Journal of Surgical Education

Editorial Board

2009-11-01

Baseball's Lesson for Surgical Educators 2009 Presidential Address

George M. Fuhrman — 2009-09-28

About 20 years ago during my surgical residency, I decided to become a surgical educator. Surgery inspired me as a medical student. I was impressed by the way surgeons could combine knowledge and common sense to solve serious challenges to patient's well-being. As a surgical educator, I believed that I could share the inspiration that I had experienced and hopefully make a difference in people's lives. That was, and today remains, my only professional objective. I have spent a lot time reflecting and trying to figure out how I have gotten here to this moment, feeling both overwhelmed and undeserving of the honor of serving as president of our outstanding organization. After careful reflection, I realize that I have been fortunate to have many important people serve as mentors along the way. These key people have helped me navigate around many professional obstacles. I would like to begin this address by publicly expressing my gratitude to these talented and generous people. They are listed in along with their contributions to my career. My reflections have also led me to the realization that I actually started my preparation for a career in surgical education on the baseball fields of my youth and through my lifelong passion for the game. This address will review the contributions of my mentors and then will transition to sharing with you some lessons that I learned from playing, and ultimately watching, baseball that are appropriate to all of us as surgical educators.

Does Medical Student Membership in the Gold Humanism Honor Society Influence Selection for Residency?

2009-11-01

Objectives: With the creation of the Gold Humanism Honor Society (GHHS) in 2002, the Arnold P. Gold Foundation established a mechanism for recognizing medical students who demonstrate exemplary humanism/professionalism/communication skills. Currently, 80 medical schools have GHHS chapters. Selection is based on peer nomination using a validated tool. The objective of this survey was to assess the percentage of residency program directors (PDs) who are aware of and are using GHHS membership as a residency selection tool.Methods: Surgery (SURG) and internal medicine (IM) PDs in 4 United States regions were surveyed for familiarity with GHHS and perceived rank of GHHS membership relative to Alpha Omega Alpha (AOA) membership, class rank, medical student performance evaluation (MSPE), clerkship grade, and United States Medical Licensing Examination (USMLE) score, in evaluating an applicant's humanism/professionalism, service orientation, and fit with their program. Program demographics and familiarity with GHHS were also surveyed.Results: The response rate was 56% (149 respondents). IM PDs rated GHHS membership higher than did SURG PDs when evaluating professionalism/humanism and service orientation. PDs familiar with GHHS ranked membership higher when considering professionalism/humanism (4.1 vs 3.2; p < 0.05) and service orientation (4.1 vs 2.9; p < 0.01). Familiarity with GHHS correlated with being an IM PD, residency based at teaching hospital, large residency program, knowledge of residents who were GHHS members, and having a GHHS chapter at their school (p < 0.01). Familiarity with GHHS was related to rankings of GHHS (professionalism/humanism F = 3.36; p < 0.05; service orientation F = 3.86; p < 0.05) more than the PDs' specialty was. In all, 157 GHHS students (from all 4 United States regions) were also surveyed about the 1197 interviews they had with residency PDs. They reported that although a few PDs were aware of GHHS, PDs of core medical specialties were more aware of GHHS than SURG PDs.Conclusions: IM PDs were more aware of GHHS (70%) than SURG PDs (30%). Awareness was related to the favorable ranking of GHHS as a selection criterion for humanism/professionalism/service orientation. PDs familiar with GHHS were from larger programs, were likely to know residents who were members, and were likely to think that GHHS membership predicted humanistic care. Membership in GHHS may set candidates apart from their peers and allow PDs to distinguish objectively the candidates who demonstrate compassionate medical care. Increased knowledge about the GHHS may therefore serve to be a useful adjunct for PDs when selecting medical students for their residency programs.

Effect of the Night Float System on Operative Case Volume for Senior Surgical Residents

Robert J. Kelly, Christopher K. Senkowski — 2009-11-01

Purpose: In response to the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour workweek, the night float coverage model was one system created to comply with the work-hour restriction. However, concern has risen as to the operative case volume achieved with this model. The purpose of this study is to determine which system of call (night float vs traditional rotating call) provided the senior surgical resident with the greatest surgical case volume while in compliance with the 80-hour workweek.Methods: A nonrandomized sequential study to evaluate the ACGME surgical operative logs (SOLs) for surgical chief residents at Memorial University Medical Center (MUMC), which is a level 1 trauma center, from 2006 to 2008 was conducted. The night float system (NFS) consisted of a PGY-4 or -5 assigned to in-house general surgery and trauma call from 6:00 pm to 6:00 am Monday through Friday morning and a 24-hour shift from 6:00 am on Sunday to 6:00 am Monday morning. Two months of night call rotations (nights) are performed each year per resident with the other 10 months devoted to daytime rotations (days). Conversely, the traditional rotating call schedule (TCS) placed each resident on-call every sixth night for a 30-hour period. The TCS required the resident to average approximately 3 weekday and 2 weekend calls per month. The data examined include all cases on the ACGME SOL submitted by each PGY-4 and 5 residents over a 2-year span. Specific designation of cases between night and day rotations was evaluated while on the NFS, and the total cases volume performed on the NFS and the TCS were analyzed.Results: An evaluation of the 2006-2007 (NFS) year demonstrates an average of 16 cases per month while on nights as compared with 20 cases per month while on day rotations. The caseload on the night rotation was less than day rotations at the PGY-4/5 level. An analysis of the 2006-2007 (NFS) and 2007-2008 (TCS) for PGY-4/5 residents revealed an average total caseload of 224 and 276, respectively. A statistically significant total case difference of 52 cases over the entire year between the 2 systems of call was appreciated.Conclusions: Because of the work-hour restrictions, maximizing surgical education has become a necessity. With the various call systems used throughout general surgery programs, this study specifically compares a traditional 1-in-6 call schedule versus an NFS. Senior residents lost significant operative experience while operating under an NFS as compared with a TCS. Evidence suggests that the more hours spent by a chief resident during normal operative time elicits more operative experience.

Factors Correlated With Surgery Resident Choice to Practice General Surgery in a Rural Area

2009-09-28

Objective: General surgery workforce shortages in the rural United States are likely to worsen over the next decade. We sought to identify reasons that general surgery residency graduates choose rural versus urban practice.Design: Questionnaires were sent to 1994 through 2008 graduates of all 4 Wisconsin surgery residency programs (2 university and 2 community). The 51-item questionnaire was designed to evaluate residency graduates' background, interests, and factors influencing their choice of practice type and location. Graduates were divided into 2 groups based upon the size of the communities in which they currently practice: rural (<50,000) or urban (≥50,000). Data were analyzed using χ2 tests; level of confidence was defined as p < 0.05.Results: Forty-five percent (98/216) of surveys were completed. Factors associated with rural practice included attending a nonurban high school (p = 0.001) or college (p = 0.001), having a spouse/partner who grew up in a nonurban area (p = 0.022), and interest in hunting birds (p = 0.010) or large game (p = 0.001). Those choosing rural practice were more likely than their urban counterparts to have completed a rural clerkship during medical school (79% vs. 37%, p = 0.001). They were also more likely to have chosen a surgical residency program committed to rural training (p = 0.046). Graduates in rural practice more often cited “broad scope of practice” as an important reason for their decision. Both rural and urban surgeons reported similar rates of medical student teaching but urban surgeons were more likely to teach surgical residents (p = 0.001) and to have completed fellowship training (p = 0.001).Conclusions: General surgery residency graduates and their spouses who choose rural practices are more likely than those selecting urban practices to have rural backgrounds and interests. Completing a rural clerkship during medical school and choosing a residency program committed to rural general surgery preparation are strongly correlated with rural practice. These findings may help formulate strategies to increase recruitment and retention of rural general surgeons.

Factors Influencing Residency Choice of General Surgery Applicants—How Important Is the Availability of a Skills Curriculum?

Dimitrios Stefanidis, William S. Miles, Frederick L. Greene — 2009-09-28

Objective: The objective of this study was to assess the factors that impact residency choice by general surgery applicants and the importance of the availability of skill curricula.Methods: Fourth-year medical students (n = 104) interviewing for a general surgery position in an academic medical center voluntarily completed an anonymous survey detailing questions about the factors that influenced their choice of a residency program. Applicants were asked to rank in order of importance 14 factors potentially influencing their decision making and to address specifically the value of skills training. Data are reported as medians (range).Results: The applicants' median age was 26 (range, 24-35) years; 44% were women, and the prior simulator exposure was 1 (range, 0-90) hour. The factors influencing the choice of residency in order of importance were the quality of life of current residents, the volume and variety of cases, and the quality of the curriculum (medians, 3-4), followed by the reputation of the institution and the program director, the location, and mentor advice (medians, 6-8); and the presence of expertise in areas of interest, the availability of a skills curriculum, the academic versus private designation, the efficiency of the hospital, and the size of residency (medians, 9-10). Women were more likely than men to rank lifestyle higher. Applicants' decision making was influenced positively in 92% by the presence of an organized skills curriculum.Conclusions: The main determinants of the applicants' choice of a general surgery program are the quality of life of the residents and the anticipated clinical experience and curriculum quality. The availability of organized skills curricula is low in the applicant priorities, but it does influence their decision-making process. These findings may help program directors to optimize their residency curriculum and interviewing process.

Four-Year Experience with a Regional Program Providing Simulation-Based Endovascular Training for Vascular Surgery Fellows

David L. Dawson, Eugene S. Lee, Nasim Hedayati, William C. Pevec — 2009-09-28

Purpose: High-fidelity procedure simulation has been found useful for training vascular surgery residents in endovascular procedures, but the costs of acquiring, maintaining, and operating simulators represent a barrier to routine use of endovascular simulation in vascular surgery programs. Providing simulation training opportunities through regional centers may make simulation more cost effective, but the costs and benefits of this approach have not been reported previously. We reviewed participation costs in a regional simulation program to provide a benchmark for comparison with other training options.Methods: Simulation-based training was offered annually from 2004 to 2007 to the 11 vascular surgery fellowships in Washington, Oregon, California, Arizona, and Utah. Participation was at the discretion of the program directors and fellows. Sessions were designed to offer individualized, hands-on training with 2-4 participants per 2-day session. SimSuite (Medical Simulation Corporation, Denver, Colorado) simulators were used.Results: During the 4-year period, participation by invited programs averaged 75%. Ten of 11 programs in the western United States region participated, with 34 fellows participating during the 4 years of the program. In addition, 2 program directors or faculty attended sessions to participate as learners, and 8 other individuals were allowed to participate (including 7 senior surgery residents and 1 vascular surgery fellow from out of the region). The average participant costs for travel, which include transportation, lodging, and meals, were $571. Simulation facility expenses, which included use of the simulator, computer-based training modules, and instructional support by an educational specialist, averaged $1055 per participant. Surgical faculty spent 12 hours per 2-day session instructing and in other direct educational activities. Costs for this time were not calculated separately.Conclusions: Vascular surgery fellows' participation in simulation training at regional centers offers program directors a lower cost alternative for providing high-fidelity simulation training, compared with acquiring and operating an endovascular procedure simulator at their individual institutions.

Graduate Medical Education as the Driver for Quality Improvement and Patient Safety: A National Initiative of Independent Academic Medical Centers

Richard Welling, Kevin Grannan, John Boberg, Kimberly Pierce-Boggs, Amy Engel — 2009-09-28

Engaging surgical residents in hospital quality-improvement (QI) initiatives could be the next important step in the evolving renaissance of surgical education. Your first reaction might be, “when are they going to have time for this?” I would suggest that it is really what they do and observe every day in their daily activity of patient care that affords them the opportunity to design QI projects. Partnering in this initiative with faculty is a means of fostering additional scholarship into the culture of surgical education. It also provides a unique educational experience in preparation for their life in surgical practice.

Implementation of an “After Hours” Resident Educational Program in a General Surgery Residency: A Paradigm for Increasing Formal Didactic Training Outside of the Hospital Setting in the Era of the 80-Hour Workweek

Ryan C. Fields, Michele C. Bowman, Bradley D. Freeman, Mary E. Klingensmith — 2009-11-01

Introduction: Residency programs have been forced to curtail many educational activities to comply with duty-hour restrictions. We describe an “after hours” educational program as a forum to provide small-group education customized for each training level to compliment our formal curriculum.Methods: Sessions within each general surgery specialty were organized such that 1 session each month was open to either junior (R1 and R2) or senior (R3-R5) trainees and hosted by surgical faculty. Attendance was optional and limited to 15 residents per session with the format determined by the hosting faculty. Participants completed a postsession survey.Results: Fourteen sessions were held during the 2008-2009 academic year. All sessions were >90% subscribed within 1 week of announcement and attendance was 88%. The average session duration was 2.6 ± 0.4 hours. Junior resident sessions focused on preparing R1 and R2 residents to handle common consult questions; senior resident sessions were modeled as “mock oral boards.” Resident and faculty responses to the postsession questionnaire were similar and favorable with respect to the educational value of this format.Conclusions: There is enthusiasm among faculty and trainees to provide small-group, level-specific educational programs outside of the hospital setting and the 80-hour workweek. Such a program is easily implemented, highly effective, and well received. This format has the added benefit of improving interaction between faculty and residents and increasing the camaraderie of a surgical training program.

Novel Hybrid Objective Structured Assessment of Technical Skills/Objective Structured Clinical Examinations in Comprehensive Perioperative Breast Care: A Three-Year Analysis of Outcomes

Vijay K. Maker, Stephanie Bonne — 2009-09-28

Purpose: Objective Structured Assessment of Technical Skills (OSATS) and Objective Structured Clinical Examinations (OSCE) are common tools used to objectively evaluate surgical residents. In 2005, our institution presented a novel hybrid OSATS/OSCE, which we renamed the Objective Structured Clinical Assessment (OSCA), encompassing all 6 core competencies regarding comprehensive care of the breast care patient. This study presents an analysis of the effects of a compulsory, comprehensive OSCA on our residents' competence in this index learning category.Methods: Completed breast OSCA, Accreditation Council for Graduate Medical Education (ACGME) operative logs, and Report D of the American Board of Surgery in Training Examination (ABSITE) were collected for 24 senior-level residents. The OSCA was implemented for post graduate year (PGY)-3 residents in the 2003-2004 year. Data were also collected for an equal number of residents before the OSCA. Competence of residents was evaluated using the procedure-based OSCA that encompasses the 6 core competencies, completed for each resident by a specialty breast surgeon. Next, ACGME operative logs for graduating seniors were analyzed. Finally, breast care questions were identified from Report D. The number of residents scoring incorrectly on these questions was divided by the total number of resident-questions to yield a percent incorrect for each group. Similarly, the percent of total incorrect ABSITE examination questions was calculated, assessing overall group improvement.Results: All assigned residents achieved competence in all designated categories of the OSCA. Since the OSCA, the average number of breast cases in our program has risen from a mean of 102 cases to 124 cases per graduating senior. ABSITE data showed 264 resident-questions before the OSCA, with 26.5% incorrect responses. After OSCA, there were 252 resident-questions, with 18.25% incorrect. This represents a significant decrease (p < 0.05) of incorrect responses to breast questions on the ABSITE. Before the OSCA, there were 2139 total resident-questions with 25.28% wrong responses and after, there were 2111 resident-questions with 23.97% wrong responses, representing no significant difference (p > 0.05) in incorrect responses on the entire examination.Conclusions: Our data show consistent competence of residents in breast disease as evaluated by the OSCA, an increase in numbers of breast cases, and a decrease in incorrect responses on breast-related ABSITE questions. We believe a comprehensive, complete care OSCA represents a valuable learning tool for residents to increase their competence and improve their outcomes in breast care. We believe that comprehensive OSCAs will be necessary tools to evaluate resident competence and should be implemented in all areas of general surgery.

Refining the Evaluation of Operating Room Performance

2009-11-01

Purpose: An accurate and consistent evaluation of resident operative performance is necessary but difficult to achieve. This study continues the examination of the Southern Illinois University (SIU) operative performance rating system (OPRS) by studying additional factors that may influence reliability, accuracy, and interpretability of results.Methods: OPRS evaluations of surgical residents by faculty at SIU, from 2001 to 2008, were analyzed for the most frequently rated procedures to determine (1) the elapsed time from the procedure until completion of rating, (2) the patterns in responses of procedure-specific and global surgical skills items, and (3) whether particular evaluating surgeons differed in their stringency of ratings of resident operative performance.Results: In all, 566 evaluations were analyzed, which consisted of open colectomy (n = 125), open inguinal hernia (n = 103), laparoscopic cholecystectomy (n = 199), and excisional biopsy (n = 139). The number of residents evaluated per training level (PGY) ranged from 88 to 161. The median time to completion of evaluations was 11 days, 9 hours. The quickest evaluation was 18 hours after assignment. Most were completed within 4.5 to 22 days. Procedure-specific and global scale scores resulted in similar rank-ordering of performances (single-measure intraclass correlation using the consistency model = 0.88; 95% confidence interval [CI] = 0.87-0.90) and similar absolute OPRS scores (single-measure intraclass correlation using the consistency model = 0.89; 95% CI, 0.87-0.90). Evaluating surgeons differed in stringency of ratings across procedures (average difference = 1.4 points of 5 possible points). Resident performance improved with increasing PGY level for all 4 procedures.Conclusions: Substantial time elapses between performance in the operating room and the completion of the evaluation. This raises the question of whether surgeons remember the nuances of the procedure well enough to rate performance accurately. The item type used for rating does not affect the absolute rating assigned or the rank ordering of the performance. Differences in stringency of evaluators indicate the need for multiple resident performance observations by multiple surgeons. These findings are the foundation for an upcoming multi-institutional trial.

Revisiting the Rotating Call Schedule in Less Than 80 Hours Per Week

2009-11-01

Purpose: The Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions have prompted many surgical training programs to adopt a night-float resident coverage system (NF). Dissatisfaction with NF prompted us to transition to a rotating junior resident call model (Q4) with 24-hour call shifts at the outset of the 2007-2008 academic year. We performed a prospective study to determine the influence of this transition on resident education, morale, and quality of life, as well as on ACGME work rule compliance and American Board of Surgery In-Training Examination (ABSITE) scores.Methods: Residents were surveyed after 1 year of NF and again 1 year after the introduction of Q4. Responses to a series of statements about the influence of the call model (NF or Q4) on educational opportunities and morale were solicited. The survey used a 5-point Likert response scale (1 = complete disagreement to 5 = complete agreement). Median values of participant responses were calculated and compared using the Wilcoxon rank-sum test. Compliance with ACGME work rules, ABSITE scores, and operative case logs from the 2006-2007 and 2007-2008 academic years were also compared.Results: Residents were significantly more enthusiastic about Q4 compared with NF, particularly when asked about the influence these systems had on morale (median response = 4.0 [Q4] compared with 2.0 [NF]; p = 0.001) and engagement of residents by the teaching faculty (median response = 4.0 [Q4] compared with 1.0 [NF]; p = 0.001). Case logs revealed a similar operative experience for first-year residents irrespective of the call schedule (p = 0.51). Excellent compliance with ACGME work rules was maintained as reflected by the percentage of monthly 80-hour violations per resident months worked (3% [Q4] compared with 0.7% [NF]). No difference was observed in the ABSITE scores of first-year residents (a mean percentile point increase of 1 was found after the introduction of Q4).Conclusions: Educational opportunities, compliance with ACGME work rules, and ABSITE scores can be preserved despite a transition from NF to Q4. Residents greatly prefer a rotating call schedule.

The Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital

2009-09-28

Objective: The purpose of this study was to determine the effectiveness of weekly didactic grand rounds presentations.Design: From 26 consecutive grand rounds presentations from July 2007 to March 2008, 2 questions were created from each lecture. A 52-question multiple choice test was administered 2 weeks after the completion of the last presentation.Setting: A tertiary care institution with an accredited surgical residency program.Participants: Attending surgeons, residents, midlevel providers, and medical students participated in the multiple choice test.Results: A total of 58 participants completed the test. The mean score was 41.5% (range, 12-69%). The senior residents had the highest mean score on the test with 51.0% (p = 0.021). With regard to global versus specific questions, there was no significant difference between the mean percentage of correct answers (41.7% vs 41.3%, respectively, p = 0.79). The great majority (76.5%) of participants indicated that they preferred to have grand rounds given by “distinguished guest speakers.” The mean score on presentations by guest speakers, however, was slightly lower than for other presenters (40.7% vs 42.2%, p= 0.37). Questions from presentations by resident physicians were answered correctly significantly more often than presentations by attending surgeons (45.9% vs 39.6%, p = 0.001). Trauma and burn are considered areas of focus for this surgical residency. There was no significant difference between mean score on topics related to trauma and burn compared with other topics (40.6% vs 41.8%, p = 0.50). Attendance had very little correlation with scores on the test (correlation coefficient, 0.004).Conclusions: Approximately 40% of material presented at grand rounds was retained within a 9 month period. Although this number seems low, this information was recalled without preparation. Despite the preference for distinguished guest speakers, there was no significant additional gain in knowledge from their expertise. Presentations from senior residents were the most successful in conveying information.

The Utility of Endovascular Simulation to Improve Technical Performance and Stimulate Continued Interest of Preclinical Medical Students in Vascular Surgery

2009-09-28

Objective: New training paradigms in vascular surgery allow for early specialization out of medical school. Surgical simulation has emerged as an educational tool for trainees to practice procedures in a controlled environment allowing interested medical students to perform procedures without compromising patient safety. The purpose of this study is to assess the ability of a simulation-based curriculum to improve the technical performance and interest level of medical students in vascular surgery.Design: Prospective observational cohort study of medical student performance.Setting: Academic medical center.Participants: Forty-one medical students (23 first year, 15 second year, 3 other) enrolled in a vascular surgery elective course. Students completed a survey of their interests and performed a renal stent procedure on an endovascular simulator (pretest). The curriculum consisted of didactic teaching and weekly mentored simulator sessions and concluded with a final renal stent procedure on the simulator (posttest). Objective procedural measures were determined during the pre- and posttest by the simulator, and subjective performance was graded by expert observers utilizing a structured global assessment scale. After the course, the students were surveyed as to their opinions about vascular surgery as a career option. Finally, 1 year after the course, all students were again surveyed to determine continued interest in vascular surgery.Results: The objective and subjective criteria measured on the simulator and structured global assessment scale significantly improved from pre- to posttest in terms of performer technical skill, patient safety measures, and structured global assessments. Before beginning the course, 8.5% of the students expressed high interest in vascular surgery, and after completing the course 70% were seriously considering vascular surgery as a career option (p = 0.0001). More than 95% of the students responded that endovascular simulation increased their knowledge and interest in vascular surgery. In the 1-year follow-up survey (n = 23 medical students), 35% had already entered their clinical years. Seventy percent of the students were still considering vascular surgery, while several other career options were still popular including the surgical subspecialties (70%), interventional cardiology (57%), and interventional radiology (48%). Most respondents indicated the major reasons for continued interest in vascular surgery were the ability to practice endovascular procedures on the simulator (100%) and mentorship from vascular surgery faculty (78%).Conclusions: The use of high fidelity endovascular simulation within an introductory vascular surgery course improves medical student performance with respect to technical skill, patient safety parameters, and global performance assessment. Mentored exposure to endovascular procedures on the simulator positively impacts long term medical student attitudes towards vascular surgery. Simulator-based courses may have the potential to be an important component in the assessment and recruitment of medical students for future surgical training programs.

Understanding Accreditation Council for Graduate Medical Education (ACGME) Guidelines: Resident and Program Director Interpretation of Work-Hour Restrictions

2009-09-28

Purpose: All residency programs must comply with the Accreditation Council for Graduate Medical Education (ACGME) work-hour guidelines, but compliance requires accurate interpretation of the rules. We previously surveyed the residents and program directors of general surgery residency programs and found significant discordance between what program directors and residents considered violations. Our current study expands our research to include family medicine and emergency medicine residents and program directors. This study aims to identify discrepancies of work-hour guideline interpretation within and between the specialties.Methods: We created 10 scenarios related to work-hour issues. The ACGME reviewed them and judged whether a violation occurred in each scenario. From these scenarios, an Internet-based survey was generated and distributed electronically to every family medicine and emergency medicine residency in the United States. (Surgery programs were previously surveyed from March 1 through May 21, 2007 with the same scenarios.) Responses were collected anonymously via our Internet-based survey database from March 1 through May 17, 2008. All respondents were asked to identify themselves as either a program director or a resident. After reading each scenario, participants were asked to answer either “yes,” “no,” or “maybe/not sure.” The option of “maybe/not sure” was in place to discourage guessing; those responses were not included in our analysis. After the data were collected, we calculated the percent of respondents that answered “yes” or “no” for each of the 10 scenarios related to work-hour issues. The results from within specialties (program directors vs residents) and between specialties (general surgery, family medicine, emergency medicine) were compared.Results: There were a total of 883 respondents (334 general surgery, 374 family medicine, and 175 emergency medicine). Respondents identified themselves as program directors (97), assistant program directors (21), or residents (765). Statistically significant differences were identified in the responses of program directors and residents within and between specialties.Conclusions: Based on the scenarios we presented, there was a difference in interpretation between residents and program directors. There was even disagreement among program directors of different specialties on the interpretation of some of the scenarios. This finding reveals an ambiguity in the work-hour restrictions. We conclude that the ACGME-mandated work-hour guidelines are confusing and not universally understood. This problem is compounded by the cross-training with “off-service” residents from other specialties such as family medicine and emergency medicine. Hence, enforcement of the work-hour restrictions may be problematic, despite the best intentions and sincere effort of directors and residents to interpret the rules.

Use of Text Messaging to Enhance Compliance with the Accreditation Council for Graduate Medical Education Resident Duty Hour Requirements

2009-11-01

Purpose: Recently, the Accreditation Council for Graduate Medical Education (ACGME) has developed and enforced a complex set of regulations limiting resident duty hours (RDHs). One potential method to comply with these stringent regulations and better document resident work hours would be to use text message (TM)/short message service (SMS), allowing rapid, inexpensive, and interactive 2-way delivery of information. The purpose of this study was to document the successful implementation of TM to enhance compliance with the ACGME RDH regulations.Methods: Our TM system uses TSHEETS (TS; Meridian, Ohio), which is an online time- and labor-management service. After our general surgical residents were registered with the system, the documentation of entry into (texting “t start” to a predetermined number) and exit out of (texting “t stop” to the same number) the hospital could easily be accomplished. The goals of this pilot study were to determine (1) the feasibility of implementing a program such as this and (2) if use of such a program was associated with high resident satisfaction and improved compliance.Results: We registered 39 residents with TS. Within 3 days, compliance rose from 76.9% to 96.2%. After implementation of TM reminders, compliance increased to 100%. A time-tracking resident satisfaction survey was distributed after 8 weeks of data collection. Twenty six of 39 (67%) residents participated in the survey, with 25 (96%) being more satisfied with the current application as compared with either of the previous (manual or swipe card) systems, specifically regarding ease of use and overall ACGME RDH compliance. Self-reported resident scores of their ability to be compliant with ACGME RDH before versus after implementation increased from 47% to 75% (p < 0.05).Conclusions: We were able to implement successfully a novel technique for ACGME RDH documentation and compliance in a general surgery residency program through the use of TM; this approach employed a state-of-the-art time-tracking method that was associated with high levels of resident work-hour compliance and overall satisfaction.

What Do Surgical Nurses Know About Surgical Residents?

2009-11-01

Objective: A fundamental premise of establishing collaborative relationships between residents and nurses is a basic understanding of the attributes of each group. The intent of this study was to determine what surgical nurses know about surgical residents.Design: A piloted survey tool was administered to a cross-section of nurses working in 3 surgical intensive care units, a surgical intermediate unit, and 2 general surgical floors. Surgical residents completed the same survey tool. The percentage of residents giving the most frequent response was compared with the percentage of nurses giving the same response.Setting: A university, teaching hospital.Participants: One hundred twenty-four of 129 surgical nurses and 24 of 25 surgical residents who completed the survey tool.Results: The response rate for nurses on the 2 survey days was 94%, or 54% of all surgical nurses employed by the hospital, and 96% for residents. The nurses surveyed were equally distributed between the units. Ninety-nine percent of nurses did not have a surgical resident as a significant other, 55% of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Seventy-eight percent of nurses correctly indicated that a medical doctorate is the highest degree required to start residency (p = 0.01), but only 57% accurately identified the length of surgical residency (p = 0.02). Nurses perceived residents devoted less time to patient care (p < 0.01) and more time to studying (p < 0.01). Forty percent of nurses do not think interns are legally physicians (p < 0.01) or hold a medical license (p < 0.01). Forty percent of nurses are aware of the 80-hour work week restriction (p < 0.01). Eighteen percent of nurses have the perception that residents are not allowed to perform bedside procedures without an attending physician present (p = 0.03), while 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician (p < 0.01). There is a misperception among 32% of nurses that residents pay tuition for residency (p < 0.01), while only 52% accurately identified the range of a resident's salary (p = 0.01) and 11% the amount of resident debt (p < 0.01).Conclusions: Despite the importance of the collaborative relationship in surgical patient care, surgical nurses have a limited understanding of surgical residents. Educating nurses about the education, roles, and responsibilities of surgical residents might improve collaborative relationships and ultimately patient care.

Visual Learning: Harnessing Images To Educate Residents Optimally

Kenneth W. Gow — 2009-09-28

Surgical educators are confronted with outdated models of education and less time for teaching. Digital images present an opportunity for a new method of education. In this method, students are presented with a series of key images, each representing an important teaching point (radiographs, patient external images, operative images, and histopathology images) and asked to construct a corresponding case presentation. In this fashion, the traditional presentation is disassembled and the learner is responsible for teaching his or her colleagues. By incorporating surgical images into the teaching process, the teacher enhances insight and learning. In addition, by prompting the students to add creative elements to the thought process for diagnosis and management, the teaching format can be a dynamic and interactive process.

Professionalism in Kurosawa's Medical Dramas

Don K. Nakayama — 2009-09-28

Film director Akira Kurosawa (1918-1998) portrayed doctors and patients in 4 films that spanned the most productive phase in his career: Drunken Angel, The Quiet Duel, Ikiru, and Red Beard. Observing death and destruction during the Second World War and the social disintegration that followed it in Japan, Kurosawa viewed the world as a dispiriting, dangerous, and chaotic place. His response was an optimistic and humanist view that life's meaning lies in the service to others. Because his main characters are doctors and patients, the films have a connection to today's medical community trying to define a modern concept of professionalism and what it means to be a physician.

Author Index

2009-11-01

Subject Index

2009-11-01

Journal of Surgical Education

Editorial Board

Contents

Baseball's Lesson for Surgical Educators 2009 Presidential Address

Does Medical Student Membership in the Gold Humanism Honor Society Influence Selection for Residency?

Effect of the Night Float System on Operative Case Volume for Senior Surgical Residents

Factors Correlated With Surgery Resident Choice to Practice General Surgery in a Rural Area

Factors Influencing Residency Choice of General Surgery Applicants—How Important Is the Availability of a Skills Curriculum?

Four-Year Experience with a Regional Program Providing Simulation-Based Endovascular Training for Vascular Surgery Fellows

Graduate Medical Education as the Driver for Quality Improvement and Patient Safety: A National Initiative of Independent Academic Medical Centers

Implementation of an “After Hours” Resident Educational Program in a General Surgery Residency: A Paradigm for Increasing Formal Didactic Training Outside of the Hospital Setting in the Era of the 80-Hour Workweek

Novel Hybrid Objective Structured Assessment of Technical Skills/Objective Structured Clinical Examinations in Comprehensive Perioperative Breast Care: A Three-Year Analysis of Outcomes

Refining the Evaluation of Operating Room Performance

Revisiting the Rotating Call Schedule in Less Than 80 Hours Per Week

The Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital

The Utility of Endovascular Simulation to Improve Technical Performance and Stimulate Continued Interest of Preclinical Medical Students in Vascular Surgery

Understanding Accreditation Council for Graduate Medical Education (ACGME) Guidelines: Resident and Program Director Interpretation of Work-Hour Restrictions

Use of Text Messaging to Enhance Compliance with the Accreditation Council for Graduate Medical Education Resident Duty Hour Requirements

What Do Surgical Nurses Know About Surgical Residents?

Visual Learning: Harnessing Images To Educate Residents Optimally

Professionalism in Kurosawa's Medical Dramas

Author Index

Subject Index