Impact of mandatory resident work hour limitations on medical students' interest in surgery

BACKGROUND: The number of US medical students applying for general surgery residency has been declining. Recent studies have shown that the issue of "controllable lifestyle" has become a critical factor in medical students' decision-making process. We postulate that widespread implementation of resident work hour limitations would bolster medical students' interest in pursuing surgical careers. STUDY DESIGN: Students from New York University School of Medicine were surveyed about their attitudes toward work hour limitations and its effect on their interest in pursuing a surgical residency. One hundred thirty-two students participated. RESULTS: Nearly 95% of respondents believed that work hour limitations were a positive change and, if all other factors were equal, they would choose a training program that used work hour limitations over one that did not. The most common reasons cited in favor of limits were improvements in resident lifestyle (42%) and patient safety (34%). Fifty-three percent of respondents indicated that presence of work hour limitations alone would increase their interest in considering a surgical residency and only 2% of medical students indicated that it would lessen their interest in surgery. Not surprisingly, intellectual interest in a specialty was the most important factor in choosing a residency for 86% of students. Nevertheless, work hour limitations were designated a higher priority than future salary by 55% of medical students. CONCLUSIONS: The presence of work hour limitations has a positive impact on medical students' interest in surgery. Widespread implementation of work hour limitations may bolster the number of applications for surgical residency.     

The Canadian Urology Fair: a model for minimizing the financial and academic costs of the residency selection process.

INTRODUCTION: In 1994, the Canadian urology residency training programs designed the "Canadian Urology Fair"--a single-site (Toronto, Ont.), 1-day fair to conduct the personal interview portion of the residency selection process. The objective of the current study was to evaluate the success of the Urology Fair in achieving its original goals of decreasing the financial burden and minimizing time away from medical training for applicants and faculty. METHODS: Both candidates and Canadian urology training programs were surveyed regarding the financial and academic costs (days absent) of attending the 2001 Urology Fair. Data from the 2001 Canadian Resident Matching Service (CaRMS) was used to compare the financial and academic costs of attending personal interviews incurred by candidates declaring urology as their first-choice discipline to candidates interviewing with other surgical specialties throughout Canada. RESULTS: Financial costs incurred by candidates to attend the Urology Fair (mean Can dollar 367) were significantly lower than candidates' estimated costs of attending on-site interviews at the individual programs (mean Can dollar 2065). The financial costs of attending personal interviews by CaRMS applicants declaring urology as their first-choice discipline (mean Can dollar 2002) were significantly lower than the costs incurred by applicants interviewing with other surgical disciplines (mean Can dollar 2744). Financial costs to urology programs attending the fair (mean Can dollar 1931) were not significantly greater than the programs' estimated costs of conducting on-site interviews at their respective program locations (mean Can dollar 1825). Days absent from medical school to attend interviews were significantly lower among CaRMS applicants declaring urology as their first-choice discipline (3 d) compared with applicants who interviewed with other surgical specialties (9.1 d). CONCLUSION: The Canadian Urology Fair represents an innovative and efficient method for residency programs to conduct the personal interview portion of the residency selection process and should serve as a model for making the interview process less expensive and time-consuming for both candidates and faculty.     

Limiting Residency Applications to Dermatology Benefits Nearly Everyone

With a 34-percent increase in dermatology residency applications in the past decade, residency programs are increasingly faced with the daunting task of reviewing more applications for a relatively fixed number of residency positions. Other specialty programs, including otolaryngology, orthopedics, plastic surgery, and ophthalmology, have called for limiting the number of residency applications. Dermatology programs have developed various ways to decrease the number of reviewed applications, from cutoffs for Step 1 board scores to Alpha Omega Alpha membership to secondary applications. While this can decrease the applicant pool, it limits a more holistic review of applications. We propose an application cap of 20 programs, which will decrease the number of applications each program receives 3- to 5-fold. Each applicant can approach the process more thoughtfully in choosing the best programs for them and will save money in application fees. As program directors rank “perceived interest” in their residency program as a primary factor for selecting applicants, a cap will allow program directors to know that all applicants are interested in their specific program. Ultimately, we contend that application caps would improve match outcomes with applicants receiving training in the best program for them, increasing the likelihood of successful fit for clinical training, opening the field to a more diverse set of applicants, and saving everyone time and money.     

The resident application process and its correlation to future performance as a resident

Many authors have attempted to determine predictors for success within a residency program. There is very little agreement about what is useful. We hypothesized that our residency selection process is effective in determining which resident applicants would be most likely to excel in our program. To test this hypothesis, we reviewed the scores that applicants received after their interview day to determine if there was a correlation with any measures used to evaluate residents once they entered residency training. Our results determined that the score given to an applicant fails to correlate with any of the areas that are evaluated throughout their residency. The only statistically significant correlation was between the scores assigned by the selection committee to applicants and the applicant scores on their first year in training examination. We concluded that our residency selection process score does not accurately predict which applicants will excel in our program.     

Attitude of Prospective Surgical Residents Regarding Surgery for Morbid Obesity

Background: Obesity and associated co-morbidities have become an epidemic in the United States. As surgery for obesity becomes more common, surgical training programs need to address this growing demand. We conducted this study to assess prospective surgery trainees' attitudes and knowledge regarding surgery for morbid obesity. Methods: An anonymous and voluntary questionnaire was given to prospective surgical residency applicants to complete during their interview. The questionnaire included basic demographic information and addressed the applicants' attitudes and basic knowledge about surgery for obesity. Results: 57 applicants to the surgical residency program completed the survey. Demographic information included: 51% male, 36% from the Northeast, 32% with obese family members, and 93% applying for a categorical surgery position. 81% of applicants had been exposed to bariatric surgery. Although 70% of applicants would perform bariatric surgery as part of their practice, only 44% would make this their career. Reasons for reluctance to treat bariatric surgery patients included: more complications (46%), non-compliant patients (33%), and technically demanding surgery (18%). 89% responded that they would recommend bariatric surgery to a family member, but only 77% would consider it for themselves. Overall correct answers regarding bariatric surgery knowledge were 74%. Conclusions: Attitudes and knowledge about surgery for morbid obesity were generally positive in prospective surgical trainees. Medical school curriculum and surgical training programs should continue to expose trainees to information from this ever-growing field.     

Comparison of basic elements of human performance scores between urologists with various extents of experience

BACKGROUND AND PURPOSE: An objective evaluation of innate ability and its ability to predict potential success as a surgical trainee is an appealing concept for the selection process of residency applications. The objective of this study was to evaluate whether basic elements of performance (BEP) could discriminate among resident applicants and urologists with various extents of surgical experience. SUBJECTS AND METHODS: One hundred forty-five participants were divided into four study groups: group A, 57 urology residency applicants to the 2002 and 2003 interview process; group B, 8 post-internship urology residents; group C, 19 urologists tested with BEP within 10 years of graduation from their residency training program; and group D, 61 urologists who had graduated from their residency training program more than 10 years prior to testing. The BEP measures consisted of 13 basic performance resources (BPR) including visual-information processing speed, visual-spatial immediate-recall capacity, and neuromotor channel capacity. RESULTS: The four study groups differed significantly in their mean age: group A=27.6 years, group B=29.1 years, group C=37.1 years, and group D=48.9 years (P<0.0005). There was essentially no significant difference between the groups with regard to immediate-recall memory, reaction time simple, or reaction time complicated. The younger participants (groups A and B) were faster than the older surgeons (groups C and D) (P<0.02). However, the older surgeons (groups C and D) were significantly more accurate than the younger groups (A and B) (P<0.0005). The only sex differences noted were in hand-grip strength and shoulder-strength scores, which were all higher in the men. CONCLUSIONS: There generally appears to be a lack of direct correlation between innate abilities and surgical experience. Urology resident applicants with no surgical experience and urology residents with limited surgical experience are faster but less accurate in innate skills testing than experienced practicing urologists.     

Resident operative experience during the transition to work-hour reform

HYPOTHESIS: The operative volume of chief residents would decrease with work-hour reform by the Accreditation Council for Graduate Medical Education (ACGME). DESIGN: Mixed-design study performed during July and December 2003. Collected data were from programs experimenting with work-hour reform and programs that had not yet implemented reform. New York programs were also included. SETTING: University-, community/university-, and community-based surgical residency programs. OTHER PARTICIPANTS: Telephone conversations occurred with 10 randomly selected program directors. MAIN OUTCOME MEASURES: Operative logs from chief residents graduating in 2002 and 2003 and a survey requesting information on programmatic changes. RESULTS: Of the 80 programs that responded, statistical analyses revealed the following findings: (1) there were no significant differences in the operative volume of chief residents based on work-hour model, program setting, or graduating class; (2) there was no significant difference in chiefs' operative volume between programs that experimented with work-hour reform and programs that did not experiment with work-hour reform during 2002-2003; (3) there was no relationship found between work hours and volume of operative cases; and (4) there was an inverse relationship found between work hours and operative volume for residents in New York programs. CONCLUSION: Several correlates must be considered for effective assessment and evaluation of the impact of work-hour reform on surgical training and education.     

Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7?years of experience in Switzerland

ABSTRACT: In 2005 the Swiss government implemented new work-hour limitations for all residency programs in Switzerland, including a 50-hour weekly limit. The reduction in the working hours of doctors in training implicate an increase in their rest time and suggest an amelioration of doctors' clinical performance and consequently in patients' outcomes and safety - which was not detectable in a preliminary study at a large referral center in Switzerland. It remains elusive why work-hour restrictions did not improve patient safety. We are well advised to thoroughly examine and eliminate the known adverse effects of reduced work-hours to improve our patients' safety.     

A young surgeon's perspective on alternate surgical training pathways

Most residents in training today are in focused on their training, and the thoughts of changing the structure of residencies and fellowships is something that they are ambivalent about or have never heard anything about. The small minority who are vocal on these issues represent an activist group supporting change. This group is very vocal and raises many of the excellent questions we have examined. In discussion with residents, some feel that shortened training will help with the financial issues facing residents. However, many people today add additional years to their training with research years or "super" fellowships. The residents demonstrate that they want to get the skill sets that they desire despite the added length of training. This is unlikely to change even if the minimum number of years of training changes with the evolution of tracked training programs. Medical students, in the Resident and Associate Society of the American College of Surgeons survey, did not indicate that shortened training would have an affect on decision to pursue or not pursue a surgical career. If the focus of these changes is to encourage medical students to pursue a residency in surgical specialties, we may need to look at other options to increase medical student interest. Medical students indicated that lifestyle issues, types of clinical problems, stress-related concerns, and interactions with the surgical faculty were far more important in their decision to enter a surgical specialty than work hours or duration of training. If we are to make a difference in the quality and quantity of applicants for surgical residencies, then changes in the structure of residencies do not seem to be the most effective way to accomplish this. We should possibly focus more on faculty and medical student interaction and the development of positive role models for medical students to see surgeons with attractive practices that minimize some of the traditionally perceived negative stereotypes. Residents in general surgery training programs often do not make decisions on the type of fellowship that they will pursue until late in their residency. Many residents are apprehensive about these types of tracked training programs because it will accelerate the timeline for choosing a track. Changes in the structure of residency and fellowships would result in residents having to decide and "match" in their second or third postgraduate years of training instead of the fourth or fifth postgraduate year time frame. Many residents will not have been exposed to all of the types of tracks by their third postgraduate year and many voice concerns over being ready to make this decision that early in their training. Acceptance and enthusiasm about this concept among all residents will likely depend on the final version of any planned changes. A wholesale rewrite of surgical training in the United States would likely not be well received. However, the addition of alternate pathways, on a limited scale and under close scrutiny and supervision, could evaluate interest and ease into this type of program. Before embarking on massive changes in surgical training, scientific, statistically valid research determining the interest of residents in these types of programs will target changes to make these programs successful.     

Correlation of manual dexterity with USMLE scores and medical student class rank

INTRODUCTION: Surgical programs often rely on objective measures of medical school cognitive performance, including United States Medical Licensing Exams (USMLE) scores and class rank, to predict success of an applicant in their training program. Although job applicants in non-medical fields often undergo dexterity testing prior to being hired, this has not been widely used in the selection process for surgical residency applicants. Thus, successful identification of applicants likely to succeed in surgical fields remains elusive. Given this difficulty, we wondered if performance on tests of manual dexterity would correlate with USMLE board scores and medical school class rank. METHODS: Fourth year medical students underwent a clinical study of dexterity testing using the Stromberg Dexterity Test (gross motor), the O'Conner Tweezer Test (fine motor), and the MIST-VR laparoscopic simulator (Mentice Corporation, Gothenberg, Sweden). Performance times were compared with USMLE Step I & II scores and class rank, as well as a self-assessment of manual dexterity. RESULTS: A total of 113 medical students participated. Gross motor dexterity was significantly correlated with class rank (P = 0.04) and USMLE Step I score (P = 0.04). Fine motor dexterity and MIST-VR performance did not correlate with class rank or USMLE scores. Self-assessment of good manual dexterity correlated with faster performance times on the MIST-VR laparoscopic simulator (0.0174). CONCLUSIONS: Gross motor skill is associated with objective measures of medical school cognitive performance, such as class rank and USMLE scores. Furthermore, self-assessment of dexterity may predict baseline laparoscopic abilities. Further research is necessary to determine whether such dexterity testing could be helpful in identifying applicants who possess the ability to develop into competent surgeons.     

Increasing the number of integrated vascular surgery residency positions is important to address the impending shortage of vascular surgeons in the United States

Objective

The demand for vascular surgeons is expected to far exceed the current supply. In an attempt to decrease the training duration and to address the impending shortage, integrated vascular surgery residencies were approved and have expanded nationally. Meanwhile, vascular fellowships have continued to matriculate approximately 120 trainees annually. We sought to evaluate the supply and demand for integrated vascular residency positions as well as changes in the quality of applicants.

What Factors Influence Applicants’ Rankings of Orthopaedic Surgery Residency Programs in the National Resident Matching Program?

Background

In accordance with the American Academy of Orthopaedic Surgeons’ strategic goal of enriching our field by building a more diverse orthopaedic workforce, the specialty needs further information delineating the factors important to the applicant pool as a whole and more specifically to women and other underrepresented minority groups.

Questions/purposes

This study aims to identify (1) factors important to residency applicants selecting an orthopaedic residency program; (2) differences in factor importance for men, women, and minorities, and (3) the importance of different information sources used when making his or her rank list.

Methods

All 742 applicants who applied to the authors’ orthopaedic surgery residency program in the 2013 National Resident Matching Program were queried. The response rate was 28% (207 of 742). Respondents were asked to rank, on a 5-point Likert scale, 37 factors that may have affected their rank lists to differing degrees. Respondents also identified the importance of sources of information used to make their rank lists, factors that residency programs considered important when ranking applicants, and their level of agreement with various sex- and racial-specific statements regarding orthopaedic training.

Results

The most important factors affecting rank lists were perceived happiness/quality of life of current residents, resident camaraderie, and impression after an away rotation. Women weighed their personal interactions and a program’s proximity to family and friends more heavily when determining a rank list. Sixty-eight percent of women eliminated residency programs from their options based on perceived sex biases versus less than 1% of men. Applicants valued information obtained from away rotations at an institution and in talking with current residents most when determining his or her rank list.

Conclusions

Programs should consider interpersonal factors, like quality of life and resident camaraderie as factors in attracting applicants. They also should minimize perceived biases and emphasize interactions with current residents during the application process to meet their goals of attracting an exceptional and more diverse orthopaedic workforce.     

Breast education in general surgery residency

Breast cancer treatment has changed substantially with increased specialization. Overall, the number of cases performed by residents upon completion of residency has decreased and the introduction of sentinel lymph node biopsy has reduced the number of axillary lymph node dissections being performed. Our objective was to evaluate the breast surgery education being provided by general surgery residency programs. A survey was administered to applicants to the Roswell Park Cancer Institute surgical oncology fellowship program in the fall of 2009. This survey examined the type of training program, the breast surgery exposure, and applicant comfort with the medical and surgical aspects of breast cancer. The survey was completed by 29 of 35 applicants. Of the respondents, 83 per cent were chief residents. Overall, participants had comfort levels above 8 (of 10) with breast related cases. For modified radical mastectomies and axillary lymph node dissections the comfort level dropped below 8. Participants were least comfortable discussing the medical management of breast cancer. General surgery residents completing training were less comfortable operating in the axilla compared with the breast. The study suggests careful attention should be paid to assuring adequate breast education in surgical residency.     

Resident work-hour rules: a survey of residents' and program directors' opinions and attitudes

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) established nationwide guidelines for resident working environments and duty hours. Following these guidelines became a requirement for all accredited residency programs. Two years after implementation, we conducted a national survey to assess the opinions and attitudes of orthopedic residents and program directors toward the ACGME work-hour regulations and the effects of these regulations on resident education, resident quality of life, and patient care. Nine hundred seventy-six residents (30% response rate) and 85 program directors (56% response rate) completed the questionnaire. For resident education, junior residents were more likely than senior residents and program directors to perceive the work-hour regulations as having a positive effect on education. There was overall agreement among the 3 groups that resident quality of life had improved as a result of work-hour regulations. For patient care, junior residents viewed the new regulations positively for surgical training and patient care, whereas senior residents and program directors disagreed. This survey showed meaningful differences in the attitudes and opinions of junior residents, senior residents, and program directors toward the new ACGME work-hour regulations.     

General surgery and fellowship training: opinions of surgical intern applicants and fellowship directors

BACKGROUND: Given the pressures that exist today to modify surgical training programs, this study was undertaken to ascertain the opinions of surgical intern applicants and fellowship program directors with regard to the length of surgical training. METHODS: Surveys were sent to fourth-year medical students who were applying for categorical surgical training during a 2-year period at a single university medical center and to fellowship program directors in 6 surgical subspecialties. RESULTS: Ninety-three percent of the applicants planned to pursue fellowship training. Sixty-eight percent of the applicants did not feel that 5 years of general surgery are necessary before beginning a fellowship. Seventy-one percent of the applicants indicated that they would be willing to "short track" into a subspecialty to reduce training time. Virtually all fellowship directors in pediatric surgery (94%), transplantation surgery (94%), and oncologic surgery (100%) felt that 5 years of general surgery training are necessary before entering a fellowship. Significantly fewer fellowship directors in vascular surgery (53%), cardiothoracic surgery (30%), and plastic surgery (17%) felt that 5 years of general surgery are essential before beginning a fellowship (P < or = .001). CONCLUSIONS: For some general surgery subspecialties, a shortened, integrated training program may be desirable from the point of view of both trainees and fellowship directors. Vascular, cardiothoracic, and plastic surgery appear to be those subspecialties that are most amenable to such programs.     

The urology residency matching program in practice

PURPOSE: We evaluate behaviors and attitudes among resident applicants and program directors related to the American Urological Association (AUA) residency matching program and recommend changes to improve the match. MATERIALS AND METHODS: Written questionnaires were mailed to 519 resident applicants and 112 program directors after the 1999 American Urological Association match. Subjects were asked about their observations, behaviors and opinions towards the match. RESULTS: Questionnaires were returned by 230 resident applicants and 94 program directors (44% and 83% response rates, respectively.) Of the resident applicants 75% spent $1,001 to $5,000 for interviewing. Of the program directors 47% recalled that applicants asked how programs would rank the applicant and 61% of applicants recalled that program directors asked applicants how they would rank programs. Dishonesty was acknowledged by 31% of program directors and 44% of resident applicants. Of program directors 82% thought applicants "lied", while 67% of applicants thought that programs "lied" (quotations indicate questionnaire language). Participants characterized their own dishonesty as "just playing the game" or they "did not feel badly." Of program directors 81% and of applicants 61% were "skeptical" or "did not believe" when informed they were a "high" or "number 1" selection. Being asked about marital status was recalled by 91% of male and 100% of female (p = 0. 02), if they had children by 53% of male and 67% of female, (p = 0. 03), and intent to have children by 25% of male and 62% of female (p <0.001), applicants, respectively. Free-form comments were written by 132 resident applicants and 28 program directors. The most frequent comments suggested the need to improve ethical behavior, modify the process so applications could be transmitted electronically and modify interviews to reduce applicant financial burden. Nine female applicants commented on their perceptions of sexual discrimination during the interviews. CONCLUSIONS: Resident applicants and program directors violate match code rules frequently. Program directors and resident applicants are skeptical of each other. Patterns of faculty behavior differ based on applicant gender. Interviews are costly for applicants. We recommend that 1) programs adopt policies to enhance fairness, 2) applications be filed electronically, 3) programs assist resident applicants with interview accommodation to reduce financial burden and 4) a post-interview code of limited or noncommunication be adopted.     

Selecting the best and brightest: A comparison of residency match processes in the United States and Canada

BACKGROUND:

Selecting candidates for plastic surgery residency training remains a challenge. In the United States, academic measures (United States Medical Licensing Exam Step I scores, medical school class rank and publications) are used as primary criteria for candidate selection for residency. In contrast, Canadian medical education de-emphasizes academic measures by using a pass-fail grading system. As a result, choosing residents from many qualified applicants may pose a challenge for Canadian programs without objective measures of academic success.

METHODS:

A 25-question online survey was distributed to program directors of Canadian plastic surgery residency-training programs. Program directors commented on number of yearly residents and applicants; application sections (ranked in importance using a Likert scale); interview invitation and rank-order list determination; and their satisfaction with the selection process.

RESULTS:

Ten Canadian plastic surgery program directors responded (90.9% response rate). The most important application components determining invitation to interview were letters of reference from a plastic surgeon (mean importance of 5.0 on the Likert scale), clinical electives in plastic surgery (mean 4.6) and electives with their program (mean 4.5). Applicants invited for interview were assessed on the quality of their responses to questions, maturity and personality. The majority of program directors agreed that a clinical elective with their program was important for consideration on their rank-order list. Program directors were neutral on their satisfaction with the selection process.

CONCLUSION:

Canadian plastic surgery residency programs emphasize clinical electives with their program and letters of reference from colleagues when selecting applicants for interviews. In contrast to their American counterparts, Canadian program directors rely on clinical interactions with prospective residents in the absence of objective academic measures.     

Success in the Pediatric Surgery Match: a survey of the 2010 applicant pool

Background/Purpose

Traditionally, basic science research and publication record have led to a successful Pediatric Surgery Match. With changing applicant research backgrounds, we evaluated if these or other factors still apply.

Methods

A SurveyMonkey questionnaire was distributed to 57 applicants with known contact information. We assessed demographic/financial data, application details and match results, research experience, publications, presence of a pediatric surgery fellowship at their home program, and applicant ranking criteria.

Results

Forty-three (75%) responses were received. Twenty-five candidates matched, 12 (48%) to 1 of their first 3 choices. The median number of programs applied to was similar for matched and unmatched candidates (30), but matched candidates attended more interviews (21 vs 14.5; P = .03). Matched applicants had more publications (9.5 vs 5.1; P = .03), although research experience was similar to unmatched candidates. Research focus for matched vs total applicants included basic science (5 vs 12), clinical (4 vs 6), and both (11 vs 16). Five candidates matched without research experience. Ten (40%) applicants matched to institutions where they completed residency/research/fellowship training. Twelve (49%) applicants matched from programs without a fellowship program.

Conclusion

A strong publication record remains important, although clinical research is being valued more. Candidates from nonfellowship programs can be successful. This information may be useful to mentor future applicants and lays the foundation for a critical evaluation of the match process.