Assessing a Structured Mental Fitness Program for Academic Acute Care Surgeons: A Pilot Study.

INTRODUCTION: There is a well-established positive correlation between improved physician wellness and patient care outcomes. Mental fitness is a component of wellness that is understudied in academic medicine. We piloted a structured mental fitness Positive Intelligence (PQ) training program for academic surgeons, hypothesizing this would be associated with improvements in PQ scores, wellness, sleep, and trainee evaluations. METHODS: This is a single-institution, prospective, mixed-methods pilot study. All active Burn/Trauma/Acute & Critical Care Surgical faculty and fellows in our division were offered the PQ program and the option to participate in this research study. The 6-wk program consists of daily exercises on a smartphone application, weekly readings, and small-group meetings with a trained mindfulness coach. Study outcomes included changes in pretraining versus post-training PQ scores, sleep hygiene, wellness, and teaching scores. A Net Promoter Score was calculated to measure user overall experience (range -100 to 100; positive scores being supportive). For secondary analysis, participants were stratified into high versus low user groups by "muscle" scores, which were calculated by program use over time. A postintervention focus group was also held to evaluate perceptions of wellness and experience with the PQ program. RESULTS: Data were analyzed for 15 participants who provided consent. The participants were primarily White (73.3%), Assistant Professors (66.7%) with Surgical Critical Care fellowship training (86.7%), and a slight female predominance (53.3%). Comparison of scores pretraining versus post-training demonstrated statistically significant increases in PQ (59 versus 65, P = 0.004), but no significant differences for sleep (24.0 versus 29.0, P = 0.33) or well-being (89.0 versus 94.0, P = 0.10). Additionally, there was no significant difference in teaching evaluations for both residents (9.1 versus 9.3, P = 0.33) and medical students (8.3 versus 8.5, P = 0.77). High versus low user groups were defined by the median muscle score (166 [Interquartile range 95.5-298.5]). High users demonstrated a statistically higher proportion of ongoing usage (75% versus 14%, P < 0.05). The final Net Promoter Score score was 25, which demonstrates program support within this group. Focus group content analysis established eight major categories: current approaches to wellness, preknowledge, reasons for participation, expected gains, program strengths, suggestions for improvement, recommendations for approaches, and sustainability. CONCLUSIONS: Our pilot study highlighted certain benefits of a structured mental fitness program for academic acute care surgeons. Our mixed-methods data demonstrate significant improvement in PQ scores, ongoing usage in high user participants, as well as interpersonal benefits such as improved connectedness and creation of a shared language within participants. Future work should evaluate this program on a higher-powered scale, with a focus on intentionality in wellness efforts, increased exposure to mental fitness, and recruitment of trainees and other health-care providers, as well as identifying the potential implications for patient outcomes.

Is It All About the Form? Norm- vs Criterion-Referenced Ratings and Faculty Inter-Rater Reliability.

Background: Little research to date has examined the quality of data obtained from resident performance evaluations. This study sought to address this need and compared inter-rater reliability obtained from norm-referenced and criterion-referenced evaluation scaling approaches for faculty completing resident performance evaluations. Methods: Resident performance evaluation data were examined from 2 institutions (3 programs, 2 internal medicine and 1 surgery; 426 residents in total), with 4 evaluation forms: 2 criterion-referenced (1 with an additional norm-referenced item) and 2 norm-referenced. Faculty inter-rater reliability was calculated with intraclass correlation coefficients (ICCs) (1,10) for each competency area within the form. ICCs were transformed to z-scores, and 95% CIs were computed. Reliabilities for each evaluation form and competency, averages within competency, and averages within scaling type were examined. Results: Inter-rater reliability averages were higher for all competencies that used criterion-referenced scaling relative to those that used norm-referenced scaling. Aggregate scores of all independent categories (competencies and the items assessing overall competence) for criterion-referenced scaling demonstrated higher reliability (z=1.37, CI 1.26-1.48) than norm-referenced scaling (z=0.88, CI 0.77-0.99). Moreover, examination of the distributions of composite scores (average of all competencies and raters for each individual being rated) suggested that the criterion-referenced evaluations better represented the performance continuum. Conclusion: Criterion-referenced evaluation approaches appear to provide superior inter-rater reliability relative to norm-referenced evaluation scaling approaches. Although more research is needed to identify resident evaluation best practices, using criterion-referenced scaling may provide more valid data than norm-referenced scaling.

Rapid development of squamous cell carcinoma at a split-thickness skin graft donor site.

The development of a Marjolin ulcer at the site of a split-thickness skin graft donor site is exceptionally rare. Here we describe the rapid development of squamous cell carcinoma at a split-thickness skin graft donor site in the setting of severe burn. We present a case of a 52-year-old male with no past medical history who presented with a 24% total body surface area burn caused by a flash flame. Four months after his initial excision and grafting, he presented for revision of a burn scar with an additional complaint of a rapidly developing skin lesion at his donor site, which arose over 2 weeks. The lesion was excised en bloc and found to be invasive squamous cell carcinoma. There are 5 previous cases of squamous cell carcinoma development at the site of split-thickness skin harvest in the setting of severe burn. While the typical Marjolin ulcer has a latency period of up to 30 years, lesions that arise in split-thickness skin graft donor sites appear to have a rapid onset of weeks to months. Squamous cell carcinoma at the site of split-thickness skin grafting is an uncommon but important sequelae of burn care.

Fungal brain abscess in a severely burned patient.

Burn patients are particularly susceptible to atypical and opportunistic infections. Here we report an unusual case of a 40-year-old previously healthy man with a 74% TBSA burn injury who developed a presumed Fusarium brain abscess. This patient had a complicated infectious course including ESBL E. coli and Elizabethkingia bacteremia and pneumonia, MRSA ventilator-associated pneumonia, Mycobacterium abscessus bacteremia, and Fusarium fungemia. After diagnosis with a fungal abscess on magnetic resonance imaging of the brain, the patient was treated with aspiration and appropriate antifungal therapies. The patient was eventually transitioned to comfort care and died on hospital day 167. This is the first published report of a Fusarium-related brain abscess since it was first reported in a case report of a burned child in 1974.

Defining the Duty Hour for Surgical Trainees.

OBJECTIVE: Being mindful of duty hours has become an integral part of surgical training. Violations can lead to disciplinary action by the American Council for Graduate Medical Education (ACGME), including probation or even withdrawal of accreditation. It is therefore crucial to ensure these hours are accurately reported. However, as these are often self-reported by the resident, what counts as a duty hour is at the discretion of the reporter. The goal of this study is to identify what trainees and faculty include in their definitions of a duty hour. We hypothesized that there would be discrepancies in faculty versus trainee definitions of the duty hour, and that there remains an unclear understanding of which nonclinical activities contribute to surgical trainee duty hours. DESIGN: An anonymous, voluntary survey was conducted at a single institution. The survey contained 14 scenarios, and participants answered either "yes" or "no" as to if they believed the scenario should be counted within duty hour reporting. Analysis of the results included evaluating overall responses to determine which scenarios were more controversial, as well as chi square analysis comparing trainee (residents and fellows) versus faculty responses to each scenario. SETTING: This survey was performed within the Department of Surgery at the University of Texas Southwestern Medical Center, a large academic institution in Dallas, TX. PARTICIPANTS: There were 91 total faculty and trainee responses to the voluntary survey within the General Surgery Department and associated subspecialties, including 50 residents (54.9%), 4 clinical fellows (4.4%) and 37 faculty (40.7%). RESULTS: When analyzing total responses, the most controversial scenarios were taking a short period of home call (50.6% of all respondents included this as a duty hour), making a presentation for resident education (48.4%), making a presentation related to patient care (57.1%), and making a monthly call schedule (44.0%). The least controversial topic was transit to and from work (91.2% of all respondents did not include this as a duty hour). Additionally, there were statistically significant differences between trainee and faculty perceptions when it came to attending departmental curricula (96.2% trainees included as a duty hour v 81.6% faculty, p =0.02), participating in nonmandatory journal club (5.7% trainees v 23.7% faculty, p =0.01), and attending mentorship meetings (30.2% trainees v 52.6% faculty, p =0.03). CONCLUSIONS: There is no consensus as to what nonclinical activities formally count towards a duty hour. There are also significant differences identified between faculty and trainee definitions, which could have implications for duty hour reporting and ACGME violations. Further research is required to obtain a clearer picture of the surgical opinion on defining the duty hour, and hopefully this will reduce duty hour violations and better optimize surgical trainee education.

Burnout in Surgical Residents of Underrepresented in Medicine Backgrounds: Key Influencing Factors and Possible Solutions.

INTRODUCTION: Alarming rates of burnout in surgical training pose a concern due to its deleterious effects on both patients and providers. Datum remains lacking on rates of burnout in surgical residents based on race and ethnicity. This study aims to document the frequency of burnout in surgical residents of racially underrepresented backgrounds and elucidate contributing factors. METHODS: A 35-question anonymized survey was distributed to general surgery residents from 23 programs between August 2018 and May 2019. This survey was designed from the validated Maslach Burnout Inventory, and included additional questions assessing participant demographics, educational, and social backgrounds. Responses were analyzed utilizing chi-square tests and Wilcoxon rank sum tests. There was also a free response portion of the survey which was evaluated using thematic analysis. RESULTS: We received 243 responses from 23 general surgery programs yielding a 9% (23/246) program response rate and 26% (243/935) response rate by surgical residents. One hundred and eighty-five participants (76%) identified as nonunderrepresented in medicine and 58 (24%) of participants identified as underrepresented in medicine. Fifty-three percent were male and 47% female. Overall, sixty-six percent of all surgical residents (n = 161) endorsed burnout with racially underrepresented residents reporting higher rates of burnout at 76% compared to 63% in their nonunderrepresented counterparts (P = 0.07). CONCLUSIONS: Although the generalizability of these results is limited, higher rates of reported burnout in racially underrepresented trainees noted in our study illuminates the need for continual dialogue on potential influencing factors and mitigation strategies.

Impact of Alcohol and Methamphetamine Use on Burn Resuscitation.

Mortality associated with burn injuries is declining with improved critical care. However, patients admitted with concurrent substance use have increased risk of complications and poor outcomes. The impact of alcohol and methamphetamine use on acute burn resuscitation has been described in single-center studies; however, has not been studied since implementation of computerized decision support for resuscitation. Patients were evaluated based presence of alcohol, with a minimum blood alcohol level of 0.10, or positive methamphetamines on urine drug screen. Fluid volumes and urine output were examined over 48 hours. A total of 296 patients were analyzed. 37 (12.5%) were positive for methamphetamine use, 50 (16.9%) were positive for alcohol use, and 209 (70.1%) with negative for both. Patients positive for methamphetamine received a mean of 5.30 ± 2.63 cc/kg/TBSA, patients positive for alcohol received a mean of 5.41 ± 2.49 cc/kg/TBSA, and patients with neither received a mean of 4.33 ± 1.79 cc/kg/TBSA. Patients with methamphetamine or alcohol use had significantly higher fluid requirements. In the first 6 hours patients with alcohol use had significantly higher urinary output (UO) in comparison to patients with methamphetamine use which had similar output to patients negative for both substances. This study demonstrated that patients with alcohol and methamphetamine use had statistically significantly greater fluid resuscitation requirements compared to patients without. The effects of alcohol as a diuretic align with previous literature. However, patients with methamphetamine lack the increased UO as a cause for their increased fluid requirements.

Outcomes of the 2021-2022 APDS General Surgery Recruitment Process Recommendations.

BACKGROUND: In recent years, mounting challenges for applicants and programs in resident recruitment have catapulted this topic into a top priority in medical education. These challenges span all aspects of recruitment-from the time an applicant applies until the time of the Match-and have widespread implications on cost, applicant stress, compromise of value alignment, and holistic review, and equity. In 2021-2022, the Association of Program Directors in Surgery (APDS) set forth recommendations to guide processes for General Surgery residency recruitment. OBJECTIVES: This work summarizes the APDS 2021-2022 resident recruitment process recommendations, along with their justification and program end-of-cycle program feedback and compliance. This work also outlines the impact of these data on the subsequent 2022-2023 recommendations. METHODS: After a comprehensive review of the available literature and data about resident recruitment, the APDS Task Force proposed recommendations to guide 2021-2022 General Surgery resident recruitment. Following cycle completion, programs participating in the categorical General Surgery Match were surveyed for feedback and compliance. RESULTS: About 122 of the 342 programs (35.7%) participating in the 2022 categorical General Surgery Match responded. Based on available data in advance of the cycle, recommendations around firm application and interview numbers could not be made. About 62% of programs participated in the first round interview offer period with 86% of programs limiting offers to the number of slots available; 95% conducted virtual-only interviews. Programs responded they would consider or strongly consider the following components in future cycles: holistic review (90%), transparency around firm requirements (88%), de-emphasis of standardized test scores (54%), participation in the ERAS Supplemental application (58%), single first round interview release period (69%), interview offers limited to the number of available slots (93%), 48-hour minimum interview offer response time (98%), operationalization of applicant expectations (88%), and virtual interviews (80%). There was variability in terms of the feedback regarding the timing of the single first round offer period as well as support for a voluntary, live site visit for applicants following program rank list certification. CONCLUSIONS: The majority of programs would consider implementing similar recommendations in 2022-2023. The greatest variability around compliance revolved around single interview release and the format of interviews. Future innovation is contingent upon the ongoing collection of data as well as unification of data sources involved in the recruitment process.

Virtual Mentoring: A Novel Approach to Facilitate Medical Student Applications to General Surgery Residency.

OBJECTIVE: The COVID-19 pandemic rapidly altered the landscape of medical education, particularly disrupting the residency application process and highlighting the need for structured mentorship programs. This prompted our institution to develop a virtual mentoring program to provide tailored, one-on-one mentoring to medical students applying to general surgery residency. The aim of this study was to examine general surgery applicant perception of a pilot virtual mentoring curriculum. DESIGN: The mentorship program included student-tailored mentoring and advising in 5 domains: resume editing, personal statement composition, requesting letters of recommendation, interview skills, and residency program ranking. Electronic surveys were administered following ERAS application submission to participating applicants. The surveys were distributed and collected via a REDCap database. RESULTS: Eighteen out of 19 participants completed the survey. Confidence in a competitive resume (p = 0.006), interview skills (p < 0.001), obtaining letters of recommendation (p = 0.002), personal statement drafting (p < 0.001), and ranking residency programs (p < 0.001) were all significantly improved following completion of the program. Overall utility of the curriculum and likelihood to participate again and recommend the program to others was rated a median 5/5 on the Likert scale (5 [IQR 4-5]). Confidence in the matching carried a premedian 66.5 (50-65) and a postmedian 84 (75-91) (p = 0.004). CONCLUSION: Following the completion of the virtual mentoring program, participants were found to be more confident in all 5 targeted domains. In addition, they were more confident in their overall ability to match. General Surgery applicants find tailored virtual mentoring programs to be a useful tool allowing for continued program development and expansion.

Chief Residents Can Safely Operate on Older and Frail Patients.

INTRODUCTION: Older age and frailty increase the risk of poor recovery after surgery. We hypothesized that general surgery operations performed by supervised chief residents, as opposed to attending physicians, would still be safe for these vulnerable patients. MATERIALS AND METHODS: We used the Veterans Affairs Surgical Quality Improvement Program database to identify 114,525 patients age 65+ y, including 18,030 patients age 80+ y and 47,555 categorized as frail, who had a general surgery procedure from 1999 to 2019 that was performed by an attending physician or by a supervised chief resident. Frailty was defined by a Risk Analysis Index score ≥30. We used inverse probability weighting on the propensity score to compare morbidity and mortality between operations performed by attendings versus chief residents. RESULTS: Patients 65 y and above had a 2.1% increase in postoperative complications when the surgery was performed by a chief resident instead of an attending surgeon (95%CI 1.2%-3.0%, P < 0.0001). A similarly increased risk of complications was seen for patients age ≥80 y old (+2.3%, 95%CI 0.7%-3.9%, P = 0.004) and for frail patients (+2.7%, 95%CI 1.4%-4.0%, P < 0.0001). There were no differences in mortality for patients age 65+ y (+0.2%, 95%CI -0.1%-0.5%, P = 0.2), 80+ y (+0.3%, 95%CI -0.6%-1.1%, P = 0.5), or frail patients (+0.2%, 95%CI -0.5%-0.8%, P = 0.6) when their operations were performed by chief residents. CONCLUSIONS: We found a small increase in morbidity and no difference in mortality when older or frail patients were operated on by chief residents rather than attending surgeons. Our findings suggest that it is reasonable and safe for training programs to allow appropriately supervised chief residents to operate on older or frail patients.

Survival after multiple episodes of cardiac arrest.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital. OBJECTIVES: The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events. METHODS: We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality. RESULTS: There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p<.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p<.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p<.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01). CONCLUSION: Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.

The Battle of the Titans-Comparing Resuscitation Between Five Major Burn Centers Using the Burn Navigator.

The goal of burn resuscitation is to provide the optimal amount of fluid necessary to maintain end-organ perfusion and prevent burn shock. The objective of this analysis was to examine how the Burn Navigator (BN), a clinical decision support tool in burn resuscitation, was utilized across five major burn centers in the United States, using an observational trial of 300 adult patients. Subject demographics, burn characteristics, fluid volumes, urine output, and resuscitation-related complications were examined. Two hundred eighty-five patients were eligible for analysis. There was no difference among the centers on mean age (45.5 ± 16.8 years), body mass index (29.2 ± 6.9), median injury severity score (18 [interquartile range: 9-25]), or total body surface area (TBSA) (34 [25.8-47]). Primary crystalloid infusion volumes at 24 h differed significantly in ml/kg/TBSA (range: 3.1 ± 1.2 to 4.5 ± 1.7). Total fluids, including colloid, drip medications, and enteral fluids, differed among centers in both ml/kg (range: 132.5 ± 61.4 to 201.9 ± 109.9) and ml/kg/TBSA (3.5 ± 1.0 to 5.3 ± 2.0) at 24 h. Post-hoc adjustment using pairwise comparisons resulted in a loss of significance between most of the sites. There was a total of 156 resuscitation-related complications in 92 patients. Experienced burn centers using the BN successfully titrated resuscitation to adhere to 24 h goals. With fluid volumes near the Parkland formula prediction and a low prevalence of complications, the device can be utilized effectively in experienced centers. Further study should examine device utility in other facilities and on the battlefield.

Educational Experience Impacts Wellness More than Hours Worked.

OBJECTIVE: The Accreditation Council for Graduate Medical Education has focused its interests on resident wellbeing and the clinical work environment in recent years. Concerns regarding both duty hours as well as service obligations versus education resulted in programs nationwide receiving citations, including ours. This study aimed to evaluate the impact of those 2 factors on surgical residents' general wellbeing, hypothesizing that service obligations would be a stronger predictor. DESIGN: We have previously reported on the use of a "Fuel Gauge" tool developed at our institution for monitoring resident wellbeing. We performed a retrospective comparison of prospectively collected cross-sectional survey data comparing the Fuel Gauge to a bimonthly "Service Versus Education" (SVE) report. This report used similar scaling and allowed residents to provide feedback on the balance of the educational quality of their current rotation in comparison to their perception of service obligation. Pearson's correlation was then used to compare those scores with duty hour logs to determine if a relationship could be identified between the 3 measurements. SETTING: Academic institution of the University of Texas Southwestern in Dallas, Texas. PARTICIPANTS: Active general surgery residents (n = 73). RESULTS: During the study period, 73 residents filled out both a Fuel Gauge assessment and a SVE assessment at least once, with 273 complete data points available for analysis. Our program's Fuel Gauge median was 4, and our program's median SVE score was 4. Fuel Gauge assessment scores demonstrated a moderate positive correlation with SVE (r = 0.65, p < 0.001), while only a weakly negative association with increasing hours worked (r = -0.15, p = 0.015). SVE also demonstrated a weak negative correlation with hours logged (r = -0.225, p = 0.001). CONCLUSIONS: While the Accreditation Council for Graduate Medical Education recognizes that multiple factors contribute to resident wellbeing issues, early efforts were focused on limiting excessive duty hours. Examining our institutional data regarding the previously understudied factor of SVE, we indeed found a stronger correlation with resident perception of low educational value rather than excessive work hours contributing to lower Fuel Gauge scores. These data, if verified, should guide program directors in identifying other institutional factors that may more strongly contribute to their own culture of resident wellness.

Little Utility of Fungal Blood Cultures in Surgical and Burn Intensive Care Units.

Critically ill patients are at risk for fungal infections, but there is a paucity of data regarding the clinical utility of dedicated fungal blood cultures to detect such infections. A retrospective review was conducted of patients admitted to the surgical and burn intensive care units at Parkland Memorial Hospital between 1 January 2013 and 31 December 2017 for whom blood cultures (aerobic, anaerobic, and/or fungal cultures) were sent. A total of 1,094 aerobic and anaerobic blood culture sets and 523 fungal blood cultures were sent. Of the aerobic and anaerobic culture sets, 42/1,094 (3.8%) were positive for fungal growth. All fungal species cultured were Candida. Of the fungal blood cultures, 4/523 (0.76%) were positive for growth. Fungal species isolated included Candida albicans, Aspergillus fumigatus, and Histoplasma capsulatum. All 4 patients with positive fungal blood cultures were on empirical antifungal therapy prior to results, and the antifungal regimen was changed for 1 patient based on culture data. The average duration to final fungal culture result was 46 days, while the time to preliminary results varied dramatically. Two of the four patients died prior to fungal culture results, thereby rendering the culture data inconsequential in patient care decisions. This study demonstrates that regular aerobic and anaerobic blood cultures sets are sufficient in detecting the most common causes of fungemia and that results from fungal cultures rarely impact treatment management decisions in patients in surgical and burn intensive care units. There is little clinical utility to routine fungal cultures in this patient population. IMPORTANCE This study demonstrates that regular aerobic and anaerobic blood culture sets are sufficient in detecting the most common causes of fungemia, and thus, sending fungal blood cultures for patients in surgical and burn intensive care units is not a good use of resources.

Assessing Videoconference Etiquette in Academia: Determining Positive and Negative Associations With Online Interactions.

INTRODUCTION: The lack of guidelines for videoconferencing etiquette elucidated frustrations during the COVID-19 pandemic. The authors aimed to assess the perceptions of faculty educators and residents regarding videoconferencing etiquette. METHODS: In 2021, a survey assessing perceptions regarding the formality of various meeting types and the importance of various videoconferencing etiquette practices (Likert scale of 1-5) was created and disseminated to all faculty educators and residents at a single institution. Responses of faculty versus residents were analyzed in general and by procedural and mixed/nonprocedural subspecialties. RESULTS: The faculty response rate was 53.5% (38/71). The resident response rate was 7.3% (115/1569). A total of 19 departments were represented. Faculty respondents reported having significantly more hours of weekly formal meetings than residents, 4 (3-10) versus 2 (1-4) h (P < 0.05), and no difference in informal meeting hours, with 3 (2-6) versus 3 (1.6-5) h (P = 0.210). Faculty and residents concurred on the formality of all meeting types except for didactics, which residents regarded more frequently as informal (80.9% versus 57.9%; P < 0.01). Faculty rated wearing professional attire and keeping one's video on as mattering more, and that videoconferencing from bed was more inappropriate (P < 0.05). Furthermore, faculty and residents in mixed/nonprocedural specialties had more significantly discordant perceptions between them than did those in procedural specialties. CONCLUSIONS: The data demonstrated that faculty educators and residents have differing perceptions regarding the formality of meeting types and etiquette practices. These should be addressed to prevent future frustrations and improve engagement in ongoing virtual conferencing education.

Laparoscopic Ambidexterity in Left-Handed Trainees.

INTRODUCTION: There is a paucity of objective data about the advantages or disadvantages of handedness in surgery. Given the need for ambidexterity in laparoscopic surgery, our study aimed to identify the patterns in handedness and performance on basic laparoscopic tasks. METHODS: A retrospective analysis of intern laparoscopic performance on bimanual tasks was assessed for delta time (differences in task time between the dominant and nondominant hand) between left-hand and right-hand dominant interns. RESULTS: Data were analyzed for 16 residents. 25% were left-handed dominant (4/16) and 75% were right-handed dominant (12/16). Of the left-handed surgeons, 75% (3/4) operated primarily with their right hand. There was a significant difference between the time to task completion in Task 2 of left-handed and right-handed residents with median (IQR) time 94 s (90.25-97) and 127 s (104.25-128.5), respectively (P value = 0.02). No significant difference was seen between left-handed and right-handed residents on Task 1 (50 s versus 49 s) and Task 3 (51 s versus 59.5 s). In all three tasks, however, left-handed dominant residents had smaller variability (IQR 4.5-8 s versus 7-24.25 s) and significantly shorter delta times. CONCLUSIONS: Although true ambidexterity is rare, the ability to be facile with both hands is crucial for laparoscopic surgery. Our data show that variability in performance between the dominant hand and nondominant hand was remarkably smaller for left-hand dominant residents. This remains true despite the majority learning to operate with their nondominant hand. These data demonstrate a possible advantage to being left-hand dominant and may lead to further insights into variations of skill acquisition and improved curriculum development.

Monthly Trauma Training and Simulation Are Associated With Improved Resident Skill and Leadership.

BACKGROUND: Training for trauma procedures has been limited to infrequent courses with little data on longitudinal performance, and few address procedural and leadership skills with granular assessment. We implemented a novel training program that emphasized an assessment of trauma resuscitation and procedural skills. OBJECTIVE: This study aimed to determine whether this program could demonstrate improvement in both skill sets in surgical trainees over time. METHODS: This was a prospective, observational study at a Level I trauma center between November 2018 and May 2019. A procedural skill and simulation program was implemented to train and evaluate postgraduate year (PGY) 1-5 residents. All residents participated in an initial course on procedures such as tube thoracostomy and vascular access, followed by a final evaluation. Skills were assessed by the Likert scale (1-5, 5 noting mastery). PGY 3s and above were additionally evaluated on resuscitation. A paired t test was performed on repeat learners. RESULTS: A total of 40 residents participated in the structured procedural skills and simulation program. Following completion of the program, PGY-2 scores increased from a Mdn [interquartile range, IQR] 3.0 [2.5-4.0] to 4.5 [4.2-4.5]. The PGY-3 scores increased from a Mdn [IQR] 3.95 [3.7-4.6] to 4.8 [4.6-5.0]. Eighteen residents underwent repeat simulation training, with Mdn [IQR] score increases in PGY 2s (3.7 [2.5-4.0] to end score 4.47 [4.0-4.5], p = .03) and PGY 3s (3.95 [3.7-4.6] to end score 4.81 [4.68-5.0], p = .04). Specific procedural and leadership skills also increased over time.

Resuscitative endovascular balloon occlusion of the aorta: simulation improves performance but may require interval training to prevent skill degradation.

PURPOSE: Surgical trainees are exposed to less procedures with increasing need for simulation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become increasingly implemented for hemorrhage control, yet most courses are catered to faculty level with little data on trainees. We propose that routine training in this critical procedure will improve trainee performance over time. METHODS: This is a prospective, observational study at a level I trauma center involving a monthly trauma procedural program. Early in the month, trainees received hands-on REBOA training; at the end, trainees underwent standardized, class-based evaluation on a perfused trainer. Score percentages were recorded (0-100%). Endpoints included early, mid and late performance (2-12 months). Paired T-test and Pearson's coefficient were used to evaluate differences and strength of association between time between training and performance. RESULTS: 25 trainees participated with 5 and 11 repeat learners in the PGY-2 and PGY-3 classes, respectively. Median early performance score was 62.5% (IQR 56-81) for PGY-2s and 91.6% (IQR 75-100) in PGY-3s. Pearson's coefficient between time between and training and score demonstrated a weak correlation in the PGY-2s (r2 = - 0.13), but was more pronounced in the PGY-3s (r2 = - 0.44) with an inflection point at 5 months. CONCLUSIONS: Routine REBOA training in trainees is associated with improvement in performance within a short period of time. Skill degradation was most pronounced in trainees who did not receive training for more than 5 months. Trainees can be successfully trained in REBOA; however, this should be done at shorter intervals to prevent skill degradation.

How We Did It: Implementing a Trainee-Focused Surgical Research Curriculum and Infrastructure.

OBJECTIVE: To describe the implementation of a department-wide research curriculum and infrastructure created to promote academic collaboration and productivity, particularly amongst trainees and junior investigators involved in basic, translational, clinical, quality, or education research. DESIGN: Description of UT Southwestern Medical Center's (UTSW) surgical research resources and infrastructure and the development of a didactic curriculum focused on research methods, writing skills, and optimizing academic time and effort. SETTING: The collaboration was initiated by UTSW Department of Surgery residents who were on dedicated research time (DRT) and grew to include trainees and faculty at all levels of the institution. Guest lecturers from institutions around the country were incorporated via virtual meeting platforms. PARTICIPANTS: Medical students, residents, and clinical and research faculty from the Department of Surgery were invited to attend research meetings, didactics, and the guest-lecture series. Additionally, all groups were given access to shared resources and encouraged to share their own work. RESULTS: A robust set of resources including data analysis tools, manuscript and grant writing templates, funding opportunities, and a comprehensive list of surgical conferences was created and made accessible to UTSW Surgery team members. Moreover, a curriculum of lectures covering a broad variety of topics for all types of research was created and has thus far reached an audience of over 40 UTSW Surgery trainees and staff. CONCLUSIONS: A comprehensive set of lectures and resources targeted toward facilitating surgical research was designed and implemented at one of the largest surgical training programs in the country. This effort represents a low-cost, feasible, and accessible way to improve academic productivity and enhance the training of surgeon-scientists and can serve as a blueprint for other institutions around the country.

Creating a Proficiency-based Remote Laparoscopic Skills Curriculum for the COVID-19 Era.

OBJECTIVE: Social distancing restrictions due to COVID-19 challenged our ability to educate incoming surgery interns who depend on early simulation training for basic skill acquisition. This study aimed to create a proficiency-based laparoscopic skills curriculum using remote learning. DESIGN: Content experts designed 5 surgical tasks to address hand-eye coordination, depth perception, and precision cutting. A scoring formula was used to measure performance: cutoff time - completion time - (K × errors) = score; the constant K was determined for each task. As a benchmark for proficiency, a fellowship-trained laparoscopic surgeon performed 3 consecutive repetitions of each task; proficiency was defined as the surgeon's mean score minus 2 standard deviations. To train remotely, PGY1 surgery residents (n = 29) were each issued a donated portable laparoscopic training box, task explanations, and score sheets. Remote training included submitting a pre-test video, self-training to proficiency, and submitting a post-test video. Construct validity (expert vs. trainee pre-tests) and skill acquisition (trainee pre-tests vs. post-tests) were compared using a Wilcoxon test (median [IQR] reported). SETTING: The University of Texas Southwestern Medical Center in Dallas, Texas PARTICIPANTS: Surgery interns RESULTS: Expert and trainee pre-test performance was significantly different for all tasks, supporting construct validity. One trainee was proficient at pre-test. After 1 month of self-training, 7 additional residents achieved proficiency on all 5 tasks after 2-18 repetitions; trainee post-test scores were significantly improved versus pre-test on all tasks (p = 0.01). CONCLUSIONS: This proficiency-based curriculum demonstrated construct validity, was feasible as a remote teaching option, and resulted in significant skill acquisition. The remote format, including video-based performance assessment, facilitates effective at-home learning and may allow additional innovations such as video-based coaching for more advanced curricula.