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Objectives: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs., Background: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown., Methods: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences., Results: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199)., Conclusions: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: ChatGPT-4 is a large language model with possible applications to surgery education The aim of this study was to investigate the accuracy of ChatGPT-4's surgical decision-making compared with general surgery residents and attending surgeons., Methods: Five clinical scenarios were created from actual patient data based on common general surgery diagnoses. Scripts were developed to sequentially provide clinical information and ask decision-making questions. Responses to the prompts were scored based on a standardized rubric for a total of 50 points. Each clinical scenario was run through Chat GPT-4 and sent electronically to all general surgery residents and attendings at a single institution. Scores were compared using Wilcoxon rank sum tests., Results: On average, ChatGPT-4 scored 39.6 points (79.2%, standard deviation ± 0.89 points). A total of five junior residents, 12 senior residents, and five attendings completed the clinical scenarios (resident response rate = 15.9%; attending response rate = 13.8%). On average, the junior residents scored a total of 33.4 (66.8%, standard deviation ± 3.29), senior residents 38.0 (76.0%, standard deviation ± 4.75), and attendings 38.8 (77.6%, standard deviation ± 5.45). ChatGPT-4 scored significantly better than junior residents (P = .009) but was not significantly different from senior residents or attendings. ChatGPT-4 was significantly better than junior residents at identifying the correct operation to perform (P = .0182) and recommending additional workup for postoperative complications (P = .012)., Conclusion: ChatGPT-4 performed superior to junior residents and equivalent to senior residents and attendings when faced with surgical patient scenarios. Large language models, such as ChatGPT, may have the potential to be an educational resource for junior residents to develop surgical decision-making skills., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Patient satisfaction is an increasingly important quality metric nationwide. The impact that surgical trainees have on patient-reported satisfaction when they perform operations independently, however, has not been studied., Methods: We conducted a prospective study at a single academic institution from October 2016 to June 2017. An office-based, postprocedure survey was developed by adapting questions from the validated Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey. Top-box scoring was used to determine satisfaction for categorical questions and a comparison of the means was used for overall quality ratings (scale 0-10). Patients indicated whether their operation was completed by an attending surgeon or a postgraduate year 3 general surgery resident. The primary outcome measured was patient satisfaction with overall quality of care. Individual questions were grouped by phase of care and composite scores were measured as a secondary outcome., Results: The survey response rate was 87.4% (n = 195). There were no differences in patient demographics or the types of procedures performed by residents or an attending surgeon. Excision of a soft tissue mass (ie, lipoma) accounted for 89.2% of all procedures performed (n = 174). There were no differences between preprocedure (resident = 92.5% vs attending = 94.2%) or postprocedure (resident = 95.3% vs attending = 97.7%) composite scores. There was, however, a significant difference in periprocedure satisfaction (resident = 78.7% vs attending = 90.7%, P = .02). There was no difference in overall ratings of quality of care given by patients who had their procedure performed by residents (9.8 ± 0.5) versus an attending surgeon (9.9 ± 0.3, P = .15). Finally, on adjusted analysis, resident care did not independently impact the likelihood of a "best possible care" rating for overall quality of care (odds ratio 0.84 ± 0.27, confidence interval 0.45-1.57, P = .58)., Conclusion: Patient satisfaction was very high when residents independently performed minor surgery operations in an office-based setting. Of note, there was no difference in satisfaction with overall quality of care compared with an attending surgeon. This study demonstrates that high resident operative autonomy and patient satisfaction are not mutually exclusive goals when postgraduate year 3 residents perform office-based outpatient procedures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality., Methods: Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as "practice ready performance/meaningfully autonomous" or "not practice ready/not meaningfully autonomous." Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy., Results: A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion., Conclusion: Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Ineffective cross-cultural communication contributes to adverse outcomes for minority patients. To address this, the authors developed a novel curriculum for surgical residents built on the principle of cultural dexterity, emphasizing adaptability to clinical and sociocultural circumstances to tailor care to the needs of the individual patient. This study's objective was to evaluate the feasibility, acceptability, and perception of this program upon conclusion of its first year., Design, Setting, and Participants: The curriculum was implemented at 3 general surgery programs. The flipped classroom model combined independent study via e-learning modules with interactive role-playing sessions. Sessions took place over 1 academic year. Four focus groups were held, each with 6 to 9 participants, to gain feedback on the curriculum. Focus groups were recorded and transcribed, and the data were analyzed using a grounded theory approach., Results: Five major themes emerged: (1) Role modeling from senior colleagues is integral in developing communication/interpersonal skills and attitudes toward cultural dexterity. (2) Cultural dexterity is relevant to the provision of high-quality surgical care. (3) Barriers to providing culturally dexterous care exist at the system level. (4) "Buy-in" at all levels of the institution is necessary to implement the principles of cultural dexterity. (5) The shared experience of discussing the challenges and triumphs of caring for a diverse population was engaging and impactful., Conclusion: Early implementation of the curriculum revealed that the tension between surgical residents' desire to improve their cultural dexterity and systemic/practical obstacles can be resolved. Combining surgically relevant didactic materials with experiential learning activities can change the paradigm of cross-cultural training., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Concerns exist regarding the competency of general surgery graduates with performing core general surgery procedures. Current competence assessment incorporates minimal procedural numbers requirements., Methods: Based on the Zwisch scale we evaluated the level of autonomy achieved by categorical PGY1-5 general surgery residents at 14 U.S. general surgery resident training programs between September 1, 2015 and December 31, 2016. With 5 of the most commonly performed core general surgery procedures, we correlated the level of autonomy achieved by each resident with the number of procedures they had performed before the evaluation period, with the intent of identifying specific target numbers that would correlate with the achievement of meaningful autonomy for each procedure with most residents., Results: Whereas a definitive target number was identified for laparoscopic appendectomy (i.e. 25), for the other 4 procedures studied (i.e. laparoscopic cholecystectomy, 52; open inguinal hernia repair, 42; ventral hernia repair, 35; and partial colectomy, 60), target numbers identified were less definitive and/or were higher than many residents will experience during their surgical residency training., Conclusions: We conclude that procedural target numbers are generally not effective in predicting procedural competence and should not be used as the basis for determining residents' readiness for independent practice., (Copyright © 2017. Published by Elsevier Inc.)

Background: Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents., Methods: We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty., Results: Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74)., Conclusion: Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy., Background: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role., Methods: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation., Results: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%., Conclusions: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Objective: General surgery training has evolved to align with changes in work hour restrictions, supervision regulations, and reimbursement practices. This has culminated in a lack of operative autonomy, leaving residents feeling inadequately prepared to perform surgery independently when beginning fellowship or practice. A resident-run minor surgery clinic increases junior resident autonomy, but its effects on patient outcomes have not been formally established. This pilot study evaluated the safety of implementing a resident-run minor surgery clinic within a university-based general surgery training program., Design: Single institution case-control pilot study of a resident-run minor surgery clinic from 9/2014 to 6/2015. Rotating third-year residents staffed the clinic once weekly. Residents performed operations independently in their own procedure room. A supervising attending surgeon staffed each case prior to residents performing the procedure and viewed the surgical site before wound closure. Postprocedure patient complications and admissions to the hospital because of a complication were analyzed and compared with an attending control cohort., Setting: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program., Participants: Ten third-year general surgery residents., Results: Overall, 341 patients underwent a total of 399 procedures (110 in the resident clinic vs. 289 in the attending clinic). Minor surgeries included soft tissue mass excision (n = 275), abscess incision and drainage (n = 66), skin lesion excision (n = 37), skin tag removal (n = 15), and lymph node excision (n = 6). There was no significant difference in the overall rate of patients developing a postprocedure complication within 30 days (3.6% resident vs. 2.8% attending; p = 0.65); which persisted on multivariate analysis. Similar findings were observed for the rate of hospital admission resulting from a complication. Resident evaluations overwhelmingly supported the rotation, citing increased operative autonomy as the greatest strength., Conclusions: Implementation of a resident-run minor surgery clinic is a safe and effective method to increase trainee operative autonomy. The rotation is well suited for mid-level residents, as it provides an opportunity for realistic self-evaluation and focused learning that may enhance their operative experience during senior level rotations., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs., Methods: Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail., Results: A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures., Conclusions: SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed., (Copyright © 2016. Published by Elsevier Inc.)

Purpose: Some General Surgery Milestones can be difficult to assess in traditional clinical settings and especially difficult to assess in junior residents. The purpose of this pilot study was to METHODS: A total of 9 categorical interns participated in a comprehensive, 4-module, SP scenario designed to evaluate and manage right upper quadrant pain. SP checklist scores (SP%) were converted to Milestone-equivalent scores for direct comparison (SP-C). Milestone scores were analyzed from 3 different sources: SP, faculty (FAC), and CCC. Interns completed course evaluations at the end of each session. Spearman's rho was used to determine correlations. Wilcoxon signed rank tests were used to test for differences between scores from different sources., Results: Individual intern Milestone scores from the 3 sources (SP-C, FAC, and CCC) did not correlate. All 7 mean Milestone scores from SPs were significantly higher than from FAC and CCC. FAC and CCC scores were statistically equivalent except for Systems-Based Practice 1 (SBP1) and Patient Care 3 (PC3) where CCC scores were significantly higher than FAC. Mean SP% scores for PC1 were significantly lower than for PROF1, MK1, MK2, and ICS1 (p < 0.05). Interns felt the modules were moderately to very useful., Conclusions: Developing an SP scenario for Milestones evaluation is feasible. SPs, faculty observers, and CCC each use different data to provide a unique source of Milestone assessment. SP scenarios may be ideally suited to assess specific resident strengths and weaknesses and provide individualized feedback, thus augmenting traditional evaluations. Additional SP scenarios, assessing a broader range of skills and Milestones, are advisable for more reliable estimates of resident performance., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: A nondesignated preliminary surgery (NDPS) position encompasses 1 year of training provided by many general surgery residencies. Our aim was to assess factors predicting success and provide evidence for program directors to support career guidance to preliminary residents., Methods: Retrospective cohort study of 221 NDPS residents who entered 5 university-based institutions were identified from 2009 to 2013. Records for trainees were reviewed. We defined primary success as obtaining a categorical position in the specialty of choice and secondary success as obtaining a categorical position in any specialty immediately after finishing their NDPS training. Statistical evaluation was performed using chi-square analysis, independent t-test and logistic regression using α <0.05., Results: Of the 221 NDPS residents, 217 (98%) completed postgraduate year (PGY)-1 and 65 (29%) completed PGY-2. Totally, 90 (41%) obtained categorical general surgery positions, 89 (40%) obtained categorical positions in other specialties, and 42 (19%) failed to obtain a categorical position immediately after their NDPS years. Ultimately, 139 (63%) of residents achieved primary success and 40 (18%) additional residents obtained categorical positions in specialties other than their first choice, resulting in a total of 179 (81%) of residents obtaining categorical positions. Mean United States Medical Licensing Examination step 1 and step 2 scores for those who obtained secondary success were 227 and 234 vs. 214 and 219, respectively, for those who failed to secure a categorical position (p < 0.01). United States Medical Licensing Examination step 2 score was a significant predictor of primary (p < 0.03) and secondary success (p < 0.02). Of 65 PGY-2 NDPS residents, 32 (49%) achieved primary success, and 11 (17%) others achieved secondary success for a total of 43 (66%). For PGY-2 NDPS, American Board of Surgery In-Training Examination was the only significant predictor of primary and secondary success (p < 0.02 and p < 0.05)., Conclusions: NDPS training provides a viable and successful opportunity for at least 81% of young physicians to pursue their career goals even after an unsuccessful first match., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Milestones evaluations in plastic surgery reflect a shift toward competency-based training but have created a number of challenges. The authors have incorporated the smartphone application evaluation tool, System for Improving and Measuring Procedural Learning (SIMPL), that was recently developed by a multi-institutional research collaborative. In this pilot study, the authors hypothesize that SIMPL can improve resident evaluation and also collect granular performance data to simplify compliance with the plastic surgery Milestones., Methods: SIMPL was prospectively piloted with a plastic surgery resident and faculty surgeon at Massachusetts General Hospital in this institutional review board-approved study. The study period was a 2-month interval corresponding to the resident's rotation., Results: The resident-faculty combination performed 20 cases together. All cases were evaluated with SIMPL. SIMPL evaluations uniformly took under 1 minute to submit. The average time to completed evaluation from surgery completion was 5 hours (<0.5 hour to 12 hours). Concrete, objective, and specific data about resident performance were collected for every case and presented in a concise format., Conclusions: SIMPL is an innovative, evidence-based evaluation system that makes performance assessment feasible for every procedure in which a plastic surgery resident participates. SIMPL's competency-based framework can be easily scaled to facilitate data collection and reporting of mandatory Milestones evaluations at the program and national levels. This technology will support a shared vocabulary between residents and faculty to enhance intraoperative education.

Purpose: There remains a debate as to whether nondesignated preliminary (NDP) positions in surgery ultimately translate into successful surgical careers for those who pursue them. We sought to identify the success with which our NDP residents were able to transition to their desired career and what, if any, factors contributed to their success., Methods: The records of all NDP residents accepted into the Massachusetts General Hospital General Surgery Residency Program from 1995 to 2010 were examined and long-term follow-up was completed., Results: Thirty-four NDP residents were identified, including 26.5% US graduates and 73.5% international medical graduates. At the end of the initial preliminary year, 30 (88%) got placed in a postgraduate residency program, whereas 4 (12%) pursued other career paths. Of those who got placed, 25 (83%) attained surgical residency positions, including 17 (57%) who continued as preliminary residents at our institution and 8 (27%) who got placed in categorical surgical positions at other programs. After multiple preliminary years, 15 of 17 achieved a categorical position, of which, 93% were in surgical fields. Overall, 64.7% of all entering NDP residents eventually went on to have careers in general surgery (50%) or surgical subspecialties (14.7%), and 24 of 34 (71%) fulfilled their desired career goals. No factor predicted success. From 1995 to 2012 there have been 15 midlevel (11 postgraduate year 4) vacancies in our program, 4 of which were filled by preliminary residents, 2 from our program and 2 from elsewhere. All have gone on to board certifications and careers in surgery., Conclusions: More than 70% of NDP residents in our program successfully transitioned to their desired career paths, many achieving categorical surgical positions and academic surgical careers, thus demonstrating the benefit of this track to both residency programs and trainees., (© 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)