A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment.

OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

Resident Operative Experience at Independent Academic Medical Centers-A Comparison to the National Cohort.

PURPOSE: Independent Academic Medical Centers (IAMCs) comprise one-third of U.S. general surgery training programs. It is unclear whether IAMCs offer qualitatively or quantitatively different operative experiences than the national cohort. We analyzed a large representative sample of IAMCs to compare operative volume and variety, with a focus on low-volume procedures. METHODS: Accreditation Council for Graduate Medical Education Program Case Reports from 27 IAMCs were collected and analyzed for 3 academic years (2012-2015). IAMCs were compared to the national cohort for specific defined category volumes and selected low-volume cases. One-sample two-way t-tests were calculated comparing IAMC totals to national program averages. RESULTS: IAMCs had a median of 3 chief residents per year (range: 1-6). IAMCs reported significantly more "total major" procedures in 2013-2014 (p = 0.046). Other case totals were statistically similar between IAMCs and the national cohort for "total major", "surgeon chief", "surgeon junior", and "teaching assistant" cases. In 2013-2014, IAMCs reported more laparoscopic complex (138.3 vs. 110.6, p = 0.010) and alimentary tract cases (276.5 vs. 253.5, p = 0.019). IAMC esophagogastroduodenoscopy case totals were higher in 2013-2014 (55.9 vs. 41, p = 0.038) and 2014-2015 (47.8 vs. 41, p = 0.047). IAMCs had fewer pancreas cases than the national cohort in all three years by about three cases per resident (p ≤ 0.026). In 2012-2013 IAMCs reported fewer (by about one) esophagectomy, gastrectomy, and abdominal perineal resections. No differences were observed in the following selected procedures: open common bile duct exploration, inguinal hernia, laparoscopic appendectomy, laparoscopic cholecystectomy, and colonoscopy. CONCLUSIONS: The IAMCs studied appear to provide equivalent exposure to specific subcategories mandated by the Accreditation Council for Graduate Medical Education and American Board of Surgery. Graduates of IAMCs gain similar operative experience in low-volume, defined categories when compared to the national cohort. Certain specific cases subject to regionalization pressure are less well represented among IAMCs. This has important implications for medical students applying to surgery residency.

Predictors of in-hospital length of stay after laparoscopic ventral hernia repair: results of multivariate logistic regression analysis.

AIM: To identify variables that predict in-hospital length of stay (LOS) after laparoscopic ventral hernia repair (LVHR). METHODS: Univariate analysis of patient and intraoperative variables was conducted on an operating room database of LVHRs performed from April 2001 to April 2009. Analysis was performed using either chi-square or linear trend analysis, as appropriate. A multivariate logistic regression model was created manually, to determine independent variables that predict LOS. p Value <0.05 was considered significant. RESULTS: A total of 221 patients, with mean age of 56 years (range 25-88 years) underwent LVHR, for a total of 121 incisional and 100 primary ventral hernias. Of patients, 40% had incarcerated hernias and 25% had complex hernias (defined as multiple points of weakness on the anterior abdominal wall). The overall conversion rate to open operation was 6%. Mean LOS was 1.54 days (range 0-22 days). Eighty-six patients (39%) were discharged on the day of the procedure. Variables associated with significantly longer LOS on univariate analysis were incisional hernia (p = 0.000009), mesh size (p = 0.00007), complex hernia (p = 0.00009), incarcerated hernia (p = 0.0004), patient age (p = 0.0006), need for lysis of adhesions (p = 0.001), and female gender (p = 0.01). American Society of Anesthesiologists (ASA) grade >2, conversion to open procedure, and recurrent hernia were not associated with longer LOS. Four factors were independently associated with significant longer length of stay on multivariate logistic regression analysis (p < 0.05): mesh size (p = 0.00005), incarcerated hernia (p = 0.002), patient age (p = 0.018), and complex hernia (p = 0.035). CONCLUSIONS: Mesh size, incarcerated hernia, patient age, and complex hernia predict longer length of stay after laparoscopic ventral hernia repair.

Littoral cell angioma of the spleen treated by laparoscopic splenectomy.

Massive splenomegaly due to multifocal littoral cell angioma was discovered incidentally in a 55-year-old man during a workup for an unrelated condition. The tumor was removed successfully by laparoscopic splenectomy. We report the second case of littoral cell angioma of the spleen treated laparoscopically.