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Intraoperative teaching is a critical component of surgery residents' education. Although prior studies have investigated best practices from the viewpoint of the expert educator, the perspective of the learner has been less explored. This study examined the ideal faculty teaching behaviors that optimize intraoperative teaching from the surgical residents' perspective.Using a grounded theory method, this study explored perspectives on intraoperative faculty teaching qualities of 5 focus groups of categorical clinical general surgical residents of the same postgraduate year from June to August 2021. Focus group discussions were recorded, transcribed, and coded. Emerging themes were identified, along with their corresponding subthemes.Thirty-nine general surgery residents participated in the focus groups. Overall, 6 themes emerged regarding resident priorities of intraoperative teaching, with 10 subthemes. Themes included the following: (1) character, with subthemes of caring, respect for resident, and self-control; (2) intraoperative skill, with subthemes of clinical and operative skill and modeling leadership in the operating room; (3) instructional approach; (4) feedback, with subthemes of content of feedback and debriefing; (5) discernment of resident needs, with subthemes of managing expectations, individualizing instruction, and autonomy; and (6) variety of teachers.Certain tangible strategies, such as demonstrating genuine care for the learner, using clear directional words, and giving actionable feedback, were considered vital by residents. In the development of great surgical educators, the emphasis should not be on conformity to a single idealized teaching style but should celebrate and encourage diversity of personas and teaching styles within a department or program.

LEAN was developed by Toyota to provide a systematic way to eliminate waste and standardize processes. We sought to introduce LEAN methodology to surgical residents with the goal of increasing rounding efficiency.A Kaizen event was used as a rounding efficiency improvement strategy. A multidisciplinary healthcare team participated in the event; first to identify the current state of rounds, second to create the ideal state. Value-stream maps were created and improved efficiency was seen by increased ratio of productive time to lead time.Two interventions were prioritized. The first introduced table rounds before walk rounds and the second changed the sign-out tool from Baton to Microsoft Word with file encryption. The ratio of productive time to lead time during morning rounds was higher after implementing these interventions (3.73 vs. 2.03).This Kaizen event introduced surgical trainees to LEAN and resulted in improved efficiency of morning rounds.

Background Departments within academic medical centers are typically comprised of clinical and research faculty, administrative staff, residents, and in many instances advance practice providers (APPs). Each member of these groups of people, at 1 point, took time, effort, and money to recruit, hire, and train. It is therefore important to consider ways to increase the “return on investment” of hiring each member of a department as well as maintaining a high level of department vitality. The Department of Surgery at Indiana University has never had a robust professional development program for all of its members. A challenge, therefore, presented itself of how best to increase faculty engagement in faculty development and to initiate opportunities for professional development for APPs and staff. Intervention We implemented a professional development program that focused on academic success with emphasis on teaching and leadership and tailored activities to meet the needs of each member. Professional development was promoted by targeting select groups of people within our department to engage rather than have members go to the effort of seeking development on their own. Setting The intervention occurred in the Department of Surgery at Indiana University which is comprised of ∼125 faculty, 100 residents and/or fellows, 60 APPs, and 19 lead business administrators for 6 divisions, all working within 5 downtown hospitals comprising the academic health center. Results Great effort has been placed into defining measures for each activity including measures of engagement, completion of deliverables, and tracking new leadership positions obtained by participants. Between 2014 and 2017, the number of faculty development activities that faculty attended has tripled since inception of our professional development program. Conclusions For those looking to enhance or begin a professional development program, appointing a director or vice chair to oversee and champion the initiative is key. From our experience, putting effort first into developing a junior faculty development program to capture internal motivation early on is likely best. For leadership development, selecting faculty to form faculty learning cohorts worked well. Finally, to deal with the barriers of time and competing interests, building in protected time for professional development is essential.

Physician assistants (PAs) and nurse practitioners (NPs) have established themselves as key members of the healthcare team to supplement practicing physicians in patient care. PAs and NPs are collectively referred to as "advanced providers" (APs) and work not only in primary care but in general surgery and surgical subspecialties. Studies have addressed AP integration into the profession of medicine and have examined cost and efficacy of APs, attitudes about APs among residents, and educational impact of APs, but very little literature exists that describes a formalized approach to AP integration into a department of surgery, specifically with AP/resident integration. The purpose of this paper is to describe an initiative for developing an operational improvement model for APs working with residents on surgical inpatient services in a large academic health center. The model consists of four components and each component is described in detail from discovery state towards continuous improvement. Formal professional development opportunities for APs as well as appointing a Clinical Director for Surgical APs have positively impacted AP integration into the department of surgery.

Background While teaching evaluation systems are common in academia, very little information is available regarding formal coaching and peer review of teaching performance in surgery. This article is a report on the development and implementation of a peer review of operative teaching program. Methods Our process was designed using a multistep sequential model which included developing a peer review of teaching instrument that was piloted to study the efficacy and utility of the tool. Results Thirty-nine peer reviews of teaching were conducted. Among the most frequent challenges that faculty identified were allowing residents to struggle/give autonomy, judging when to take over the case, communicating effectively, being patient, balancing education and patient safety, and giving feedback. Conclusions Our peer review of teaching program is systematic, feasible, and can be adopted by other surgery departments. Faculty’s identified strengths and challenges have been incorporated into our faculty development curricula.

OBJECTIVE Residency coordinators are valuable members of the education leadership administration. In General Surgery, program directors must devote time to both their clinical practice and as the leader of the education program for surgical residents. With the introduction of competencies and the Next Accreditation System, the responsibilities of training programs have increased, with much of the necessary day to day management being driven by the residency coordinator. The purpose of this study was to identify the current roles of a residency coordinator in surgery to determine appropriate language for a standardized job description that accurately describes the responsibilities of a program coordinator. DESIGN AND PARTICIPANTS A survey was created and distributed via email to 317 general surgery program coordinators in programs with continued, initial, or pre-accreditation status by the ACGME in October–December 2017. Questions were asked about coordinator demographics, ADS involvement, and communication with program director, recruitment, and professional development. 223 coordinators (70%) completed the survey. RESULTS Thirty-five percent of coordinators reported that their program director expects them to complete the annual ADS update in its entirety with a final review by the program director before submission, whereas 15% stated that the program director expects the program coordinator to input, update, and submit the annual ADS update without oversite from the program director. Fifty percent of program coordinators speak with their program director 2 to 4 days a week, whereas 38% speak with their program director daily. Eighty-nine percent of coordinators reported that their program directors trust them to make appropriate administrative decisions during scheduled or emergent absences. Sixty-nine percent of coordinators strongly agreed that they assist their program directors with collating and analyzing recruitment data post-recruitment season. Eighty-six percent of coordinators regularly participate in one or more professional development activities. Forty-six percent of coordinators stated that they oversee administrative staff in their office, division, or department. CONCLUSION Given the current makeup of today's residency coordinator in general surgery programs, the need for baseline qualifications and a standardized job description allowing for recruitment and retention of a coordinator capable of managing a residency along with a program director. The data from our survey indicate that most coordinators currently perform tasks and take on responsibilities of a manager, but they hold current job descriptions that do not adequately reflect the role. The current proposed ACGME revisions state that there must be a program coordinator for a residency program, citing the coordinator as an integral member of the residency leadership team. Therefore, human resource departments need a job description that identifies level of responsibility, contribution, leadership, and management required of a program coordinator.

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.

This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy.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.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.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%.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.

Background Integrated residencies are now commonplace, co-existing with categorical general surgery residencies. The purpose of this study was to define the impact of integrated programs on categorical general surgery operative volume. Methods Case logs from categorical general, integrated plastics, vascular, and thoracic surgery residents from a single institution from 2008 to 2016 were collected and analyzed. Results Integrated residents have increased the number of cases they perform that would have previously been general surgery resident cases from 11 in 2009–2010 to 1392 in 2015–2016. Despite this, there was no detrimental effect on total major cases of graduating chief residents. Conclusions Multiple integrated programs can co-exist with a general surgery program through careful collaboration and thoughtful consideration to longitudinal needs of individual trainees. As additional programs continue to be created, both integrated and categorical program directors must continue to collaborate to insure the integrity of training for all residents.

Volunteer Clinical Faculty (VCF) are essential for the education of medical students at most medical schools with regional campuses. Indiana University School of Medicine is the largest medical school in the United States, with over 1,400 medical students experiencing part or all of their medical education at nine campuses (one academic center and eight regional medical campuses). Given the large number of students learning in the community, we surveyed our VCF in 2016 to better understand their characteristics, reasons for teaching, and professional development needs. Survey participants reported personal enjoyment from teaching as their primary reason for continuing to teach, but time pressure as a limiting factor. They identified faculty development opportunities in areas of efficient teaching, giving feedback, and adapting teaching style for various learners. Interventions were designed to create a unique, state-wide model of both face-to-face and online professional development to ensure the success of our VCF.

To determine the academic contribution as measured by number of publications, citations, and National Institutes of Health (NIH) funding from PhD scientists in US departments of surgery.The number of PhD faculty working in US medical school clinical departments now exceeds the number working in basic science departments. The academic impact of PhDs in surgery has not been previously evaluated.Academic metrics for 3850 faculties at the top 55 NIH-funded university and hospital-based departments of surgery were collected using NIH RePORTER, Scopus, and departmental websites.MD/PhDs and PhDs had significantly higher numbers of publications and citations than MDs, regardless of academic or institutional rank. PhDs had the greatest proportion of NIH funding compared to both MDs and MD/PhDs. Across all academic ranks, 50.2% of PhDs had received NIH funding compared with 15.2% of MDs and 33.9% of MD/PhDs (P0.001). The proportion of PhDs with NIH funding in the top 10 departments did not differ from those working in departments ranked 11 to 50 (P = 0.456). A greater percentage of departmental PhD faculty was associated with increased rates of MD funding.The presence of dedicated research faculty with PhDs supports the academic mission of surgery departments by increasing both NIH funding and scholarly productivity. In contrast to MDs and MD/PhDs, PhDs seem to have similar levels of academic output and funding independent of the overall NIH funding environment of their department. This suggests that research programs in departments with limited resources may be enhanced by the recruitment of PhD faculty.

Objective The release of general surgery residency program rankings by Doximity and U.S. News & World Report accentuates the need to define and establish measurable standards of program quality. This study evaluated the extent to which program rankings based solely on peer nominations correlated with familiar program outcomes measures. Design Publicly available data were collected for all 254 general surgery residency programs. To generate a rudimentary outcomes-based program ranking, surgery programs were rank-ordered according to an average percentile rank that was calculated using board pass rates and the prevalence of alumni publications. A Kendall τ -b rank correlation computed the linear association between program rankings based on reputation alone and those derived from outcomes measures to validate whether reputation was a reasonable surrogate for globally judging program quality. Results For the 218 programs with complete data eligible for analysis, the mean board pass rate was 72% with a standard deviation of 14%. A total of 60 programs were placed in the 75th percentile or above for the number of publications authored by program alumni. The correlational analysis reported a significant correlation of 0.428, indicating only a moderate association between programs ranked by outcomes measures and those ranked according to reputation. Seventeen programs that were ranked in the top 30 according to reputation were also ranked in the top 30 based on outcomes measures. Conclusions This study suggests that reputation alone does not fully capture a representative snapshot of a program’s quality. Rather, the use of multiple quantifiable indicators and attributes unique to programs ought to be given more consideration when assigning ranks to denote program quality. It is advised that the interpretation and subsequent use of program rankings be met with caution until further studies can rigorously demonstrate best practices for awarding program standings.

Background To further understand how faculty promote resident autonomy in the operating room (OR), we explored their perceptions, and those of senior residents, on the behaviors and techniques they employ to foster independence. Methods Twenty postgraduate year PGY4 and PGY5 residents were asked to list 3 general surgery faculty who give the most and least autonomy to residents in the OR. Two focus groups were conducted with residents to identify behaviors and techniques for promoting autonomy from the resident perspective. Individual semistructured interviews were conducted with top-rated and low-rated faculty to identify behaviors and techniques from the attending perspective. Results Behaviors and techniques faculty exhibit to promote increased autonomy included allowing residents time to struggle, letting residents begin case themselves, and forcing residents to think about steps of procedure before case. The main “triggers” for granting autonomy were increased familiarity and trust with resident's capabilities, how well resident comes prepared to OR, and faculty confidence that they can “fix anything.” Reasons why low-rated faculty seldom give autonomy included feeling a deep moral obligation for personally seeing patient through the operation, residents not coming fully prepared to perform case, and being young in their own maturation process. Conclusion Our results suggest that increased autonomy depends greatly on establishing a trusting relationship between faculty and resident; a partnership that can only happen when time is given for trust to mature. Program directors must work to refine the training paradigm in order to build relationships. Residents can also be coached to demonstrate increased OR preparedness.

Surgeons are most likely to fill the role of communicating adverse outcomes following surgery and nearly two-thirds are faced with conveying the news of death during surgery. However, surgeon-patient communication research focuses primarily on presurgery issues such as recommendations and decision making rather than improvement of postsurgical communication. Several studies have examined the consequences of avoiding adverse event disclosure, but as yet, there is no conceptual framework for understanding why these interactions are difficult. In this reflection, we propose that 3 dimensions (relational distance, information-poor environment, and physical harm to patients) distinguish the adverse event context from other physician-patient encounters. We conclude by offering recommendations for educational and research efforts, drawing attention to empathy in the surgical context and barriers to empathic disclosure more broadly.

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.

Clinical Assessment and Management Examination--Outpatient (CAMEO) is a metric for evaluating the clinical performance of surgery residents. The aim of this study was to investigate the measurement characteristics of CAMEO and propose how it might be used as an evaluation tool within the general surgery milestones project.A total of 117 CAMEO evaluations were gathered and used for analysis. Internal consistency reliability was estimated, and item characteristics were explored. A Kruskal-Wallis procedure was performed to discern how well the instrument discriminated between training levels. An exploratory factor analysis was also conducted to understand the dimensionality of the evaluation.CAMEO evaluations were collected from 2 departments of surgery geographically located in the Midwestern United States. Combined, the participating academic institutions graduate approximately 18 general surgery residents per year.In this retrospective data analysis, the number of evaluations per resident ranged from 1 to 7, and evaluations were collected from 2006 to 2013. For the purpose of data analysis, residents were classified as interns (postgraduate year 1 [PGY1]), juniors (PGY2-3), or seniors (PGY4-5).CAMEO scores were found to have high internal consistency (Cronbach's α = 0.96), and all items were highly correlated (≥ 0.86) to composite CAMEO scores. Scores discriminated between senior residents (PGY4-5) and lower level residents (PGY1-3). Per an exploratory factor analysis, CAMEO was revealed to measure a single dimension of "clinical competence."The findings of this research aligned with related literature and verified that CAMEO scores have desirable measurement properties, making CAMEO an attractive resource for evaluating the clinical performance of surgery residents.

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.

Background Guidance in the operating room impacts resident confidence and ability to function independently. The purpose of this study was to explore attending surgeon guidance practices in the operating room as reported by faculty members themselves and by junior and senior residents. Methods This was an exploratory, cross-sectional survey research study involving 91 categorical residents and 82 clinical faculty members at two academic general surgery training programs. A series of analyses of variance along with descriptive statistics were performed to understand the impact of resident training year, program, and surgeon characteristics (sex and type of surgery performed routinely) on guidance practices. Results Resident level (junior versus senior) significantly impacted the amount of guidance given as reported by faculty and as perceived by residents. Within each program, junior residents perceived less guidance than faculty reported giving. For senior guidance practices, however, the differences between faculty and resident practices varied by program. In terms of the effects of surgeon practice type (mostly general versus mostly complex cases), residents at both institutions felt they were more supervised closely by the faculty who perform mostly complex cases. Conclusion More autonomy is given to senior than to junior residents. Additionally, faculty report a greater amount of change in their guidance practices over the training period than residents perceive. Faculty and resident agreement about the need for guidance and for autonomy are important for achieving the goals of residency training.

Objective In an attempt to better define the success of our residency program with regard to resident development, we committed to develop an ongoing assessment of residency performance and devised an outcomes assessment system. Design We describe the process and structure that we used to construct an outcomes assessment system. We discuss the process we used to discern whether or not our program is successful as well as offer tips on what data to collect and track should other residency programs decide to devise a similar outcomes assessment database. Conclusion Taking time to “step back” to take inventory of a residency program and ensure year over year and at the end of training residents have developed and matured as planned is an educationally sound practice. Structuring an outcomes assessment system like the one that we discuss here can aid program directors with this important task.

Background PhD and EdD educators in departments of surgery have and are increasingly becoming valuable colleagues. Professional educators typically assist chairpersons and program directors by positively impacting the education, research, and service missions. Objective The purpose of this article is 3-fold: (1) to identify ways of finding prospective PhD/EdD educators, (2) to recognize ways to work with educators in a complimentary way so the educator and directors mutually benefit, and (3) to identify various ways departments and programs can benefit from employing a professional educator.

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.

In 1999, the Indiana University School of Medicine implemented a new curriculum based on the attainment of core competencies beyond medical knowledge.The objective was to document how the Student Promotions Committee (SPC) has adjudicated students' competency-related deficiencies over the past decade.Using SPC records, the authors determined the frequency of competency-related deficiencies reported to the SPC over time, the nature of those deficiencies, and how the deficiencies were remediated. For the purposes of this study, traditional knowledge-related deficiencies like course failures were excluded from analysis.From 1999 to 2009, 191 students (138 male, 53 female) were referred to the SPC for competency-related deficiencies in 8 performance domains involving communication, basic clinical skills, lifelong learning, self-awareness, social context, ethics, problem solving, and professionalism. By comparison, 1,090 students were referred to the SPC for knowledge-related deficiencies during this time. Collectively, the 191 students were cited for 317 separate competency-related deficiencies (M ± SD = 1.7 ± 1.3; range = 1-10). Of these 317 deficiencies, the most prevalent were in the competencies of professionalism (29.3%), basic clinical skills (28.4%), and self-awareness (17.7%). Each of the remaining competencies constituted less than 10% of the total. Successful remediation utilized 12 methods ranging from a simple warning letter to repeating the year under close monitoring. Remediation was unsuccessful for 17 students (8.9%) who were dismissed from medical school primarily due to unprofessional behaviors and poor self-awareness.Competency-related deficiencies can be identified and remediated in most cases, but deficiencies in professionalism and self-awareness are especially challenging.

Background Surgical residency training is evolving, and trainees who wish to practice hepato-pancreato-biliary (HPB) surgery in the future will be required to obtain advanced training. As this paradigm evolves, it is crucial that HPB fellowship incorporation into an established surgical residency programme does not diminish surgical residents' exposure to complex HPB procedures. We hypothesized that incorporation of a HPB fellowship in a high-volume clinical training programme would not detract from residents' HPB experience. Methods Resident operative case logs and HPB fellow case logs were reviewed. Resident exposure to complex HPB procedures for 3 years prior to and 3 years after fellowship incorporation were compared. Results No significant changes in surgical resident exposure to liver and pancreatic resection were seen between the two time periods. Surgical resident exposure to complex biliary procedures decreased in the 3 years after HPB fellowship incorporation ( P = 0.003); however, exceeded the national average in each year except 2006. Graduating residents' overall HPB experience was unchanged in the 3 years prior to and after incorporating an HPB fellow. Expansion of HPB volume was a critical part of successful HPB fellowship implementation. Discussion An HPB fellowship programme can be incorporated into a high-volume clinical training programme without detracting from resident HPB experience. Individual training programmes should carefully assess their capability to provide an adequate clinical experience for fellows without diminishing resident exposure to complex HPB procedures.

The Accreditation Council for Graduate Medical Education (ACGME) has mandated a shift from a structure- and process-based educational system to a competency-based system. The ACGME has not provided criteria (standards), preferring to leave that to the discretion of the individual training programs. Such criteria and an overall strong evaluation process are essential for residents to attain the appropriate knowledge, skills, and attitudes. With this need in mind, the authors describe an evaluation process in which they developed ACGME-competency-based promotion criteria for family medicine residents at the University of Kentucky College of Medicine in 2004. The authors thought that by providing residents and faculty with minimum criteria that residents must demonstrate at each level, the residency program could address the ACGME mandate to provide competency-based training and improve residents' progress toward promotion. Along with the promotion criteria, the method of instruction and the setting for each criterion were identified. Tools were developed to assess the criteria, including a computer-based "same day preceptor evaluation", a resident portfolio, and multisource feedback instruments. This information was formatted into a matrix. Making the task and criteria clearer to learners allows them to better demonstrate what is expected of them. Residency educators can target remediation in those residents failing to meet the criteria and improve faculty skills, especially in terms of how to train for and assess competence. The authors describe the initial use of the promotion criteria, including how the faculty and residents responded to it.

Support of surgical education is critical for the future viability of United States healthcare. This is particularly important in the current era where there is predicted to be significant shortages in physicians, especially primary care and general surgeons, due to an aging population and an increasing number of insured individuals through the Affordable Care Act (ACA). Surgical education must constantly evolve to incorporate new technologies and discoveries to meet the changing demands on future surgeons and the needs of patients. Thus, it requires a tremendous investment of time, effort, money, and resources. Federal and state government support of graduate medical education is declining, and significant cuts to future funding are predicted. With increasing financial pressures both internally and externally, the investment in surgical education will require far more support than surplus clinical dollars of departments of surgery. The business and finance of surgical education has become quite complex, and optimally going forward education programs would have strong and multidimensional (hospital, school of medicine, department) advocacy, experienced surgeon leaders with formal education in business and education and/or supportive staff with formal education in business and education. Creative approaches and solutions to financing surgical education are needed, so we can maintain the viability of the system to produce a high-quality surgeon work force trained to address the public needs.

Historically, the surgery clerkship at the Indiana University School of Medicine (IUSM) has received poor evaluations from medical students, and the authors of this article hypothesized that this negative feedback may reflect, at least in part, inherent differences in the personality styles of the learners compared with those of the surgery teachers (faculty and residents). Differences between teachers and learners could impede effective communication and impact adversely students' perception of, and satisfaction with, the learning environment. The objective of this study was to compare the inherent personality styles of surgery teachers and medical students.Using the Myers-Briggs Type Indicator (MBTI) to assess personality styles, we administered the instrument to 154 teachers in the surgery department and to 1395 medical students. Aggregate MBTI data for teachers and learners were analyzed based on four dichotomous scales. Chi square tests of independence were performed to examine the relationship between teachers and learners on the MBTI scales.The study was undertaken at IUSM, which has been engaged in a process of cultural change for over 10 years, in part to ensure that both the formal curriculum and the learning environment support the development of self-awareness and professionalism among our graduates.We found that teachers were similar to learners on the Introversion/Extraversion scale and dissimilar from learners on the three remaining scales: Sensing/Intuition scale (p0.008), Thinking/Feeling scale (p0.000), and the Judging/Perceiving scale (p0.022).These results suggest that differences in personality styles may affect the teacher-learner interaction during the surgery clerkship and may influence negatively students' perception of the learning environment.

Although ethics education in undergraduate medical school curricula has become essentially universal, and because ethics and professionalism have become integral parts of competency-based curricula for residents in nearly all specialties of medicine and surgery, it is not clear to what extent postgraduate surgical training routinely includes ethics education or skills training. Most general surgery residencies do not routinely integrate in-depth ethics skills training and assessment into their didactic curricula. In this article, we review the literature concerning ethics education in postgraduate surgical training programs. The few studies in the literature suggest that ethics education, when integrated in surgical residency curricula, can lead to measurable improvements in resident-centered outcomes, which include knowledge and confidence in handling ethical dilemmas. These curricula may lead to improvements in patient care. These findings suggest that ethics education for surgical residents is valuable but that questions regarding the optimal "dose" of ethics education and training as well as the optimal teaching methods would benefit from extended systematic evaluation and inquiry.

Background This study sought to determine to what extent surgery programs are remediating residents who fail to achieve competency and to offer remediation strategies. Methods A web-based survey was e-mailed to 253 program directors of all US surgery residency programs. Questions were asked about remediation and probation practices for residents failing to meet the competencies. Results Programs seem to struggle the least with knowing how to remediate medical knowledge and patient care deficits and struggle more with professionalism and interpersonal communication skills. Most programs have no remediation methods in place for systems-based practice and practice-based learning and improvement deficits. Conclusions Surgery residency programs are cognizant of the reality that some residents perform unsatisfactorily. Most have remediation plans for residents and understand that a process needs to be in place. Remediation methods tend to vary depending on the deficit and are devised tailored to the resident's needs.

Hypothesis Surgery residents can learn continuous quality improvement (CQI) principles within a structured curriculum and propose quality improvement projects. Design Curriculum within a surgical residency program. Setting A university surgical residency program with multiple hospital training sites. Participants Fifteen surgical residents during the dedicated research year. Intervention A curriculum in CQI that focuses on devising a quality improvement project. Main Outcome Measures Resident self-reported attitudes about quality improvement and implementation of resident-initiated quality improvement projects. Results Resident survey data demonstrated an improvement in knowledge, self-efficacy, and experiences within CQI. Fifteen individual residents, within smaller teams, created 4 quality improvement projects worthy of implementation. Conclusions A structured CQI curriculum can be successfully integrated into a general surgery residency program. Residents can learn the skill of constructing CQI project ideas within the framework of the plan-do-study-act cycle. Residents are eager to make improvements in their local system of residency. By giving them the tools to critically investigate systems improvement and a much needed ear to hear their concerns and suggestions for improvement, we found ways to potentially enhance patient care and developed ideas to improve the education of future surgeons. In doing so, we provided the residents with “buy-in” into their residency program, while addressing the competency of practice-based learning and improvement required by the Accreditation Council for Graduate Medical Education for resident education.

Relatively little is known about how medical genetics is being taught in the undergraduate medical curriculum and whether educators concur regarding topical priority. This study sought to document the current state of medical genetics education in U.S. and Canadian accredited medical schools.In August 2004, surveys were sent from the Indiana University School of Medicine to 149 U.S. and Canadian medical genetics course directors or curricular deans. Returned surveys were collected through June 2005. Participants were asked about material covered, number of contact hours, year in which the course was offered, and what department sponsored the course. Data were collated according to instructional method and course content.The response rate was 75.2%. Most respondents (77%) taught medical genetics in the first year of medical school; only half (47%) reported that medical genetics was incorporated into the third and fourth years. About two thirds of respondents (62%) devoted 20 to 40 hours to medical genetics instruction, which was largely concerned with general concepts (86%) rather than practical application (11%). Forty-six percent of respondents reported teaching a stand-alone course versus 54% who integrated medical genetics into another course. Topics most commonly taught were cancer genetics (94.2%), multifactorial inheritance (91.3%), Mendelian disorders (90.3%), clinical cytogenetics (89.3%), and patterns of inheritance (87.4%).The findings provide important baseline data relative to guidelines recently established by the Association of American Medical Colleges. Ultimately, improved genetics curricula will help train physicians who are knowledgeable and comfortable discussing and answering questions about genetics with their patients.

References 1. Fitzpatrick JL, Sanders JR, Worthen BR. Program Evaluation: Alternative Approaches and Practical Guidelines. 4th ed. Upper Saddle River, NJ: Pearson Education; 2011. 2. Christie CA, Alkin MC. An evaluation theory tree. In: Alkin MC, ed. Evaluation Roots. 2nd ed. Thousand Oaks, CA: Sage; 2013:11–57. 3. Stufflebeam DL. The relevance of the CIPP evaluation model for educational accountability. J Res Dev Educ. 1971;5:19–25. 4. Durning SJ, Hemmer P, Pangaro LN. The structure of program evaluation: An approach for evaluating a course, clerkship, or components of a residency or fellowship training program. Teach Learn Med. 2007;19:308–318. 5. Musick DW. A conceptual model for program evaluation in graduate medical education. Acad Med. 2006;81:759–765. Author contact: Rebecca.BlanchardPhD@baystatehealth.org Program evaluation, or programmatic assessment, is the application of defensible criteria to determine the worth or merit of a program, project, or curriculum.1 “Decision-oriented,” “outcomes-oriented,” and “expert-oriented” are three common approaches to program evaluation1 in medical education. This snapshot provides a brief review of program evaluation within each approach along the following dimensions: Do internal stakeholders or external stakeholders drive the evaluation? Is the evaluation examining a broad scope of the program or delving deeply into one or two particular aspects in greater detail? Is this evaluation reasonably straightforward to complete, or does it require specialized knowledge and resources? Do the evaluation results benefit local decision makers or those in a broader audience? Does the evaluation rely on a theory, or is it largely atheoretical?

Purpose - International Medical Graduates (IMGs) are increasingly filling Family Medicine residency positions. (1) To what extent are residency programs recruiting and accepting IMG applicants? (2) What are program directors’ perceptions of IMG applicants? (3) What program characteristics are associated with their practices and perceptions? Methods - A 2002 national survey of Family Medicine program directors assessed program demographics and directors’ recruiting practices and perceptions regarding IMG applicants. Results - Although 88% of respondents would rank IMG applicants, only 40% agreed that they would perform as well as U.S. graduates. Programs with IMG faculty were more likely to have IMG residents (p