Preparedness for Residency: Now More Than Ever

Transitions in medical education, particularly the transition to residency training, are increasingly identified as meriting additional thought and care for the appropriate development of the new physician. In this issue of JAMA Surgery, Engelhardt and colleagues aptly demonstrate that a resident’s sense of preparedness for this transition plays a crucial role in their mental health; the identified association between resident preparedness and meaningful on-call experiences as students likely applies to most specialties requiring in-house call

The business of educating the next generation of surgeons

Surgical education community needs to be informed about how education is funded and how it is threatened. In order to explore these issues the Association of Surgical Education convened a panel with significant experience in managing surgery departments to discuss the business of surgical education. They specifically addressed methods to recognize and reward faculty, educate residents on safety, quality and cost, and increase departmental revenue. This information is important in the current educational environment where there is an increased need for institutions to find alternate revenue streams to sustain graduate medical education. It is also important to find additional revenue streams to fund new residency slots to accommodate the greater number medical students who have been admitted to medical schools in response to meet the projected shortage of physicians

“Show me the Data”: A Recipe for Quality Improvement Success in an Academic Surgical Department

Background Surgeons in academic medical centers have traditionally taken a siloed approach to reducing postoperative complications. We initiated a project focusing on transparency and sharing of data in order to engage surgeons in collaborative quality improvement. Its key features were the development of a comprehensive Department Quality Dashboard and the creation of a Clinical Operations Council that oversaw quality. The purpose of this study was to assess the impact of those efforts. Study Design We compared inpatient outcomes before and after our intervention, allowing one quarter as the diffusion period. The outcomes analyzed were: risk-adjusted length of stay (LOS), mortality and direct cost and unadjusted incidence of complications and 30-day all-cause readmissions, as determined by the Vizient Clinical Database. We examined the outcomes of three groups: Group 1 (Surgery), Group 2 - all other surgical departments (Other Surgery) and Group 3 - all other patients (Non-Surgery). Two-tailed Students’s t-test was used for analysis and a p value of <0.05 considered statistically significant. Results Group 1 demonstrated statistically significant improvements in mortality (p=0.01), LOS (p=0.002), cost (p=0.0001) and complications (p=0.02) while the all-cause readmission rate was unchanged, resulting in mean decrease of 0.55 LOS days and direct cost savings of $2300 per surgical admission. The comparison groups had only modest decreases in some of the analyzed outcomes and an increase in complication rates. Conclusions These data suggest that a collaborative, data-driven and transparent approach to assessing the quality of surgical care can yield significant improvements in patient outcomes

Are Surgeons Behind the Scientific Eight Ball: Delayed Acquisition of the NIH K08 Mentored Career Development Award

Background: Surgery residents complete their research training early in residency. Non-surgical trainees typically have research incorporated toward the last two years of their fellowship, conferring an advantage to apply for grants with recent research experience and preliminary data. Methods: The NIH RePORTER database was queried for K08 awardees trained in medicine, pediatrics, and surgery from 2013 to 2017. 406 K08 recipients were identified and time from completion of clinical training to achieving a K08 award was measured. Data were compared using ANOVA and expressed as mean. P < 0.05 was considered significant. Results: Surgeons took longer to obtain a K08 than those trained in internal medicine (surgery = 3.7 years, internal medicine = 2.58 years p < 0.0001)). All K08 recipients without a PhD took longer to obtain a K08 than recipients with a PhD (MD = 3.50 years and MD/PhD = 2.42 years (p=<0.0001). Conclusions: Surgeons take longer to achieve a K08 award than clinicians trained in internal medicine, possibly due to an inherent disadvantage in training structure

High‐speed Intraoperative Assessment of Breast Tumor Margins by Multimodal Ultrasound and Photoacoustic Tomography

Conventional methods for breast tumor margins assessment need a long turnaround time, which may lead to re‐operation for patients undergoing lumpectomy surgeries. Photoacoustic tomography (PAT) has been shown to visualize adipose tissue in small animals and human breast. Here, we demonstrate a customized multimodal ultrasound and PAT system for intraoperative breast tumor margins assessment using fresh lumpectomy specimens from 66 patients. The system provides the margin status of the entire excised tissue within 10 minutes. By subjective reading of three researchers, the results show 85.7% [95% confidence interval (CI), 42.0% ‐ 99.2%] sensitivity and 84.6% (95% CI, 53.7% ‐ 97.3%) specificity, 71.4% (95% CI, 30.3% ‐ 94.9%) sensitivity and 92.3% (95% CI, 62.1% ‐ 99.6%) specificity, and 100% (95% CI, 56.1% ‐ 100%) sensitivity and 53.9% (95% CI, 26.1% ‐ 79.6%) specificity respectively when cross‐correlated with post‐operational histology. Furthermore, a machine learning‐based algorithm is deployed for margin assessment in the challenging ductal carcinoma in situ tissues, and achieved 85.5% (95% CI, 75.2% ‐ 92.2%) sensitivity and 90% (95% CI, 79.9% ‐ 95.5%) specificity. Such results present the potential of using mutlimodal ultrasound and PAT as a high‐speed and accurate method for intraoperative breast tumor margins evaluation

A Competency-based Laparoscopic Cholecystectomy Curriculum Significantly Improves General Surgery Residents’ Operative Performance and Decreases Skill Variability: Cohort Study

Objective: To demonstrate the feasibility of implementing a CBE curriculum within a general surgery residency program and to evaluate its effectiveness in improving resident skill. Summary of Background Data: Operative skill variability affects residents and practicing surgeons and directly impacts patient outcomes. CBE can decrease this variability by ensuring uniform skill acquisition. We implemented a CBE LC curriculum to improve resident performance and decrease skill variability. Methods: PGY-2 residents completed the curriculum during monthly rotations starting in July 2017. Once simulator proficiency was reached, residents performed elective LCs with a select group of faculty at 3 hospitals. Performance at curriculum completion was assessed using LC simulation metrics and intraoperative operative performance rating system scores and compared to both baseline and historical controls, comprised of rising PGY-3s, using a 2-sample Wilcoxon rank-sum test. PGY-2 group’s performance variability was compared with PGY-3s using Levene robust test of equality of variances; P < 0.05 was considered significant. Results: Twenty-one residents each performed 17.52 ± 4.15 consecutive LCs during the monthly rotation. Resident simulated and operative performance increased significantly with dedicated training and reached that of more experienced rising PGY-3s (n = 7) but with significantly decreased variability in performance (P = 0.04). Conclusions: Completion of a CBE rotation led to significant improvements in PGY-2 residents’ LC performance that reached that of PGY-3s and decreased performance variability. These results support wider implementation of CBE in resident training

Ranking Surgical Residency Programs: Reputation Survey or Outcomes Measures?

Objective The release of general surgery residency program rankings by Doximity and U.S. News &amp; World Report accentuates the need to define and establish measurable standards of program quality. This study evaluated the extent to which program rankings based solely on peer nominations correlated with familiar program outcomes measures. Design Publicly available data were collected for all 254 general surgery residency programs. To generate a rudimentary outcomes-based program ranking, surgery programs were rank-ordered according to an average percentile rank that was calculated using board pass rates and the prevalence of alumni publications. A Kendall τ-b rank correlation computed the linear association between program rankings based on reputation alone and those derived from outcomes measures to validate whether reputation was a reasonable surrogate for globally judging program quality. Results For the 218 programs with complete data eligible for analysis, the mean board pass rate was 72% with a standard deviation of 14%. A total of 60 programs were placed in the 75th percentile or above for the number of publications authored by program alumni. The correlational analysis reported a significant correlation of 0.428, indicating only a moderate association between programs ranked by outcomes measures and those ranked according to reputation. Seventeen programs that were ranked in the top 30 according to reputation were also ranked in the top 30 based on outcomes measures. Conclusions This study suggests that reputation alone does not fully capture a representative snapshot of a program’s quality. Rather, the use of multiple quantifiable indicators and attributes unique to programs ought to be given more consideration when assigning ranks to denote program quality. It is advised that the interpretation and subsequent use of program rankings be met with caution until further studies can rigorously demonstrate best practices for awarding program standings