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Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Pawlak et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Traumatic injuries are proportionally higher in low- and middle-income countries (LMICs) than high-income counties. Data on trauma epidemiology and patients' outcomes are limited in LMICs., Methods: A retrospective review of medical records was performed for trauma admissions to the Princess Marina Hospital general surgical (GS) wards from August 2017 to July 2018. Data on demographics, mechanisms of injury, body parts injured, Revised Trauma Score, surgical procedures, hospital stay, and outcomes were analysed., Results: During the study period, 2610 patients were admitted to GS wards, 1307 were emergency admissions. Trauma contributed 22.1% (576) of the total and 44.1% of the emergency admissions. Among the trauma admissions, 79.3% (457) were male. The median[ interquartile range (IQR)](range) age in years was 30[24-40](13-97). The main mechanisms of injury were interpersonal violence (IPV), 53.1% and road traffic crashes (RTCs), 23.1%. More females than males suffered animal bites (5.9% vs. 0.9%), and burns (8.4% vs. 4.2%), while more males than females were affected by IPV (57.8% vs. 35.3%) and self-harm (5.5% vs. 3.4%). Multiple body parts were injured in 6.6%, mainly by RTCs. Interpersonal violence (IPV) and RTCs resulted in significant numbers of head and neck injuries, 57.3% and 22.2% respectively. More females than males had multiple body-parts injury 34.5% vs. 18.5%. Revised Trauma Score (RTS) of ≤11 was recorded in IPV, 38.4% and RTCs, 33.6%. Surgical procedures were performed on 44.4% patients. The most common surgical procedures were laparotomy (27.8%), insertion of chest tube (27.8%), and craniotomy/burr hole(25.1%). Complications were recorded in 10.1% of the patients(58) including 39 deaths, 6.8% of the 576., Conclusion: Trauma contributed significantly to the total GS and emergency admissions. The most common mechanism of injury was IPV with head and neck the most frequently injured body part. Further studies on IPV and trauma admissions involving paediatric and orthopaedic patients are warranted., Competing Interests: The authors declare no conflicts of interest., (© 2018 Published by Elsevier Ltd. CC BY-NC-ND 4.0.)

Background: In recent years, surgical education has increased its focus on the non-technical skills such as communication and interpersonal relationships while continuing to strive for technical excellence of procedures and patient care. An awareness of the ethical aspects of surgical practice that involve non-technical skills and judgment is of vital concern to surgical educators and encompasses disparate issues ranging from adequate supervision of trainees to surgical care access., Methods: This bibliographical research effort seeks to report on ethical challenges from a sub-Saharan Africa (SSA) perspective as found in the peer-reviewed literature employing African Journals Online, Bioline, and other sources with African information as well as PubMed and PubMed Central. The principles of autonomy, non-maleficence, beneficence, and justice offer a framework for a study of issues including: access to care (socioeconomic issues and distance from health facilities); resource utilization and decision making based on availability and cost of resources, including ICU and terminal extubation; informed consent (both communication about reasonable expectations post-procedure and research participation); research ethics, including local projects and international collaboration; quality and safety including supervision of less experienced professionals; and those religious and cultural issues that may affect any ethical decision making. The religious and cultural environment receives attention because beliefs and traditions affect medical choices ranging from acceptance of procedures, amputations, to end-of-life decisions., Results and Conclusions: Ethics awareness and ethics education should be a vital component of non-technical skills training in surgical education and medical practice in SSA for trainees. Continuing professional development of faculty should include an awareness of ethical issues.

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

: There is an unacceptably high burden of death and disability from conditions that are treatable by surgery, worldwide and especially in low- and middle-income countries (LMICs). The major actions to improve this situation need to be taken by the surgical communities, institutions, and governments of the LMICs. The US surgical community, including the US academic surgical community, has, however, important roles to play in addressing this problem. The American Surgical Association convened a Working Group to address how US academic surgery can most effectively decrease the burden from surgically treatable conditions in LMICs. The Working Group believes that the task will be most successful (1) if the epidemiologic pattern in a given country is taken into account by focusing on those surgically treatable conditions with the highest burdens; (2) if emphasis is placed on those surgical services that are most cost-effective and most feasible to scale up; and (3) if efforts are harmonized with local priorities and with existing global initiatives, such as the World Health Assembly with its 2015 resolution on essential surgery. This consensus statement gives recommendations on how to achieve those goals through the tools of academic surgery: clinical care, training and capacity building, research, and advocacy. Through all of these, the ethical principles of maximally and transparently engaging with and deferring to the interests and needs of local surgeons and their patients are of paramount importance. Notable benefits accrue to US surgeons, trainees, and institutions that engage in global surgical activities.

Introduction: Global surgery is increasingly recognized as a vital component of international public health. Access to basic surgical care is limited in much of the world, resulting in a global burden of treatable disease. To address the lack of surgical workforce in underserved environments and to foster ongoing interest in global health among US-trained surgeons, our institution established a residency rotation through partnership with an academic hospital in Kijabe, Kenya. This study evaluates the perceptions of residents involved in the rotation, as well as its impact on their future involvement in global health., Materials and Methods: A retrospective review of admission applications from residents matriculating at our institution was conducted to determine stated interest in global surgery. These were compared to post-rotation evaluations and follow-up surveys to assess interest in global surgery and the effects of the rotation on the practices of the participants., Results: A total of 78 residents matriculated from 2006 to 2016. Seventeen participated in the rotation with 76% of these reporting high satisfaction with the rotation. Sixty-five percent had no prior experience providing health care in an international setting. Post-rotation surveys revealed an increase in global surgery interest among participants. Long-term interest was demonstrated in 33% (n = 6) who reported ongoing activity in global health in their current practices. Participation in global rotations was also associated with increased interest in domestically underserved populations and affected economic and cost decisions within graduates' practices.

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

Background: Postoperative follow-up using telehealth may increase patient access and decrease resource use. We aimed to define patient and operative criteria likely to be associated with successful telehealth follow-up (telehealth-amenable)., Methods: We assembled a retrospective cohort of veterans who underwent general operations between September 2012 and July 2013 to characterize telehealth-amenable postoperative follow-up, excluding patients with sensitive operative sites (breast, anus) and postoperative inpatient complications. Telehealth-amenable follow-up was defined as: postoperative care accomplished in a single clinic visit without an invasive procedure or focal concern and no new complication diagnosed or managed. Operations were categorized by site and complexity. Patient and operative characteristics predictive of telehealth-amenable follow-up were delineated using multivariable logistic regression., Results: Eligible patients (251/300) were 94% men, on average 60 years old (±12.0 years) and attended a median of one postoperative visit (interquartile range [IQR] 1-2). Forty-seven percent (119/251) had telehealth-amenable follow-up, including 70% of simple abdominal operations, 75% of neck operations, and 38% of skin/soft tissue operations. After adjustment, predictors of telehealth-amenable follow-up included simple abdominal (odds ratio 3.37, 95% confidence interval 1.20-9.51) and neck operations (odds ratio 4.56, 95% confidence interval 1.01-20.54). Patients with postoperative durations of stay of ≥4 days were less likely telehealth-amenable (odds ratio 0.15, 95% confidence interval 0.04-0.50). Most patients who initiated contact with the operative team between discharge and follow-up did not have telehealth-amenable follow-up (43/53, 81%)., Conclusion: Telehealth postoperative follow-up may be feasible for patients undergoing select abdominal, neck, and skin/soft tissue operations with uncomplicated courses, operative duration of stay <4 days, and no interval contact with the operative team., (Published by Elsevier Inc.)

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future., Competing Interests: Competing interests: AV is director of Developing Health Globally at the GE foundation, the philanthropic organisation of GE. SMR is Chief Executive Officer of Gradian Health Systems, a non-profit medical device company that manufactures and distributes technology for anaesthesia and surgical applications in low income environments.

Background: Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being., Methods: We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care., Results: In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001)., Conclusions: As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

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

Importance: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training., Objective: To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance., Design, Setting, and Participants: Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period., Exposures: National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs., Main Outcomes and Measures: Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance., Results: In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period., Conclusions and Relevance: Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

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

Objective: For the past 15 years at our institution's general surgery residency program, 3 of the senior residents have been chosen to be awarded either (1) Best Resident in Research, (2) Best Resident in Teaching, or (3) Best Resident Overall. Considering that these awards serve as data representing outstanding performance as surgical residents, the objective of this study was to determine the association between receiving one of these awards and objective measures of performance., Methods: Individual files were reviewed for the 103 residents who graduated from our institution's general surgery program from 1994 to 2010. These data were studied as a whole, and then divided into an award-winning group and a non-award winning group and subsequently compared across several objective parameters, including The United States Medical Licensing Examination (USMLE) scores, American Board of Surgery In-Training Examination (ABSITE) scores, first-time American Board of Surgery Certifying and Qualifying Examination pass rates, Alpha Omega Alpha membership status, and number of research years, using a logistic regression model., Results: Overall, 103 residents completed their general surgery residency training at our institution from 1994 to 2010, and of these residents, 16 (16%) received the Best Resident in Research award, 15 (16%) received the Best Resident in Teaching award, and 17 (17%) received the Best Resident Overall award in their final years of training. Compared with those who did not receive an award, a hypothesis-based one-tailed test revealed that award winners had a significantly lower median USMLE Step 1 scores (p = 0.04) and marginally lower median USMLE Step 2 scores (p = 0.05). Alpha Omega Alpha membership status, median ABSITE percent correct overall, first-time American Board of Surgery examination pass rates, and number of research years during residency were not significantly different between the 2 groups., Conclusion: Many factors contribute to success during general surgery residency. Our study showed that higher USMLE and ABSITE scores were not associated with receiving top awards in final years of training at one institution over 15 years., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: In 2002 and 2003 the ACGME Outcome Project (assessing residents based on competencies) and duty-hours restrictions were implemented. One strategy for assisting PDs in the increased workload was to hire nonphysician educators with training and experience in curriculum design, teaching techniques, adult learning theories, and research methods. This study sought to document prevalence and responsibilities of nonphysician educators., Methods: IRB approval was received for a two-part study. All 247 general surgery PDs were e-mailed the question, "Do you have a nonphysician educator as a member of your surgery education office?" Those who replied "yes" or volunteered "not currently but in the past" were e-mailed a link to an electronic survey concerning the role of the nonphysician educator., Setting: Residency training programs in general surgery., Participants: General surgery program directors., Results: Of the 126 PDs who responded to the initial query, 37 said "yes" and 4 replied "not currently but in the past". Thirty-two PDs of the initial 41 respondents completed the survey. Significant findings included: 65% were hired in the last 6 years; faculty rank is held by 69%; and curriculum development was the most common responsibility but teaching, research, and administrative duties were often listed. PDs perceived that faculty, residents, and medical students had mostly positive attitudes towards nonphysician educators., Conclusions: The overall results seem to support the notion that nonphysician educators serve as vital members of the team., (Copyright © 2014 Association of Program Directors in Surgery. All rights reserved.)

Background: In 2011, the Accreditation Council for Graduate Medical Education Surgery Residency Review Committee first provided guidelines for elective international general surgery rotations. The Vanderbilt general surgery residency program received Surgery Residency Review Committee approval for a fourth-year elective in Kenya beginning in the 2011-2012 academic year. Because this rotation would break ground culturally and geographically, and as an educational partnership, a briefing and debriefing process was developed for this ground-breaking year., Objectives: Our objectives were to prepare residents to maximize the experience without competing for cases with local trainees or overburdening the host institution and to perform continuous quality assessment and improvement as each resident returned back., Methods: Briefing included health protection strategies, a procedures manual containing step-by-step preparation activities, and cultural-sensitivity training. Institutional Review Board exemption approval was obtained to administer a questionnaire created for returning residents concerning educational value, relations with local trainees, physical environment, and personal perceptions that would provide the scaffold for the debriefing conference., Results: The questionnaire coupled with the debriefing discussion for the first 9 participants revealed overall satisfaction with the rotation and the briefing process, good health, and no duty hours or days-off issues. Other findings include the following: (1) emotional effect of observing African families weigh cost in medical decision making; (2) satisfactory access to educational resources; (3) significant exposure to specialties such as urology and radiology; and (4) toleration of 4 weeks as a single and expressed need for leisure activity materials such as books, DVDs, or games. The responses triggered adjustments in the briefing sessions and travel preparation. The host institution invited the residents to return for the 2012-2013 year as well as 2013-2014., Conclusion: Detailed preparation and the follow-up evaluation for assessment and improvement of this nascent international surgery experience are associated with resident satisfaction and the host institution has agreed to continue the rotation., (Copyright © 2013 Association of Program Directors in Surgery. All rights reserved.)

Objective: To measure the implications of the new Accreditation Council for Graduate Medical Education duty hour regulations for education, well-being, and burnout., Design: Longitudinal study., Setting: Eleven university-based general surgery residency programs from July 2011 to May 2012., Participants: Two hundred thirteen surgical interns., Main Outcome Measures: Perceptions of the impact of the new duty hours on various aspects of surgical training, including the 6 Accreditation Council for Graduate Medical Education core competencies, were measured on 3-point scales. Quality of life, burnout, balance between personal and professional life, and career satisfaction were measured using validated instruments., Results: Half of all interns felt that the duty hour changes have decreased the coordination of patient care (53%), their ability to achieve continuity with hospitalized patients (70%), and their time spent in the operating room (57%). Less than half (44%) of interns believed that the new standards have decreased resident fatigue. In longitudinal analysis, residents' beliefs had significantly changed in 2 categories: less likely to believe that practice-based learning and improvement had improved and more likely to report no change to resident fatigue (P < .01, χ2 tests). The majority (82%) of residents reported a neutral or good overall quality of life. Compared with the normal US population, 50 interns (32%) were 0.5 SD less than the mean on the 8-item Short Form Health Survey mental quality of life score. Approximately one-third of interns demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%) or reported that their personal-professional balance was either "very poor" or "not great" (32%). Although many interns (67%) reported that they daily or weekly reflect on their satisfaction from being a surgeon, 1 in 7 considered giving up their career as a surgeon on at least a weekly basis., Conclusions: The first cohort of surgical interns to train under the new regulations report decreased continuity with patients, coordination of patient care, and time spent in the operating room. Furthermore, suboptimal quality of life, burnout, and thoughts of giving up surgery were common, even under the new paradigm of reduced work hours.

Background: The Accreditation Council for Graduate Medical Education implemented new intern work-hour regulations in July 2011 that have unique implications for surgical training at Veterans Affairs (VA) medical centers. Implementation of these new regulations required profound restructuring of trainee night coverage systems at many VA medical centers. This article offers approaches and potential solutions to the Accreditation Council for Graduate Medical Education regulations used by different surgery programs throughout the country that are applicable to the VA training environment., Methods: The information contained in this article was derived from the opinion of a panel of academic surgical leaders in the VA system and responses to a survey that was sent to national VA surgical leaders., Results: The most common solution chosen by the VA centers was hiring physician extenders (37%). The most common type of extender was a nonphysician extender, that is, nurse practitioner or physician assistant (70%), followed by a surgical hospitalist (33%), and surgical resident moonlighter (24%). Other common solutions included the following: night float for residents (22%) or interns (19%), establishing early versus late shifts (19%), or establishing cross-institutional or disciplinary coverage (19%)., Conclusions: The public expects the medical community to produce safe, experienced surgeons, while demanding they are well rested and directly supervised at all times. The ability to meet these expectations can be challenging., (Published by Elsevier Inc.)

Background: With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education., Methods: A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs., Results: A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time., Conclusions: This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: International elective experiences are becoming an increasingly important component of American general surgery education. In 2011, the Residency Review Committee (RRC) approved these electives for credit toward graduation requirements. Previous surveys of general surgery program directors have established strong interest in these electives but have not assessed the feasibility of creating a national and international database aimed at educational standardization. The present study was designed to gain in-depth information from program directors about features of existing international electives at their institution and to ascertain interest in national collaboration., Methods: This cross-sectional study of 253 United States general surgery program directors was conducted using a web-based questionnaire program., Results: Of the program directors who responded to the survey, twelve percent had a formal international elective in place at their institution, though 80% of these did not have a formal associated curriculum for the rotation. Sixty percent of respondents reported that informal international electives existed for their residents. The location, length, and characteristics of these electives varied widely. Sixty-eight percent of program directors would like to participate in a national and international database designed to facilitate standardization of electives and educational exchange., Conclusions: In a world of increasing globalization, international electives are more important than ever to the education of surgery residents. However, a need for standardization of these electives exists. The creation of an educational consortium and database of international electives could improve the academic value of these electives, as well as provide increased opportunities for twinning and bidirectional exchange.

Background: In a time of increasing specialization, academic training institutions provide a compartmentalized learning environment that often does not reflect the broad clinical experience of general surgery practice. This study aimed to evaluate the contribution of the Veterans Affairs (VA) general surgery surgical experience to both index Accreditation Council for Graduate Medical Education (ACGME) requirements and as a unique integrated model in which residents provide concurrent care of multiple specialty patients., Methods: Institutional review board approval was obtained for retrospective analysis of electronic medical records involving all surgical cases performed by the general surgery service from 2005 to 2009 at the Nashville VA. Over a 5-year span general surgery residents spent an average of 5 months on the VA general surgery service, which includes a postgraduate year (PGY)-5, PGY-3, and 2 PGY-1 residents. Surgeries involved the following specialties: surgical oncology, endocrine, colorectal, hepatobiliary, transplant, gastrointestinal laparoscopy, and elective and emergency general surgery. The surgeries were categorized according to ACGME index requirements., Results: A total of 2,956 surgeries were performed during the 5-year period from 2005 through 2009. Residents participated in an average of 246 surgeries during their experience at the VA; approximately 50 cases are completed during the chief year. On the VA surgery service alone, 100% of the ACGME requirement was met for the following categories: endocrine (8 cases); skin, soft tissue, and breast (33 cases); alimentary tract (78 cases); and abdominal (88 cases). Approximately 50% of the ACGME requirement was met for liver, pancreas, and basic laparoscopic categories., Conclusions: The VA hospital provides an authentic, broad-based, general surgery training experience that integrates complex surgical patients simultaneously. Opportunities for this level of comprehensive care are decreasing or absent in many general surgery training programs. The increasing level of responsibility and simultaneous care of multiple specialty patients through the VA hospital systems offers a crucial experience for those pursuing a career in general surgery., (Published by Elsevier Inc.)

Sixty-eight (68) patients with serious upper extremity suppurative infections, presenting within a period of fifteen (15) months, were prospectively studied clinically, Gram stain of aspirates/pus were performed, specimen cultured, planted, and where indicated glucose levels and haemoglobin genotype determined. Half of the patients had hand infections. Staphylococcus aureus was isolated from thirty-nine (39) patients. Gram Negative bacilli, including Salmonella were more isolated from patients with diabetes mellitus or Hgb SS or SC. The Gram stain results correlated with the culture result 90%. When Gram Positive cocci were demonstrated in the primary microscopic examination, cultures were not mandatory. When no organism was demonstrated on primary Gram stain or the patient was diabetic or a sickler, cultures of the specimens were done. The Gram stain, well performed, remains a useful, inexpensive, technologically appropriate laboratory test for abetting decision making in patients with upper extremity suppurative infections. Organisms encountered in this study included: Staphylococcus aureus, Streptococcus pyogenes, Salmonella typhi, Proteus mirabilis, Pseudomonas aeruginosa, and Coliforms.

The spiritual dimensions of surgical palliative care encompass recognition of mortality (physician and patient); knowledge of moral and ethical dilemmas of medical decision making; respect for each individual and for all belief systems; responsibility to remain physically and psychologically present for the patient and family; and knowledge of when chaplains, palliative care professionals, or social workers should be consulted. Certain aspects of surgical palliative care distinguish it from palliative care in other medical disciplines such as the 2 definitions (palliative procedure and palliative care), treating a disproportionate share of patients who suffer unforeseen tragic events, and the surgical system., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Two important changes in the past decade have altered the landscape of graduate medical education (GME) in the U.S. The national restrictions on trainee duty hours mandated by the Accreditation Council for Graduate Medical Education (ACGME) were the most visible and generated much controversy. Equally important is the ACGME Outcome Project, which mandates competency-based training. Both of these changes have unique implications for surgery trainees, who traditionally spent long hours caring for patients in the hospital, and who must be assessed in 2 broad domains: their medical care of pre- and postoperative patients, and their technical skill with procedures in and out of the operating room. This article summarizes 3 key challenges that lie ahead for surgical educators. First, the changes in duty hours in the past 7 years are summarized, and the conversation about added restrictions planned for July 2011 is reviewed. Next, the current state of the assessment of competency among surgical trainees is reviewed, with an outline of the challenges that need to be overcome to achieve widespread, competency-based training in surgery. Finally, the article summarizes the problems caused by increased reliance on handoffs among trainees as they compensate for decreased time in the hospital, and suggests changes that need to be made to improve safety and efficiency, including how to use handoffs as part of our educational evaluation of residents., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: the aim of this study was to explore professional values, value conflicts, and assessments of the Accreditation Council for Graduate Medical Education's duty-hour restrictions., Methods: questionnaires distributed at 15 general surgery programs yielded a response rate of 82% (286 faculty members and 306 residents). Eighteen items were examined via mean differences, percentages in agreement, and significance tests. Follow-up interviews with 110 participants were explored for main themes., Results: residents and faculty members differed slightly with respect to core values but substantially as to whether the restrictions conflict with core values or compromise care. The average resident-faculty member gap for those 13 items was 35 percentage points. Interview evidence indicates consensus over professional values, a gulf between individualistic and team orientations, frequent moral dilemmas, and concerns about the assumption of responsibility by residents and "real-world" training., Conclusions: the divide between residents and faculty members over conflicts between the restrictions, core values, and patient care poses a significant issue and represents a challenge in educating the next generation of surgeons., (2011 Elsevier Inc. All rights reserved.)

Background: Some anticipated that the Accreditation Council for Graduate Medical Education duty hours restrictions would foster a team-focused "new professionalism" among residents. This study explores the prevalence and challenges of a new professionalism and whether they vary by program size., Method: Questionnaires distributed in 15 general surgery programs produced an 82% response rate (N = 306); 52 semistructured follow-up interviews were completed. Results include means, percentage who "agree or strongly agree," significance tests, and main themes from the interviews., Results: A new professionalism is limited by residents' reluctance to pass work from day to night teams, unclear guidance regarding stay-or-go decisions during shift transitions, little educational emphasis on sign-outs, and the practice of long hours in the name of professionalism. Program size is largely unassociated with these beliefs and behaviors., Conclusions: A new professionalism represents a stalled revolution among surgical residents. The new professionalism's emphasis on teamwork requires additional attention to staffing and workload management.

Three fourths of chief residents in general surgery receive further specialty training. The end to start-of-year transition can create administrative conflicts between the residency and the specialty training program. An Internet-based questionnaire surveyed general surgery and surgical specialty program directors to define issues and possible solutions associated with end to start-of-year transitions using a Likert scale. There was an overall response rate of 17.5 per cent, 19.6 per cent among general surgery directors, and 15.8 per cent among specialty directors. Program directors in general surgery felt strongly that the transition is an administrative problem (P < 0.001). They opposed extra days off at the end of the chief resident year or ending in mid-June, which specialty directors favored (P < 0.001). Directors of specialty programs opposed starting the year 1 or 2 weeks after July 1, a solution that general surgery directors favored (P < 0.001). More agreement was reached on whether chief residents should take vacation week(s) at the end of the academic year, having all general surgery levels start in mid-June, and orientation programs in July for specialty trainees. Program directors acknowledge that year-end scheduling transitions create administrative and patient care problems. Advancing the start of the training year in mid-June for all general surgery levels is a potential solution.

Purpose: General Surgery residents are increasingly pursuing fellowships. We examine whether perceived subspecialty content, dedicated services, and fellows impact fellowship choices., Methods: Specialty content was assessed through a survey linking 228 operations to 9 content areas. The presence of dedicated services and fellows and the post-residency activities of graduates 1997-2006 were collected from 2 program directors., Results: A total of 75% of residents (26 University of Mississippi, UM; 22 Vanderbilt University, VU) completed surveys. Five dedicated services and 2 fellowships at UM and VU were identical; VU had an additional 4 services and 3 fellowships. UM and VU residents similarly associated 184 operations (81%) with General Surgery. Agreement was not linked to services or fellows. A total of 44% of UM graduates and 68% of VU graduates pursued fellowships. The top choice at UM was Plastic/Hand (14%, versus 6% VU) and Oncology/Endocrine at VU (19%, versus 2% UM). Differences in specialties selected could not be linked consistently to dedicated services or fellows., Conclusion: Dedicated services and fellows appear to have little impact on fellowship specialty selection by chief residents. There may be a generic effect of dedicated services favoring fellowship versus no fellowship. Differential faculty mentoring skills may influence specific fellowship choices.

Purpose: Narrative medicine is a patient-centered approach to the practice of medicine that rescues the patients' stories and integrates what is important to them into decisions regarding their health care. Our hypothesis is that narrative understanding enhances the patient-provider relationship and contributes to optimizing patient care. We propose to use written narrative reflection to capture and measure the general competencies of systems-based practice, practice-based learning, communication skills, and professionalism. DEVELOPMENT/METHODS: The development of this narrative-based project is based on a pilot study that we conducted at our institution with third-year surgical clerkship students. In the pilot, students produced in-depth narrative write-ups on a patient they had had the opportunity to "know." We plan a similar approach for surgical resident education. After a brief discussion of narrative medicine during our scheduled didactic conference, the residents are asked to initiate a written narrative reflection on a patient of their choosing. The narratives will be collected 1 week later. Our plan is to repeat this assessment quarterly so that 4 narratives will be generated annually from internship through the chief resident year., Evaluation: The narratives will be analyzed for content and recurring themes that capture the resident's communication skills, professionalism, as well as self-critique (practice-based learning) and value attributed to health-care teams (systems-based practice)., Outcome Measures: After completion of the narratives, a 5-point Likert response survey will be given to the residents to assess their experience and the perceived value of written reflection. The written narratives will become part of the resident's ongoing portfolio. IMPLEMENTATION/EXPERIENCE TO DATE: Feedback from the medical student pilot study was favorable. When asked in a follow-up questionnaire, most students reported the experience to be valuable and recommended the use of narrative reflection in medical education. To assess the feasibility of this approach in surgical residency, we introduced the concept of narrative reflection to our residents during surgery grand rounds. Thirty-three narratives were collected 1 week later. CONCLUSION/NEXT STEPS: This preliminary experience suggests that acquisition of resident-authored narrative reflection is feasible during surgical residency. Use of this narrative-based approach in surgical resident education has the potential to capture and measure the general competencies of systems-based practice, practice-based learning, communication skills, and professionalism.

Major changes in surgical practice and myriad external mandates have affected residency education in surgery. The traditional surgery residency education and training model has come under scrutiny, and calls for major reform of this model have been made by a variety of stakeholders. The American Surgical Association appointed a Blue Ribbon Committee in 2002 to consider the recent changes in surgical practice and surgical education and propose solutions that would ensure a well-educated and well-trained surgical workforce for the future. This committee included representatives from the American Surgical Association, the American College of Surgeons, the American Board of Surgery, and the Residency Review Committee for Surgery. The committee made several far-reaching recommendations relating to residency education in surgery. After the Blue Ribbon Committee completed its task in 2004, representatives from the aforementioned four organizations, the Association of Program Directors in Surgery, and the Association for Surgical Education created a national consortium called the Surgical Council on Resident Education (SCORE). This consortium is pursuing efforts to reform residency education in surgery and implement several key recommendations of the Blue Ribbon Committee. The principal area of focus of SCORE is the development of a national curriculum for surgery residency education and training. Other activities of SCORE include the development of a Web site to support surgery residency education and pursuit of international collaboration. SCORE's efforts will be key to offering surgery residents the best educational experiences, preparing residents for future practice, and supporting delivery of surgical care of the highest quality. The authors examine the current state of residency education in surgery and explore efforts underway to reform this educational model.