Postlaparotomy pain management: Comparison of patient-controlled analgesia pump alone, with subcutaneous bupivacaine infusion, or with injection of liposomal bupivacaine suspension.

OBJECTIVE: Efforts to achieve balance between effective pain management and opioid-related adverse events (ORAEs) have led to multimodal analgesia regimens. This study compared opioids delivered via patient-controlled analgesia (PCA) plus liposomal bupivacaine, a long-acting local anesthetic with potential to be an effective component of such regimens, to opioids delivered through PCA alone or PCA plus subcutaneous bupivacaine infusion (ONQ), following laparotomy. DESIGN: Prospective, randomized controlled trial. SETTING: Single, tertiary-care institution. PATIENTS: One hundred patients undergoing nonemergent laparotomy. INTERVENTIONS: Patients were randomly assigned to one of three study treatments: PCA only (PCAO), PCA with ONQ, or PCA with injectable liposomal bupivacaine suspension (EXP). MAIN OUTCOME MEASURES: Cumulative opioid use, daily mean patient-reported pain scores, and ORAEs through 72 hours postoperatively. RESULTS: On average, the EXP (n = 31) group exhibited less than 50 percent of the total opioid consumption of the PCAO (n = 36) group, and less than 60 percent of that for the ONQ (n = 33) group. Postoperative days 1 and 3 pain scores were significantly lower for the EXP group as compared to the ONQ and PCAO groups (p ≤ 0.005). Fewer patients in the EXP group (19.4 percent) experienced ORAEs compared to the PCAO (41.1 percent) and ONQ (45.5 percent) groups (p = 0.002). CONCLUSIONS: Laparotomy patients treated with liposomal bupivacaine as part of a multimodal regimen consumed less opioids, had lower pain scores, and had fewer ORAEs. The role of liposomal bupivacaine in the postoperative care of laparotomy patients merits further study.

Assessing the 16 hour intern shift limit: Results of a multi-center, mixed-methods study of residents and faculty in general surgery.

BACKGROUND: The study explores how residents and faculty assess the ACGME's 16-h limit on intern shifts. METHODS: Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes. RESULTS: Few view the intern shift limit as a positive change. Views differ (P < 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected. CONCLUSIONS: The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty.

The promise and problems of non-physician practitioners in general surgery education: Results of a multi-center, mixed-methods study of faculty.

BACKGROUND: Nurse Practitioners and Physician Assistants - called non-physician practitioners or NPPs - are common, but little is known about their educational promise and problems. METHODS: General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. RESULTS: NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. CONCLUSIONS: NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes.

Evaluating Surgical Residents Quickly and Easily Against the Milestones Using Electronic Formative Feedback.

OBJECTIVE: This study was conducted to assess the effectiveness of a newly implemented electronic web-based review system created at our institution for evaluating resident performance relative to established milestones. DESIGN: Retrospective review of data collected from a survey of general surgery faculty and residents. SETTING: Tertiary care teaching hospital system and independent academic medical center. PARTICIPANTS: A total of 12 general surgery faculty and 17 general surgery residents participated in this study. The survey queried the level of satisfaction before and after the adoption of QuickNotes using several statements scored on a 5-point scale, with 1 being the lowest rating as "not satisfied," and 5 being the highest rating as "completely satisfied." RESULTS: The weighted average improvements from pre- to post-QuickNotes implementation for the faculty responding to the survey ranged from 10% to 40%; weighted average improvements for the residents responding to the survey ranged from 5% to 73%. For the survey of faculty, both sets of weighted averages tended to be higher than the weighted average for the resident's survey responses. The highest rated topic was the faculty's level of satisfaction with the "frequency to provide feedback" with a post-QuickNotes implementation weighted average of 4.25, closely followed by the residents' level of satisfaction with the "evaluation includes positive feedback" with a post-QuickNotes implementation weighted average of 4.24. The most notable increases in weighted averages from preimplementation to postimplementation were noted for "overall satisfaction" (20% increase for faculty, 37% for residents), "reflects actual criteria that matter" (36% increase for faculty, 73% for residents), faculty "opportunity for follow-up" (increase of 40%), resident "reflects overall trends" (increase of 37%), and resident "provides new information about my performance" (increase of 37%). CONCLUSIONS: Our institutional adoption of QuickNotes into the resident evaluation process has been associated with an overall increased level of satisfaction in the evaluation process by both faculty and residents. The design of QuickNotes facilitates its integration into the resident training environment, as it is web based, easy to use, and has no additional cost over the standard New Innovations subscription. Although it is designed to capture snapshots of trainee behavior and performance, monthly reports through QuickNotes can be used effectively in conjunction with the more traditional end-of-rotation evaluations to show trends, identify areas of strength that should be reinforced, demonstrate areas needing improvement, allow for a more tailored individual education plan to be developed, and permit a more accurate determination of milestone progression.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies.

PURPOSE: Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. METHOD: Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. RESULTS: A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. CONCLUSIONS: Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Program Factors That Influence American Board of Surgery In-Training Examination Performance: A Multi-Institutional Study.

OBJECTIVE: To determine the influence of program strategies, such as program directors' (PD) attitudes about the American Board of Surgery In-Training Examination (ABSITE) and approach to ABSITE preparation, on residents' ABSITE performance. DESIGN: A 17-item questionnaire was sent to PDs at surgical residency programs. The questions were designed to elicit information regarding the educational curriculum, remediation protocols, and opinions relating to the ABSITE. Main outcome measure was categorical resident ABSITE percentile scores from the January 2014 examination. Statistical analysis was performed using the Student t-test, analysis of variance, and linear regression as appropriate. SETTING: The study was carried out at general surgery residency programs across the country. PARTICIPANTS: In total, 15 general surgery residency PDs participated in the study. RESULTS: The PD response rate was 100%. All 460 resident ABSITE scores from the 15 programs were obtained. In total, 10 programs (67%) identified as university affiliated, 4 programs (27%) as independent academic, and 1 program (7%) as hybrid. The mean number of residents per program was 30.7 (range: 15-57). In total, 14 PDs (93%) indicated that an ABSITE review curriculum was in place and 13 PDs (87%) indicated they had a remediation protocol for residents with low ABSITE scores (with differing thresholds of <30th, <35th, and <40th percentile). The median overall ABSITE score for all residents was 61st percentile (interquartile range = 39.5). The mean ABSITE score for each program ranged from 39th to 75th percentile. Program factors associated with higher ABSITE scores included tracking resident reading throughout the year (median 63rd percentile with tracking vs 59th percentile without, p = 0.040) and the type of remediation (by PD: 77th percentile, by PD and faculty: 57th percentile, faculty only: 64th percentile, with Surgical Education and Self-Assessment Program (SESAP): 63rd percentile, outside review course: 43rd percentile; p < 0.001). Programs with a remediation protocol trended toward higher ABSITE scores compared with programs without remediation protocols (median 61st percentile vs 53rd percentile, p = 0.098). Factors not significantly associated with ABSITE performance included number of structured educational hours per week and frequency of ABSITE review sessions. CONCLUSIONS: Program factors appear to significantly influence ABSITE performance. Programs where the PD was actively involved in remediation mentorship and the tracking of resident reading achieved higher ABSITE percentile scores on the January 2014 examination. Counterintuitively, residents from programs with a lower ABSITE threshold for remediation performed better on the examination.

Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance.

IMPORTANCE: Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations. OBJECTIVES: To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS: An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide. MAIN OUTCOMES AND MEASURES: Scores from the 2014 ABSITE. RESULTS: A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance. CONCLUSIONS AND RELEVANCE: Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

The 80-hour work week: will we have less-experienced graduating surgeons?

OBJECTIVE: Our primary concern when modifying the Mount Carmel Medical Center surgical residency to comply with the "80-hour work week" was the effect on operative experience. Our goal was to measure the impact that work-hour restrictions have on operative volumes and to evaluate the potential benefit of a night rotation to minimize the number of "lost operations." DESIGN: Categorical surgical residents (PGY I-IV) recorded missed surgical procedures on post-call days from September 1, 2002 to March 31, 2004. The data collection is split between the pre-night rotation (September 1, 2002 to March 31, 2003) and post-night rotation (April 1, 2003 to March 31, 2004) periods. The post-night rotation period is further divided to account for the end of the academic year. Previous graduate operative logs were reviewed for comparison. SETTING: Mount Carmel Health System is a tertiary referral, community-based hospital in Columbus, Ohio. PARTICIPANTS: Categorical general surgery residents (Postgraduate Years I to V). RESULTS: In the 7-month period, extending from September 1, 2002 to March 31, 2003, the average number of missed cases for successive levels was PGY I: 21, PGY II: 31, PGY III: 26, and PGY IV: 40. From April 1, 2003 to June 30, 2003, the average number of missed cases for successive levels was PGY I: 3, PGY II: 7, PGY III: 5, and PGY IV: 6. From July 1, 2003 to March 31, 2004, the average number of missed cases for successive levels was PGY I: 34, PGY II: 8, PGY III: 14, and PGY IV: 30. Before the implementation of a night rotation, residents were projected to miss an average of 202 operations over 4 years. After implementation of a night rotation, the projected loss would drop to 107 operations over 4 years. CONCLUSIONS: Work-hour restrictions result in a significant decrease in operative experience. This detriment can be partially alleviated with the institution of a night rotation to better regulate in-house call.