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There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship.Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed.There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P.01) and graduate from a high-volume program (49.2% vs 33.0%, P.01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P.01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P.01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P.01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P.01).This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Background: Recent data suggest that acidosis alone is not a good predictor of mortality in trauma patients. Little data are currently available regarding factors associated with survival in trauma patients presenting with acidosis. Aims: The aims were to characterize the outcomes of trauma patients presenting with acidosis and to identify modifiable risk factors associated with mortality in these patients. Settings and Design: This is a retrospective observational study of University of Arkansas for Medical Sciences (UAMS) trauma patients between November 23, 2013, and May 21, 2017. Methods: Data were collected from the UAMS trauma registry. The primary outcome was hospital mortality. Analyses were performed using t-test and Pearson's Chi-squared test. Simple and multiple logistic regressions were performed to determine crude and adjusted odds ratios. Results: There were 532 patients identified and 64.7% were acidotic (pH < 7.35) on presentation: 75.9% pH 7.2–7.35; 18.5% pH 7.0–7.2; and 5.6% pH ≤ 7.0. The total hospital mortality was 23.7%. Nonsurvivors were older and more acidotic, with a base deficit >−8, Glasgow Coma Scale (GCS) ≤ 8, systolic blood pressure ≤ 90, International Normalized Ratio (INR) >1.6, and Injury Severity Score (ISS) >15. Mortality was significantly higher with a pH ≤ 7.2 but mortality with a pH 7.2–7.35 was comparable to pH > 7.35. In the adjusted model, pH ≤ 7.0, pH 7.0–7.2, INR > 1.6, GCS ≤ 8, and ISS > 15 were associated with increased mortality. For patients with a pH ≤ 7.2, only INR was associated with increase in mortality. Conclusions: A pH ≤ 7.2 is associated with increased mortality. For patients in this range, only the presence of coagulopathy is associated with increased mortality. A pH > 7.2 may be an appropriate treatment goal for acidosis. Further work is needed to identify and target potentially modifiable factors in patients with acidosis such as coagulopathy.

Background Burnout affects surgical residents’ well-being. Objective We sought to identify factors associated with burnout among surgery residents. Methods An electronic/anonymous survey was sent to surgical residents at 18 programs, consisting of demographic/programmatic questions and validated scales for burnout, depression, perceived stress, self-efficacy, and social support. Residents were grouped into quartiles based off burnout, and predictors were assessed using univariate and multivariate analyses. Results 42% of residents surveyed completed it. Burnout was associated with depression, higher perceived stress/debt, fewer weekends off, less programmatic social events, and residents were less likely to reconsider surgery if given the chance. Low burnout was associated with lower depression/stress, higher social support/self-efficacy, more weekends off per month, program mentorship, lower debt, and residents being more likely to choose surgery again if given the chance. On multivariate analysis, higher depression/perceived stress were associated with burnout, and lower burnout scores were associated with lower stress/higher self-efficacy. Conclusions Burnout in surgery residents is associated with higher levels of depression and perceived stress. The addition of programmatic social events, limiting weekend work, and formal mentoring programs may decrease burnout.

The optimization of intensive care unit (ICU) care impacts clinical outcomes and resource utilization. In 2017, our surgical ICU (SICU) adopted a "closed-collaborative" model. The aim of this study is to compare patient outcomes in the closed-collaborative model versus the previous open model in a cohort of trauma surgical patients admitted to our adult level 1 trauma center.A retrospective review of trauma patients in the SICU from August 1, 2015 to July 31, 2019 was performed. Patients were divided into those admitted prior to August 1, 2017 (the "open" cohort) and those admitted after August 1, 2017 (the "closed-collaborative" cohort). Demographic variables and clinical outcomes were analyzed. Trauma severity was assessed using injury severity score (ISS).We identified 1669 patients (O: 895; C: 774). While no differences in demographics were observed, the closed-collaborative cohort had a higher overall ISS (O: 21.5 ± 12.14; C: 25.10 ± 2.72; P 0.0001). There were no significant differences between the two cohorts in the incidence of strokes (O: 1.90%; C: 2.58%, P = 0.3435), pulmonary embolism (O: 0.78%; C: 0.65%; P = 0.7427), sepsis (O: 5.25%; C: 7.49%; P = 0.0599), median ICU charges (O: $7784.50; C: $8986.53; P = 0.5286), mortality (O: 11.40%; C: 13.18%; P = 0.2678), or ICU length of stay (LOS) (O: 4.85 ± 6.23; C: 4.37 ± 4.94; P = 0.0795).Patients in the closed-collaborative cohort had similar clinical outcomes despite having a sicker cohort of patients. We hypothesize that the closed-collaborative ICU model was able to maintain equivalent outcomes due to the dedicated multidisciplinary critical care team caring for these patients. Further research is warranted to determine the optimal model of ICU care for trauma patients.

A near-peer teaching experience for upper-level medical students could help prepare them for surgical residency by providing specific education opportunities and exposure to the field of surgery. Five medical students were selected to be near-peer teachers (NPTs) in gross anatomy, and then they reflected on their experiences. The NPTs spent the majority of effort in a teaching role, and reported improved NTS, anatomy knowledge, and dissection skills. MS1s and faculty also reported on the value of the ASP. Further development and evaluation of the ASP may be an excellent opportunity for future surgeons.

BACKGROUND Web analytics is the measurement, collection, analysis, and reporting of website and web application usage data. While common in the e-commerce arena, web analytics is underutilized in graduate medical education (GME). OBJECTIVE The University of Arkansas for Medical Sciences Department of Surgery website was revamped with input from in-house surgeons in August 2017. This study investigated the use of web analytics to gauge the impact of our department’s website redesign project. METHODS Google Analytics software was used to measure website performance before and after implementation of the new website. Eight-month matched periods were compared. Factors tracked included total users, new users, total sessions, sessions per user, pages per session, average session duration, total page views, and bounce rate (the percentage of visitors who visit a site and then leave [ie, bounce] without continuing to another page on the same site). RESULTS Analysis using a nonpaired Student t test demonstrated a statistically significant increase for total page views (before vs after: 33,065 vs 81,852; PP CONCLUSIONS Web analytics is a practical measure of a website’s efficacy. Our data suggest that a modern website significantly improves user engagement. An up-to-date website is essential for contemporary GME recruitment, will likely enhance engagement of residency applicants with GME programs, and warrants further investigation.

Bilateral ureteropelvic junction (UPJ) tears are rare. Trauma can obscure this diagnosis. The objective of this case report is to highlight the rapid diagnosis of this injury and care in the case of pregnancy. A 22-year-old pregnant female was ejected from her car and presented with abdominal pain. The patient got a computed tomography (CT)-chest, abdomen, pelvis (CT-CAP) revealing bilateral ureteral injury, which was confirmed on retrograde cystoscopy. Her injuries were treated with nephrostomy tubes with plans for definitive repair after pregnancy. Fetus remained stable throughout her care and the patient was discharged with no complications. Due to the rapid diagnosis and effective stabilization, the patient and fetus recovered well from the injuries and multiple procedures. While there are many explanations for bilateral UPJ tears, deceleration and hyperextension seem to be the two major mechanisms of this injury.

Objectives: To evaluate and analyze the efficacy of implementation of hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of students with controlling major hemorrhage and they will find this a valuable skill set for medical and other healthcare professional students. Methods: After IRB and institutional approval was obtained, hemorrhage-control education was incorporated into the surgery clerkship curriculum for 96 third-year medical students at the University of Arkansas for Medical Sciences using the national Stop The Bleed program. Using a prospective study design, participants completed pre- and post-training surveys to gauge prior experiences and comfort levels with controlling hemorrhage and confidence levels with the techniques taught. Course participation was mandatory; survey completion was optional. The investigators were blinded as to the individual student’s survey responses. A knowledge quiz was completed following the training. Results: Implementation of STB training resulted in a significant increase in comfort and confidence among students with all hemorrhage-control techniques. There was also a significant difference in students’ perceptions of the importance of this training for physicians and other allied health professionals. Conclusion: Hemorrhage-control training can be effectively incorporated into the formal medical school curriculum via a single 2-hour Stop The Bleed course, increasing students’ comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education. We believe this should be a standard part of undergraduate medical education.

Mobile computing devices provide an appealing platform to support the learning needs of busy medical students, surgery trainees, and professionals in practice. This report discusses the application of mobile spaced education in surgical specialties and highlights key findings to date across the surgical education continuum. Scoping review methods were used to identify all mobile spaced surgical education evaluation studies published through mid-February 2020. Among 31 eligible studies reviewed, mobile spaced education has been applied and evaluated in many general and subspecialty surgical settings covering a variety of topics. Most of the studies have been done in graduate medical education settings, whereas far fewer were identified in medical school or continuing medical education settings. The majority of studies reviewed showed significant improvements in medical knowledge and learner satisfaction with mobile spaced educational methods. Several studies also demonstrated improved clinical skills or behaviors. Although practical research and practice considerations exist in implementing and evaluating mobile spaced education strategies, the multiple benefits identified in this review suggest a substantial return on investment.

Background Despite increasing usage since their introduction, there exist no evidence-based guidelines on all-terrain vehicles (ATVs) and injury prevention. While the power and speed of these vehicles has increased over time, advancements in ATV safety have been rare. Methods A priori questions about ATV injury pattern and the effect of helmet and safety equipment use and legislation mandating use were developed. A query of MEDLINE, PubMed, Cochrane Library, and Embase for all-terrain vehicle injury was performed. Letters to the editor, case reports, book chapters, and review articles were excluded. Grading of Recommendations Assessment, Development, and Evaluation methodology was used to perform a systematic review and create recommendations. Results Twenty-eight studies were included. Helmet use reduced traumatic brain injury (TBI). However, studies examining whether legislation mandating helmet use reduced TBI had mixed results. When ATV safety legislation was enforced, overall injury rates and mortality decreased. However, enforcement varied widely and lack of enforcement led to decreased compliance with legislation and mixed results. There was not enough evidence to determine the effectiveness of non-helmet-protective equipment. Conclusion Helmet use when riding an ATV reduced the rate of TBI. ATV safety legislation, when enforced, also reduced morbidity and mortality. Compliance with laws is often low, however, possibly due to poor enforcement. We recommend helmet use when riding on an ATV to reduce TBI. We conditionally recommend implementing ATV safety legislation as a means to reduce ATV injuries, noting that enforcement must go hand in hand with enactment to ensure compliance.

Objectives With the recent utilization of Accreditation Council for Graduate Medical Education developmental milestones as part of resident evaluation, we sought to explore whether milestone-based ratings were associated with American Board of Surgery In-Training Examination (ABSITE) scores. Methods Mid-year milestone ratings were obtained from the Accreditation Council for Graduate Medical Education Accreditation Database System for years 2014, 2015, and 2016 for all postgraduate years 1-5 general surgery residents in our program and paired with ABSITE scores (n = 69) from January of the following year. Linear regression was used to assess predictor importance of milestones on both ABSITE percentage correct scores and ABSITE percentile scores. Results Minimal to small positive correlations were observed between milestones and ABSITE percentile scores (r = 0.09-0.25), while moderately large correlations were observed between milestones and percentage correct scores (r = 0.65-0.76). The Medical Knowledge 1 (MK1) milestone significantly predicted ABSITE percentage correct scores, and explained 60% of the variance (adjusted R2 = 0.603). MK1 also significantly predicted ABSITE percentile scores, although weaker in magnitude, with MK1 explaining 20% of the variance (adjusted R2 = 0.197). Postgraduate year level and other milestones were not influential predictors of ABSITE scores. Conclusions The mid-year MK1 milestone rating was predictive of ABSITE scores and may serve as a useful marker for Clinical Competency Committees to identify residents who could benefit from additional support to prepare for the ABSITE, although given the small exploratory nature of this study, additional research is still needed.

Background Venous thromboembolisms (VTEs) continue to be a leading cause of death among trauma patients. Predicting which patients will develop a VTE can be difficult. This study investigated whether the Injury Severity Score (ISS) could be used in conjunction with the Abbreviated Injury Score (AIS) to assess a trauma patient's risk for subsequent VTE development. Materials and Methods Participants were found by querying a trauma center registry. There were 2,213 patients included for evaluation. The patients were categorized based on their ISS and the anatomical region with the greatest injury (determined by the AIS). Odds ratios for developing VTEs were calculated for each ISS category. Results The results showed that in most categories VTE risk increased as ISS increased. Patients with trauma to their head/neck, chest, or extremities with ISS values of 21 or greater were all at significantly increased risk for VTE development. Patients in these categories with an ISS less than 21 seemed to have little or only moderately increased odds of developing a VTE, although these values were not statistically significant. Patients with abdominal trauma were at increased risk even with ISS values of 11-21. Conclusion Trauma to the head/neck region, chest, and extremities (including pelvis) with ISS of 21 or higher had significantly increased odds of developing a VTE. Patients with abdominal trauma of any severity appeared to have increased odds of developing a VTE.

Background Hemorrhage, especially when complicated by coagulopathy, is the most preventable cause of death in trauma patients. We hypothesized that assessing hemostatic function using rotational thromboelastometry (ROTEM) or conventional coagulation tests can predict the risk of mortality in patients with severe trauma indicated by an injury severity score greater than 15. Methods We retrospectively reviewed trauma patients with an injury severity score >15 who were admitted to the emergency department between November 2015 and August 2017 in a single level I trauma center. Patients with available ROTEM and conventional coagulation data (partial thromboplastin time [PTT], prothrombin time [PT], and international normalized ratio) were included in the study cohort. Logistic regression was performed to assess the relationship between coagulation status and mortality. Results The study cohort included 301 patients with an average age of 47 y, and 75% of the patients were males. Mortality was 23% (n = 68). Significant predictors of mortality included abnormal APTEM (thromboelastometry (TEM) assay in which fibrinolysis is inhibited by aprotinin (AP) in the reagent) parameters, specifically a low APTEM alpha angle, a high APTEM clot formation time, and a high APTEM clotting time. In addition, an abnormal international normalized ratio significantly predicted mortality, whereas abnormal PT and PTT did not. Conclusions A low APTEM alpha angle, an elevated APTEM clot formation time, and a high APTEM clotting time significantly predicted mortality, whereas abnormal PT and PTT did not appear to be associated with increased mortality in this patient population. Viscoelastic testing such as ROTEM appears to have indications in the management and stabilization of trauma patients.

A 33-year-old female, 32 weeks and 1 day gestation, with known placenta accreta who presented to the emergency department with 2 h of severe abdominal pain, nausea and vomiting. She became hypotensive and underwent emergency cesarean section. Emergency general surgery was consulted for placement of a resuscitative endovascular balloon for aortic occlusion (REBOA). After successful delivery, the balloon was inflated in zone 3 and systolic blood pressure rose from 70 to 170 mmHg. The patient underwent hysterectomy for ongoing hemorrhage. The patient was taken to the surgical intensive care unit. The patient was noted to have pulses following removal of the sheath. Arterial brachial indices and arterial duplex was performed 48 h after sheath removal. The patient was found to have complete occlusion of the right external iliac artery. Vascular surgery was consulted and cut-down performed with thrombus removal via fogarty catheter. The patient was discharged 2 days later without further complication.

A 23-year-old man presented to the emergency department with multiple gunshot wounds to the chest and abdomen, and was taken to the operating room emergently for exploratory laparotomy due to hemodynamic instability. The patient underwent inferior vena cava (IVC), bowel and ureter repair during the procedure, requiring massive amounts of blood products. The patient transferred to the surgical intensive care unit with a routine post-operative course for approximately the next 7 days before presenting with signs of stroke. The patient was diagnosed with deep vein thrombosis in IVC at the repair site on a follow-up venogram. Upon further work-up with echocardiography, the patient was determined to have a patent foramen ovale (PFO), with paradoxical embolism as the most likely cause of the stroke. We present this unusual case of a GSW leading to stroke due to embolism from a venous source through a PFO.

A 30-year-old male presented to an outside facility with acute pancreatitis and triglycerides of 1594. He was transferred to our facility after becoming febrile, hypoxic and in acute renal failure with triglycerides of 4243. CT scan performed showed wall-off pancreatic necrosis. He underwent continuous renal replacement therapy and his acute renal failure resolved. He was treated with broad spectrum antibiotics and discharged. He developed a fever to 101 a week later and was found to have a large infected pancreatic pseudocyst. This was managed with an IR placed drain. This was continued for 6 weeks. He came to the emergency department several weeks later with shortness of breath and 3+ edema to bilateral lower extremities and lower abdomen. TTE performed showed an EF of 15%. He was diuresed 25 L during that stay. His heart failure was medically managed. We present this case of dilated cardiomyopathy secondary to acute pancreatitis.

Background Mock oral examinations (MOEs) are valuable tools for knowledge assessment and preparation for the surgical certifying examinations. Use of MOE is not standardized. We sought to determine the current use in vascular residencies/fellowships. Methods Program directors (PD) of all U.S. vascular training programs were sent anonymous online surveys in July of 2015 evaluating importance of MOEs, current use, barriers to implementation, and preparedness of trainees to sit for the certifying board examination (CE). Comparisons were performed between programs that use MOEs and those that do not. Results Fifty-four percent (59/108) of program directors completed the survey. The majority believed MOEs are important for vascular residents and fellows (86% versus 81%); however, only 51% (30/59) use them. The most common reason for using MOE was to provide feedback about readiness for the CE (90%). Of programs not giving MOE, 69% expected their trainees to get oral examinations at national conferences. The most common barriers to implementation/continuation of MOEs were availability of faculty (48%) or time (31%). Irrespective of whether they used MOE or not, 29% believed vascular fellows were better prepared for the CE than vascular residents. Conclusions MOEs are regarded as a valuable tool to prepare trainees for the CE. However, it is not a commonly adopted practice, due to variables such as institutional/faculty availability. A third of program directors believed that vascular fellows were more prepared to pass the CE than vascular residents which may warrant further investigation into how programs can more rigorously prepare vascular residents for the vascular CEs.

BackgroundReadmissions after a traumatic brain injury (TBI) have significant impact on long-term patient outcomes through interruption of rehabilitation. This study examined readmissions in a rural population, hypothesizing that readmitted patients after TBI will be older and have more comorbidities than those not readmitted.MethodsDischarge data on all patients 15 years and older who were admitted to an Arkansas-based hospital for TBI were obtained from the Arkansas Hospital Discharge Data System from 2010 to 2014. This data set includes diagnoses (principal discharge diagnosis, up to 3 external cause of injury codes, 18 diagnosis codes using the International Classification of Disease, 9th Edition, Clinical Modifications), age, gender, and inpatient costs. Hospital Cost and Utilization Project Clinical Classification and Chronic Condition Indicator were used to identify chronic disease and body systems affected in principal diagnosis.ResultsOf the 3114 cases of significant head trauma, more than two-thirds were attributed to fall injuries, with motor vehicle crashes accounting for 20% of the remainder. The mean length of stay was 6.5 days. 691 of these patients were admitted to an Arkansas hospital in the following year, totaling 1368 readmissions. Of the readmissions, 16.4% of patients were admitted for altered mental status, 12.9% with shortness of breath (SOB), and 9.4% with chest pain. Mental disorders (psychosis, dementia, and depression) and organic nervous symptoms (Alzheimer’s disease, encephalopathy, and epilepsy) were the primary source of readmissions. More than one-third of the patients were admitted in the following year for chronic diseases such as heart failure (8.6%), psychosis (5.2%), and cerebral artery occlusion (4.1%).DiscussionThis study showed that there is a significant rate of readmissions in the year after a diagnosis of TBI. Complications with existing chronic diseases are among the most reported reasons for admission in this time period, demonstrating the effect severe head trauma has on long-term treatment.Level of evidenceLevel IV, Retrospective epidemiological study.

Mock oral examinations (MOEs) are used within surgery residency programs to prepare trainees for the American Board of Surgery (ABS) Certifying Exam (CE), but little work exists to guide programs in terms of best practices for implementing a general surgery MOE program. This study, endorsed by the Association for Program Directors in Surgery (APDS) Research Committee, aimed to better understand the national scope of current practices for general surgery MOEs.General surgery residency program directors (PDs) were invited via the APDS listserv to complete a 27-item survey about their perceptions of the importance and correlates of MOEs, how their exams are structured, implementation barriers, and recent revisions to their MOE program.Of 98 PDs responding to the survey, 94% (n = 92) responded about the characteristics of their formal MOE programs. The majority required upper level resident participation and held the exams 2 to 3 times annually; far fewer involved lower level residents. Most programs structure their MOEs to mimic the CE format with 3 exam rooms (76%), using premade questions (66%), presenting 4 scenarios per room (59%), and using two examiners per room (85%). Most PDs (88%) believed MOEs were very important or essential for surgery trainees, which correlated with their ratings of how important MOEs are to their Clinical Competency Committee for determining resident advancement (r = 0.32, p0.002). Common barriers for implementing MOEs were availability of examiners and scenarios. About half indicated making recent or ongoing revisions to improve their MOEs. Many PDs indicated interest in collaborating regionally or nationally on MOE initiatives.MOEs were largely regarded as a highly valuable tool by PDs to prepare trainees for the general surgery CE. The majority of programs in this study provide a testing experience as similar to the CE as possible, although some variability in the structure of MOEs was identified. PDs also reported significant implementation barriers and a desire for more MOE collaboration.

A 67-year-old male presented with acute pancreatitis secondary to gallstones, also known as acute biliary pancreatitis, and subsequently developed gastric outlet obstruction and was transferred to our hospital. A gastro-jejunal feeding tube was placed and an open cholecystectomy was performed. The patient had a pancreatic drain placed for interval increase in pancreatic necrosis and then nearly exsanguinated from gastroduodenal artery pseudoaneurysm bleed. This was managed by coiling the gastroduodenal artery. The patient underwent a pancreatic necrosectomy with malencot drain placement and developed a post-operative upper gastrointestinal bleeding. An EGD showed diffuse gastritis, but no varices. And 18 days later the patient rebled, with the same diffuse gastritis. After further complications the patient elected to receive palliative care at a hospice facility. We are presenting this unusual case of diffuse, hemorrhagic gastritis after acute necrotizing pancreatitis.

Objective: Communication in the hospital setting is an easy target for quality improvement. Capturing this change via communication between providers during hand-offs is necessary to reduce delays and errors. While this process has been more widely characterized in medical specialties, we designed this study to address the knowledge gap in surgical specialties.Methods: Our institution’s division of Acute Care Surgery (ACS) implemented Morning Report (MR) in October of 2015. At MR, all admissions and service transfers were discussed from Trauma, Emergency General Surgery (EGS), and Surgical Critical Care services from the previous 24 hours. This study compared patients who underwent a surgical procedure during their hospital stay before and after protocol implementation.Results: 974 patients were included in this study. The average patient was 50.3 years of age, 65.4% were white, and 51.7% were male. The average length of stay (LOS) was 8.3 days with 1.75 days to procedure. The post-MR cohort LOS was 2.7 shorter and had 0.85 fewer days to procedure. In an adjusted regression analysis, days to procedure and LOS decreased by 33% (p < .01) and 17% (p < .01) respectively.Conclusions: Implementation of MR led to a decrease in the overall LOS and days to procedure for operative patients. Our results advocate for the standard use of structured hand-offs in surgical units.

The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate the knowledge and readiness of trainees to sit for the general surgery qualifying examination. It is often used as a tool for resident promotion and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however, its presence and effects on surgical trainees' performance are not well studied. We sought to understand factors including burnout and study habits that may contribute to performance on the ABSITE examination.Anonymous electronic surveys were distributed to all residents at 10 surgical residency programs (n = 326). Questions included demographics as well as study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout because of both exhaustion and disengagement. These surveys were then linked to the individual's 2016 ABSITE and United States Medical Licensing Examination (USMLE) step 1 and 2 scores provided by the programs to determine factors associated with successful ABSITE performance.In total, 48% (n = 157) of the residents completed the survey. Of those completing the survey, 48 (31%) scored in the highest ABSITE quartile (≥75th percentile) and 109 (69%) scored less than the 75th percentile. In univariate analyses, those in the highest ABSITE quartile had significantly higher USMLE step 1 and step 2 scores (P 0.001), significantly lower burnout scores (disengagement, P 0.01; exhaustion, P 0.04), and held opinions that the ABSITE was important for improving their surgical knowledge (P 0.01). They also read more frequently to prepare for the ABSITE (P 0.001), had more disciplined study habits (P 0.001), were more likely to study at the hospital or other public settings (e.g., library, coffee shop compared with at home; P 0.04), and used active rather than passive study strategies (P 0.04). Gender, marital status, having children, and debt burden had no correlation with examination success. Backward stepwise multiple regression analysis identified the following independent predictors of ABSITE scores: study location (P 0.0001), frequency of reading (P = 0.0001), Oldenburg Burnout Inventory exhaustion (P = 0.02), and USMLE step 1 and 2 scores (P = 0.007 and 0.0001, respectively).Residents who perform higher on the ABSITE have a regular study schedule throughout the year, report less burnout because of exhaustion, study away from home, and have shown success in prior standardized tests. Further study is needed to determine the effects of burnout on clinical duties, career advancement, and satisfaction.

BackgroundModern acute care surgery (ACS) programs depend on consistent patient hand-offs to facilitate care, as most programs have transitioned to shift-based coverage. We sought to determine the impact of implementing a morning report (MR) model on patient outcomes in the trauma service of a tertiary care center.MethodsThe University of Arkansas for Medical Sciences (UAMS) Division of ACS implemented MR in October 2015, which consists of the trauma day team, the emergency general surgery day team, and a combined night float team. This study queried the UAMS Trauma Registry and the Arkansas Clinical Data Repository for all patients meeting the National Trauma Data Bank inclusion criteria from January 1, 2011 to April 30, 2018. Bivariate frequency statistics and generalized linear model were run using STATA V.14.2ResultsA total of 11 253 patients (pre-MR, n=6556; post-MR, n=4697) were analyzed in this study. The generalized linear model indicates that implementation of MR resulted in a significant decrease in length of stay (LOS) in trauma patients.DiscussionThis study describes an approach to improving patient outcomes in a trauma surgery service of a tertiary care center. The data show how an MR session can allow for patients to get out of the hospital faster; however, broader implications of these sessions have yet to be studied. Further work is needed to describe the decisions being made that allow for a decreased LOS, what dynamics exist between the attendings and the residents in these sessions, and if these sessions can show some of the same benefits in other surgical services.Level of evidenceLevel 4, Care Management.

Background A 2005 survey reported 87% of surgery program directors believed practice management training should occur during residency. However, only 8% of program directors believed residents received adequate training in practice management [1] . In addition to the gap in practice financial management knowledge, we recognized the need for training in personal finance among residents. A literature review and needs assessment led to the development of a novel curriculum for surgery residents combining principles of practice management and personal finance. Methods An 18-h curriculum was administered over the 2012 academic year to 28 post graduate year 1–5 surgery residents and faculty. A self-assessment survey was given at the onset and conclusion of the curriculum [2] . Pre-tests and post-tests were given to objectively evaluate each twice monthly session's content. Self-perception of learning, interest, and acquired knowledge were analyzed using the Wilcoxon signed ranks test. Results Initial self-assessment data revealed high interest in practice management and personal finance principles but a deficiency in knowledge of and exposure to these topics. Throughout the curriculum, interest increased. Residents believed their knowledge of these topics increased after completing the curriculum, and objective data revealed various impacts on knowledge. Conclusions Although surgery residents receive less exposure to these topics than residents in other specialties, their need to know is no less. We developed, implemented, and evaluated a curriculum that bridged this gap in surgery education. After the curriculum, residents reported an increase in interest, knowledge, and responsible behavior relating to personal and practice financial management.

Objective One of the General Surgery milestones focuses on effective handoffs between residents as they change shifts. Although the content of handoffs is crucial, we recognized that the culture of handoffs was equally important. After the reorganization of the trauma service at our institution, there were difficulties in maintaining the standardized handoff culture. We analyzed the culture of handoffs on the trauma service to create an environment more conducive to effective handoffs. Design All trauma activations from 2012 to 2013 were evaluated from our institution's trauma data registry. Data on timing of activations and disposition of the patient were analyzed to understand service work flow. A survey was developed and administered to the residents to assess the culture of trauma handoffs. Setting This work occurred at an academic, state-designated level 1 trauma center. Participants All current residents in the general surgery residency who rotated on the trauma service in the last 5 years. Results There were 1654 admissions to the trauma service from June 2012 to July 2013. The single busiest hour for trauma admissions (7% of admissions) was the same time the residents were designated to handoff. Interruptions occurred often; 83% of residents indicated that a handoff interruption occurred daily, and 73% indicated a new activation interrupted handoffs weekly. A large majority, 61%, felt patient care was frequently compromised by an ineffective handoff. Similarly, as a direct result of inadequate handoffs, 50% felt uncomfortable answering nurses' pages at night. Conclusions The unique situation of the trauma service impaired the handoff culture for residents. Assessment of our trauma activation flow indicates the timing of handoffs was adversely affecting our resident's ability to handoff effectively, requiring interventions to improve the efficacy and safety of handoffs.

Summary: Mucormycosis is a rare fungal infection in immunocompetent patients. It is not commonly seen in trauma patients who sustain multisystem injuries and are often exposed to numerous infectious sources. A multidisciplinary approach between medical and surgical specialties is crucial to ensuring timely diagnosis and treatment as morbidity and mortality can be high once acquired. In addition to antifungal therapy, radical debridement and reconstruction by plastic surgery is often necessary. Review of the literature shows that there is no definitive reconstructive technique for mucormycosis of the forehead and sinuses because the amount of tissue destruction may be varied in location and depth, therefore requiring varying extents of debridement. However, other reconstructive techniques commonly used for oncologic and trauma reconstructions can be used to achieve functionality and a satisfactory cosmetic result. Few facial reconstructions after infection with mucormycosis have been documented in the literature.