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ObjectiveThis study aimed to determine the post-matriculation perceptions of interns and faculty who participated in the 2020-2021 virtual interview process and how their expectations of the program and the applicants, respectively, aligned with reality.Design, setting, and participantsPublished surveys on virtual interviewing were reviewed and modified to design two surveys, for interns and for faculty who interviewed. Interns and faculty members from the Departments of Surgery and Medicine at one institution who participated in the 2020-2021 virtual interview process completed the surveys four to six months after the start of the academic year. Following survey completion, surgical interns from the same application cycle participated in one in-person focus group nine months after the start of the academic year to clarify points raised in the surveys.ResultsForty-six interns and faculty members responded to the survey (subgroup response rates ranging from 13-30%) and ten interns participated in the focus group (participation rate 100%). Most faculty and intern participants found that expectations formed during virtual interviews were accurate. However, our respondents noted limitations to virtual interviews that reduced their usefulness, including challenges with unnatural social interactions, understanding city fit, and getting a sense of resident and program culture. Participants provided possible solutions to address these challenges.ConclusionsOverall, this mixed-methods study at a single institution found that perceptions from virtual interviews were generally accurate but with some limitations. We describe several opportunities to improve the virtual interview process and optimize the application experience.

ObjectiveWorkplace-based assessments (WBAs) are used in multiple surgical specialties to facilitate feedback to residents as a form of formative assessment. The validity evidence to support this purpose is limited and has yet to include investigations of how users interpret the assessment and make rating decisions (response processes). This study aimed to explore the validity evidence based on response processes for a WBA in surgery.DesignSemi-structured interviews explored the reasonings and strategies used when answering questions in a surgical WBA, the System for Improving and Measuring Procedural Learning (SIMPL). Interview questions probed the interpretation of the three assessment questions and their respective answer categories (level of autonomy, operative performance, case complexity). Researchers analyzed transcripts using directed qualitative content analysis to generate themes.SettingSingle tertiary academic medical center.ParticipantsEight residents and 13 faculty within the Department of Otolaryngology-Head and Neck Surgery participating in a 6-month pilot of SIMPL.ResultsWe identified four overarching themes that that characterized faculty and resident response processes while completing SIMPL: (1) Faculty and resident users had similar content-level interpretations of the questions and corresponding answer choices; (2) Users employed a variety of cognitive, behavioral, and emotional processes to make rating decisions; (3) Contextual factors influenced ratings; and (4) Tensions during interpretation contributed to rating uncertainty.ConclusionsResponse processes are a key source of evidence to support the validity for the formative use of WBAs. Evaluating response process evidence should go beyond basic content-level analysis as contextual factors and tensions that arise during interpretation also play a large role in rating decisions. Additional work and a continued critical lens are needed to ensure that WBAs can truly meet the needs for formative assessment.

ObjectiveThe COVID-19 pandemic provided an opportunity for surgical residency programs to rethink their methods of evaluating and recruiting candidates. However, the past year has not been seamless, with a soaring number of applications, reports of programs and applicants having difficulty evaluating each other, and an increasingly uneven distribution of interviews among applicants. Consequently, many have called for national changes to the residency application process to address these longstanding concerns.ResultsHere, we review the evolving literature and advocate for the permanent adoption of visiting rotations, virtual interviews with a universal release date and data-driven attendance limits, and opportunities for in-person applicant visits.ConclusionsWe believe these changes leverage the strengths of each format, allow for satisfactory bidirectional evaluation, and promote principles of justice, equity, diversity, and inclusion.

ObjectiveTo explore the use of electronic health record (EHR) data to estimate surgery resident duty hours and monitor real time workload.DesignRetrospective analysis of resident duty hours logged using a voluntary global positioning system (GPS)-based smartphone application compared to duty hour estimates by an EHR-based algorithm. The algorithm estimated duty hours using EHR activity data and operating room logs. A dashboard was developed through Plan-Do-Study-Act cycles for real-time monitoring of workload.SettingSingle tertiary/quaternary medical center general surgery residency program with approximately 90 categorical, preliminary, and integrated residents at eight clinical sites.ParticipantsCategorical, preliminary, and integrated surgery residents of all clinical years who volunteered to pilot a GPS application to track duty hours.ResultsOf 2,623 work periods by 59 residents were logged with both methods. EHR-estimated work periods started later than GPS logs (median 0.3 hours, interquartile range [IQR] -0.1 - 0.3); EHR-estimated work periods ended earlier than GPS logs (median 0.1 hours, IQR -0.7 - 0.3); and EHR-estimated duty hour totals were less than totals logged by GPS (median -0.3 hours, IQR -0.8 - +0.1). Overall correlation between weekly duty hours logged by EHR and GPS was 0.79. Correlations between the 2 systems stratified from PGY-1 through PGY-5 were 0.76, 0.64, 0.82, 0.87, and 0.83, respectively. The algorithm identified six 80-hour workweek violations (averaged over 4 weeks), while GPS logs identified 8. EHR-based duty hours and operational data were integrated into a dashboard to enable real time monitoring of resident workloads.ConclusionsEHR-based estimation of surgical resident duty hours has good correlation with GPS-based assessment of duty hours and identifies most workweek duty hour violations. This approach allows for dynamic workload monitoring and may be combined with operational data to anticipate and prevent duty hour violations, thereby optimizing learning.

The 2020-2021 General Surgery Residency Match presents unique challenges in the setting of the COVID-19 pandemic and highlights pre-existing concerns. In order to move toward an equitable and manageable surgical residency application process for both programs and applicants, systemic change is warranted.

ObjectiveThe COVID-19 pandemic has disrupted graduate medical education, impacting Accreditation Council for Graduate Medical Education (ACGME)-mandated didactics. We aimed to study the utility of 2 methods of virtual learning: the daily National Surgery Resident Lecture Series (NSRLS), and weekly "SCORE School" educational webinars designed around the Surgical Council on Resident Education (SCORE) curriculum.Design and settingNSRLS: The National Surgery Resident Lecture Series was a daily virtual educational session initially led by faculty at an individual surgical residency program. Thirty-eight lectures were assessed for number of live viewings (March 23, 2020-May 15, 2020).Score schoolAttendance at eleven weekly SCORE educational webinars was characterized into live and asynchronous viewings (May 13, 2020-August 5, 2020). Each 1-hour live webinar was produced by SCORE on a Wednesday evening and featured nationally recognized surgeon educators using an online platform that allowed for audience interaction.ResultsNSRLS: There were a mean of 71 live viewers per NSRLS session (range 19-118). Participation began to decline in the final 2 weeks as elective case volumes increased, but sessions remained well-attended.Score schoolThere were a range of 164-3889 live viewers per SCORE School session. Sessions have most commonly been viewed asynchronously (89.8% of viewings). Live viewership decreased as the academic year ended and then rebounded with the start of the new academic year (range 4.9%-27%). Overall, the eight webinars were viewed 11,135 times. Each webinar continues to be viewed a mean of 43 times a day (range 0-102). Overall, the eleven webinars have been viewed a total of 22,722 times.ConclusionsVirtual didactics aimed at surgical residents are feasible, well-attended (both live and recorded), and have high levels of viewer engagement. We have observed that careful coordination of timing and topics is ideal. The ability for asynchronous viewing is particularly important for attendance. As the COVID-19 pandemic continues to disrupt healthcare systems, training programs must continue to adapt to education via virtual platforms.

BackgroundMany residents become parents during residency and the adequacy of parental leave is integrally related to resident wellness.ObjectiveTo understand current parental leave policies in ophthalmology residency programs and program director perceptions of the impact of parental leave on trainees.DesignCross-sectional study.SettingMulticenter among all U.S. ophthalmology residency programs.ParticipantsOphthalmology residency program directors during the 2017 to 2018 academic year.ResultsSixty-eight percent (82/120) program directors participated in this study. The majority of programs had written maternity leave policies (89%) and partner leave policies (72%). The typical duration of maternity leave taken ranged from 4 to 6 weeks while typical partner leave duration taken ranged from 1 day to 2 weeks. Residents who take leave may need to extend training at 72% of programs. Program directors perceived that parental leave negatively impacts resident scholarly activities and surgical skills and volume. Male program directors, relative to female program directors, perceived that becoming a childbearing parent negatively impacts resident dedication to patient care. Program directors raised concerns including local support and policy, extension of residency, impact on residents, impact on programs, consistency and fairness, and desire for national policy change.ConclusionsParental leave practices vary significantly among ophthalmology training programs with residents typically taking less leave than permitted. Program directors are challenged to accommodate parental leave while balancing resident training and wellness for all trainees in their program.

ObjectiveThe COVID-19 pandemic has drastically transformed the healthcare community and medical education across the United States. The aim of this study was to evaluate the impact of COVID-19 on the surgical resident training experience, assess possible sources of stress or anxiety among surgery residents, and examine how patterns of anxiety vary by resident rank.DesignWe developed and disseminated a survey, which included the Generalized Anxiety Disorder 7-Item Scale (GAD-7), to all general and integrated plastic surgery residents in their clinical years of training at the University of California, San Francisco. Statistical analysis of the survey responses was performed using the Kruskal-Wallis or Wilcoxon rank sum test. Post-hoc analysis was performed using the Bonferroni-corrected Dunn test. Survey data were combined with aggregated duty hour information and operative case numbers from select hospitals for March and April of 2019 (historical baseline) and 2020.ResultsThe overall survey response rate was 73.7% (n = 73). With an estimated operative volume reduction of 63.3% for general surgery cases, over 90% of residents expressed concern about the decline in operative exposure. While the senior residents tended to work more shifts, they were not more likely to have higher risk perception scores for contracting COVID-19 nor higher anxiety levels about the possibility of contracting COVID-19. They were, however, significantly more likely to have high GAD-7 scores (≥ 10) when compared to interns (z = -2.82, p-adj = 0.014). Overall, residents were more concerned about the general health of loved ones than about their own risk of contracting COVID-19 (U = 3897.5, p < 0.01).ConclusionsWhile the work-related experiences of residents varied across a number of factors during the pandemic, residents tended to report similar sources of anxiety. Moving forward, surgical residency training programs will need to develop ways to optimize available surgical experiences and address the unique resident anxieties that an infectious pandemic presents.

ObjectiveTo determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training.DesignQualitative thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019.SettingAn urban, academic, multihospital general surgery residency program with a robust robotic surgery program.ParticipantsConvenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews.ResultsResidents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings' trust in the residents' console skills was a major determining factor in allowing residents on the console.ConclusionsMost robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.

ObjectiveTo determine if three-dimensional (3D) printed models can be used to improve acetabular fracture pattern recognition and be a valuable adjunct in orthopedic resident education.DesignFifteen randomized testing stations with each containing plain radiographs (XRs), two-dimensional computed tomography (CT) scans, or 3D model of an acetabular fracture.SettingTwo orthopedic residency programs based at Level 1 trauma centers.ParticipantsForty-one orthopedic residents, PGY 1-5.ResultsSenior residents were superior to junior residents at correctly identifying the provided acetabular fracture pattern. Overall, use of CT scans or the 3D model improved fracture classification as compared to standard XRs, but there was no significant difference between use of the CT scans and 3D models. Subjective survey results indicated agreement among residents that 3D models were accurate representations of acetabular fractures and that models would be a desired educational modality.Conclusions3D models improved the accuracy of acetabular fracture identification compared to XR. In addition, trainees were able to use 3D models to obtain similar accuracy compared to CT scans despite not having previous exposure to the models. Interobserver agreement improved when comparing CT to 3D, but did not provide greater than a fair agreement indicating that fracture patterns were difficult to accurately classify even with the use of 3D models. Residents' subjective responses indicated a positive experience with the use of 3D models. We conclude that the incorporation of 3D models could be an important adjunct to orthopedic residency education for the evaluation complex fracture patterns, but is not significantly superior to identification with CT scans.

Objective: Resident-Applicant Buddy Programs (RABPs) are a new initiative designed to improve resident recruitment. This study aims to evaluate the impact and perceived value of RABPs and to identify areas for improvement for future recruitment cycles., Design: Anonymous online survey study of RABP participants with mixed-methods approach to evaluate participants' experience and perceived impact of the program. The survey queried demographics, Likert responses, and open-ended responses. Qualitative thematic analysis of open-ended responses was performed with inductive coding in an iterative fashion by 2 raters., Setting: This study was conducted at a general surgery residency program at a tertiary academic institution during 2022-2023 recruitment cycle., Participants: Of 125 RABP participants (n = 39 residents and n = 86 interviewed applicants), surveys from n = 45 participants (n = 19 residents, 66%; n = 26 applicants, 30%) were completed and analyzed., Results: Applicants were predominantly female (65%) and first-generation physicians (69%). Buddy pairings were 65% gender concordant and 48% race/ethnicity concordant. Many applicants (60%) participated in RABPs at other institutions. Buddies connected for a mean (SD) of 52 (28) minutes. Majority of applicants agreed the program decreased stress/apprehension about interviewing (70%, 4.0 [1.1]), helped understand resident life at the program (91%, 4.3 [1.0]), and increased desire to match in the program (65%, 4.0 [1.1]). Residents agreed they enjoyed participation (89%, 4.5 [0.7]), the program should be continued (100%, 4.8 [0.4]), and desired to participate again (100%, 4.8 [0.4]). Thematic analysis revealed applicants valued the program as an approachable source of information, illumination of program culture, aid in interview preparation, and connection between applicant and program. Applicants appreciated the intentionality of the program to create a RABP., Conclusions: RABP decreased applicants' stress, improved understanding of resident life, and for the majority, increased desire to match at the program. Resident engagement and desire for ongoing participation in the RABP was high. Overall, RABPs can increase applicant interest and program transparency., (Published by Elsevier Inc.)

Objective: To improve the well-being and sense of community of surgical trainees., Design: Residents were invited to participate in confidential discussion groups during protected education time to have a safe space to support each other through common struggles. The groups were facilitated by licensed mental health professionals with experience working with medical trainees. An anonymous voluntary wellness survey and a qualitative feedback survey were used to understand residents' experience participating in these discussion groups., Setting: Single large academic institution., Participants: General surgery and obstetrics and gynecology residents., Results: 677 resident responses to the wellness survey were collected between 2020 and 2023. Compared to residents who participated in < 5 discussion group sessions, residents participating in ≥ 5 sessions reported improved self-perception of their own competency and capability (p = 0.012), and in their ability to contribute to others' well-being (p = 0.045). They also reported considering more of their co-residents as friends (p = 0.002), increased willingness to discuss personal problems with their co-residents (p < 0.001), and were more likely to report recently working with peers to solve a common problem (p = 0.041). In a second qualitative survey (n = 53), resident feedback revealed an appreciation for the opportunity to discuss shared experiences, creating community, having a safe space and dedicated time for introspection, and receiving input from a therapist. Opportunities for improvement included providing more structure to the discussion, increasing the frequency of group meetings, and focusing on developing coping skills., Conclusion: Therapist-facilitated discussion groups can improve aspects of trainees' mental well-being and help foster relatedness, community, and shared problem solving with peers. Residency programs should consider incorporating similar programs into their wellness initiatives., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the design, implementation, and evaluation of a two-week rotation intended to enhance junior surgical residents' preparation for their dedicated professional development time (PDT) and academic careers., Design: As part of a multifaceted effort to promote residents' academic development, we designed a two-week, nonclinical "Academic Development Block" (ADB) rotation for postgraduate year (PGY)-2 and -3 residents. During this rotation, residents meet with clinical, research, and peer mentors and work on academic activities, with relevant deliverables specific to each class year. We analyzed feedback from postrotation surveys and interviews, which were inductively coded and thematically analyzed, and data on resident grant applications and earnings before and after implementation., Setting: The general surgery residency program at a major urban, university-affiliated academic medical center. ADBs were first implemented in 2021., Participants: A total of 39 PGY-2 and PGY-3 residents rotated through the program with 51 ADBs over the first two years of implementation., Results: Surveys indicated overwhelmingly positive perceptions on the value of ADBs, including the amount of structure and resources available. Free-response and interview themes indicated appreciation for time to meet with mentors, develop ideas, and complete academic work. Residents believed the ADB rotation accelerated their transition into PDT and was a marker of institutional commitment. Areas for improvement pertained to the timing of ADBs and pairing of mentors. Both cohorts who participated in at least 1 ADB had higher proportions of residents who successfully applied for grants and a greater amount of total funding awarded compared to all 4 of the most recent cohorts prior to implementation., Conclusions: A short academic development rotation protected from clinical responsibilities is a well-regarded intervention to help residents refine their career goals and prepare for their PDT. Similar initiatives may be of interest to residency programs seeking to foster their residents' academic career development., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: In response to Covid-19, the Association of American Medical Colleges (AAMC) recommended for residency interviews to take place virtually. Benefits of virtual interviews include substantial cost saving and scheduling flexibility. However, it is more difficult to understand program culture and there is concern that more emphasis will be placed on board examination scores and class rank. Programs are split in their decision to keep virtual interviews in the future. This study aims to provide more clarification on students' perspectives and explore the role of an optional second look day to bridge the gap left by the lack of in-person interaction., Design: This cross-sectional study surveyed applicants at our general surgery residency program during the 2022 to 2023 cycle. An optional second look day event was held after submission of the program's rank list. The first survey was sent to all applicants who interviewed with the residency program and asked to pick an interview style that they favored (in person vs virtual) and then asked to rate factors that impacted their decision. It also asked if an optional second look day event was made available, what factors would applicants consider to be important in their decision to attend. The second survey was sent to applicants who attended second look day and asked applicants to state importance of factors that led to their decision to attend., Results: About 50/110 completed the first survey. Applicants preferred virtual over in-person interviews (52% vs 28%). Those who chose virtual selected factors of time commitment and financial burden to be very important compared to those who chose in-person. Applicants who preferred in-person interviews placed most importance on avoiding technical issues and having personal interactions such as: with attending surgeons, with residents, assessment of program culture, visiting facilities, and visiting the town. Applicants were asked to pick important factors if they were to attend an optional second look day after their virtual interview. The following factors were chosen as very important: time commitment, financial burden, interaction with program leadership, interaction with attending surgeons, interaction with residents, visiting facilities, and visiting the town. We then held a second look event after the submission of our rank list. 34/110 attended and 17 complete the survey. Cost and time commitment were not as important to this group who actually attended; they chose in-person interactions with leadership and residents and assessing the program culture to be most important., Conclusion: This study aimed to determine the best interview method based on student perceptions. We also piloted an optional second look day to determine whether or not it fills the gaps left by the suspension of in-person interviews. We recommend continuing with virtual interviews as this is what applicants prefer. It alleviates the financial burden of travel and allows for better time management. However, the significance of in-person interactions cannot be ignored. We propose that second look days should be incorporated after submission of the program's rank list to allow applicants the opportunity for in-person interactions, exploration of the town, and enhance their overall interviewing experience., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Night float rotations are associated with decreased feedback, educational conference attendance, and operative time. Interns are also more isolated and spend less time on teams. We therefore developed a novel post night shift initiative to address these shortcomings and examined its impact on the educational experience and sense of belonging among interns., Methods: A program of weekly senior resident-led post night shift sessions was instituted at a university-based general surgery residency program for the first quarter of the academic year. Four interns and one senior resident participated in each session. Feedback surveys were administered. A previously validated Belonging in Surgery survey was also administered to all general surgery interns at the end of the quarter., Results: Eleven interns had night float rotations within the first 3 months of the academic year. The intern feedback survey response rate was 93% (10/11). All intern respondents attended at least 3 sessions. Interns felt that the sessions increased familiarity with each other (85%) and senior residents (92%), improved clinical decision making (77%), and provided a safe space for discussion (69%). The senior resident survey response rate was 86% (n = 14). All senior residents enjoyed teaching the sessions and felt that they improved their familiarity with interns. The intern belonging survey response rate was 84% (16/19). Categorical interns had significantly higher belonging scores than preliminary interns at the end of the first quarter (mean 48.1 vs 41.6, p = 0.009). There was a trend toward decreased belonging scores for interns who had night float rotations early in the year which did not meet statistical significance (42.9 vs 47.4, p = 0.059)., Conclusion: This novel program improved intern decision-making, familiarity with other residents, and comfort calling senior residents for assistance overnight. There was no statistically significant difference in belonging between interns who started residency on night float versus those who did not. Similar programs may help address concerns regarding missed learning opportunities and decreased sense of community during these rotations., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The American Board of Surgery In-Training Examination (ABSITE) is an important factor in general surgery resident career development. The use of practice question banks for ABSITE preparation improves exam scores and completing more practice questions results in higher scores. The objective of this study is to describe the design of a novel, team-based ABSITE competition implemented into our residency program and analyze its effect on exam performance., Design: For the 2023 to 2024 academic year (AY), residents were randomly sorted into teams. The number of TrueLearn (TL) practice questions completed by each team during the 6-month period preceding the 2024 ABSITE was monitored at regular intervals. Paired sample t-test was used to compare total questions completed and ABSITE percent scores from the prior AY. Simple linear regression was performed to determine if total completed questions predicted ABSITE percent scores, and if the change in total completed questions predicted a change in ABSITE percent scores for unique residents., Setting: University-affiliated general surgery residency program., Participants: 34 clinical and research general surgery residents., Results: Mean total TL questions completed per resident increased by 175.2, with a difference trending toward statistical significance (1037.9 ± 583.6 vs 1213.1 ± 596.0, p = 0.08). Mean ABSITE percent scores significantly increased by 4.6% (68.2 ± 8.7 vs 72.8 ± 5.7, p < 0.001). Total completed questions positively correlated with ABSITE percent scores (R 2  = 0.21, F (1,66) = 17.04, p < 0.001). Among individual residents, completing more questions than the prior AY predicted improvement in ABSITE percent scores (R 2 =.18, F (1,32) = 7.02, p = 0.01). Our model predicts that by completing 300 additional practice questions (e.g. 10 more questions/day for 1 month) a resident's ABSITE percent score will increase by 4.8 percentage points., Conclusion: Implementation of a team-based ABSITE competition is a straightforward and effective intervention that increases general surgery resident question bank utilization and significantly improves ABSITE percent scores., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Effective communication about serious illness is pivotal in delivering surgical palliative care-a crucial component of comprehensive surgical critical care (SCC). However, limited educational strategies exist for fellow-level trainees, who are often directing clinical decision-making and building mutual trust with patients and families. This pilot study assess implications of a novel serious illness communication training opportunity tailored specifically for SCC fellows., Design: Prospective implementation of a multimodal training session (1 hour-didactic lecture, 2 hours-live-action simulation), using pre- and postcourse surveys to assess self-perceived confidence., Setting: University of Michigan in Ann Arbor, Michigan., Participants: Eleven ACGME-accredited SCC fellows during the 2023 to 2024 academic year participated and completed all 3 survey assessments., Results: Following the course, 6 of 7 confidence domains showed improvement, with 2 reaching statistical significance-communication skills to discuss goals of care and/or code status (3.73 vs. 4.36, p = 0.018) and end-of-life care or transition to comfort-focused care (3.36 vs. 4.18, p = 0.023) with a patient or family member. At 6-month follow up, fellows reported further increases in all queried domains, though changes were nonsignificant. Greatest absolute increases were noted in delivering serious news (4.18 vs. 4.55, p = 0.143) and expressing nonverbal empathy (4.09 vs. 4.50, p = 0.197). The majority (91%) of respondents felt more comfortable having serious illness conversations with patients and families due to their training course experience., Conclusion: Implementation of a 3-hour training course tailored for SCC fellows significantly boosted both the immediate and long-term confidence in their serious illness communication skills and ability to manage complex care scenarios., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Step 1 has historically been a major criterion to evaluate students for residency match. With Step 1 now being pass/fail (P/F), students are uncertain how to distinguish their applications. We aim to understand student's opinions surrounding the scoring change as this is the first class of students applying to residency in the P/F era., Materials and Methods: An electronic survey was sent to 3rd and 4th year American medical students., Results: Of the 255 students surveyed, 61.6% prefer Step 1 in the P/F format. Students applying for highly competitive specialties (HCS) preferred numerical scoring (55.6%). On a 5-point Likert scale, students entering HCS believed more strongly that they would have a better chance at matching if Step 1 was graded numerically (3.47 vs 2.71) and creates an unfair advantage for those who can afford to pursue a research year (3.46 vs 2.95). Students entering HCS felt finances played a significant role in whether they took a research year and felt added pressure to engage in research. Respondents believe that students from prestigious medical schools, well-connected students, and MD students will benefit most., Conclusions: While students mostly prefer P/F scoring, there were differences of opinion between those going into HCS and LCS. Students indicated that those who have financial means are at a distinct advantage as they can afford to utilize a research year to distinguish their applications. Future efforts should be made to address student concerns and unintended consequences of the scoring change to create an equitable system., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The study is intended to show that the operative quality of a resident in orthopedic trauma surgery is comparable to that of a senior physician in the most common orthopaedic trauma surgeries (Plate osteosynthesis in ankle fractures and distal radius fractures, ESIN in pediatric forearm fractures, implantation of a proximal femoral nail in pertrochanteric femur fractures and hemiarthroplasty in femoral neck fractures) with appropriate supervision by a senior physician. With only minimal deviations in the operating time, which is becoming increasingly relevant in everyday clinical practice, surgical training of residents could be supported., Material and Methods: 200 patients of the above-mentioned fracture patterns each, who were treated surgically between January 1, 2016 and December 31, 2020, were detected and categorized. In particular, a qualitative characteristic was determined for each fracture on the basis of the standard pre and postoperative X-rays taken during surgery and statistically evaluated with the surgery time, the fracture classification and the training status of the anonymized surgeon. Anonymized x-rays were evaluated by 2 senior physicians and 2 residents., Results: Operations were performed by residents in 33.5 % of the cases (ankle fractures 42.0%; distal radius fractures 30.5%; pediatric forearm fractures 30.5%; pertrochanteric femur fractures 50.5%; femoral neck fractures 14.0%). Surgical complication rate was 4.8% in the resident group and 9.0% in the attending surgeon group. Revision surgeries were performed in 2.1% of resident cases, and in 4.1% of attending surgeon cases. In the resident group, time of surgery was 7.4 min longer for ankle fractures, 4.4 min for distal radius fractures, 2.8 min for forearm fractures, 2.3 min longer in proximal femur fractures 8.2 min longer for femoral neck fractures. No statistically significant difference in radiological outcome was observed in any of the groups after evaluation of the x-rays., Conclusion: This study shows that only slightly more than one third of all mentioned operations are performed by residents, although there is no statistical difference in quality. The operating time is extended on average by only 5 minutes. The surgical complication rate as well as the revision rate is higher in the group of senior physicians, whereby the more complicated fractures were treated by them. Resident involvement in trauma surgery is therefore not associated with increased morbidity or mortality of patients., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the validity evidence supporting the use and interpretation of a multifaceted assessment system in the early years of surgical training., Design: This was a national retrospective cohort study analyzing the validity and reliability of an assessment process for surgical residents over a 2-year period. Data from all elements of the assessment process was evaluated using Messick's unified validity framework. Assessments were categorized as Workplace-based, Structured assessment performed in the academic center and Multiple Mini Interview., Setting: Our Institution is a health sciences university and the body responsible for the training and certification of all surgeons in our national program. Residents on the Core Surgical Training program undergo multiple assessments over the first 2 years of postgraduate training, both in the workplace and the academic training center, which inform their progression into higher surgical training in their chosen specialty., Participants: Data was collected from 2 cohorts of the entire population of postgraduate trainees nationally (N = 114)., Results: Best practice standards for educational testing aligned with the results supporting the use of this assessment process. Findings indicate a robust assessment system, demonstrating validity evidence in content, response process, internal structure, relations to other variables, and consequences. Composite score reliability of the assessment was 0.89 which demonstrates a highly reliable process. Correlation between workplace-based assessments and standardized tests performed in the simulation setting was also very high (0.93)., Conclusions: The Core Training Assessment System (CTAS) provides a psychometrically rigorous system to measure trainee competence during the initial years of training. Residency programs of all sizes can replicate the methods described here to demonstrate the validity of their assessment processes, thereby being able to stand over decisions on surgical competency., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Medical conscientious objection is a federally protected right of physicians to refuse participation in medically indicated services or research activities that are incompatible with their ethical, moral, or religious beliefs. Individual provider objections to gender-affirming surgery have been documented, however the prevalence of such objections is unknown. Our study aimed to characterize physician objections to gender-affirming surgery in plastic surgery and urology residencies and to assess related institutional policies., Design, Setting, Participants: A cross-sectional electronic survey was administered to program leadership of 239 accredited US plastic surgery and urology residencies from February to October 2023. Trainee exposure to gender-affirming surgery, programmatic experience with objections, and presence and content of institutional objection policies were collected. Bivariate analyses were performed to determine associations with objectors., Results: One-hundred and twenty-four plastic surgery (n = 59) and urology (n = 65) residencies completed the survey, representing a 52% response rate. Most programs included didactic training (n = 107, 86%) and direct clinical exposure (n = 98, 79%) to gender-affirming surgery. Few (n = 24, 19%) endorsed existent objection policies. Sixteen programs (13%) experienced objections to gender-affirming surgery by trainees (n = 15), faculty (n = 6), and staff (n = 1). Neither geographic region, exposure to gender-affirming surgery, nor presence of objection policies significantly contributed to programmatic objections. Programs with formal objection policies reported increased confidence in addressing future objection events (p = 0.017)., Conclusions: Objection to gender-affirming surgery is a rare, but plausible occurrence amongst plastic surgery and urology trainees. Residency programs should consider anticipatory policies to protect patients and, when feasible, provide reasonable accommodations for objecting trainees., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The USMLE Step 1 exam, an important metric in the integrated plastic surgery match, transitioned to pass/fail scoring in January 2022. No previous studies have investigated the impact of this new scoring system on the process of ranking applicants in the integrated plastic surgery match., Design: 330 Plastic Surgery Common Applications (PSCAs) were submitted to a single academic center in the 2023-2024 match cycle. Applicants were sorted into tiers via a holistic review process, and quantifiable data, including USMLE Step 1 scores, were then compared between tiers., Setting: Our Institution's Integrated Plastic Surgery Residency Program., Participants: Integrated Plastic Surgery applicants in the 2023-2024 match cycle., Results: 317 of 330 PSCAs were analyzed in this study, excluding applicants who did an elective rotation at our institution. Applicants were sorted into 3 tiers: high (n = 100), middle (n = 118) and low (n = 99), with a significant difference in match rate per tier, respectively (88.0%, 58.5%, 30.3%, p < 0.0001). The majority of USMLE Step 1 scores were reported as pass/fail (186/317, 58.7%). There was a significant difference (p < 0.0001) between the average USMLE Step 1 score between the high (mean 250.5, SD 10.4), middle (mean 241, SD 14.6), and low tiers (mean 235.5, SD 16.5). More applicants in the low tier (50%) and high tier (40%) reported numeric USMLE Step 1 scores than those in the middle tier (35%, p = 0.0734). Stepwise logistic regression revealed USMLE Step 1 score to be an independent predictor of tier placement between the high and middle tier (p = 0.0030) and high and low tier (p = 0.0001). Lastly, 3 applicants reported their USMLE Step 1 score as 'pass' instead of their given numeric score., Conclusions: Comparing applicants with numeric USMLE Step 1 scores to those with pass/fail scores can have a significant impact on the ranking of those applicants and should be carefully considered during the plastic surgery match process., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Assessment is a fundamental part of teaching and learning that provides the basis for making inferences about the development of learners. Inequity in assessment disproportionately impacts underrepresented in medicine learners and can limit their opportunities for achievement., Observations: Unfortunately, inequity in assessment is prevalent in the surgical learning environment due to systemic and individual factors. The Antideficit Achievement framework can be effectively applied to address sources of inequity., Conclusions and Relevance: This paper explores sources of inequity in assessment in the surgical learning environment and illuminates them with a descriptive case study. Recommendations created using the Antideficit Achievement framework provide effective, practical ways to begin to advance equity in assessment in the surgical learning environment., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Over half of junior learners (JL) feel pressure to work independently and report rarely calling their supervisor. It is unclear how JL decide whether or not to call their supervisor. The study aims to identify factors that JL consider when responding to clinical scenarios and deciding whether to call senior residents (SR) and compare them to factors identified by SR., Methods: Fifteen cognitive interviews were conducted with SR and JL. Participants were given 8 to 15 sample pages and probed regarding the factors they considered when triaging the page and deciding whether to inform a SR. De-identified interview transcripts were inductively coded using an interpretative phenomenological analysis (IPA) approach., Setting: Department of Surgery, Faculty of medicine at the University of Ottawa in Canada., Participant: Five general surgery SR and ten JL, which included 5 senior medical students and 5 general surgery junior residents., Results: JL and SR indicated a clear need to call SR when managing high acuity pages, which included hemodynamic instability, decreased level of consciousness, or codes (ie, trauma, cardiac arrest). In the absence of high acuity findings, JL judged whether to call SR based on 10 patient and learner-related factors. Patient-related factors include: 1) time since surgery, 2) patient appearance, 3) patient requires intervention, and 4) lack of improvement after initial independent management attempt. Learner-related factors were categorized into clinical (5-8) and social factors (9-10): 5) nurse's level of concern, 6) familiarity with the patient, 7) gut feeling, 8) prior experience managing this presentation, 9) time of day, and 10) interpersonal dynamic with SR. While SR identified all patient-related and clinical factors, they did not cite the 2 social factors JL considered., Conclusion: When pages lack high-acuity findings, JL consider various patient and learner factors when deciding whether to inform SR. Discussing these factors may help guide new JL regarding when they should call their supervisor. Understanding social factors is important to create a culture that minimizes their influence on JL's decision-making and promotes patient safety., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To characterize Otolaryngology residency program strategies for recruiting underrepresented minorities in medicine (URiM) residents and their perceived effectiveness, and explore perceived barriers to recruitment., Design: We conducted a survey of Otolaryngology program directors (PDs) at the 122 accredited programs within the United States, utilizing a validated and previously published survey utilized within the OB-GYN literature. We solicited information regarding recruitment of underrepresented minorities in medicine (URiM) applicants, effectiveness of strategies, and perceived barriers in recruitment., Setting: A national survey of U.S. accredited residency programs in Otolaryngology in 2022-2023., Results: A total of 42 (34%) PDs responded. 55% of programs reported an increase in URiM residents, of which 18(43%) described an intentional change. Almost all PDs reported placing at least "some" significance in the recruitment of URiM residents (95%). Statistically significant differences were seen in recruitment methods between programs that saw an increase in URiM resident recruitment an those that did not. Additionally, Program Directors believed that increased face-face interaction with applicants were the most effective forms of recruitment. PDs found the biggest challenge to recruitment was a lack of diverse applicants (6.3/10) and faculty (5.8/10). This perception did not change when adjusted for programs that saw an increase in URiM trainee recruitment., Conclusions: This study demonstrates the URiM resident recruitment practices and perceived effectiveness of these strategies within otolaryngology programs nationally. The results and analysis may provide programs who are looking to diversify their workforce with some effective and meaningful strategies to start the process., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We aimed to develop a holistic screening tool for surgical residency application processing to capture the diverse skills and attributes of the applicant, based on characteristics most commonly associated with success in our residency program., Design: We developed an application-scoring rubric with 4 domains based on ACGME Holistic reviewing criteria: academic potential, experiences, personal attributes, and clinical competency. We scored academic potential based on a composite of Step 2 score, MSPE tier rank, surgery clerkship grade, college honors, publications, and presentations. An additional score accounted for personal adversity overcome or "distance travelled". This included previous homelessness, first-generation college student or immigrant status, noted socioeconomic hardship, disability overcome, or other stated personal experience of discrimination including underrepresented in medicine status. We sorted the list of top 200 candidates by adversity score, Step 2 score, academic potential score, and total overall score to compare the groups in terms of interview offers., Setting: We are an academic surgical residency program housed within a private medical college in the Northeast region., Participants: All categorical applicants to our program were managed with our holistic screening approach., Results: There were 29 students with the highest adversity score (AS) of 4 and 26 (90%) were selected to interview based on holistic overall score and reviewer comments. Fourteen students had an AS of 3, and 12 (86%) were selected to interview. Twenty-five students had an AS of 2, and 23 (92%) were selected to interview. If Step 2 score alone had been used to determine which applicants should be interviewed, only 11 students (38%) with an AS of 4 would have been interviewed. If the academic potential alone was used for screening, only 10 (35%) of students with an AS of 4 would have been interviewed. Taking all students with any adversity score into account (n = 70), when screened with only Step 2 scores, just 31(44%) would have been interviewed. When ranked by academic potential score, 35 (50%) would have been interviewed. When applying our holistic overall score alone, 56 (80%) would have been interviewed., Conclusions: Performing a holistic application review and ranking students not only by standardized exam scores, but also considering other history of academic achievement, personal attributes, experiences in leadership or service, and clinical competency can allow for mitigation of implicit bias. Allowance for an adversity score can help programs recognize students who have significantly longer "distance traveled" to make it through medical education and who have the potential to be fantastic residents., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In surgical training, a mentor is a more senior and experienced surgeon who guides a surgical trainee to meet personal, professional, and educational goals. Although mentorship is widely assumed to positively affect surgical residents' professional development, a more nuanced understanding of mentorship's impact is lacking and urgently needed as burnout rates among residents increase. This study aims to summarize the current literature on the effects of mentorship on surgical residents' burnout and well-being., Methods: A comprehensive literature review was performed with key terms related to "surgical resident" and "mentor" using Pubmed, Embase, and ProQuest databases for primary studies published in the United States or Canada from January 1, 2010 to December 9, 2022 that measured outcomes related to burnout and well-being. Multiple reviewers screened titles and abstracts for relevance, then full-text articles for eligibility., Results: Initial search resulted in 1,468 unique articles, and 19 articles were included after review. Only one article was a randomized controlled trial. Twelve studies described a decrease in burnout rates or in outcomes related to burnout. In contrast, 4 studies identified negative outcomes related to burnout. Six studies showed improved well-being or related outcomes. One study was not able to show a change in self-valuation between coached and noncoached residents., Conclusion: High quality mentorship can be associated with improved well-being and decreased burnout in surgical residents, but the key elements of effective and helpful mentorship remain poorly characterized. This summary highlights the importance of making mentorship accessible to surgical residents, and training faculty to be effective mentors., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

The Challenge: A basic science curriculum is foundational to surgical training. However, engagement in, and satisfaction with, standard lectures is notoriously poor and antithetical to adult education principles., The Tool: We developed a worksheet-based delivery system to improve participation and engagement in basic science., Methods: The SCORE curriculum objectives were used to create interactive worksheets that could be filled out in advance and were reviewed as a group during protected education time. All PGY levels in our community-based academically affiliated program participated (19 residents total). The worksheets were created by a resident in her research year and vetted by the attending moderating each session. The same amount of time allotted for our former basic science lectures was used for worksheet review as a group. The frequency of active resident participation was recorded before and after implementing the worksheet-based curriculum. A survey was created to determine resident satisfaction with the curriculum and was sent out before and after the implementation of the new curriculum. Mean resident survey scores with lecture-based and worksheet-based curriculum were compared utilizing paired t-tests., Results: Fourteen residents responded to the survey. With the lecture-based format, active participation was noted 30% of the time or less. With the worksheet-based format, engagement increased to 100% of the time. Additionally, there was a statistically significant increase in the resident opinion of the utility of the sessions, congruence with their learning style, and improvement in knowledge. About 64% of the residents who completed the survey either "always" or "sometimes" completed the worksheets ahead of time and 92% of the residents who completed the worksheets ahead of time felt like it allowed them to increase their engagement in didactics., Conclusions: Engagement is a core tenet of adult education and changing from lectures to worksheets in the delivery of basic science capitalizes on this concept, leading to increased resident satisfaction. This initiative is easily translatable to any type of residency program and can be completed within the currently allotted timeframe for the basic science conference., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To highlight the evolution of surgical morbidity and mortality conferences (MMCs) from the early 20 th century as a means of identifying surgeon error into current practices as identifying hospital-based system factors that contribute to adverse patient events. Further, to elucidate differences in the perception of MMCs between trainees and attending surgeons as well as differences in the structure of MMCs geographically and by institution type., Design: We developed a survey that was distributed to current American College of Surgeon members through Survey Monkey., Setting: Survey-based study., Participants: Current members of the American College of Surgeons, including Board of Governors, surgeons, and trainees., Results: There were a total of 1,396 responses to the survey, 814 (58%) from surgical trainees and 582 (42%) from attending surgeons. Both surgical trainees and attending surgeons noted that the most common day for MMCs was Wednesday and that the most common time for MMCs was before 7:30 AM. Further, most surgical trainees and attending surgeons noted that there was no structured format to their institution's MMCs and that increased attending surgeon engagement would make MMCs more educational. Significant variations in MMCs existed across both geographic region and by institution type., Conclusion: The results from this survey highlight key aspects of MMCs that contribute to their educational value. Staff engagement was noted to be the most educational aspect of MMCs. While geographic and institutional differences will likely persist, efforts should be made to increase staff engagement at MMCs in addition to a more structured approach., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Electronic medical records (EMRs) have streamlined workflows for health care professionals, yet their full potential is not always actualized. Modern EMRs are often capable of generating automated prepopulated inpatient lists, however if these capabilities are not made available to inpatient teams or not designed with the end user in mind, resident physicians may be left to create alternative, manual solutions to ensure reliable and efficient care. The purpose of the current study was to longitudinally compare the impact of both manual and automated inpatient lists on resident education, wellness, and patient safety., Design: Retrospective standardized surveys were administered to resident physicians in the orthopedic surgery department at a level I trauma center over a 3-year period to evaluate the impact of various automated and manual list iterations coinciding with changes to the EMR. Data collected included post graduate year (PGY) status, arrival time to work, daily time spent preparing and updating the list, perceived impact on patient safety, resident workload, education, and sleep. We compared manual versus automated list data with unpaired t-tests and chi-squared tests., Setting: The study was conducted at Brooke Army Medical Center, a level 1 trauma center in San Antonio, Texas. It is an Academic Medical Center and the Department of Defense's largest medical facility., Participants: A total of 71 surveys were collected from 33 orthopedic surgery residents in all levels of training., Results: Intern list prep time in the morning was 27 ± 16 minutes for the automated list (n = 17) vs 72 ± 21 minutes for the manual lists (n = 23) (p < 0.0001). Total time spent by interns updating the list for the entire day was on average 83 minutes for the automated list (n = 17) vs 196 minutes for the manual lists (n = 23) (p < 0.0001). In addition, 86% of interns felt the time spent on the manual list impacted their education, with 96% stating that it directly impacted the amount of time they had to study and 100% agreed that it negatively impacted their sleep (n = 23). Only 48% of interns (n = 23) were satisfied with the performance of the manual lists compared to 94% satisfaction (n = 17) with the automated list. Further, 87% of interns felt the manual list negatively impacted patient care and negatively affected their job satisfaction. In comparison, 59% of interns felt the automated list improved their job satisfaction. Ultimately, for an intern an automated list versus a manual list affords them an extra 106 minutes per day for education, sleep, or other activities. PGY2 residents and above noted similar trends regarding their experience with the lists., Conclusions: The benefits of utilizing automated inpatient lists as determined by our study are improved efficiency in the morning with less preparation and maintenance throughout the day. Additionally, with automated lists there was more perceived time for education and sleep, with improved job satisfaction. Most importantly, respondents felt that automated lists were safer for patient care when compared to manual lists. This should compel further research and efforts into improving automated EMR tracking lists in hospitals. In summary, as compared to the automated electronic medical record inpatient list, manual lists resulted in substantially more preparation time and maintenance throughout the day thereby negatively impacting resident education and quality of life, while raising concerns for patient safety., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical resident schedules are demanding. Despite ACGME requirements that residents be able to attend personal appointments, many residents put off essential health tasks due to work hours. We designed a method for surgical residents to request a "flex" or personal day utilizing an online system for requesting and tracking., Design: Residents were given 5 days to use during 1 academic year. A float rotation was implemented to cover scheduled absences. We conducted an anonymous REDCap survey pre and postimplementation regarding resident ability to attend personal appointments and wellbeing. The results of these surveys were compared using descriptive statistics, t-test, and chi-square testing., Setting: Single large academic training institution., Participants: Sixty general surgery residents., Results: Over 9 months, we scheduled 195 flex days and 91% of residents had used the program. The most common uses were travel, time with family/friends, and attending personal health appointments Postimplementation, of residents who needed an appointment, an increased percentage attended a physician (92% vs. 71%, p 0.02), dental (94% vs. 65%, p < 0.01) or mental health (96% vs. 64%, p < 0.01) appointment. A decreased percentage delayed a necessary appointment due to work hours (45% vs. 19.5%, p 0.01), 94% reported improved schedule control, and 100% believed the program was important for wellbeing. When comparing Mayo Wellbeing Index scores pre and postimplementation there was a decrease in the number of trainees reporting high distress (18.8% vs. 29.3%, p 0.03). Postimplementation, our program noted an 80% decrease in the number of duty hours violations (16 vs. 3 violations) and a 12% increase in compliance with the ACGME survey for ability to attend personal appointments., Conclusion: "Flex" days offer surgical residents improved schedule control and the ability to schedule essential personal appointments. They are feasible, even within large training programs, with significant uptake in our sample., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Traditional options for unmatched applicants in urology include pursuing a research fellowship or completing a preliminary general surgery training year. We aimed to create a novel urology-focused preliminary curriculum., Design: The general surgery program commits three preliminary positions for urology-focused interns. These interns complete six months of urology rotations and six months of general surgery rotations. Additionally, they are paired with a urology faculty member to participate in a longitudinal coaching and mentorship program., Setting: The curriculum is situated within a Department of Surgery, which includes the Division of Urology, at one academic institution., Participants: Eight residents have completed the urology-focused preliminary curriculum in three academic years (2022-2023)., Results: Six residents have obtained categorical urology positions. Four matched via the American Urological Association Urology Match into a post-graduate year 1 (PGY1) position, and two matched outside of a formal matching process into a PGY2 position., Conclusion: This urology-focused preliminary curriculum presents a novel strategy to address the growing number of unmatched applicants in competitive surgical subspecialties such as urology., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Concerns exist about clinical and operative skill decay in surgery residents when they dedicate time away from clinical training to pursue research. However, it remains undetermined how to best prevent these negative impacts. Our study evaluated the perspectives of surgical research residents on interventions to improve their reentry into clinical training., Design, Setting, and Participants: An anonymous web-based survey was distributed between 5/01/2023 and 6/01/2023 to 102 current and former (within the previous 3 years) general surgery research residents from 4 academic medical centers in Boston, MA., Results: Survey response rate was 35.3% (36/102 residents). About 22 of 36 residents (61.1%) felt that their clinical aptitude decreased during the research years, whereas 33 of 36 (91.7%) reported reduced surgical skills. When reflecting on their re-entry to residency, former research residents reported feeling anxious and less confident (3.84/5 on a 1-5 Likert scale) as well as being below the expected level of clinical performance (3.42/5). Most of them (12 of 17; 70.6%) reported that it took up to 6 months, whereas 5 of them (29.4%) up to 12 months to feel at the expected level. When compared to nonmoonlighting residents, those who moonlighted often and operated during moonlighting, denied a decrease in clinical and surgical skills, and reported less anxiety, higher confidence, and a quicker return to the expected level of performance. Interventions proposed for improving their clinical re-entry included individualized development plans for 3 months before returning to clinical training, established curriculum for clinical work throughout the research years, clinical preceptorships throughout the research years, and simulation curriculum throughout the research years., Conclusions: General surgery residents feel that their clinical and surgical skills decreased during the research years, leading to anxiety and lack of confidence when returning to residency. Therefore, comprehensive interventions are needed to improve the reentry of the research residents into clinical training., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Following the transition to virtual interviews in 2021, interviewees began receiving gifts as a recruitment strategy in lieu of the preinterview dinner. This study characterizes quantity, type, and frequency of gift receipt in relation to program perception and ranking., Design: An anonymous survey study was conducted. Variables included demographics, interview modality, gift type, frequency of gift receipt, monetary value, and changes in program perception and ranking. Descriptive analyses and Pearson's chi-square testing were performed., Setting: Single institution with a medium to large general surgery program size., Participants: All general surgery residents at the single institution without exclusion., Results: About 25 residents responded (60% response). Two respondents (8%) participated in both in-person (IPIs) and virtual interviews (VIs). About 72% (n = 18) participated in VIs, 36% (n = 9) IPIs. About 68% matched in 2021 or later. Overall, 76% received a gift during interviews. 100% of IPIs received a gift, while 67% of VIs received a gift. 88.9% of IPIs received a meal. VIs received: meal shared (28.6%), meal not shared (14.3%), food-specific gift card (28.6%), other food items (21.4%), or other (7.1%). About 66.7% of IPIs (n = 6) reported 76% to100% of programs offered a meal, whereas no VIs reported 76% to 100% of programs offering (p = 0.0002). VIs were less likely to have a shared meal experience (p = 0.017). About 55.5% of IPIs and VIs received nonfood gifts. Residents' perception of a program's interest, resources, and ranking of the program were not significantly different based on gifting., Conclusion: Virtual interviews introduced heterogeneity in the receipt of gifts. The impact of a variable gifting experience is uncertain but raises concern for a potential new source of bias in the recruitment process., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Digital education tools are a cornerstone in the evolution to CBME through EPAs. Successful implementation requires understanding the variable impacts of EHR-driven delivery of EPAs, flexible digital device access to EPAs, and user-behavior trends., Methods: Through a HIPAA compliant, flexible-device accessible, surgical education platform, general surgery training programs at 21 institutions collected EPA from July 2023 to April 2024. At 5 EHR-integrated institutions (EHR+), EPA were created for clinical activities based on the OR schedule, automatically pushed to attendings and residents with built in completion reminders. At 16 institutions without EHR integration (EHR-), EPA were initiated manually. To improve user experience, care phases were bundled (cEPA). We compared the EHR+ and EHR- groups, computing descriptive statistics on the cEPAs completed and user behavior metrics., Results: We collected 4187 cEPAs in total, with 82% at EHR+ institutions and 18% at EHR- institutions. Platform triggering dramatically drove cEPA completion for both faculty and residents, 88% and 81%, respectively. Only 3% were initiated by the faculty or resident. Faculty at EHR+ institutions strongly preferred the automated OR-triggered workflow to start their EPAs (Chi-squared test, p ≈ 0). Faculty completed all 3 care phases nearly 80% of the time. Time reminders specifically drive EPA completion for residents and faculty on weekdays and build habits on weekends. 71% of cEPAs completed were by computer, and 29% by phone. More comments were provided when computers were used. Residents reviewed feedback with a median lag of 1 hour and 29 min after results were available., Conclusions: EHR-driven delivery of EPA leads to a 4.6-fold increase in EPAs completed. EPA initiation is the most critical phase in the workflow and EHR-data driven alerts drive this action. These alerts are also effective drivers of habit formation. Flexible device access is important to increase EPAs completed and improve the usefulness through comments for residents., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: COVID-19 had a tremendous impact on surgical residency education and training. With little experience or training in using online learning in pedagogically informed ways, some surgical educators and learners experienced the disadvantages of online learning which may have contributed to a greater sense of burnout in the pandemic. The purpose of this study is to survey the level of burnout in surgical educators and assess educators' perspectives on factors that increased or decreased burnout in synchronous online teaching during the pandemic., Methods: A cross-sectional study consisting of 4 sections was sent to surgical educators at the University of Toronto. Demographic data, validated surveys on burnout and videoconferencing fatigue (the Maslach Burnout Inventory-Educators Survey (MBI-ES) and the Zoom Exhaustion and Fatigue (ZEF) scale respectively), and quantitative questions about teaching factors in synchronous online environments were collected and analyzed., Results: The MBI-ES demonstrated a high degree of emotional exhaustion, and depersonalization and a moderate degree of personal accomplishment in surgeon educators. The ZEF scale noted moderate fatigue across all domains. Although educators noted online learning to be a moderate factor contributing to burnout during the pandemic, there was no correlation between the number of hours or percentage of time teaching online to burnout or zoom fatigue scores. The largest reported contributing factor to online learning leading to burnout was lack of connection to learners, whereas the largest mitigating factor was decreased travel time., Interpretations: The study found a moderate degree of exhaustion and burnout among surgical educators in Canada during COVID-19 and examined how aspects of online synchronous learning may have contributed to or helped mitigate these experiences. Based on this, we present approaches and educational theories to improve the online learning experience for surgical educators going forward., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Our study investigated the effects of surgical training on residents' personal relationships. It aimed to address the gaps in understanding of how the surgical training commitment can influence relationship stability, decision-making, and life planning within this unique professional group., Design: We used cross-sectional survey methodology to gather data on the intricacies of relationship dynamics amid the rigors of surgical training. The survey focused on marital status, relationship dynamics, personal life choices, the challenges and rewards of dual-healthcare relationships, and the support networks that individuals and couples rely on., Setting: All surgical departments at The Johns Hopkins Hospital., Participants: The study comprised 111 participants, including residents, fellows, and attending surgeons. Of those reporting sex, 56/105 (53%) were female, and the predominant age category was 25 to 34 years, making up 61/104 (59%) of respondents., Results: The majority (73/105, 70%) of respondents were or had been married, and 50/96 (52%) had partners in the medical field. Among those in a dual-healthcare relationship, 38/46 (83%) reported that their relationship was strengthened through understanding and empathy, yet 37/46 (80%) acknowledged complications in work-life balance. However, women were significantly more likely than men to report at least one negative effect of a dual-healthcare relationship (84% [16/19] versus 22% [6/27], p = .003). Among those with partners outside medicine, 39/46 (85%) acknowledged that their partner had to adjust their lifestyle significantly. A considerable number (73/92, 79%) postponed life events such as starting a family, and 57/85 (67%) experienced relationship strain due to long working hours., Conclusions: Residents in dual-healthcare couples derived support from their relationships, but surgical training placed a significant strain on residents' personal relationships and often prompted residents to postpone major life events such as starting a family. Enhanced support systems and targeted interventions are needed to assist surgical professionals in navigating the complexities of balancing a demanding career with personal life., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation., Design: An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers., Setting: Academic medical training centers or conferences in the United States, Rwanda and Kenya., Participants: 10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident., Results: The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox., Conclusion: The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate interview and match outcomes of medical students who received pass/fail USMLE reporting vs medical students with numeric scoring during the same period., Design: Retrospective analysis of a cross-sectional survey-based study., Setting: United States 2023 residency match., Participants: Medical student applicants in the 2023 residency match cycle who responded to the Texas Seeking Transparency in Application to Residency (STAR) survey., Results: Among 6756 applicants for the 2023 match, 496 (7.3%) took USMLE Step 1 with pass/fail reporting. Pass/fail reporting was associated with lower USMLE Step 2-CK scores (245.9 vs 250.7), fewer honored clerkships (2.4 vs 3.1), and lower Alpha Omega Alpha membership (12.5% vs 25.2%) (all p < 0.001). Applicants with numeric USMLE Step 1 scores received more interview offers after adjusting for academic performance (beta coefficient 1.04 (95% CI 0.28-1.79); p = 0.007). Numeric USMLE Step 1 scoring was associated with more interview offers in nonsurgical specialties (beta coefficient 1.64 [95% CI 0.74-2.53]; p < 0.001), but not in general surgery (beta coefficient 3.01 [95% CI -0.82 to 6.84]; p = 0.123) or surgical subspecialties (beta coefficient 1.92 [95% CI -0.78 to 4.62]; p = 0.163). Numeric USMLE Step 1 scoring was not associated with match outcome., Conclusions: Applicants with numeric USMLE Step 1 scoring had stronger academic profiles than those with pass/fail scoring; however, adjusted analyses found only weak associations with interview or match outcomes. Further research is warranted to assess longitudinal outcomes., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The transition of Step 1 to pass/fail has generated concerns over selecting promising candidates. Holistic reviews integrate other proficiencies, including extracurriculars such as sports. Grit - defined as perseverance and passion for long-term goals - has been positively associated with competitive activities and is predictive of academic success. The prevalence and impact of sports participation and its relationship to grit in the general surgery resident population has not been described and was investigated in this study., Design: Surveys measuring sports participation and grit were distributed after the 2021 ABSITE. Grit was assessed through the short grit scale. Inferential statistics were performed., Setting/participants: General surgery residents in all US training programs who completed the 2021 ABSITE., Results: Of 5468 respondents (response rate 59.6%), 2,548 (46.7%) were female, 917 (17.4%) URiM, 2171 (39.8%) married, and 1,069 (19.6%) parents. About 4284 (83.8%) residents reported being involved in competitive sports. Grit was higher in residents with a competitive sports history (3.67 ± 0.58 versus 3.60 ± 0.61, p = 0.0022). Greater time commitment and being part of a team was positively correlated to grit (both p < 0.0001). Individuals that self-identified as underrepresented in medicine (URiM) had higher grit (3.71 ± 0.59 versus 3.65 ± 0.58 for non-URiM, p < 0.0001) as did female (p = 0.0016), married residents (p < 0.0001), and parents (p < 0.0001). Being an athlete was associated with significantly higher grit for nearly all demographic subgroups, including URiM (p = 0.0068), married (p = 0.0175), and parents (p = 0.0487)., Conclusions: Higher grit was found in athletes and marginalized groups including females, URiM, and residents that were married or parents. Our data suggests that recruiting applicants of diverse backgrounds and experiences will result in a grittier cohort; a group potentially equipped to weather the arduous surgical residency training path. Recruiting residents with characteristics associated with higher grit can potentially impact diversity of the surgical workforce., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Many surgical residencies have passed along attendings preferences and procedural knowledge as a highly utilized but informal resource. The objective was to assess the effect of providing operative steps and attending preferences on surgical resident performance., Design: This was a prospective observational study with a survey-based design., Setting: We created and shared vascular surgery operative steps including institutional and attending preferences with junior residents at the Massachusetts General Hospital., Participants: There were a total of 31 residents who completed a survey to assess self-perception of performance in operative knowledge and Accreditation Council for Graduate Medical Education (ACGME) Milestone criteria., Results: Advice from colleagues was the most utilized resource, followed by web-based materials. Of the web-based materials, almost all residents utilized Google searches over other web-based resources designed to specifically help surgical trainees. The vascular surgery resource was used by 90% of residents more than 3 times per week to prepare for operative cases. There was significant improvement in patient positioning, instrument selection, operative field exposure, anatomy, sequence of procedure, procedure choices, and peri-operative care knowledge., Conclusions: Development of institutional resources that specifically capture attending surgeon procedural variations can improve resident performance, encourage resident autonomy, and provide a catalog of approaches to challenging operative situations., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Gossip-evaluative talk about an absent third party-exists in surgical residency programs. Attending surgeons may engage in gossip to provide residents with feedback on performance, which may contribute to bias. Nevertheless, the perspectives of attending surgeons on gossip has not been studied., Design: In this qualitative study, semi-structured interviews about gossip in surgical training were conducted with attending surgeons. We performed a reflexive thematic analysis of transcripts with a grounded theory approach to describe attendings' perceptions of their role in gossip within surgical residency., Setting: Interviews were conducted from September 23, 2023, to November 27, 2023 via Zoom™., Participants: Eighteen surgery attendings associated with 7 surgical training programs were interviewed., Results: Six themes were developed: 1) Attendings typically view gossip with a negative lens; thus, well-intended conversations about resident performance that meet the academic definition of gossip are not perceived as gossip; 2) Gossip can damage attendings' reputations as surgeons and educators; 3) Mitigating the negative impacts of gossip by maintaining accurate and objective standards of honest communication is hard; 4) Attendings express concerns about hearing other attendings' impressions of residents prior to formulating their own opinion; 5) The surgical hierarchy restricts the volume and content of gossip that reaches attendings, which may limit their knowledge of program culture; and 6) It is very difficult to mitigate gossip at the program level. Ultimately, attendings utilize gossip (e.g. triangulating their experience) with the goal of providing residents feedback., Conclusions: Defining important conversations about resident performance as gossip should not discourage these critically important conversations but rather underscore the importance of combating harmful gossip through 3 behaviors: 1) committing to objective communication; 2) limiting or reframing information about resident performance that is shared with attendings who have yet to formulate their own opinions; and 3) regulating gossip in particular high-stakes microenvironments (e.g. the operating room)., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The healthcare sector accounts for 8.5% of United States (U.S.) greenhouse gas emissions, of which one-third comes from operating rooms (ORs). As a result, there is great interest in decarbonizing the OR and surgical care. However, surgical residents are not routinely educated on the negative environmental impact of surgery or how to reduce it. In this paper, we present a formal needs assessment for a sustainability curriculum geared towards surgical residents., Methods: Using Kern's Six-Step Framework for curriculum development, we conducted focus groups with surgical residents to perform a targeted needs assessment on 3 main topics: 1) the current state of surgical sustainability curricula; 2) resident knowledge regarding the environmental impact of surgery and barriers to sustainable practice; and 3) preferred educational methods and topics within sustainability education. We audio-recorded all focus groups and performed thematic analysis using anonymized transcripts., Results: Fourteen residents participated in 3 focus groups, from which a qualitative analysis revealed 4 themes. First, surgery residents receive limited formal teaching on the negative environmental impact of surgical care or how to reduce this impact. Second, surgery residents have variable levels of prior education about and interest in sustainability in surgery. Third, several barriers prevent the implementation of sustainable changes in surgical practice, including a lack of institutional initiative, cultural inertia, concerns about workflow efficiency, and limited formal education. Finally, residents prefer to learn about practical ways to reduce waste, specifically through interactive approaches such as quality improvement initiatives., Conclusions: Given the increasing importance of sustainability in surgery, there is an urgent need for formal resident education on this topic. This needs assessment provides a valuable foundation for future sustainability curriculum development., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Resident performance on the Plastic Surgery In-Service Examination (PSITE) is used as a predictor of success on the American Board of Plastic Surgery Written Examination, as well as resident progression and fellowship applications. However, information specifically addressing strategies on optimal PSITE preparation is lacking in the plastic surgery literature when compared to general surgery. For this reason, we aim to understand if the topic is well-studied and denote effective study strategies and curricular interventions in both fields that can help residents and programs optimize PSITE performance., Methods: A literature search including studies from 2012 to 2022 was conducted following PRISMA guidelines in PubMed and EMBASE to identify articles on strategies to improve in-service exam scores for general surgery and plastic surgery. Only studies that reported measurable outcomes in raw score, percentile score, or percent correct were included., Results: Qualitative analysis of 30 articles revealed 2 categories of interventions: individual study habits and institutional curricular interventions. In general surgery literature, 27 articles examined interventions positively impacting resident ABSITE scores, with 21 studies classified as institutional curricular interventions and 6 articles addressing individual study habits. Themes associated with improved ABSITE performance included mandatory remediation programs, dedicated study time, and problem-based learning interventions. In contrast, only 3 articles in plastic surgery literature discussed interventions associated with improved PSITE scores, all falling under curricular interventions., Conclusion: Unfortunately, the plastic surgery literature lacks concrete evidence on how residents can improve performance. Future research in plastic surgery should replicate successful strategies from general surgery and further investigate optimal preparation strategies for the PSITE. Such endeavors can contribute to improving resident performance and advancing plastic surgery education and patient care., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: In the context of surgical education reform, the integration of residency programs represents a significant milestone. Concerns about potential disruptions to patient care metrics amid these changes necessitate empirical investigation., Methods: This study assessed the impact of integrating surgical residency programs on patient outcomes within Trauma and Acute Care Surgery services. Pre- and postintegration data were meticulously analyzed to evaluate key metrics, including length of hospital stay, recovery rates, and complication rates., Results: Contrary to initial concerns, the introduction of residency programs did not yield significant alterations in patient care metrics. Analysis revealed consistent outcomes pre- and post-integration, indicating the resilience of patient care amidst educational reforms. Despite the introduction of a high-stakes training environment, patient outcomes remained stable., Conclusion: The study highlights the compatibility of educational advancements with the preservation of optimal patient care standards in Trauma and Acute Care Surgery services. Demonstrating the stability of patient care metrics in the face of educational reforms offers valuable insights for healthcare institutions considering similar initiatives. Overall, these findings contribute to the discourse on the value of surgical residency programs, reinforcing the importance of maintaining high-quality patient care standards while advancing surgical education., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The lack of diversity among applicants successfully matching into integrated plastic surgery residency continues to be a topic of significant discussion, yet substantial improvements in representation remain elusive. This article aims to highlight the systemic barriers contributing to the decline in diverse plastic surgery trainees., Design: This perspective summarizes current and existing challenges in improving recruitment efforts of underrepresented in medicine (URiM) trainees and those from socioeconomically disadvantaged backgrounds., Conclusions: While acknowledging current DEI initiatives, the authors point out those underappreciated modifiable and nonmodifiable obstacles that perpetuate the lack of equity and inclusivity in the match process. We emphasize the importance of continued commitment from program directors and chairs to these initiatives and its generational augmentative effects on achieving true and lasting diversity and equity., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Obtaining surgical informed consent (SIC) is a critical skill most residents are expected to learn "on-the-job." This study sought to quantify the effect of 1 year of clinical experience on performance obtaining SIC in the absence of formal informed consent education., Design: In this case-control cohort study, PGY1 and PGY2 surgical residents in an academic program were surveyed regarding their experiences and confidence in obtaining SIC; then assessed obtaining informed consent for a right hemicolectomy from a standardized patient., Setting: Single academic general surgery residency program in Buffalo, NY., Participants: Ten PGY1 and eight PGY2 general surgery residents were included in the study, after excluding residents with additional years of training., Results: PGY2 residents had significantly more experience obtaining SIC compared to PGY1 residents (median response: ">50" vs "between 6 and 15," p = 0.001), however there was no difference in self-reported confidence in ability obtaining SIC (mean 3.2/5 in PGY1 vs 3.4/5 in PGY2, p = 0.61), self-reported knowledge of SIC (mean 3.1/5 in PGY1 vs 3.6/5 in PGY2, p = 0.15), performance on a test regarding SIC (mean score 9.0/20, SD 3.9 for PGY1 vs mean score 9.6/20, SD 3.5, t = 0.387, p = 0.739) or performance during a standardized patient interview (mean 11.2/20, SD 2.78 for PGY1 vs mean 11.4/20, SD 1.51 for PGY2, p = 0.87). In the interviews all residents addressed general risks (bleeding/infection), however both groups performed worse in addressing procedure-specific risks including anastomotic leak as risk for hemicolectomy., Conclusions: A year of clinical training between PGY1 to PGY2 did not improve performance in obtaining surgical informed consent when lacking formal education, despite self-confidence in their ability. A curriculum covering the content, delivery and assessment of informed consent should be initiated for residents upon arrival to surgical training., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several factors contribute to surgical outcome disparities, including structural racism and implicit bias. Research into how surgical residency programs intervene on Cultural Complications via education remains sparse. We review the literature for how surgical residency programs use education to combat staff and patient exposure to Cultural Complications., Methods: We searched PubMed, SCOPUS, and Google Scholar for curricula aimed at improving cultural competency in surgical residencies. OBGYN curricula were included. Non-US studies were excluded., Results: Studies were organized by intervention type: Didactic, Grand Rounds, and M&M. The most common interventions were Didactics, with Grand Rounds being the least common. Target measures improved anywhere from 20-88%., Conclusions: The common types of cultural competency curricula are clear, and certain interventions show improvement in trainees' education. Scarcity of data on these curricula does not necessarily indicate their lack of existence but does suggest additional research is needed into curricular interventions and how they may address cultural complications., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)