Evolution of Characteristics From Letters of Recommendation in General Surgery Residency Applications.

OBJECTIVE: Letters of recommendation (LOR) describe applicants being considered for Surgery Residencies. Although objective measures have been studied, the descriptive language of LOR and changes over time has yet to be evaluated. The objective of this study was to evaluate the descriptions of autonomy, teamwork, and ACGME core competencies in the LOR of applicants over time. DESIGN: After IRB approval, LOR of residents who matriculated into our Surgery Residency were evaluated. Residents were grouped into early (1973-1999) vs. late (2000-2016) applications, and generational groups (baby boomers: 1943-1960, generation X: 1961-1980, millennial: 1981-1999), to identify the following themes: autonomy, teamwork, ACGME core competencies, and technical skills. Content analysis was performed using Nvivo 11. SETTING: Independent academic medical center. PARTICIPANTS: LOR from 76 of 77 residents who matriculated into our Surgery Residency from 1973-2016. RESULTS: 255 LOR were available. Autonomy was described 175 times in 43 residents, and teamwork was described 263 times in 51 residents. Teamwork was more common in late vs. early applications (82% vs 53%; p = 0.007), and autonomy was present in 53% vs 61% of early vs late applications (p = 0.490). Teamwork was more commonly noted among millennial versus generation X and baby boomer applicants (92% vs 59% vs 47%; p = 0.006). Core competencies were detected 1445 times, with an increase in systems-based practice, and practice-based learning and improvement in early versus late applications (0 vs 16%, p = 0.001; 37% vs 74%, p = 0.025). Professionalism (68% vs 79%) and medical knowledge (74% vs 79%) were described consistently in early and late applications. Technical skills were described in 58% of early and 71% of late applications (p = 0.230). CONCLUSIONS: LOR for surgery residency applicants has evolved over time with increased teamwork concepts. Descriptions of practice-based learning, system-based practice, research, and volunteerism have increased, while professionalism, medical knowledge, and technical skills were consistently described over time.

International Surgery Electives During General Surgery Residency: A 9-Year Experience at an Independent Academic Center.

OBJECTIVE: International experiences are an increasingly emphasized feature of general surgery residency programs. In 2008, an international elective (IE) was implemented for general surgery residents at our institution. This effort was augmented by the establishment of a pathway for formal approval of IEs by the American Board of Surgery and Accreditation Council for Graduate Medical Education in 2012. DESIGN: A retrospective review of Accreditation Council for Graduate Medical Education case logs was completed. IE operative volumes were compared to home institution general surgery service volumes. An electronic survey of IE participants was conducted to assess preresidency goals, prior international exposure, overall experience on IEs, and current or planned engagement with international experiences, volunteerism, or global philanthropy. SETTING: Independent Academic Medical Center. PARTICIPANTS: Fourteen general surgery residents who participated in IEs from 2008 to 2017. RESULTS: IE locations included the Dominican Republic (9), Ecuador (1), Ethiopia (3), and Nicaragua (1). IEs were a first-time international surgical experience for 10 (71%) residents. Nine (64%) reported that they would not or may not have participated in an IE during residency had established opportunities not been available. Ten residents had graduated at the time of this study and 3 of them have participated in international service. Median case volumes were 17 cases per week during IEs compared to 8 cases per week for residents on home institution rotations. Residents were exposed to a variety of first-time operations during IEs including open cholecystectomies, gynecologic procedures, thyroidectomies for goiter, and prostatectomies. CONCLUSIONS: Incorporation of IEs into our general surgery residency has demonstrated numerous benefits. IE participation provides valuable operative experience in both volume and variety, and can be especially impactful for those who may not have elected to pursue such opportunities independently. These experiences have the potential to empower general surgery residents to invest in similar practices and acts of generosity in their future careers.

Enhancing Confidence in Graduating General Surgery Residents: Establishing a Chief Surgery Resident Service at an Independent Academic Medical Center.

OBJECTIVE: Providing opportunities for autonomy to enhance the development of independence and confidence during surgery residency remains among the greatest challenges of the current training paradigm. The objective of this study was to evaluate the implementation and outcomes of a chief resident service (CRS). DESIGN: A CRS was designed with operative, call and office responsibilities. Supervision and evaluation were consistent with institutional guidelines. CRS operative logs from 2011 to 2014 were compared with logs from the participants' first year in practice. Select procedures were compared and evaluations were reviewed. Residency graduates' satisfaction with the CRS was evaluated. SETTING: Independent academic medical center. PARTICIPANTS: Nine general surgery residency graduates with one complete year in practice. RESULTS: Nine residents completed CRS rotations and submitted case logs. Median total case volume was 1101 (994-1311) during the 5-year residency, 92 (20-149) during CRS and 299 (99-784) during the first year in practice. Median case volumes for selected procedures for the entire 5-year residency, CRS, and first year of practice were: 93 (66-97), 7 (3-16), and 9 (1-26) laparoscopic appendectomies; 146 (120-157), 24 (3-32), and 34 (15-112) laparoscopic cholecystectomies; 81 (51-94), 1 (1-4), and 3 (0-8) ileocolectomies; 57 (35-86), 4 (0-9), and 8 (2-34) ventral/incisional hernia repairs; 102 (87-137), 12 (3-16), and 13 (3-86) inguinal hernia repairs. Graduates reported that the CRS experience was very beneficial to their current practice. Annual program reviews emphasized the CRS as a major strength of our residency. CONCLUSIONS: Creation of a CRS to increase resident autonomy and provide continuity of patient care with appropriate faculty supervision was successful. Case mix and volumes provided an opportunity for independent operative and clinical experience during residency which realistically paralleled graduates' first year of practice.

A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment.

OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

"Same as it ever was"--only different: a successful ACGME innovative project to equip PGY I residents to take at-home call.

OBJECTIVE: Establish a competency-based system for advancement of postgraduate year (PGY) I residents to take at-home call, with indirect and direct supervision available. DESIGN: Application of an innovative project approved by the ACGME to equip PGY I residents to take at-home call was successful. Formal education of PGY I residents with a variety of modalities included the successful completion of the Fundamentals of Surgery Curriculum and a structured 12-week curriculum, which focused on medical knowledge, patient care, systems-based practice, and skills lab scenarios. Residents were responsible for inpatient care during the day with direct supervision. Patient care logs (PCLs) were maintained by the resident for patient encounters. The PGY I residents were evaluated with faculty and senior resident review of the PCLs, a written examination, nurse mock pages, and oral proficiency examinations. The decision to permit the resident to take at-home call was determined by the Clinical Competency Committee (CCC). SETTING: Independent academic medical center with 3 categorical surgical residents per year. PARTICIPANTS: Categorical PGY I surgery residents from 2013 to 2014. RESULTS: Residents completed the structured program and successfully passed the oral and written examinations. The CCC determined that the residents were able to take at-home call starting in October of the PGY I year. The number and type of patients were monitored with specified limitations and ongoing maintenance and review of PCLs. A formal backup system, with senior resident and faculty availability by phone or physical presence, was used. CONCLUSION: We present an Accreditation Council for Graduate Medical Education-approved innovative project, which appears to have been successful in implementing at-home call for PGY I residents. This enables the progressive development of PGY I residents and assists our CCC in the development of competency-based milestones for advancement. The effect of this project is significant for those residency programs where incorporation of at-home call is possible.

A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency.

OBJECTIVE: To outline a structured approach for general surgery resident integration into institutional quality improvement and patient safety education and development. DESIGN: A strategic plan to address Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described. SETTING: Gundersen Lutheran Medical Foundation is an independent academic medical center graduating three categorical residents per year within an integrated multi-specialty health system serving 19 counties over 3 states. RESULTS: The quality improvement and patient safety education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings. CONCLUSIONS: Structured education regarding and participation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data.

Factors correlated with surgery resident choice to practice general surgery in a rural area.

OBJECTIVE: General surgery workforce shortages in the rural United States are likely to worsen over the next decade. We sought to identify reasons that general surgery residency graduates choose rural versus urban practice. DESIGN: Questionnaires were sent to 1994 through 2008 graduates of all 4 Wisconsin surgery residency programs (2 university and 2 community). The 51-item questionnaire was designed to evaluate residency graduates' background, interests, and factors influencing their choice of practice type and location. Graduates were divided into 2 groups based upon the size of the communities in which they currently practice: rural (<50,000) or urban (>or=50,000). Data were analyzed using chi(2) tests; level of confidence was defined as p < 0.05. RESULTS: Forty-five percent (98/216) of surveys were completed. Factors associated with rural practice included attending a nonurban high school (p = 0.001) or college (p = 0.001), having a spouse/partner who grew up in a nonurban area (p = 0.022), and interest in hunting birds (p = 0.010) or large game (p = 0.001). Those choosing rural practice were more likely than their urban counterparts to have completed a rural clerkship during medical school (79% vs. 37%, p = 0.001). They were also more likely to have chosen a surgical residency program committed to rural training (p = 0.046). Graduates in rural practice more often cited "broad scope of practice" as an important reason for their decision. Both rural and urban surgeons reported similar rates of medical student teaching but urban surgeons were more likely to teach surgical residents (p = 0.001) and to have completed fellowship training (p = 0.001). CONCLUSIONS: General surgery residency graduates and their spouses who choose rural practices are more likely than those selecting urban practices to have rural backgrounds and interests. Completing a rural clerkship during medical school and choosing a residency program committed to rural general surgery preparation are strongly correlated with rural practice. These findings may help formulate strategies to increase recruitment and retention of rural general surgeons.

Advanced laparoscopic fellowship and general surgery residency can coexist without detracting from surgical resident operative experience.

OBJECTIVE: Concern has been voiced that general surgery residents who train at institutions that also offer advanced laparoscopic fellowships may receive inadequate advanced laparoscopic operative experience. The purpose of our study was to compare the operative experience of general surgery residents who graduated from our institution before initiation of an advanced laparoscopic fellowship with the experience of those who graduated after the fellowship began. METHODS: Operative case logs of surgery residents who graduated from 2000 through 2007 and of advanced laparoscopic fellows from 2004 through 2007 were reviewed. Surgery resident experience with basic and nonbariatric advanced laparoscopic cases during the 4 years before the fellowship was compared with the experience during the 4 years after the fellowship began. RESULTS: Residents who graduated before 2004 performed a mean of 140.5 +/- 19.4 basic and 77.0 +/- 17.8 advanced laparoscopic cases during their 5-year residency, compared with 193.3 +/- 34.5 basic (p = 0.003) and 113.3 +/- 23.5 advanced cases (p = 0.005) performed by those who graduated in 2004 or later. The number of nonbariatric advanced laparoscopic cases performed by each graduating surgical resident during the chief year ranged from 26 to 47 cases from 2000 to 2003 and from 36 to 69 cases from 2004 to 2007. Fellows reported from 40 to 85 nonbariatric advanced laparoscopic cases annually. CONCLUSIONS: General surgery residents did not experience a reduction in the total number of basic and nonbariatric advanced laparoscopic cases with the addition of an advanced laparoscopic fellowship, nor did they perform fewer cases during the chief year. As the result of a cooperative venture between the surgery residency and fellowship directors as well as an expansion of the total number of laparoscopic cases performed at our institution because of changes in clinical practice, surgery residents reported an increase in the number of laparoscopic cases while a successful fellowship was established.