The value of resident teaching to improve student perceptions of surgery clerkships and surgical career choices

BACKGROUND: A fundamental function of attending faculty is to teach and mentor medical students, but the benefit of the resident's role is recognized increasingly. METHODS: Our Standardized Institutional Clinical Clerkship Assessment allows students to rate 27 factors relative to a clinical clerkship. Scores from 1998 to 2005 were used to evaluate our surgical clerkship program and to compare resident and attending teachers. Student surgery career choices also were monitored. RESULTS: Medical students routinely scored residents more highly than attending faculty. Attendings' scores did not improve; however, residents' teaching and overall clerkship scores improved during the study period and paralleled students' increased selection of a surgical career. CONCLUSIONS: Students perceived residents as teachers more than attendings. Residents may have significant influence over students' career choice by their teaching and mentoring activities, which benefit attending efforts.     

Missed opportunities: a descriptive assessment of teaching and attitudes regarding communication skills in a surgical residency

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires that "residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates." The authors sought to assess current methods of teaching and attitudes regarding communication skills in their surgical residency. METHODS: After obtaining Institutional Review Board (IRB) exemption, voluntary anonymous surveys were completed by a sample of convenience at the Vanderbilt University Medical Center: surgical residents at Grand Rounds and attending surgeons in a faculty meeting. Data were evaluated from 49 respondents (33 of 75 total surgical residents, 16 representative attending surgeons). RESULTS: One hundred percent of respondents rated the importance of communication to the successful care of patients as "4" or "5" of 5. Direct attending observation of residents communicating with patients/families was confirmed by residents and faculty. Residents reported varying levels of comfort with different types of conversations. Residents were "comfortable" or "very comfortable" as follows: obtaining informed consent, 91%; reporting operative findings, 64%; delivering bad news, 61%; conducting a family conference, 40%; discussing do not resuscitate (DNR) orders, 36%; and discussing transition to comfort care, 24%. Resident receptiveness to communication skills education varied with proposed venues: 84% favored teaching in the course of routine clinical care, 52% via online resources, and 46% in workshops. Residents were asked how frequently they received feedback specific to their communication skills during the past 6 months: Most residents reported 0 (39%) or 1 (21%) feedback episode. Only 30% of resident respondents reported receiving feedback that they perceived helpful. Attending surgeons reported that they did provide residents feedback specific to their communication skills. When asked to estimate the number of feedback episodes in the last 6 months, 16 faculty members reported a total of 67 feedback episodes, whereas 33 residents reported a total of only 24 episodes. Most faculty members rated their comfort with providing feedback specific to communication skills as "very comfortable" (56%) or "comfortable" (19%). "Time constraints" was the most frequently cited barrier to teaching communication skills. CONCLUSIONS: Communication skills are valued as integral to patient care by both residents and faculty in this study. Residents are most receptive to teaching of communication skills in the clinical setting. Faculty members report they are providing feedback to residents. Although residents report direct observation by faculty, currently only a minority (30%) are receiving feedback regarding communication that they consider helpful. A need exists to facilitate the feedback process to resolve this discrepancy. The authors propose that an evaluation instrument regarding communication skills may strengthen the feedback process.     

Comparing resident measurements to attending surgeon self-perceptions of surgical educators

OBJECTIVE: The purpose of this study was to evaluate the initiation and utility of evaluating attending surgeons as educators by resident trainees. Additionally, we were interested in comparing resident measurements to attending self-perceptions. METHODS: A written evaluation form, (utilizing five-point ordinal scale assignments) queried respondents regarding the performance of surgical attendings in the operating room, and other clinical settings. A similar form was distributed to the faculty members, which they used to evaluate themselves. Mean scores were determined, as were comparisons between self-perception and resident assessments. Differences in scores with p values less than 0.05 were considered statistically significant. RESULTS: Thirty-six residents evaluated 23 attendings. Mean assignments by residents of performance in the operating room, other clinical settings, and overall scores for all faculty members as a group were 4.22 +/- 0.04, 4.11 +/- 0.03, and 4.16 +/- 0.03, respectively, with a score of five, generally corresponding to a most favorable rating. When overall scores were analyzed, 10 attendings received scores that differed significantly from those received by their peers, with half of subjects above, and the other half being below the 95% confidence interval. Eighteen (78%) of attendings completed the self-evaluation forms, and of these, 11 (61%) had self-perceptions that differed significantly from overall scores as reported by the residents. CONCLUSIONS: Our evaluation process delineated significant differences among attending faculty members and identified individual strengths and weaknesses. Many educators' self-perceptions differed significantly from resident assessments, and attendings who did not evaluate themselves scored lower than their peers.     

Defining service and education: the first step to developing the correct balance

BACKGROUND: Service and education activities have not been well defined or studied. The purpose of this study is to describe how attendings and residents categorize common resident activities on a service-education continuum. METHODS: A web-based survey was designed to categorize resident activities. A panel of residents and surgical educators reviewed the survey for content validity. Residents and attendings categorized 27 resident activities on a 5-point scale from 1 (pure service) to 5 (pure education). Data analysis was performed using SPSS ver.12. RESULTS: 125 residents and 71 attendings from eight residency programs participated. 66% of residents and 90% of attendings were male. On average, attendings had practiced 14.3 years. Residents' post-graduate year ranged from PGY-1 to PGY-6 (mean of 2.78). Attendings and residents agreed on the categorization of most activities. Residents felt more time should be devoted to pure education than did attendings. Forty percent of residents felt that more than half of their time was spent in pure service versus 10% of attendings. Twenty-five percent of residents and 23% of attendings were dissatisfied with the service-education balance. CONCLUSIONS: The Residency Review Committee mandates that education is the central purpose of the surgical residency without clearly defining the balance between education and service. Attendings and residents agree on the educational value of most activities and that the balance between education and service is acceptable. When compared with attendings, residents feel they need significantly more time in education. Adequate learning can be facilitated by the development of clear definitions of service and education and guidelines for the distribution of resident time.     

Struggles with autonomy: Exploring the dual identities of surgeons and learners in the operating room

BackgroundDeveloping autonomy is a critical component of becoming an attending surgeon. General surgery training has evolved in recent decades, however, leaving residents less time to work with attendings to establish entrustment. Limited entrustment can impact resident learning and engagement.MethodsA constructivist grounded theory approach was used to guide interviews of 12 general surgery residents and 10 attendings.ResultsEngagement in the OR is perceived by both residents and attendings as fundamental to achieving autonomy. Our study uncovered three key tensions: 1. Residents and attendings both occupy dual roles in the OR; 2. System demands put those roles in tension and opposition constantly; 3. Residents and attendings do deploy strategies to seek balance in those tensions.ConclusionsIn an academic OR setting, competing priorities can negatively impact resident engagement. Participants described some strategies for helping residents and attendings prioritize learning and teaching to better prepare residents for future practice.     

Warm-up on a simulator improves residents’ performance in laparoscopic surgery: a randomized trial

Introduction and hypothesis

Our aim was to assess the impact of immediate preoperative laparoscopic warm-up using a simulator on intraoperative laparoscopic performance by gynecologic residents.

Methods

Eligible laparoscopic cases performed for benign, gynecologic indications were randomized to be performed with or without immediate preoperative warm-up. Residents randomized to warm-up performed a brief set of standardized exercises on a laparoscopic trainer immediately before surgery. Intraoperative performance was scored using previously validated global rating scales. Assessment was made immediately after surgery by attending faculty who were blinded to the warm-up randomization.

Results

We randomized 237 residents to 47 minor laparoscopic cases (adnexal/ tubal surgery) and 44 to major laparoscopic cases (hysterectomy). Overall, attendings rated upper-level resident performances (postgraduate year [PGY-3, 4]) significantly higher on global rating scales than lower-level resident performances (PGY-1, 2). Residents who performed warm-up exercises prior to surgery were rated significantly higher on all subscales within each global rating scale, irrespective of the difficulty of the surgery. Most residents felt that performing warm-up exercises helped their intraoperative performances.

Conclusion

Performing a brief warm-up exercise before a major or minor laparoscopic procedure significantly improved the intraoperative performance of residents irrespective of the difficulty of the case.     

When Should a Surgical Resident Call an Attending Surgeon?

BACKGROUND: Many interactions exist between surgical residents and attending surgeons, where residents debate whether they should "bother" to call an attending. Several instances have occurred when a senior resident or an attending has not been notified about a patient's status by a junior resident. Because of poor communication, care might be delayed, and surgeons and patients' relatives might not be informed of a change in status. Sometimes the resident's initial management was different than an attending's management. Communication issues were raised at our weekly Morbidity & Mortality conference. We decided to investigate the range of judgment as to when a resident should notify an attending surgeon. STUDY DESIGN: The objective was to investigate the range of judgment as to when a surgical resident should notify an attending surgeon. The purpose of this study was to determine the clinical circumstances when surgical residents should contact an attending surgeon directly or leave a message with the service. To investigate communication questions, we developed a survey of 34 clinical circumstances in which a surgical resident could call an attending. Sixteen residents and 16 attendings completed the survey entitled "Conditions where a surgical resident should consider contacting the surgical attending." From the information obtained from this study, a "must leave message" and "must speak to directly" list were created to guide residents as to when to call an attending. RESULTS: A significant difference existed in the answers provided by residents and attendings. Residents and attendings agreed universally that an attending should be spoken to directly for 2 reasons: cardiopulmonary arrest and death. We created a "must speak to directly" list based on the attendings' answers. This list includes 10 clinical circumstances in which a surgical resident should speak directly with an attending regarding patient issues. Likewise, a "must leave message" list was created of an additional 8 reasons when a surgical resident must at least call the service of an attending and leave a message. CONCLUSION: The purpose of our study was to help standardize communication between surgical residents and attendings regarding patient status. With these 2 standardized "must" lists, residents will have less uncertainty or hesitation to awaken an attending at night. This finding should improve the communication skills of surgical residents and ultimately improve the quality of patient care.     

Effects of sentinel lymph node biopsy on surgical residency training

Axillary node dissection (AND) is an integral part of surgical training. Sentinel lymph node biopsy (SLN) was introduced into our residency in 1997. Our purpose in this study was to evaluate the impact of SLN on AND experience. AND/SLN operative experience of residents and attendings at our residency was reviewed using resident case-logs and questionnaires from 2002 and 2005. The perception of performing and teaching AND was assessed. Thirty-three residents and 24 attendings participated. Graduating chiefs from the class of 2000 performed no SLN, which increased to 4.25 in 2002 and to 8.5 in 2005. In contrast, graduating chiefs performed 25 AND in 2000, which decreased to 16.5 in 2002 and to 13.25 in 2005. The majority of the residents felt that AND was a senior level case (56% postgraduate year [PGY] I and II and 87% PGY III-V). The majority of the residents felt that SLN was a junior level case (89% PGY I and II and PGY III-V). Fifty-six per cent of PGY III-V felt that SLN introduction negatively impacted their ability to perform AND. Attendings cited 15 and 24 AND before feeling comfortable performing and teaching the procedure to a resident. Since the introduction of SLN into our residency, the number of AND has decreased, with senior residents feeling that SLN has decreased their ability to perform AND. As fewer AND are performed than our attendings cite to feel comfortable, future residents may not be competent to perform or teach AND.     

Surgical residents' knowledge of documentation and coding for professional services: an opportunity for a focused educational offering

INTRODUCTION: A working knowledge of documentation and coding for physician services (DCPS) is increasingly important for a successful practice. There is no standardized, widely available educational offering available to surgical residents in DCPS. The purpose of this study was to survey surgical residents and attendings for their knowledge of documentation and coding and their opinions about its importance in their training and practice. METHODS: A convenience sample of 60 surgical residents and 46 attendings from 5 surgical residency training programs were administered a written survey on DCPS. RESULTS: The majority of residents were male (60%), in university-based programs (82%), and planned to work in a surgical specialty (55%) A larger proportion of attendings were male (80%) and in general surgery practice (62%), and a smaller proportion was university based (61%). Similar proportions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS. The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attendings stated that they were somewhat knowledgeable. As a group, residents answered 54% of 25 knowledge questions correctly, and attendings answered 77% correctly. Ninety-two percent of residents believed that expertise in DCPS would make a difference in their practice, whereas 80% of attendings stated that this knowledge was currently important to their practice. Similar proportions of residents and attendings, 85% and 87%, respectively, thought that it should be an important part of residency training. CONCLUSIONS: Residents in this survey are aware of the importance of DCPS but feel inadequately prepared for this area of practice. The residents' knowledge of basic concepts in DCPS is marginal. Attendings surveyed had similar opinions and somewhat better knowledge of the subject. A widely available, standardized educational offering on DCPS is needed and should be provided as part of the practice-based core competencies of surgical residency training.     

The early effects of code 405 work rules on attitudes of orthopaedic residents and attending surgeons

BACKGROUND: The impact of strict enforcement of Section 405 of the New York State Public Health Code to restrict resident work to eighty hours per week and the adoption of a similar policy by the Accreditation Council on Graduate Medical Education in 2002 for orthopaedic residency training have not been evaluated. Adoption of these rules has created accreditation as well as staffing problems and has generated controversy in the surgical training community. The purposes of this study were (1) to evaluate the attitudes of orthopaedic residents and attending surgeons toward the Code 405 work-hour regulations and the effect of those regulations on the perceived quality of residency training, quality of life, and patient care and (2) to quantify the effect of the work-hour restrictions on the actual number of hours worked. METHODS: We administered a thirty-four-question Likert-style questionnaire to forty-eight orthopaedic surgery residents (postgraduate years [PGY]-2 through 5) and a similar twenty-nine-question Likert-style questionnaire to thirty-nine orthopaedic attending surgeons. All questionnaires were collected anonymously and analyzed. Additionally, resident work hours before and after strict enforcement of the Code 405 regulations were obtained from resident time sheets. RESULTS: The average weekly work hours decreased from 89.25 to 74.25 hours for PGY-2 residents and from 86.5 to 73.25 hours for PGY-3 residents, and they increased from 61.5 to 68.5 hours for PGY-4 residents. Residents at all levels felt that they had increased time available for reading. There was general agreement between attending and resident surgeons that their operating experience had been negatively impacted. Senior residents thought that their education had been negatively affected, while junior residents thought that their operating experience in general had been negatively affected. Senior residents and attending surgeons felt that continuity of care had been negatively impacted. All agreed that quality of life for the residents had improved and that residents were more rested. CONCLUSIONS: On the basis of the survey data, the implementation of the new work-hour restrictions was found to result in a decrease in the number of hours worked per week for PGY-2 and PGY-3 residents and in an increase in work hours for PGY-4 residents. This could explain the definite difference between the attitudes expressed by the senior residents and those of the junior residents. Senior residents felt that their education was negatively impacted by the work rules, while junior residents expressed a more neutral view. However, senior residents did not believe that their operative experience was as negatively impacted as did junior residents. Although junior and senior residents and attending surgeons agreed that resident quality of life had improved, we were not able to determine whether this offset the perceived negative impact on education, continuity of care, and operative experience.     

Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship

BACKGROUND: There has been declining interest in surgery among medical students and one reason might be the third-year clerkship experience. The aim of this study was to clarify the perceptions and expectations of attendings, residents, and medical students on the clerkship experience. STUDY DESIGN: A survey was distributed to all general surgery attendings, the entire general surgery house staff, and an entire third year medical school class inclusive of the 2001-2002 academic year at a single institution. Statistic analysis consisted of chi-square and Kruskal-Wallis-ANOVA on ranks with Dunn's test for multiple comparisons. A p < 0.05 was significant. RESULTS: Responses were obtained from 59 attending surgeons (50%), 38 surgical residents (32%), and 107 medical students (66%). Of this student cohort, 35% were planning to choose a surgical specialty as a career. Agreement was high among faculty, students, and residents about factors considered important in evaluation, expectations of skills, and level of skills needed before the clerkship. Medical students desired more hours of instruction, believed they performed fewer procedures per week, and thought that feedback was poor compared with the opinions of faculty and residents (p < 0.002). Nearly 50% of medical students believed they were an inconvenience to the service; 30% of house officers and 27% of faculty (p < 0.001) believed this also. Almost all faculty and residents, however, wanted medical students on the service (> 95%). Faculty believed residents did a better job teaching than either the students or residents themselves did (p < 0.001), and students thought that residents were the primary source of education in patient care. CONCLUSIONS: Considerable differences exist between faculty, surgical resident, and medical student perceptions and expectations of medical student education. Structured direct faculty contact, definition of medical student roles on the surgical team, and more consistent feedback can be rapidly improved.     

Role of surgical residents in undergraduate surgical education.

OBJECTIVES: To identify the role and impact of surgical residents on the various activities of a senior (4th year) surgical clerkship, and to explore students' perceptions of differences between the teaching behaviours of attending physicians and residents. DESIGN: A survey by questionnaire. SETTING: McGill University, Montreal. METHOD: A 67-item questionnaire was administered to fourth-year medical students at the end of their 8-week surgical clerkship. Analysis of the data was performed using the Wilcoxon signed-rank test, Dunn's multiple comparison test and mean average. MAIN OUTCOME MEASURES: Overall satisfaction with the clerkship, teaching behaviours and teaching of clinical skills and basic principles. RESULTS: Overall satisfaction with the clerkship was 6.31 out of 10. Surgical residents were perceived as being significantly more active than the attending staff in 14 out of 15 teaching behaviours. They were also seen as important in teaching certain clinical skills such as suturing, assisting in the operating room and managing emergency situations. They also contributed significantly to teaching the basic principles of surgery such as infections, surgical bleeding and fluid and electrolytes. On a 10-point scale, students felt that more learning was achieved by independent reading, tutorials and residents' teaching than by other teaching modalities, including attending physicians' and nurses' teaching. CONCLUSIONS: Medical students perceive surgical residents as being significantly more active in their education process than the attending staff. Residents appear to be responsible for teaching various technical and patient management skills necessary for patient care. Along with independent reading and tutorials, resident teaching contributes a significant portion of the medical student's acquisition of knowledge and appears to contribute to the students' choice of surgery as a career.     

Surgical resident and attending physician attitudes toward glucose control in the surgical patient

Hyperglycemia is a common occurrence in postoperative surgical patients and has been related to adverse outcomes, including increased infections, delayed wound healing, and increased postoperative mortality. Therefore, the management of hyperglycemia has become an increasingly important part of surgical practice. A 16-point questionnaire was distributed to general surgery housestaff and attending physicians at three teaching hospitals in southern California. The survey was scaled 1 to 5 (1, strongly disagree; 5, strongly agree). Answers of 1 and 2 were considered a negative response, whereas 4 and 5 were considered affirmative responses. There were 105 survey respondents (60 surgical residents, 45 surgical attendings). Only half of respondents were confident in their ability to adequately control blood sugar in their hospitalized patients. Approximately 60 per cent of attendings rely on residents to manage glucose control. Less than half of the attendings (49%) and less than one-third of residents (27%) stated they were current with the latest guidelines for glucose control. Only one-third of the attendings would consult an internist or endocrinologist to assist in glycemic management. This study reveals an important knowledge deficit among surgical resident and attending physicians. Focused education on glycemic control in the perioperative patient should be a mandatory component of surgical training.     

The expanding role of the nurse practitioner in an academic medical center and its impact on graduate medical education

PURPOSE: Academic medical centers (AMCs) have used nurse practitioners (NPs) for the provision of direct patient care for many years. However, as more NPs are hired to fill in the void created by both the 80-hour work week and the increased demands on attendings' time, their role has evolved in terms of patient care and graduate medical education. We sought to evaluate the expanded role of the NP in our large tertiary AMC to help clarify the interrelationships with the patient care delivery model and GME. METHODS: Data were collected through interviews of NPs, nurses, attendings, and residents. Data were analyzed to identify trends contributing to successful models of practice and their impact on patient care and graduate medical education (GME). RESULTS: Interviews were completed with 58/74 (78%) NPs employed at our medical center. Anonymous written surveys were completed by 41 (55%) providers. In terms of perceived impact on the role NPs played in GME, 77% of NPs surveyed felt that their role complimented the resident training; 9% felt that their role competed with resident training; and 14% felt that their role had no impact on resident training. CONCLUSION: We believe that the presence of an experienced NP on a care deliver team can enhance the educational experience of residents as well as provide continuity of patient care in the era of the 80-hour work week.     

Are you a surgical role model?

PURPOSE: Multiple papers have examined the recent decline in the number of surgical residency applicants. Many have concluded that a lack of role models in surgery is at least partially responsible for this decline. However, to date, the definition of a surgical role model does not exist. This paper defines a surgical role model based on criteria determined by surgery residents. METHODS: Fourth- and fifth-year surgical residents from 1 residency program were asked to collaboratively define 9 characteristics that make a surgical role model. The 9 criteria as defined by the residents were didactic teaching, teaching rounds, attendance at didactic activities, demonstrates skills and decision making in the operating room with confidence and virtuosity, allows [resident] to do procedures according to ability, allows autonomy to make independent decisions, provides feedback, stimulates critical thinking with use of literature, and assists [resident] to find and complete research for publication. Each resident in the program was then given a questionnaire and asked to evaluate each of the 49 teaching attendings on each of the 9 criteria, on a 3-point scale. Finally, residents evaluated each attending based on professionalism and mutual respect on a scale of I Don't Want To Emulate Him/Her, OK, or Role Model. These categories were also assigned a number (1, 2, and 3, respectively). Pearson correlation and stepwise multiple regression were used to determine the relationship between "Role Model" and the 9 criteria. The unit of analysis was the mean rating given each attending on each of the 10 scales. RESULTS: A total of 847 questionnaires were analyzed. Each of the 9 criteria correlated significantly with the Role Model rating (all p < 0.01). The average correlation was 0.73 (range, 0.64 to 0.78). Of the 9 criteria, 4 correlated best with the Role Model, as shown in. The stepwise regression indicates that 3 of the 9 criteria are uniquely associated with the Role Model variable. These 3 criteria are stimulates critical thinking with use of literature, allows autonomy to make independent decisions, and attendance at didactic activities. CONCLUSIONS: All of the 9 criteria are important factors in residents' perception of the Role Model characteristics of attending faculty. A parsimonious, operational definition of the surgical attending role model is one who stimulates the resident to think, gives the resident the opportunity to think and act independently, and is available to the resident.     

A comparison of faculty and resident perception of resident learning needs in the operating room

OBJECTIVES: The purpose of this study was to gain an understanding of faculty and resident perception of residents' learning needs regarding operative management. Our hypothesis is that surgical faculty and residents have significantly different perceptions of residents' learning needs. DESIGN: This study used a 27-item survey designed to determine (1) the extent to which traditional learning resources are used by residents when preparing for cases in the operating room, (2) which Web-based resources residents use for operating room preparation, and (3) which operative management topics residents were deficient in despite preoperative preparation. SETTING: The settings for this study were the exhibit hall area during the 90th American College of Surgeons' Clinical Congress Meeting and a weekly resident conference. PARTICIPANTS: Participants for this study included a convenience sample of faculty and resident volunteers from the Clinical Congress and residents of our program (N = 246). RESULTS: On a scale of 1-5, with 5 indicating frequent use, residents rated their most frequently used resources as Major Surgical Texts (3.99) and Advice from colleagues (3.97). The top 3 operative management topics residents felt least prepared for after studying were "instrument use" (67.7%), "suture selection" (65.3%), and "operative field exposure" (50.0%). The top 3 operative management topics faculty felt residents were least prepared for were "anatomy" (73.9%), "natural history of disease" (73.9%), and "procedure choices" (69.6%). Chi-square analysis comparing faculty and resident perceptions of resident learning needs showed significant differences (p < 0.05) in 12 of the 12 operative management topics rated. CONCLUSION: A critical step in guiding development and proper use of learning technologies for surgical education is the conduct of needs assessments. The disparity between faculty and resident perception of residents' learning needs in the operating room underscores the need for residents to be included in needs assessments relating to surgical training.     

Barriers to advancement in academic surgery: views of senior residents and early career faculty

Background

A significant faculty attrition rate exists in academic surgery. The authors hypothesized that senior residents and early-career faculty members have different perceptions of advancement barriers in academic surgery.

Methods

A modified version of the Career Barriers Inventory–Revised was administered electronically to surgical residents and early-career surgical faculty members at 8 academic medical centers.

Results

Residents identified a lack of mentorship as a career barrier about half as often as faculty members. Residents were twice as likely as faculty members to view childbearing as a career barrier.

Conclusions

Many early-career faculty members cite a lack of mentors as a limitation to their career development in academic surgery. Childbearing remains a complex perceived influence for female faculty members in particular. Female faculty members commonly perceive differential treatment and barriers on the basis of their sex. Faculty development programs should address both systemic and sex-specific obstacles if academic surgery is to remain a vibrant field.     

Resident involvement in postoperative conversations: an underused opportunity

Background

Because of established attending-patient and family relationships and time constraints, residents are often excluded from the immediate postoperative conversation with family. Interpersonal and communication skills are a core competency, and the postoperative conversation is an opportunity to develop these skills. Our objective is to assess attitudes, experience, and comfort regarding resident participation during postoperative conversations with families.

Materials and methods

Residents and attending surgeons in an academic surgery center were surveyed regarding resident involvement in the postoperative conversation with families. Paper surveys were administered anonymously. Nonparametric statistics compared responses.

Results

There were 45 survey respondents (23 residents, 22 attendings). All residents rated postoperative conversations with families, as “important” or “very important”. Residents reported being “comfortable” or “very comfortable” with postoperative conversations. However, on average, residents reported fewer than 10 postoperative conversation experiences per year. Feedback was received by <30% on postoperative communication skills, but 88% wanted feedback. Most attendings reported it is “important” or “very important” for residents to communicate well with families during postoperative conversations, but rated residents' performance as significantly lower than the residents' self-assessments (P < 0.001). Attendings on average were only “somewhat comfortable” or “moderately comfortable” with residents conducting postoperative conversations with families, and only 68% reported allowing residents to do so. When bad news was involved, only 27% allowed resident participation. Most attendings (86%) believed residents need more opportunities with postoperative conversations.

Conclusions

Although most residents reported being comfortable with postoperative conversations, these survey results indicate that they have few opportunities. Developing a workshop on communication skills focused on the postoperative conversations with families may be beneficial.     

How Do Surgical Residents and Non-Physician Practitioners Play Together in the Sandbox?

INTRODUCTION: The reduction of resident work hours due to the 80-hour workweek has created pressure on academic health-care systems to find "replacement residents." At the authors' institution, a group of nurse practitioners (NPs) and physician assistants (PAs), collectively referred to as non-physician practitioners (NPPs), were hired as these reinforcements, such that the number of NPPs (56) was almost twice the number of clinical categorical surgery residents (37). An experienced leader with national credibility was hired to run the NPP program. On each service, the call system was changed to a night float system, whereby residents were pulled from traditional resident teams to serve as nighttime residents during the week. A total of 1-3 NPPs were hired for each team, but whether NPPs worked for the team as a whole, or were assigned to individual attendings, was left to the discretion of the division chiefs. One year after the start of this program, the authors wanted to study the effects it has had on both surgery resident education and NPP job satisfaction. METHODS: An electronic, anonymous survey was conducted during a monthly surgery resident meeting, and out of 72 categorical and preliminary surgery residents, 50% submitted answers to 12 questions. A similar electronic survey was administered to all 56 NPPs, with 45% responding. RESULTS: Overall, 63% of residents believed that lines of communication between surgery team members were clear, and 58% of residents and 71% of NPPs believed that attendings, residents, and NPPs worked together effectively. A total of 91% of residents believed that the addition of NPPs to the teams was positive overall, and 80% of NPPs were satisfied with their positions. Overall, 60% of residents and 50% of NPPs felt that educational goals were being met. DISCUSSION: Implementation of the 80-hour workweek and introduction of NPs and PAs onto the inpatient surgical services has altered resident education at the authors' institution. Although overall most residents view the addition of NPPs to the clinical services as positive, there are concerns about the program. Although hired to fill the void left by decreasing labor hours of residents, NPPs do not necessarily have the same goals as surgery residents and there is confusion about how NPPs fit into the hierarchy of the traditional surgical team.     

Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy

BACKGROUND: Resident participation in laparoscopic cholecystectomy (LC) is important for education but increases the time of operation. This time cost in training programs is not well-defined, and available data show no decrease in operative time as residents progress in training. We undertook this study to determine the effect of the resident and attending surgeon seniority on the operative performance of LC. PATIENTS AND METHODS: We undertook a retrospective review of LCs performed for all indications over two academic years in our training program. Operations were performed by junior (PGY 1-3) or senior (PGY 4-5) residents, assisted by junior (trained after 1994) or senior attending surgeons, none of whom had fellowship training in advanced laparoscopy. Demographics, surgeon, assistant, operative time, and operative complications were recorded. Operative diagnoses were defined as noninflammatory (biliary colic, dyskinesia, or polyps) or inflammatory (cholecystitis, pancreatitis). The primary outcome was time in minutes from skin incision to closure; secondary outcomes were complications and conversions to laparotomy. ANOVA, Student's t-test, and chi2 tests were used as appropriate with statistical significance attributed to P < 0.05. RESULTS: Three hundred fifteen LCs were performed. Two hundred seventy were without conversion to laparotomy or intraoperative cholangiography and were included in time and complication analysis. Junior attendings averaged 4 and senior attendings averaged 21 postresidency years. No differences were found on univariate analysis between groups in demographics or diagnosis category. Operative times were longer for junior residents irrespective of attending seniority: Jr Res/Jr Staff (n = 65): 86 +/- 32 min; Jr/Sr (n = 78): 88 +/- 38 min; Sr/Jr (n = 52): 73 +/- 27 min; Sr/Sr (n = 75): 67 +/- 24 min (P < 0.05). The overall rate of operative complications was higher in junior than senior resident cases (5.6% versus 0.78%, P < 0.05). The most common complication was cystic duct leak, of which 4/5 occurred in junior resident cases. Senior attendings had a trend toward increased conversions (8.4% versus 3.7%, P = 0.09). CONCLUSION: Resident, but not attending surgeon, seniority influences operative time and complication rate in LC. This information may help surgical educators maximize both resident learning and operative efficiency and safety.