Journal of Surgical Education - Articles in Press

Establishing a Usable Electronic Portfolio for Surgical Residents: Trying to Keep It Simple - Corrected Proof

Connie C. Schmitz, Bryan A. Whitson, Ann Van Heest, Michael A. Maddaus — 2010-03-04

Elaborate web-based portfolios may not be needed for resident evaluation and career development. An approach for busy academic medical departments is described.

Use of the Surgical Council on Resident Education (SCORE) Curriculum as a Template for Evaluating and Planning a Program's Clinical Curriculum - Corrected Proof

Jonathan Fryer, Noreen Corcoran, Debra DaRosa — 2010-02-08

Background: The SCORE curriculum defines surgical operations/procedures that residents are expected to be competent with by the end of the residency.Objective: The purpose of this study was to conduct a gap analysis to determine how well the operative experience in a general surgery residency program approximates the expectations of the SCORE curriculum, especially regarding those procedures considered essential to general surgical training.Design: Setting/Participants: Final ACGME resident operative experience reports of recent Northwestern University general surgery program graduates (n = 15) were compared with the specific procedures and procedure levels (ie, Essential-Common, Essential-Uncommon, Complex) defined in the SCORE curriculum. The average numbers of individual SCORE procedures and procedures per SCORE procedure level performed per resident were summarized using descriptive statistics.Results: During their 5 years of training general surgery residents logged a mean of 1025.7 (SD 152.9) primary procedures per resident. We were able to match 87.1% of these ACGME logged procedures with specific procedures identified in the SCORE curriculum. On average, of the Essential-common procedures, 23 (35%) were performed >10 times and 35 (53%) were performed >five times. Conversely, the number of Essential-uncommon and Complex procedures performed >five times were 3 (5%) and 10 (7%), respectively. Several procedures identified in the SCORE curriculum were performed at very low frequency during residency training.Conclusions: This experience suggests that leadership at SCORE and the ACGME need to make the curriculum and logging system compatible and that surgical residents need to be better educated with regards to case logging. Despite these issues, important differences appeared to exist between actual resident operative experiences and expectations set by the SCORE curriculum. Based on these finding we advocate that similar gap analyses be performed at other surgical residency training programs to identify discrepancies between program experience and SCORE curriculum expectations.

Complexity Theory and the “Puzzling” Competencies: Systems-Based Practice and Practice-Based Learning Explored - Corrected Proof

Russell S. Gonnering — 2010-02-08

Of all the clinical competencies, the least understood are Systems-Based Practice and Practice-Based Learning and Improvement. With a shift to competency-based education and evaluation across the spectrum of surgical education and practice, a clear understanding of the power and utility of each competency is paramount. Health care operates as a complex adaptive system, with dynamics foreign to many health care professionals and educators. The adaptation and evolution of such a system is related directly to both the individual and the organizational learning of the agents within the system and knowledge management strategies. Far from being “difficult,” Systems-Based Practice and Practice-Based Learning form the heart of quality improvement initiatives and future productivity advances in health care.

Does Participation in Graduate Medical Education Contribute to Improved Patient Outcomes as Outlined by Surgical Care Improvement Project Guidelines? - Corrected Proof

Axel Thors, Erik Dunki-Jacobs, Amy M. Engel, Sarah McDonough, Richard E. Welling — 2010-02-08

Background: Patient quality outcomes are a major focus of the health care industry. It is unknown what effect involvement in graduate medical education (GME) has on patient outcomes. The purpose of this study is to begin to examine whether GME involvement in postoperative care impacts patient quality outcomes.Methods: The retrospective cohort included all patients who underwent a nonemergent colectomy from January 1, 2007 to January 1, 2008 at a 2-hospital system. Data collected included patient demographics, patient quality outcomes, complications, and GME involvement. Patient quality outcomes were based on compliance with the Surgical Care Improvement Project (SCIP) guidelines.Results: A total of 159 nonemergent colectomies were analyzed. The GME group accounted for 116 (73%) patients. A significant difference was found in several SCIP process-based measures of quality when comparing the GME group with the non-GME group. Postoperative antibiotics were more likely to be stopped within 24 hours (p = 0.010), and preoperative heparin and postoperative deep vein thrombosis (DVT) prophylaxis were more likely to be administered (p < 0.001). Additionally, patients in the GME group showed improved quality outcomes as there were significantly fewer postoperative complications (p < 0.001) and a shorter duration of stay (p = 0.008). The use of gastrointestinal prophylaxis was more common in the non-GME group (p = 0.002). No significant differences were observed between the 2 groups in respect to age, sex, diabetes, preoperative antibiotics, antibiotics, 1 hour before surgery, postoperative antibiotics, and continuation of home β blockade.Conclusions: GME at teaching institutions has a positive impact on patient quality outcomes. At our institution, many of the SCIP measurable outcomes had improved compliance if an attending physician participated in the GME program.

The Eighty-Hour Workweek: Surgical Attendings' Perspectives - Corrected Proof

Devan Griner, Rema P. Menon, Cyrus A. Kotwall, Thomas V. Clancy, William W. Hope — 2010-02-08

Objective: The year 2008 was a sentinel year in resident education; this was the first graduating general surgery class trained entirely under the 80-hour workweek. The purpose of this study was to evaluate attending surgeon perceptions of surgical resident attitudes and performance before and after duty-hour restrictions.Design: An electronic survey was sent to all surgical teaching institutions in North Carolina. Both surgeon and hospital characteristics were documented. The survey consisted of questions designed to assess residents' attitudes/performance before and after the implementation of the work-hour restriction.Results: In all, 77 surveys were returned (33% response rate). The survey demonstrated that 92% of educators who responded to the survey recognized a difference between the restricted residents (RRs) and the nonrestricted residents (NRRs), and most respondents (67%) attributed this to both the work-hour restrictions and the work ethic of current residents. Most attending surgeons reported no difference between the RRs and the NRRs in most categories; however, they identified a negative change in the areas of work ethic, technical skills development, decision-making/critical-thinking skills, and patient ownership among the RR group. Most surgeons expressed less trust (55%) with patient care and less confidence (68%) in residents' ability to operate independently in the RR group. Eighty-nine percent indicated that additional decreases in work hours would continue to hamper the mission of timely and comprehensive resident education.Conclusions: The perception of surgical educators was that RRs are clearly different from the NRRs and that the primary difference is in work ethic and duty-hour restrictions. Although similar in most attributes, RRs are perceived as having a lower baseline work ethic and a less developed technical skill set, decision-making ability, and sense of patient ownership. Subsequent study is needed to evaluate these concerns.

Things Ain't What They Used to Be and Probably Never Was (Will Rogers) - Corrected Proof

Jeffrey G. Chipman — 2010-02-08

How many times have you heard the phrase, “when I was a resident?” It is frequently mentioned to emphasize differences and to indict the current process and trainees. I remember feeling inferior to the generation of surgeons before me who frequently reminded me how they cared for 30 patients on the VA general surgery service while I only had 10. It took me a residency to realize that 20 of their 30 patients were inpatients getting preoperative evaulations or were recovering from what had become outpatient procedures. I was taking care of the same patients, just in a different place. The system had changed, but that did not mean the ability of the trainees had deteriorated.

Challenges of Multisite Surgical Teaching Programs: A Review of Surgery Clerkship - Corrected Proof

Victor K. Ng, Andrew McKay — 2010-01-04

Objective: As the enrollment in medical schools increases, the need for affiliated sites to participate in clerkship teaching will continue. The aim of this literature review was to provide a summary of measures that have been used to compare the training in affiliated community hospital sites with the tertiary teaching hospitals.Methods: An extensive literature search was conducted using PubMed, MEDLINE, and EMBASE. A total of 386 articles were identified, of which 20 were found to be relevant to this topic. The references of those articles were also consulted and were included in the preparation of this manuscript when deemed appropriate.Results: A significant difference does not seem to exist in either written examination or clinical performance evaluations among medical students who receive training at either tertiary care teaching hospitals or affiliated community hospital sites. Positive role models are important in influencing the choice of a surgical career, regardless of where clerkship training takes place.Conclusions: Although more research is merited in this area, the current evidence suggests that affiliated sites are comparable in their ability to train medical students during their surgical clerkship.

General Surgical Trainee Experiences of Mentoring: A UK Regional Audit - Corrected Proof

Usman Jaffer, Aaron Pennell, Patrick Musonda — 2009-12-28

Objective: Mentoring is advocated as an essential adjunct in work-based learning providing support in career and noncareer related issues. This study aims to investigate trainee experiences and satisfaction with mentoring arrangements.Design: E-mail survey of surgical trainees from the East of England Higher Surgical Training Deanery, UK.Main outcome measurES: Factors affecting presence of a mentoring relationship and satisfaction with mentoring arrangements were analyzed.Results: Of all respondents, 62.85% stated that they were not sure or did not have a mentor; 34.29% said that they had had a meaningful meeting with their mentor; 57.14% said that they were aware of the responsibilities of a mentor; 34.29% strongly agreed or agreed that mentoring had been useful; 25.71% said that mentoring had been useful in career development; and 20% found it useful in noncareer related issues. Of those with a mentor, only 31.43% were satisfied with mentoring. Factors affecting satisfaction with mentoring included having had a meaningful meeting, having clear objectives set, and help in job transition and noncareer related issues. Knowledge of a mentor's responsibilities was also associated with satisfaction. The only factor associated with the presence of a mentoring relationship was having a mentor appointed.Conclusions: We advocate the establishment of a mentoring matching scheme for mentors and mentees together with mentor training to improve mentoring provision for surgical trainees.

Stimulation of Interest in Resident Completion of Necessary Administrative Work: Implementation and Evaluation of a Publicly Displayed “Administrative Grade” - Corrected Proof

John Richard Barbour, Thomas E. Brothers, Susan F. Wetherholt — 2009-12-28

Work hour restrictions and educational standards that are constantly in flux pose substantial challenges for modern residency programs. Rapidly developing technologies, extraordinary scientific advances, changes in societal expectations, focus on physician competence and patient safety, and new mandates have all played a major role in the evolution of surgical practice and surgical education. Implementation and enforcement of the 80-hour work week has limited the hours available for resident education, creating a need for innovative approaches to effectively teach surgical residents.

The Public Mock Oral: A Useful Tool for Examinees and the Audience in Preparation for the American Board of Surgery Certifying Examination - Corrected Proof

Armen Aboulian, Samuel Schwartz, Amy H. Kaji, Christian de Virgilio — 2009-12-28

Objective: The objective of the study was to investigate the value of an educational program instituted in our general surgery residency training in preparation for the American Board of Surgery (ABS) Certifying Examination (CE).Design: From 2006 to 2009, a series of public mock oral examinations were administered by the program director to PGY residents 4 through 6 on a variety of surgery topics in front of all residents, faculty, and medical students. Anonymous surveys (5-point Likert scale) were collected from both the examinees and the audience to determine the perceived utility of the mock oral. Performance on the ABS CE for residents who partook in the program was compared with the five previous years.Setting: The study was undertaken at Harbor-University of California at Los Angeles (UCLA) Medical Center, a level I trauma center in Los Angeles County.Results: Overall 201 surveys were collected, 170 from the audience and 31 from examinees. The surveys demonstrated a high and equal level of satisfaction for both examinees (4.8) and the audience (4.6, p = 0.12). First-time pass rates on the ABS CE increased from 88% (38/43) before the public mock oral to 100% (19/19) after the mock oral (p = 0.3).Conclusions: The mock oral examination, which is conducted in a conference format in front of an audience of faculty and trainees, is a valuable educational tool as it helps both the examinee and the audience in preparation for the ABS CE. In addition, it has an educational value for those who are not preparing for the CE as it is perceived to expand surgical knowledge.Competencies: Medical Knowledge, Problem-Based Learning and Improvement, Interpersonal and Communications Skills