Prevention of surgical resident attrition by a novel selection strategy.

OBJECTIVE(S): We modified the resident selection strategy in an attempt to reduce resident attrition (RA). SUMMARY BACKGROUND DATA: Despite implementation of the Accreditation Council for Graduate Medical Education work rules, lifestyle and generational priorities have fostered a persistent and relatively high attrition rate for surgical trainees. METHODS: An independent external review of residents who left the training program and a detailed analysis of the resident selection strategy were performed by an organizational management expert. Modifications implemented in 2005 (the intervention) included standardization of the screening and interview format. Applicants were required to submit a 500 words essay related to stress management, organizational skills, future aspirations, and prioritization abilities. Their responses formed the basis of an extended, personalized, and structured interview script. Candidate characteristics and RA were compared for the 5 years before and after the intervention, using Fisher exact test or chi2. RESULTS: Age, sex, birthplace, medical school ranking, step 1 score, and American Board of Surgey In-Training Examination performance were not significantly different between the selection strategy groups. Risk factors for RA included ABSITE performance and gender. Resident performance and subsequent RA were significantly affected by the resident selection strategy. CONCLUSIONS: RA was dramatically reduced following the intervention. A custom designed process to identify candidates most likely to succeed substantially improved resident retention in a demanding academic training program.

Living long with short bowel syndrome: a historical case of twenty-nine years of living with home parenteral nutrition.

BACKGROUND: This paper traces the 29-year survival of Robert Thomas, who received home parenteral nutrition (PN), and contrasts his oral narrative with the clinical history of PN. METHODS: Interviews, chart review, review of the literature, and historical analysis. RESULTS: Bobby Thomas was part of an early group of patients scattered throughout the country who, with their medical team, provided the foundation for more successful survival with home PN. They learned together and taught numerous nutrition support clinicians the intricacies of patient management. The importance of the patient to the teaching function of new and experienced practitioners is highly critical. Patients like Robert Thomas gave practitioners firsthand evidence of both the tenacity of the human spirit and the complexity and difficulties of chronic illness and its treatments. CONCLUSIONS: While Bobby struggled with the complications and difficulties that came with the disease and the treatment keeping him alive, his own experiences over 29 years, as told to his medical team during his treatment and to informed interviewers before he died, tell a story that is both intersecting and parallel to the medical history. Pioneering patients like Bobby Thomas confirm the possibility of survival. They also, through their own negotiations to maintain a sense of control, can live lives they themselves help define.

The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience.

BACKGROUND: We based the Patient Safety Leadership Academy (PSLA) on the premise that improving management skills could improve patient safety and employee satisfaction. STUDY DESIGN: Fellows completed baseline surveys on leadership skills knowledge, patient safety knowledge, and program goals. They completed the same surveys 7 months later at the final PSLA session. The fellows also completed a survey assessing how PSLA improved expertise and comparing PSLA to other patient safety learning opportunities. Matched pairs t tests were used to compare baseline and postprogram results. RESULTS: Baseline scores indicated appropriateness of focusing on leadership, with average leadership knowledge (2.48) significantly lower than patient safety knowledge (3.22). For patient safety, postprogram results were significant for 8 of 10 questions. All results were significant for leadership. Fellows also rated skills covered by the curriculum on a scale of 1 to 10. For all areas, the median score for knowledge gained was 7. When compared with other patient safety learning experiences, participants rated PSLA as 4 or 5, where 1 indicated the other experience much more valuable and 5 much more valuable. CONCLUSIONS: PSLA demonstrates that leadership skills are perceived as important by physicians and managers in surgical areas. This study demonstrated that a leadership skills approach to patient safety training could improve knowledge in specific leadership areas and general patient safety.

How do surgical residents and non-physician practitioners play together in the sandbox?

INTRODUCTION: The reduction of resident work hours due to the 80-hour workweek has created pressure on academic health-care systems to find "replacement residents." At the authors' institution, a group of nurse practitioners (NPs) and physician assistants (PAs), collectively referred to as non-physician practitioners (NPPs), were hired as these reinforcements, such that the number of NPPs (56) was almost twice the number of clinical categorical surgery residents (37). An experienced leader with national credibility was hired to run the NPP program. On each service, the call system was changed to a night float system, whereby residents were pulled from traditional resident teams to serve as nighttime residents during the week. A total of 1-3 NPPs were hired for each team, but whether NPPs worked for the team as a whole, or were assigned to individual attendings, was left to the discretion of the division chiefs. One year after the start of this program, the authors wanted to study the effects it has had on both surgery resident education and NPP job satisfaction. METHODS: An electronic, anonymous survey was conducted during a monthly surgery resident meeting, and out of 72 categorical and preliminary surgery residents, 50% submitted answers to 12 questions. A similar electronic survey was administered to all 56 NPPs, with 45% responding. RESULTS: Overall, 63% of residents believed that lines of communication between surgery team members were clear, and 58% of residents and 71% of NPPs believed that attendings, residents, and NPPs worked together effectively. A total of 91% of residents believed that the addition of NPPs to the teams was positive overall, and 80% of NPPs were satisfied with their positions. Overall, 60% of residents and 50% of NPPs felt that educational goals were being met. DISCUSSION: Implementation of the 80-hour workweek and introduction of NPs and PAs onto the inpatient surgical services has altered resident education at the authors' institution. Although overall most residents view the addition of NPPs to the clinical services as positive, there are concerns about the program. Although hired to fill the void left by decreasing labor hours of residents, NPPs do not necessarily have the same goals as surgery residents and there is confusion about how NPPs fit into the hierarchy of the traditional surgical team.

Patterns and predictions of resident misbehavior--a 10-year retrospective look.

BACKGROUND: Surgical educators are charged with ensuring that their trainees conduct themselves in a professional manner. The authors retrospectively reviewed a 10-year experience of incident reports on surgical housestaff to determine patterns and predictors of behavior. METHODS: A retrospective review of all letters, e-mails, and incident reports was conducted for general surgery residents from 1995 to 2005. Descriptive variables were selected for binary categorization (not mutually exclusive): poor professional conduct, protocol violation, administrative deficiency, verbal mistreatment, physical boundary issues, mistreatment of superiors, and deficient medical student interaction. Resident status was defined as current, graduate, and attrition. RESULTS: Of 110 residents [90 [82%] categorical, 23 [21%] undesignated preliminary (3 overlapped both groups); 87 [79%] male, 23 [21%] female] who trained at the University of Pennsylvania during this period, 66 complaints were generated about 29 individuals. Overall, 50 of the 66 complaints (76%) were directed toward men and the remaining 16 (24%) toward women; 24% of all men and 35% of all women received 1 or more complaints. A total of 76% of complaints concerned categorical residents and 24% undesignated preliminary residents. And 26% of all categorical residents and 26% of all preliminary residents received at least 1 complaint. The most common complaints concerned professional conduct (83%), protocol violation (33%), verbal mistreatment (23%), deficiencies of administrative duties (8%), violations of physical boundaries (5%), deficient medical student interaction (5%), and mistreatment of attendings by residents (3%). Recipients of verbal mistreatment included staff nurses (27%), radiology technicians (13%), medical students (13%), environmental services employees (7%), security guards (7%), patients (7%), surgery attendings (7%), anesthesia attendings (7%), internal medicine chief residents (7%), and pharmacists (7%). A total of 31% of the complaints were regarding residents who involuntarily departed and 7% regarding residents who left voluntarily before completion. The mean PGY level at first complaint was 2.2 years. Of the 29 residents receiving complaints, 16 had recurrent offenses (range 2 to 7 total complaints, positive predictive value [PPV] 53%). CONCLUSION: Resident misbehavior manifests early and recurs often. Furthermore, it is frequently directed toward perceived subordinates. Nondesignated preliminary status, premature departure from the program, and the eventual selection of specific subspecialty fellowships seems to increase the risk for resident misbehavior. Identified residents require close surveillance and remediation.

Contributions of surgical residents to patient satisfaction: impact of residents beyond clinical care.

PURPOSE: Little is known about the relationship between resident performance and patient satisfaction. To this end, our institution added housestaff-specific questions to Press-Ganey surveys (Press-Ganey, South Bend, Indiana) administered to patients. This study sought to investigate the impact residents have on patients' overall rating of care compared with faculty and nursing staff. Our hypothesis was that residents play an important but historically underappreciated role in patient satisfaction. METHODS: Between April 2005 and June 2006, half of all discharged patients randomly received Press-Ganey surveys, including questions on the following categories: admissions, patient room, food, diagnostic testing, guest services, faculty/attending physician, discharge, emotional needs, housestaff, nurse practitioners, and primary nurse. responses were grouped into overall category scores and used as predictor variables for regression analysis. a separate question asked patients to rate overall care provided. Chief resident schedules and evaluation scores by faculty were provided by the Division of Surgery Education. Regression, and ANOVA models were run using JMP 6 software (JMP 6, SAS Institute, Cary, North Carolina). RESULTS: During this period, 49,081 patients were discharged, 24,540 surveys were mailed, and 5828 surveys were returned (24% response rate). In a simple regression analysis, the predictor variables for nursing, housestaff, and faculty accounted for 57%, 33%, and 28%, respectively, of the variation of overall rating of care delivered (p < 0.005). The actual overall score for each group varied slightly: faculty (89.8), nursing (86.6), and housestaff (84.2) (p < 0.005). In a multiple regression analysis, all predictors above were significant (p < 0.05). A small difference in scores existed between surgical (83.9) and nonsurgical (85.0) housestaff (p < 0.05). When data were sorted by surgical services, ratings of surgical housestaff ranged from a high of 86.8 (thoracic) to a low of 79.0 (orthopedics) (p < 0.05). Admission month had no significant effect on overall rating of care (range, 85-90), although comparing the means of resident scores by month (range, 81-86) showed that at the end (May-June) and at the beginning (July-Aug) of an academic year, a significant reduction in resident scores occurred (p < 0.05). The lowest score of the year (82.4) occurred in June, whereas the highest scores occurred in January-April (85-86). Resident evaluation scores by faculty and ratings of housestaff by patients were completely uncorrelated, although certain housestaff achieved significantly higher ratings by patients than others. CONCLUSIONS: Compared with faculty and residents, nurses have a greater impact on the variation of patient satisfaction. However, the actual scores given to residents, faculty, and nurses are all high. A slight difference exists in scores of surgical and nonsurgical residents. For all residents, the time of the academic year impacts resident scores positively in the middle and negatively in the beginning and end. For surgical residents clear differences exist between specialty services, but it is not apparent whether these differences are caused by individual residents or by the clinical service milieu. Residents contribute significantly to overall satisfaction, and additional investigation of the variation in resident scores is needed.

Surgeon contribution to hospital bottom line: not all are created equal.

OBJECTIVE: We hypothesized that surgeon productivity is directly related to hospital operating margin, but significant variation in margin contribution exists between specialties. SUMMARY BACKGROUND DATA: As the independent practitioner becomes an endangered species, it is critical to better understand the surgeon's importance to a hospital's bottom line. An appreciation of surgeon contribution to hospital profitability may prove useful in negotiations relating to full-time employment or other models. METHODS: Surgeon total relative value units (RVUs), a measure of productivity, were collected from operating room (OR) logs. Annual hospital margin per specialty was provided by hospital finance. Hospital margin data were normalized by dividing by a constant such that the highest relative hospital margin (RHM) in fiscal year 2004 expressed as margin units (mu) was 1 million mu. For each specialty, data analyzed included RHM/OR HR, RHM/case, and RHM/RVU. RESULTS: Thoracic (34.55 mu/RVU) and transplant (25.13 mu/RVU) were the biggest contributors to hospital margin. Plastics (-0.57 mu/RVU), maxillofacial (1.41 mu/RVU), and gynecology (1.66 mu/RVU) contributed least to hospital margin. Relative hospital margin per OR HR for transplant slightly exceeded thoracic (275.74 mu vs 233.94 mu) at the top and plastics and maxillofacial contributed the least (-3.83 mu/OR HR vs 9.36 mu/OR HR). CONCLUSIONS: Surgeons contribute significantly to hospital margin with certain specialties being more profitable than others. Payer mix, the penetration of managed care, and negotiated contracts as well as a number of other factors all have an impact on an individual hospital's margin. Surgeons should be fully cognizant of their significant influence in the marketplace.