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Background: Earlier work suggested that telephone follow-up could be used in lieu of in-person follow-up after surgery, saving patients time and travel and maximizing use of scarce surgeon and facility resources. We report our experience implementing and evaluating telephone postoperative follow-up within an integrated health system., Study Design: We conducted a pre-post evaluation of a general surgery telephone postoperative clinic at a tertiary care Veterans Affairs facility from April 2015 to February 2016. Patients were offered a telephone postoperative visit from a surgical provider in lieu of an in-person clinic visit. Telephone clinic operating procedures were refined through iterative cycles of change using the Plan-Do-Study-Act method. The study period included 2 months pre-intervention and 9 months post-intervention. The primary end point was mean number of clinic visits per eligible patient before and after telephone clinic implementation. Secondary outcomes were rates of emergency department visits and readmissions before vs after telephone clinic implementation and complication rates in patients scheduled for telephone vs in-person postoperative care., Results: During the study period, 200 patients underwent eligible operations, 29 pre-intervention and 171 post-intervention. In-person clinic use decreased from 0.83 visits per eligible patient pre-intervention to 0.40 after implementation of the telephone clinic (p < 0.01). There was no difference in rates of emergency department presentation or readmission in eligible patients (0.17 visits/patient pre-intervention vs 0.12 post-intervention; p = 0.36). Complication rates were comparable for eligible patients who were and were not scheduled for telephone care (6% vs 8%; p = 0.31)., Conclusions: Telephone postoperative care can be used in select populations as a triage tool to identify patients who require in-person care and decrease overall in-person clinic use., (Published by Elsevier Inc.)

Background: The 2011 ACGME resident duty hour reform implemented additional restrictions to existing duty hour policies. Our objective was to determine the association between this reform and patient outcomes among several surgical specialties., Study Design: Patients from 5 surgical specialties (neurosurgery, obstetrics/gynecology, orthopaedic surgery, urology, and vascular surgery) were identified from the American College of Surgeons NSQIP. Data from 1 year before and 2 years after the reform was implemented were obtained for teaching and nonteaching hospitals. Hospital teaching status was defined based on the percentage of operations with a resident present intraoperatively. Difference-in-differences models were developed separately for each specialty and adjusted for patient demographics, comorbidities, procedural case-mix, and time trends. The association between duty hour reform and a composite measure of death or serious morbidity within 30 days of surgery was estimated for each specialty., Results: The unadjusted rate of death or serious morbidity decreased during the study period in both teaching and nonteaching hospitals for all surgical specialties. In multivariable analyses, there were no significant associations between duty hour reform and the composite outcomes of death or serious morbidity in the 2 years post-reform for any surgical specialty evaluated (neurosurgery: odds ratio [OR] = 0.90; 95% CI, 0.75-1.08; p = 0.26; obstetrics/gynecology: OR = 0.96; 95% CI, 0.71-1.30; p = 0.80; orthopaedic surgery: OR = 0.95; 95% CI, 0.74-1.22; p = 0.70; urology: OR = 1.16; 95% CI, 0.89-1.51; p = 0.26; vascular surgery: OR = 1.07; 95% CI, 0.93-1.22; p = 0.35)., Conclusions: Implementation of the 2011 ACGME resident duty hour reform was not associated with a significant change in patient outcomes for several surgical specialties in the 2 years after reform., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Several challenges threaten the traditional premise of graduated independence in general surgery training, leading to a lack of readiness in graduating surgeons. The objective of this study was to determine the factors contributing to faculty decisions to grant residents autonomy in the operating room, the barriers to granting this autonomy, and the factors that facilitate entrustment., Study Design: An anonymous online survey was distributed to 239 attending surgeons at 7 institutions. Questions consisted of open-ended and structured 5-point Likert scale questions. Descriptive statistics were calculated, and a qualitative analysis of free-text responses was performed to identify emergent themes., Results: There were 116 attending surgeons who responded to the survey (49%). Factors most important to increasing resident responsibility and autonomy in the operating room were the resident's observed clinical skill and the attending surgeon's confidence level with the operation. Factors believed to prevent awarding graduated responsibility and autonomy in the operating room included an increased focus on patient outcomes, a desire to increase efficiency and finish operations earlier, and expectations of attending surgeon involvement by the hospital and patients. Among themes discerned in faculty responses to an open-ended question about the greatest challenges in graduate surgical education, 47% of faculty identified work-hour regulations/time restrictions. Fourteen percent pointed to a change to a shift-work mentality and decreased ownership of responsibility for patients by residents; 13% described a lack of resident autonomy due to increased supervision requirements., Conclusions: This study identified several factors that attending surgeons report as significant limitations to transitioning autonomy to surgical residents in the operating room. These issues must be addressed in a direct manner if progressive graduated responsibility to independence is to occur in the next era of graduate surgical training., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)