A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Attracting the Best Students to a Surgical Career.

The predicted shortage of surgeons in the future workforce is already occurring in rural areas and is expected to worsen. US allopathic medical school graduates have been losing interest in surgery for the past 40 years. The residency match remains unaffected because of foreign and osteopathic applicants. Negative myths regarding surgeon training, lifestyle, and personality persist among medical students, proving to be a powerful deterrent to students who might consider a surgical career. Proven strategies for making surgery more attractive to students are not always used and can be as simple as getting early exposure to students before clinical rotations.

Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic.

Importance: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume. Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume. Design, Setting, and Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations. Main Outcome and Measures: Total major cases performed by each resident during the first 4 months of the pandemic. Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03). Conclusions and Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.

A multi-institutional study assessing general surgery faculty teaching evaluations.

BACKGROUND: Resident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists. STUDY DESIGN: Twenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful. RESULTS: Number of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest. CONCLUSION: There was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development.

Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life.

BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

Comprehensive Multicenter Graduate Surgical Education Initiative Incorporating Entrustable Professional Activities, Continuous Quality Improvement Cycles, and a Web-Based Platform to Enhance Teaching and Learning.

BACKGROUND: It is increasingly important for faculty to teach deliberately and provide timely, detailed, and formative feedback on surgical trainee performance. We initiated a multicenter study to improve resident evaluative processes and enhance teaching and learning behaviors while engaging residents in their education. STUDY DESIGN: Faculty from 7 US postgraduate training programs rated resident operative performances using the perioperative briefing, intraoperative teaching, debriefing model, and rated patient visits/academic performances using the entrustable professional activities model via a web-based platform. Data were centrally analyzed and iterative changes made based on participant feedback, individual preferences, and database refinements, with trends addressed using the Plan, Do, Check, Act improvement methodology. RESULTS: Participants (92 surgeons, 150 residents) submitted 3,880 assessments during July 2014 through September 2017. Evidence of preoperative briefings improved from 33.9% ± 2.5% to 95.5% ± 1.5% between April and September 2014 compared with April and September 2017 (p < 0.001). Postoperative debriefings improved from 10.6% ± 2.7% to 90.2% ± 2.5% (p < 0.001) for the same period. Meaningful self-reflection by residents improved from 28.6% to 67.4% (p < 0.001). The number of assessments received per resident during a 6-month period increased from 6.4 ± 6.2 to 13.4 ± 10.1 (p < 0.003). Surgeon-entered assessments increased from 364 initially to 685 in the final period, and the number of resident assessments increased from 308 to 445. We showed a 4-fold increase in resident observed activities being rated. CONCLUSIONS: By adopting recognized educational models with repeated Plan, Do, Check, Act cycles, we increased the quality of preoperative learning objectives, showed more frequent, detailed, and timely assessments of resident performance, and demonstrated more effective self-reflection by residents. We monitored trends, identified opportunities for improvement and successfully sustained those improvements over time, applying a team-based approach.

Prevention of postoperative pulmonary complications.

Postoperative pulmonary complications (PPCs) occur frequently among general surgical patients. The spectrum of illness is broad and includes preventable causes of morbidity and death. Careful preoperative evaluation can identify undiagnosed and undertreated illness and allow for preoperative intervention. Optimization of patient, surgical, and anesthetic factors is crucial in the prevention of PPCs.

The certifying examination of the american board of surgery: the effect of improving communication and professional competency: twenty-year results.

PURPOSE: In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS: Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS: There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION: Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

Patient misunderstanding of the academic hierarchy is prevalent and predictable.

BACKGROUND: Medical personnel introduce themselves to patients using titles that reflect their level of training, although these titles may not be inherently obvious to the patient. This study explored patient understanding of commonly used physician and student titles. MATERIALS AND METHODS: A survey was developed asking patients to match six mutually exclusive medical titles to six levels of training. Categories included attending physician, chief resident, resident, intern, medical student, and pre-medical student. Respondent age, gender, medical training, employment in a healthcare field, educational level, income, and number of visits to a physician per y were requested. A brief intervention was then performed in which a second group of patients were advised of the designations and then asked to match the same categories. RESULTS: A total of 365 surveys were collected from the first group and 102 from the second group. Respondents accurately identified the level of training required for all six titles in only 44.5% of surveys collected, and in 52.0% after the intervention. Patients with at least some college education or income>$50,000 per y were more likely to answer correctly (P<0.001). On the other hand, even respondents with graduate degrees or incomes>$100,000 per y had difficulty correctly identifying the training of all team members. CONCLUSIONS: Patients do not understand the distinctions in training of surgical team members, especially those patients with decreased income or education; therefore, clinicians may wish to pay particular attention to these introductions. The survey did identify this as being important to patients.

Endoscopy education in general surgery residencies: meeting the new RRC requirements.

BACKGROUND: The Residency Review Committee (RRC) for General Surgery recently increased the number of endoscopy cases required from 29 to 85. We sought to evaluate how programs were meeting these guidelines and what adaptations were occurring. METHODS: Surveys were sent by regular mail and e-mail to program directors at accredited general surgery residencies. RESULTS: Eighty-one of 250 surveys were returned (24%); 52% were university based; 100% of respondents were compliant with the old requirement, while 90% were compliant with the new RRC levels; 52% utilized a dedicated rotation and commonly in the private practices settings (75%). Virtually every program reported use of endoscopy suites (98%) or operating rooms (85%); fewer (64%) reported endoscopies in ICUs; 29% of programs had at least half of endoscopies taught by non-surgeons. The mean number of endoscopies performed was 160 (range 55-450), which exceeded the mean number of endoscopies (90) program directors believed were needed to gain privileges. The most commonly identified barriers to increasing endoscopy experience were work hour restrictions (38%) and referral patterns (42%). CONCLUSIONS: Most programs responding to our survey are already compliant with the new RRC requirement. Much of this teaching occurs by non-surgeons and commonly away from the dominant teaching hospital. Future changes in endoscopy requirements should consider the impact of increasing nonsurgical teaching time. It seems likely that non-responding programs have even lower numbers than those responding and may have an even higher barrier to successfully increasing endoscopy education by surgeons.

What is an hour-lecture worth?

BACKGROUND: Although there are many ways to convey knowledge, attitudes, and techniques when teaching residents and students, the most optimal method (lecture, online lecture, online tutorial, simulator practice, and so on) is yet to be determined. METHODS: This study was designed to be a prospective analysis of change in resident behavior, and the model chosen was resident compliance with alcohol screening during admissions to the trauma service. Baseline values were determined the month before the educational "intervention," which was planned to be a 1-hour lecture during Grand Rounds on the importance of screening for alcohol disuse syndromes. After the "intervention," results were analyzed at 3 points in time: during the first month after the lecture and then at 3 and 12 months. RESULTS: Resident compliance with alcohol usage screening rose from 53% at baseline to 80% at 1 year. CONCLUSIONS: This straightforward model of utility of a lecture showed a significant change in resident behavior.