Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers.

BACKGROUND: Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention. OBJECTIVES: The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons. SETTING: Two mid-Atlantic quaternary care academic centers. METHODS: Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05). RESULTS: We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period. CONCLUSIONS: RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

Assessing Content of Accredited Colon and Rectal Surgery Fellowship Websites: Is there Adequate Information for Applicants?

Electronic information is a vital resource used by fellowship applicants. This study aimed to assess the completeness of colon and rectal surgery (CRS) fellowship program online information. Program information on the Association of Program Directors for Colon and Rectal Surgery (APDCRS) website as well as each institutional website was evaluated based on templated criteria. Sixty-eight accredited fellowship programs were identified. Six (9%) programs had complete profiles on the APDCRS platform, with an average of 3.5 details completed per program. Sixty-two (91%) websites were easily accessible. None of these contained all 28 criteria assessed and 47 (69%) contained less than half of assessed content. The most common data point was fellowship program description (96%), while board pass rate (1%) was the least common. Most CRS fellowship websites were grossly incomplete. Electronically available information is vital to fellowship applicants, and programs should try to provide easily accessible information about their program.

Keep it SIMPL: Improved Feedback After Implementation of an App-Based Feedback Tool.

BACKGROUND: Data defining the utility of the system for improving and measuring procedural learning (SIMPL) in surgical education is limited. The aim of this pilot study is to describe the impact of SIMPL on resident and faculty perspectives regarding operative feedback. METHODS: Residents and faculty were surveyed prior to and 6 months after SIMPL implementation. Associations were analyzed using χ2 for categorical and Student's t-test for continuous variables. Statistical significance was defined as P-value < .05. RESULTS: The proportion of residents receiving intraoperative feedback at least once/day increased significantly (35% to 73%, P = .025); there was a trend toward increased postoperative feedback (15% to 33%, P = .201). Faculty reported an increase in intraoperative (55% to 91%, P = .041) and postoperative feedback (21% to 64%, P = .020). Satisfaction with intraoperative feedback improved from a score of 3.50 ± 1.05 to 3.93 ± .62, although not statistically significant (P = .181). Satisfaction with postoperative feedback improved significantly from 2.85 ± .93 to 3.50 ± .65 (P = .032). The proportion of faculty who felt they were providing effective feedback increased (53% to 91%, P = .032). The proportion of residents who perceived that feedback enhanced their surgical skill increased as well (65% to 93%, P = .048). DISCUSSION: Despite a modest increase in frequency of postoperative feedback, perceived quality of feedback improved substantially after implementation of SIMPL. Introduction of SIMPL also increased the amount of feedback provided by faculty intraoperatively. SIMPL, via direct and indirect effects, has a positive impact on the resident operative learning environment. Further work is necessary to examine the influence this may have on resident operative skill and patient outcomes.

Ten Year Trends in Minimally Invasive Surgery Fellowship.

BACKGROUND: Minimally Invasive Surgery (MIS) is one of the more recently established surgical fellowships, with many candidates applying due to a perception of inadequate exposure to advanced MIS during residency. The desire for advanced training should be reflected in increased competitiveness for fellowship positions. The aim of this study is to determine the desirability of MIS fellowships over time through review of national application data. METHODS: We reviewed the fellowship match statistics obtained from The Fellowship Council, the organizing body behind the MIS fellowship match. Data from January 1, 2008 - December 31, 2019 were included. We compared match rates to other specialties using the National Resident Matching Program, a nonprofit organization established for US residency and some fellowship programs. RESULTS: In the period of 2008 to 2019, the number of certified MIS fellowship programs increased from 124 to 141. While this program expansion was associated with a 19% increase in available positions, the number of applications increased 36%. As a result, the number of positions filled increased from 83% to 97%, but the match rate among US applicants fell from 82% to 71% during this interval. In comparison, the match rates for pediatric surgery, surgical oncology, vascular surgery, and surgical critical care fellowships remained largely unchanged, most recently 50%, 56%, 99%, and 100% respectively. CONCLUSION: Over the last decade, US residents have shown an increased interest in pursuing MIS fellowship positions. As a consequence, the match process for MIS fellowships is becoming increasingly competitive.

Love at First Click: Surgery Residency Websites in the Virtual Era.

INTRODUCTION: Frequently, a residency program's website is the first interaction students interested in surgery have with the program. In the setting of virtual interviews for residency in 2020, the online availability of program information is of heightened importance. We sought to assess how academic versus community-based general surgery residency programs compared with respect to certain details on their websites. METHODS: A total of n = 268 surgery residency programs were investigated. Our database of website characteristics included: direct link to residency website from the American Council on Graduate Medical Education (ACGME) program page, resident research requirement, listing of residents' publications, availability of residents' demographic information, program alumni information, board pass rates, attrition rate, detail of educational/academic activities, residents' evaluation methods, diversity, and mentorship. Inter-group analyses between academic and community-based programs were performed using Pearson's Chi-squared test. RESULTS: Academic and community-based general surgery residency program websites were compared based on twelve (12) different parameters. Statistically significant differences were observed for eight of these comparisons: direct website access from ACGME (p = 0.007), research highlighted (p < 0.001), resident research requirement (p = 0.002), resident demographic information available (p=0.004), alumni information (p = 0.005), resident evaluation methods (p = 0.016), diversity (p < 0.001), and mentorship (p = 0.012). Across these domains, academic programs had more information available on their websites than the community programs did. The program websites did not differ significantly based on the frequency of mentioning resident publications, board pass rate, attrition rate, or resident education. CONCLUSION: Many general surgery programs are lacking detailed information on their websites. The amount of website information available on general surgery residency programs differs when comparing academic and community-based programs.

USMLE Step 1 Is Pass/Fail - Should the ABSITE Follow Suit?

The United States Medical Licensing Examination (USMLE) Step 1 was recently made pass/fail. This decision was controversial largely because of the reliance on USMLE Step 1 scores in resident selection. However, these scores do not correlate with resident ability. In this manuscript, we consider if the American Board of Surgery In-Training Examination (ABSITE) should be pass/fail as well. The ABSITE has been used for "high-stakes" purposes, such as preliminary resident advancement and prospective fellow evaluation, for which it was not intended. Moreover, similar to the USMLE Step 1 exam, ABSITE scores have demonstrated no correlation with clinical ability. A pass/fail ABSITE would return the exam to its original purpose and minimize an over-reliance on scores. Moving forward, new objective measures will need to be developed to assess surgical trainees in a more holistic manner.

The Rise of Minimally Invasive Surgery: 16 Year Analysis of the Progressive Replacement of Open Surgery with Laparoscopy.

OBJECTIVE: The expansion of Minimally Invasive Surgery (MIS) has been exponential since the introduction of laparoscopic surgery in the late 1980s. This shift in operative technique has led many to believe that surgery residents are not developing the skills needed to adequately perform open operations. METHODS: We performed a retrospective review of the Accreditation Council for Graduating Medical Education national operative case log database of general surgery residents from January 2003 to December 2019. We compared the open vs. laparoscopic case numbers for six different operations, including cholecystectomy, appendectomy, inguinal hernia repair, colectomy, gastrectomy, and Nissen fundoplication. The Cochran-Armitage test was used to assess the linear trend in the procedures performed. RESULTS: Total average residency case volumes for the procedures studied have increased from 270 to 368 (36%) over the 16-year period with MIS steadily representing a greater proportion of these cases. From 2003 to 2018, MIS representation increased in all studied procedures: cholecystectomy (88% to 94%, p = 0.048), inguinal hernia repair (20% to 47%, p ≤ 0.001), appendectomy (38% to 93%, p ≤ 0.001), colectomy (8% to 43%, p ≤ 0.001), gastrectomy (43% to 84%, p = 0.048), and Nissen (71% to 91%, p = 0.21). CONCLUSION: While the overall operative volume has increased nationally for surgical residents, the representation of open cases has steadily declined since the advent of MIS. The experience needed in open surgery during resident training is still to be determined and may be necessary now that laparoscopy is progressively replacing open operations.