdomens," (VA) is presently being practiced. We aimed to determine outcomes of patients with VA undergoing operative and nonoperative management of SBO. A retrospective review of patients with SBO was performed; outcomes of patients with VA were analyzed. SBO with a VA was found in 103 patients over a 5-year period. With a mean follow-up of 4.5 years, nonoperative management was associated with successful resolution of obstruction in 61 per cent (63/103) of patients. Of those managed nonoperatively, 58/63 (92.1%) did not experience a recurrence. Of the 21 patients with a complete/high-grade SBO on imaging, 16 (76.2%) were managed operatively. Of the 64 patients with a partial/low-grade obstruction or partial obstruction/ileus on imaging, 53 (82.8%) were managed nonoperatively. These data suggest that selected patients with SBO and a VA may safely undergo nonoperative management under close surgical monitoring.

A decade of selective use of adjustable cutting seton combined with fistulotomy for anal fistula.

Previous studies have demonstrated that the division of sphincter muscle in the treatment of anal fistula may precipitate fecal incontinence. Cutting setons may pose a particular risk of unrecoverable injury to the sphincter apparatus. To evaluate if the use of an adjustable cutting seton mitigates this risk, we performed a retrospective review of all patients operated on for anal fistulae in a 10-year period by a single surgeon. Adjustable cutting setons (consisting of heavy silk ligature with patient-controllable tension) were used selectively. Forty-seven patients met the study criteria. Ninety-four per cent of the fistulae treated were transsphincteric. All of the fistulae were treated with at least partial fistulotomy. Ninety-nine per cent of patients were followed to completion of treatment. One (2%) patient subsequently developed fecal incontinence, and four (9%) developed a recurrent or persistent fistula in the same location. Adjustable cutting setons have been used in our practice with a high success rate and low risk of complications. Our data support adjustable cutting setons as a useful tool in the surgeon's repertoire for treating fistulae that involve the anal sphincter complex.

Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study.

BACKGROUND: We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents. DESIGN: Retrospective review. SETTING: Seventeen general surgery training programs in the western United States. PARTICIPANTS: Six hundred seven residents who graduated in 2000-2007. MAIN OUTCOME MEASURES: First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research. RESULTS: The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]). CONCLUSIONS: Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Views of surgery program directors on the current ACGME and proposed IOM duty-hour standards.

PURPOSE: The purpose of this study was to survey the experiences of surgery program directors with the current Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards and views of the Institute of Medicine (IOM) proposed duty-hour recommendations. METHODS: A total of 118 program directors (47.6% of all surgery programs in the US) responded to the survey. RESULTS: Results showed that the current duty-hour standards have hindered clinical education opportunities by reducing or eliminating rotations on many services, didactic teaching conferences, and clinical bedside teaching opportunities. Additionally, patient safety has been compromised by frequent hand offs of care. Most IOM recommendations were perceived as extremely difficult or impossible to implement, with the exception of the moonlighting recommendation. The results indicated that adopting the IOM recommendations is not feasible given current workforce limitations, and most program directors supported maintaining the current duty-hour standards until such time as there is evidence-based outcomes research to direct change. CONCLUSIONS: The conclusion was that the current ACGME duty-hour standards have reduced teaching opportunities and narrowed the scope of training.

Operative strategy can reduce the incidence of major bile duct injury in laparoscopic cholecystectomy.

Major bile duct injury (BDI) rates remain in the range of 0.3 to 0.5 per cent for laparoscopic cholecystectomy (LC). The dominant surgical technique worldwide continues to be the "infundibular" technique of dissection that was popularized in the early 1990s. Proponents of the "critical view of safety" (CV) technique have suggested that most of these injuries are avoidable. The objective of our study was to determine whether routine use of the CV technique reduced the observed/expected single-institution rate of major BDI over a 5-year period in a teaching hospital. All patients (n = 3042) who underwent LC for any indication at one institution over a 60-month period were identified by database search. Major BDI was identified by Common Procedural Terminology codes indicating operative repair and confirmed by review of medical records. One patient sustained a transection-excision of the common duct requiring hepaticoduodenostomy. Based on published data, the observed BDI rate was one in nine to one in 15 of the expected rate. This represents an order-of-magnitude improvement in the safety of LC at a single institution where the majority of cases were performed by residents. We suggest that the "critical view" technique should be widely adopted.

Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis.

HYPOTHESIS: Early laparoscopic cholecystectomy (LC) results in a shorter length of stay and acceptable conversion and complication rates when compared with antibiotic therapy plus interval LC or percutaneous cholecystostomy in patients admitted to a surgical service because of acute cholecystitis. However, actual practice does not conform to current evidence. DESIGN: Retrospective cohort study. SETTING: Urban teaching hospital. METHODS: Data were abstracted from the medical records of all patients with acute cholecystitis admitted to the surgical service via the emergency department during 36 months (October 1, 2002, to September 30, 2005). Patients were divided into 5 groups on the basis of treatment received. Length of stay, duration of symptoms, major complications, and conversion rates were analyzed. RESULTS: Of 173 patients with acute cholecystitis, 71 (41%) underwent early LC. Of 102 patients treated with antibiotic therapy alone (59%), 57 were discharged; antibiotic therapy was unsuccessful in 45 patients. Of the patients in whom antibiotic therapy was unsuccessful, 26 underwent late LC and 19 underwent percutaneous cholecystostomy. Interval LC was eventually performed in 55 patients who did not undergo surgery during the index admission. Length of stay was significantly shorter in the early LC group compared with the interval LC group (P < .001). Conversion rates were not statistically different for the 3 LC groups (early LC, 5.6%; late LC, 11.5%; and interval LC, 9.1%). The only biliary complication occurred in the interval LC group. CONCLUSIONS: Early laparoscopic cholecystectomy resulted in a significantly reduced length of stay, no major complications, and no significant difference in conversion rates when compared with initial antibiotic treatment and interval LC. Despite these advantages, early LC is not the most common treatment for acute cholecystitis in practice.

Hospitalization for acute diverticulitis does not mandate routine elective colectomy.

BACKGROUND: Previous studies suggest that elective colectomy is often required after an episode of acute diverticulitis. HYPOTHESIS: Acute diverticulitis initially treated nonoperatively does not require elective colectomy. DESIGN: Retrospective cohort study. SETTING: Twelve Kaiser Permanente hospitals in Southern California. PATIENTS: Three thousand one hundred sixty-five patients with acute diverticulitis. INTERVENTIONS: Colectomy or nonoperative treatment with or without percutaneous abscess drainage. MAIN OUTCOME MEASURES: Recurrent diverticulitis. RESULTS: Emergency colectomy was performed in 614 patients (19.4%). Nonoperative treatment was initially used in 2551 patients (80.6%). Of these, 185 patients (7.3%) had an elective colectomy and the remaining 2366 patients (92.7%) did not. Factors associated with undergoing elective colectomy compared with nonoperative treatment were younger age of the patient, fewer comorbidities, and percutaneous abscess drainage. Mean follow-up was 8.9 years, with a maximum of 12 years. After nonoperative treatment, 314 patients (13.3%) recurred-222 patients had a single recurrence and 92 patients had a rerecurrence. After adjusting for other variables, older age (hazard ratio, >/=50 years vs <50 years = 0.68; 95% confidence interval, 0.53-0.87) was associated with a lower recurrence, whereas higher comorbidity was associated with higher recurrence. Gender and percutaneous abscess drainage had no influence on recurrence. All 92 rerecurrences were treated nonoperatively. The risk of a rerecurrence (29.3%) was significantly higher than a first recurrence (P<.001). Age, gender, Charlson comorbidity index, and percutaneous abscess drainage did not predict rerecurrence. CONCLUSIONS: Very few patients with acute diverticulitis treated nonoperatively have recurrence. Younger age was associated with recurrence. A first recurrence was the only factor that predicted rerecurrences. The low recurrence rate argues against routine elective colectomy after successful nonoperative management of acute diverticulitis.

Axillary dissection is not required for all patients with breast cancer and positive sentinel nodes.

HYPOTHESIS: Sentinel node (SN) biopsy for breast cancer enhances staging sensitivity, often demonstrating only micrometastases (<2 mm) or isolated, keratin-positive cells. When SN metastasis is present, the value of additional axillary dissection is unclear and not all patients benefit from axillary lymph node dissection (ALND). DESIGN: Prospective cohort study, median 32-month follow-up. SETTING: Multidisciplinary breast cancer centers. PATIENTS: Forty-six women having SN metastases diagnosed between May 1, 1996, and September 1, 2001, who refused ALND or were recommended to omit ALND owing to serious comorbid conditions. INTERVENTIONS: Isosulfan blue dye-directed SN biopsy. Axillary lymph node dissection was not performed. Standard breast irradiation was given. Adjuvant systemic therapy was provided as determined by an oncologist. Interval clinical evaluation was performed. MAIN OUTCOME MEASURE: Axillary and systemic failure rates. RESULTS: Mean patient age was 61.6 years (age range, 36-92 years). Mean tumor size was 1.65 cm (range, 0.4-5.5 cm). Thirty-five (76%) of 46 tumors were ductal carcinomas and 39 (87%) of 45 were estrogen receptor-positive. A mean of 2.6 SNs were identified (median, 2; range, 1-7). Thirty-nine patients (85%) had a single positive SN; the remaining 7 patients (15%) had 2 positive SNs. Seven patients (15%) had macrometastases (>2 mm); 16 (35%) had micrometastases (<2 mm); and 23 (50%) had cellular metastases. Only 16 positive SNs (35%) were seen on hematoxylin-eosin staining, while 30 SNs (65%) had positive immunohistochemical staining. There have been no axillary recurrences. One patient (2%) developed distant metastases during follow-up (range, 4-61 months). CONCLUSIONS: Patients with SN metastases who did not have ALND had a low incidence of regional failure. To confirm this observation, we suggest that patients with SN metastases are ideal candidates for trials evaluating the necessity of ALND.

Acute diverticulitis in the young adult is not "virulent.".

Acute diverticulitis historically has been considered rare before the age of 40 but "virulent" when it does occur and frequently requiring emergency operation. Recent experience suggests that the demographics and management of this disease are changing. Outcomes at Kaiser Permanente Los Angeles Medical Center were reviewed. Between January 1997 and July 2001 261 patients were discharged with the diagnosis of acute diverticulitis; 46 or 18 per cent of these were aged < or = 40. Patients' mean age was 35, 76 per cent were men, 65 per cent were Latino, and 72 per cent were obese (body mass index > or = 30 kg/m2). An operation at initial presentation was performed on 35 per cent (16/46) patients. Only 19 per cent of these (3/16) had a correct preoperative diagnosis. The 30 patients who were treated nonoperatively all were managed successfully; one required a percutaneous drain. Given the apparent increasing frequency of acute diverticulitis in young adults and the high success rate of initial nonoperative management surgeons should consider this diagnosis in selected patients who present with abdominal symptoms. Knowledge of typical clinical features and judicious use of computed tomography may decrease the number of unnecessary emergency operations in young adults with acute diverticulitis. Our data do not support a "virulent" label for this disease in the young.