Does surgery residency prepare residents to work at critical access hospitals?

Examining the Applicability of Surgical Coaching Rules for Resident Autonomy in Non-teaching Hospitals

INTRODUCTION

This retrospective study aims to analyze the impact of standardized rules for teaching in university hospitals on surgical resident autonomy and patient safety, as measured by patient outcomes, and also examines the learning curves for residents and their impact on patient outcomes in a non-teaching hospital.

METHODS

The data for the study was collected retrospectively from medical records of 2000 adult patients who went through surgical procedures from January 2020 to December 2022. Participants were categorized into two groups based on the supervision level provided by attending surgeons and residents. Appropriate statistical methods were used to analyze the data.

RESULTS

It was observed that operative times of cases handled by both attending and resident surgeons were less than those handled by residents alone. On the other hand, the former group had a significantly higher burden of comorbidities and higher rate of perioperative complications than the latter. These results have important implications for the training of medical residents and the overall delivery of healthcare services in university hospitals.

CONCLUSION

The findings will also help towards better understanding of the effectiveness of these rules and their potential for improving the quality of care provided by residents in these settings.

The American Board of Surgery flexible endoscopy curriculum prepares individuals to pass the fundamentals of endoscopic surgery manual skills test

BACKGROUND

The American Board of Surgery (ABS) has required Fundamentals of Endoscopic Surgery (FES) certification for general surgery applicants since 2018. Flexible Endoscopy Curriculum (FEC) completion is recommended prior to taking the FES exam. The objective of the study was to determine if FEC completion prepares individuals to pass the FES manual skills test.

METHODS

Participants included first-attempt FES examinees from June 2014 to February 2019. De-identified data were reviewed, Self-reported data included gender, PGY, glove size, upper (UE) and lower (LE) endoscopy experience, simulation training time, and participation in an endoscopy rotation (ER). FES skills exam performance was reported by FES staff. Those completing all vs. none of the FEC were compared.

RESULTS

Of 2023 participants identified, 809 (40.0%) reported completion of all FEC components, 1053 (52.1%) completed of some, and 161 (8.0%) completed none. Men and candidates taking FES later in residency were more likely to complete all FEC requirements (p = 0.002, p < 0.001). FES pass rates were higher for those who completed all FEC components compared to those who completed none (88.4% vs 72.7%, p < 0.001). On logistic regression analysis, completion of all components (OR 2.3, 95% CI 1.5-3.7, p < 0.001) and male gender (OR 3.1, 95% CI 1.7-5.7, p < 0.001) were predictors of passing, while glove size (OR 1.5, 95% CI 1.0-2.5, p = 0.08), simulator time (OR 1.1, 95% CI 0.9-1.4, p = 0.37) and PGY were not (OR 1.1, 95% CI 0.9-1.4, p = 0.38). On multivariate analysis controlling for glove size and gender, completion of all FEC components was still associated with a higher likelihood of passing the FES skills exam (OR 1.6, 95% CI 1.2-2.1, p < 0.001).

CONCLUSIONS

Completion of FEC is strongly associated with passing the FES skills test. This study supports the ABS recommendation for completion of FEC prior to taking the FES skills test.

The aging general surgeon of rural America

PURPOSE

Nonmetropolitan communities are faced with health care professional shortages and prior reports suggest that general surgeons are no exception. The purpose of this brief is to evaluate the age difference and distribution of rural versus urban general surgeons to highlight the growing need to recruit medical students and residents for rural practice.

METHODS

A secondary data analysis of residency graduated general surgeon demographics at the county level was performed using data from the Area Health Resource File. General surgeon demographic data were compared between nonmetropolitan and metropolitan areas.

FINDINGS

The number of general surgeons practicing in rural communities is decreasing by a rate of approximately 0.5%-1.0% annually. Moreover, the entry of younger (<35 years of age) general surgeons into rural counties (8.7%) was less than urban regions (12.1%). Rural general surgeons tended to be older than their urban peers, and on average, rural general surgeon age exhibits a negative skewed, platykurtic distribution.

CONCLUSIONS

Immediate action must be taken to generate more surgeons for rural practice. A failure to increase recruitment and retention of rural surgeons may have severe consequences on the health status of rural communities.

The Isolated Surgeon: A Scoping Review

BACKGROUND

Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care.

METHODS

We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role.

RESULTS

From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings.

CONCLUSIONS

This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.

Initial and Ongoing Training of the Rural Surgeon

Over the last 2 decades, rural locations have realized a steady decrease in surgical access and direct care. Owing to societal expectations for equal general and subspecialty surgical care in urban or rural areas, the ability to attract, train, and hold onto the rural surgeon has come into question. Our current general surgery training curriculum has been reevaluated as to its relevance for rural surgery and several alternatives to the traditional surgical training model have been proposed. The authors discuss and evaluate current and proposed methods for surgical training curriculums and methods for rural surgeon retention through continuing education models.

Scope of Practice of the Rural Surgeon

The scope of practice of a rural surgeon depends not only the individual skillset of the surgeon, but also local resources.

Rural General Surgery Experience as a Valuable Adjunct to an Academic Based General Surgery Residency

OBJECTIVE

Few general surgery residencies offer rural rotations. We aim to evaluate the contribution of our institution's rural rotation to meeting the Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements for graduation, and residents' perceptions of the educational value of this rotation.

DESIGN

ACGME case log data were obtained from categorical general surgery residents who had completed at least 1 month-long rural surgery rotation and 1 month-long general surgery rotation at our academic medical center within the same clinical year. Cases were classified per ACGME defined categories. For each category, the number of cases per month per resident was calculated, and the means for each educational setting were compared using the paired t-test. Residents also completed a 10-question Likert scale survey regarding their perceptions of the rotation.

SETTING

Residents rotated at Vidant Medical Center, a tertiary AMC¹ affiliated with East Carolina University in Greenville, NC, and at Vidant Chowan, a critical access hospital within the Vidant Health hospital system located in Edenton, NC.

PARTICIPANTS

Categorical general surgery residents eligible to rotate through the rural surgery rotation and the general surgery rotation at the AMC.

RESULTS

Eleven total residents completed 23 months of rural surgery (mean 2.1 months per resident) and 39 months at the AMC (mean 3.5 months per resident). Significantly more endoscopic cases, hernia repairs, breast cases, and vascular cases were performed on the rural surgery rotation. More abdominal and alimentary tract cases in addition to endocrine, thoracic, and head/neck cases were performed at the AMC. Frequencies of biliary and soft tissue cases were not significantly different. Survey responses regarding the rural rotation were universally positive including more hands-on experience, increased satisfaction with patient care and continuity, and operative confidence and competence.

CONCLUSIONS

At our institution, residents benefit from an enriching rural surgery rotation that provides case numbers different from the comparative AMC general surgery rotation.

Challenges confronting rural hospitals accentuated during COVID-19

The Balanced Budget Act of 1997 created a designation for critical access hospitals (CAHs) to sustain care for people living in rural communities who lacked access to care due to hospital closures over the preceding decade. Twenty-five years later, 1350 CAHs serve approximately 18% of the US population and a systematic policy evaluation has yet to be performed. This policy analysis serves to define challenges faced by CAHs through a literature review addressing the four major categories of payment, quality, access to capital, and workforce. Additionally, this analysis describes how current challenges to maintain sustainability of CAHs over time are accentuated by gaps in public health infrastructure and variability in individual health care plans exhibited during the COVID-19 pandemic.

Distribution of General Surgery Residencies in the United States and Gender Inequality: Are We There Yet?

OBJECTIVE

Surgeons are unevenly distributed across the United States (U.S.), possibly as a result of disproportionately distributed General Surgery (GS) residencies. This study primarily aimed to examine the relationship between the distribution of GS residency positions and population by U.S. region and states. Differences in the distribution by race and gender were also examined.

DESIGN

A review of the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) National Residency Matching Program (NRMP) data over 5 years. Categorical Surgery Residency PGY1 positions (SurgPGY1) were categorized into Northeast, Midwest, South, and West regions. SurgPGY1 to population ratios were compared by region. The distribution of SurgPGY1s by race/gender was also compared.

PARTICIPANTS

Medical students who match into SurgPGY1 positions through the NRMP.

RESULTS

The mean SurgPGY1s per 10⁶ population was 4.18 ± 0.52 for 2018. Most commonly, SurgPGY1s are concentrated in the Northeast (5.79 ± 0.64) then the South (5.12 ± 1.41), then the Midwest (4.22 ± 0.37), and lastly the West (1.91 ± 0.39). NY, MA, and DC had significantly higher SurgPGY1s ratios, with DC topping at 27.05. Four States had no SurgPGY1s (AK, ID, MT, WY), while AR, MS, and UT were under 2 SurgPGY1s/10⁶. From 2014 to 2018, the percent of ACGME positions given to females increased 2.93%, while the AOA positions increased 11.84%. When adjusted for the population the race with the most residencies for their population was Asian (482.42% ACGME, 324.52% AOA).

CONCLUSION

There is a significant disproportion in the distribution of GS residencies and not proportional to population, race or gender.

Development of an Assessment Tool for Surgeons in Their First Year of Independent Practice: The Junior Surgeon Performance Assessment Tool

OBJECTIVE

The purpose of this study was to create an assessment tool to evaluate newly practicing surgeons.

DESIGN

In this prospective mixed methods study, a needs assessment was performed by conducting focus groups with practicing general surgeons, asking questions regarding essential surgeon qualities, behaviors observed in inexperienced surgeons, current assessment methods, and desired assessment tool elements and attributes. A qualitative analysis was performed using a grounded theory methodology. The Junior Surgeon Performance Assessment Tool (JSPAT) was created using a 4-point scale for each category developed, with themes identified in the qualitative analysis used to create behavioral anchors. The JSPAT was evaluated by focus group participants and by members of the American College of Surgeons Advisory Council for Rural Surgery using an online survey.

SETTING

Rural and nonuniversity-based hospitals throughout the state of Oregon.

PARTICIPANTS

Practicing general surgeons.

RESULTS

Focus groups consisted of 31 surgeons (mean age 49, mean experience 17 years) from 11 different hospitals. Qualitative analysis revealed 91 different themes, which were grouped into 5 domains (technical skills, interaction with patients, interaction with surgeon colleagues, interactions with the greater medical community, and self-care) to create the assessment tool. Twenty online survey responses providing feedback on the assessment tool were obtained, with 75% rating the JSPAT useful or very useful and 69% satisfied or very satisfied with the time to complete the tool.

CONCLUSIONS

A mixed-methods model was used to create an assessment tool for surgeons in their first year of independent practice. Survey data demonstrated that practicing surgeons find value in the JSPAT.

When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area

BACKGROUND

Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons.

METHODS

We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed.

RESULTS

We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures.

CONCLUSIONS

Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training.

What They May Not Tell You and You May Not Know to Ask: What is Expected of Surgeons in Their First Year of Independent Practice

OBJECTIVE

The objective of this study was to explore the views and expectations that practicing general surgeons have of their junior colleagues who have recently finished training.

DESIGN

This is a qualitative study performed using focus group data consisting of open-ended questions concentrating on essential qualities and attributes of surgeons, behaviors observed in newly-graduated surgeons, and appropriate oversight of junior partners. Qualitative analysis was performed using grounded theory methodology with transcripts coded by 3 independent reviewers.

SETTING

Focus groups were conducted with surgeons practicing in rural and urban community settings.

PARTICIPANTS

Focus groups consisted of practicing general surgeons throughout the state of Oregon.

RESULTS

Focus groups were comprised of 31 practicing surgeons (10 female, 21 male) with varying ages and levels of experience practicing in both rural and urban environments. Qualitative analysis revealed the need for surgeons with strong interpersonal skills, teamwork, judgment, and broad technical skills who possess the appropriate amount of confidence and know when to ask for help. Frequently noted themes identified, included not knowing when to ask for help, overconfidence or underconfidence, as well as lack of judgment and lack of either quality or breadth of technical skill. Current oversight included direct observation, subjective evaluations from staff and colleagues, analysis of outcomes/quality, and either formal or informal mentorship arrangements.

CONCLUSIONS

This study highlights the need for graduating surgeons to be competent in multiple domains. The importance of knowing when to ask for help was stressed by practicing surgeons in both the rural and urban community setting, but is underemphasized in residency training, possibly due to less indirect resident supervision. Surgeons also emphasized the importance of mentorship, as professional growth continues long after completion of training.

Training for a Career in Rural and Nonmetropolitan Surgery-A Practical Needs Assessment

OBJECTIVE

The current shortage of surgeons in rural and smaller communities is predicted to get worse. In this study, we solicited practicing rural surgeons' opinions about the skill set needed in a rural practice in order to inform curriculum development for general surgery residents who intend to embark on rural careers.

DESIGN

We developed an online survey consisting of demographic questions and closed- and open-ended questions regarding current practice environment and scope of practice. Priorities for training were identified using descriptive analyses of both the quantitative and qualitative data, including frequency of responses regarding specific skills training.

PARTICIPANTS

We surveyed currently practicing surgeons who subscribe to the American College of Surgeons Rural Surgery listserv.

RESULTS

237 surgeons from 49 states and 1 Canadian territory responded; 60% of participants had been in practice for 20 or more years, and 70% did not pursue subspecialty training. Valuable skills identified for rural surgeons were: endoscopy, advanced laparoscopy, and basic non-general surgery subspecialty procedures. Regardless of years of practice or setting, respondents felt that rural experience during residency was highly valuable (82%) and overwhelmingly supported training future rural surgeons at residency programs with broad general surgery experiences and high case volumes with no or few fellows.

CONCLUSIONS

Practicing rural surgeons identify endoscopy, basic non-general surgery subspecialty procedures, and advanced laparoscopy as key components of their current practice. These skills may not be strongly emphasized in traditional general surgery training programs. Surgical educators should focus on developing curricula that emphasize these areas in order to prepare residents for careers in rural surgery.

Meeting Increasing Demands for Rural General Surgeons

Dynamic assessment of the effective surgical workforce recommends 27,300 general surgeons in 2030; 2,525 more than are presently being trained. Rural shortages are already critical and there has been insufficient preparation for this need. A literature review of the factors influencing the choice of rural practice was performed. A systematic search was conducted of PubMed and the Web of Science to identify applicable studies in rural practice, surgical training, and rural general surgery. These articles were reviewed to identify the pertinent reports. The articles chosen for review are directed to four main objectives: 1) description of the challenges of rural practice, 2) factors associated with the choice of rural practice, 3) interventions to increase interest and preparation for rural practice, and 4) present successful rural surgical practice models. There is limited research on the factors influencing surgeons in the selection of rural surgery. The family practice literature suggests that physicians are primed for rural living through early experience, with reinforcement during medical school and residency, and retained through community involvement, and personal and professional satisfaction. However, more research into the factors drawing surgeons specifically to rural surgery, and keeping them in the community, is needed.