The impact of work hour restrictions on surgical resident education

The importance and benefits of defining full-time equivalence in the field of acute care surgery

Acute care surgery (ACS) encompasses five major pillars - trauma, surgical critical care, emergency general surgery, elective general surgery and surgical rescue. The specialty continues to evolve and due to high-acuity, high-volume and around-the-clock care, the workload can be significant leading to workforce challenges such as rightsizing of staff, work-life imbalance, surgeon burnout and more. To address these challenges and ensure a stable workforce, ACS as a specialty must be deliberate and thoughtful about how it manages workload and workforce going forward. In this article, we address the importance, benefits and challenges of defining full-time equivalence for ACS as a method to establish a stable ACS workforce for the future.

An asynchronous web-based intervention for neurosurgery residents to improve education on cost-effective care

OBJECTIVE

To gauge resident knowledge in the socioeconomic aspects of neurosurgery and assess the efficacy of an asynchronous, longitudinal, web-based, socioeconomics educational program tailored for neurosurgery residents.

METHODS

Trainees completed a 20-question pre- and post-intervention knowledge examination including four educational categories: billing/coding, procedure-specific concepts, material costs, and operating room protocols. Structured data from 12 index cranial neurosurgical operations were organized into 5 online, case-based modules sent to residents within a single training program via weekly e-mail. Content from each educational category was integrated into the weekly modules for resident review.

RESULTS

Twenty-seven neurosurgical residents completed the survey. Overall, there was no statistically significant difference between pre- vs post-intervention resident knowledge of billing/coding (79.2 % vs 88.2 %, p = 0.33), procedure-specific concepts (34.3 % vs 39.2 %, p = 0.11), material costs (31.7 % vs 21.6 %, p = 0.75), or operating room protocols (51.7 % vs 35.3 %, p = 0.61). However, respondents' accuracy increased significantly by 40.8 % on questions containing content presented more than 3 times during the 5-week study period, compared to an increased accuracy of only 2.2 % on questions containing content presented less often during the same time period (p = 0.05).

CONCLUSIONS

Baseline resident knowledge in socioeconomic aspects of neurosurgery is relatively lacking outside of billing/coding. Our socioeconomic educational intervention demonstrates some promise in improving socioeconomic knowledge among neurosurgery trainees, particularly when content is presented frequently. This decentralized, web-based approach to resident education may serve as a future model for self-driven learning initiatives among neurosurgical residents with minimal disruption to existing workflows.

Routine Assessment of Surgical Resident Wellness-Related Concerns During Biannual Review

BACKGROUND

Surgery residency confers stress burdens on trainees. To monitor and mitigate areas of concerns, our education team implemented a 6-item biannual survey querying potential stressors. We reviewed the initial 5-year experience to assess for trends and improve efforts in maintaining resident well-being.

STUDY DESIGN

Surgery residents from all postgraduate years were asked to complete a survey of common concerns, prioritizing them in order of importance. The items to be ranked were: needs of family/friends; nonwork time for study; financial concerns; personal well-being needs; concerns for clinical performance; and administrative demands. Changes in ranking were trended across 10 review periods. Results were analyzed using a Kruskal-Wallis test.

RESULTS

A completion rate of 96.5% was rendered from the completion of 333 surveys. Rankings changed significantly for nonwork time for study (p = 0.04), personal well-being needs (p = 0.03) and concerns for clinical performance (p = 0.004). Nonwork time for study and concerns on clinical performance were consistently ranked as top two stressors over study period, except for spring 2020. Personal well-being needs ranked highest in spring 2020; 41% of residents placed this as top 2 rankings. A decrease in concerns for clinical performance was observed in spring 2020, corresponding to the coronavirus disease 2019 (COVID-19) pandemic emergency declaration.

CONCLUSIONS

Surgery residents generally prioritized time for study and concerns for assessment of clinical performance as highest areas of concern. With the occurrence of a pandemic, increased prioritization of personal well-being was observed. Used routinely with biannual reviews, the survey was able to identify plausible changes in resident concerns. Determination of levels of actual stress and actual association with the pandemic requires additional study.

The Role of Senior Resident Clinics in Plastic Surgery Education in Canada

Background

Senior resident clinics are a means to encourage independent practice and problem solving and enhance surgical skills. The objective of this study is to investigate senior resident clinics across Canada and their utility in providing comprehensive plastic surgery training.

Methods

A web-based survey was sent to all plastic surgery program directors (PDs) and senior residents (SRs; postgraduate years 3, 4, and 5) across Canada. The surveys focused on demographics, clinic structure, procedures commonly performed, perceived autonomy, educational benefit, competency-based design considerations, and areas for improvement. Chi-square tests were used to compare responses between PDs and SRs.

Results

A total of 10 PDs (100% response rate) and 26 SRs (41% response rate) responded. Half of the training programs across Canada currently have senior clinics, and the format varies between institutions. Clinics generally focus on hand trauma and aesthetics. Both PDs and SRs felt that there is considerable autonomy for resident care in both the pre/post-operative and operative setting. Common barriers to implementing a senior clinic include not enough staff, not enough time, and the medicolegal risk. Most core competencies are felt to be addressed through the use of senior clinics. Methods to improve senior clinics could include more regular and higher volume clinics, enhanced equipment, and separation of hand and aesthetics clinics.

Conclusions

Senior clinics are a useful method to improve plastic surgery education and address many core aspects of plastic surgery training. Implementation of supported clinics focused on hand and aesthetics surgery separately may be useful for training programs that currently lack a senior clinic.

Neuroendoscopic training in neurosurgery: a simple and feasible model for neurosurgical education

BACKGROUND

The development of high levels of technical competence and excellent decision-making skills are key goals of all neurosurgical residency training programs. This acquisition of technical skills is becoming increasingly difficult due to many factors including less exposure to operative cases, demand for more time and cost-effective practices, and resident work hour restrictions. We describe a step-by-step method for how to build a low-cost and feasible model that allows residents to improve their neuroendoscopic skills.

METHODS

The bell pepper-based model was developed as an endoscopic training model. Using continuous irrigation, several hands-on procedures were proposed under direct endoscopic visualization. Endoscope setup, endoscopic third ventriculostomy, septostomy, and tumor biopsy procedures were simulated and video recorded for further edition and analysis.

RESULTS

The model can be setup in less than 15 min with minimal cost and infrastructure requirements. A single model allows simulation of all the exercises described above. The model allows exposure to the camera skills, instrument handling, and hand-eye coordination inherent to most neuroendoscopic procedures.

CONCLUSION

Minimal infrastructure requirements, simplicity, and easily setup models provide a proper environment for regular training. The bell pepper-based model is inexpensive, widely available, and a feasible model for routine training. Neurosurgery residents may benefit from the use of this model to accelerate their learning curve and familiarize themselves with the neuroendoscopic core principles in a risk-free environment without time or resource constraints.

How to Increase the Burden on Trauma Centers: Implement the 80-hour Work Week

The 80-hour week was implemented in 2003 to improve outcomes and limit errors. We hypothesize that there has been no change in outcomes postimplementation of the restrictions. Outcomes were queried from the trauma registry from 1997 to 2002 (PRE) and 2004 to 2009 (POST). Primary outcomes were mortality, intensive care unit length of stay (ICU LOS), and length of stay (LOS). Patients were stratified based on demographics, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Score, base deficit). Outcomes were then compared PRE with POST. A total of 41,770 patients were admitted during the study period. The mean age was 38 years with most being male (73%) and blunt mechanism (78%). Although patients admitted in the POST period had a slightly higher blood pressure, they were older and had higher injury severity. ICU LOS, LOS, self-pay, and mortality were higher in the POST period. After adjusted analysis, admission in the POST period was no longer a predictor of mortality (odds ratio, 1.02; confidence interval, 0.92 to 1.14). Whereas patients were more slightly more injured in the POST period, the adjusted analysis shows no difference in mortality and both a longer LOS and ICU LOS. Whether the increase is the result of more severe injury in the POST period or less efficient disposition remains to be elucidated. This study adds to the mounting evidence that the implementation of the limits on work hours does not lead to better outcomes.

Feasibility of the Epiduroscopy Simulator as a Training Tool: A Pilot Study

Epiduroscopy is a type of spinal intervention that visualizes the epidural space through the sacral hiatus using a fiberoptic scope. However, it is technically difficult to perform compared to conventional interventions and susceptible to complications. Surgery simulator has been shown to be a promising modality for medical education. To develop the epiduroscopy simulator and prove its usefulness for epiduroscopy training, we performed a case-control study including a total of 20 physicians. The participants were classified as the expert group with more than 30 epiduroscopy experiences and the beginner group with less experience. A virtual simulator (EpiduroSIM™, BioComputing Lab, KOREATECH, Cheonan, Republic of Korea) for epiduroscopy was developed by the authors. The performance of the participants was measured by three items: time to reach a virtual target, training score, and number of times the dura and nerve are violated. The training score was better in the expert group (75.00 vs. 67.50; P < 0.01). The number of violations was lower in the expert group (3.50 vs. 4.0; P < 0.01). The realism of the epidural simulator was evaluated to be acceptable in 40%. Participants improved their simulator skills through repeated attempts. The epiduroscopy simulator helped participants understand the anatomical structure and actual epiduroscopy.

Simulation Training in the ICU

Because of an emphasis on patient safety and recognition of the effectiveness of simulation as an educational modality across multiple medical specialties, use of health-care simulation (HCS) for medical education has become more prevalent. In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed. We examine the evidence base related to domains of procedural mastery, development of communication skills, and interprofessional team performance, with specific examples from the literature in which simulation has been used successfully in these domains in critical care training. We also review the data assessing the value of simulation in other areas highly relevant to critical care practice, including assessment of performance, integration of HCS in decision science, and critical care quality improvement, with attention to the areas of system support and high-risk, low-volume events in contemporary health-care systems. When possible, we report data evaluating effectiveness of HCS in critical care training based on high-level learning outcomes resulting from the training, rather than lower level outcomes such as learner confidence or posttest score immediately after training. Finally, obstacles to the implementation of HCS, such as cost and logistics, are examined and current and future strategies to evaluate best use of simulation in critical care training are discussed.

Epidemiologic and Outcome Analysis of Epistaxis in a Tertiary Care Center Emergency Department

Background

The association between hypertension and recurrent epistaxis is controversial. The objective of this study is to examine the factors associated with recurrent epistaxis visits to the emergency department (ED) and establish an otolaryngology (ENT [ear, nose, and throat]) consult algorithm to optimize treatment and minimize unnecessary consultation.

Methods

A retrospective review of 100 patients presenting to the ED for epistaxis requiring ENT consult from 2013 to 2018 was conducted. Patient demographics, comorbidities, epistaxis etiology, blood pressure measurements during admission, and treatment methods were analyzed. Patient charts were reviewed for ED admissions, complications, and procedures. A consult algorithm was subsequently devised and retrospectively applied to our cohort.

Results

Patients who required more than one ED visit for epistaxis were more often males (77.8% vs 49.3%, P = .01), required posterior packing (51.9% vs 17 .8%, P < .001), and had more comorbid hypertension (66.7% vs 38.4%, P = .01) compared to patients who had 1 visit. Compared to patients presenting during summer and fall (May–October), patients presenting during winter and spring (November–April) were more often treated for anterior epistaxis with Surgicel®/Surgifoam® rather than posterior nasal packing (57.4% vs 37.0%, P = .04). Application of our consult algorithm decreased consultation by 78% and liberated 58.5 hours of ENT resident time.

Conclusion

Patients with recurrent epistaxis tended to be male and had more comorbid hypertension. Further prospective studies are warranted to ascertain the factors associated with recurrent epistaxis. Our consult algorithm for epistaxis helped reduce unnecessary ENT consultation and facilitated reallocation of valuable resident work hours.

Addition of Advanced Practice Providers May Improve ABSITE Scores Through Enhanced Resident Education

BACKGROUND

Resident work hour restrictions and required protected didactic time limit their ability to perform clinical duties and participate in structured education. Advanced practice providers (APPs) have previoulsy been shown to positively impact patients' outcomes and overall hospital costs. We describe a model in which nurse practitioners (NPs) improve resident education and American Board of Surgery In Training Examination (ABSITE) scores by providing support to our trauma and acute care surgery (ACS) service thereby protecting resident didactic time.

MATERIALS AND METHODS

A new educational model aimed to improve ABSITE scores was created, increasing protected resident didactic time. The addition of three full-time NPs to the ACS service allowed implementation of this redesigned academic curriculum to be put into effect without neglecting patient or service-related responsibilities that were previously fulfilled by resident staff. Resident ABSITE results including standard score, percent correct, and percentile were compared before and after the educational changes were instituted.

RESULTS

Eleven residents' scores were included. For each ABSITE score, we used a mixed model with time and postgraduate year (PGY) level as fixed effects and subject ID as a random effect. The interaction term between PGY level and time was not significant and removed from the model. A significant main effect of PGY level and of time was then observed. A statistically significant improvement in ABSITE scores after intervention was observed across all the PGY levels. Standard score increased 77.3 points (P-value = 0.001), percent correct increased 5.9% (P-value = 0.002), and percentile increased 23.8 (P-value = 0.02). Following the educational reform, no residents scored below the 35th percentile.

CONCLUSIONS

Utilization of NPs on our ACS service provided adequate service coverage, allowing the implementation of an educational reform increasing protected resident education time and improved ABSITE scores.

The Utility and Efficiency of a Resident Hand Clinic for the Management of Acute Hand Trauma at the University of Alberta

BACKGROUND

The University of Alberta established a resident-run hand clinic in 2005 to expeditiously manage the growing numbers of patients with traumatic hand injuries. The purpose of this study was to examine the clinical volume and types of cases assessed and treated in the clinic, as well as gauge patient satisfaction with care received.

METHODS

A retrospective chart review and patient satisfaction questionnaire were conducted for patients assessed in the hand clinic in 2015. Demographic data, referral data, and treatment required were recorded. Patients were asked to complete a survey on their experience at the end of their visit.

RESULTS

A total of 1022 charts were reviewed. The most common reason for referral was a fracture or dislocation (57%), followed by tendon injury (18%). The average wait time to be seen in clinic was 2.97 ± 2.13 days in the winter and 4.12 ± 2.14 days in the summer. Forty-seven percent of patients required splinting, 17% required a procedure, and 21% of patients were referred for surgery. Patient satisfaction on average was 9.29 ± 0.87 on a satisfaction scale of 10.

CONCLUSION

In a 6-month period, residents attending hand clinic assessed and treated 1022 patients, providing timely management of acute injuries. A resident-run hand clinic is an effective model to decrease wait times for patients, to decrease time spent assessing nonemergent injuries in the emergency department, and to concentrate hand trauma in a setting conducive to resident training, while still maintaining high patient satisfaction.

Utilizing Intraprocedural Interactive Video Capture With Google Glass for Immediate Postprocedural Resident Coaching

BACKGROUND

Video coaching has been found to be an effective teaching method because it incorporates many of the established principles of successful adult learning. The goal of our study was to assess the feasibility and effectiveness of using a point-of-view video camera (Google Glass) to improve the surgical skills education of orthopaedic surgery residents.

METHODS

Forty-two residents from 4 institutions participated in a partially blinded randomized control trial performing an intra-articular distal tibial fracture reduction task while wearing Google Glass to record the performance. Participants underwent a structured coaching session with 20 participants (intervention group) using the recorded video to augment this session, and 22 participants (control group) receiving verbal coaching alone. The task was repeated again immediately after the coaching session. Performance was scored using an Objective Structured Assessment of Technical Skills checklist, Global Rating Scale, fluoroscopic usage, and reduction quality. A semistructured interview was then performed to assess experience of participants.

RESULTS

There was no significant difference (p > 0.05) seen in score improvement in the Objective Structured Assessment of Technical Skills checklist, Global Rating Scale, fluoroscopic usage, or reduction quality between the control and intervention groups. Thematic analysis of interview showed majority of participants found video coaching increased effectiveness in understanding of goals, developing techniques and strategies, and process of self-reflection. Their involvement was seen overall as a positive experience, with participants wanting to see more inclusion of video coaching within surgical education.

CONCLUSIONS

No difference in performance improvement between the 2 groups was seen, but majority of participants found the video coaching sessions valuable and could have potential beneficial role in education.

Resident Survey on Gastroenterology Training in Canada

BACKGROUND

Gastroenterology training in Canada is guided by the Royal College of Physicians and Surgeons of Canada. Resident perspectives on training and the degree of heterogeneity across training programs have not been previously surveyed.

AIM

This study aims to evaluate the current Canadian adult gastroenterology training experience from a resident perspective and provide insight into the heterogeneity among training programs.

METHOD

A survey designed by three current gastroenterology residents was distributed to trainees attending the Gastroenterology Residents-in-Training course at Canadian Digestive Diseases Week 2018. Categorical data from the survey was analyzed in table format. Other continuous data was converted to dichotomous data and analyzed in groups of small and large programs, the large program defined as greater than six trainees.

RESULTS

The overall response rate was 45 of 56 (80%), representing 13 of 14 accredited training sites. Mandatory rotations and core procedures varied widely across respondents, with only inpatient training consistent across all sites. Small programs had a higher call burden (P=0.039), but staff were more likely to be available to cover call if the resident coverage was unavailable (P=0.002). There were nonsignificant trends in small programs in the inability to take a post-call day (P=0.07) and a resident perception of being well trained (P=0.07).

CONCLUSIONS

There is heterogeneity across programs in mandatory rotations and core procedures. With the upcoming shift to competency-based medical education, it is an opportune time to re-evaluate and perhaps standardize how gastroenterology training is delivered in Canada.

Progressive Surgical Autonomy Observed in a Hand Surgery Resident Clinic Model

OBJECTIVE

Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model.

DESIGN

A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system.

SETTING

A tertiary hand surgery referral center.

RESULTS

A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks.

CONCLUSIONS

Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs.

Developing an objective assessment of surgical performance from operating room video and surgical imagery

An unbiased, repeatable process for assessing operating room performance is an important step toward quantifying the relationship between surgical training and performance. Hip fracture surgeries offer a promising first target in orthopedic trauma because they are common and they offer quantitative performance metrics that can be assessed from video recordings and intraoperative fluoroscopic images. Hip fracture repair surgeries were recorded using a head-mounted point-of-view camera. Intraoperative fluoroscopic images were also saved. The following performance metrics were analyzed: duration of wire navigation, number of fluoroscopic images collected, degree of intervention by the surgeon's supervisor, and the tip-apex distance (TAD). Two orthopedic traumatologists graded surgical performance in each video independently using an Objective Structured Assessment of Technical Skill (OSATS). Wire navigation duration correlated with weeks into residency and prior cases logged. TAD correlated with cases logged. There was no significant correlation between the OSATS total score and experience metrics. Total OSATS score correlated with duration and number of fluoroscopic images. Our results indicate that two metrics of hip fracture wire navigation performance, duration and TAD, significantly differentiate surgical experience. The methods presented have the potential to provide truly objective assessment of resident technical performance in the OR.

Systematic Review of Factors Influencing Surgical Performance: Practical Recommendations for Microsurgical Procedures in Neurosurgery

BACKGROUND

Microneurosurgical techniques involve complex manual skills and hand-eye coordination that require substantial training. Many factors affect microneurosurgical skills. The goal of this study was to use a systematic evidence-based approach to analyze the quality of evidence for intrinsic and extrinsic factors that influence microneurosurgical performance and to make weighted practical recommendations.

METHODS

A literature search of factors that may affect microsurgical performance was conducted using PubMed and Embase. The criteria for inclusion were established in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) statement.

RESULTS

Forty-eight studies were included in the analysis. Most of the studies used surgeons as participants. Most used endoscopic surgery simulators to assess skills, and only 12 studies focused on microsurgery. This review provides 18 practical recommendations based on a systematic literature analysis of the following 8 domains: 1) listening to music before and during microsurgery, 2) caffeine consumption, 3) β-blocker use, 4) physical exercise, 5) sleep deprivation, 6) alcohol consumption before performing surgery, 7) duration of the operation, and 8) the ergonomic position of the surgeon.

CONCLUSIONS

Despite the clear value of determining the effects of various factors on surgical performance, the available body of literature is limited, and it is not possible to determine standards for each surgical field. These recommendations may be used by neurosurgical trainees and practicing neurosurgeons to improve microsurgical performance and acquisition of microsurgical skills. Randomized studies assessing the factors that influence microsurgical performance are required.

Creation of a novel simulator for minimally invasive neurosurgery: fusion of 3D printing and special effects

OBJECTIVE Recent advances in optics and miniaturization have enabled the development of a growing number of minimally invasive procedures, yet innovative training methods for the use of these techniques remain lacking. Conventional teaching models, including cadavers and physical trainers as well as virtual reality platforms, are often expensive and ineffective. Newly developed 3D printing technologies can recreate patient-specific anatomy, but the stiffness of the materials limits fidelity to real-life surgical situations. Hollywood special effects techniques can create ultrarealistic features, including lifelike tactile properties, to enhance accuracy and effectiveness of the surgical models. The authors created a highly realistic model of a pediatric patient with hydrocephalus via a unique combination of 3D printing and special effects techniques and validated the use of this model in training neurosurgery fellows and residents to perform endoscopic third ventriculostomy (ETV), an effective minimally invasive method increasingly used in treating hydrocephalus. METHODS A full-scale reproduction of the head of a 14-year-old adolescent patient with hydrocephalus, including external physical details and internal neuroanatomy, was developed via a unique collaboration of neurosurgeons, simulation engineers, and a group of special effects experts. The model contains "plug-and-play" replaceable components for repetitive practice. The appearance of the training model (face validity) and the reproducibility of the ETV training procedure (content validity) were assessed by neurosurgery fellows and residents of different experience levels based on a 14-item Likert-like questionnaire. The usefulness of the training model for evaluating the performance of the trainees at different levels of experience (construct validity) was measured by blinded observers using the Objective Structured Assessment of Technical Skills (OSATS) scale for the performance of ETV. RESULTS A combination of 3D printing technology and casting processes led to the creation of realistic surgical models that include high-fidelity reproductions of the anatomical features of hydrocephalus and allow for the performance of ETV for training purposes. The models reproduced the pulsations of the basilar artery, ventricles, and cerebrospinal fluid (CSF), thus simulating the experience of performing ETV on an actual patient. The results of the 14-item questionnaire showed limited variability among participants' scores, and the neurosurgery fellows and residents gave the models consistently high ratings for face and content validity. The mean score for the content validity questions (4.88) was higher than the mean score for face validity (4.69) (p = 0.03). On construct validity scores, the blinded observers rated performance of fellows significantly higher than that of residents, indicating that the model provided a means to distinguish between novice and expert surgical skills. CONCLUSIONS A plug-and-play lifelike ETV training model was developed through a combination of 3D printing and special effects techniques, providing both anatomical and haptic accuracy. Such simulators offer opportunities to accelerate the development of expertise with respect to new and novel procedures as well as iterate new surgical approaches and innovations, thus allowing novice neurosurgeons to gain valuable experience in surgical techniques without exposing patients to risk of harm.

Progressive Surgical Autonomy in a Plastic Surgery Resident Clinic

Background:

Resident clinics are thought to catalyze educational milestone achievement through opportunities for progressively autonomous surgical care, but studies are lacking for general plastic surgery resident clinics (PSRCs). We demonstrate the achievement of increased surgical autonomy and continuity of care in a PSRC.

Methods:

A retrospective review of all patients seen in a PSRC from October 1, 2010, to October 1, 2015, was conducted. Our PSRC is supervised by faculty plastic surgery attendings, though primarily run by chief residents in an accredited independent plastic surgery training program. Surgical autonomy was scored on a 5-point scale based on dictated operative reports. Graduated chief residents were additionally surveyed by anonymous online survey.

Results:

Thousand one hundred forty-four patients were seen in 3,390 clinic visits. Six hundred fifty-three operations were performed by 23 total residents, including 10 graduating chiefs. Senior resident autonomy averaged 3.5/5 (SD = 1.5), 3.6/5 (SD = 1.5), to 3.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. A linear mixed model analysis demonstrated that training level had a significant impact on operative autonomy when comparing postgraduate years 6 and 8 (P = 0.026). Graduated residents’ survey responses (N = 10; 100% response rate) regarded PSRC as valuable for surgical experience (4.1/5), operative autonomy (4.4/5), medical knowledge development (4.7/5), and the practice of Accreditation Council of Graduate Medical Education core competencies (4.3/5). Preoperative or postoperative continuity of care was maintained in 93.5% of cases.

Conclusion:

The achievement of progressive surgical autonomy may be demonstrated within a PSRC model.

Paediatric cardiology fellowship training: effect of work-hour regulations on scholarly activity

BACKGROUND

In 2003, work-hour regulations were implemented by the Accreditation Council for Graduate Medical Education. Much has been published regarding resident rest and quality of life as well as patient safety. There has been no examination on the effect of work-hour restrictions on academic productivity of fellows in training. Paediatric subspecialty fellows have a scholarly requirement mandated by the American Board of Pediatrics. We have examined the impact of work-hour restrictions on the scholarly productivity of paediatric cardiology fellows during their fellowship.

METHODS

We conducted a literature search for all paediatric cardiology fellows between 1998 and 2007 at a single academic institution as first or senior authors on papers published during their 3-year fellowship and 3 years after completion of their categorical fellowship (n=63, 30 fellows before 2003 and 33 fellows after 2003). The numbers of first- or senior-author fellow publications before and after 2003 were compared. We also collected data on final paediatric cardiology subspecialty career choice.

RESULTS

There was no difference in the number of fellow first-author publications before and after 2003. Before work-hour restrictions, the mean number of publications per fellow was 2.1 (±2.2), and after work-hour restrictions it was 2.0 (±1.8), (p=0.89). By subspecialty career choice, fellows who select electrophysiology, preventative cardiology, and heart failure always published within the 6-year time period.

CONCLUSIONS

Since the implementation of work-hour regulations, total number of fellow first-authored publications has not changed. The role of subspecialty choice may play a role in academic productivity of fellows in training.

Association Between Flexible Duty Hour Policies and General Surgery Resident Examination Performance: A Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Analysis

BACKGROUND

Concerns persist about the effect of current duty hour reforms on resident educational outcomes. We investigated whether a flexible, less-restrictive duty hour policy (Flexible Policy) was associated with differential general surgery examination performance compared with current ACGME duty hour policy (Standard Policy).

STUDY DESIGN

We obtained examination scores on the American Board of Surgery In-Training Examination, Qualifying Examination (written boards), and Certifying Examination (oral boards) for residents in 117 general surgery residency programs that participated in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Using bivariate analyses and regression models, we compared resident examination performance across study arms (Flexible Policy vs Standard Policy) for 2015 and 2016, and 1 year of the Qualifying Examination and Certifying Examination. Adjusted analyses accounted for program-level factors, including the stratification variable for randomization.

RESULTS

In 2016, FIRST trial participants were 4,363 general surgery residents. Mean American Board of Surgery In-Training Examination scores for residents were not significantly different between study groups (Flexible Policy vs Standard Policy) overall (Flexible Policy: mean [SD] 502.6 [100.9] vs Standard Policy: 502.7 [98.6]; p = 0.98) or for any individual postgraduate year level. There was no difference in pass rates between study arms for either the Qualifying Examination (Flexible Policy: 90.4% vs Standard Policy: 90.5%; p = 0.99) or Certifying Examination (Flexible Policy: 86.3% vs Standard Policy: 88.6%; p = 0.24). Results from adjusted analyses were consistent with these findings.

CONCLUSIONS

Flexible, less-restrictive duty hour policies were not associated with differences in general surgery resident performance on examinations during the FIRST Trial. However, more years under flexible duty hour policies might be needed to observe an effect.

No Correlation Between Work-Hours and Operative Volumes--A Comparison Between United States and Danish Operative Volumes Achieved During Surgical Residency

OBJECTIVE

Since 2003, United States residents have been limited to an 80-hour workweek. This has prompted concerns of reduced educational quality, especially inadequate operating exposure. In contrast, the Danish surgical specialty-training program mandates a cap on working hours of 37 per week. We hypothesize that there is no direct correlation between work-hours and operative volume achieved during surgical residency. To test the hypothesis, we compare Danish and US operative volumes achieved during surgical residency training.

DESIGN

Retrospective comparative study.

PARTICIPANTS

The data from the US population was extracted from the Accreditation Council for Graduate Medical Education database for General Surgery residents from 2012 to 2013. For Danish residents, a questionnaire with case categories matching the Accreditation Council for Graduate Medical Education categories were sent to all Danish surgeons graduating the national surgical residency program in 2012 or 2013, 54 in total.

RESULTS

In all, 30 graduated residents (55%) responded to the Danish survey. We found no significant differences in mean total major procedures (1002.4 vs 976.9, p = 0.28) performed during residency training, but comparing average major procedures per year, the US residents achieve significantly more (132.3 vs 195.4, p <0.01). When factoring in differences in time spent in training, this amounts to a weekly average difference of 1.2 cases throughout training.

CONCLUSIONS

In this study, we find no difference in overall surgical volumes between Danes and US residents during their surgical training. When time in training was accounted for, differences between weekly surgical volumes achieved were minor, indicating a lack of direct correlation between weekly work-hours and operative volumes achievable. Factors other than work-hours seem to effect on operative volumes achieved during training.

The role of simulation in neurosurgery

PURPOSE

In an era of residency duty-hour restrictions, there has been a recent effort to implement simulation-based training methods in neurosurgery teaching institutions. Several surgical simulators have been developed, ranging from physical models to sophisticated virtual reality systems. To date, there is a paucity of information describing the clinical benefits of existing simulators and the assessment strategies to help implement them into neurosurgical curricula. Here, we present a systematic review of the current models of simulation and discuss the state-of-the-art and future directions for simulation in neurosurgery.

METHODS

Retrospective literature review.

RESULTS

Multiple simulators have been developed for neurosurgical training, including those for minimally invasive procedures, vascular, skull base, pediatric, tumor resection, functional neurosurgery, and spine surgery. The pros and cons of existing systems are reviewed.

CONCLUSION

Advances in imaging and computer technology have led to the development of different simulation models to complement traditional surgical training. Sophisticated virtual reality (VR) simulators with haptic feedback and impressive imaging technology have provided novel options for training in neurosurgery. Breakthrough training simulation using 3D printing technology holds promise for future simulation practice, proving high-fidelity patient-specific models to complement residency surgical learning.

Work Hour Reduction: Still Room for Improvement

OBJECTIVE

The effect of resident duty hour restrictions continues to yield conflicting results on patient outcomes. Failure to rescue (FTR), or death after a major complication, has become a topic of increasing quality assessment. The aim of this study is to evaluate the effect of duty hour restrictions on in-hospital mortality, complication rates, and FTR in patients suffering traumatic injuries.

DESIGN

Data from the National Trauma Data Bank (NTDB) were retrospectively reviewed (Research Data Set 2007-2008 and version 7.2). Patients admitted to Level I or II teaching institutions were dichotomized into pre-duty hour restriction (2002-2003) and post-duty hour restriction (2007-2008) time periods. Patients who had nonsurvivable injuries (any region Abbreviated Injury Scale score = 6), died within 48 hours, or had missing data were excluded. Multivariate logistic regression was used to adjust for differences in patient characteristics and derive adjusted outcomes.

SETTING

Level I and II teaching institutions in the NTDB.

PARTICIPANTS

All patients with trauma admitted to a Level I or II teaching institution between January 1, 2002 and June 30, 2003 and between January 1, 2007 and December 31, 2008.

RESULTS

Although overall adjusted in-hospital mortality was decreased (adjusted odds ratio [AOR] = 0.7, p < 0.001) in the post-duty hour restriction era, overall complications (AOR = 2.0, p < 0.001) and FTR (AOR = 2.0, p < 0.001) were significantly higher.

CONCLUSION

Although there may be some benefit to resident duty hour restrictions, there is still room for improvement in patient care. Individual institutions should carefully review their own complication data to identify preventable systems issues, such as poor handoffs, and opportunities for increased resident supervision.

Occupational stress and related factors among surgical residents in Korea

Purpose

The application rate for surgical residents in Korea has continuously decreased over the past few years. The demanding workload and the occupational stress of surgical training are likely causes of this problem. The aim of this study was to investigate occupational stress and its related factors in Korean surgical residents.

Methods

With the support of the Korean Surgical Society, we conducted an electronic survey of Korean surgical residents related to occupational stress. We used the Korean Occupational Stress Scale (KOSS) to measure occupational stress. We analyzed the data focused on the stress level and the factors associated with occupational stress.

Results

The mean KOSS score of the surgical residents was 55.39, which was significantly higher than that of practicing surgeons (48.16, P < 0.001) and the average score of specialized professionals (46.03, P < 0.001). Exercise was the only factor found to be significantly associated with KOSS score (P = 0.001) in univariate analysis. However, in multiple linear regression analysis, the mean number of assigned patients, resident occupation rate and exercise were all significantly associated with KOSS score.

Conclusion

Surgical residents have high occupational stress compared to practicing surgeons and other professionals. Their mean number of assigned patients, resident recruitment rate and exercise were all significantly associated with occupational stress for surgical residents.

Effect of 2011 Accreditation Council for Graduate Medical Education Duty-Hour Regulations on Objective Measures of Surgical Training

OBJECTIVE

In July 2011, new Accreditation Council for Graduate Medical Education duty-hour regulations were implemented in surgical residency programs. We examined whether differences in objective measures of surgical training exist at our institution since implementation.

DESIGN

Retrospective reviews of the American Board of Surgery In-Training Examination performance and surgical case volume were collected for 5 academic years. Data were separated into 2 groups, Period 1: July 2008 through June 2011 and Period 2: July 2011 through June 2013.

SETTING

Single-institution study conducted at the Mount Sinai Hospital, New York, NY, a tertiary-care academic center.

PARTICIPANTS

All general surgery residents, levels postgraduate year 1 through 5, from July 2008 through June 2013.

RESULTS

No significant differences in the American Board of Surgery In-Training Examination total correct score or overall test percentile were noted between periods for any levels. Intern case volume increased significantly in Period 2 (90 vs 77, p = 0.036). For chief residents graduating in Period 2, there was a significant increase in total major cases (1062 vs 945, p = 0.002) and total chief cases (305 vs 267, p = 0.02).

CONCLUSIONS

The duty-hour regulations did not negatively affect objective measures of surgical training in our program. Compliance with the Accreditation Council for Graduate Medical Education duty-hour regulations correlated with an increase in case volume. Adaptations made by our institution, such as maximizing daytime duty hours and increasing physician extenders, likely contributed to our findings.

A Structured Educational Curriculum Including Online Training Positively Impacts American Board of Surgery In-Training Examination Scores

OBJECTIVE

To assess the effect of a structured postgraduate year 1 educational curriculum, including online surgical training, on American Board of Surgery In-Training Examination (ABSITE) scores.

DESIGN

This was a retrospective cohort study.

SETTING

The study was performed in an academic surgical residency program in a tertiary care hospital, Cleveland Clinic Foundation, Cleveland, Ohio.

PARTICIPANTS

The participants were 140 surgical postgraduate year 1 residents from 2000 to 2009. Interns from 2000 to 2004 were grouped together and completed a self-directed learning curriculum. Interns from 2005 to 2009 participated in a structured educational curriculum that included lectures and the use of an online program. Lectures were based on the American College of Surgeons curriculum. The online program consisted of 8 to 12 hours of assigned tutorials and quizzes that corresponded to the lectures and 3 multiple-choice (MC) examinations.

RESULTS

Use of a structured educational curriculum led to improved ABSITE scores (66 ± 9%) compared with that of those who had no curriculum (55 ± 10%, p < 0.001). Several variables positively correlated with the ABSITE score: United States Medical Licensing Examination step 1 score (p < 0.001), monthly quiz scores (p = 0.003), average MC examination scores (p = 0.005), lecture attendance (p = 0.02), and time spent online (p = 0.04). Multivariable analysis demonstrated that the step 1 United States Medical Licensing Examination score, time spent online, and MC examination score are predictive of total the ABSITE score. When ABSITE subscores (basic science and clinical science) were compared, the online curriculum had a greater effect on basic science subscores, whereas lectures had a greater effect on clinical science subscores.

CONCLUSIONS

Providing surgery residents a structured curriculum with lectures and an online component positively impacts ABSITE scores.

How to Further Decrease the Efficiency of Care at a Level I Trauma Center: Implement the Amended Resident Work Hours

Work-hour restrictions were amended in 2011 to limit interns to 16 continuous duty hours, essentially requiring a night float system of 12-hour shifts. We hypothesize that there has been no improvement in outcomes after implementation of the amended work-hour restrictions. Outcomes from trauma admissions were queried from the trauma registry from 2009 to 2011 (PRE) and 2011 to 2013 (POST). The primary outcome was mortality with secondary outcomes intensive care unit length of stay (LOS) and LOS. Patients were stratified based on age, mechanism, gender, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Scale, Base Deficit). Outcomes were then compared from admissions PRE to POST. A total of 9178 patients were included in the study population. The mean age was 42 with most being male (72%) and blunt mechanism (81%). Patient populations were well matched except patients in the POST period were slightly older (43 vs 42 years; P = 0.01). Intensive care unit LOS and LOS were higher in the POST period. After adjusted analysis, admission in the POST period was not a predictor of mortality (odds ratio 0.857; confidence interval 0.655–1.12). The POST period was an independent predictor for LOS (β = 0.74; P = 0.002). This study adds to the mounting evidence that the implementation of the amended limits on work hours leads to furthermore decreased efficiency of care.

Are graduating surgical residents confident in performing open vascular surgery? Results of a national survey

INTRODUCTION

General surgical training has changed significantly over the past decade with work-hour restrictions, increasing use of minimally invasive techniques, and increasing specialization, leading to decreased resident exposure to open operative techniques. Furthermore, the presence of vascular surgery fellows and the advent of dedicated vascular surgery residencies have had the potential to diminish further the vascular surgery experience of general surgery residents. Given these changes, this study was undertaken to assess the confidence of graduating general surgery residents in performing certain key open vascular maneuvers, approaches that might be required in a general surgery practice, and to determine factors associated with variations in reported confidence.

METHODS

A survey was developed and sent to graduating chief surgical residents nationally. We queried them regarding demographics and program characteristics and asked them to rate their confidence (rated 1-5 on a Likert scale) in performing a vascular anastomosis and 4 specific vascular control maneuvers. We then compared those who indicated confidence with those who did not.

RESULTS

We received 653 responses from fifth-year (postgraduate year 5) surgical residents: 69% men, 67.5% from university programs, and 51% from programs affiliated with a Veterans Affairs hospital; additionally, 22% were from small programs, 34% from medium programs, and 44% from large programs. Although 70% of respondents indicated confidence performing a vascular anastomosis, less than 25% indicated confidence performing each of the 4 specified vascular maneuvers. Age, program size, future fellowship plans, surgical volume, estimated percentage of cases performed laparoscopically, and geographic location were all associated with variations in reported confidence.

CONCLUSIONS

Graduating general surgical residents indicated a significant lack of confidence in performing specific open vascular surgical maneuvers. This decreased confidence varied regionally and was associated with both demographic and program-specific factors.

Interventions that affect resident performance on the American Board of Surgery In-Training Examination: a systematic review

OBJECTIVE

To systematically review the published literature on the effectiveness of interventions intended to improve residents' American Board of Surgery In-Training Examination (ABSITE) performances.

DESIGN

A systematic review was conducted by 2 independent investigators to identify all publications that examined the effect of specific interventions on residents' ABSITE performances from 1975 to 2013.

RESULTS

Overall, 26 published articles met study criteria. Structured reading programs and setting clear expectations with mandatory remedial programs were consistently effective in improving ABSITE performance, whereas the effect of didactic teaching conferences and problem-based learning groups was mixed. There was marked heterogeneity in the usage of study designs and reporting of results.

CONCLUSIONS

Structured reading programs and mandatory remedial programs appear to be consistently effective measures that can improve residents' ABSITE performances. There is a need for improved study design and reporting in future research conducted in this field.

What effects have resident work-hour changes had on education, quality of life, and safety? A systematic review

BACKGROUND

More than 15 years ago, the Institute of Medicine (IOM) identified medical error as a problem worthy of greater attention; in the wake of the IOM report, numerous changes were made to regulations to limit residents' duty hours. However, the effect of resident work-hour changes remains controversial within the field of orthopaedics.

QUESTIONS/PURPOSES

We performed a systematic review to determine whether work-hour restrictions have measurably influenced quality-of-life measures, operative and technical skill development, resident surgical education, patient care outcomes (including mortality, morbidity, adverse events, sentinel events, complications), and surgeon and resident attitudes (such as perceived effect on learning and training experiences, personal benefit, direct clinical experience, clinical preparedness).

METHODS

We performed a systematic review of PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were any English language peer-reviewed articles that analyzed the effect(s) of orthopaedic surgery resident work-hour restrictions on patient safety, resident education, resident/surgeon quality of life, resident technical operative skill development, and resident surgeon attitudes toward work-hour restrictions. Eleven studies met study inclusion criteria. One study was a prospective analysis, whereas 10 studies were of level IV evidence (review of surgical case logs) or survey results.

RESULTS

Within our identified studies, there was some support for improved resident quality of life, improved resident sleep and less fatigue, a perceived negative impact on surgical operative and technical skill, and conflicting evidence on the topic of resident education, patient outcomes, and variable attitudes toward the work-hour changes.

CONCLUSIONS

There is a paucity of high-level or clear evidence evaluating the effect of the changes to resident work hours. Future research in this area should focus on objective measures that include patient safety as a primary outcome.

Are general surgery residents adequately prepared for hepatopancreatobiliary fellowships? A questionnaire-based study

BACKGROUND

The present study was conducted to assess the preparedness of hepatopancreatobiliary (HPB) fellows upon entering fellowship, identify challenges encountered by HPB fellows during the initial part of their HPB training, and identify potential solutions to these challenges that can be applied during residency training.

METHODS

A questionnaire was distributed to all HPB fellows in accredited HPB fellowship programmes in two consecutive academic years (n = 42). Reponses were then analysed.

RESULTS

A total of 19 (45%) fellows responded. Prior to their fellowship, 10 (53%) were in surgical residency and the rest were in other surgical fellowships or surgical practice. Thirteen (68%) were graduates of university-based residency programmes. All fellows felt comfortable in performing basic laparoscopic procedures independently at the completion of residency and less comfortable in performing advanced laparoscopy. Eight (42%) fellows cited a combination of inadequate case volume and lack of autonomy during residency as the reasons for this lack of comfort. Thirteen (68%) identified inadequate preoperative workup and management as their biggest fear upon entering practice after general surgery training. A total of 17 (89%) fellows felt they were adequately prepared to enter HPB fellowship. Extra rotations in transplant, vascular or minimally invasive surgery were believed to be most helpful in preparing general surgery residents pursing HPB fellowships.

CONCLUSIONS

Overall, HPB fellows felt themselves to be adequately prepared for fellowship. Advanced laparoscopic procedures and the perioperative management of complex patients are two of the challenges facing HPB fellows. General surgery residents who plan to pursue an HPB fellowship may benefit from spending extra rotations on certain subspecialties. Focus on perioperative workup and management should be an integral part of residency and fellowship training.

Strategies for improving education on night-float rotations: a review

INTRODUCTION

Night float rotations (NF) have been developed as a means of achieving duty hour compliance among residency programs. These were initially pioneered in the late 1980s as a response to fatigue among residents. The NF experience had its genesis in work hour reform and providing hospital service moreso than education. However, as NF has become ubiquitous, it is not clear that we have adequately revisited the educational component of this experience. We systematically reviewed the literature on educational aspects of a night float experience.

METHODS

PubMed searches were conducted for the terms "night float" and "night, curriculum, residency." This yielded 320 articles. Concerning educational aspects of the NF reduced the total to 134 articles. Editorials and those concerning procedural volumes or handoffs were also excluded. Most articles used surveys as methodology, so formal statistical analysis was not possible.

RESULTS

In total, 42 independent articles were found that directly related to the educational value of NF rotations, spanning all of the medical disciplines. Each study was searched for interventions or strategies that may affect the educational value of the NF experience. These may be grouped broadly into 3 discrete categories: (1) attention to the sleep-wake cycle, (2) addition of personal to augment the experience and (3) incorporation of formal educational elements to night rotations. A summary of these strategies is presented in Table 3.

CONCLUSIONS

NF is a practical solution to the challenge of work hour restrictions in residency, and is likely to persist in the future. Some educational issues arise due to the altered physiology of a reversed sleep-wake cycle, which may be best resolved through structural limitations of the night rotations. Other deficiencies are based on lack of interactions, for which there are strategies to improving the NF educational experience.

The impact of 2011 ACGME duty hour restrictions on internal medicine resident workload and education

The Accreditation Council for Graduate Medical Education (ACGME) implemented work hour restrictions for physicians in training in 2003 that were revised July 1, 2011. Current published data are insufficient to assess whether such work hour restrictions will have long-term impact on residents' education. We searched computer-generated reports of hospital in-patient census, continuity clinic census, in-training exam scores and first-year resident attendance at educational conferences for the academic years 2010-2011 (August 1, 2010-May 31, 2011) and 2011-2013 (August 1, 2011-May 31, 2013). During the first year of the study period, the residents' inpatient internal medicine services admitted 1,754 patients; during this same period for academic years 2011-2012 and 2012-2013, the teaching services admitted 1,539 and 1,428 patients respectively, yielding a decrease of 16.4%. Monthly, these services cared for a mean of 27.1 (27.1/175.4 [15.4%]) fewer patients and 9.7 (9.7/34.4 [28.2%]) fewer patients per intern than in the previous year. No statistical difference was observed regarding continuity clinic attendance and in-training exam scores. Residents in the years following work hours restrictions attended more educational conferences. Implementation of 2011 ACGME work hour regulations resulted in fewer patients seen by first-year residents in hospital, but did not affect in-training exam scores. Whether these findings will translate into differences in patient outcomes, and quality of care remains to be seen.

Evaluation of a novel phantom-based neurosurgical training system

Background:

The complexity of neurosurgical interventions demands innovative training solutions and standardized evaluation methods that in recent times have been the object of increased research interest. The objective is to establish an education curriculum on a phantom-based training system incorporating theoretical and practical components for important aspects of brain tumor surgery.

Methods:

Training covers surgical planning of the optimal access path based on real patient data, setup of the navigation system including phantom registration and navigated craniotomy with real instruments. Nine residents from different education levels carried out three simulations on different data sets with varying tumor locations. Trainings were evaluated by a specialist using a uniform score system assessing tumor identification, registration accuracy, injured structures, planning and execution accuracy, tumor accessibility and required time.

Results:

Average scores improved from 16.9 to 20.4 between first and third training. Average time to craniotomy improved from 28.97 to 21.07 min, average time to suture improved from 37.83 to 27.47 min. Significant correlations were found between time to craniotomy and number of training (P < 0.05), between time to suture and number of training (P < 0.05) as well as between score and number of training (P < 0.01).

Conclusion:

The training system is evaluated to be a suitable training tool for residents to become familiar with the complex procedures of autonomous neurosurgical planning and conducting of craniotomies in tumor surgeries. Becoming more confident is supposed to result in less error-prone and faster operation procedures and thus is a benefit for both physicians and patients.

ACGME Duty Hour Requirements: Perceptions and Impact on Resident Training and Patient Care

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created national guidelines for resident work hours to promote safe care and high-quality learning. However, some reports suggested that the 2003 rules did not reduce resident fatigue or improve patient care. Since July 2011, further restrictions have been in effect. The changes have been the source of much controversy regarding their impact on resident education and patient safety. We reviewed existing literature on the effects of the new and old rules, with a focus on the field of orthopaedics. In addition, we conducted a national survey of orthopaedic residents and residency directors to assess the general opinions of the orthopaedic community. Overall, only 19.7% of all respondents were satisfied with the new 2011 regulations, whereas 58.9% believe the 80-hour work week averaged over 4 weeks is appropriate. The results will inform discussions and decisions related to changing residency education in the future.

Surgery residency curriculum examination scores predict future American Board of Surgery in-training examination performance

IMPORTANCE

A protected block curriculum (PBC) with postcurriculum examinations for all surgical residents has been provided to assure coverage of core curricular topics. Biannual assessment of resident competency will soon be required by the Next Accreditation System.

OBJECTIVE

To identify opportunities for early medical knowledge assessment and interventions, we examined whether performance in postcurriculum multiple-choice examinations (PCEs) is predictive of performance in the American Board of Surgery In-Training Examination (ABSITE) and clinical service competency assessments.

DESIGN

Retrospective single-institutional education research study.

SETTING

Academic general surgery residency program.

PARTICIPANTS

A total of 49 surgical residents.

INTERVENTION

Data for PGY1 and PGY2 residents participating in the 2008 to 2012 PBC are included. Each resident completed 6 PCEs during each year.

MAIN OUTCOME MEASURES

The results of 6 examinations were correlated to percentage-correct ABSITE scores and clinical assessments based on the 6 Accreditation Council for Graduate Medical Education core competencies. Individual ABSITE performance was compared between PGY1 and PGY2. Statistical analysis included multivariate linear regression and bivariate Pearson correlations.

RESULTS

A total of 49 residents completed the PGY1 PBC and 36 completed the PGY2 curriculum. Linear regression analysis of percentage-correct ABSITE and PCE scores demonstrated a statistically significant correlation between the PGY1 PCE 1 score and the subsequent PGY1 ABSITE score (p = 0.037, β = 0.299). Similarly, the PGY2 PCE 1 score predicted performance in the PGY2 ABSITE (p = 0.015, β = 0.383). The ABSITE scores correlated between PGY1 and PGY2 with statistical significance, r = 0.675, p = 0.001. Performance on the 6 Accreditation Council for Graduate Medical Education core competencies correlated between PGY1 and PGY2, r = 0.729, p = 0.001, but did not correlate with PCE scores during either years.

CONCLUSIONS AND RELEVANCE

Within a mature PBC, early performance in a PGY1 and PGY2 PCE is predictive of performance in the respective ABSITE. This information can be used for formative assessment and early remediation of residents who are predicted to be at risk for poor performance in the ABSITE.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores

PURPOSE

To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.

METHOD

The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.

RESULTS

The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores.

CONCLUSIONS

The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Neurosurgical Training With a Novel Cervical Spine Simulator

BACKGROUND:

Neurosurgical residents have traditionally been instructed on surgical techniques and procedures through an apprenticeship model. Currently, there has been research and interest in expanding the neurosurgical education model.

OBJECTIVE:

To establish a posterior cervical decompression educational curriculum with a novel cervical simulation model.

METHODS:

The Congress of Neurological Surgeons developed a simulation committee to explore and develop simulation-based models. The educational curriculum was developed to have didactic and technical components with the incorporation of simulation models. Through numerous reiterations, a posterior cervical decompression model was developed and a 2-hour education curriculum was established.

RESULTS:

Individual's level of training varied, with 5 postgraduate year (PGY) 2 participants, 1 PGY-3 participant, 2 PGY-5 participants, and 1 attending, with the majority being international participants (6 of 9, 67%). Didactic scores overall improved (7 of 9, 78%). The technical scores of all participants improved from 11 to 24 (mean, 14.1) to 19 to 25 (mean, 22.4). Overall, in the posterior cervical decompression simulator, there was a significant improvement in the didactic scores (P = .005) and the technical scores (P = .02).

CONCLUSION:

The posterior cervical decompression simulation model appears to be a valuable tool in educating neurosurgery residents in the aspects of this procedure. The combination of a didactic and technical assessment is a useful teaching strategy in terms of educational development.

The ACGME Duty Hour Standards and Board Certification Examination Performance Trends in Surgical Specialties

BACKGROUND

Duty hour limitations initiated by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 could improve resident education in surgical specialties.

OBJECTIVE

The purpose of this study was to evaluate national surgical board examination performance and its relationship to the ACGME duty hour standards.

METHODS

In this retrospective cohort study, electronically published website content was evaluated for examination statistics for the 10 surgical boards in the American Board of Medical Specialties. To evaluate examination trends over time, we performed simple linear regression. We also performed interrupted time series analyses, using segmented logistic regression. The secondary analyses consisted of a χ(2) test of passing and failing examinees before and after 2003. All statistics used α  =  .05.

RESULTS

There were 8 of 10 (80%) surgical boards with examinations that met inclusion criteria and a total of 72 482 unique examination results. Of the 16 examinations evaluated (50% written, 50% oral), 13 (81%) had either significant pass rate trends on regression analyses and/or a significant pre-post pass rate surrounding the initiation of the ACGME duty hour standards in 2003 in the secondary analysis (P < .05).

CONCLUSIONS

There are both increasing examination pass rates and some downward trends in examination performance on surgical board examinations since the initiation of the ACGME duty hour standards in 2003. The etiology of these trends is unclear, but trends are important to know for individual examinees, residency training programs, and surgical boards.

The effect of reducing maximum shift lengths to 16 hours on internal medicine interns' educational opportunities

PURPOSE

To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours.

METHOD

The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010; 47 interns) and after (2011; 50 interns) duty hours restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences.

RESULTS

Following the duty hours restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = 0.94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49).

CONCLUSIONS

Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hours restrictions.

Surgical residents' perception of competence and relevance of the clinical curriculum to future practice

INTRODUCTION

General surgery residents maintain a case log throughout residency in order to achieve a targeted number of designated operations. Program directors must certify that each graduate is competent to enter general surgery practice without direct supervision. Our purpose was twofold, to determine: 1) graduates' perception of competence and relevance of specific operations to their practice; and 2) if case volume is related to competence.

METHODS

Six classes from a general surgery residency program (n=26) were surveyed one year after graduation. The survey was piloted and revised base on findings. It listed 67 operations encompassing all facets of general surgery. Each operation corresponded to two four-point scales (strongly agree to strongly disagree). One scale was headed with "I was well prepared to work-up, independently perform the operation, and effectively care for the patient post-operatively" and the other "This operation is relevant to my current practice profile". A linear regression analysis was utilized to study the relationship between total case volume and overall competence. An unpaired T-test was utilized to study the relationship between volume of specific operations and perceptions of competence.

RESULTS

Twenty-two graduates completed the survey (85% response rate). All respondents felt prepared to perform 24% (16/67) of the operations. Fifty percent or more of respondents felt prepared to perform 91% (61/67) of the operations. Fifty percent or more did not feel competent performing the surgical treatment of necrotizing enterocolitis, orchiopexy, transhiatal esophagectomy, adrenalectomy, and open/endovascular abdominal aortic aneurysm repair. Twenty-six operations were felt to be irrelevant to the practice of 50% or more of graduates. No operation was unanimously felt to be relevant. For 12% of operations (8/67) at least 10% of graduates felt the operation was relevant to their practice but were not comfortable performing it. These operations (abdominoperineal resection, transanal excision of tumor, transhiatal esophagectomy, superficial inguinal lymph node dissection, right hepatectomy, whipple, colonoscopy, and adrenalectomy) were considered to be in need of educational improvement at a program level. After analyzing individual case logs, increased case volume only correlated with competence for esophagectomy (5 vs. 1 p = .014), EGD (32 vs. 9 p = .018), orchiopexy (2.5 vs. 0 p = .03), and adrenalectomy (3 vs. 1 p = .001). Total major operations performed did not correlate with overall competence (p = .12).

CONCLUSION

As program directors must document graduates' competency they must do so with confidence. Our results suggest graduates to not feel competent performing many operations, and several are relevant to their practice. Competence in all aspects of general surgery may be unrealistic, even with robust volume. These findings might help in the restructuring curricula of residency.