Implementing a resident acute care surgery service: Improving resident education and patient care

Factors Influencing Exam Performance of Surgical Trainees in Sub-Saharan Africa: A Retrospective Analysis of the College of Surgeons in East, Central, and Southern Africa Membership Examination

INTRODUCTION

The College of Surgeons of East, Central, and Southern Africa (COSECSA) has been expanding surgical training in sub-Saharan Africa to respond to the shortage in the region. However, acquiring surgical skills requires rigorous training, and these skills are repeatedly assessed throughout training. Therefore, understanding the factors influencing these assessments is crucial. Previous research has identified individual characteristics, educational background, curriculum structure and previous exam outcomes to influence performance. However, COSECSA's Membership of the College of Surgeons (MCS) exam has not been investigated for factors influencing performance, which this study aims to investigate.

METHODS

Data from MCS trainees who took the exam between 2015 and 2021 were analyzed. Trainee demographics, institutional affiliation, operative experience, and exam performance were considered. Linear regression models were used to analyze the factors related to written and clinical exam performance.

RESULTS

Out of 354 trainees, 228 were included in the study. Factors such as training duration, the ratio of emergency surgeries, institutional funding source, and country language were associated with written exam performance. Training duration, funding source, exposure to major surgeries, and the ratio of performing operations were significant factors for the clinical exam.

DISCUSSION

Operative experience, institutional affiliation, training duration, and language proficiency influence exam performance. Hospitals funded by faith-based organizations or nongovernmental organizations had trainees with higher scores. Prolonged training did not guarantee improved performance. Lastly, having English as an official language improved written exam scores. Gender and country of training did not significantly impact performance.

CONCLUSION

This study highlights the importance of operative experience, institutional affiliation, and language proficiency in the exam performance of surgical trainees in COSECSA. Interventions to enhance surgical training and improve exam outcomes in sub-Saharan Africa should consider these factors. Further research is needed to explore additional outcome measures and gather comprehensive data on trainee and hospital characteristics.

Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers

Objective

Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes.

Background

Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes.

Methods

Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses.

Results

After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions.

Conclusions

VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

Educational Value of Surgical Residents Operating as Teaching Assistant

OBJECTIVE

To assess the educational of value of teaching assistant (TA) cases from the perspectives of attending, chief resident, and junior resident. We hypothesized the greatest educational value of TA cases would be for chief residents more so than other team members.

DESIGN

A prospective survey was designed and collected for TA cases separately from attendings, chief residents, and junior residents to assess operative details and educational value. The study period ran from August 2021 through December 2022. Qualitative and quantitative analysis was undertaken to compare answers and discover themes in the free-text responses of attendings and residents.

SETTING

Single center, tertiary care institution, Maine Medical Center, Department of Surgery, Portland, ME PARTICIPANTS: Sixty-nine teaching assistant cases were captured from a total of 117 completed surveys that were completed by 44 chief residents, 49 junior residents, 22 attendings (n = 22) and 2 APPs.

RESULTS

A wide variety of TA cases were included in the study with the most common reason for performing a TA case being resident request 68%. Operative complexity was most commonly rated easiest third (50%) and middle third (41%) of overall cases. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time. Attendings reported learning something about the resident's skills that they were not expecting in 59% of the cases. Thematic analysis: attendings focused on the steps of the procedure, including the technical aspects, particularly regarding opening while residents largely focused on communication and preparation.

CONCLUSIONS

Teaching assistant cases seem to have more educational value for chief and junior residents than attendings. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time.

Quality Metrics and Indicators for Surgical Training: A Scoping Review

BACKGROUND

Surgical training quality is critical to ensure that trainees receive adequate preparation to perform surgical procedures independently and that patients receive safe, effective, and high-quality care. Numerous surgical training quality indicators have been proposed, investigated and implemented. However, the existing evidence base for these indicators is limited, with most studies originating from English-speaking, high-income countries.

OBJECTIVES

This scoping review aimed to identify the range of quality indicators that have been proposed and evaluated in the literature, and to critically evaluate the existing evidence base for these indicators.

METHODS

A systematic literature search was conducted using MEDLINE and Embase databases to identify studies reporting on surgical training quality indicators. A total of 68 articles were included in the review.

RESULTS

Operative volume is the most commonly cited indicator and has been investigated for its effects on trainee exam performance and career progression. Other indicators include operative diversity, workplace-based assessments, regular evaluation and feedback, academic achievements, formal teaching, and learning agreements, and direct observation of procedural skills. However, these indicators are largely based on qualitative analyses and expert opinions and have not been validated quantitatively using clear outcome measures for trainees and patients.

CONCLUSIONS

Future research is necessary to establish evidence-based indicators of high-quality surgical training, including in low-resource settings. Quantitative and qualitative studies are required to validate existing indicators and to identify new indicators that are relevant to diverse surgical training environments. Lastly, any approach to surgical training quality must prioritize the benefit to both trainees and patients, ensuring training success, career progression, and patient safety.

Trends in pancreatic surgery experience in general surgery residency in the US, 1990–2021

BACKGROUND

We hypothesized a decline in resident pancreatic operative experience. The study assesses trends in that experience since 1990.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residency graduates from 1990 to 2021 were reviewed. Collected and analyzed were the mean and median total number of pancreatic operations per resident, the mean number of specific case types performed, and the annual number of residency graduates. For selected procedures, the mean number of cases by resident role (Surgeon-Chief and Surgeon-Junior) was also analyzed.

RESULTS

Both the mean and median total number of resident pancreatic operations has declined since 2009 as have the mean number of several specific pancreatic case types, including resections. The annual number of residency graduates has significantly increased since 1990, and particularly since 2009.

CONCLUSIONS

Resident volume in pancreatic operations has significantly declined over the last decade.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment

OBJECTIVE

We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending.

DESIGN

We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications.

SETTING

Tertiary care center, single institution.

PARTICIPANTS

Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period.

RESULTS

Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09).

CONCLUSIONS

Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.

For the People and the Profession

In 1982 Dean Warren delivered the presidential address "Not for the Profession… For the People" in which he identified substandard surgical residency programs graduating residents who were unable to pass American Board of Surgery exams. Drs. Warren and Shires as members of the independent ACGME began to close the substandard programs in order to improve surgical care for average Americans i.e. "for the people". By 2003 these changes dramatically reduced the failure rate for the ABS exams and trained good surgeons who could operate independently however the residents were on duty for every other or every third night. In 2003 the ACGME mandated duty hour restrictions in order improve resident wellness and improve the training environment for the profession. However, work hour restrictions reduced the time surgical residents spent in the hospital environment primarily when residents had more autonomy and had exposure to emergency cases which degraded readiness for independent practice. Surgical educators in the 2 decades after the work hour restrictions have improved techniques of training so graduates could not only pass the board exams but also be prepared for independent practice. Surgical residency training has improved by both the changes implemented by the independent ACGME in 1981 and by the work hour restrictions mandated in 2003. Five recommendations are made to ensure that Dr Warren's culture of excellence in surgical training continues in an environment that enhances wellbeing of the trainee i.e. "For the People and the Profession".

Chief Resident Indirect Supervision in Training Safety Study: Is a Chief Resident General Surgery Service Safe for Patients?

OBJECTIVE

There has been concern expressed amongst the medical educational community regarding the readiness of general surgery residents in the United States to be competent practicing attendings upon graduation and that limited autonomy may be a contributing factor to this unpreparedness. The purpose of this study was to evaluate an RRC-accredited general surgery residency chief resident acute care surgery service with indirect supervision of cases in terms of safety and outcomes compared to traditional general surgeon cases with direct supervision. The study focused on common general surgical procedures, specifically cholecystectomies, appendectomies, and inguinal and ventral hernia repairs.

DESIGN

A retrospective review was conducted of patient data from August 2016 to June 2018 to review all patients 16 years old and older who had received one of the following procedures: appendectomy, cholecystectomy, inguinal hernia repair, or ventral hernia repair. Patient characteristics, procedure type, procedure time, estimated blood loss, complications, length of hospital stay, 30-day readmission, 30-day ED visit, need for reoperation, and mortality were compared between attending direct supervision and chief resident indirect supervision surgery services.

SETTING

A single institution associated with a community based-university associated hybrid general surgery residency was included in this study.

PARTICIPANTS

Patients aged 16 years or older who underwent one of the operations of interest and were discharged between the dates of August 2016 and June 2018. The operations were performed by, or indirectly supervised by, attendings who were both private surgeons and also covered the chief resident service.

RESULTS

A total of 1000 cases were reviewed, with a total of 960 included in the final data after exclusions applied. Of the 960 cases included, 68.4% were traditional attending surgeon cases with direct supervision and 31.6% were chief resident service cases with indirect supervision. A total of 161 appendectomies, 396 cholecystectomies, 201 inguinal hernias and 202 ventral hernias were included. Overall, patients in the chief resident service were more often minorities (27.7 vs. 9.4%, p < 0.001), female (56.4 vs. 44.6%, p = 0.001), younger (40 vs. 55 years, p < 0.001), had a higher BMI (31.2 vs. 29.6, p = 0.018), and a lower ASA class (class 1+2 was 86.4 vs. 65.6%, p < 0.001). The median Charleson Comorbidity Index of the chief resident service patients was lower than that of the attending service (0 vs. 2, p < 0.001). Chief resident service cases were also more often urgent cases (40.6 vs. 22.8%, p < 0.001). Overall, the 30-day complication rate was similar between the two services (5.6 vs. 5.8%, p = 1.000). Complications observed from chief resident service and attending service supervised cases included pneumonia (0.3 vs. 0.5%, p = 1.000), surgical site infection (2.3 vs. 1.5%, p = 0.389), UTI (1.0 vs. 0.6%, p = 0.685), acute kidney injury (0.0 vs. 0.8%, p = 0.333), small bowel obstruction (0.0 vs. 0.6%, p = 0.314), cerebrovascular accident (0.0 vs. 0.2%, p = 1.000), and hematoma/seroma (2.3 vs. 1.7%, p = 0.500). There were no statistically significant differences in procedure-specific complications between services. There was one 30-day mortality in the study population, in the attending service group.

CONCLUSIONS

This study's data suggest that a chief resident acute care surgery service with indirect supervision of cases is safe in this community with regards to appendectomies, cholecystectomies and hernia repairs.

Impact of the acute care surgery model on resident operative experience in emergency general surgery

Background:

The acute care surgery (ACS) model has been shown to improve patient, hospital and surgeon-specific outcomes. To date, however, little has been published on its impact on residency training. Our study compared the emergency general surgery (EGS) operative experiences of residents assigned to ACS versus elective surgical rotations.

Methods:

Resident-reported EGS case logs were prospectively collected over a 9-month period across 3 teaching hospitals. Descriptive statistics were tabulated and group comparisons were made using χ² statistics for categorical data and t tests for continuous data.

Results:

Overall, 1061 cases were reported. Resident participation exceeded 90%). Appendiceal and biliary disease accounted for 49.7% of EGS cases. Residents on ACS rotations reported participating in twice as many EGS cases per block as residents on elective rotations (12.64 v. 6.30 cases, p < 0.01). Most cases occurred after hours while residents were on call rather than during daytime ACS hours (78.8% v. 21.1%, p < 0.01). Senior residents were more likely than junior residents to report having a primary operator role (71.3% v. 32.0%, p < 0.01). Although the timing of cases made no difference in the operative role of senior residents, junior residents assumed the primary operator role more often during the daytime than after hours (50.0% v. 33.1%, p = 0.01).

Conclusion:

Despite implementation of the ACS model, residents in our program obtained most of their EGS operative experience after hours while on call. Although further research is needed, our study suggests that improved daytime access to the operating room may represent an opportunity to improve the quantity and quality of the EGS operative experience at our academic network.

Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles

BACKGROUND

Progressive autonomy leading to conditional independence is necessary to achieve competence in surgical skills and decision making. Trust and transparency are ethical imperatives, but practices vary regarding the extent of disclosure of specific resident roles. We tested whether a standardized preoperative script would improve patient acceptance of resident involvement in perioperative care.

METHODS

Patients admitted to a resident-run acute care general surgery service between October 2017 and October 2018 were enrolled in an IRB-approved study. During the first half of the rotation (control), operative consent was obtained according to individual practice without specified explanation of resident roles. During the second half (intervention), the senior resident read a short semistructured script specifically explaining team roles and responsibilities, including the degree of resident independence and supervision by attendings. On postoperative day 3, patients completed a survey assessing understanding of their surgical care.

RESULTS

Sixty-two patients under the care of 10 rotating chief residents were enrolled; 46 patients completed the survey, 23 in each arm (74% response rate). Ten patients in the control arm (43%) compared to only 3 (13%) in the intervention arm indicated that residents should not be allowed to perform portions of operations (odds ratio 4.94, p = 0.047). Patients in the intervention arm felt that care team roles were more adequately explained to them before their operation (p = 0.002). There was no difference in the number of patients naming a resident as "their doctor."

CONCLUSIONS

Use of a short script specifying resident roles improves patient acceptance of trainee participation in perioperative care.

A Preoperative Educational Time-Out is Associated with Improved Resident Goal Setting and Strengthens Educational Experiences

OBJECTIVE

The purpose of this study was to assess the impact of a preoperative Educational Time-Out (ETO) with structured postoperative feedback on resident preoperative goal-setting and the educational experience of a clinical rotation.

DESIGN

A preoperative ETO was developed during which trainees and faculty jointly identified an operative goal and discussed the trainee's operative autonomy. Postoperative feedback with a smartphone application was encouraged. From November 2016 to October 2017, the intervention was piloted with 1 surgical service. Outcomes included ETO completion rate, goal setting rate, and subjects' perception of the impact of the ETO on identification of performance deficits, trainee autonomy, and receipt of feedback. Data were analyzed using descriptive statistics.

SETTING

This study was performed in an institutional hospital setting.

PARTICIPANTS

Third-year general surgery residents and surgical faculty in the Department of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center took part in the intervention.

RESULTS

Seven residents and 7 attending surgeons participated in this study. Residents performed a median of 15 procurements during an average of 6.5 weeks each on service. The ETO completion rate was 83%. Resident-reported preoperative goal setting increased after the intervention (from 36% to 78%, p = 0.015). Subjects reported a positive impact of the intervention, with high resident agreement that the ETO helped identify deficits (82% median agreement), increased autonomy (82% median agreement), and increased receipt of feedback (84% median agreement). Residents and attendings agreed that the educational experience was stronger due to the ETO (median 81% and 77%, respectively).

CONCLUSIONS

The ETO intervention improved rates of resident preoperative goal setting and strengthened perceived educational experiences. Resident participants also reported improvements in autonomy and rates of postoperative feedback. Broader implementation of this brief preoperative pause is an easy way to emphasize procedural education in the operating room.

Moving skills training closer to application: In-rotation skills curriculum is feasible and effective

PURPOSE

Using simulation can help surgical trainees acquire surgical skills but at the expense of clinical learning time. We postulate an in-rotation skills curriculum is feasible and minimizes time away from clinical experiences.

METHODS

Surgical residents (PGY2-5) were allotted two hours of weekly protected time for rotation specific simulation modules that included assessment, mentoring, and practice. Between September 2015 and February 2016 performance data was collected and participants were surveyed.

RESULTS

Completion rates of 87-100% were achieved and post-test scores improved significantly, indicating improved performance. The survey (29/30 RR) revealed that 81.5% felt 2 hours a week was 'just right' and 79.3% agreed or strongly agreed the in-rotation aspect was a benefit. Improved confidence in the OR was reported by 86.2% of residents Intra-operative skill was self-assessed as improved in 79.3%.

CONCLUSION

In-rotation skills curriculum with high completion rates is feasible and allows training in close proximity to clinical application. Performance in the simulated environment significantly improved with corresponding improvements in confidence and self-assessed skill in the operating room.