Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines.

BACKGROUND: We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS. METHODS: A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed. RESULTS: ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes. CONCLUSION: ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

Cost Effectiveness of a Fast-Track Protocol for Urgent Laparoscopic Cholecystectomies and Appendectomies.

BACKGROUND: Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA). STUDY DESIGN: This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F). RESULTS: There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups. CONCLUSIONS: FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.

Sarcopenia and frailty in elderly trauma patients.

BACKGROUND: Sarcopenia describes a loss of muscle mass and resultant decrease in strength, mobility, and function that can be quantified by CT. We hypothesized that sarcopenia and related frailty characteristics are related to discharge disposition after blunt traumatic injury in the elderly. METHODS: We reviewed charts of 252 elderly blunt trauma patients who underwent abdominal CT prior to hospital admission. Data for thirteen frailty characteristics were abstracted. Sarcopenia was measured by obtaining skeletal muscle cross-sectional area (CSA) from each patient's psoas major muscle using Slice-O-Matic(®) software. Dispositions were grouped as dependent and independent based on discharge location. χ (2), Fisher's exact, and logistic regression were used to determine factors associated with discharge dependence. RESULTS: Mean age 76 years, 49 % male, median ISS 9.0 (IQR = 8.0-17.0). Discharge destination was independent in 61.5 %, dependent in 29 %, and 9.5 % of patients died. Each 1 cm(2) increase in psoas muscle CSA was associated with a 20 % decrease in dependent living (p < 0.0001). Gender, weakness, hospital complication, and cognitive impairment were also associated with disposition; ISS was not (p = 0.4754). CONCLUSIONS: Lower psoas major muscle CSA is related to discharge destination in elderly trauma patients and can be obtained from the admission CT. Lower psoas muscle CSA is related to loss of independence upon discharge in the elderly. The early availability of this variable during the hospitalization of elderly trauma patients may aid in discharge planning and the transition to dependent living.

Twelve Tips for Improving the General Surgery Resident Night Float Experience.

Restriction of resident duty hours has resulted in the implementation of night float systems in surgical and medical programs. Many papers have examined the benefits and structure of night float, but few have addressed patient safety issues, quality patient care, and the impact on the residency education system. The objective of this review is to provide practical tips to optimize the night float experience for resident training while continuing to emphasize patient care. The tips provided are based on the experiences and reflections of residents, supervising staff, group discussions, and the available literature in a hospital-based general surgery residency program. Utilizing these resources, we concluded that the night float system addresses resident work hour restrictions; however, it ultimately creates new issues. Adaptations will help achieve a balance between resident education and patient safety.

Tackling technical skills competency: a surgical skills rating tool.

BACKGROUND: The Accreditation Council for Graduate Medical Education common program requirements mandate a competency-based assignment of duties. To accomplish this, valid and reliable assessment tools must be developed to evaluate competence. This study evaluated a rating tool to assess competence in basic surgical suturing skills. METHODS: A technical skills exercise consisting of the closure of three incisions, 3 cm long, was devised in 2006. The incisions were closed with simple stitches with two-handed knots, vertical mattress stitches with instrument knots, and a running stitch with one-handed knots. Fifteen min were allotted for completion. A rating instrument with 17 competency markers worth 1 point and a global 5-point Likert scale competency score was used to evaluate the performance. Twelve first-week post graduate year 1 surgical residents completed the exercise in 2006, and 16 final-month post graduate year 1 surgical residents completed it in 2011. All tasks were scored on video review by two independent raters. Statistical analysis included descriptive statistics, t-score analysis, rank sum analysis, Cohen's kappa coefficient, and Cronbach's alpha. RESULTS: The mean total score (11.8 versus 13.9, P = 0.002) and median global competency rating (1 versus 3, P < 0.001) were lower for the first-week cohort. Cohen's kappa coefficient of inter-rater reliability was 0.77. Cronbach's alpha measure of internal consistency was 0.87. CONCLUSION: This rating form is a valuable tool to evaluate technical skill competency. Construct validity was demonstrated with improvement in total score and global rating. Excellent internal consistency and inter-rater reliability were also demonstrated. This form may be used to assess technical skill competency in an efficient skills exercise.

Comparison of outcomes with coils versus vascular plug embolization of the internal iliac artery for endovascular aortoiliac aneurysm repair.

OBJECTIVE: To compare the safety and efficacy of coil embolization (COIL) to Amplatzer vascular plug embolization (PLUG) to achieve internal iliac artery (IIA) occlusion prior to endovascular aortiliac aneurysm repair (EVAR). METHODS: Data from consecutive patients who underwent IIA embolization prior to EVAR over a 6-year period (2004-2010) were retrospectively reviewed. Patient demographics, treatment modalities, and outcomes were compared. RESULTS: From January 1, 2004 to December 31, 2010, a total of 53 patients underwent percutaneous embolization of 57 IIAs prior to EVAR. Twenty-nine IIAs underwent COIL and 28 IIAs underwent PLUG embolization. Patient demographics and risk factors were similar between the two groups. Patients underwent repair for aneurysmal dilation of the infrarenal aorta in conjunction with the common or internal iliac arteries (n = 35, 62%) or isolated iliac artery aneurysms (n = 19, 38%). A significantly greater number of embolization devices were used in the COIL group (5.8 ± 3.8 vs 1.1 ± 0.4; P < .0001). Patients undergoing PLUG embolization demonstrated significantly shorter procedure times (118.4 ± 64.7 minutes vs 72.6 ± 22.4 minutes; P = .008) and fluoroscopy times (32.6 ± 14.6 vs 14.4 ± 8.6 minutes; P = .002). However, radiation dose between the groups did not differ (COIL: 470,192.7 ± 190,606.6 vs PLUG: 300,972.2 ± 191,815.7 mGycm(2); P = .10). Overall periprocedural morbidity did not differ between the groups (COIL: 11% vs PLUG: 6%; P = 1.0), and there were no perioperative mortalities or severe complications. Nontarget embolization occurred in two COIL and no PLUG cases (COIL: 6.9% vs PLUG: 0%; P = .49). Patient-reported buttock claudication at 1 month was 17.2% for COIL and 39.3% for PLUG patients (P = .08). At last follow-up, persistent buttock claudication was reported in 13.8% of COIL and in 14.3% of PLUG embolizations (P = 1.0). There was no significant difference in charges for the embolization material, operating room, or overall hospital charges (COIL: 44,720 ± 19,153 vs 37,367 ± 10,915; P = .22). Lastly, zero endoleaks in the COIL group and three in the PLUG group (P = .40) were detected on the most recent follow-up computed tomography imaging. No endoleak was related to the site of IIA embolization. CONCLUSIONS: COIL and PLUG embolization both provide effective IIA embolization with low complication rates when used for EVAR. Buttock claudication did occur in approximately one-third of patients but resolved in half of those affected. PLUG embolization took significantly less time to perform and required decreased fluoroscopy times. Based on outcomes and cost-analysis, COIL and PLUG embolization are equivalent methods to achieve IIA occlusion during EVAR.

A multidisciplinary course on injury prevention and control for medical students.

PURPOSE: Medical student education has begun to embrace integration across specialties in order to improve understanding of diseases. The Medical College of Wisconsin's Trauma and Injury Control course was developed to expose students to the science, principles, and practice of injury prevention and control, with emphasis on collaboration among disciplines. This paper describes the development, implementation, and evaluation of that course. METHODS: This retrospective study evaluated learner satisfaction and knowledge gained during a fourth-year selective from March 2007 to 2009. The educational experience provided unique activities developed through an interprofessional approach. Student assessment included oral presentations, small-group discussions, and participation in activities. Students evaluated the quality of the experience using written narrative evaluations. Two independent, blinded raters analyzed student narratives using the constant comparative method associated with grounded theory. RESULTS: Thirty-seven students completed the course and provided comments. Evaluations demonstrated high satisfaction. Five themes emerged as strengths and outcomes: (1) recognition of injury as preventable, (2) variety of interactive educational experiences, (3) understanding physician's role in injury policy, (4) opportunity to see the system of injury care, (5) recognition of injury as a disease. Criticisms of the course related to problems with coordination. CONCLUSION: Horizontal integration of the teaching of injury is feasible and should be promoted as a valued instructional technique.

Intraabdominal vascular injury: are we getting any better?

BACKGROUND: Intraabdominal vascular injury (IAVI) as a result of penetrating and blunt trauma carries a high mortality rate. This study was performed to compare current mortality rates with a previously reported historic control. METHODS: The experience at our institution from 1970 to 1981 was previously reported with an overall mortality rate of 32% in 112 patients with penetrating IAVI. In a retrospective analysis, this historic cohort was compared with 248 patients with penetrating and blunt IAVI during a 138-month interval ending in June 2007. RESULTS: Overall mortality rate was 28.6%. The most commonly injured arteries were the iliac artery, aorta, and superior mesenteric artery. The most commonly injured veins were the inferior vena cava, iliac vein, and portal vein. Injury to the aorta, IVC, and portal vein had the highest mortality rates of 67.8%, 42.1%, and 66.6%, respectively. One hundred forty-four patients with one vessel injured had a mortality rate of 18.7%, whereas those with more than one vessel injured had a mortality rate of 48.7% (p < 0.001). A total of 46% of 117 patients in shock died compared with 9.6% of 104 patients not in shock (p < 0.001). Patients with a base deficit of less than -15 had a mortality rate of 72%, whereas those with a base deficit of 0 to -15 (p < 0.001) had a mortality rate of 18.9%. There was no difference in the overall mortality rate for penetrating trauma compared with the previous study. CONCLUSIONS: Although over 20 years have passed, no significant changes have occurred in the mortality associated with IAVI. Patients presenting in shock with IAVI continue to have a high mortality rate.

Perforated appendicitis: Short duration antibiotics are noninferior to traditional long duration antibiotics.

BACKGROUND: Appendicitis usually manifests as either uncomplicated or complicated disease. Uncomplicated appendicitis is generally treated with an appendectomy without further antibiotic therapy. In contrast, complicated appendicitis can be treated in a myriad of ways. Nonoperative treatment has been proven to be effective but has variable failure rates. Operative management typically involves resection with postoperative antibiotics. The duration of antibiotic therapy is a topic of interest. Past studies have shown that a shorter duration of antibiotics (3-5 days) are equally as effective in treating intra-abdominal contamination. In the fall 2015, our practice pattern for antibiotic duration for acute complicated appendicitis changed to reflect this finding. The purpose of this study is to retrospectively review this change in practice. HYPOTHESIS: The aim of this study was to determine if a shorter duration of antibiotics for acute complicated appendicitis is as effective as a traditional longer duration of antibiotics with a historical cohort. We also aim to determine if the duration of stay improved with the shorter duration of antibiotics. METHODS: Appendicitis cases documented after September 2015 until the present were identified. Study inclusion criteria included patients aged ≥18 and patients undergoing an appendectomy (open or laparoscopic). Exclusion criteria included patients age <18, appendicitis cases not undergoing an operation, pregnant, or immunocompromised patients. Patient demographics, operation performed, pathology reports, antibiotic duration, duration of stay, infectious and postoperative complications, and 30-day readmission rates were collected through chart review. A sample of our treatment group prior to September 2015 was also obtained in a similar technique. RESULTS: The durations of stay between cohorts were not different; both were about 6.1 days. The duration of antibiotics was less in the post-2015 group (5.5 days vs 4.1 days, P = .005). The 30-day readmission rate was significantly less in the post-2015 group (16% vs 2%; P < .017). Neither in hospital infectious complications nor types of complications were statistically significantly different between groups. CONCLUSION: This study shows that adherence to short duration antibiotic treatment appears to be effective in decreasing the 30-day readmission rate without increasing in hospital infectious complications. Short duration of antibiotics did not, however, decrease the duration of hospital stay.

Implementation of an adhesive small bowel obstruction protocol using low-osmolar water soluble contrast and the impact on patient outcomes.

BACKGROUND: Small bowel obstruction (SBO) is a common condition leading to numerous hospital admissions and operations. Standardized care of adhesive SBO patients has not been widely implemented in hospital systems. METHODS: A prospective cohort of SBO patients was compared to a historical cohort of SBO patients after implementation of a SBO protocol using evidence-based guidelines and Omnipaque, a low-osmolar water soluble contrast. Patients without a history of abdominal surgery were excluded and data was collected through chart review. RESULTS: Univariate analyses demonstrated a decrease in both LOS by 1.35 days and in the proportion of patients receiving surgery (37% vs 25%; p < 0.05). There was a decrease in time to surgery, rate of SBR, and rate of complications, yet an increase in readmission, although these findings were not statistically significant. CONCLUSIONS: Utilizing an evidence-based SBO protocol can lead to shorter LOS and may result in fewer operations for adhesive SBO patients.

Enteric Fistula Treatment and Management: Results of an Institutional Inpatient Treatment Protocol.

INTRODUCTION: Enterocutaneous fistulae (ECF) are abnormal communications between the gastrointestinal tract and skin that may occur following an abdominal operation and result in significant morbidity and even mortality. Standardized care of patients with ECF has not been implemented at the majority of tertiary hospitals. We sought to evaluate the benefits of a multidisciplinary team utilizing an evidence-based clinical treatment protocol for inpatient management of ECF. METHODS: We performed an Institutional Review Board-approved retrospective analysis of outcomes after the implementation of an evidence-based clinical treatment protocol for patients admitted with ECF to the acute care surgical service at a large academic medical facility. Patients managed prior to the established protocol were considered part of the pre-protocol cohort (pre) while patients managed following implementation were included in the postprotocol cohort (post). A review of all eligible patients' hospital and clinic medical records was performed. RESULTS: In the pre cohort (n = 6), the average length of stay was 37 days, ranging from 16-67 days, with a 16% spontaneous closure rate and 60% requiring operative management for closure. A single patient was not offered surgery due to significant comorbidities. The post cohort (n = 13) demonstrated an average length of stay of just 16 days, ranging from 4 to 28 days, with an 84% spontaneous closure rate and 16% requiring operative closure. CONCLUSION: Utilization of a standardized treatment approach results in high spontaneous closure rates with a decreased hospital length of stay.

Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma.

BACKGROUND: As more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma mechanisms. METHODS: A retrospective review was conducted of all patients diagnosed with PTX by chest CT between January 2011 and December 2016. Patients were excluded if they had an associated hemothorax, an immediate TT (TT placed before the initial chest CT), or if they were on mechanical ventilation. Size of PTX was quantified by measuring the radial distance between the parietal and visceral pleura/mediastinum in a line perpendicular to the chest wall on axial imaging of the largest air pocket. Based on previous work, a cutoff of 35 mm on the initial CT was used to dichotomize the groups. Failure of observation was defined as the need for a delayed TT during the first week. A univariate analysis was performed to identify predictors of failure in both groups, and multivariate analysis was constructed to assess the independent impact of PTX measurement on the failure of observation while controlling for demographics and chest injuries. RESULTS: Of the 1,767 chest trauma patients screened, 832 (47%) had PTX, and of those meeting inclusion criteria, 257 (89.0%) were successfully observed until discharge. Of those successfully observed, 247 (96%) patients had a measurement of 35 mm or less. The positive predictive value for 35 mm as a cutoff was 90.8% to predict successful observation. In the univariant analyses, rib fractures (p = 0.048), Glasgow Coma Scale (p = 0.012), and size of the PTX (≤35 mm or >35 mm) (P < 0.0001) were associated with failed observation. In multivariate analysis, PTX measuring 35 mm or less was an independent predictor of successful observation (odds ratio, 0.142; 95% confidence interval, 0.047-0.428)] for the combined blunt and penetrating trauma patients. CONCLUSION: A 35-mm cutoff is safe as a general guide with only 9% of stable patients failing initial observation regardless of mechanism. LEVEL OF EVIDENCE: Therapeutic, level III.

The Surgical Learning and Instructional Portfolio (SLIP) as a self-assessment educational tool demonstrating practice-based learning.

PURPOSE: Time constraints on the teaching and evaluation of residents continue to alter the way in which medical knowledge must be imparted and assessed. Lifelong learning is a component of the practice-based learning competency. A portfolio is one way to assess practice-based learning, but its use is unfamiliar to most surgical programs. The authors describe the evolution of the Surgical Learning and Instructional Portfolio (SLIP) into a worthwhile educational tool. METHODS: In March 2001, the authors began a program to encourage residents to develop a case-based portfolio to document their experience and demonstrate acquisition of knowledge in caring for a variety of surgical diseases. The monthly case topic was chosen by the resident and reported using a template: case history, supporting diagnostic studies, differential diagnosis, final diagnosis with ICD-9 coding, management options, treatment used, 3 lessons learned, embellishment of 1 lesson, and 2 articles supporting the experience. Initially, cases were submitted to the program coordinator and reviewed every 6 months with a faculty advisor to provide feedback. RESULTS: After the first 18 months of this program, resident compliance was less than 50%, satisfaction was low, and formal review did not occur. In July 2004, a single faculty member became responsible for evaluating and providing feedback on the monthly SLIPs. The assignments were handled electronically with feedback delivered within the month via e-mail. SLIP quality as measured by resident compliance and satisfaction improved. CONCLUSION: These SLIPs have matured into a valuable educational tool satisfying multiple ACGME competencies. This portfolio system required direct faculty feedback to become successful.

Establishing a conceptual framework for handoffs using communication theory.

BACKGROUND: A significant consequence of the 2003 Accreditation Council for Graduate Medical Education duty hour restrictions has been the dramatic increase in patient care handoffs. Ineffective handoffs have been identified as the third most common cause of medical error. However, research into health care handoffs lacks a unifying foundational structure. We sought to identify a conceptual framework that could be used to critically analyze handoffs. METHODS: A scholarly review focusing on communication theory as a possible conceptual framework for handoffs was conducted. A PubMed search of published handoff research was also performed, and the literature was analyzed and matched to the most relevant theory for health care handoff models. RESULTS: The Shannon-Weaver Linear Model of Communication was identified as the most appropriate conceptual framework for health care handoffs. The Linear Model describes communication as a linear process. A source encodes a message into a signal, the signal is sent through a channel, and the signal is decoded back into a message at the destination, all in the presence of internal and external noise. The Linear Model identifies 3 separate instances in handoff communication where error occurs: the transmitter (message encoding), channel, and receiver (signal decoding). CONCLUSIONS: The Linear Model of Communication is a suitable conceptual framework for handoff research and provides a structured approach for describing handoff variables. We propose the Linear Model should be used as a foundation for further research into interventions to improve health care handoffs.

Geriatric small bowel obstruction: an analysis of treatment and outcomes compared with a younger cohort.

BACKGROUND: Small bowel obstruction (SBO) is a common condition, but little is known about its presentation, management, and outcomes in geriatric patients. METHODS: A retrospective review was performed comparing geriatric (≥65 years of age) and nongeriatric patients admitted with SBO. Admission characteristics, treatment, and outcomes were compared. Data analysis included Student t test and chi-square test or Fisher's exact test. RESULTS: Among 80 geriatric and 136 nongeriatric patients, no difference was observed among admission characteristics, treatment, time to or type of surgery, length of postoperative stay, or overall complications. Cardiac complications (15% vs 0%, P = .0082) and subacute care facility discharge (29% vs 5%, P < .001) were more common for geriatric patients. CONCLUSIONS: Compared with younger adults, elderly patients with SBO have similar presentations and overall outcomes with the exception of cardiac morbidity and discharge disposition. Preoperative attention to cardiac risk profile and discharge disposition discussion should be encouraged.

Elderly surgical patients: are there gaps in residency education?

BACKGROUND: Geriatric education is essential to ensure the competency of residents caring for the aging population. This study assesses and correlates resident and faculty perceptions of resident geriatric-related competencies to clinical care. METHODS: A survey was sent to 40 general surgery residents and 57 faculty members. Five clinical care markers were identified for chart audit. A retrospective chart audit was performed of 22 injured elderly patients. RESULTS: Among the respondents, 30 of 40 (75%) residents and 22 of 57 (39%) faculty completed the survey. Residents rated their competency higher than faculty on all competency-related questions (p = 0.0002). The following 4 questions had a mean faculty rating below acceptable: screening guidelines, delirium management, contraindicated medications, and medication adjustments. On chart review: code status was documented in 7 of 22 (32%) patients and goals of care in 1 of 22 (5%) patients. Pain control included rib block or epidural in 14 of 22 (64%) patients. Contraindicated medications were prescribed in 13 of 22 (59%) patients. CONCLUSION: A competency-based needs assessment of geriatric training in a general surgery residency has identified educational "gaps." This needs assessment supports implementation of geriatric education initiatives in our general surgery program.

Surgery residency curriculum examination scores predict future American Board of Surgery in-training examination performance.

IMPORTANCE: A protected block curriculum (PBC) with postcurriculum examinations for all surgical residents has been provided to assure coverage of core curricular topics. Biannual assessment of resident competency will soon be required by the Next Accreditation System. OBJECTIVE: To identify opportunities for early medical knowledge assessment and interventions, we examined whether performance in postcurriculum multiple-choice examinations (PCEs) is predictive of performance in the American Board of Surgery In-Training Examination (ABSITE) and clinical service competency assessments. DESIGN: Retrospective single-institutional education research study. SETTING: Academic general surgery residency program. PARTICIPANTS: A total of 49 surgical residents. INTERVENTION: Data for PGY1 and PGY2 residents participating in the 2008 to 2012 PBC are included. Each resident completed 6 PCEs during each year. MAIN OUTCOME MEASURES: The results of 6 examinations were correlated to percentage-correct ABSITE scores and clinical assessments based on the 6 Accreditation Council for Graduate Medical Education core competencies. Individual ABSITE performance was compared between PGY1 and PGY2. Statistical analysis included multivariate linear regression and bivariate Pearson correlations. RESULTS: A total of 49 residents completed the PGY1 PBC and 36 completed the PGY2 curriculum. Linear regression analysis of percentage-correct ABSITE and PCE scores demonstrated a statistically significant correlation between the PGY1 PCE 1 score and the subsequent PGY1 ABSITE score (p = 0.037, ß = 0.299). Similarly, the PGY2 PCE 1 score predicted performance in the PGY2 ABSITE (p = 0.015, ß = 0.383). The ABSITE scores correlated between PGY1 and PGY2 with statistical significance, r = 0.675, p = 0.001. Performance on the 6 Accreditation Council for Graduate Medical Education core competencies correlated between PGY1 and PGY2, r = 0.729, p = 0.001, but did not correlate with PCE scores during either years. CONCLUSIONS AND RELEVANCE: Within a mature PBC, early performance in a PGY1 and PGY2 PCE is predictive of performance in the respective ABSITE. This information can be used for formative assessment and early remediation of residents who are predicted to be at risk for poor performance in the ABSITE.

Assessing competency in practice-based learning: a foundation for milestones in learning portfolio entries.

BACKGROUND: Graduate medical education is undergoing a dramatic shift toward competency-based assessment of learners. Competency assessment requires clear definitions of competency and validated assessment methods. The purpose of this study is to identify criteria used by surgical educators to judge competence in Practice-Based Learning and Improvement (PBL&I) as demonstrated in learning portfolios. METHODS: A total of 6 surgical learning and instructional portfolio entries served as documents to be assessed by 3 senior surgical educators. These faculty members were asked to rate and then identify criteria used to assess PBL&I competency. Individual interviews and group discussions were conducted, recorded, and transcribed to serve as the study dataset. Analysis was performed using qualitative methodology to identify themes for the purpose of defining competence in PBL&I. The assessment themes derived are presented with narrative examples to describe the progression of competency. RESULTS: The collaborative coding process resulted in identification of 7 themes associated with competency in PBL&I related to surgical learning and instructional portfolio entries: (1) self-awareness regarding effect of actions; (2) identification and thorough description of learning goals; (3) cases used as catalyst for reflection; (4) reconceptualization with appropriate use and critique of cited literature; (5) communication skills/completeness of entry template; (6) description of future behavioral change; and (7) engagement in process--identifies as personally relevant. CONCLUSIONS: The identified themes are consistent with and complement other criteria emerging from reflective practice literature and experiential learning theory. This study provides a foundation for further development of a tool for assessing learner portfolios consistent with the Accreditation Council for Graduate Medical Education's Next Accreditation System requirements.

An evaluation of the success of a surgical resident learning portfolio.

BACKGROUND: Learning portfolios have gained modest acceptance in graduate medical education because of challenges related to user satisfaction, time and resource commitment, and quality assessment. In 2001, the Department of Surgery implemented the Surgical Learning and Instructional Portfolio (SLIP) to help residents develop a case-based portfolio demonstrating practice-based learning. In 2008, the format was changed to a Web-based platform with open viewing of portfolios for all learners. This study was performed to evaluate the SLIP program using resident and faculty perspectives in the domains of satisfaction, compliance, and educational value. METHODS: Likert scale surveys were distributed to residents to assess satisfaction. Using a semistructured format with subsequent qualitative analysis of the meeting transcript, a focus group discussion was held with the SLIP director, SLIP facilitator, and program coordinator. An analysis of the program compliance was performed by review of SLIP entry dates. Finally, the quality of the SLIP entries (n = 420) was analyzed in a blinded manner using a locally developed standardized SLIP assessment tool. Data analysis was performed using Pearson's correlation and Cronbach's alpha. RESULTS: Residents were satisfied with the program and felt the Web-based format promoted self-reflection. They perceived that time spent was appropriate. Residents also believed they gained medical knowledge of their own specific entry topics but did not learn routinely from others' entries. Faculty asserted that the Web-based platform eased the administrative burden but did not necessarily alter the quality of the SLIP entries. Compliance with the assignment was 100%. SLIP entry analysis demonstrated the reflection and understanding of the topics chosen. However, the overall quality assessment of entries was hindered by suboptimal interrater reliability (inter-rater reliability (IR) = 0.636). CONCLUSIONS: The SLIP program allows residents to demonstrate practice-based learning and improvement of medical knowledge. The Web-based format provides transparency and ease of administration. Quality assessment of individual portfolio entries remains a challenge to the widespread adoption of portfolios.