Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

OBJECTIVE: To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon. BACKGROUND: Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons. METHODS: We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days. RESULTS: We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01). CONCLUSION: Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

Association Between American Board of Surgery Initial Certification and Risk of Receiving Severe Disciplinary Actions Against Medical Licenses.

Importance: Board certification is used as a marker of surgeon quality and professionalism. Although some research has linked certification in surgery to outcomes, more research is needed. Objective: To measure associations between surgeons obtaining American Board of Surgery (ABS) certification and examination performance with receiving future severe disciplinary actions against their medical licenses. Design, Setting, and Participants: Retrospective analysis of severe license action rates for surgeons who attempted ABS certification based on certification status and examination performance. Surgeons who attempted to become certified were classified as certified or failing to obtain certification. Additionally, groups were further categorized based on whether the surgeon had to repeat examinations and whether they ultimately passed. The study included surgeons who initially attempted certification between 1976 and 2017 (n = 44 290). Severe license actions from 1976 to 2018 were obtained from the Federation of State Medical Boards, and certification data were obtained from the ABS database. Data were analyzed between 1978 and 2008. Main Outcomes and Measures: Severe license action rates were analyzed across certified surgeons and those failing to obtain certification, as well as across examination performance groups. Results: The final dataset included 36 197 men (81.7%) and 8093 women (18.3%). The incidence of severe license actions was significantly greater for surgeons who attempted and failed to obtain certification (incidence rate per 1000 person-years = 2.49; 95% CI, 2.13-2.85) than surgeons who were certified (incidence rate per 1000 person years = 0.77; 95% CI, 0.71-0.83). Adjusting for sex and international medical graduate status, the risk of receiving a severe license action across time was also significantly greater for surgeons who failed to obtain certification. Surgeons who progressed further in the certification examination sequence and had fewer repeated examinations had a lower incidence and less risk over time of receiving severe license actions. Conclusions and Relevance: Obtaining board certification was associated with a lower rate of receiving severe license actions from a state medical board. Passing examinations in the certification examination process on the first attempt was also associated with lower severe license action rates. This study provides supporting evidence that board certification is 1 marker of surgeon quality and professionalism.

Confidence and Competence in Volunteer Examiners of the American Board of Surgery.

BACKGROUND: Previous work has demonstrated the impact of sex on the relationship between confidence and competence, with women having less confidence and less self-perceived competence. Recent recruitment of examiners by the American Board of Surgery (ABS) allowed exploration of confidence and perceived competence. STUDY DESIGN: We solicited 23,869 eligible board-certified surgeons (4,382 women) via email to serve as examiners for the ABS General Surgery Certifying Examination (GCE). Volunteers were asked about practice and comfort examining in the 14 GCE content areas. Regression models investigated the relationship between reported practice and confidence examining. RESULTS: There were 2,157 surgeons who volunteered, of whom 420 (19.5%) were female. Men reported practicing in a greater number of content areas than women (6.59 vs 5.36, p < 0.001) and selected more content areas in which they felt comfortable examining (7.69 vs 6.64, p < 0.001). The average male volunteer was comfortable examining in 0.70 more content areas than women, controlling for self-reported practice. CONCLUSIONS: Men reported practicing more broadly and were more confident than women in their ability to examine across ABS Certifying Examination content areas. However, the confidence of male surgeons was not restricted to those areas in which they reported practicing. These data have important implications for training, leadership, and professional development.

Orthopedic Surgeon Decision-Making Processes for Postsurgical Opioid Prescribing.

INTRODUCTION: Acute pain and chronic pain are significant burdens in the Department of Defense, compounded by the ongoing opioid crisis. Given the ubiquity of (leftover) opioid prescriptions following orthopedic surgery, it is essential to identify feasible and acceptable avenues of opioid risk mitigation efforts. The present quality improvement project builds on recent studies by evaluating factors related to opioid prescribing decisions in a sample of orthopedic surgery providers. MATERIALS AND METHODS: This quality improvement project received a Determination of Not Research and was conducted through a collaboration between the Department of Orthopaedic Surgery and the Department of Anesthesiology and Pain Management at Walter Reed National Military Medical Center. Providers in the Department of Orthopaedic Surgery completed an anonymous online survey assessing opioid prescribing education, factors influencing prescribing practices, opioid-safety practices, and perspectives on potential opioid safety initiatives. RESULTS: In total, 39 respondents completed surveys. There was variability in exposure to different types of opioid prescribing education, with some variation between attendings/physician assistants and residents. Patients' acute postsurgical pain, using a standardized amount for most patients, and prescription histories were the three most influential factors. Concern of patients running out and fear of patient dissatisfaction were the least influential factors. Respondents commonly reported engagement in promoting nonpharmacological pain management, as well as coordinating with chronic pain providers when applicable, but did not commonly report educating patients on leftover opioid disposal. Respondents indicated that a barrier to opioid risk mitigation was the difficulty of accessing appropriate electronic health record data to inform decisions. Lastly, they reported openness to proposed opioid safety initiatives. CONCLUSION: The results of this quality improvement project identified several target areas for future initiatives focused on improving opioid prescribing practices. This included a provider training program, improved patient education system, increased awareness and use of opioid tracking databases, and development of a standardized (but adaptable per patient characteristics and history) recommended dose for common orthopedic surgeries. Future projects will target tailored development, implementation, and evaluation of such efforts.

Recertification Exam Performance in General Surgery is Associated With Subsequent Loss of License Actions.

OBJECTIVES: To measure associations between first-time performance on the American Board of Surgery (ABS) recertification exam with subsequent state medical licensing board disciplinary actions. BACKGROUND: Time-limited board certification has been criticized as unnecessary. Few studies have examined the relationship between recertification exam performance and outcomes. METHODS: Retrospective analysis of loss-of-license action rates for general surgeons who were initially certified by the ABS from 1976 to 2005 and attempted to take a surgery recertification exam. Disciplinary actions from 1976 to 2016 were obtained from the Disciplinary Action Notification System through the American Board of Medical Specialties. RESULTS: A total of 14,169 general surgeons attempted to pass the surgery recertification exam. The rate of loss-of-license actions was significantly higher for surgeons who failed their first exam attempt [incidence rate 3.41, 95% confidence interval (CI) 2.27-4.56] than those who passed on their first attempt (incidence rate .01, 95% CI 0.87-1.14). A Cox proportional-hazards regression model found that the adjusted hazard rate for loss-of-license actions for surgeons who failed their first recertification exam were significantly higher than those who passed their first attempt after adjusting for multiple surgeon characteristics (adjusted hazard rate 2.98, 95% CI 1.85-4.81). CONCLUSIONS: Failing the first recertification exam attempt was associated with a greater rate of subsequent loss-of-license actions. These results suggest that demonstrating sufficient surgical knowledge is a significant predictor of future loss-of-license actions.

Is There Gender Bias on the American Board of Surgery General Surgery Certifying Examination?

BACKGROUND: When oral examinations are administered, examiner subjectivity may possibly affect ratings, particularly when examiner severity is influenced by examinee characteristics (e.g., gender) that are independent of examinee ability. This study explored whether the ratings of the general surgery oral certifying examination (CE) of the American Board of Surgery and likelihood of passing the CE were influenced by the gender of examinees or examiners. MATERIALS AND METHODS: Data collected from examinees who attempted the general surgery CE in the 2016-2017 academic year were analyzed. There were 1341 examinees (61% male) and 216 examiners (82% male). Factorial analysis of variance and logistic regression analyses were used to evaluate the effect of examinee and examiner gender on CE ratings and likelihood of passing the CE. RESULTS: Examinees received similar ratings and had similar likelihood of passing the CE regardless of examinee or examiner genders and different combinations of examiner gender pairs (all P values > 0.05). CONCLUSIONS: These results indicate that CE ratings of examinees are not influenced by examinee or examiner gender. There was no evidence of examiner bias due to gender on the CE.

Rapid evolution of reproductive isolation between incipient outcrossing and selfing Clarkia species.

A major goal of speciation research is to understand the processes involved in the earliest stages of the evolution of reproductive isolation (RI). One important challenge has been to identify systems where lineages have very recently diverged and opportunities for hybridization are present. We conducted a comprehensive examination of the components of RI across the life cycle of two subspecies of Clarkia xantiana, which diverged recently (ca. 65,000 bp). One subspecies is primarily outcrossing, but self-compatible, whereas the other is primarily selfing. The subspecies co-occur in a zone of sympatry but hybrids are rarely observed. Premating barriers resulted in nearly complete isolation in both subspecies with flowering time and pollinator preference (for the outcrosser over the selfer) as the strongest barriers. We found that the outcrosser had consistently more competitive pollen, facilitating hybridization in one direction, but no evidence for pollen-pistil interactions as an isolating barrier. Surprisingly, postzygotic isolation was detected at the stage of hybrid seed development, but in no subsequent life stages. This crossing barrier was asymmetric with crosses from the selfer to outcrosser most frequently failing. Collectively, the results provide evidence for rapid evolution of multiple premating and postzygotic barriers despite a very recent divergence time.

The dimensionality of ecological networks.

How many dimensions (trait-axes) are required to predict whether two species interact? This unanswered question originated with the idea of ecological niches, and yet bears relevance today for understanding what determines network structure. Here, we analyse a set of 200 ecological networks, including food webs, antagonistic and mutualistic networks, and find that the number of dimensions needed to completely explain all interactions is small ( < 10), with model selection favouring less than five. Using 18 high-quality webs including several species traits, we identify which traits contribute the most to explaining network structure. We show that accounting for a few traits dramatically improves our understanding of the structure of ecological networks. Matching traits for resources and consumers, for example, fruit size and bill gape, are the most successful combinations. These results link ecologically important species attributes to large-scale community structure.

The ghost of nestedness in ecological networks.

Ecologists are fascinated by the prevalence of nestedness in biogeographic and community data, where it is thought to promote biodiversity in mutualistic systems. Traditionally, nestedness has been treated in a binary sense: species and their interactions are either present or absent, neglecting information on abundances and interaction frequencies. Extending nestedness to quantitative data facilitates the study of species preferences, and we propose a new detection method that follows from a basic property of bipartite networks: large dominant eigenvalues are associated with highly nested configurations. We show that complex ecological networks are binary nested, but quantitative preferences are non-nested, indicating limited consumer overlap of favoured resources. The spectral graph approach provides a formal link to local dynamical stability analysis, where we demonstrate that nested mutualistic structures are minimally stable. We conclude that, within the binary constraint of interaction plausibility, species preferences are partitioned to avoid competition, thereby benefiting system-wide resource allocation.