Remote Assessment of Real-World Surgical Safety Checklist Performance Using the OR Black Box: A Multi-Institutional Evaluation.

BACKGROUND: Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale. STUDY DESIGN: In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated. RESULTS: Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out. CONCLUSIONS: Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures.

The Relationship Between Program and Applicant Characteristics With Applicant Program Signals in the 2022 Residency Recruitment Cycle: Findings From 3 Specialties.

PURPOSE: Continuing increases in application volume have driven a national dialogue to reform the residency recruitment process. Program signaling allows applicants to express interest in a program at the preinterview stage with the goal of helping programs identify applicants with more genuine interest in their programs. This study explored the relationship between program signals and program and applicant characteristics. METHOD: Participating dermatology, general surgery, and categorical internal medicine (IM) programs and applicants of the 2022 supplemental ERAS application (SuppApp) were included. Data from the SuppApp, the MyERAS Application for Residency Applicants (MyERAS), and the 2020 GME Track Survey were used. Cohen's h was used to determine effect size, and chi-squared was used to determine statistical significance. RESULTS: There was an uneven distribution of signals to programs, with 25% of programs receiving about half of the signals across all 3 specialties. Programs with larger numbers of both residents and applicants received greater numbers of program signals relative to their program density, although this effect was small ( h < 0.50, P < .001). No meaningful differences were seen across genders for any specialty. Only Hispanic applicants in IM sent a higher proportion of signals to programs with more underrepresented in medicine residents than White only applicants (40% vs 26%, h = 0.30, P < .001). Across all specialties, there was a small-to-moderate effect for international medical graduate (IMG) applicants sending a larger proportion of signals to programs with more IMG residents ( h < 0.80, P < .001). CONCLUSIONS: This first-year pilot study (i.e., SuppApp) provided initial evidence that supports the feasibility and fairness of program signals in residency selection. As program signals become more common across specialties, future research should continue to evaluate trends in where applicants send signals, and possible relationships between program and application characteristics.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Coaching with audiovisual technology in acute-care hospital settings: systematic review.

BACKGROUND: Surgical coaching programmes are a means of improving surgeon performance. Embedded audiovisual technology has the potential to further enhance participant benefit and scalability of coaching. The objective of this systematic review was to evaluate how audiovisual technology has augmented coaching in the acute-care hospital setting and to characterize its impact on outcomes. METHODS: A systematic review was conducted, searching PubMed, Ovid MEDLINE, Embase, PsycInfo, and CINAHL databases using PRISMA. Eligible studies described a coaching programme that utilized audiovisual technology, involved at least one coach-coachee interaction, and included healthcare professionals from the acute-care hospital environment. The risk of bias 2 tool and grading of recommendations, assessment, development, and evaluations (GRADE) framework were used to evaluate studies. Synthesis without meta-analysis was performed, creating harvest plots of three coaching outcomes: technical skills, self-assessment/feedback, and non-technical skills. RESULTS: Of 10 458 abstracts screened, 135 full texts were reviewed, and 21 studies identified for inclusion. Seventeen studies were conducted within surgical specialties and six classes of audiovisual technology were utilized. An overall positive direction of effect was demonstrated for studies measuring improvement of either technical skills or non-technical skills. Direction of effect for self-assessment/feedback was weakly positive. CONCLUSION: Audiovisual technology has been used successfully in coaching programmes within acute-care hospital settings to facilitate or assess coaching, with a positive impact on outcome measures. Future studies may address the additive benefits of video over in-person observation and enhance the certainty of evidence that coaching impacts on surgeon performance, surgeon well-being, and patient outcomes.

Alone Together: Is Strain Experienced Concurrently by Members of Operating Room Teams?: An Event-based Study.

Objective: To identify which strain episodes are concurrently reported by several team members; to identify triggers of strain experienced by operating room (OR) team members during the intraoperative phase. Summary: OR teams are confronted with many sources of strain. However, most studies investigate strain on a general, rather than an event-based level, which does not allow to determine if strain episodes are experienced concurrently by different team members. Methods: We conducted an event-based, observational study, at an academic medical center in North America and included 113 operations performed in 5 surgical departments (general, vascular, pediatric, gynecology, and trauma/acute care). Strain episodes were assessed with a guided-recall method. Immediately after operations, participants mentally recalled the operation, described the strain episodes experienced and their content. Results: Based on 731 guided recalls, 461 strain episodes were reported; these refer to 312 unique strain episodes. Overall, 75% of strain episodes were experienced by a single team member only. Among different categories of unique strain episodes, those triggered by task complexity, issues with material, or others' behaviors were typically experienced by 1 team member only. However, acute patient issues (n = 167) and observations of others' strain (n = 12) (respectively, 58.5%; P < 0.001 and 83.3%; P < 0.001) were often experienced by 2 or more team members. Conclusions and relevance: OR team members are likely to experience strain alone, unless patient safety is at stake. This may jeopardize the building of a shared understanding among OR team members.

Outcomes of the 2021-2022 APDS General Surgery Recruitment Process Recommendations.

BACKGROUND: In recent years, mounting challenges for applicants and programs in resident recruitment have catapulted this topic into a top priority in medical education. These challenges span all aspects of recruitment-from the time an applicant applies until the time of the Match-and have widespread implications on cost, applicant stress, compromise of value alignment, and holistic review, and equity. In 2021-2022, the Association of Program Directors in Surgery (APDS) set forth recommendations to guide processes for General Surgery residency recruitment. OBJECTIVES: This work summarizes the APDS 2021-2022 resident recruitment process recommendations, along with their justification and program end-of-cycle program feedback and compliance. This work also outlines the impact of these data on the subsequent 2022-2023 recommendations. METHODS: After a comprehensive review of the available literature and data about resident recruitment, the APDS Task Force proposed recommendations to guide 2021-2022 General Surgery resident recruitment. Following cycle completion, programs participating in the categorical General Surgery Match were surveyed for feedback and compliance. RESULTS: About 122 of the 342 programs (35.7%) participating in the 2022 categorical General Surgery Match responded. Based on available data in advance of the cycle, recommendations around firm application and interview numbers could not be made. About 62% of programs participated in the first round interview offer period with 86% of programs limiting offers to the number of slots available; 95% conducted virtual-only interviews. Programs responded they would consider or strongly consider the following components in future cycles: holistic review (90%), transparency around firm requirements (88%), de-emphasis of standardized test scores (54%), participation in the ERAS Supplemental application (58%), single first round interview release period (69%), interview offers limited to the number of available slots (93%), 48-hour minimum interview offer response time (98%), operationalization of applicant expectations (88%), and virtual interviews (80%). There was variability in terms of the feedback regarding the timing of the single first round offer period as well as support for a voluntary, live site visit for applicants following program rank list certification. CONCLUSIONS: The majority of programs would consider implementing similar recommendations in 2022-2023. The greatest variability around compliance revolved around single interview release and the format of interviews. Future innovation is contingent upon the ongoing collection of data as well as unification of data sources involved in the recruitment process.

Real-Time Student Feedback on the Surgical Learning Environment: Use of a Mobile Application.

OBJECTIVE: Improvements to the medical student surgical learning environment are limited by lack of granular data and recall bias on end-of-clerkship evaluations. The purpose of this study was to identify specific areas for intervention using a novel real-time mobile application. DESIGN: An application was designed to obtain real-time feedback from medical students regarding the learning environment on their surgical clerkship. Thematic analysis of student experiences was performed at the conclusion of 4 consecutive 12-week rotation blocks. SETTING: Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts. RESULTS: Fifty-four medical students at a single institution were asked to participate during their primary clerkship experience. Students submitted 365 responses over 48 weeks. Multiple themes emerged which were dichotomized into positive and negative emotions centered on specific student priorities. Approximately half of responses were associated with positive emotions (52.9%) and half with negative emotions (47.1%). Student priorities included the desire to feel included in the surgical team (resulting in feeling engaged/ignored), to have a positive relationship with members of the team (perceiving kind/rude interactions), to witness compassionate patient care (observing empathy/disrespect for patients), to have a well-planned surgical rotation (experiencing organization/disorganization within teams), and to feel that student well-being is prioritized (reporting opportunities/disregard for student wellness). CONCLUSION: A novel, user-friendly mobile application identified several areas to improve the experience and engagement of students on their surgery clerkship. Allowing clerkship directors and other educational leaders to collect longitudinal data in real time may allow for more targeted, timely improvements to the medical student surgical learning environment.

Crew Autonomy During Simulated Medical Event Management on Long Duration Space Exploration Missions.

OBJECTIVE: Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. BACKGROUND: There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. METHOD: We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. RESULTS: Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. CONCLUSION: Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support. APPLICATION: Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

National Comparison of Program Director Perceptions vs. Resident Reports of the Learning Environment and Well-Being.

OBJECTIVE: Our research objectives were to (1) assess the correlation between PD perceptions and their residents' reported experiences and (2) identify PD and program characteristics associated with alignment between PD perceptions and their residents' reports. DESIGN, SETTING, PARTICIPANTS: A survey was administered to US general surgery residents following the 2019 American Board of Surgery In-Training Examination (ABSITE) to study wellness (burnout, thoughts of attrition, and suicidality) and mistreatment (gender discrimination, sexual harassment, racial/ethnic/religious discrimination, bullying). General surgery program directors (PDs) were surveyed about the degree to which they perceived mistreatment and wellness within their programs. Concordance between PDs' perceptions and their residents' reports was assessed using Spearman correlations. Multivariable logistic regression models examined factors associated with alignment between PDs and residents. RESULTS: Of 6,126 residents training at SECOND Trial-enrolled programs, 5,240 (85.5%) responded to the ABSITE survey. All 212 PDs of programs enrolled in the SECOND Trial (100%) responded to the PD survey. Nationally, the proportion of PDs perceiving wellness issues was similar to the proportion of residents reporting them (e.g., 54.9% of PDs perceive that burnout is a problem vs. 40.1% of residents experience at least one burnout symptom weekly); however, the proportion of PDs perceiving mistreatment vastly underestimated the proportion of residents reporting it (e.g., 9.3% of all PDs perceive vs. 65.9% of all residents report bullying). Correlations between PDs' perceptions of problems within their program and their residents' reports were weak for racial/ethnic/religious discrimination (r = 0.176, p = 0.019), sexual harassment (r = 0.180, p = 0.019), burnout (r = 0.198, p = 0.007), and thoughts of attrition (r = 0.193, p = 0.007), and non-existent for gender discrimination, bullying, or suicidality. Multivariable regression models did not identify any program or PD characteristics that were consistently associated with improved resident-program director alignment. CONCLUSIONS: Resident and PD perceptions were generally disparate regarding mistreatment, burnout, thoughts of attrition, and suicidality. Reconciling this discrepancy is critical to enacting meaningful change to improve the learning environment and resident well-being.

EQIP's First Year: A Step Closer to Higher Quality in Surgical Education.

OBJECTIVE: To describe the first year of the Educational Quality Improvement Program (EQIP) DESIGN: The Educational Quality Improvement Program (EQIP) was formed by the Association of Program Directors in Surgery (APDS) in 2018 as a continuous educational quality improvement program. Over 18 months, thirteen discrete goals for the establishment of EQIP were refined and executed through a collaborative effort involving leaders in surgical education. Alpha and beta pilots were conducted to refine the data queries and collection processes. A highly-secure, doubly-deidentified database was created for the ingestion of resident and program data. SETTING & PARTICIPANTS: 36 surgical training programs with 1264 trainees and 1500 faculty members were included in the dataset. 51,516 ERAS applications to programs were also included. Uni- and multi-variable analysis was then conducted. RESULTS: EQIP was successfully deployed within the timeline described in 2020. Data from the ACGME, ABS, and ERAS were merged with manually entered data by programs and successfully ingested into the EQIP database. Interactive dashboards have been constructed for use by programs to compare to the national cohort. Risk-adjusted multivariable analysis suggests that increased time in a technical skills lab was associated with increased success on the ABS's Qualifying Examination, alone. Increased time in a technical skills lab and the presence of a formal teaching curriculum were associated with increased success on both the ABS's Qualifying and Certifying Examination. Program type may be of some consequence in predicting success on the Qualifying Examination. CONCLUSIONS: The APDS has proved the concept that a highly secure database for the purpose of continuous risk-adjusted quality improvement in surgical education can be successfully deployed. EQIP will continue to improve and hopes to include an increasing number of programs as the barriers to participation are overcome.

A Pregnant Pause-Time to Address Mentorship for Expectant Residents.

This Viewpoint discusses support during pregnancy and post partum for surgical residents.

Gender and Racial/Ethnic Disparities in Operative Volumes of Graduating General Surgery Residents.

INTRODUCTION: Gender disparities in resident operative experience have been described; however, their etiology is poorly understood, and racial/ethnic disparities have not been explored. This study investigated the relationship between gender, race/ethnicity, and surgery resident case volumes. MATERIALS AND METHODS: A retrospective analysis of graduating general surgery resident case logs (2010-2020) at an academic medical center was performed. Self-reported gender and race/ethnicity data were collected from program records. Residents were categorized as underrepresented in medicine (URM) (Black, Hispanic, Native American) or non-URM (White, Asian). Associations between gender and URM status and major, chief, and teaching assistant (TA) mean case volumes were analyzed using t-tests. RESULTS: The cohort included 80 residents: 39 female (48.8%) and 17 URM (21.3%). Compared to male residents, female residents performed fewer TA cases (33 versus 47, P < 0.001). Compared to non-URM residents, URM residents graduated with fewer major (948 versus 1043, P = 0.008) and TA cases (32 versus 42, P = 0.038). Male URM residents performed fewer TA cases than male non-URM residents (32 versus 50, P = 0.031). Subanalysis stratified by graduation year demonstrated that from 2010 to 2015, female residents performed fewer chief (218 versus 248, P = 0.039) and TA cases (29 versus 50, P = 0.001) than male residents. However, from 2016 to 2020, when gender parity was achieved, no significant associations were observed between gender and case volumes. CONCLUSIONS: Female and URM residents perform fewer TA and major cases than male non-URM residents, which may contribute to reduced operative autonomy, confidence, and entrustment. Prioritizing gender and URM parity may help decrease case volume gaps among underrepresented residents.

Improving the financial wellness of general surgery residents: A nationwide survey.

BACKGROUND: Our study evaluated general surgery resident indebtedness and perspectives on financial compensation. METHODS: In May 2020, a survey was distributed nationwide by general surgery program directors in the Association of Program Directors in Surgery on a voluntary basis to their residents. RESULTS: The survey was completed by 419 general surgery residents. Median salary was $60-65 K and median medical educational debt was $200-250 K. Approximately 61% of residents reported that their financial needs were not met by their income. Most residents (76%) believe that for a fair compensation, their salaries should be 30-50% higher. Proposed interventions for improvement in resident compensation included: overtime payment, redirection of GME funds to the residency programs, and compensating residents for billable services. CONCLUSIONS: Residents enter training with significant medical educational debt and feel unfairly compensated for their work. Therefore, comprehensive interventions with input from residents are needed to improve their financial well-being.

Paternity Leave During Surgical Training: Perspectives of Male Residents.

OBJECTIVE: Recent literature on parental leave during residency has focused on the importance of supporting new mothers, but the needs and challenges faced by expectant nonchildbearing residents are less well described. Male residents are more likely than their female counterparts to have children during surgical training, and they experience similar stressors including childcare and conflicts between work and home priorities. As nonchildbearing parents of this generation become more involved in childrearing, the need to establish inclusive parental leave policies is essential. The aim of this study was to provide a deeper understanding of the perspectives of male residents about parental leave. DESIGN: A semi-structured interview guide was developed using a literature search and an expert panel. Interviews were audio-recorded and transcribed verbatim and emergent themes were identified using content analysis. SETTING: Four academic institutions. PARTICIPANTS: Four focus groups were held with of a total of 15 male resident-parents. These were selected using convenience sampling. RESULTS: Multiple themes emerged: 1) male residents perceive greater stigma attached to taking leave compared to female colleagues; 2) paternity leave policies are vague and sometimes non-existent; 3) male residents experience a high burden of guilt related to burdening peers with clinical coverage while on leave; 4) male residents face internal conflict between surgical and parental responsibilities; 5) male residents have little mentorship on successful work-life integration and feel compelled to model the behavior of their attendings who often prioritize career before family; and 6) shifts in family values and priorities are common following childbirth and impact how male resident-parents view other new parents in training. CONCLUSIONS: Significant challenges exist for residents who become fathers during their surgical training. Key stressors include poorly defined leave policies, historic paradigms of prioritizing professional duties before personal duties, stigma against taking time off for parental bonding in the absence of medical need, and guilt related to extra work imposed on colleagues by time away. Establishment of formal parental leave policies for both genders, programmatic support to offset the increased workload on colleagues, and greater mentorship on balancing family and career are needed to foster a culture of work-life integration.

The APDS General Surgery Education Quality Improvement Program (EQIP).

BACKGROUND: Although the ACGME has called for outcomes-based evaluation of residency programs, few metrics or benchmarks exist connecting educational processes with resident educational outcomes. To address this deficiency, a national Education Quality Improvement Program (EQIP) for General Surgery training is proposed. METHODS: We describe the initial efforts to create this platform. In addition, a national survey was administered to 330 Program Directors to assess their interest in and concerns about a continuous educational quality improvement project. RESULTS: We demonstrate that through a collaborative process and the support of the Association of Program Directors in Surgery (APDS), we were able to develop the groundwork for a national surgical educational improvement project, now called EQIP. The survey response rate was 45.8% (152 of 332 programs) representing a mix of university (55.3%), university-affiliated (18.4%), independent (24.3%), and military (2.0%) programs. Most respondents (66.2%) had not previously heard of EQIP. Most respondents (69.7%) believe that educational outcomes can be measured. The majority of respondents indicated they believed EQIP could be successful (57%). Only 2.3% thought EQIP would not be successful. Almost all programs (98.7%) expressed a willingness to participate, although 19.1% did not believe that they had adequate resources to participate. CONCLUSION: The APDS EQIP platform holds promise as a useful and achievable method to obtain educational outcomes data. These data can be used as a basis for continuous surgical educational quality improvement. General Surgery Program Directors have expressed enthusiasm for EQIP and are willing to participate in the program examining outcomes of General Surgery training programs, with an ultimate goal of improving overall residency training.