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Purpose: Extramural funding is critical to career success and advancement in academic surgery, and surgical residents can apply for both societal and federal funding. Many federal funding mechanisms require proposals to be submitted before residents' formal research years., Methods: To better understand the resident experience with grantsmanship, we distributed a validated grantsmanship self-efficacy assessment inventory for voluntary completion at our academic general surgery training program with 2 years of dedicated research. The survey covers 3 domains: conceptualizing, designing and analyzing, and funding a study. All questions are scored 0 to 10 with 0 indicating no confidence and 10 indicating complete confidence. Median scores for the 3 domains were calculated for all respondents and compared between training years using Kruskal-Wallis with post-hoc Dunn testing., Results: Forty-four surveys were completed with a response rate of 84%. Resident self-efficacy in grantsmanship improved throughout the training years with the greatest changes being in their comfort with conceptualizing and funding a study. Dunn testing identified specific differences between PGY2 and PGY7 comfort with conceptualizing studies (median 5 vs. 7.5, p = 0.003) and understanding of funding mechanisms (median 2.0 vs. 7, p = 0.003)., Conclusions: While comfort with conceptualizing and funding studies does increase throughout the training years, this often develops after critical funding deadlines have already passed and can disadvantage surgical residents interested in academic careers. A curriculum that emphasizes familiarity with the grant writing and funding processes may better facilitate long term career success., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Increasingly, medical schools integrate clinical skills into early didactic coursework. The Stop the Bleed® Campaign emphasizes prehospital hemorrhage control to reduce preventable deaths; however, this course overlooks team interactions. We assessed the impact of high-fidelity simulation during medical student orientation on identification and treatment of life-threatening hemorrhage in a team setting., Design: In this mixed method, prospective pre-, post-, and follow-up survey analysis assessing student knowledge and attitudes, student teams encountered a standardized patient in a prehospital environment with pulsatile bleeding from an extremity wound. Individual students completed surveys assessing previous experience, willingness and ability to assist bleeding person(s), and knowledge and attitudes about tourniquets. Postscenario, faculty preceptors made qualitative observations on teamwork., Setting: Medical student orientation at a tertiary care academic medical center with long-term follow-up., Participants: Medical students (N = 150)., Results: Ninety students (60%) completed both pre- and postsimulation questionnaires. Sixteen (17%) students had previous tourniquet training experience although none had applied a tourniquet outside of training. Postsimulation, students reported increased likelihood of providing treatment until additional help arrived (p = 0.035), improved ability to identify life-threatening hemorrhage (p < 0.001), and more favorable opinions about tourniquet use (p < 0.001) and potential for limb-salvage (p = 0.018). Long-term follow-up respondents (n = 34, 23%) reported increased ability to identify life-threatening hemorrhage (p = 0.010) and universal willingness to intervene until additional help arrived. Follow-up survey responses elicited themes in hemorrhage control including recognition of the importance of continuous pressure, appropriate use of tourniquets, a desire for repeated team training, and the recognition of clerkship rotations as an optimal setting for skill reinforcement. Preceptors noted variable team responses but uniformly endorsed the exercise., Conclusions: High-fidelity bleeding simulation during medical student orientation improved students' knowledge and attitudes about treating life-threatening hemorrhage and served as an introduction to team-based emergency care. Future studies should further explore team training and hemorrhage control education., (Copyright © 2024 Association of Program Directors in Surgery. All rights reserved.)

Objective: Comprehensive, socially-minded healthcare has historically been delivered in the primary care setting. For underserved patient populations, however, a surgical care episode may serve as the health care access point. To maximize patient wellbeing during the perioperative period, our surgical center developed the Additional Needs Screener (ANS). Operationalized into practice by GME and UME trainees, this tool screens surgical patients across 3 domains (social, emotional, and immigration needs) and connects patients to partner organizations if appropriate. This study describes the pilot utilization of the ANS among underserved and underinsured surgical patients., Design: Clinical quality improvement and retrospective cohort study of patients completing the ANS from implementation in September 2021 to September 2022., Setting: The Hospital of the University of Pennsylvania, PA-a tertiary care center., Participants: One hundred and 10 underinsured and/or underserved patients completed at least 1 ANS domain., Results: Patients were majority female (55F, 53M, 2 other) and Hispanic/Latinx (72%) with a median age of 38 (IQR = 34-48). Most patients spoke a primary language other than English (77%), and nearly all were either uninsured (82%) or received emergency medical assistance or Medicaid (14%) at referral. Patients demonstrated significant needs; 39% endorsed difficulty affording housing, 32% endorsed difficulty paying for food, 29% endorsed experiencing current life-interfering distress, and 75% had undocumented immigration status. Ultimately, 57% of screened patients accepted referrals to our needs response teams., Conclusions: Underserved and underinsured patients presenting for surgical care face significant challenges relating to social, emotional, and immigration needs. Through adoption of the ANS, trainees gained competency identifying and addressing these barriers in the perioperative period. Future works will focus on categorizing referral outcomes, developing interventions to increase patient trust, and improving screener dissemination., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To date, education about health equity for early-stage healthcare trainees is largely situated outside of surgical disciplines. This study aims to evaluate the effectiveness of a surgical equity curriculum offered to a voluntary group of medical and graduate students., Design: Mixed-methods cohort study from January to June 2021. Pre- and post-course surveys measured domains of attitudes, self-reported confidence, and knowledge via 5-point Likert scale and multiple-choice questions. Paired t tests were used to analyze quantitative responses. Qualitative responses were studied via iterative thematic analysis., Setting: At the University of Pennsylvania in Philadelphia, PA which provides tertiary level, institutional care, 10, interdisciplinary 1.5-hour sessions were held over 1 semester, teaching surgical equity topics that spanned the peri-operative continuum., Participants: Twenty-four medical and graduate students from across the University of Pennsylvania enrolled. Twenty completed both surveys., Results: From pre- to post-course, students improved across all domains. Students improved in their self-rated ability to identify strategies to talk about sensitive health topics with patients (pre: 20%, post: 90%) and identify strategies to address healthcare disparities in surgery (pre: 10%, post: 90%). Qualitatively, from pre- to post-course, more students could articulate the role of bias and identify opportunities for surgeons to engage in surgical equity. The course strengthened any pre-existing interest in surgical equity, and for 1 student, created interest in a surgical career where it had not previously existed. Many also expressed greater resolve to provide patient-centric care., Conclusions: Formal curricula can improve students' ability to advocate for surgical equity. A similar framework may fill a need for medical students interested in health equity and surgical careers at other institutions., Competing Interests: CONFLICT OF INTEREST This work was supported by the Penn Graduate Center Community Impact Fund and Perelman School of Medicine Medical Student Government funding, which was used toward books and educational supplies for this initiative., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Despite the overall shift in care delivery to an ambulatory setting, the majority of general surgical education still relies on the experience of caring for inpatients. We aimed to investigate how the inpatient practice patterns of newly minted general surgeons (GS) have changed since 2008, in order to better inform education policies regarding both training approach and setting for modern surgical trainees., Methods: State discharge data from NY and FL (2008-2017) were linked to data on GS from the American Medical Association Masterfile, and to hospital data from the American Hospital Association annual survey. Mean annual inpatient case volume (CV) and case type breadth (CB) were compared between surgeons who were new-to-practice (0-3 years of experience) in 2008 and in 2013. Each new surgeon cohort was followed for 5 years. Case type was classified by organ system., Results: The 2008 cohort included 328 GS with a mean age of 37.1, 79.6% male and 94.2% board-certified. The 2013 cohort included 359 GS with a mean age of 36.2, 73.0% male and 93.9% board-certified. CV was higher among the 2008 cohort than the 2013 cohort for each year of practice in the study period. CB included at least 4 organ system types for all new GS with greater breadth among the 2008 cohort for each year in the study period., Conclusions: Declining rates of inpatient surgery affect general surgeons who were new-to-practice in 2013 significantly more than those entering practice only 5 years ahead of them. New surgeons continue to start their practices broadly, suggesting a need to continue broad training while expanding formal educational policies to include the full spectrum of ambulatory surgery., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is the examine the effect of a holistic review process on the recruitment of women and students underrepresented in medicine (UIM) in a general surgery residency program., Design: A retrospective study comparing the proportion of women and UIM students ranked and matched into categorical positions from 2013 to 2020 before and after the implementation of the holistic application review process. United States Medical Licensing Exam (USMLE) scores and American Board of Surgery In-training Exam (ABSITE) scores were also compared between groups., Setting: General Surgery residency program at a tertiary, academic center., Participants: Medical students applying for and matriculated to categorical positions., Results: After the implementation of holistic review in 2017, there was a statistically significant increase in the proportion of women (42% vs. 61%, p < 0.01) and UIM students (14% vs. 20%, p = 0.046) ranked in our program compared with the prior "traditional" approach. The proportion of matched female (33% vs. 54%, p = 0.11) and UIM applicants (14% vs. 21%, p = 0.48) also increased after holistic review, although the changes were not statistically significant. The median USMLE Step 1 scores were equivalent for both ranked (250 vs. 250, p = 0.81) and matched (250 vs. 249, p = 0.32) applicants before and after the intervention. The median ABSITE scores for the matched intern classes was lower after initiation of holistic review (519 vs. 483, p = 0.01). However, these scores were consistently above the national medians and subgroup analysis showed no difference between the median aggregate ABSITE scores for UIM and female categorical interns and non-UIM males (475 vs. 520, p = 0.09)., Conclusions: Increasing emphasis is being placed on the diversification of residency training to reflect an expanding, diverse patient population. The incorporation of a holistic review process, providing broader assessment of applicants, can play a pivotal role in increasing the proportion of women and UIM students represented in the general surgery recruitment process., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical boot camps enhance the confidence of medical students and surgical interns. The impact of boot camps on the confidence of post-graduate year (PGY) 2 residents is unknown. We hypothesized that a postinternship boot camp would improve the confidence of PGY-2 residents in managing their newfound responsibilities. We also hypothesized that the effect of a tailored high-impact boot camp would persist over time., Design: A 2-hour boot camp at our simulation center was implemented for PGY-2 residents in 2016 and 2017. Confidence in handling boot camp scenarios was measured on a 1 to 5 Likert scale before and after the boot camp. Three-month follow-up was assessed in the 2017 cohort., Participants: Thirty-one PGY-2 residents (n = 16 in 2016, n = 15 in 2017) completed the boot camp., Results: Residents reported increased confidence in placing central lines (p < 0.001), placing chest tubes (p = 0.01), managing emergency airways (p < 0.001), running a code (p = 0.03), and fulfilling the role of in-house senior resident (p < 0.001). Three-month follow-up in 2017 (n = 10) demonstrated no difference in confidence compared to postboot camp results., Conclusions: Boot camps can durably improve confidence in skills expected of PGY-2 residents assuming in-house senior resident responsibilities., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To examine patient safety event reporting behavior by trainees caring for surgical patients compared to other clinicians., Design: Qualitative analysis of a patient safety event reporting system comparing reports entered by trainees to those entered by attending physicians and nurses. Categorical data associated with reports were compared, and free-text event descriptions underwent content analysis focusing on themes related to report completeness and report focus., Setting: The Hospital of the University of Pennsylvania, an academic tertiary care hospital in Philadelphia, Pennsylvania., Participants: All patient safety event reports related to surgical patients from a 6-month period (July-December 2016)., Results: One thousand four hundred twenty-three reports were entered by trainees (T), attendings (A), and nurses (N). Trainees had a lower number of reports entered per reporter compared to nurses (T median [IQR]: 1 [1-2], N: 2 [1-3]), and the highest percentage of reports entered anonymously for any group (T: 28.7%, N: 9.9%, A: 4.6%). The overall distribution of event location and event type differed significantly between groups (p < 0.001). Trainee reports were found to have a broader range of focus, more elements associated with completeness of reports, and more frequent use of blame language., Conclusions: Surgical trainees report a wide variety of issues in the perioperative, floor, and ICU settings. Their reports often include more details than those entered by other clinicians, but feature higher rates of anonymous reporting and use of blame language. Analysis of patient safety event reports by trainees compared with other healthcare professionals can reveal important insights into the clinical learning environment and areas for safety improvement., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The ability to use electronic medical records (EMR) is an essential skill for surgical residents. However, frustration and anxiety surrounding EMR tasks may detract from clinical performance. We created a series of brief, 1-3 minutes "how to" videos demonstrating 7 key perioperative EMR tasks: booking OR cases, placing preprocedure orders, ordering negative-pressure wound dressing supplies, updating day-of-surgery history and physical notes, writing brief operative notes, discharging patients from the postanesthesia care unit, and checking vital signs. Additionally, we used "Cutting Insights"-a locally developed responsive mobile application for surgical trainee education-as a platform for providing interns with easy access to these videos. We hypothesized that exposure to these videos would lead to increased resident efficiency and confidence in performing essential perioperative tasks, ultimately leading to improved clinical performance., Methods: Eleven surgery interns participated in this initiative. Before watching the "how to" videos, each intern was timed performing the aforementioned 7 key perioperative EMR tasks. They also underwent a simulated perioperative emergency requiring the performance of 3 of these EMR tasks in conjunction with 5 other required interventions (including notifying the chief resident, the anesthesia team, and the OR coordinator; and ordering fluid boluses, appropriate laboratories, and blood products). These simulations were scored on a scale from 0 to 8. The interns were then directed to watch the videos. Two days later, their times for performing the 7 tasks and their scores for a similar perioperative emergency simulation were once again recorded. Before and after watching the videos, participants were surveyed to assess their confidence in performing each EMR task using a 5-point Likert scale. We also elicited their opinions of the videos and web-based mobile application using a 5-point scale. Statistical analyses to assess for statistical significance (p ≤ 0.05) were conducted using paired t-test for parametric variables and a Wilcoxon matched-pair test for nonparametric variables., Setting: Hospital of the University of Pennsylvania, Philadelphia, PA (a quaternary teaching hospital within the University of Pennsylvania Health System)., Participants: Eleven out of 15 interns (12 entered and 11 completed the study) from our categorical and preliminary general surgery residency programs during the 2016 academic year., Results: Before exposure to the brief "how to" videos, 6 of 11 interns were unable to complete all 7 EMR tasks; after exposure, all 11 interns were able to complete all 7 EMR tasks. Moreover, interns' times for each task improved following exposure. Interns self-reported improved confidence in booking an OR case (4 ± 0.9 vs. 4.7 ± 0.6, p = 0.05), ordering negative-pressure wound therapy supplies (3.1 ± 1.6 vs. 4.5 ± 0.7, p < 0.05), writing a brief operative note (3.7 ± 1.2 vs. 4.6 ± 0.7, p = 0.05), discharging patients from the postanesthesia care unit (3.3 ± 1.0 vs. 4.4 ± 0.8, p < 0.05), checking vital signs (2.5 ± 1.4 vs. 4.5 ± 0.8, p ≤ 0.01), and performing necessary EMR tasks during an emergency situation (2.4 ± 0.8 vs. 4.6 ± 0.7, p ≤ 0.0001). Participants also demonstrated a significant improvement in average clinical score on the emergency simulations (5.2 ± 1.7 vs. 6.6 ± 0.9, p < 0.05). Interns' opinions of the videos and the mobile phone application were favorable., Conclusions: In our group of 11 surgery interns, exposure to a series of short "how to" videos led to increased confidence and shortened times in performing 7 essential EMR tasks. Additionally, during a simulated perioperative emergency, EMR tasks were performed significantly faster. Clinical performance also improved significantly following exposure to the videos. This just-in-time educational intervention could improve workflow efficiency and clinical performance, both of which may ultimately enhance perioperative patient safety., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery., Design: 9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training., Setting: Tertiary care, university based teaching institution., Participants: A total of 9 general surgery residents at the intern level., Results: The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001)., Conclusion: Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar., Design: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests., Setting: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016., Results: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies., Conclusions: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To systematically review the literature surrounding operating room-based in situ training in surgery., Methods: A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible., Results: The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics., Conclusions: Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Many medical schools have begun to offer surgical boot camps to senior medical students. The aim of the present study is to systematically review the literature and evidence surrounding medical school surgical boot camps to direct future research into the effectiveness of boot camps., Methods: A systematic review was conducted, searching MEDLINE, EMBASE, PsycINFO, CINAHL, and ERIC. The review was conducted according to the PICOTS structure, with an intervention of a surgical boot camp for senior medical students entering surgical residencies., Results: The search resulted in 5351 database hits, from which we identified 10 published studies that met the inclusion criteria. Two reviews were identified that met the PICOTS criteria but were excluded from data synthesis. Boot camps increase the confidence and competence of medical students entering their surgical internships. There is no objective assessment of the effect of boot camps on the clinical performance of interns., Conclusions: Despite the success of medical school surgical boot camps, no objective data exist to show that boot camps translate into improved performance during internship., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to understand the effect of a team-based surgical skills intervention on the technical and nontechnical skills of surgery residents., Design: This was a prospective cohort study with pretesting or posttesting. We designed basic tasks for the assessment and learning of nontechnical skills in the operating room (OR). A total of 15 postgraduate year 1 residents performed an open gastrojejunostomy in a simulated OR setting (pretest), followed by training in the 3 team-based tasks designed to teach communication and teamwork, followed by performance of a gastrojejunostomy in the simulated OR (posttest)., Setting: Tertiary care, university-based teaching institution., Participants: A total of 15 general surgery residents at the intern level., Results: The mean nontechnical skills for surgeons (NOTSS) score improved postteam task training (10.04 ± 0.33 vs. 12.14 ± 1.33). There was a concomitant increase in the objective structured assessment of technical skills (OSATS) score (18.56 ± 0.86 vs. 22.86 ± 0.15, p = 0.006). The percentage increases in OSATS and NOTSS score for each resident was similar (19.49 ± 4.8 % for NOTSS vs. 21.22 ± 4.92 % for OSATS, p = 0.502)., Conclusion: Nontechnical skills positively correlate with the technical performance of a surgeon. Simple, easily designed tasks can be used to improve NOTSS in the OR. These team tasks and development of curricula based on them can be used to explicitly address one of the most important components of ACGME core competencies for surgical residents, namely interpersonal skills and communication., (Copyright © 2016. Published by Elsevier Inc.)

Objective: To improve physician/patient communication and familiarize surgeons with contemporary skills for and metrics assessing communication, courses were developed to provide academic general surgery residents and faculty with a toolkit of information, behaviors, and specific techniques. If academic faculty are expected to mentor residents in communication and residents are expected to learn good communication skills, then both should have the necessary education to accomplish such a goal., Design: Didactic lectures introduced current concepts of physician-patient communication including information on better patient care, fewer malpractice suits, and the move toward transparency of communication metrics. Next, course participants viewed and critiqued "Surgi-Drama" videos, with actors simulating "before" and "after" physician-patient communication scenarios. Finally, participants were provided with a "toolkit" of techniques for improving physician-patient communication including "2-3-4"-a semiscripted short communication tool residents and other physicians can use in patient encounters-and a number of other acronymic approaches., Results: Each participant was asked to complete an anonymous evaluation to assess course content satisfaction. Overall, 86% of residents participated (68/79), with a 52% response rate (35/68) for the evaluation tool. Overall, 88% of faculty participated (84/96), with an 84% response rate (71/84). Residents voiced satisfaction with all domains. For faculty, satisfaction was quantitatively confirmed (Likert score 4 or 5) in 4 of 7 domains, with the highest satisfaction in "communication of goals" and "understanding of the HCAHPS metric." The percentage of "top box" Doctor Communication Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and national percentile ranking showed a sustained increase more than 1 and 2 years from the dates of the courses., Conclusions: The assessment of communication skills is increasing in importance in the practice of surgery. A course in communication, as developed here, quantitatively confirms the effectiveness of this approach to teaching communication skills as well as identifying areas for improvement. Such a course was part of a plan to increase the percentage of "top box" HCAHPS scores and percentile rankings. Faculty can impart the skills gained from such a course to residents attempting to successfully navigate the Accreditation Council for Graduate Medical Education (ACGME) Milestones and future careers as practicing surgeons., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To disseminate materials and learning from the proceedings of the Association of Program Directors 2014 Annual Meeting workshop on the integration of quality improvement (QI) education into the existing educational infrastructure., Background: Modern surgical practice demands an understanding of QI methodology. Yet, today׳s surgeons are not formally educated in QI methodology. Therefore, it is hard to follow the historical mantra of "see one, do one, teach one" in the quality realm., Methods: Participants were given a brief introduction to QI approaches. A number of concrete examples of how to incorporate QI education into training programs were presented, followed by a small group session focused on the identification of barriers to incorporation. Participants were provided with a worksheet to help navigate the initial incorporation of QI education in 3 steps., Results: Participants were representative of all types of training programs, with differing levels of existing QI integration. Barriers to QI education included lack of resident interest/buy-in, concerns over the availability of educational resources (i.e., limited time to devote to QI), and a limited QI knowledge among surgical educators. The 3 steps to kick starting the educational process included (1) choosing a specific method of QI education, (2) incorporation via barrier, infrastructure, and stakeholder identification, and (3) implementation and ongoing assessment., Conclusions: Recent changes in the delivery of surgical care along with the new accreditation system have necessitated the development of QI education programs for use in surgical education. To continue to make surgery safer and ensure optimal patient outcomes, surgical educators must teach each resident to adopt quality science methodology in a meaningful way., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Controversy exists over the optimal use of the Milestones in the process of resident evaluation and feedback. We sought to evaluate the performance of a Milestones-based feedback system in comparison to a traditional model., Methods: The traditional evaluation system (TES) consisted of a generic 16-item survey using a 5-point Likert scale ranging from 1 to 5, and a free-text comments section. The Milestones-based evaluation system (MBES) was launched in July 2014, ranging from 0 to 4. Individual milestones were mapped to rotations based on resident educational goals by postgraduate year (PGY). The MBES consisted of a survey with a maximum of 7 items, followed by a free-text comment section. Within each evaluation system, an overall composite score was calculated for each categorical general surgical resident. To scale the 2 systems for comparison, TES scores were adjusted downward by 1 point. Descriptive statistics were performed. Univariate analysis was performed with the Wilcoxon signed-rank test. A test for trend across PGY was used for the MBES only., Results: In the traditional system, the median score was 3.66 (range: 3.2-4.0). There was no meaningful difference in the median score by PGY. In the new system, the median score was 2.69 (range: 1.5-3.7, p < 0.01). The median score differed across PGY and increased by PGY of training (p < 0.01). There was an increase in differences between median scores by PGY., Conclusions: On using the milestones to facilitate faculty evaluation of resident knowledge and skill, there was a trend in increasing score by PGY of training. In the MBES, scores could be used to better discriminate resident skill and knowledge levels and resulted in improved differentiation in scoring by PGY. The use of the milestones as a basis for evaluation enabled the program to provide more meaningful feedback to residents and represents an improvement in surgical education., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for use in profiling the aggregated resident operative experience by postgraduate training year and to demonstrate the extent to which a surgical registry could be used to examine resident exposure to adverse events., Background: Independent data regarding the operative experience and clinical effectiveness across residency programs remain elusive. In the absence of reliable data, the ability to standardize surgical education and reduce variation in practice remains an unachievable goal., Methods: We identified general surgery cases using the ACS NSQIP Participant Use File 2011. Resident participation was defined according to postgraduate year (PGY). Descriptive statistical analyses were performed regarding procedure type and clinical outcomes., Results: Of the total general surgery cases, a PGY 1 to 5 resident participated in 87% (45,423), and 28% (n = 14,559) were performed with PGY 5 residents. Interns were involved with 10% (n = 5448) of the cases. The type of procedures performed varied by PGY, but cholecystectomy was the most common. Overall, 11% (4773) of cases were associated with an adverse event or mortality or both, with a mortality rate of 0.8% (374). The most common adverse event was bleeding (5%)., Conclusions: The ACS NSQIP captures the breadth of the resident experience in operative case mix and exposure to adverse events. Although the program was originally designed to uncover areas for quality improvement, the findings of our study demonstrate the utility of an outcomes registry as a guide for the development of future educational content in the resident curriculum., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To perform a national climate survey of general surgery residents regarding attitudes and perceptions of the influence of sexual orientation on the training experience., Methods: A cross-sectional voluntary online survey was distributed to all Accreditation Council for Graduate Medical Education-accredited general surgery programs. Residents self-identified as heterosexual, lesbian, gay, or bisexual. Descriptive statistics were performed. For the purposes of further analysis, respondents were classified as heterosexual or LGBT. Demographic characteristics and survey responses were examined by sexual orientation using the Fisher exact test., Results: Of 388 resident respondents, 10 identified as lesbian (2.6%), 24 as gay (6.3%), and 9 as bisexual (2.4%). More than 30% of LGBT residents did not reveal their sexual orientation when applying for general surgery residency owing to fear of not being accepted. No statistical differences were found between LGBT and heterosexual residents regarding future career plans, happiness at work, good program fit, and rapport with fellow residents. Although no differences were found in relationship status between LGBT and heterosexual residents, more LGBT residents reported feeling uncomfortable openly discussing their spouse/partner with fellow residents (36% vs 3.0%, p < 0.001) and with surgical attending physicians (59% vs 9.3 %, p < 0.001) when compared with heterosexual peers. Additionally, LGBT residents felt more uncomfortable bringing their spouse/partner to formal surgery department events (42% vs 2.7%, p < 0.001). Among all respondents, 54% (n = 206) witnessed homophobic remarks by nurses and residents and 30% (n = 114) by surgical attending physicians. Of LGBT residents, 57% reported actively concealing their sexual orientation from fellow residents owing to fear of rejection and 52% from surgical attending physicians owing to fear of poor evaluations. LGBT residents reported experiencing targeted homophobic remarks by fellow residents (21%) and by surgical attending physicians (12%). None of the surgical residents who experienced directed homophobic remarks reported the event to their supervisors for reasons including fear of reprisal (13%-17%), not wanting to create more "trouble" (25%-50%), and a belief that nothing would be done about the event (17%-25%)., Conclusion: Now, more than ever, issues related to sexual orientation have been at the forefront of political and public attention. No data exist that explore how these issues affect the training experience of general surgery residents. Our study showed that although there was no difference overall in reported work happiness or program fit, LGBT residents reported a greater need to conceal their personal lives from their surgery program peers and attending physicians. Whether these differences affect patient care, team work, career satisfaction, and personal cost of surgical training warrants further study., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Surgery residents are expected to demonstrate the ability to communicate with patients, families, and the public in a wide array of settings on a wide variety of issues. One important setting in which residents may be required to communicate with patients is in the disclosure of medical error. This article details one approach to developing a course in the disclosure of medical errors by residents., Design: Before the development of this course, residents had no education in the skills necessary to disclose medical errors to patients. Residents viewed a Web-based video didactic session and associated slide deck and then were filmed disclosing a wrong-site surgery to a standardized patient (SP). The filmed encounter was reviewed by faculty, who then along with the SP scored each encounter (5-point Likert scale) over 10 domains of physician-patient communication. The residents received individualized written critique, the numerical analysis of their individual scenario, and an opportunity to provide feedback over a number of domains. A mean score of 4.00 or greater was considered satisfactory. Faculty and SP assessments were compared with Student t test., Setting: Residents were filmed in a one-on-one scenario in which they had to disclose a wrong-site surgery to a SP in a Simulation Center., Participants: A total of 12 residents, shortly to enter the clinical postgraduate year 4, were invited to participate, as they will assume service leadership roles. All were finishing their laboratory experiences, and all accepted the invitation., Results: Residents demonstrated satisfactory competence in 4 of the 10 domains assessed by the course faculty. There were significant differences in the perceptions of the faculty and SP in 5 domains. The residents found this didactic, simulated experience of value (Likert score ≥4 in 5 of 7 domains assessed in a feedback tool). Qualitative feedback from the residents confirmed the realistic feel of the encounter and other impressions., Conclusions: We were able to quantitatively demonstrate both competency and opportunities for improvement across a wide range of domains of interpersonal and communication skills. Residents are expected to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds. As academic surgeons, we must be mindful of our roles as teachers, mentors, and coaches by teaching good communication skills to our residents. Courses such as the one described here can help in improving physician-patient communication. The differing perspectives of faculty and SPs regarding resident performance warrants further study., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients., Methods: Three VP cases were developed using commercially available software to simulate common surgical scenarios. Surgical clerks volunteered to complete VP cases. Upon case completion, an individual performance score (IPS, 0-100) was generated and a 16-item survey was administered. Surgery shelf exam scores of clerks who completed VP cases were compared with a cohort of students who did not have exposure to VP cases. Descriptive statistics were performed to characterize survey results and mean IPS., Results: Surgical clerks felt that the VP platform was simple to use, and both the content and images were well presented. They also felt that VPs enhanced learning and were helpful in understanding surgical concepts. Mean IPS at conclusion of the surgery clerkship was 69.2 (SD 26.5). Mean performance on the surgery shelf exam for the student cohort who had exposure to VPs was 86.5 (SD 7.4), whereas mean performance for the unexposed student cohort was 83.5 (SD 9)., Discussion: The VP platform represents a new educational tool that allows surgical clerks to direct case progression and receive feedback regarding clinical-management decisions. Its use as an assessment tool will require further validation., (Published by Elsevier Inc.)

Objective: The Accreditation Council for Graduate Medical Education work rules have forced programs to critically appraise the overall educational value (OEV) of rotations. Successful rotations must satisfy Residency Review Committee mandates and optimize the service-to-education ratio (SER). This study was designed to examine the relationship between the OEV and SER and identify rotation characteristics (RC) associated with both., Design, Setting, and Participants: The Division of Surgery Education at the Hospital of the University of Pennsylvania administered a survey in FY2011 to all residents detailing resident perceptions regarding OEV, SER, and other RC. Responses were linked to additional rotation data. The relationship between OEV and SER was examined before and after controlling for significant RC identified in univariate analyses. Subgroup analyses by junior (CY1-2) and senior (CY3-5) resident status were performed., Results: The survey was sent to 85 residents participating in 48 general surgery rotations, with an overall response rate of 87%. OEV was inversely proportional to SER. All RC were significant predictors of OEV in univariate models except rotation length, patient care participation and the presence of fellows. SER alone was a significant predictor of OEV (coefficient = -1.24, p < 0.001) and explained 68% of the variation in OEV. After including other RC, SER remained a significant predictor (coefficient = -1.08, p < 0.001) and the model explained 85% of the variation in OEV. In subgroup analysis, SER remained a significant predictor of OEV for junior residents (coefficient = -1.27, p = < 0.001), but not for senior residents (coefficient = -0.46, p = 0.15)., Conclusions: The SER is inversely correlated with the OEV of general surgery rotations for the aggregate group of surgical residents, but this relationship appears to be attenuated by other factors in the senior resident group. Identification of the factors that affect junior surgical residents may provide the ability to improve the SER for junior residents and allow for significant improvements in perceived OEV for the resident body as a whole., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Medical school does not specifically prepare students for surgical internship. Preinternship courses are known to increase confidence in multiple key areas. We examined the immediate effect and durability of effect of a surgical pregraduation preparatory course or "boot camp" on provider confidence in technical and medical management skills., Design: A 5-day boot camp was offered to senior medical students (SMS) entering surgical programs. SMS were anonymously surveyed before, after, and 6 months following the course. The same survey was given 6 months into internship to a control group of surgical interns who graduated from the same medical school but did not participate in boot camp before graduation. Data were compared between the time intervals and across cases and controls using the Wilcoxon rank-sum and signed-rank tests and the Student t test., Setting: A joint effort between the University of Pennsylvania School of Medicine, the Department of Surgery at the Hospital of the University of Pennsylvania, and the Penn Medicine Simulation Center in Philadelphia, PA., Participants: All senior medical students set to graduate from a single institution entering general surgery or surgery subspecialties were offered the course. Twenty-nine students participated in the course., Results: Post-boot camp confidence scores of SMS were significantly greater in all areas except placement of a peripheral intravenous catheter compared with pre-boot camp scores. Six months into internship, the SMS boot camp group felt more confident than controls in their ability to perform a cricothyroidotomy (median 2.5 vs 1.0, p = 0.04) and to insert a chest tube (median 3.3 vs 1.0, p = 0.05). Otherwise, there was no residual difference in confidence levels between the boot camp group and the controls., Conclusions: Boot camps can improve self-confidence in young doctors in many areas of perioperative care before enrolling in surgical residency. The effect is most durable in high risk, infrequently performed technical tasks. Future studies are under design to examine the impact of boot camps on the "July Effect.", (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate the cost associated with the American College of Surgery (ACS)/Association of Program Directors in Surgery (APDS)-based surgical skills curriculum (SSC) within a general surgery residency program., Methods: The Penn Surgical Simulation Center (PSSC) of the University of Pennsylvania was established by the Department of Surgery during the 2006-2007 academic year and became a Level-I ACS Accredited Education Institute in 2008. Each academic year, 38 junior residents are assigned to a 4-week dedicated simulation rotation based on the ACS/APDS-based SSC. In conjunction with voluntary participation by faculty, a salaried educational fellow is responsible for maintaining the schedule and administering the surgical skills training modules. The costs associated with the ACS/APDS-based SSC were divided in initial implementation capital expenses and annual operational maintenance expenses., Results: The overall capital expenditures associated with the implementation of the curriculum were $4.204 million. These costs included the purchase of low and high-fidelity simulation equipment and initial construction costs to renovate a previous operating room (OR) and recovery suite into the Penn Medicine Clinical Simulation Center (PMCSC) which has housed the PSSC since 2008. The annual operational expenses are $476,000 and include the salary for the educational fellow, disposables, and other supplies, and the PMCSC average student fees. The annual cost per resident for the 4-week dedicated simulation rotation is $12,516. This figure does not include the average cost for teaching efforts including the simulation teaching per participating faculty member which is $30,000 in Relative Teaching Value Units per year., Conclusions: The expenditures associated with the implementation and maintenance of the ACS/APDS-based surgical skills curriculum in a surgical residency program are significant. This center's experience might be useful to programs deciding on more cost-effective means of implementing the ACS/APDS-SSC into their training., (Copyright © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions have prompted many surgical training programs to adopt a night-float resident coverage system (NF). Dissatisfaction with NF prompted us to transition to a rotating junior resident call model (Q4) with 24-hour call shifts at the outset of the 2007-2008 academic year. We performed a prospective study to determine the influence of this transition on resident education, morale, and quality of life, as well as on ACGME work rule compliance and American Board of Surgery In-Training Examination (ABSITE) scores., Methods: Residents were surveyed after 1 year of NF and again 1 year after the introduction of Q4. Responses to a series of statements about the influence of the call model (NF or Q4) on educational opportunities and morale were solicited. The survey used a 5-point Likert response scale (1 = complete disagreement to 5 = complete agreement). Median values of participant responses were calculated and compared using the Wilcoxon rank-sum test. Compliance with ACGME work rules, ABSITE scores, and operative case logs from the 2006-2007 and 2007-2008 academic years were also compared., Results: Residents were significantly more enthusiastic about Q4 compared with NF, particularly when asked about the influence these systems had on morale (median response = 4.0 [Q4] compared with 2.0 [NF]; p = 0.001) and engagement of residents by the teaching faculty (median response = 4.0 [Q4] compared with 1.0 [NF]; p = 0.001). Case logs revealed a similar operative experience for first-year residents irrespective of the call schedule (p = 0.51). Excellent compliance with ACGME work rules was maintained as reflected by the percentage of monthly 80-hour violations per resident months worked (3% [Q4] compared with 0.7% [NF]). No difference was observed in the ABSITE scores of first-year residents (a mean percentile point increase of 1 was found after the introduction of Q4)., Conclusions: Educational opportunities, compliance with ACGME work rules, and ABSITE scores can be preserved despite a transition from NF to Q4. Residents greatly prefer a rotating call schedule.

Background: Much has been written about the influences of Accreditation Council for Graduate Medical Education (ACGME) work restrictions, the litigious climate in American medicine, and the proliferation of subspecialty fellowships on general surgery training. Few previous studies have addressed general surgical residents' perceptions of surgical training on a national level., Methods: A 38-question Institutional Review Board-approved survey was sent via e-mail to the program directors at all ACGME-approved general surgical training programs for distribution to categorical general surgery residents. Voluntary responses to statements focusing on job satisfaction, quality of life, and the influences of operative experience, work hours, fellows, physician extenders, as well as faculty and administration on resident training were solicited., Results: Overall, 997 responses were received from residents of all clinical levels from 40 states. Most respondents were from university-based programs (79%) with a broad representation of program sizes (mean of 6 graduates per year; range 2 to 11). Residents believe that they will be prepared to enter clinical practice at the conclusion of their training (86%), that the duration of surgical training is adequate (85%), and that they are exposed to sufficient case volume and complexity (85% and 84%, respectively). Only 360 respondents (36%) believe that they are financially compensated appropriately. Although most respondents support the ACGME work-hour restrictions (70%), far fewer feel that they improve their training or patient care (46.6% and 46.8%, respectively). Most respondents are proud to be surgical residents (88%), view surgery as a rewarding profession (87%), and would choose surgery as a profession again (77%)., Conclusions: Surgical residents are positive regarding the quality of their training and life, although they feel poorly compensated for their work. Most residents intend to pursue fellowship training. Survey responses were consistent irrespective of gender, ethnicity, and program type.

Purpose: Little is known about the relationship between resident performance and patient satisfaction. To this end, our institution added housestaff-specific questions to Press-Ganey surveys (Press-Ganey, South Bend, Indiana) administered to patients. This study sought to investigate the impact residents have on patients' overall rating of care compared with faculty and nursing staff. Our hypothesis was that residents play an important but historically underappreciated role in patient satisfaction., Methods: Between April 2005 and June 2006, half of all discharged patients randomly received Press-Ganey surveys, including questions on the following categories: admissions, patient room, food, diagnostic testing, guest services, faculty/attending physician, discharge, emotional needs, housestaff, nurse practitioners, and primary nurse. responses were grouped into overall category scores and used as predictor variables for regression analysis. a separate question asked patients to rate overall care provided. Chief resident schedules and evaluation scores by faculty were provided by the Division of Surgery Education. Regression, and ANOVA models were run using JMP 6 software (JMP 6, SAS Institute, Cary, North Carolina)., Results: During this period, 49,081 patients were discharged, 24,540 surveys were mailed, and 5828 surveys were returned (24% response rate). In a simple regression analysis, the predictor variables for nursing, housestaff, and faculty accounted for 57%, 33%, and 28%, respectively, of the variation of overall rating of care delivered (p < 0.005). The actual overall score for each group varied slightly: faculty (89.8), nursing (86.6), and housestaff (84.2) (p < 0.005). In a multiple regression analysis, all predictors above were significant (p < 0.05). A small difference in scores existed between surgical (83.9) and nonsurgical (85.0) housestaff (p < 0.05). When data were sorted by surgical services, ratings of surgical housestaff ranged from a high of 86.8 (thoracic) to a low of 79.0 (orthopedics) (p < 0.05). Admission month had no significant effect on overall rating of care (range, 85-90), although comparing the means of resident scores by month (range, 81-86) showed that at the end (May-June) and at the beginning (July-Aug) of an academic year, a significant reduction in resident scores occurred (p < 0.05). The lowest score of the year (82.4) occurred in June, whereas the highest scores occurred in January-April (85-86). Resident evaluation scores by faculty and ratings of housestaff by patients were completely uncorrelated, although certain housestaff achieved significantly higher ratings by patients than others., Conclusions: Compared with faculty and residents, nurses have a greater impact on the variation of patient satisfaction. However, the actual scores given to residents, faculty, and nurses are all high. A slight difference exists in scores of surgical and nonsurgical residents. For all residents, the time of the academic year impacts resident scores positively in the middle and negatively in the beginning and end. For surgical residents clear differences exist between specialty services, but it is not apparent whether these differences are caused by individual residents or by the clinical service milieu. Residents contribute significantly to overall satisfaction, and additional investigation of the variation in resident scores is needed.