Variation in Competence of Graduating General Surgery Trainees.

OBJECTIVE: To examine the readiness of general surgery residents in their final year of training to perform 5 common surgical procedures based on their documented performance during training. DESIGN: Intraoperative performance ratings were analyzed using a Bayesian mixed effects approach, adjusting for rater, trainee, procedure, case complexity, and postgraduate year (PGY) as random effects as well as month in academic year and cumulative, procedure-specific performance per trainee as fixed effects. This model was then used to estimate each PGY 5 trainee's final probability of being able to independently perform each procedure. The actual, documented competency rates for individual trainees were then identified across each of the 5 most common general surgery procedures: appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. SETTING: This study was conducted using data from members of the SIMPL collaborative. PARTICIPANTS: A total of 17,248 evaluations of 927 PGY5 general surgery residents were analyzed from 2015 to 2021. RESULTS: The percentage of residents who requested a SIMPL rating during their PGY5 year and achieved a ≥90% probability of being rated as independent, or "Practice-Ready," was 97.4% for appendectomy, 82.4% for cholecystectomy, 43.5% for ventral hernia repair, 24% for groin hernia repair, and 5.3% for partial colectomy. CONCLUSIONS: There is substantial variation in the demonstrated competency of general surgery residents to perform several common surgical procedures at the end of their training. This variation in readiness calls for careful study of how surgical residents can become more adequately prepared to enter independent practice.

Right Case, Right Time: Which Procedures Best Differentiate General Surgery Trainees' Operative Performance?

OBJECTIVE: Assessing surgical trainee operative performance is time- and resource-intensive. To maximize the utility of each assessment, it is important to understand which assessment activities provide the most information about a trainee's performance. The objective of this study is to identify the procedures that best differentiate performance for each general surgery postgraduate year (PGY)-level, leading to recommendations for targeted assessment. DESIGN: The Society for Improving Medical Professional Learning (SIMPL) operative performance ratings were modeled using a multilevel Rasch model which identified the highest and lowest performing trainees for each PGY-level. For each procedure within each PGY-level, a procedural performance discrimination index was calculated by subtracting the proportion of "practice-ready" ratings of the lowest performing trainees from the proportion of "practice-ready" ratings of the highest performing trainees. Four-quadrant plots were created using the median procedure volume and median discrimination index for each PGY-level. All procedures within the upper right quadrant were considered "highly differentiating, high volume" procedures. SETTING: This study was conducted across 70 general surgical residency programs who are members of the SIMPL collaborative. PARTICIPANTS: A total of 54,790 operative performance evaluations of categorical general surgery trainees were collected between 2015 and 2021. Trainees who had at least 1 procedure in common were included. Procedures with less than 25 evaluations per training year were excluded. RESULTS: The total number of evaluations per procedure ranged from 25 to 2,131. Discrimination values were generated for 51 (PGY1), 54 (PGY2), 92 (PGY3), 105 (PGY4), and 103 (PGY5) procedures. Using the above criteria, a total of 12 (PGY1), 15 (PGY2), 22 (PGY3), 21 (PGY4), and 28 (PGY5) procedures were identified as highly differentiating, high volume procedures. CONCLUSIONS: Our study draws on national data to identify procedures which are most useful in differentiating trainee operative performance at each PGY-level. This list of procedures can be used to guide targeted assessment and improve assessment efficiency.

Opportunities to Increase Workplace Feedback: A Multi-institutional Examination.

OBJECTIVE: While feedback is an essential component of resident education, there are few large-scale studies examining when and under what conditions formative feedback is provided. Workplace-based assessment systems offer an opportunity to identify factors influencing when faculty provides feedback to trainees. Influential factors affecting feedback may provide targets for increasing and improving feedback in resident education. DESIGN: Data on whether dictated feedback was provided were obtained from the Society for Improving Medical Professional Learning (SIMPL) mobile application. We used generalized linear mixed effects models to identify the degree to which faculty members, procedures, surgical case characteristics, and trainee performance were associated with whether narrative feedback was provided using SIMPL. SETTING: This study was conducted using data from members of the SIMPL collaborative. PARTICIPANTS: 67,434 evaluations from 70 general surgery programs were included from 2015 to 2021. Of these, 25,355 evaluations included dictated feedback. RESULTS: Approximately 61% of the variation in whether dictated feedback was provided was attributable to the individual faculty member. Compared to residents who achieved autonomy ratings of "Active Help," residents who achieved ratings of "Supervision Only" (odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.72, 0.88) had a lower likelihood of receiving dictated feedback. Residents who achieved ratings of "Intermediate" (OR = 0.81, CI = 0.74, 0.89), "Practice-Ready" (OR = 0.50, CI = 0.45, 0.57), or "Exceptional (OR = 0.64, CI = 0.54, 0.76) showed a lower likelihood of receiving dictated feedback compared to those rated as "Inexperienced." Cases rated as "High" in terms of complexity were associated with an increased likelihood of having dictation (OR = 1.35, CI = 1.26, 1.44). CONCLUSIONS: The largest contributing factor for whether dictated feedback is included in a SIMPL evaluation are factors specific to the attending surgeon. Resident performance, resident autonomy, and case complexity had only modest associations with feedback decisions. Efforts to improve the amount of formative feedback for trainees should be directed towards reducing the variation in which attending surgeons elect to provide feedback.

Reducing opioid misuse among adolescents through physician education.

Increased prescribing of opioids has been associated with an epidemic of nonmedical prescription opioid use in the United States; adolescents and young adults are particularly vulnerable to opioid misuse. The role of physicians as health care providers, educators, and confidants for their adolescent patients equips them to intervene in adolescent opioid misuse. The authors advocate for improving the education of physicians and residents regarding opioid use and misuse among adolescents. To achieve this, we can require residency education that includes opioid misuse and appropriate prescribing, widely disseminate existing resources on management of pain and opioid misuse, and develop pain management and addiction mentorship programs.

A previously unclassified variant of sternalis muscle.

PURPOSE: We propose an addition to the Snosek et al. classification to include a subtype variant of sternalis muscle: mixed type and triple subtype. METHODS: Dissection of the anterior thorax of a 96-year-old female cadaver revealed bilateral sternalis muscles with an undocumented variant of the right sternalis muscle. RESULTS: The left sternalis muscle presented as a simple type-left single using the Snosek et al. classification scheme. The right sternalis muscle revealed a previously undocumented classification type. It consisted of three bellies and two heads, with the lateral head formed by two converging bellies and the medial head formed from the superficial medial belly. CONCLUSIONS: The unique presentation of right sternalis muscle can be classified by expanding the Snosek et al. classification scheme to include triple-bellied subtypes. This presentation is classified as a mixed type-right triple, with single bicipital converging and single bicipital diverging. Documentation of sternalis muscle variations can prevent misdiagnoses within the anterior thorax.