Neuropsychological Differences Between Surgery Interns and Age-Matched Adults.

OBJECTIVE: The purpose of this study was to assess how neuropsychological factors differ between general surgery interns and normative data from age-matched adults in the general population. DESIGN: Participants completed a comprehensive neuropsychological assessment battery. Neuropsychological factors assessed included: executive function (Behavioral Rating Inventory of Executive Function, BRIEF), working memory (Wechsler Adult Intelligence Scale, or WAIS, digit span), psychomotor speed (WAIS coding, Trails A and B), selective attention (D2 Test of Attention), and problem solving (Tower of London, TOL). Data for all measures was compared to previously published normative data for age-matched, healthy adults in the general population using one-sample t-tests. SETTING: This study was completed at Indiana University School of Medicine in Indianapolis, IN, which is a large academic healthcare training institution. PARTICIPANTS: Postgraduate year 1 general surgery residents (PGY1s) voluntarily participated in this study. RESULTS: Twenty-six general surgery PGY1s completed all measures. We found that PGY1s had significantly better behavioral inhibition, working memory, selective attention, problem solving, and psychomotor speed than their counterparts in the general population (Table 1). Conversely, we found that PGY1s had significantly lower cognitive flexibility (p = 0.02) and ability to monitor task progress (p = 0.006) than the general population. CONCLUSIONS: The results from this study indicate that there are several neuropsychological factors that may help explain the high achievement of general surgery PGY1s. Assessment of these factors could aid general surgery programs in the selection and training of high-caliber residents. However, there are indicators that PGY1s struggle from cognitive inflexibility and task monitoring compared to the general population. These skills are needed to manage the complex and dynamic nature of surgical performance, so educators should consider methods to enhance junior residents' development of these characteristics.

Relationship between stress and resident non-technical skills during interdisciplinary trauma simulations.

BACKGROUND: Non-technical skills, such as communication and situation awareness, are vital for patient care and effective surgical team performance. Previous research has found that residents' perceived stress is associated with poorer non-technical skills; however, few studies have investigated the relationship between objectively assessed stress and non-technical skills. Accordingly, the purpose of this study was to assess the relationship between objectively assessed stress and non-technical skills. METHODS: Emergency medicine and surgery residents voluntarily participated in this study. Residents were randomly assigned to trauma teams to manage critically ill patients. Acute stress was assessed objectively using a chest-strap heart rate monitor, which measured average heart rate and heart rate variability. Participants also evaluated perceived stress and workload using the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index. Non-technical skills were assessed by faculty raters using the non-technical skills scale for trauma. Pearson's correlation coefficients were used to examine relationships between all variables. RESULTS: Forty-one residents participated in our study. Heart rate variability (where higher values reflect lower stress) was positively correlated with residents' non-technical skills overall and leadership, communication, and decision-making. Average heart rate was negatively correlated with residents' communication. CONCLUSION: Higher objectively assessed stress was associated with poorer non-technical skills in general and nearly all non-technical skills domains of the T-NOTECHS. Clearly, stress has a deleterious effect on residents' non-technical skills during trauma situations, and given the importance of non-technical skills in surgical care, educators should consider implementing mental skills training to reduce residents' stress and optimize non-technical skills during trauma situations.

Evidence-based Surgical Competency Outcomes from the Clinical Readiness Program.

OBJECTIVES: 1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice. BACKGROUND: Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness. METHODS: We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance. RESULTS: Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain. CONCLUSIONS: Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.

The Impact of Simulation Based Training on the Fundamentals of Endoscopic Surgery Performance Examination.

OBJECTIVE: To determine if simulation training is required to pass the FES skills test and assess the relationship between simulation training, clinical training, and FES skills test performance. SUMMARY OF BACKGROUND DATA: The ABS began requiring completion of the Flexible Endoscopy Curriculum for all applicants beginning in 2018. The role of simulation-based training in FES skills test performance after this requirement has not been evaluated. METHODS: De-identified data from the initial FES skills tests after the Flexible Endoscopy Curriculum requirement was reviewed, and 731 unique participants with reported simulation experience demographics were identified. Self-reported data included sex, upper (UE) and lower (LE) endoscopy experience, and simulator training hours (SE). Final FES skills exam scores and pass/fail designations for each participant were reported by the FES program staff. RESULTS: There was a statistically discernible difference in mean FES total scores between those reporting no SE and more experienced groups ( P = 0.002), and between less and more experienced UE and LE groups ( P < 0.001). There was no statistically discernible difference in FES skills exam pass rates between SE groups ( P = 0.2), but there was a strong relationship between clinical experience (UE & LE) and pass rate ( P < 0.001). Finally, on logistic regression analysis, LE was a discernible predictor of passing [odds ratio (OR) = 1.4, 95% confidence interval (CI) 1.1-1.8, P = 0.02], while UE [odds ratio (OR) = 1, 95% CI 0.8-1.3, P = 0.9] and SE (OR = 1,95% CI 0.9- 1.3, P = 0.7) were not. CONCLUSIONS: There is no threat to the validity of the FES skills test from a need for simulation training to pass the FES skills test. Similarly, the amount of simulation practice is not predictive of passing, but can improve performance on certain FES tasks.

The American Board of Surgery flexible endoscopy curriculum prepares individuals to pass the fundamentals of endoscopic surgery manual skills test.

BACKGROUND: The American Board of Surgery (ABS) has required Fundamentals of Endoscopic Surgery (FES) certification for general surgery applicants since 2018. Flexible Endoscopy Curriculum (FEC) completion is recommended prior to taking the FES exam. The objective of the study was to determine if FEC completion prepares individuals to pass the FES manual skills test. METHODS: Participants included first-attempt FES examinees from June 2014 to February 2019. De-identified data were reviewed, Self-reported data included gender, PGY, glove size, upper (UE) and lower (LE) endoscopy experience, simulation training time, and participation in an endoscopy rotation (ER). FES skills exam performance was reported by FES staff. Those completing all vs. none of the FEC were compared. RESULTS: Of 2023 participants identified, 809 (40.0%) reported completion of all FEC components, 1053 (52.1%) completed of some, and 161 (8.0%) completed none. Men and candidates taking FES later in residency were more likely to complete all FEC requirements (p = 0.002, p < 0.001). FES pass rates were higher for those who completed all FEC components compared to those who completed none (88.4% vs 72.7%, p < 0.001). On logistic regression analysis, completion of all components (OR 2.3, 95% CI 1.5-3.7, p < 0.001) and male gender (OR 3.1, 95% CI 1.7-5.7, p < 0.001) were predictors of passing, while glove size (OR 1.5, 95% CI 1.0-2.5, p = 0.08), simulator time (OR 1.1, 95% CI 0.9-1.4, p = 0.37) and PGY were not (OR 1.1, 95% CI 0.9-1.4, p = 0.38). On multivariate analysis controlling for glove size and gender, completion of all FEC components was still associated with a higher likelihood of passing the FES skills exam (OR 1.6, 95% CI 1.2-2.1, p < 0.001). CONCLUSIONS: Completion of FEC is strongly associated with passing the FES skills test. This study supports the ABS recommendation for completion of FEC prior to taking the FES skills test.

Early implementation of Fundamentals of Endoscopic Surgery training using a simulation-based mastery learning curriculum.

BACKGROUND: After the American Board of Surgery announcement of the Flexible Endoscopy Curriculum requirement in 2014, we implemented a dedicated endoscopy rotation at the post graduate year (PGY)2 level including a simulation curriculum for Fundamentals of Endoscopic Surgery skills. Here we evaluate the outcomes of this implementation. METHODS: Beginning in 2015, we developed a clinical endoscopy and simulation-based rotation to prepare for Fundamentals of Endoscopic Surgery testing. Originally, our curriculum was based on the published Texas Association of Surgical Skills Laboratories curriculum using the GI Mentor and transitioned to a mastery learning curriculum using the Endoscopy Training System in 2016. We evaluated the success of the curriculum in terms of first-time pass rates, training time required, and comparison to previously published benchmarks based on clinical experience. RESULTS: Since 2015, a total of 37 general surgery residents in our program were Fundamentals of Endoscopic Surgery tested (PGY2 = 24, PGY3 = 4, PGY5 = 9); 84% (31) completed the Endoscopy Training System curriculum. At the time of testing, 73% (27) had performed <25 esophagogastroduodenoscopies, and 46% had performed <25 colonoscopies. Ninety-two percent (34) spent 10 hours or less completing the curriculum. The first-time pass rate for those completing the Endoscopy Training System curriculum was 97% vs 67% for those not completing the Endoscopy Training System curriculum (P = .01). For residents completing the Endoscopy Training System curriculum, total Fundamentals of Endoscopic Surgery scores were discernibly higher (472 vs 389, P < .01), as were 3/5 task scores (Nav1 80 vs 67, P = .02; Loop2 36 vs 8, P = .02; Retro3 89 vs 71, P = .02). Despite clinical inexperience (<25 esophagogastroduodenoscopies and <50 colonoscopies), PGY2s yielded a mean score of 454 and a pass rate of 92%. This was similar to PGY5s (427, 89%; P = .3) and compares to benchmark data of endoscopists with >300 cases. CONCLUSION: Early implementation of flexible endoscopy training with a simulation-based curriculum results in Fundamentals of Endoscopic Surgery performance equal to a clinical experience not often gained during surgical residency. Often requiring <10 hours, this represents a fantastic return on investment for this training.

Piloting the FIRE: A Novel Error Management Training Simulation Curriculum for Fasciotomy Instruction.

BACKGROUND: Multiple studies have demonstrated poor performance of lower extremity fasciotomy (LEF), highlighted by missed and/or inadequately released compartments. Incorporating error management training (EMT) into surgical simulation has been promoted as a way to gain deeper understanding of procedural errors and overall performance. The purpose of this study was to evaluate LEF performance using a Fasciotomy Improvement through Recognition of Errors (FIRE) simulation training curriculum to train novice surgical trainees. METHODS: A mastery learning-based EMT curriculum was developed, and surgical residents were enrolled and pretested with a multiple-choice question (MCQ) written test, and a simulated fasciotomy using a lower leg model. Each trainee then watched a 15-minute narrated presentation followed by 2 rounds of fasciotomy error recognition and management training exercises to a mastery standard. During each round, trainees performed hands-on assessment of unique premade fasciotomy leg models containing a variable number of procedural errors. They were required to identify and propose corrective action for all errors. Serial rounds of remediation were implemented until the mastery standard was attained on both error identification rounds. All trainees were post-tested with the same MCQ and another simulated fasciotomy. RESULTS: All 14 residents had minimal experience with only 0.3 ± 0.6 fasciotomies performed prior to instruction. There were 3 ± 1.6 missed or inadequately released compartments on the pretest. Residents examined 14 ± 2.5 legs, including 2 ± 2.5 legs during remediation to attain mastery. All residents demonstrated significant improvement following the FIRE of Error curriculum for the MCQ (57% ± 16% vs 78% ± 13%; p = 0.01; Cohen's d = 1.4), fasciotomy score (10 ± 7.1 vs 28 ± 1.9; p < 0.001; Cohen's d = 3.6), and achieving a complete fasciotomy (14% ± 36% vs 93% ± 27%; p < 0.001; Cohen's d = 2.5). Only a single cumulative compartment was missed on post-testing. CONCLUSIONS: Implementation of a mastery learning-based EMT curriculum for fasciotomy simulation training results in significant improvement in fasciotomy technique without reliance on repeated procedure performance nor clinical fasciotomy exposure. This curriculum is a highly effective option for surgical trainees lacking fasciotomy training during residency.

Fact or Fiction? Practice on a Simulator is Not Required to Pass the Fundamentals of Endoscopic Surgery (FES)TM Skills Exam.

PURPOSE: Initial work on the validity evidence used to support the Fundamentals of Endoscopic Surgery (FES) performance exam as a measure of technical competency showed a strong relationship to clinical experience. Despite this evidence, there is a perception among some program directors that the exam cannot be successfully passed without practice on a simulator. We assess the validity of this perception. METHODS: Deidentified data from the initial FES skills examination (prior to the 2014 FEC requirement) was reviewed, and 335 unique participants with reported simulation experience demographics were identified. Self reported data analyzed included gender, total clinical endoscopy procedure experience (1-150, 151-300, >300), and endoscopy simulator training hours (0, 1-5, 6-10, 11-20, >20). Final FES skills exam scores, and pass/fail designations for each participant were reported by the FES program staff. Continuous variables were compared between groups using one-way analysis of variance with post-hoc analysis where appropriate. Categorical variables were compared using Pearson Chi-Squared. The effect of variables on pass rate was assessed using univariate and multivariate logistic regression. RESULTS: Simulation training experience (SE) was categorically reported in hours(n,%): 0 (98, 29%), 1-5 (135, 40%), 6-10 (52, 16%), 11-20 (24, 7%), and >20 (26, 8%). Clinical endoscopy experience (CE), reported categorically as total cases performed (n,%), was available for 323 of 355 identified participants: 1-150 (126, 39%), 151-300 (99, 31%), >300 (98, 30%). There was no statistically discernible differences in mean FES total or task scores across the SE groups (total score 0:72 ± 15, 1-5:72 ± 13, 6-10:71 ± 14, 11-20:71 ± 16, 20:78 ± 13; p = 0.28), while both total score and task scores were discernibly higher in the more experienced CE groups (>151) compared to the least experienced group (total score; <150:67 ± 15, 151-300:75 ± 1, >300:77 ± 14; p < 0.01). Similarly, there was no statistically discernible difference in FES skills exam pass rates between SE groups (0: 80%, 1-5: 82%, 6-10: 79%, 11-20: 75%, >20: 85%; x2 = 2.5, p = 0.6), but there was a strong relationship between clinical experience and pass rate (<150: 70%, 151-300: 87%, >300: 89%; x2 = 15.8, p < 0.001). Finally, on both univariate and multivariate logistic regression, CE remained a discernible predictor of passing, even when controlling for SE (odds ratio = 2, 95% confidence interval 1.4-2.9, p < 0.001). CONCLUSIONS: FES skills examination data collected on participants completing the examination before the FEC requirement shows no demonstrable relationship with self-reported training experience on a simulator but confirms a strong relationship with clinical endoscopy experience. This lends further evidence to the validity of the FES exam as a marker of clinical endoscopic skill.

The Fundamentals of Endoscopic Surgery (FES) skills test: factors associated with first-attempt scores and pass rate.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) program became required for American Board of Surgery certification as part of the Flexible Endoscopy Curriculum (FEC) for residents graduating in 2018. This study expands prior psychometric investigation of the FES skills test. METHODS: We analyzed de-identified first-attempt skills test scores and self-reported demographic characteristics of 2023 general surgery residents who were required to pass FES. RESULTS: The overall pass rate was 83%. "Loop Reduction" was the most difficult sub-task. Subtasks related to one another only modestly (Spearman's ρ ranging from 0.11 to 0.42; coefficient α = .55). Both upper and lower endoscopic procedural experience had modest positive association with scores (ρ = 0.14 and 0.15) and passing. Examinees who tested on the GI Mentor Express simulator had lower total scores and a lower pass rate than those tested on the GI Mentor II (pass rates = 73% vs. 85%). Removing an Express-specific scoring rule that had been applied eliminated these differences. Gender, glove size, and height were closely related. Women scored lower than men (408- vs. 489-point averages) and had a lower first-attempt pass rate (71% vs. 92%). Glove size correlated positively with score (ρ = 0.31) and pass rate. Finally, height correlated positively with score (r = 0.27) and pass rate. Statistically controlling for glove size and height did not eliminate gender differences, with men still having 3.2 times greater odds of passing. CONCLUSIONS: FES skills test scores show both consistencies with the assessment's validity argument and several remarkable findings. Subtasks reflect distinct skills, so passing standards should perhaps be set for each subtask. The Express simulator-specific scoring penalty should be removed. Differences seen by gender are concerning. We argue those differences do not reflect measurement bias, but rather highlight equity concerns in surgical technology, training, and practice.

Fundamentals of Anorectal Technical Skills: A Concise Surgical Skills Course.

INTRODUCTION: Anorectal diseases, among the most common surgical conditions, are underrepresented in medical training. The Fundamentals of Anorectal Technical Skills course was developed to provide cost-effective formal training in diagnosis of common anorectal conditions and in commonly performed anorectal procedures using the theories of deliberative practice and perceptual and adaptive learning. MATERIALS AND METHODS: First- through third-year general surgery and internal medicine residents and third- and fourth-year medical students participated in a course consisting of didactic instruction and hands on skills stations. The course covered common anorectal conditions, including internal and external hemorrhoids, fissures, condylomata, abscesses, fistula-in-ano, rectal prolapse, pilonidal disease, pruritis ani, and anal and rectal cancer, as well as common procedures such as anoscopy, excision of thrombosed external hemorrhoids, banding of internal hemorrhoids, rigid proctoscopy, incision and drainage of an abscess, administration of local anesthesia, and reduction of rectal prolapse. Before the course, participants completed a questionnaire consisting of demographics; previous anorectal experience, as measured by procedural case volume; confidence diagnosing and treating anorectal conditions; and a clinical knowledge multiple-choice quiz. Immediately following the course, participants took an additional survey reassessing their confidence and testing their clinical knowledge. This study was granted an educational exception by the Institutional Review Board at Walter Reed National Military Medical Center. RESULTS: Forty-three learners participated in this course. Forty-six percent of participants had not participated in any anorectal cases, 26% had participated in 1 to 5 cases, 17% had participated in 6 to 10 cases, 6% had been involved with 11 to15 cases, and 6% had been involved with more than 15 cases. For learners who had no prior experience, 1 to 5 prior cases, or 6 to 10 cases, there were statistically and educationally significant increases in confidence for all diagnoses and procedures. Additionally, there were statistically and educationally significant increases between pre-course and post-course quiz scores for learners who had no prior experience (7.8 ± 2.0 vs. 11.8 ± 2.5, P < 0.01, Cohen's d = 1.8) and for those who had only participated in 1 to 5 cases (11.0 ± 3.7 vs. 14.2 ± 2.0, P = 0.04, Cohen's d = 1.1). The changes in quiz scores for learners who previously had been involved with six or more cases were not statistically significant. CONCLUSION: This course provides a cost-effective training that significantly boosts learners' confidence in diagnosis of common anorectal procedures and confidence in performance of common anorectal procedures, in addition to improving objectively measured anorectal clinical knowledge.

Video-based assessment for laparoscopic fundoplication: initial development of a robust tool for operative performance assessment.

INTRODUCTION: While better technical performance correlates with improved outcomes, there is a lack of procedure-specific tools to perform video-based assessment (VBA). SAGES is developing a series of VBA tools with enough validity evidence to allow reliable measurement of surgeon competence. A task force was established to develop a VBA tool for laparoscopic fundoplication using an evidence-based process that can be replicated for additional procedures. The first step in this process was to seek content validity evidence. METHODS: Forty-two subject matter experts (SME) in laparoscopic fundoplication were interviewed to obtain consensus on procedural steps, identify potential variations in technique, and to generate an inventory of required skills and common errors. The results of these interviews were used to inform creation of a task inventory questionnaire (TIQ) that was delivered to a larger SME group (n = 188) to quantify the criticality and difficulty of the procedural steps, the impact of potential errors associated with each step, the technical skills required to complete the procedure, and the likelihood that future techniques or technologies may change the presence or importance of any of these factors. Results of the TIQ were used to generate a list of steps, skills, and errors with strong validity evidence. RESULTS: Initial SMEs interviewed included fellowship program directors (45%), recent fellows (24%), international surgeons (19%), and highly experienced super SMEs with quality outcomes data (12%). Qualitative analysis of interview data identified 6 main procedural steps (visualization, hiatal dissection, fundus mobilization, esophageal mobilization, hiatal repair, and wrap creation) each with 2-5 sub steps. Additionally, the TIQ identified 5-10 potential errors for each step and 11 key technical skills required to perform the procedure. Based on the TIQ, the mean criticality and difficulty scores for the 11/21 sub steps included in the final scoring rubric is 4.66/5 (5 = absolutely essential for patient outcomes) and 3.53/5 (5 = difficulty level requires significant experience and use of alternative strategies to accomplish consistently), respectively. The mean criticality and frequency scores for the 9/11 technical skills included is 4.51/5 and 4.51/5 (5 = constantly used ≥ 80% of the time), respectively. The mean impact score of the 42/47 errors incorporated into the final rubric is 3.85/5 (5 = significant error that is unrecoverable, or even if recovered, likely to have a negative impact on patient outcome). CONCLUSIONS: A rigorous, multi-method process has documented the content validity evidence for the SAGES video-based assessment tool for laparoscopic fundoplication. Work is ongoing to pilot the assessment tool on recorded fundoplication procedures to establish reliability and further validity evidence.

Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs.

INTRODUCTION: The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME. METHODS: Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs. RESULTS: One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047). CONCLUSIONS: Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.

Surgery at Sea: Exploring the Training Gap for Isolated Military Surgeons.

OBJECTIVE: Newly-graduated military general surgeons often find themselves isolated at sea, solely responsible for all surgical care of several thousand sailors, regardless of the surgical specialty training required for any individual procedure. This educational need assessment explored trends in afloat surgical care over the last 25 years, and assessed trainees' preparedness for their expected role as an isolated surgeon. DESIGN: A sample of deidentified US Navy Ship's Surgeon case logs were reviewed to determine afloat case load trends in 5 common afloat case categories (urologic/gynecologic, anorectal, hernia, appendectomy, and hand/orthopedic/trauma) from 1990s to 2017. Individual procedures were mapped to American College of Surgeons/Military Health System Knowledge, Skills, and Attitudes line items to ensure afloat-relevant skills were identified. Recent military resident case logs were then compared with afloat cases to evaluate relevant trainee experience. SETTING: US Navy ships at sea from 1995 to 2017. PARTICIPANTS: US Navy afloat-deployed surgeons, totaling 1340 cases within the study period. RESULTS: Case log analysis of 1340 surgeries, comprising >200 months at sea, reflected 46 named procedures; 34 of 46 (74%) correlated to an intraoperative knowledge, skills, and attitudes item. The most common surgeries were vasectomy, (304 of 1340, 23%). No difference in case mix was apparent comparing pre- and post-2000 deployments (representing afloat laparoscopic integration) in 4 of 5 categories, while hernias proportionally declined. Case volume per deployment markedly declined overall (p < 0.001) and in each category. Resident case log analysis from 2012 to 2016 showed experience was limited in urologic/gynecologic, orthopedic, and open appendectomy categories. CONCLUSIONS: No formal case repository exists for afloat surgery, making detailed analysis problematic. Current training provides excellent surgical education but minimal exposure to rare-but-real cases expected on deployments, which may not translate to competency for the isolated, afloat surgeon. Military surgical leadership should embrace training for these cases and assertively invest in the development of the military's newest surgeons.

Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance.

BACKGROUND: Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training. METHODS: In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula. RESULTS: Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments CONCLUSIONS: Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.

The SAGES flexible endoscopy course for fellows: a worthwhile investment in furthering surgical endoscopy.

BACKGROUND: The SAGES flexible endoscopy course for minimally invasive surgery (MIS) fellows improves confidence and skills in performing gastrointestinal (GI) endoscopy. This study evaluated the long-term retention of these confidence levels and investigated how fellows changed practices within their fellowships due to the course. METHODS: Participating MIS fellows completed surveys 6 months after the course. Respondents rated their confidence to independently perform 16 endoscopic procedures (1 = not at all; 5 = very), barriers to use of endoscopy, and current uses of endoscopy. Respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (FES) certification. Comparisons of responses from the immediate post-course survey to the 6-month follow-up survey were examined. McNemar and paired t tests were used for analyses. RESULTS: 23 of 57 (40%) course participants returned to the 6-month survey. No major barriers to endoscopy use were identified. Fellows reported less competition with GI providers as a barrier to practice compared to their original post-course expectations (50% vs. 86%, p < 0.01). In addition, confidence was maintained in performing the majority of the 16 endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (- 26%; p < 0.05), control of variceal bleeding (- 39%; p < 0.05), colonic stenting (- 48%; p < 0.01), BARRX (- 40%; p < 0.05), and TIF (- 31%; p < 0.05). Fewer fellows used the GI suite to manage surgical problems than was anticipated post course (26% vs. 74%, p < 0.01). Fellows who passed FES noted no significant loss of independence, changes in use, or barriers to use. 18% made additional partnerships with industry after the course. 41% stated flexible endoscopy has influenced their post-fellowship job choice. CONCLUSIONS: The SAGES flexible endoscopy course for MIS fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures 6 months later. Additionally, fellows experienced no major barriers to implementing endoscopy into practice.

A Cross-Sectional Study of Emotional Intelligence in Military General Surgery Residents.

OBJECTIVE: Higher emotional Intelligence (EI) is linked to improved doctor-patient relationships, empathy, teamwork, communication skills, stress management, and leadership in medicine. This study analyzes the effects of age, postgraduate year (PGY), gender, and prior military experience on EI in military general surgery residents, and compares these to the general population and civilian surgery residents. DESIGN: This is a retrospective, observational study. Results were analyzed using independent sample t test and linear regression to compare general surgery residents with the normative population and civilian general surgery residents. SETTING: The general surgery department at Walter Reed National Military Medical Center, a single-center, academic institution. PARTICIPANTS: All general surgery residents, PGY 1 to 6, were surveyed at the beginning of academic year, in June 2016. RESULTS: There were no statistically discernable differences in global EI between male (n = 27) and female residents (n = 19), PGY, or prior military experience. Female general surgery residents show higher global EI, and both males and females scored higher in the self-control factor than the normative population. Mid-residency, there is a nonstatistically discernible dip in many factors and facets of EI. CONCLUSIONS: Gender differences in EI present in the general population were not appreciated in our cohort of surgery residents, which confirms the results of previous studies. This may be due to the fact that general surgery residents are a more uniform group than the population at large. Additionally, our cohort of military surgery residents demonstrated similar global EI to civilian surgery residents. While PGY had no statistically discernable affect on global, facet, or factor EI, more studies are needed to longitudinally follow changes in EI over the course of surgery residency.

How Much Are We Spending on Resident Selection?

INTRODUCTION: Rigorous selection processes are required to identify applicants who will be the best fit for training programs. This study provides a national snapshot of selection practices used within surgical residency programs and their associated financial costs. METHODS: A 17-item online survey was distributed to General Surgery Program Directors (PDs) via the Association of Program Directors in Surgery listserv. The survey examined program characteristics, applicant pool size, and interview day components of the prior match year. PD/coordinator teams also provided hard costs associated with interview day components, as well as time and effort estimations among program faculty, residents, and staff during the past interview season. Effort estimates were translated to dollar values via national salary data reports of hourly wages for faculty and annual wages for administrative staff and residents. Descriptive statistics and one-way analysis of variance via SPSS 24.0 were used to examine the data. RESULTS: One-hundred and twenty-eight responses were received, reflecting 48% (128/267) of programs in the 2017 match. Average hard costs (±SD) were $8053 ± 6467, covering food ($3753 ± 4042), social sessions ($3175 ± 3749), supplies ($329 ± 866), hotel ($328 ± 1381), room reservations ($120 ± 658), shuttle fees ($84 ± 403), tour guide fees ($50 ± 379), and other ($146 + 824). Costs for personnel effort was $77,601 ± 62,413 for faculty, $12,393 ± 33,518 for residents, $6447 ± 11,107 for coordinators, and $1294 ± 1943 for staff. Total average cost associated with the interview process (hard + effort) was $100,438±87,919, with university-based programs ($128,686 ± 101,565) spending significantly more than independent-university affiliated ($61,162 ± 33,945), independent ($74,793 ± 73,261), and military ($62,495 ± 38,532) programs (p < 0.01). Average cost for each residency program per position being filled was $18,648 ± 13,383, and average cost per interviewee was $1221 ± 894. CONCLUSIONS: In an era of declining resources for medical education, PDs must understand the time and effort associated with resident selection. These data reveal that residency programs are spending significant time and resources on the current selection process. Program leaders can use these data to assess their current selection strategies, review faculty and staff time allocation, and identify opportunities for making the process more efficient.