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Fajardo OM, Grebenyuk E, Chaves KF, Zhao Z, Ding T, Curlin HL, Harvey LFB. Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy. J OBSTET GYNAECOL 2024; 44:2330697. [PMID: 38520272 DOI: 10.1080/01443615.2024.2330697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/05/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications. METHODS A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2). RESULTS Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications. CONCLUSION Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.
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Affiliation(s)
- Olga M Fajardo
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI, USA
| | - Ekaterina Grebenyuk
- Department of Obstetrics and Gynecology, Lankenau Medical Center, Wynnewood, PA, USA
| | - Katherine F Chaves
- Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Main Line Health, Wynnewood, PA, USA
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tan Ding
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Howard L Curlin
- Minimally Invasive Gynecologic Surgery Division, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lara F B Harvey
- Minimally Invasive Gynecologic Surgery Division, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
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Grogan RS, Wieser AP, Bennie BA, Fischer CL, Paramesh V, Jarman BT. Effect of General Surgery Resident Participation in Thoracic Surgery on Oncologic Outcomes: An Observational Cohort Study. Am Surg 2024:31348241269407. [PMID: 39058406 DOI: 10.1177/00031348241269407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Background: Despite increasing sub-specialization, general surgeons continue to perform oncologic thoracic surgeries. Our objective was to determine whether general surgery resident participation in thoracic surgery affects surgical quality or oncologic outcomes. We hypothesized that patient outcomes with and without resident participation would be similar. Methods: We retrospectively reviewed the electronic health records of patients with stage 0-IV lung cancer undergoing oncologic pulmonary resection at BLINDED FOR REVIEW during an 11-year period (2012-2022). Patients younger than 18 years or older than 85 years were excluded, as were those who had incomplete follow-up data or were unregistered in our institutional cancer registry. Patients were divided into groups based on whether residents or staff surgeons completed >50% of the critical portions of the operation. We compared 30-day morbidity outcomes, overall survival (OS), and disease-free survival (DFS). Results: Three hundred thirteen patients met inclusion criteria. Demographic and clinical characteristics were similar between groups, as were types of surgical resection and median operative times. A statistical difference was found in the distribution of surgical approach. The odds of morbidity were 65% higher in the Staff group (OR=1.65; 95% CI, 1.007-2.71). Resident participation was not significantly associated with OS or DFS (P =.32 and P =.54, respectively). Discussion: General surgery resident involvement in lung cancer operations is not associated with longer operative times but is associated with a higher likelihood of a thoracotomy. General surgery resident involvement was associated with decreased postoperative morbidity and did not significantly affect OS or DFS.
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Affiliation(s)
- Riley S Grogan
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Alex P Wieser
- Department of Research Navigation, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Barbara A Bennie
- Department of Research Navigation, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Cathy L Fischer
- Department of Research Navigation, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Venki Paramesh
- Department of Cardiothoracic Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Benjamin T Jarman
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
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Kawa N, Araji T, Kaafarani H, Adra SW. A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation. J Surg Res 2024; 295:468-476. [PMID: 38070261 DOI: 10.1016/j.jss.2023.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done. METHODS In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them. RESULTS Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon's experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon. CONCLUSIONS While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.
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Affiliation(s)
- Nisrine Kawa
- Department of Dermatology, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York City, New York
| | - Tarek Araji
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haytham Kaafarani
- Division of Trauma, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Emergency Surgery and Critical Care, Boston, Massachusetts
| | - Souheil W Adra
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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Beaulieu-Jones BR, de Geus SWL, Rasic G, Woods AP, Papageorge MV, Sachs TE. A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology. Surg Oncol 2023; 48:101925. [PMID: 36913848 PMCID: PMC10200751 DOI: 10.1016/j.suronc.2023.101925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/12/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery. METHODS Patients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4-5) or a fellow (post-graduate years 6-8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching. RESULTS In total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43). CONCLUSIONS Senior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | | | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
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Rasic G, Parikh PP, Wang ML, Keric N, Jung HS, Ferguson BD, Altieri MS, Nahmias J. The silver lining of the pandemic in surgical education: virtual surgical education and recommendations for best practices. GLOBAL SURGICAL EDUCATION : JOURNAL OF THE ASSOCIATION FOR SURGICAL EDUCATION 2023; 2:59. [PMID: 38013862 PMCID: PMC10205563 DOI: 10.1007/s44186-023-00137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/04/2023] [Accepted: 05/14/2023] [Indexed: 11/29/2023]
Abstract
Virtual education is an evolving field within the realm of surgical training. Since the onset of the COVID-19 pandemic, the application of virtual technologies in surgical education has undergone significant exploration and advancement. While originally developed to supplement in-person curricula for the development of clinical decision-making, virtual surgical education has expanded into the realms of clinical decision-making, surgical, and non-surgical skills acquisition. This manuscript aims to discuss the various applications of virtual surgical education as well as the advantages and disadvantages associated with each education modality, while offering recommendations on best practices and future directions.
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Affiliation(s)
- Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA USA
| | - Priti P. Parikh
- Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH USA
| | - Ming-Li Wang
- Department of Surgery, University of New Mexico, Albuquerque, NM USA
| | - Natasha Keric
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, Banner-University Medical Center Phoenix, University of Arizona College of Medicine, Phoenix, AZ USA
| | - Hee Soo Jung
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Benjamin D. Ferguson
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, University of New Mexico, Albuquerque, NM USA
| | - Maria S. Altieri
- Division of Gastrointestinal Surgery, Department of Surgery, Pennsylvania Hospital, Penn Medicine, Philadelphia, PA USA
| | - Jeffry Nahmias
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California Irvine, Orange, CA USA
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Tsivian M, Bole R, Packiam VT, Boorjian SA, Thapa P, Frank I, Tollefson MK. The Association of Trainee Involvement in Radical Cystectomy With Perioperative and Oncologic Outcomes. Urology 2022; 165:128-133. [PMID: 35038487 DOI: 10.1016/j.urology.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/07/2021] [Accepted: 01/02/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the impact of trainee involvement in surgery on perioperative and oncological outcomes of patients undergoing radical cystectomy (RC). MATERIALS AND METHODS We reviewed the records of patients undergoing RC for urothelial carcinoma between 2000 and 2015 at our institution. Trainee level was categorized as fellow, chief, senior and junior residents. Demographic, perioperative and oncological outcomes were recorded and compared between the groups. Specifically, operative time, 30-day complications, severe complications (Clavien III-V) and oncological outcomes (overall, cancer-specific and recurrence-free survival) were assessed. RESULTS A total of 895 patients were included for study. On multivariable analysis, operative times were 30-40 minutes longer in procedures assisted by junior residents as compared to more senior trainees. Notably, trainee level was not associated with overall or severe complications on multivariable analyses. Similarly, trainee level was not associated with oncologic outcomes. CONCLUSION While cases assisted by junior residents had longer operative times, complication rates and oncological outcomes were comparable across trainee groups. Trainee level does not appear to have an impact on perioperative and oncological outcomes of RC for urothelial carcinoma.
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Affiliation(s)
| | - Raevti Bole
- Department of Urology, Mayo Clinic, Rochester, MN.
| | | | | | - Prabin Thapa
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN
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Stevens A, Meier J, Balentine C. Resident Involvement in Inguinal Hernia Repair is Safe but Associated With Increased Operative Time. J Surg Res 2022; 276:305-313. [PMID: 35421741 DOI: 10.1016/j.jss.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Understanding how resident participation in surgery affects outcomes is critical for academic surgeons. The purpose of this study was to evaluate if resident participation was associated with adverse outcomes for inguinal hernia repair. METHODS We used the Veterans Affairs Surgical Quality Improvement Program to look at 61,737 patients aged ≥18 y who had open inguinal hernia repairs from 1998 to 2018. Propensity weighting was used to compare postoperative complications and operative time for patients having surgery performed by an attending alone versus attending with a postgraduate year (PGY) 1, 3, or 5 residents. RESULTS There were 29,806 hernias (48%) repaired by an attending, 12,024 (19%) by an intern, 9008 (15%) by a PGY-3 resident, and 10,898 (18%) by a PGY-5 resident. After propensity weighting, there was a 0.13% (95% CI -0.11% to 0.38%, P = 0.29) increase in complications with PGY-1 participation compared to cases performed by attendings alone, a 0.3% increase (95% CI 0.01% to 0.59%, P = 0.04) for PGY-3 residents, and a 0.4% increase (95% CI 0.11% to 0.69%, P = 0.007) for PGY-5 residents. There was also an increase in operative time of 26 min (95% CI 25 to 27, P < 0.001) with PGY-1 participation, 19 min (95% CI 18 to 20, P < 0.001) with PGY-3 participation, and 23 min (95% CI 22 to 24, P < 0.001) with PGY-5 participation. CONCLUSIONS Resident involvement in inguinal hernia surgery was associated with a significant increase in operative time but had a minimal impact on postoperative complications. Although resident participation in hernia surgery is safe, surgical programs should focus on enhancing operative efficiency for residents.
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Affiliation(s)
- Audrey Stevens
- Department of Surgery, University of Texas Southwestern, Dallas, Texas; Department of Surgery, VA North Texas Healthcare System, Dallas, Texas; Surgical Center for Outcomes, Implementation, and Novel Interventions (S-COIN), Department of Surgery, Dallas, Texas.
| | - Jennie Meier
- Department of Surgery, University of Texas Southwestern, Dallas, Texas; Department of Surgery, VA North Texas Healthcare System, Dallas, Texas; Surgical Center for Outcomes, Implementation, and Novel Interventions (S-COIN), Department of Surgery, Dallas, Texas
| | - Courtney Balentine
- Department of Surgery, University of Texas Southwestern, Dallas, Texas; Department of Surgery, VA North Texas Healthcare System, Dallas, Texas; Surgical Center for Outcomes, Implementation, and Novel Interventions (S-COIN), Department of Surgery, Dallas, Texas
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Effect of Resident and Fellow Involvement on Outcomes of Sarcoma Surgery: A NSQIP Database Cross-Sectional Study. Sarcoma 2021; 2021:2645737. [PMID: 34961809 PMCID: PMC8710164 DOI: 10.1155/2021/2645737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/20/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
Background The complexity of sarcoma surgery often justifies surgical assistants of higher levels of academic training: senior residents, fellows, or co-surgeons. The association between the level of training of assistants and outcomes of these procedures has yet to be studied. Methods The Current Procedural Terminology (CPT) codes comprising the “core” procedures for musculoskeletal oncology fellowships were gathered. After CPTs primarily capturing nononcologic procedures were excluded, the National Surgical Quality Improvement Program (NSQIP) database was used to find procedures with these CPTs. The severity of complications was assessed using the Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery (SWORD) score. Resident/fellow presence was analyzed both as a binary variable and stratified by level of training. Results In 159 cases meeting inclusion criteria, higher-level assistants were associated with increased rate of any complication (p=0.006) and greater need for transfusion (p=0.001) but also tended to be used in cases of longer duration (p=0.001) and with higher total work relative value units (wRVUs) (p=0.001). Multivariate analysis showed that while higher-wRVU procedures persisted as an independent predictor of increased complications (OR 1.028 per RVU unit, p=0.002), neither the presence nor level of training of assistants had an independent effect on complication rates. Other independent predictors of 30-day complications were treatment comorbidity (OR 3.433, p=0.010) and lower extremity location of the tumor (OR 4.393, p=0.006). Severity of complications did not differ between any of the groups on either univariate or multivariate analysis. Conclusions Trainees of higher levels of academic training tend to be present for longer, higher-complexity musculoskeletal oncology cases, but the overall severity of complications from these do not significantly differ from lower-risk cases without trainees. Orthopedic oncologists may reassure patients that the presence of trainees and co-surgeons is not only safe but it may also help reduce the severity of complications in more complex procedures.
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Transition from trainee to educator in the operating room: A needs assessment and framework to support junior faculty. Am J Surg 2021; 223:1112-1119. [PMID: 34799075 DOI: 10.1016/j.amjsurg.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transitioning from trainee to attending surgeon requires learners to become educators. The purpose of this study is to evaluate educational strategies utilized by surgeons, define gaps in preparation for operative teaching, and identify opportunities to support this transition. METHODS A web-based, Association of Surgical Education approved survey was distributed to attending surgeons. RESULTS There were 153 respondents. Narrating actions was the most frequently reported educational model, utilized by 74% of junior faculty [JF] (0-5yrs) and 63% of senior faculty [SF] (>6yrs). Other models used included educational time-outs (29% JF, 27% SF), BID teaching model (36% JF, 51% SF), and Zwisch model (13% JF, 25% SF). Compared with 91% JF, 65% SF reported struggling with instruction (p < 0.001). Five themes emerged as presenting difficulty during the resident to attending transition: lack of relationships, ongoing learning, systems-based, cognitive load, impression management. CONCLUSIONS Our results represent a needs assessment in the transition from learner to educator in the OR.
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Zambare WV, Hess DT, Kenzik K, Pernar LI. Outcomes in Laparoscopic Roux-en-Y Gastric Bypass and Implications for Surgical Resident Education. JOURNAL OF SURGICAL EDUCATION 2021; 78:e161-e168. [PMID: 34219036 DOI: 10.1016/j.jsurg.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Some surgery residents feel inadequately prepared to perform advanced operations, partly due to losing operative opportunities to fellows. In turn, they are prompted to pursue fellowships. Allowing residents the opportunity to participate in advanced procedures and complex cases may alleviate this cycle, if their participation is safe. This study examined the effects of resident participation in laparoscopic Roux-en-Y gastric bypass procedures (LRYGBs). DESIGN Our MBSAQIP database was used to identify LRYGBs performed at our institution between 2015 and 2018. Operative notes were reviewed to determine training level of the assistant. Patient comorbidities and outcomes (duration of surgery, length of stay, post-operative complications, readmissions, and reoperations) were stratified by assistant level of training for comparison. SETTING Urban tertiary care hospital. PARTICIPANTS Trainees and attending surgeons acting as assistants during LRYGBs. RESULTS Among 987 total cases, the assistants for the procedures were chief residents (n = 549, 56%), fourth-year residents (n = 258, 26%), attending surgeons (n = 143, 14%), and third-year residents (n = 37, 4%). Attending surgeons assisted more often when patients had a BMI ≥ 45 (38% attendings vs. 25% residents, p = 0.007), ≥ 2 comorbidities (54% vs. 40%, p = 0.007), or had a history of prior bariatric surgery (22% vs. 3%, p < 0.0001).Post-operative complication rate was low (4%) and did not differ significantly between all training levels (p = 0.86). Average length of stay, readmission rates, and reoperation rates were not significantly different across training levels (p = 0.75, p = 0.072, and p = 0.91 respectively). CONCLUSION Complication rates, hospital length of stay, readmission rates, and reoperation rates were equivalent for patients regardless of the level of training of the assistant for LRYGBs. Involving residents in complex bariatric procedures such as LRYGB is a safe model of education that does not compromise patient safety or hospital outcomes. Involvement in advanced cases allows general surgery residents to more confidently move toward independent practice.
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Affiliation(s)
| | - Donald T Hess
- Boston University School of Medicine, Boston, MA; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston, Massachusetts; Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham, Birmingham, Alabama
| | - Luise I Pernar
- Boston University School of Medicine, Boston, MA; Department of Surgery, Boston Medical Center, Boston, Massachusetts.
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Traven SA, McGurk KM, Althoff AD, Walton ZJ, Leddy LR, Potter BK, Slone HS. Resident Level Involvement Affects Operative Time and Surgical Complications in Lower Extremity Fracture Care. JOURNAL OF SURGICAL EDUCATION 2021; 78:1755-1761. [PMID: 33903063 DOI: 10.1016/j.jsurg.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/01/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this study is to evaluate the effect of resident participation on operative time and surgical complications in isolated lower extremity fracture care. SETTING Patients who were treated at teaching hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PARTICIPANTS A total of 2,488 patients who underwent surgical fixation of isolated hip fractures, femoral or tibial shaft fractures, and ankle fractures. DESIGN Patients were stratified by surgical procedure and post-graduate year (PGY) of the resident involved. Total operative time and surgical complications were analyzed with respect to resident participation and seniority. Multivariable logistic regression analyses were used to adjust for potential confounders including case complexity, wound class, and patient comorbidity burden. RESULTS As PGY level increased, operative time increased for each procedure. The odds for a deep surgical site infection decreased as resident seniority increased, but the odds for wound dehiscence increased as resident seniority increased. We found no difference in the incidences of superficial infections or return to the OR with respect to PGY level. Academic quarter within the academic year did not correlate with any of the surgical complications. Furthermore, when cases performed with residents were compared to those performed without residents, there was no increased risk of superficial infections, deep infections, or return to the OR. CONCLUSIONS This nationally representative dataset demonstrates that operative times for lower extremity orthopedic trauma increased as resident seniority increased. Additionally, senior resident participation was associated with increased wound dehiscence, whereas junior resident participation was associated with an increased risk of deep surgical site infections. However, there was no associated "July effect" for residents at any level of training and there was no increased risk for surgical site infections or return to the OR in cases involving resident participation.
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Affiliation(s)
- Sophia A Traven
- Medical University of South Carolina, Charleston, South Carolina.
| | - Kathy M McGurk
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Zeke J Walton
- Medical University of South Carolina, Charleston, South Carolina
| | - Lee R Leddy
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Harris S Slone
- Medical University of South Carolina, Charleston, South Carolina
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Abstract
Within general surgery education circles, the state of autonomy for residents in surgery training programs has been of growing concern. Although there is no direct evidence showing less autonomy in modern surgical training, multiple surrogates have been cited as reasons for concern. Many reasons have been given for lost autonomy including the 80-hour work week, financial constraints, concerns over quality of patient care, patient expectations, new and innovative technologies, legal limitations, and public opinion. This article discusses the current state of general surgery resident autonomy, why autonomy is important, barriers to autonomy, and ways to support autonomy.
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13
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Lederhuber H, Hanßke B, Dahlstrand U. Impact of Trainee Participation on Inguinal Hernia Repair Outcome: A Study Based on the Swedish Hernia Register. Ann Surg 2021; 274:e62-e69. [PMID: 31365364 DOI: 10.1097/sla.0000000000003497] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether differences in postoperative outcome exist between open inguinal hernia repairs performed by surgical trainees and those performed by specialist surgeons. SUMMARY OF BACKGROUND DATA Inguinal hernia repair is the prototype educational surgical procedure. The impact of trainee participation on postoperative outcome is still controversial and despite earlier studies no reliable hernia-specific data exist. METHODS The study cohort was based on the Swedish Hernia Register and consisted of 61,161 cases of male patients aged 18 years and older with open anterior mesh repair of a primary inguinal hernia between January 1, 2002, and December 31, 2014. The study cohort was selected to represent the typical trainee procedure in Sweden. Primary outcome measures were reoperation due to hernia recurrence and postoperative 30-day complications. RESULTS Procedures with longer operating times were at a higher risk for reoperation when performed by supervised trainees [57 to 72 minutes: hazard ratio (HR) 1.55, 99% confidence interval (99% CI) 1.05-2.27] or unsupervised trainees (57 to 72 minutes: HR 1.60, 99% CI 1.18-2.17; >72 minutes: HR 1.72, 99% CI 1.25-2.37). The same was true for specialist and trainee-assisted specialists with operating times <43 minutes (HR 1.63, 99% CI 1.25-2.13; HR 1.58, 99% CI 1.09-2.28). Postoperative 30-day complications were generally associated with longer operating times and occurred at all levels of experience. CONCLUSION Trainee participation in open inguinal repair in combination with longer operating time is a risk factor associated with higher reoperation rates. This calls for a more structured supervision of trainees in an assumedly basic procedure.
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Affiliation(s)
- Hans Lederhuber
- Department of General Surgery, Torsby Hospital, Region Värmland County Council, Värmland, Sweden
| | - Bengt Hanßke
- Department of General Surgery, Torsby Hospital, Region Värmland County Council, Värmland, Sweden
| | - Ursula Dahlstrand
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Salvia R, Andrianello S, Ciprani D, Deiro G, Malleo G, Paiella S, Casetti L, Landoni L, Tuveri M, Esposito A, Marchegiani G, Bassi C. Pancreatic surgery is a safe teaching model for tutoring residents in the setting of a high-volume academic hospital: a retrospective analysis of surgical and pathological outcomes. HPB (Oxford) 2021; 23:520-527. [PMID: 32859493 DOI: 10.1016/j.hpb.2020.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Academic hospitals must train future surgeons, but whether residents could negatively affect the outcomes of major procedures is a matter of concern. The aim of this study is to assess if pancreatic surgery is a safe teaching model. METHODS Outcomes of 1230 major pancreatic resections performed at a high-volume pancreatic teaching hospital between 2015 and 2018 were compared according to the first surgeon type, attending vs resident. RESULTS Residents performed a selection of 132 (16%) pancreaticoduodenectomies (PD) and 46 (11%) distal pancreatectomies (DP). For PD, pancreatic fistula (25% vs 0, p < 0.001), biliary fistula (7.1% vs 3.5%, p = 0.04) and operative time (400 vs 390 min, p < 0.001) were lower for residents but post-pancreatectomy hemorrhage was higher (20.5% vs 13% p = 0.024). For DP, pancreatic fistula rate was lower for residents (31.7% vs 17.5% p = 0.046). There was no difference in terms of lymph nodes retrieval both for PDs and DPs, while the R1 resections were more frequent among PDs performed by attending surgeons (31.5% vs 15.7%, p = 0.023). CONCLUSION The active participation of residents does not negatively affect outcomes of major pancreatic resections in a high-volume center. By means of case selection and continuous tutoring, pancreatic surgery represents a safe and valid teaching model.
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Affiliation(s)
- Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Debora Ciprani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giacomo Deiro
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Impact of fellow compared to resident assistance on outcomes of minimally invasive surgery. Surg Endosc 2021; 36:1554-1562. [PMID: 33763745 DOI: 10.1007/s00464-021-08444-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION As fellowship training after general surgery residency has become increasingly common, the impact on resident education must be considered. Patient safety and procedure outcomes are often used as justification by attendings who favor fellows over residents in certain minimally invasive surgery (MIS) operations. The aim of the present study was to compare the impact of trainee level on the outcomes of selected MIS operations to determine if giving preference to fellows on grounds of outcomes is warranted. METHODS Patients who underwent elective laparoscopic hiatal hernia repair (LHHR), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic splenectomy (LS), laparoscopic cholecystectomy (LC), or laparoscopic ventral hernia repair (LVHR) with assistance of a general surgery chief resident or fellow were identified from the American College of Surgeon's National Surgical Quality Improvement Program database (2007-2012). Patients were matched 1:1 based on propensity score for the odds of undergoing operations assisted by a fellow. RESULTS 5145 patients underwent LHHR, 1396 LSG, 9656 LRYGB, 863 LS, 13,434 LC, and 3069 LVHR. Fellows assisted in 41.7% of LHHR, 49.2% of LSG, 56.4% of LRYGB, 25.7% of LS, 17.1% of LC, and 27.0% of LVHR cases. After matching, overall and severe complication rates were comparable between cases performed with assistance of a fellow or chief resident. Median operative time was longer for LSG, LRYGB, and LC when a fellow assisted. CONCLUSIONS Surgical outcomes were similar between fellow and chief resident assistance in MIS operations, arguing that increased resident participation in basic and complex laparoscopic operations is appropriate without compromising patient safety.
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Yip W, Vij SC, Li J, Samplaski MK. The effect of trainee involvement on surgical outcomes and complications of male infertility surgical procedures. Andrologia 2020; 52:e13719. [PMID: 32557781 DOI: 10.1111/and.13719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/28/2020] [Indexed: 11/27/2022] Open
Abstract
In this study, we sought to determine the effect of trainee (resident or fellow physician) involvement in male infertility surgical procedures on patient surgical outcomes and complications. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for fertility surgical procedures from 2006 to 2012. The procedures included were as follows: epididymectomy, spermatocelectomy, varicocelectomy ± hernia repair, ejaculatory duct resection, vasovasostomy, vasoepididymostomy and 'unlisted procedure male genital system' (to capture sperm retrieval procedures). A variety of peri- and post-operative outcomes were examined. Trainee and nontrainee-involved groups were compared by Wilcoxon rank sum tests, followed by logistic regression, univariate and multivariate analyses. 924 cases were included: 309 with trainees and 615 without. The median post-graduate trainee year was 3 (range: 0-10). Patients in the trainee-involved cohort had higher rates of chronic obstructive pulmonary disease, steroid usage and black race. Mean operative time was 42.5% longer in trainee-involved cases, even after controlling for other covariates (76.2 vs. 49.5 min, p = .00). Hospital stay length was also longer in trainee-involved cases (0.41 vs. 0.35 days, p = .02). There were no differences in superficial infections (p = 1.00), deep wound infections (p = 1.00), urinary tract infections (p = .26), or reoperations (p = .23) with or without trainee involvement.
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Affiliation(s)
- Wesley Yip
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Sarah C Vij
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jianbo Li
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mary K Samplaski
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
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Abstract
Supervision of resident physicians is a high-risk area of emergency medicine, and what constitutes appropriate supervision is a complex question. In this article, policies and procedures for appropriate supervision of resident physicians and the implications for billing are reviewed. Recommendations on supervision of resident physicians in the emergency department are detailed, with attention paid to addressing challenges in balancing patient safety with resident autonomy and education during the course of patient care and graduate medical education.
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Affiliation(s)
- Alexander Y Sheng
- Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, 800 Harrison Avenue, BCD Building, 1st Floor, Boston, MA 02118, USA.
| | - Avery Clark
- Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, 800 Harrison Avenue, BCD Building, 1st Floor, Boston, MA 02118, USA
| | - Cristopher Amanti
- Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, 800 Harrison Avenue, BCD Building, 1st Floor, Boston, MA 02118, USA
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Do WS, Sheldon RR, Phillips CJ, Eckert MJ, Sohn VY, Martin MJ. Senior surgical resident autonomy and teaching assistant cases: A prospective observational study. Am J Surg 2020; 219:846-850. [PMID: 32139104 DOI: 10.1016/j.amjsurg.2020.02.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Teaching assistant (TA) cases allow senior residents (SR) to gain autonomy. We compared the safety profiles of TA cases performed under direct vs. indirect staff supervision. METHODS Prospective observational study of operative cases where a SR served as the TA between 7/2014-6/2017 (n = 161). Patient/operative characteristics, 30-day outcomes, and SR survey data were compared by level of supervision. RESULTS Case mix included 68 laparoscopic appendectomies (42%), 49 laparoscopic cholecystectomies (30%), 10 I&Ds (6%), 10 umbilical hernia repairs (6%), 4 port placements (3%), and 11 others. Indirectly supervised cases were shorter (61 vs. 76 min, p < 0.01), with less blood loss (11 vs. 24 ml, p < 0.05), and lower conversion rates (0% vs. 5.7%, p < 0.05). Perceived difficulty was high in 20% of cases with indirect vs. 49% with direct supervision (p < 0.01). Mean SR comfort was high (4.4 vs. 4.6 out of 5) regardless of level of staff supervision. 30-day complications did not differ for indirect vs. direct supervision (all p = NS). DISCUSSION Carefully selected TA cases offer SRs opportunities to practice autonomy without sacrificing operative time or patient safety.
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Affiliation(s)
- Woo S Do
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
| | - Rowan R Sheldon
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
| | - Cody J Phillips
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
| | - Matthew J Eckert
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
| | - Vance Y Sohn
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
| | - Matthew J Martin
- Department of Surgery, Scripps Mercy Hospital, San Diego, CA, USA.
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Gimm O, Barczyński M, Mihai R, Raffaelli M. Training in endocrine surgery. Langenbecks Arch Surg 2019; 404:929-944. [PMID: 31701231 PMCID: PMC6935392 DOI: 10.1007/s00423-019-01828-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. METHODS A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. RESULTS For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs. CONCLUSIONS Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.
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Affiliation(s)
- Oliver Gimm
- Department of Surgery and Department of Clinical and Experimental Medicine (IKE), Linköping University, 58183 Linköping, Sweden
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202 Kraków, Poland
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 7DU United Kingdom
| | - Marco Raffaelli
- U.O. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
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Chen A, Ghodoussipour S, Titus MB, Nguyen JH, Chen J, Ma R, Hung AJ. Comparison of clinical outcomes and automated performance metrics in robot-assisted radical prostatectomy with and without trainee involvement. World J Urol 2019; 38:1615-1621. [PMID: 31728671 DOI: 10.1007/s00345-019-03010-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE In this study, we investigate the effect of trainee involvement on surgical performance, as measured by automated performance metrics (APMs), and outcomes after robot-assisted radical prostatectomy (RARP). METHODS We compared APMs (instrument tracking, EndoWrist® articulation, and system events data) and clinical outcomes for cases with varying resident involvement. Four of 12 standardized RARP steps were designated critical ("cardinal") steps. Comparison 1: cases where the attending surgeon performed all four cardinal steps (Group A) and cases where a trainee was involved in at least one cardinal step (Group B). Comparison 2, where Group A is split into Groups C and D: cases where attending performs the whole case (Group C) vs. cases where a trainee performed at least one non-cardinal step (Group D). Mann-Whitney U and Chi-squared tests were used for comparisons. RESULTS Comparison 1 showed significant differences in APM profiles including camera movement time, third instrument usage, dominant instrument moving time, velocity, articulation, as well as non-dominant instrument moving time and articulation (all favoring Group A p < 0.05). There was a significant difference in re-admission rates (10.9% in Group A vs 0% in Group B, p < 0.02), but not for post-operative outcomes. Comparison 2 demonstrated a significant difference in dominant instrument articulation (p < 0.05) but not in post-operative outcomes. CONCLUSIONS Trainee involvement in RARP is safe. The degree of trainee involvement does not significantly affect major clinical outcomes. APM profiles are less efficient when trainees perform at least one cardinal step but not during non-cardinal steps.
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Affiliation(s)
- Andrew Chen
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Saum Ghodoussipour
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Micha B Titus
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Jessica H Nguyen
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Jian Chen
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Runzhuo Ma
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Andrew J Hung
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA.
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de Geus SWL, Geary AD, Arinze N, Ng SC, Carter CO, Sachs TE, Hall JF, Hess DT, Tseng JF, Pernar LIM. Resident involvement in minimally-invasive vs. open procedures. Am J Surg 2019; 219:289-294. [PMID: 31722797 DOI: 10.1016/j.amjsurg.2019.10.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/24/2019] [Accepted: 10/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the impact of resident involvement on surgical outcomes in laparoscopic compared to open procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program 2007-2012 was queried for open and laparoscopic ventral hernia repair (VHR), inguinal hernia repair (IHR), splenectomy, colectomy, or cholecystectomy (CCY). Multivariable regression analyses were performed to assess the impact of resident involvement on surgical outcomes. RESULTS In total, 88,337 VHR, 20,586 IHR, 59,254 colectomies, 3301 splenectomies, and 95,900 CCY were identified. Resident involvement was predictive for major complication during open VHR (AOR, 1.29; p < 0.001), but not during any other procedure. Resident participation significantly prolonged operative time for open, as well as laparoscopic VHR, IHR, colectomy, splenectomy, and CCY (all p < 0.01). CONCLUSIONS The results of this study suggest that resident participation has a similar impact on surgical outcomes during laparoscopic and open surgery, and is generally safe.
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Affiliation(s)
- Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Alaina D Geary
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Nkiruka Arinze
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Cullen O Carter
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Jason F Hall
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Donald T Hess
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Luise I M Pernar
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Fieber JH, Bailey EA, Wirtalla C, Johnson AP, Leeds IL, Medbery RL, Ahuja V, VanderMeer T, Wick EC, Irojah B, Kelz RR. Does Perceived Resident Operative Autonomy Impact Patient Outcomes? JOURNAL OF SURGICAL EDUCATION 2019; 76:e182-e188. [PMID: 31377204 DOI: 10.1016/j.jsurg.2019.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/30/2019] [Accepted: 06/06/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE We investigated the association of perceived trainee autonomy with patient clinical outcomes following colorectal surgery. DESIGN This was a prospective multi-institutional study that consisted of surgery trainees completing a survey tool immediately after participating in colorectal resections to rate their self-perceived autonomy and case characteristics. Self-perception of autonomy was classified as observer, assistant, surgeon, or teacher. The completed trainee surveys were linked with patient information available through each hospital's internal NSQIP directory. The primary outcome was death and serious morbidity (DSM) and secondary outcome was 30-day readmissions. Separate mixed effects regression models were used to examine the association between perceived trainee autonomy and DSM or 30-day readmissions. Fixed effects were used to control for the effects of the training environment. The models were constructed to adjust for patient and trainee characteristics associated with each outcome independently. SETTING This study was conducted at 7 general surgery training programs (5 academic medical centers and 2 independent training programs) with general surgery or colorectal surgery services. PARTICIPANTS This study included a total of 63 residents and fellows rotating on surgery services that performed colorectal resections at the included 7 general surgery training programs from January until March 2016. RESULTS The 63 trainees that participated in this study completed 417 surveys with over a 95% response rate. National Surgical Quality Improvement Program (NSQIP) patient records were available for 67% (n = 273) of completed surveys. The clinical year of the trainees were 6.1% PGY 1/2, 36% Post graduate year (PGY) 3, 40.9% PGY 4/5, and 17% fellows. Residents perceived their participation in the case to be that of an observer in 9.2% of surveys, an assistant in 51.6% of surveys, and the surgeon/teacher in 39.3% of surveys. About 50% of patients were male, 80% were White, the majority had an American Society of Anesthesiologists classification of 3, almost half had prior abdominal surgery, and over 80% of surgeries were elective. The primary operation types performed were laparoscopic (40.3%) and open (35.9%) partial colectomies. The rate of DSM in patients was approximately 24% when trainees perceived their role as observers, 23% when trainees perceived their role as assistants, and 18% when trainees perceived their role as surgeons/teachers. After adjustment for patient, trainee, and training environment, we found that the perceived level of trainee autonomy of a surgeon/teacher was associated with a 4-fold lower rate of DSM (odds ratio: 0.23, confidence of interval: 0.05-0.97, p = 0.045) compared to observers. The rate of readmissions was approximately 20% when trainees perceived their role as observers, 14% when trainees perceived their role as assistants and 9% when trainees perceived their role as surgeons/teachers. After adjustment for patient, trainee, and training environment, we found that the perceived level of trainee autonomy of a surgeon/teacher was significantly associated with a 10-fold lower rate of 30-day readmissions (odds ratio: 0.09, confidence of interval: 0.01-0.70, p = 0.022) compared to observers. CONCLUSIONS There was an association between increased perceived trainee autonomy and improved patient outcomes, suggesting that when trainees identify with an increased role in the operation, patients may have improved care. Further research is needed to understand this association further.
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Affiliation(s)
- Jennifer H Fieber
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia, Pennsylvania.
| | - Elizabeth A Bailey
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia, Pennsylvania.
| | - Chris Wirtalla
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia, Pennsylvania.
| | - Adam P Johnson
- Thomas Jefferson University Hospital, Department of Surgery, Philadelphia, Pennsylvania.
| | - Ira L Leeds
- Johns Hopkins Hospital, Department of Surgery, Baltimore, Maryland.
| | - Rachel L Medbery
- Emory University Hospital, Department of Surgery, Atlanta, Georgia.
| | - Vanita Ahuja
- Sinai Hospital, Department of Surgery, Baltimore, Maryland.
| | - Thomas VanderMeer
- Guthrie Robert Packer Hospital, Department of Surgery, Sayre, Pennsylvania.
| | - Elizabeth C Wick
- Johns Hopkins Hospital, Department of Surgery, Baltimore, Maryland.
| | - Busayo Irojah
- Wellspan York Hospital, Department of Surgery, York, Pennsylvania.
| | - Rachel R Kelz
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia, Pennsylvania.
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Wojcik BM, Lee JM, Peponis T, Amari N, Mendoza AE, Rosenthal MG, Saillant NN, Fagenholz PJ, King DR, Phitayakorn R, Velmahos G, Kaafarani HM. Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery. JOURNAL OF SURGICAL EDUCATION 2018; 75:e156-e167. [PMID: 30195664 DOI: 10.1016/j.jsurg.2018.07.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/10/2018] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs. DESIGN The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs. SETTING A large tertiary care teaching hospital. PARTICIPANTS Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident. RESULTS A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs. CONCLUSIONS The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.
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Affiliation(s)
- Brandon M Wojcik
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jae Moo Lee
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Peponis
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Noor Amari
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - April E Mendoza
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Martin G Rosenthal
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Noelle N Saillant
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter J Fagenholz
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George Velmahos
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Acheampong DO, Paul P, Guerrier S, Boateng P, Leitman IM. Effect of Resident Involvement on Morbidity and Mortality Following Thoracic Endovascular Aortic Repair. JOURNAL OF SURGICAL EDUCATION 2018; 75:1575-1582. [PMID: 29709469 DOI: 10.1016/j.jsurg.2018.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/27/2018] [Accepted: 04/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). SUMMARY OF BACKGROUND DATA Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values < 0.05 were considered statistically significant. RESULTS A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). CONCLUSIONS The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. MINI ABSTRACT This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.
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Affiliation(s)
- Derrick O Acheampong
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Philip Paul
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shanice Guerrier
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Percy Boateng
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - I Michael Leitman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
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Groves DK, Altieri MS, Sullivan B, Yang J, Talamini MA, Pryor AD. The Presence of an Advanced Gastrointestinal (GI)/Minimally Invasive Surgery (MIS) Fellowship Program Does Not Impact Short-Term Patient Outcomes Following Fundoplication or Esophagomyotomy. J Gastrointest Surg 2018; 22:1870-1880. [PMID: 29980972 DOI: 10.1007/s11605-018-3704-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/25/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes. METHODS The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication. RESULTS There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001). CONCLUSION The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS.
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Affiliation(s)
- Donald K Groves
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA.
| | - Maria S Altieri
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Brianne Sullivan
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Jie Yang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Mark A Talamini
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Stony Brook University, Stony Brook, NY, USA
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Impact of resident participation on outcomes following lumbar fusion: An analysis of 5655 patients from the ACS-NSQIP database. J Clin Neurosci 2018; 56:131-136. [DOI: 10.1016/j.jocn.2018.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 05/01/2018] [Accepted: 06/19/2018] [Indexed: 01/21/2023]
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Rajakumar C, Mallick R, Posner G, Schramm D, Singh SS, Lortie K, Pascali D, Chen I. Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes. J Minim Invasive Gynecol 2018; 25:1088-1093. [PMID: 29496583 DOI: 10.1016/j.jmig.2018.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.
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Affiliation(s)
- Chandrew Rajakumar
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | | | - Glenn Posner
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - David Schramm
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Otolaryngology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sukhbir S Singh
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Karine Lortie
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Dante Pascali
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Innie Chen
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada.
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Nocera NF, Pyfer BJ, De La Cruz LM, Chatterjee A, Thiruchelvam PT, Fisher CS. NSQIP Analysis of Axillary Lymph Node Dissection Rates for Breast Cancer: Implications for Resident and Fellow Participation. JOURNAL OF SURGICAL EDUCATION 2018; 75:1281-1286. [PMID: 29605705 DOI: 10.1016/j.jsurg.2018.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/11/2018] [Accepted: 02/25/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Management of the axilla in invasive breast cancer (IBC) has shifted away from more radical surgery such as axillary lymph node dissection (ALND), towards less invasive procedures, such as sentinel lymph node biopsy. Because of this shift, we hypothesize that there has been a national downward trend in ALND procedures, subsequently impacting surgical trainee exposure to this procedure using the ACS-NSQIP database to evaluate this. METHODS Women with IBC were identified in the ACS-NSQIP database from 2007 to 2014. Procedures including ALND were identified using CPT codes. This number was divided by total cases, given a varying number of participating institutions each year. Next, cases involving resident participation were identified and divided by training level: junior (post graduate year-[PGY] 1-2), senior (PGY 3-5) and fellow (PGY ≥ 6). Two tailed z tests were used to compare proportions, with significance determined when p < 0.05. RESULTS A total of 128,372 women were identified with IBC with 36,844 ALND. ALND rates decreased by an average of 2.43% yearly from 2007 to 2014. Resident participation significantly drops in 2011, from 49.3% before to 29.4% after (p < 0.01). Junior residents experienced a significant decrease in participation rate (43.3%-32.2%, p < 0.05). Senior residents and fellows experienced an upward trend in their participation, although not significant (51.2%-56.3%, p = 0.35, and 5.6%-11.6%, p = 0.056, respectively). CONCLUSIONS Using the ACS-NSQIP database, we demonstrate the downward trend in rate of ALND for IBC with subsequent decrease in resident participation. Junior residents experienced a significant decrease in their participation with no significant change for senior or fellow-level trainees. Awareness of this trend is important when creating future surgical curriculum changes for general surgery and fellowship training programs.
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Affiliation(s)
- Nadia F Nocera
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
| | - Bryan J Pyfer
- Division of Plastic, Maxillofacial and Oral Surgery, Duke University Hospital, Durham, North Carolina
| | - Lucy M De La Cruz
- Comprehensive Breast Care Program, Jupiter Medical Center, Jupiter, Florida
| | | | - Paul T Thiruchelvam
- Department of Breast Surgery, Imperial College London, London, United Kingdom
| | - Carla S Fisher
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Aisen CM, James M, Chung DE. The Impact of Teaching on Fundamental General Urologic Procedures: Do Residents Help or Hurt? Urology 2018; 121:44-50. [PMID: 30092301 DOI: 10.1016/j.urology.2018.05.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/06/2018] [Accepted: 05/29/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the effects of trainee involvement on fundamental urology procedures. METHODS Current Procedural Terminology codes were used to identify patients within the National Surgical Quality Improvement Program database who underwent a selection of fundamental general urology procedures (2005-2013). Operative time and perioperative complications (30-day) were compared between cases with and without trainee involvement. RESULTS 29,488 patients had general urology procedures with information regarding trainee involvement, 13,251 (44.9%) with trainee involvement, and 16,237 (55.1%) without. Overall patients who underwent procedures with trainee involvement were younger and had fewer comorbidities (Table 1). Trainee involvement showed significant increase in operative time in all procedures included in the study (Table 2). On multivariate analysis trainee involvement increased the risk of complications (Odds Ratio (OR) 1.61, 95% CI 1.45-1.78, P < .001). Other factors that increased the risk of complications were: American Society of Anesthesiologists (ASA) class 3-4 (OR 2.01, 95% CI 1.46-2.77, P < .001), partially or totally dependent functional status (OR 2.22, 95% CI 1.68-2.94, P < .001), diabetes mellitus (OR 1.21, 95% CI 1.05-1.39, P = .008), heart disease (OR 1.19, 95% CI 1.02-1.38, P = .027), and respiratory disease (OR 1.33, 95% CI 1.09-1.63, P = .027). CONCLUSION While trainees are valuable members of the urology team at teaching hospitals and training is necessary, their involvement in urologic surgery appears to increase operative time for all procedures and complications in certain procedures. Further research needs to be done on how to mitigate these effects while preserving surgical education quality.
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Affiliation(s)
- Carrie M Aisen
- Department of Urology, Columbia University, New York, NY.
| | - Maxwell James
- Department of Urology, Columbia University, New York, NY
| | - Doreen E Chung
- Department of Urology, Columbia University, New York, NY
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Bailey EA, Johnson AP, Leeds IL, Medbery RL, Ahuja V, VanderMeer T, Wick EC, Irojah B, Kelz RR. Quantification of Resident Work in Colorectal Surgery. JOURNAL OF SURGICAL EDUCATION 2018; 75:564-572. [PMID: 28986275 DOI: 10.1016/j.jsurg.2017.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/11/2017] [Accepted: 09/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine resident intraoperative participation, perceived autonomy, and communication patterns between residents and attending surgeons using a novel survey tool. DESIGN This was a prospective multi-institutional study. Operative residents completed the survey tool immediately after each colorectal resection performed during the study period. Resident intraoperative participation was quantified including degree of involvement in the technical aspects of the case, self-perception of autonomy, and communication strategies between the resident and attending. SETTING This study was conducted at 7 general surgery residency programs: 5 academic medical centers, and 2 independent training programs. PARTICIPANTS Residents and fellows rotating on a colorectal surgery service or general surgery service. RESULTS Sixty-three residents participated in this study with 417 surveys completed (range 19-79 per institution) representing a 95.4% response rate across all sites. Respondents ranged from clinical year 1 (CY1) to fellows. CY3s (35.7%) and CY5s (34.7%) were most heavily represented. Residents completed ≥50% of the skin closure in 88.7% of cases, ≥50% of the fascial closure in 87.1%, and t ≥ 50% of the anastomosis in 78.4% of the cases. Increasing resident participation was associated with advancing resident CY across all technical aspects of the case. This trend remained significant when controlling for site (p < 0.001). Resident self-perception of autonomy revealed learners of all stages: Observer (11.5%, n = 48), Assistant (53.7%, n = 224), Surgeon (33.8%, n = 141), and Teacher (0.96%, n = 4). Level of perceived autonomy increased with resident CY when controlling for site (p < 0.001). Residents who discussed the case before the day of surgery were twice as likely to rate themselves as Surgeon or Teacher (OR = 2.01) when controlling for CY (p = 0.011). CONCLUSIONS Brief surveys can easily capture resident work in the operating room. Resident intraoperative involvement and perceived autonomy are associated with CY. Early communication with the attending is significantly associated with increased perception of autonomy regardless of CY.
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Affiliation(s)
- Elizabeth A Bailey
- Department of Surgery, Hospital of the University of Pennsylvania, Center for Surgery and Health Economics, Philadelphia, Pennsylvania.
| | - Adam P Johnson
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ira L Leeds
- Department of Surgery, Johns Hopkins University Hospital, Baltimore, Maryland
| | - Rachel L Medbery
- Department of Surgery, Emory University Hospital, Atlanta, Georgia
| | - Vanita Ahuja
- Department of Surgery, WellSpan York Hospital, York, Pennsylvania
| | - Thomas VanderMeer
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Elizabeth C Wick
- Department of Surgery, Johns Hopkins University Hospital, Baltimore, Maryland
| | - Busayo Irojah
- Department of Surgery, WellSpan York Hospital, York, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Center for Surgery and Health Economics, Philadelphia, Pennsylvania
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Slopnick EA, Hijaz AK, Henderson JW, Mahajan ST, Nguyen CT, Kim SP. Outcomes of minimally invasive abdominal sacrocolpopexy with resident operative involvement. Int Urogynecol J 2018; 29:1537-1542. [DOI: 10.1007/s00192-018-3578-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/26/2018] [Indexed: 12/11/2022]
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Gorelik M, Godelman S, Elkbuli A, Allen L, Boneva D, McKenney M. Can Residents Be Trained and Safety Maintained? JOURNAL OF SURGICAL EDUCATION 2018; 75:1-6. [PMID: 28676300 DOI: 10.1016/j.jsurg.2017.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/16/2017] [Accepted: 06/10/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Teaching hospitals and faculty need to balance the educational mission for training residents with patient safety. There are no data studying the change in trauma patient outcomes before and after implementation of a surgical residency. The objective of this study was to compare trauma center outcomes before and after the advent of a surgical training program. We predicted that patient-centric outcome metrics would not be affected by the integration of surgical residents into trauma patient care. METHODS A retrospective review was performed using the Crimson Continuum of Care (CCC) dataset and the Trauma Injury Severity Scores (TRISS) for the year before implementation of a surgical residency, compared to the 6 months following initiation of the residency. Severity and risk-adjusted performance measures included mortality, readmissions, complications, and length of stay. Using TRISS, actual, and predicted mortality was compared. RESULTS There were 1535 trauma admissions to the acute Care Trauma Service the year before starting the residency, and 856 admissions for the 6 months following the implementation of the program. The demographics were similar between the 2 groups. There was no clinically significant difference in observed mortality after the initiation of a surgery residency, based on CCC dataset variables and TRISS datasets. There were also no significant differences in complications and readmission rates. CONCLUSIONS We found that initiating a surgical training program did not affect mortality rates or complications of trauma patients. Training of general surgery residents in a high-performing trauma center can be effectively implemented without compromising patient safety.
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Affiliation(s)
- Marina Gorelik
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida.
| | - Steven Godelman
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida
| | - Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida
| | - Lauren Allen
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
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Wojcik BM, Fong ZV, Patel MS, Chang DC, Long DR, Kaafarani HM, Petrusa E, Mullen JT, Lillemoe KD, Phitayakorn R. Structured Operative Autonomy: An Institutional Approach to Enhancing Surgical Resident Education Without Impacting Patient Outcomes. J Am Coll Surg 2017; 225:713-724.e2. [DOI: 10.1016/j.jamcollsurg.2017.08.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 08/20/2017] [Accepted: 08/21/2017] [Indexed: 11/15/2022]
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Assessing the effort associated with teaching residents. J Plast Reconstr Aesthet Surg 2017; 70:1725-1731. [PMID: 28882492 DOI: 10.1016/j.bjps.2017.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/08/2017] [Accepted: 07/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Intraoperative resident education is an integral mission of academic medical centers and serves as the basis for training the next generation of surgeons. The actual effort associated with teaching residents is unknown as it pertains to additional operative time. Using a large validated multi-institutional dataset, this study aims to quantify the effect of having a resident present in common plastic surgery procedures on operative time. Future directions for developing standardized methods to record and report teaching time are proposed, which can help inform prospective studies. STUDY DESIGN The 2006-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify seven isolated plastic surgical procedures that were categorized based on resident involvement and supervision. Linear regression models were used to calculate the difference in operative time with respect to resident participation while controlling for patient and operative factors. RESULTS Resident involvement was associated with longer operative times for muscle flap trunk procedures (53 min, 95% CI = [25, 80], p-value = 0.0002) and breast reconstruction procedures with a latissimus dorsi flap (55 min, 95% CI = [22, 88], p-value = 0.001). For six of the seven surgeries evaluated, resident involvement was associated with longer operative times, as compared to no resident involvement. CONCLUSION Resident involvement is associated with an increase in operative time for certain plastic surgery procedures. This finding underscores the need for a mechanism to quantify the time and effort that the attending surgeons allocate toward intraoperative resident education. Further study is also necessary to determine the causal impact on patient care.
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Brady JS, Crippen MM, Filimonov A, Nadpara NV, Eloy JA, Baredes S, Park RCW. The effect of training level on complications after free flap surgery of the head and neck. Am J Otolaryngol 2017; 38:560-564. [PMID: 28716300 DOI: 10.1016/j.amjoto.2017.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/02/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Analyze postoperative complications after free flap surgery based on PGY training level. METHODS Data on free flap surgeries of the head and neck performed from 2005 to 2013 was collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cases identifying the status of resident participation in the surgery and the PGY level were included. RESULTS There were 582 cases with primary surgeon data available. 63 cases were performed with a junior resident, 211 were performed with the assistance of a senior resident, 279 cases were performed with a fellow, and 29 cases were performed by an attending alone without resident involvement. The overall complication rate was 55.2%. There was no statistically significant difference in the rate of complications between groups (47.6%, 59.7%, 53.0%, 58.6%, p=0.277). After controlling for all confounding variables using multivariate analysis there was no significant difference in morbidity, mortality, readmissions, and reoperation amongst the groups. Furthermore, when comparing resident versus fellow involvement using multivariate analysis there were no significant differences in morbidity (OR=0.768[0.522-1.129]), mortality (OR=1.489[0.341-6.499]), readmissions (OR=1.018[0.458-2.262]), and reoperation (OR=0.863[0.446-1.670]). CONCLUSION Resident and fellow participation in microvascular reconstructive cases does not appear to increase 30-day rates of medical, surgical, or overall complications.
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Affiliation(s)
- Jacob S Brady
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Meghan M Crippen
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Andrey Filimonov
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Neil V Nadpara
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Richard Chan Woo Park
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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Feeney T, Price LL, Chen L, Graham R, Chatterjee A. Resident and fellow participation in Thyroid and Parathyroid surgery: an ACS-NSQIP clinical outcomes analysis. J Surg Res 2017; 220:346-352. [PMID: 29180202 DOI: 10.1016/j.jss.2017.07.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/19/2017] [Accepted: 07/18/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of decreased overall hours of training in surgical specialties is still being examined. Of particular interest is the safety of patients undergoing surgeries with trainee surgeons. The aim of this study was to identify if there were significant differences in outcomes of patients undergoing commonly performed thyroid and parathyroid surgeries when trainees were involved. MATERIALS AND METHODS Postoperative complication rates, length of stay (LOS), and total operation time (OT) data were gathered from the American College of Surgeons National Surgical Quality Improvement Project database. The cases were identified by CPT code and were divided based on the training level of the participating resident surgeon: Junior (postgraduate year [PGY] 1-2), senior (PGY 3-5), fellow (PGY >5), as well as an attending-only group where no resident was present. We compared the clinical outcomes, LOS, and OT in each trainee group to the attending-only group as the reference. RESULTS A total of 84,711 cases were identified of which 45.33% involved trainee participation. Odds ratios (ORs) and 95% confidence interval for overall, neurologic, and bleeding complications were calculated. No difference in the odds of overall patient complications or neurologic complications was observed. A decrease in the odds of bleedings complications when a junior or senior trainee was present was observed. Overall complications in operations including a junior trainee (PGY 1-2) had an OR of 1.04 (0.85, 1.29), a senior trainee (PGY 3-5) had an OR of 1.00 (0.89, 1.13), and a fellow had an OR of 0.98 (0.74, 1.31). Mean OT was found to be significantly different between attending only and junior and senior trainees. There was no significant difference in OT between fellows and attending only. LOS did not meaningfully differ across groups. CONCLUSIONS In three commonly performed thyroid and parathyroid operations, there is not an increased overall or neurologic complication odds when a surgical trainee is involved; there are decreased odds of a bleeding complication.
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Affiliation(s)
- Timothy Feeney
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts.
| | - Lori Lyn Price
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Lilian Chen
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Roger Graham
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
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Carr RA, Chung CW, Schmidt CM, Jester A, Kilbane ME, House MG, Zyromski NJ, Nakeeb A, Schmidt CM, Ceppa EP. Impact of Fellow Versus Resident Assistance on Outcomes Following Pancreatoduodenectomy. J Gastrointest Surg 2017; 21:1025-1030. [PMID: 28194616 DOI: 10.1007/s11605-017-3383-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/31/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Participation by surgical trainees in complex procedures is key to their development as future practicing surgeons. The impact of surgical fellows versus general surgery resident assistance on outcomes in pancreatoduodenectomy (PD) has not been well studied. The purpose of this study was to determine differences in patient outcomes based on level of surgical trainee. METHODS Consecutive cases of PD (n = 254) were reviewed at a single high-volume institution over a 2-year period (July 2013-June 2015). Thirty-day outcomes were monitored through the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) and Quality In-Training Initiative. Patient outcomes were compared between PD assisted by general surgery residents versus hepatopancreatobiliary fellows. RESULTS The hepatopancreatobiliary surgery fellows and general surgery residents participated in 109 and 145 PDs, respectively. The incidence of each individual postoperative complication (renal, infectious, pancreatectomy-specific, and cardiopulmonary), total morbidity, mortality, and failure to rescue were the same between groups. CONCLUSIONS Patient operative outcomes were the same between fellow- and resident-assisted PD. These results suggest that hepatopancreatobiliary surgery fellows and general surgery residents should be offered the same opportunities to participate in complex general surgery procedures.
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Affiliation(s)
- Rosalie A Carr
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Catherine W Chung
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Christian M Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Andrea Jester
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Molly E Kilbane
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., EH 541, Indianapolis, IN, 46202, USA.
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Does Surgical Teaching Take Time? Resident Participation in Minimally Invasive Hysterectomy for Endometrial Cancer. J Minim Invasive Gynecol 2017; 24:783-789. [PMID: 28336363 DOI: 10.1016/j.jmig.2017.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 03/11/2017] [Accepted: 03/13/2017] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To determine the association between resident involvement and operative time for minimally invasive surgery (MIS) for endometrial cancer. DESIGN A retrospective cohort study (Canadian Task Force classification II-2). SETTING An integrated health care system in Northern California. PATIENTS A total of 1433 women who underwent MIS for endometrial cancer and endometrial intraepithelial neoplasia from January 2009 to January 2014. INTERVENTIONS Resident participation in 430 of 688 laparoscopic cases (62%) and 341 of 745 robotic cases (46%). MEASUREMENTS AND MAIN RESULTS The primary outcome was the impact of resident involvement on surgical time. When residents were involved in laparoscopic and robotic surgery, there was an increase of 61 minutes (median operative time, 186 vs 125 minutes; p < .001) and 31 minutes (median operative time, 165 vs 134 minutes; p < .001), respectively. Resident participation was associated with increased operative times in all levels of surgical complexity from hysterectomy alone to hysterectomy with pelvic and para-aortic lymph node dissection. Resident participation was also associated with increased major intraoperative complications (3.4% vs 1.8%, p = .02) as well as major postoperative complications (6.4% vs 3.8%, p = .003). CONCLUSION The presence of a resident was associated with a 32% increase in operative time for minimally invasive cases in gynecologic oncology for endometrial cancer. Because of the retrospective nature, we cannot infer causality of operative outcomes because residents were also involved in more high-risk patients and complex cases. For health care systems using surgical metrics, there may be a need to allocate more time for resident involvement.
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Can MF. The Trainee Effect on Early Postoperative Surgical Outcomes: Reflects the Effect of Resident Involvement or Hospital Capacity to Overcome Complications? J INVEST SURG 2017; 31:67-68. [PMID: 28107089 DOI: 10.1080/08941939.2016.1274346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mehmet F Can
- a Department of Surgery , Gulhane School of Medicine, University of Health Sciences , Etlik, Ankara , Turkey
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Does Trainee Involvement in Fluoroscopic Injections Affect Fluoroscopic Time, Immediate Pain Reduction, and Complication Rate? PM R 2017; 9:1013-1019. [PMID: 28093372 DOI: 10.1016/j.pmrj.2016.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/30/2016] [Accepted: 12/23/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients have expressed concern about undergoing procedures involving trainees, even with direct attending physician supervision. Little literature has examined the effect of trainee involvement on patient outcomes. OBJECTIVE We aimed to evaluate the effect of trainee involvement on patient complications, immediate pain reduction, and fluoroscopic time for different fluoroscopic injection types. DESIGN Retrospective review. SETTING Four academic outpatient institutions with Accreditation Council for Graduate Medical Education (ACGME)-accredited residency (physical medicine and rehabilitation, or anesthesiology) or fellowship (sports medicine or pain medicine) programs from 2000 to 2015. PATIENTS All patients receiving fluoroscopically guided hip (HI), sacroiliac joint (SIJI), transforaminal epidural (TFEI), and/or interlaminar epidural injections (ILEI, performed at only 1 institution). METHODS Outcome measures were examined based on the presence or absence of a trainee during the procedure. MAIN OUTCOME MEASUREMENTS The primary outcome was the number of immediate complications, with secondary outcomes being fluoroscopic time per injection (FTPI) and immediate numeric rating scale percentage improvement. RESULTS Trainees were involved in 67.0% of all injections (N = 7,833). Complication rates or improvements in numeric rating scale scores showed no significant differences with trainee involvement for any injection type (P > .05). Trainee involvement was associated with increased FTPI for ILEIs (18.2 ± 10.1 seconds with trainees versus 15.1 ± 8.5 seconds without trainees, P < .001), but not for HIs (P = .60) or SIJIs (P = .51). Trainee involvement with TFEIs was dependent on institution for outcome with respect to FTPI (P < .001), with 28.1 ± 17.9 seconds with trainees and 32.1 ± 22.1 seconds without trainees (P = 0.51). CONCLUSIONS This large multicenter study of academic institutions demonstrates that trainee involvement in fluoroscopically guided injections does not affect immediate patient complications or pain improvement. Trainee involvement does not increase fluoroscopic time for most injections, although there is an institutional difference seen. This study supports the notion that appropriate trainee supervision likely does not compromise patient safety for fluoroscopically guided injections. LEVEL OF EVIDENCE II.
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Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes. Ann Vasc Surg 2017; 38:42-53. [DOI: 10.1016/j.avsg.2016.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 09/09/2016] [Accepted: 09/29/2016] [Indexed: 11/20/2022]
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Sippey M, Spaniolas K, Kasten KR. Elucidating Trainee Effect on Outcomes for General, Gynecologic, and Urologic Oncology Procedures. J INVEST SURG 2016; 30:359-367. [PMID: 27929699 DOI: 10.1080/08941939.2016.1255805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical complications delay adjuvant therapy in oncology patients. Current literature remains unclear regarding resident effect on postoperative outcomes, with inappropriate coverage possibly endangering patients in spite of attending oversight. We assessed resident postgraduate year (PGY) effect on 30-day overall morbidity in cancer patients undergoing major intra-abdominal and non-abdominal surgery. METHODS Patients undergoing non-emergent major intra- and extra-abdominal operations from 2005-2012 were queried using the American College of Surgeons' National Surgical Quality Improvement Program. Attending alone and resident PGY cohorts were compared for demographics, 30-day overall morbidity, mortality, and relevant outcomes. RESULTS A total of 156,941 cancer patients undergoing major intra-abdominal (n = 76,385) or major non-abdominal (n = 80,556) procedures were captured. Demographics were clinically similar across attending and PGY levels. Rates of overall morbidity increased significantly with PGY level, along with operative time and length of stay. For major intra-abdominal procedures, all resident levels except PGY2 level adversely affected overall morbidity. Above PGY4 level, resident involvement had a stronger association with adverse outcome than preoperative comorbidities and preoperative chemotherapy. Interestingly, gastric, gall bladder, liver, pancreas, esophageal, and thyroid procedures demonstrated no effect of resident involvement on overall morbidity. CONCLUSIONS Resident PGY is independently associated with increased overall morbidity in patients undergoing selected major surgical procedures. Understanding surgical procedures affected by resident involvement will maximize outcomes.
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Affiliation(s)
- Megan Sippey
- a Department of Surgery , Brody School of Medicine at East Carolina University , Greenville , North Carolina , USA
| | - Konstantinos Spaniolas
- a Department of Surgery , Brody School of Medicine at East Carolina University , Greenville , North Carolina , USA
| | - Kevin R Kasten
- b Department of Surgery , Carolinas Health Care System , Charlotte , North Carolina , USA
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Kempenich JW, Willis RE, Blue RJ, Al Fayyadh MJ, Cromer RM, Schenarts PJ, Van Sickle KR, Dent DL. The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care. JOURNAL OF SURGICAL EDUCATION 2016; 73:e111-e117. [PMID: 27663084 DOI: 10.1016/j.jsurg.2016.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/05/2016] [Accepted: 05/09/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To decipher if patient attitudes toward resident participation in their surgical care can be improved with patient education regarding resident roles, education, and responsibilities. DESIGN An anonymous questionnaire was created and distributed in outpatient surgery clinics that had residents involved with patient care. In total, 3 groups of patients were surveyed, a control group and 2 intervention groups. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents. The first pamphlet used an analogy-based explanation. The second pamphlet used literature citations and statistics. SETTING Keesler Medical Center, Keesler AFB, MS. University of Texas Health Science Center at San Antonio, San Antonio, TX. PARTICIPANTS A total of 454 responses were collected and analyzed-211 in the control group, 118 in the analogy pamphlet group, and 125 in the statistics pamphlet group. RESULTS Patients had favorable views of residents assisting with their surgical procedures, and the majority felt that outcomes were the same or better regardless of whether they read an informational pamphlet. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care. Further, 52% of patients in the control group agreed or strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% of the patients who read the analogy pamphlet and statistics pamphlet, respectively (p = 0.05). When we combined the 2 intervention groups compared to the control group, this significant difference persisted (p = 0.02). CONCLUSION Most patients welcome resident participation in their surgical care, but they expect to be asked permission for resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently.
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Affiliation(s)
- Jason W Kempenich
- Department of General Surgery, Keesler Medical Center, Keesler AFB, Biloxi, Mississippi.
| | - Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Robert J Blue
- Department of General Surgery, Keesler Medical Center, Keesler AFB, Biloxi, Mississippi
| | - Mohammed J Al Fayyadh
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Robert M Cromer
- Department of General Surgery, Keesler Medical Center, Keesler AFB, Biloxi, Mississippi
| | - Paul J Schenarts
- Division of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kent R Van Sickle
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Daniel L Dent
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Wojcik BM, Fong ZV, Patel MS, Chang DC, Petrusa E, Mullen JT, Phitayakorn R. The Resident-Run Minor Surgery Clinic: A Pilot Study to Safely Increase Operative Autonomy. JOURNAL OF SURGICAL EDUCATION 2016; 73:e142-e149. [PMID: 27886972 DOI: 10.1016/j.jsurg.2016.08.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/15/2016] [Accepted: 08/29/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE General surgery training has evolved to align with changes in work hour restrictions, supervision regulations, and reimbursement practices. This has culminated in a lack of operative autonomy, leaving residents feeling inadequately prepared to perform surgery independently when beginning fellowship or practice. A resident-run minor surgery clinic increases junior resident autonomy, but its effects on patient outcomes have not been formally established. This pilot study evaluated the safety of implementing a resident-run minor surgery clinic within a university-based general surgery training program. DESIGN Single institution case-control pilot study of a resident-run minor surgery clinic from 9/2014 to 6/2015. Rotating third-year residents staffed the clinic once weekly. Residents performed operations independently in their own procedure room. A supervising attending surgeon staffed each case prior to residents performing the procedure and viewed the surgical site before wound closure. Postprocedure patient complications and admissions to the hospital because of a complication were analyzed and compared with an attending control cohort. SETTING Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. PARTICIPANTS Ten third-year general surgery residents. RESULTS Overall, 341 patients underwent a total of 399 procedures (110 in the resident clinic vs. 289 in the attending clinic). Minor surgeries included soft tissue mass excision (n = 275), abscess incision and drainage (n = 66), skin lesion excision (n = 37), skin tag removal (n = 15), and lymph node excision (n = 6). There was no significant difference in the overall rate of patients developing a postprocedure complication within 30 days (3.6% resident vs. 2.8% attending; p = 0.65); which persisted on multivariate analysis. Similar findings were observed for the rate of hospital admission resulting from a complication. Resident evaluations overwhelmingly supported the rotation, citing increased operative autonomy as the greatest strength. CONCLUSIONS Implementation of a resident-run minor surgery clinic is a safe and effective method to increase trainee operative autonomy. The rotation is well suited for mid-level residents, as it provides an opportunity for realistic self-evaluation and focused learning that may enhance their operative experience during senior level rotations.
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Affiliation(s)
- Brandon M Wojcik
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Madhukar S Patel
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Emil Petrusa
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Fecso AB, Bonrath EM, Grantcharov TP. Training in Laparoscopic Gastric Cancer Surgery in the Western World: Current Educational Practices, Challenges, and Potential Opportunities at a Large University Centre. JOURNAL OF SURGICAL EDUCATION 2016; 73:749-755. [PMID: 27137666 DOI: 10.1016/j.jsurg.2016.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/10/2016] [Accepted: 03/05/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The purpose of this study was to explore and understand how surgeons distribute tasks during a laparoscopic gastrectomy for gastric cancer in an academic teaching environment. DESIGN An anonymous, cross-sectional, census survey was used to poll trainees' and staff members' opinions pertaining to laparoscopic gastrectomy. SETTING Academic and community tertiary teaching hospitals, affiliated with the University of Toronto. PARTICIPANTS All surgeons, within the Department of General Surgery at the University of Toronto, who practice laparoscopic gastrectomy for gastric cancer, were invited to participate. All general surgery residents, postgraduate year 1-5, minimally invasive surgery and surgical oncology fellows at the University of Toronto were invited to participate. Overall response rate was 74.35% (n = 87/117). RESULTS The results suggested that trainees do not routinely perform the major operative steps. Trainees agreed with faculty in this regard; however, there was a statistically significant difference in opinions, related to the degree of the perceived active operating of the trainees. There was also a difference in opinion, between trainees and faculty, regarding the common reasons for takeover. CONCLUSIONS The present survey highlights that current level of active exposure of surgical trainees to laparoscopic gastric surgery might be insufficient. A lack of role clarity may further hinder an optimal educational experience during these cases. Adopting a stepwise approach, with task deconstruction, could optimize training. Additional training modalities may be required to ensure technical proficiency is acquired before independent practice.
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Affiliation(s)
- Andras B Fecso
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Esther M Bonrath
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Schreckenbach T, El Youzouri H, Bechstein W, Habbe N. Proctologic surgery done by residents – Complications preprogrammed? J Visc Surg 2016; 153:167-72. [DOI: 10.1016/j.jviscsurg.2015.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sippey M, Spaniolas K, Manwaring ML, Pofahl WE, Kasten KR. Surgical resident involvement differentially affects patient outcomes in laparoscopic and open colectomy for malignancy. Am J Surg 2016; 211:1026-34. [DOI: 10.1016/j.amjsurg.2015.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/16/2015] [Accepted: 07/19/2015] [Indexed: 12/21/2022]
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Watkins AA, Bliss LA, Cameron DB, Eskander MF, Tseng JF, Kent TS. Deconstructing the "July Effect" in Operative Outcomes: A National Study. J Gastrointest Surg 2016; 20:1012-9. [PMID: 26932502 DOI: 10.1007/s11605-016-3120-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/22/2016] [Indexed: 01/31/2023]
Abstract
This study analyzes the relationship between hospital teaching status, failure to rescue, and time of year in select gastrointestinal operations. Procedure codes for laparoscopic cholecystectomy, colectomy, and pancreatectomy were queried from the Nationwide Inpatient Sample (2004-2011). Failure to rescue was defined as inpatient mortality when ≥1 complication. A total of 2,777,267 laparoscopic cholecystectomies, 2,519,903 colectomies, and 129,619 pancreatectomies were performed. Teaching hospitals had increased overall rates of failure to rescue compared to non-teaching hospitals, 10.0 vs. 9.5 % (p = 0.0187), particularly between May and August. There was greater inter-month variability in non-teaching hospitals amongst individual operations. On multivariable analysis, July was not predictive of increased odds of failure to rescue. Teaching status, hospital characteristics, and patient demographics were associated with increased odds of failure to rescue. Although teaching hospitals have a higher overall failure to rescue rate amongst the selected gastrointestinal operations, odds of failure to rescue are not increased in the month of July. Non-teaching hospitals tend to exhibit more monthly variation in failure to rescue rates, and hospital/patient demographics are predictive of failure to rescue. Further investigation targeted at identifying drivers of temporal variation is warranted to optimize patient outcomes.
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Affiliation(s)
- Ammara A Watkins
- Beth Israel Deaconess Medical Center, 330 Brookline Ave. Stoneman 9, Boston, MA, 02215, USA
| | - Lindsay A Bliss
- Beth Israel Deaconess Medical Center, 330 Brookline Ave. Stoneman 9, Boston, MA, 02215, USA
| | | | | | - Jennifer F Tseng
- Beth Israel Deaconess Medical Center, 330 Brookline Ave. Stoneman 9, Boston, MA, 02215, USA
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, 330 Brookline Ave. Stoneman 9, Boston, MA, 02215, USA.
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Ferraris VA, Harris JW, Martin JT, Saha SP, Endean ED. Impact of Residents on Surgical Outcomes in High-Complexity Procedures. J Am Coll Surg 2016; 222:545-55. [DOI: 10.1016/j.jamcollsurg.2015.12.056] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
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Shaikh T, Wang L, Ruth K, Hallman M, Chen DY, Greenberg RE, Li J, Crawford K, Horwitz EM. The impact of trainee involvement on outcomes in low-dose-rate brachytherapy for prostate cancer. Brachytherapy 2016; 15:156-62. [PMID: 26832675 DOI: 10.1016/j.brachy.2015.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/09/2015] [Accepted: 12/29/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE To determine the impact of fellow, resident, or medical student (MS) involvement on outcomes in patients undergoing permanent (125)I prostate seed implant. METHODS AND MATERIALS The study population consisted of men with clinically localized low/intermediate-risk prostate cancer treated with low-dose-rate permanent interstitial brachytherapy. Cases were stratified according to resident, fellow, MS, or attending involvement. Outcomes were compared using analysis of variance, logistic regression, and log rank tests. RESULTS A total of 291 patients were evaluated. Fellows, residents, and MS were involved in 47 (16.2%), 231 (79.4%), and 34 (11.7%) cases, respectively. Thirteen (4.4%) cases were completed by an attending physician alone. There was no difference in freedom from biochemical failure when comparing the resident, fellow, or attending alone groups (p = 0.10). There was no difference in V100 (volume of the prostate receiving 100% of the prescription dose) outcomes when comparing resident cases to fellow cases (p = 0.72) or attending alone cases (p = 0.78). There was no difference in D90 (minimum dose covering 90% of the postimplant volume) outcomes when comparing resident cases to fellow cases (p = 0.74) or attending alone cases (p = 0.58). When examining treatment toxicity, fellow cases had higher rates of acute Grade 2 + GU toxicity (p = 0.028). With the exception of higher urethra D90 among PGY 2-3 cases (p = 0.02), dosimetric outcomes were similar to cases with PGY 4-5 resident participation. There was no difference in outcomes for cases with and without MS participation. CONCLUSIONS Interstitial prostate seed implants can be safely performed by trainees with appropriate supervision. Hands-on brachytherapy training is effective and feasible for trainees.
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Affiliation(s)
- Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Lora Wang
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Karen Ruth
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Mark Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - David Y Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | - Jinsheng Li
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Kevin Crawford
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA.
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