The Effects of Single Accreditation and Pass/Fail Licensing Exams on Osteopathic Medical Students Applying to Surgical Residency Programs.

OBJECTIVE: To examine the effects of single accreditation and pass/fail licensing exams on osteopathic (DO) medical students applying for surgical residency. DESIGN: Electronic surveys were distributed to 1509 program directors (PD) in 10 surgical specialties. PDs were separated into 2categories based on their program's accreditation status prior to single accreditation: formerly accredited by the American Osteopathic Association (AOA) or not accredited by the AOA. Separate chi-squared and binomial tests were used to determine statistical differences between PDs in each category and within each surgical specialty. SETTING: Voluntary, anonymous, electronic survey. PARTICIPANTS: Three hundred survey responses were received (response rate 19.8%) and 234 responses were included in statistical analyses. Sixty-six responses were excluded because the survey was incomplete, the survey was not completed by a PD, or the PD indicated disqualification of DO applicants from matching at that program. RESULTS: The majority of PDs in both categories recommend or require that DO students take both United States Medical Licensing Examination (USMLE) Step1 [Χ2 (2, N = 234) = 8.939, p = 0.011] and USMLE Step 2 CK [Χ2 (2, N = 234) = 4.161, p = 0.125] despite pass/fail outcomes only on Step 1 and Level 1. When deciding whom to interview, PDs in both categories highly ranked USMLE Step 2 CK scores and letters of recommendation (LOR). Formerly-AOA-accredited programs highly ranked COMLEX-USA Level 2 scores (p = < 0.001) and completion of an audition rotation (p = 0.001). Non-AOA-accredited programs highly ranked the Medical Student Performance Evaluation (MSPE) (p = < 0.001) and clerkship grades/evaluations (p = 0.001). CONCLUSIONS: Significant differences exist in programs despite single accreditation. DO applicants should take both USMLE Step 1 and Step 2 CK to be considered competitive for any surgical specialty. Additionally, DO students should prioritize formerly-AOA-accredited programs for audition rotations.

Comparison of Osteopathic (DO) and Allopathic (MD) Candidates Matching Into Selected Surgical Subspecialties.

Context Medical students and graduates apply for post-graduate year-one positions every year through the Single Accreditation System (SAS) National Residency Match Program (NRMP). New opportunities have arisen for osteopathic graduates through the transition to a single match. There is a paucity of information evaluating the effects of this single match on osteopathic (DO) and allopathic (MD) candidates in relation to match rates in competitive surgical sub-specialties such as neurosurgery, thoracic surgery, vascular surgery, otolaryngology (ENT), plastic surgery, orthopedic surgery, and general surgery. Objectives This paper utilizes published data to accomplish three tasks. Firstly, it investigates the effects of the SAS on DO and MD match rates in surgical subspecialties of neurosurgery, thoracic surgery, vascular surgery, ENT, plastic surgery, orthopedic surgery, and general surgery. Secondly, it investigates whether program director credentials and impressions correlate with the match rates of DO or MD candidates in each of these specialties. Finally, it discusses solutions for addressing ways to improve match outcomes for all candidates. Methods Previously published NRMP, National Matching Services, and Accreditation Council for Graduate Medical Education websites were queried for the number of DO and MD senior applicants for each position, match success rates, program director impressions, and program director credentials for the years 2018-2023. Match success rates were defined as a ratio of the number of candidates that applied to the number who successfully matched. Data were analyzed using descriptive statistics, chi-squared testing, student t-tests, and linear regression where appropriate. A p-value of less than 0.05 was considered significant. Results From 2020-2023, an increasing proportion of DO residents applied for the selected surgical subspecialties, increasing from 599 applicants in 2020 to 743 candidates in 2023. Overall match rates for DOs remain significantly lower than MD match rates for each of these specialties as well as overall (p-values all <0.05) with summative match rates of 52.89% for DOs compared to 73.61% for MDs in 2023 for the selected surgical subspecialties. From 2020 to 2023 match rates were 30.88% for DOs compared to 74.82% for MDs in neurosurgery, 16.67% versus 46.45% (DO vs MD) in thoracic surgery, 4.17% vs 68.84% (DO vs MD) in plastic surgery, 57.62% vs 73.18% (DO vs MD) in general surgery, 23.21% vs 74.18% (DO vs MD) in vascular surgery, 53.10% vs 72.57% (DO vs MD) for ENT, and 56.92% vs 72.51% (DO vs MD) for orthopedics. There was a statistically significant correlation between the proportion of DO program directors with the rate of DOs matching in the associated specialty (p=0.012). Conclusion There were significantly lower rates for DO candidates compared to MD candidates matching into selected surgical subspecialties of neurosurgery, thoracic surgery, vascular surgery, ENT, plastic surgery, orthopedic surgery, and general surgery. This may be addressed through increasing advocacy at local and national levels, improving mentorship, increasing DO medical student exposure to surgical subspecialties, and ensuring increasing selected surgical subspecialty involvement in teaching these diverse DO applicants in order to strengthen medicine and continue to address predicted growing physician shortages.

Non-operative Management of Sarcina ventriculi-Associated Severe Emphysematous Gastritis: A Case Report.

We report a case of a 64-year-old Jehovah's Witness male, who was post-operative day five of laparoscopic cholecystectomy. He presented with anemia, severe ischemic gastritis, and pneumatosis seen on CT with intravenous contrast. A subsequent upper endoscopy revealed patchy gastric ulceration with bleeding but no overt evidence of perforation. Biopsies were taken, and immunohistological staining identified Sarcina ventriculi. The patient was treated non-operatively with fluconazole and piperacillin-tazobactam for the infection and with sucralfate tablets and pantoprazole injections for ulcer treatment. After five days, a repeat CT scan revealed a resolved pneumatosis. S. ventriculi is a rare bacterium that is increasingly being reported as a cause of emphysematous gastritis with potentially fatal perforation. Surgical intervention should be reserved for unstable patients with perforations and significant, overt bleeding. In this case, non-operative treatment with antibiotics and proton pump inhibitor (PPI) medications were preferred in the setting of anemia in a Jehovah's Witness patient without perforation. The patient showed clinical and radiologic improvement. Further understanding of the role of surgical intervention versus non-operative management is needed for this rare and potentially life-threatening organism.

Bridging the Gap: How to Get Osteopathic Residents Into Fellowships.

Introduction The fellowship match process is convoluted, with each specialty having its match on its timeline- with some programs having a Post Graduate Year (PGY) 4th-year or 5th-year match. This study aims to identify tangible recommendations for osteopathic surgery residents to use to improve their applications and, ultimately, the success rate for matching into post-graduate fellowship training. Methods In October 2021, as a part of the American College of Osteopathic Surgeons (ACOS) Strategic Planning efforts, the ACOS Resident Student Section sent a questionnaire to the listed email contact for each surgical fellowship program. Fellowship coordinators and program directors were included in the survey. The programs that were included in the study were vascular, thoracic (which included cardiothoracic), surgical critical care, endocrine, hepatobiliary, transplant, pediatric, surgical oncology, breast, minimally invasive, and colorectal surgery. Results Of the 108 programs that answered the survey, 36% of them reported they currently had an osteopathic fellow, and another 29% said they had an osteopathic fellow in the past. 35% of the programs listed that they had never had an osteopathic fellow in their program. In regards to how residents can improve their application for fellowship matches the most common answer was research in the field, they were trying to match into. They wanted to see high scores on the United States Medical Licensing Examination (USMLE) and American Board of Surgery In-Training Examination (ABSITE) exams. They also noted that they wanted candidates from more well know residency programs, where they knew the residents would have gotten good training. Conclusion We recommend that any potential fellowship applicant focus on the following three areas increase competitiveness for matching into fellowship training: publication in the desired field, increased overall scholarly activity, and increased ABSITE scores.

Identifying Attitudes Toward and Acceptance of Osteopathic Graduates in Surgical Residency Programs in the Era of Single Accreditation: Results of the American College of Osteopathic Surgeons Medical Student Section Questionnaire of Program Directors.

Purpose The purpose of this study was to quantify the number of surgical programs currently training osteopathic residents and to solicit advice for current osteopathic medical students who are interested in pursuing a surgical residency.  Methods A questionnaire was sent to all listed Electronic Residency Application Service® (ERAS®) email contacts for the following specialties: General Surgery, Neurological Surgery, Orthopedic Surgery, Otolaryngology, Urology, Integrated Vascular Surgery, Integrated Plastic Surgery, and Integrated Thoracic Surgery. The questionnaire was sent a total of three times. Results Two hundred sixty-four of the 1,040 surgical residency programs responded to the questionnaire. Of these responses, 19% were formerly American Osteopathic Association (AOA) accredited programs. About 47.3% of responding programs indicated they are not currently training an osteopathic physician. One hundred thirteen programs provided additional comments on how osteopathic medical students may improve the competitiveness of their residency applications. These comments included increasing volumes of research activities, performing well on the United States Medical Licensing Exam (USMLE), and completing a sub-internship in the desired field or at a specific institution.  Conclusion Osteopathic students still face many barriers to matching into surgical residencies. This study provides concrete steps students may take to increase the competitiveness of their application.

The Effect of Single Accreditation on Medical Student Match Rates in Surgical Specialties.

Introduction The year 2020 marked the first year in which a match under single accreditation took place. Both osteopathic (DO) and allopathic (MD) students would participate in the first match cycle without a dedicated DO match system. Our primary objective was to investigate how single accreditation has impacted the DO applicants attempting to match into surgical specialties. Our secondary objective was to investigate the impact of single accreditation at the program director (PD) level and whether or not this process would see a change in DO PD distribution in previously American Osteopathic Association (AOA)-approved programs. Method Information on number of applicants and post-match positions was gathered from AOA and National Residency Match Program (NRMP) websites. Credentials of PDs were obtained from the Accreditation Council on Graduate Medical Education website. Based on the available data, the following surgical specialties were compared for the years 2020, 2018, and 2016: General Surgery, Neurological Surgery (NSGY), Orthopedic Surgery, Otolaryngology/ENT (ENT), Plastic Surgery, and Thoracic Surgery. Data from 2016 were not included in the results as the AOA match results analysis was insufficient and unable to be directly compared to the NRMP data. Results of matched DO and MD applicants were compared using bivariate analysis. A p-value of <0.05 was considered significant. Results From the year 2018 to 2020, the DO applicants saw a decrease of 3% in the total number of matched postgraduate year 1 spots in surgical specialties. NRMP results from 2020 saw that 51.7% of DO applicants matched and 67.7% (p < 0.001) of MD applicants matched for the specialties examined. Percent of matched:applied for DO applicants was lower than MD applicants in the fields of NSGY (p < 0.001), ENT (p < 0.001), Plastic Surgery (p < 0.001), General Surgery (p < 0.001), and Thoracic Surgery (p = 0.011). After evaluating 60 former AOA General Surgery programs, 56% were found to have MD as PD. Another 26 former AOA surgical programs were investigated, and 58% were found to have MD PD.  Conclusion Single accreditation has impacted the match process now that a large number of both MD and DO applicants are using the NRMP match system for postgraduate placement. Based on the available data, our results indicate that in the examined surgical specialties, there is a statistically significant difference in the number of MD and DO residents.

The benefit of negative pressure dressings in vascular surgery patients with infrainguinal incisions.

OBJECTIVE: Within the vascular patient population, there is an increased risk of developing wound complications especially in infrainguinal incisions. There has been increasing interest in using closed incisional negative pressure dressings to decrease the risk of wound complications. To assess the efficacy of these incisional wound dressings, we studied surgical site infections (SSI) and seroma rates of infrainguinal incisions in our vascular patient population. METHODS: This was a multi-institutional, retrospective study from July 2015 to June 2019. In 2017, our institution began using the Prevena incisional wound system. Wound complication rates were compared with the non-Prevena group before 2017. There were a total of 100 infrainguinal incisions (left and right combined) that received the Prevena wound system and 138 infrainguinal incisions that had not. The primary end point was to assess for wound complication rates, including SSIs and seroma formation. SSIs were graded based on the American College of Surgeons National Surgical Quality Improvement Plan SSI criteria. Seroma formation was diagnosed based on clinical diagnosis, imaging studies (ultrasound examination, computed tomography scan) or needle aspiration of fluid collection. RESULTS: This analysis showed a statistically significant decrease in the rate of SSIs in the Prevena group when compared with the non-Prevena group (P = .012). There was no statistical difference between the two groups in the rate of seroma formation (P = .155). Of the 100 incisions that received the Prevena wound system, 1.2% (1/82) had a femoral SSI and 22.0% (4/18) had a popliteal SSI. For seroma formation, 24.4% (20/82) had a femoral seroma and 11.1% (2/18) had a popliteal seroma. Of the 138 incisions that did not have the Prevena wound system, 9.6% (10/104) had a femoral SSI and 8.8% (3/34) had a popliteal SSI. For seroma formation, 24.0% (25/104) had a femoral seroma and 8.8% (3/34) had a popliteal seroma. Comorbid conditions were assessed in the two study groups and there was no statistical significance regarding rates of SSIs between the groups. CONCLUSIONS: The use of an incisional negative pressure dressing decreases the rate of SSIs in infrainguinal incisions. Regarding the use of these wound systems for seromas, our study did not show a statistically significant decrease in seroma rates.

Can educational videos reduce opioid consumption in trauma inpatients? A cluster-randomized pilot study.

BACKGROUND: Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS: We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS: In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION: Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Prevention of Firearm Violence Through Specific Types of Community-based Programming: An Eastern Association for the Surgery of Trauma Evidence-based Review.

OBJECTIVE: The purpose of this review was to provide an evidence-based recommendation for community-based programs to mitigate gun violence, from the Eastern Association for the Surgery of Trauma (EAST). SUMMARY BACKGROUND DATA: Firearm Injury leads to >40,000 annual deaths and >115,000 injuries annually in the United States. Communities have adopted culturally relevant strategies to mitigate gun related injury and death. Two such strategies are gun buyback programs and community-based violence prevention programs. METHODS: The Injury Control and Violence Prevention Committee of EAST developed Population, Intervention, Comparator, Outcomes (PICO) questions and performed a comprehensive literature and gray web literature search. Using GRADE methodology, they reviewed and graded the literature and provided consensus recommendations informed by the literature. RESULTS: A total of 19 studies were included for analysis of gun buyback programs. Twenty-six studies were reviewed for analysis for community-based violence prevention programs. Gray literature was added to the discussion of PICO questions from selected websites. A conditional recommendation is made for the implementation of community-based gun buyback programs and a conditional recommendation for community-based violence prevention programs, with special emphasis on cultural appropriateness and community input. CONCLUSIONS: Gun violence may be mitigated by community-based efforts, such as gun buybacks or violence prevention programs. These programs come with caveats, notably community cultural relevance and proper support and funding from local leadership.Level of Evidence: Review, Decision, level III.

Leadership Amongst Regional and National Surgical Organizations: The Tides Are Changing.

INTRODUCTION: Leadership amongst professional organizations is a key opportunity for scholarly activity which is essential for academic advancement. Our objective was to examine the differences between men and women in leadership within surgical organizations. METHODS: Credentials were obtained through an internet search. Variables included organization type, leadership role, gender, advanced degree, medical school graduation year, and publications. A bivariate analysis was performed between genders. A p-value <0.05 was considered statistically significant. RESULTS: Five hundred forty-three leaders were identified in 43 surgical organizations. There was a significant difference in the number of male and female leaders (72.7% vs 27.3%, p=0.016). Women were most likely to hold the role of "Other", which consisted of lower-level leadership roles including committee chair positions and resident and medical student delegates (35.5%). Fewer women had publications (85.8% vs 92.9%, p=0.01), more women had advanced degrees (24.5% vs 17.0%, p=0.049), and women were involved earlier in their careers (5.9 years, 95% CI 4.1-7.7 years, p<0.001) than their male colleagues. CONCLUSION: Gender disparity in leadership of surgical organizations exists. Women are involved earlier in their careers and hold lower-level leadership positions reflecting potential for increased involvement in high-level leadership roles in the future. Data need to be trended to discern if women in surgical organizations rise within leadership roles as more women continue to enter surgical subspecialties.

Effects of Ohio's opioid prescribing limit for the geriatric minimally injured trauma patient.

BACKGROUND: Geriatric patients, age ≥65, frequently require no operation and only short observation after injury; yet many are prescribed opioids. We reviewed geriatric opioid prescriptions following a statewide outpatient prescribing limit. METHODS: Discharge and 30-day pain prescriptions were collected for geriatric patients managed without operation and with stays less than two midnights from May and June of 2015 through 2018. Patients were compared pre- and post-limit and with a non-geriatric cohort aged 18-64. Fall risk was also assessed. RESULTS: We included 218 geriatric patients, 57 post-limit. Patients received fewer discharge prescriptions and lower doses following the limit. However, this trend preceded the limit. Geriatric patients received fewer opioid prescriptions but higher doses than non-geriatric patients. Fall risk was not associated with reduced prescription frequency or doses. CONCLUSIONS: Opioid prescribing has decreased for geriatric patients with minor injuries. However, surgeons have not reduced dosage based on age or fall risk.

Bedside dysphagia screens in patients with traumatic cervical injuries: An ideal tool for an under-recognized problem.

BACKGROUND: We initiated a prospective interventional study using a nurse-driven bedside dysphagia screen (BDS) in patients with cervical spine injury (CI) to address three objectives: (1) determine the incidence of dysphagia, (2) determine the utility of the new BDS as a screening tool, and (3) compare patient outcomes, specifically dysphagia-related complications, in the study period with a retrospective cohort. METHODS: All patients with CI admitted to a Level I trauma center were enrolled in a prospective 12-month study (June 2016-June 2017) and then were compared with a previous 18-month cohort of similar patients. Our new protocol mandated that every patient underwent a BDS before oral intake. If the patient failed the BDS, a modified barium swallow (MBS) was obtained. Exclusion criteria were emergency department discharge, inability to participate in a BDS, leaving against medical advice, BDS protocol violations, or death before BDS. A failed MBS was defined as a change in diet and a need for a repeat MBS. Dysphagia was defined as a failed MBS or the presence of a dysphagia-related complication. RESULTS: Of 221 consecutive prospective patients identified, 114 met inclusion criteria. The incidence of dysphagia was 16.7% in all prospective study patients, 14.9% in patients with isolated CI, and 30.8% in patients with spinal cord injury. The BDS demonstrated 84.2% sensitivity, 95.8% specificity, 80.0% positive predictive value, and 96.8% negative predictive value. There were no dysphagia-related complications. The prospective study patients demonstrated significantly less dysphagia-related complications (p = 0.048) when compared with the retrospective cohort of 276 patients. CONCLUSIONS: The introduction of the BDS resulted in increased dysphagia diagnoses, with a significant reduction in dysphagia-related complications. We recommend incorporating BDS into care pathways for patients with CI. LEVEL OF EVIDENCE: Study type diagnostic test, level III.

Current Pneumonia Surveillance Methodology: Similar Underestimation in Trauma and Surgical Patients in the Intensive Care Unit.

BACKGROUND: In 2013, the Centers for Disease Control and Prevention (CDC) developed new surveillance definitions for ventilator-associated events (VAE), leading to concerns that hospitals may be underreporting the true incidence of ventilator-associated pneumonias (VAPs). We sought to compare rates of clinically diagnosed VAP with CDC defined possible VAPs (PVAPs) in patients with a VAE in the surgical/trauma intensive care unit (STICU). HYPOTHESIS: Significant difference exists between rates of clinical VAP and PVAP in patients with at least one VAE. PATIENTS AND METHODS: All STICU patients with ≥1 VAE, between 1/1/2013 and 10/31/2015 were identified. Age, length of stay (LOS), ICU and ventilator days were collected. RESULTS: There were 134 patients who had ≥1 VAE. Mean age was 54.3 (±17.1) years. Mean LOS, median ICU, and median ventilator days were 26.3 (±14.1), 21.0 (17.0-33.0), and 17.0 (12.8-24.0) days, respectively. There were 68 cases of clinically diagnosed VAP, but only 37% met PVAP criteria. We compared 43 cases of clinical VAP, not meeting PVAP criteria, with the 25 PVAPs. Both groups had similar outcomes. The PVAPs were more likely to have an abnormal temperature (48.0% vs. 14.0%, p = 0.004), abnormal white blood cell count (84.0% vs. 18.6%, p < 0.001), or new antibiotic agent initiated (100% vs. 18.6%, p < 0.001) as VAE triggers. Comparison of the 93 trauma and 41 surgical patients demonstrated trauma patients were younger (51.2 vs. 61.5 y, p = 0.001), but had similar outcomes and rates of clinical VAP (48.4% and 43.9%, p = NS). Only 20.4% of trauma and 14.6% of surgical patients, however, had a PVAP reported. For patients with at least one VAE, the sensitivity and specificity for PVAP detecting VAP was 36.8% and 96.0%, respectively. CONCLUSION: The new CDC definition for PVAP grossly underestimates the clinical diagnosis of VAP and reports less than a third of the patients treated for VAP. Reporting differences were similar for trauma and surgical patients.

Traumatic vascular injuries: who are repairing them and what are the outcomes?

BACKGROUND: Traumatic vascular injuries are infrequent but can be devastating. This study characterized their incidence and the need for vascular surgeons in their repair. Outcomes for patients repaired by vascular and trauma surgeons were compared. METHODS: Patients age ≥14, needing operations for acute traumatic vascular injuries from January 1, 2008 to December 31, 2013 were included. RESULTS: Of the 27,224 adult trauma patients, 1.4% had vascular injuries needing operations. Trauma surgeons treated 40% of them. The need for repair by vascular surgeons varied based on mechanism, transfer status, injury location, time of injury, trauma staff practice, and experience (P < .05). Patients repaired by vascular surgeons had more transfusions, longer arrival-to-operation time, surgery duration, hospital stay but lower mortality (P < .05). This mortality difference dissipated after excluding early deaths. CONCLUSIONS: Approximately 3% of trauma patients had vascular injuries. Trauma surgeons treated a significant portion of them; using less resources and achieving similar outcomes in select patients when compared with vascular surgeons.