Fasciotomy following North American pit viper envenomation in Texas 2004-2021.

INTRODUCTION: North American pit viper envenomation occurs over 4,000 times annually in the United States, with polyvalent Fab antivenom being the primary treatment. Fasciotomy is occasionally performed due to concerns about compartment syndrome. We utilized our direct access to Texas Poison Center Network data to create a new snakebite abstraction form and database on relevant available information between 2004 and 2021 and to identify, describe, and estimate the incidence of fasciotomy following pit viper envenomation in Texas. METHODS: We searched the Texas Poison Center Network database for cases during 2004-2021 using keywords such as fasciotomy, surgery, compartment pressure, and compartment syndrome. Descriptive statistics summarized the data. RESULTS: Of 16,911 reported envenomations, 0.69 percent involved fasciotomies (n = 117). Most common bite sites were digits/hands and lower extremities. Patients who underwent fasciotomy were typically male, aged 20-59, and 10 years younger than the total snakebite population. Only 6 percent of reported compartment syndrome cases had a compartment pressure measurement. Antivenom was administered in 101 (86.3 percent) cases, 92 (91.1 percent) of which received only Fab antivenom product. Patients with bites from rattlesnakes (47.9 percent) were associated with most fasciotomies. DISCUSSION: Our findings suggest a potential increase in snakebite exposures, accompanied by a decrease in fasciotomies. Overall, copperheads constituted the majority of snakebites, but most fasciotomies were from rattlesnake envenomations (47.9 percent). In this cohort, compartment syndrome diagnosis and decisions regarding fasciotomy were primarily based on clinical evaluation/surgeon expertise without compartment pressure measurements. Despite the efficacy of antivenom, only 86.3 percent of patients in our study received antivenom. CONCLUSIONS: Fasciotomy after North American pit viper envenomation in Texas is uncommon (0.69 percent) and has decreased over time, possibly due to increased antivenom use or surgeon comfort with nonsurgical management.

Surgical critical care: Is work-life expectancy increasing? An analysis of American Board of Surgery recertification rates across subspecialties.

The practice of surgical critical care (SCC) has traditionally necessitated additional in-house, extended night and weekend clinical commitments, which can be viewed as less desirable for many surgeons. Therefore, the authors have observed that some SCC surgeons elect to transition their practice to focus solely on general surgery (GS) rather than continuing practicing both SCC and GS. We hypothesized that surgeons with a practice focused on SCC are more likely to make the transition to a GS practice than those who have certification in other subspecialties that are certified through the American Board of Surgery.

A Look at Demographics and Transition to Virtual Assessments: An Analysis of Bias in the American Board of Surgery General Surgery Certifying Exams.

OBJECTIVE: The goals of this study were (1) to assess if examiner ratings in the American Board of Surgery (ABS) General Surgery Cetifying Exam (CE) are biased based on the gender, race, and ethnicity of the candidate or the examiners, and (2) if the format of delivering of the exams, in-person or virtual, affects how examiners rate candidates. DESIGN: We included every candidate-examiner combination for first time takers of the general surgery oral exam. Total scores and pass/fail outcomes based on the 4 scores given by examiners to candidates were analyzed using multilevel models, with candidates as random effects. Explanatory variables included the gender, race, and ethnicity of candidates and examiners, and the format of the exam (in-person or virtual). Candidates' first attempt scores on the ABS General Surgery Qualifying Exam (QE) were also included in the models to control for the baseline knowledge of the candidate. Three sets of models were evaluated for each demographic variable (gender, race, ethnicity) due to missingness in data. p-values and coefficients of determination R2 were used to quantify the statistical and practical significance of the model coefficients (an existent relationship between the explored variables on CE scores was considered statistically and practically significant if the p-value was lower than 0.01 and R2 higher than 1%). PARTICIPANTS: All first-time takers of the American Board of Surgery General Surgery Certifying Exam from 2016 to 2022 that had demographic data, and the examiners that participated in those exams. RESULTS: The number of candidates/examiners for the 3 sets of models was 8665/514 (gender), 5906/465 (race), and 4678/295 (ethnicity). The demographic variables, format of the exam, or their interactions were not found to significantly relate to examiner-candidate ratings or pass/fail outcomes. The only variable that was significantly related to CE scores was candidates' QE scores, which was added to the models as a measure of candidates' initial knowledge; this held for all models for total scores (F[1,8659] = 1069.89, p-value < 0.01, R2 = 5% [gender models], F(1,5696.3) = 589.13, p-value < 0.01, R2 = 5% [race models], F(1,4459.5) = 278.33, p-value < 0.01, R2 = 5% [ethnicity models]), and pass/fail outcomes (CI = 1.61-1.73, p-value < 0.01, R2 = 3% [gender models], CI = 1.67-1.85, p-value < 0.01, R2 = 3% [race models], CI = 2.17-2.90, p-value < 0.01, R2 = 3% [ethnicity models]). CONCLUSIONS: This study shows that there is not a relationship between candidate and examiner gender, race, or ethnicity, and exam outcomes based on statistical models looking at examiner-candidate ratings and pass/fail outcomes. In addition, the delivery of the certifying exam in a virtual format appears to have no statistical impact on outcomes compared to in-person delivery. This suggests that the ABS is performing well in both demographic bias and virtual space.

How Does the Sequence of the American Board of Surgery Examinations Impact Pass/Fail Outcomes?

OBJECTIVE: Historically, the American Board of Surgery required surgeons to pass the qualifying examination (QE) before taking the certifying examination (CE). However, in the 2020-2021 academic year, with mitigating circumstances related to COVID-19, the ABS removed this sequencing requirement to facilitate the certification process for those candidates who were negatively impacted by a QE delivery failure. This decoupling of the traditional order of exam delivery has provided a natural comparator to the traditional route and an analysis of the impact of examination sequencing on candidate performance. METHODS: All candidates who applied for the canceled July 2020 QE were allowed to take the CE before passing the QE. The sample was then reduced to include only first-time candidates to ensure comparable groups for performance outcomes. Logistic regression was used to analyze the relationship between the order of taking the QE and the CE, controlling for other examination performance, international medical graduate status, and gender. RESULTS: Only first-time candidates who took both examinations were compared (n=947). Examination sequence was not a significant predictor of QE pass/fail outcomes, OR=0.54; 95% CI, 0.19-1.61, P =0.26. However, examination sequence was a significant predictor of CE pass/fail outcomes, OR=2.54; 95% CI, 1.46-4.68, P =0.002. CONCLUSIONS: This important study suggests that preparation for the QE increases the probability of passing the CE and provides evidence that knowledge may be foundational for clinical judgment. The ABS will consider these findings for examination sequencing moving forward.

Diversity and Inclusion Analysis of the Association of Program Directors in Surgery's Annual Conference From 2010 to 2022.

INTRODUCTION: Explored the diversity and inclusion of our annual meeting. The authors compared our members' diversity to the participation in the impactful portions of our annual conference as a measure of our organizational inclusion. METHODS: The authors retrospectively reviewed and calculated the diversity demographics of our membership based on our 2022 data. Demographics consisted of institutional affiliation and gender. Also the authors retrospectively analyzed the topics discussed at our annual meeting from 2010 to 2022. RESULTS: In 2022, the Association of Program Directors in Surgery (APDS) had 308 members; while we had 100% of the institutional affiliation, most members did not self-report gender or ethnicity information. One hundred eleven members self-reported gender information in 2022: 76% were men and 24% were women. Fifty-seven percent of our institutions had a medical school affiliation, 40% had a nonmedical school affiliation, and 3% had a military instillation affiliation. CONCLUSION: The authors' current analysis demonstrates disparities in the distribution of meaningful space in the APDS meeting program. Future efforts are ongoing to identify members and their demographics, track participation, and encourage more diverse involvement across membership.

Implementation of entrustable professional activities in multiple surgical residencies: A quality improvement approach.

BACKGROUND: The COVID-19 pandemic decreased the operative case volume for surgical residents. Our institution implemented Entrustable Professional Activities (EPAs) in all core surgical training programs to document the competency of graduating residents. Continuation of this project aimed to improve implementation. METHODS: This project occurred at a large academic center with eight surgical specialties during the 2020-21 (Year 1) and 2021-22 (Year 2) academic years. Each specialty chose five EPAs, and residents were asked to obtain three micro-assessments per EPA. After the initial pilot year, program directors were surveyed regarding perceptions of EPA utility and barriers to implementation. RESULTS: Seventy senior residents completed 732/906 (80.8%) micro-assessments. Of these, 99.6% were deemed practice ready. Total micro-assessment completion rates in four specialties, four specific EPAs (including one EPA identified "at risk" due to the COVID-19 pandemic), and overall were significantly higher in Year 2 than Year 1 (p â€‹< â€‹0.05) CONCLUSIONS: Implementing EPAs in all core surgical specialties at an institution is achievable, though expectedly initially imperfect. An ongoing quality collaborative initiative focused on barriers to implementation can improve completion rates.

Effective Mentoring Across Differences-Best Practices and Effective Models to Address the Needs of Underrepresented Trainees in Surgical Residency Programs.

BACKGROUND: Mentorship plays a critical role in the career development of surgical trainees and faculty. As the surgical workforce continues to diversify, mentoring trainees who differ) race, ethnicity, country of origin, socioeconomic status, educational background, religion, gender, sexual orientation or ability) can pose challenges to the experience for both mentor and mentee. OBJECTIVE: The aim of this manuscript is to introduce surgical educators to the systemic barriers faced by trainees and to models of effective mentorship. METHODS: At the 2022 APDS Meeting, a panel convened to highlight the current challenges of mentoring across differences and effective models for surgical educators. This paper highlights and expands the summary of this panel. RESULTS: Examples of novel mentoring models are described. CONCLUSIONS: Acknowledgment of barriers, Implementation of deliberate mentoring strategies, and collaboration with national surgical organizations and surgery departments and faculty may help to reduce physician attrition.

How Did We Get Here and Where Are We Going? Career Trajectories of United States General Surgery Residency Program Directors.

OBJECTIVE: To develop the future of United States (US) surgical education leadership, surgical trainees and early career faculty who aspire to become program directors (PDs) must understand the potential career pathways and requisite skills and experience to become a general surgery residency PD. The objective of this study was to understand the demographics, career experiences, and professional satisfaction of US PDs in general surgery. DESIGN: An anonymous, cross-sectional survey utilizing a novel instrument. SETTING: An electronic survey distributed to US general surgery PDs between June and November 2022 PARTICIPANTS: PDs of US general surgery residency programs. A list of the Accrediting Council for Graduate Medical Education (ACGME)-accredited general surgery PDs was created from the ACGME list from the 2022 to 23 academic year. RESULTS: The survey achieved a response rate of 46.2% (159/344). Only 32.1% of PDs identified as female and 67.3% identified as male with 1 respondent preferring not to identify their gender. PDs were White or Caucasian (68.6%), Asian (13.8%), and Black (3.7%); 4.4% were Hispanic or Latino. Only 83.7% of PDs completed fellowship training. PDs have been in the role for an average of 5.5 ± 4.9 years. The PDs were compensated for an average of 54.7% (±14.9% SD, 0%-100% range) of their time towards clinical duties. They were compensated on average for 35.7% (±12.6%, 0%-100%) of effort for residency-related administrative duties. Only 5% of PDs had obtained or were enrolled in an education-related degree. Only 55.4% of PDs had received formal surgical education training in teaching and assessment. 54.1% of PDs were interested in obtaining a more senior leadership position in the future. Most PDs (38.4%) expect to serve as PD for 5 to 8 years in total. Overall, the majority of PDs were very satisfied (29.6%) or satisfied (51.6%) professionally; similarly 28.9% were very satisfied and 48.4% satisfied personally. CONCLUSIONS: This study represents the most up-to-date characterization of the personal, academic, and career-related features of current surgical residency PDs across the US. PDs enjoy a high degree of professional and personal satisfaction and most aspire to increasing leadership within their organizations. Compared to prior data, PDs have become more diverse in terms of both gender and race over time. Opportunities exist for increased mentorship of aspiring and current PDs as well as increased training in teaching and assessment.

Gender Discrepancies in Middle Author Publications in US Academic General Surgery.

INTRODUCTION: To explore gender discrepancies in publications at general surgery departments, we performed a cross-sectional comparing the number of women and men at each academic rank and their number of first author (FA), middle author (MA), last author (LA), and total publications. METHODS: Thirty academic general surgery departments were randomly selected. For each faculty, we tabulated: first, middle, last names, gender, academic rank, educational leadership, year of medical school graduation, and additional graduate degrees. Bibliography, H-index, and citations were downloaded from the Scopus database. RESULTS: One thousand three hundred twenty-six faculty sampled, 881 (66.4%) men and 445 (33.5%) women. Men outnumbered women at all ranks, with increasing disparity at higher ranks. Men outnumbered women in all subspecialties-largest difference in transplant surgery (84.4% versus 15.6%, P < 0.001). Men at all ranks had more MA publications: assistant professor (rate ratio 1.20; 95% confidence interval, 1.01-1.43, P = 0.024), associate professor (1.65; 1.31-2.06, P < 0.001), and professor (1.50; 1.20-1.91, P = 0.008). Men associate professors had more LA publications (1.74; 1.34-2.37, P < 0.001). No differences found in FA publications at any rank, nor LA publications at assistant professor and professor ranks. At subspecialty level, men in surgical oncology (1.95; 1.55-2.45, P < 0.001) and transplant surgery (1.70; 1.09-2.66, P = 0.02) had more MA publications. CONCLUSIONS: While FA and LA publications did not differ significantly across genders, the largest difference lies in MA publications, beginning at junior ranks and persisting with seniority. Discrepancies in MA publications may reflect gender discrepancies in collaborative opportunities, hence total publications should be used cautiously when determining academic productivity.

The Program Director Perspective: Perceptions of PGY5 Residents' Operative Self-Efficacy and Entrustment.

INTRODUCTION: A 2020 survey of post-graduate year 5 (PGY5) general surgery residents linked to the American Board of Surgery In-Training Examination (ABSITE) revealed significant deficits in self-efficacy (SE), or personal judgment of one's ability to complete a task, for 10 commonly performed operations. Identifying whether this deficit is similarly perceived by program directors (PDs) has not been well established. We hypothesized that PDs would perceive higher levels of operative SE compared to PGY5s. METHODS: A survey was distributed through the Association of Program Directors in Surgery listserv; PDs were queried about their PGY5 residents' ability to perform the same 10 operations independently and their accuracy of patient assessments and operative plans for components of several core entrustable professional activities (EPAs). Results of this survey were compared to PGY5 residents' perception of their SE and entrustment based on the 2020 post-ABSITE survey. Chi-squared tests were used for statistical analysis. RESULTS: 108 responses were received, representing ∼32% (108/342) of general surgery programs. Perceptions from PDs of PGY5 residents' operative SE were highly concordant with resident perceptions; no significant differences were observed for 9 of 10 procedures. Both PGY5 residents and PDs perceived adequate levels of entrustment; no significant differences were observed for 6 of 8 EPA components. CONCLUSIONS: These findings show concordance between PDs and PGY5 residents in their perceptions of operative SE and entrustment. Though both groups perceive adequate levels of entrustment, PDs corroborate the previously described operative SE deficit, illustrating the importance of improved preparation for independent practice.

Forum Theatre to Address Peer-to-Peer Mistreatment in General Surgery Residency.

OBJECTIVE: Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution. DESIGN: Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered. SETTING: General surgery residency at University of Texas Health San Antonio. PARTICIPANTS: General surgery residents. 32 of 66 (48.5%) residents participated. RESULTS: Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well. CONCLUSIONS: We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.

Lived Experiences of Mistreatment in a General Surgery Residency.

OBJECTIVE: Explore the lived experiences of General Surgery residents to identify how they perceive, define mistreatment, and which factors can contribute to or mitigate mistreatment within the Clinical Learning Environment. DESIGN: This is a phenomenological study conducted during 2019-2020 using Giorgi's psychological descriptive phenomenology methodology. Researcher bias, trustworthiness, and triangulation were addressed using bracketing, check-ins with program leadership, comparisons to resident survey, and team consensus based on Consensual Qualitative Research. SETTING: General Surgery Residency program at Long School of Medicine, UT Health San Antonio, Texas. PARTICIPANTS: All residents in the general surgery program were invited to participate (n= 66, 43% female and 63% non-Hispanic). Specific demographic and identifying data for each participant was not collected. Approximately 50 (76% of program) residents from General Surgery participated. RESULTS: We were able to identify four themes that helped to delineate the lived experience of residents including program cultural factors, resident internal processing, and perceived effects of mistreatment by the residents. The resulting psychological structure and conceptual framework help clarify the interrelations between the themes and the Clinical Learning Environment. The scenarios discussed were adapted and depersonalized to use as prompts for the Forum Theater intervention. This project set out to explore resident's lived experiences and allow the data to reveal the main outcomes. The data was coded and analyzed following strict guidelines from descriptive psychological phenomenology and Consensual Qualitative Research with the aim of informing a later experiential intervention based on Forum Theater. CONCLUSIONS: The lived experience of general surgery residents helped identify cultural factors and behaviors that contribute to and/or mitigate mistreatment providing information to plan interventions at the resident and faculty level. Mitigating or stopping mistreatment can improve the Clinical Learning Environment and hence, the quality of training.

Leadership Diversity in the Association of Program Directors in Surgery: A Report of Progress.

BACKGROUND: Across the last several years, numerous surgical departments and societies have focused on addressing the lack of diversity, equity, and inclusion (DEI) in the field. Since the Association of Program Directors in Surgery (APDS) Diversity and Inclusion Taskforce was created in 2017 (and solidified as a formal committee in 2018, herein referred to as the APDS-DIC), it has sought to address gaps in diversity at various phases of training and development from medical student to surgical leader. OBJECTIVE: In follow-up to a 2018 study that benchmarked leadership demographics of the APDS, this study analyzed how the APDS' efforts have aligned with recommended DEI strategies and whether this produced demographic changes in organizational leadership. METHODS: Fifteen years (2008-2022) of publicly available APDS annual meeting program data and APDS membership lists were analyzed. Leadership positions in the organization were examined by officer, program/vice chair, executive committee, and board of directors. A 2-tailed T-test compared differences in the average proportion of leaders from specific demographic groups before and after the APDS-DIC inception (2008-2016 vs. 2017-2022). RESULTS: APDS has 724 unique faculty and 140 resident members. The majority of both groups identified as White (68% of faculty and 58% of residents). Over 15 years, there have been 307 available leadership positions held by 67 individuals. All presidents and president-elect positions have been held by White surgeons; nearly 80% have been men. The average proportion of female leaders and the average proportion of racial/ethnic minority leaders were both significantly higher after implementation of the APDS-DIC in 2017 (p=0.0009 for gender and p=0.036 for racial/ethnic minorities). CONCLUSIONS: The APDS' commitment to DEI efforts and establishment of the APDS-DIC in 2017 was associated with a significant increase in women and non-White minorities in organizational leadership positions. The specific role of the APDS-DIC in propelling surgeons from underrepresented groups into leadership and promoting key DEI efforts is broadly applicable to other surgical organizations.

The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents' self-efficacy.

BACKGROUND: Implementation of the Fundamentals of Laparoscopic Surgery (FLS) by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for educational structure for laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy (SE) with laparoscopic procedures. METHODS: We conducted a national survey, linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9275 residents from 325 US General Surgery Training Programs participated. The online survey included multimodal questions that analyzed whether participants felt they could perform the most commonly-logged laparoscopic operations among residents [Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), Laparoscopic Right Hemicolectomy (LRH), Diagnostic Laparoscopy (DL)] without faculty assistance. This used a 5-point scaled assessment, ranging from "not able to" to "definitely able to." Multivariate analyses determined if completion of FLS made a difference for resident self-efficacy, stratified by post-graduate year (PGY). RESULTS: At the time of the survey, 2300 reported completion of FLS. The percentage of FLS completion increased from PGY1 to PGY5 (4.2% n = 59 vs 85.8% n = 893). PGY1 residents who completed FLS, from 48 diverse institutions, demonstrated the most significant increases in SE (p < 0.05) with significantly higher perceived self-efficacy in LA (p = 0.001) and LRH (p = 0.012). PGY2 and PGY3 residents indicated increased SE in DL (p = 0.037, p = 0.015, respectively), based on FLS completion. These FLS effects were less evident in the more senior classes. CONCLUSIONS: Completion of FLS arguably has the greatest benefits for more junior residents, as it establishes a foundation of laparoscopic knowledge and skill, upon which further residency training can build. Successful completion of the curriculum and assessment offered by the Fundamentals of Laparoscopic Surgery leads to greater sense of ability in early trainees.

Identifying Potential Attrition during the Residency Applicant Screening Process Using a Situational Judgment Test.

OBJECTIVE: As USMLE Step 1 moves to pass/fail, residency programs are seeking alternate interview selection processes. Attrition in general surgery is reported as high as 26%. Thus, it is important to ensure that programs are selecting and matching applicants with shared values. Situational judgment tests (SJTs) measure educational and cultural values by posing ambiguous situations and individuals rate the effectiveness of possible reactions. SJTs have previously been shown to identify job applicants with shared values while promoting diversity. Scoring categories are high, moderate, or low values congruence. We sought to explore predictive validity of the SJT relative to program attrition. DESIGN: Residents who matched into our program between 2018 and 2021 completed the SJT. We tracked attrition. SETTING: UT Health San Antonio, Texas PARTICIPANTS: Fifty-six categorical general surgery residents RESULTS: Per SJT ratings, the numbers of residents who had high, moderate, and low values congruence were 27, 16, and 13, respectively. Attrition numbers for residents who scored high and moderate congruence were similar, indicating that these ratings were indistinguishable. As such, we combined those 2 categories to create a 2 × 2 matrix and used signal detection theory as a framework for analysis. Overall attrition was 16.1% (9/56). Of the 43 residents who scored high or moderate congruence, 90.7% remained in the program. There was a 9.3% chance of attrition for these residents. Of the 13 residents who scored low congruence, 38.5% attrited. While scoring as low congruence on the SJT does not definitively indicate attrition, it does indicate that attrition is 4.14 times more likely for these residents (chi-square, p = 0.0121). CONCLUSIONS: One of the most important aspects of residency applicant selection and interviewing is mitigating risk by identifying applicants who carry a high risk of attrition. The SJT significantly identifies at-risk applicants.

Individual and Institutional Factors Associated with PGY5 General Surgery Resident Self-Efficacy: A National Survey.

BACKGROUND: Variability in post-graduate year 5 (PGY5) residents' operative self-efficacy exists; yet the causes of variability have not been explored. Our study aims to determine resident-related and program-dependent factors associated with residents' perceptions of self-efficacy. STUDY DESIGN: Following the 2020 American Board of Surgery In-Training Examination, a national survey of self-efficacy in 10 of the most commonly performed Accreditation Council for Graduate Medical Education case-log procedures was completed. RESULTS: A total of 1,145 PGY5 residents completed the survey (response rate 83.8%), representing 296 surgical residency programs. Female sex (odds ratio [OR] 0.46 to 0.67; 95% CI 0.30 to 0.95; p < 0.05) was associated with decreased self-efficacy for 6 procedures. Residents from institutions with emphasis on autonomy were more likely to report higher self-efficacy for 8 of 10 procedures (OR 1.39 to 3.03; 95% CI 1.03 to 4.51; p < 0.05). In addition, increased socialization among residents and faculty also correlated with increased self-efficacy in 3 of 10 procedures (OR 1.41 to 2.37; 95% CI 1.03 to 4.69; p < 0.05). Procedures performed with higher levels of resident responsibility, based on Graduated Levels of Resident Responsibility (GLRR) and Teaching Assistant (TA) scores, were correlated with higher self-efficacy (p < 0.001). CONCLUSION: Ensuring that residents receive ample opportunities for GLRR and TA experiences, while implementing programmatic support for resident-dependent factors, may be crucial for building self-efficacy in PGY5 residents. Institutional support of resident "autonomy" and increasing methods of socialization may provide a means of building trust and improving perceptions of self-efficacy. In addition, reevaluating institutional policies that limit opportunities for graduated levels of responsibility, while maintaining patient safety, may lead to increased self-efficacy.

Diversity, Equity, and Inclusion: A Current Analysis of General Surgery Residency Programs.

BACKGROUND: Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally. MATERIALS AND METHODS: General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses. RESULTS: A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05). DISCUSSION: In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.

American Board of Surgery Entrustable Professional Activities (EPAs): Assessing Graduating Residents' Perception of Preoperative Entrustment.

OBJECTIVE: To determine if graduating surgical residents are achieving entrustment of surgical entrustable professional activities (EPAs). We hypothesize that postgraduate year 5 (PGY5) residents are achieving evaluation and management entrustment in the selected EPAs. DESIGN: In January 2020, surgical residents completed a survey following the American Board of Surgery In-Training Examination (ABSITE) to measure their levels of entrustment in 4 of the 5 ABS-selected EPAs. A Resident Entrustability Index (REI) score was developed to ascertain PGY5 residents' levels of entrustment (range 1-5). Residents indicated how often their assessments and operative plans were modified in the prior 6 months for each EPA (1=Always, 2=Frequently, 3=Occasionally, 4=Rarely, 5=Never). An independent clinical decision-making score (ICDM) was developed with subsequent evaluation of its relationships to intrinsic, resident-related and extrinsic, program-dependent factors. SETTING: A national post-ABSITE survey. PARTICIPANTS: All general surgery residents participating in ABSITE were invited to participate. Of the 1367 PGY5 residents that completed the survey, 1049 residents (76.7%) responded to the surgical EPA items. RESULTS: Residents achieved an average REI of 4, indicating rare modification of assessments and operative plans for the 4 EPAs assessed. Complete entrustment was reported for inguinal hernias and penetrating abdominal trauma (Median REI = 5, IQR 4, 5) indicating assessments and operative plans were never modified. Lack of entrustment (REI ≤3) was reported by a minority of residents (ranging from 8.6% for operative plan of right lower quadrant pathology to 12.8% for operative plan of blunt abdominal trauma). Significant resident-related and program-dependent factors associated with achievement of expected ICDM was socializing with a co-resident (p = 0.001), while training in one's hometown (p < 0.001) and policies that mandate attendings be scrubbed in (p = 0.022) were associated with decreased achievement of expected ICDM. Overall, 89.2% and 90.3% of PGY5 residents are attaining appropriate levels of entrustment and ICDM abilities, respectively, within 6 months of graduating. CONCLUSIONS: Of the EPAs evaluated, PGY5 residents are achieving appropriate levels of entrustment in evaluation and management. Although this is the case for a vast majority of PGY5 residents, there is still work to be done to ensure that all PGY5 residents are attaining entrustment prior to graduation. Our study also provides content validity for the surgical EPAs in assessing levels of entrustment in PGY5 residents.