Percutaneous injuries in a high-volume podiatric surgical residency program.

Percutaneous injuries (i.e., needlesticks) are a possible occupational hazard to all residents performing invasive procedures. Transmission of blood-borne pathogens has become a potential risk in these injuries. As such, the purpose of this investigation was to assess the frequency and circumstances involving percutaneous injuries in the podiatric surgical resident. A survey of 20 present residents from July 1991 to July 1999 was conducted to assess percutaneous injuries. These residents participated in 19,505 surgical cases in this timeframe; 16,185 were podiatric cases and 3,347 were nonpodiatric. Using a two-part questionnaire to assess the circumstances surrounding any percutaneous injury, 80% of the residents reported at least one percutaneous injury during their training. A total of 33 were injuries reported for the 19,505 cases. The incidence of injury per surgical case was 0.17% overall, and 0.14% for foot and ankle cases. Analysis of the data showed a median = 2, mode = 2, and a mean = 1.63 injuries per resident with a range of 0-5. When analyzing the circumstances involving the injuries, most injuries were self-inflicted (66.7%), occurred during wound closure (72.7%), and were caused by a nonhollow bore needle or instrument (81.8%). Also, no correlation could be made to the time of day during which the procedure was performed, the year of residency training, or the number of cases that the resident performed that day before the injury occurred. Interestingly, over 67% of the injuries occurred to the resident's left hand. Although 97% of the injuries were reported to the employee health officer, the patient and resident were screened for HIV and hepatitis B or C in only 78.8% of the cases. In those tested, no resident was exposed to HIV or hepatitis B or C.     

Evaluating the reliability of surgical assessment methods in an orthopedic residency program

Background

Orthopedic surgical education in Canada has seen major change in the last 15 years. Work hour restrictions and external influence have led to new approaches for surgical training. With a change toward competency-based educational models under the CanMEDS headings there is a need to ensure the validity of modern assessment methods. Our objective was to evaluate the reliability of a currently used surgical skill assessment tool within an orthopedic residency program, as measured by the Surgical Encounters Form.

Methods

A surgical assessment tool has previously been created at our institution that comprises 15 items spanning 4 of the CanMEDS competencies. Results were blinded to the primary investigator and coded by a third party. The assessments were collected, and we measured percent agreement using Cronbach’s α and Fleiss κ.

Results

Over a 5-month period 11 staff members assessed 10 residents. Eighty-eight assessments were completed in total. Weighted percent agreement was 90.9%. Cronbach’s α averaged 0.865 for the medical expert role, 0.920 for technical skills, 0.934 for the communicator role, 1.00 for the collaborator role and 1.00 for the health advocate role. The mean Fleiss κ score was 0.147 (95% confidence interval &0.071 to 0.364), demonstrating low interrater reliability.

Conclusion

Despite the development of a validated assessment tool to evaluate surgical skills acquisition, interrater reliability results suggest low levels of agreement among assessors.     

Organizational rites and culture in a surgical residency program

Six organizational rites in a surgical residency program were analyzed as a means to reveal aspects of the culture of the program. The rites generally depicted a program culture characterized by professional values of total commitment and availability, an ideology based on expert power, and strict behavioral norms supportive of the hierarchical program authority. These rites have important implications for leadership in surgical education.     

Reducing medication errors in a surgical residency training program

Medication errors contribute to in-hospital morbidity and mortality. Teaching hospitals and the surgical residency training programs they support should take proactive steps to reduce error frequency. In order to accomplish meaningful error reduction, we must first define the scope and nature of the problem. Pharmacists at the Monmouth Medical Center prospectively recorded medication prescribing errors made by surgical residents during 2 years. These data were reviewed to determine the types of medication errors made most frequently by surgical house officers. Seventy-five medication-prescribing errors were made by surgical house staff in the years 2001 and 2002. Thirty-three of these errors involved orders for antibiotic therapy. Errors that could not be directly attributed to knowledge deficits were responsible for 36 of the 75 errors (48%), whereas specific knowledge deficits were responsible for 39 of the 75 errors (52%). Twentyeight of the 36 errors not directly attributable to knowledge deficits (78%) were made at the postgraduate year one level, whereas only 15 of the 39 knowledge deficit errors (38%) were made at the postgraduate year one level. Though targeted education to address specific knowledge deficits may substantially reduce the occurrence of "knowledge deficit" medication errors within surgical residency training programs, more costly measures such as the implementation of physician computerized order entry will likely be needed to reduce maximally the frequency of medication ordering errors. Many prescribing errors cannot be attributed to specific knowledge deficits.     

Significance of the in-training examination in a surgical residency program

The exact role that the American Board of Surgery In-Training Examination plays in resident evaluation remains poorly defined. We have required that all residents take the In-Training Examination annually. An analysis was performed of the results of the In-Training Examination and the Qualifying Examination of the American Board of Surgery for 16 residents who completed their residencies between July 1976 and July 1981. Twelve graduates passed their initial Qualifying Examinations with a mean +/- 1 SEM score of 81 +/- 2. Four graduates failed with a score of 70 +/- 0.3. Corresponding scores on their final In-Training Examinations were 42 +/- 9 and 11 +/- 6 (p less than 0.001). Each year the In-Training Examination Scores obtained by the residents who passed the Qualifying Examination were significantly higher than were those scores obtained by the graduates who failed. Linear regression analysis identified a significant correlation between the graduates' initial (r = 0.676) and final (r = 0.760) In-Training Examination scores and the Qualifying Examination score. In our resident training program, In-Training Examination results correlated well with Qualifying Examination results and may be used as an objective determinant for remedial measures and resident retentions. These data should be developed on a national level. While Board certification was or likely will be accomplished by all our residents, our goal is to strengthen the academic characteristics of the training program to produce uniform success on the initial Qualifying Examination.     

上海市外科住院医师规范化培训10年实践与经验

目的总结上海市开展外科住院医师规范化培训10年的实践与经验,为今后进一步提高外科住院医师规培化培训质量提供理论依据。方法统计2010—2021年上海市32家外科住院医师规范化培训基地的基本情况、外科床位数、带教师资人数、研究生导师人数,招录及出站人数、性别、年龄、学历背景、培训年限,结业综合考合格率、申请课题及发表论文情况、就业情况等信息。结果上海市共有32家外科专业基地,以三级甲等综合性医院为主,目前累计招录了住培医师4597名,已结业3162名,绝大多数外科住培医师达到培训要求并通过考核结业。上海市外科住院医师规范化培训工作在建立健全制度建设,开展教学活动,推广信息化管理,师资培训与督导检查,临床科研培养等方面取得了满意的成效。同时现阶段工作中仍有不足之处,包括规范教学活动、加强医学人文及思政教育、落实外科培训细则、待遇保障等方面。结论外科住院医师规范化培训已成为培养高水平外科医学人才的重要途径,后续住院医师规范化培训重点应进一步加强各外科基地培训效果的同质化、标准化、规范化,注重内涵建设和质量建设。     

An Internet-based evaluation system for a surgical residency program

BACKGROUND: Efficient and meaningful evaluation of performance is critical to the professional development of trainees in surgical residency programs. Current paper-based evaluation instruments have numerous limitations. We developed an Internet-based evaluation system to more rapidly and efficiently assess the experience of residents, faculty, and rotations. STUDY DESIGN: An on-line evaluation system was designed and implemented in October 1999. Custom evaluations were created for residents, faculty, and rotations. Evaluations were completed via the Internet site from remote locations with standard computers and standard Web browser software. Completed evaluations were automatically available on-line for review and data analysis. Data were analyzed by chi-square analysis with a probability value of less than 0.05 considered statistically significant. RESULTS: Compliance in completion of evaluations improved from 50% to 80% in the initial 6 months of implementation (p < 0.01) with the Web-based system. There was no significant difference between faculty and resident compliance. In evaluation of "ease of use," a total of 612 responses were received over this period with a total average score of 3.5 (5 point scale, 5 = strongly agree). Residents' opinions (average score, 3.69) were slightly more positive than those of faculty (average score, 3.31). Confidentiality was improved over paper-based systems by a detailed security network. CONCLUSIONS: This Internet-based evaluation system is a potentially powerful instrument for evaluating our surgical residency program and making changes to improve the educational experience in a timely and efficient manner.     

Cognitive learning during surgical residency. A model for curriculum evaluation.

The program summary of the American Board of Surgery In-Service Training Exam (ABSITE) can be used to quantitate cognitive learning during a surgical residency and to identify areas of curricular weakness in a residency program. Knowledge on each question is categorized as high (known) or low (unknown) depending on the percentage of residents who answered correctly. Knowledge of Level 1 (entry) residents is then compared with Level 5 (exit) residents. Each ABSITE question can thus be categorized on entry versus exit as known-known, unknown-unknown, unknown-known, and known-unknown. Only about half of unknown knowledge on entry appears to become known on exit. Very little knowledge known on entry becomes unknown on exit. Weaknesses in specific subject areas can be readily identified by ranking questions according to the number of exiting residents who answer incorrectly. Use of this technique to quantitate cognitive learning in a residency program may allow objective assessment of changes in curriculum.     

The professionalism curriculum as a cultural change agent in surgical residency education

BackgroundTeaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture.MethodsThe goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents' perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group.ResultsStudy 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents' skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as “slightly better” or “much better” compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department's leadership view toward professionalism as “much better” compared with 5 years ago.ConclusionsAll 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago.     

Resident and faculty perceptions of a surgical residency program merger

To evaluate resident and faculty perceptions of a residency merger process.Survey of faculty and residents of a recently merged general surgical residency. Nineteen separate program characteristics were evaluated via a numerical scoring system, and additional written commentary regarding dominant perceived benefits and detriments of the merger was solicited. Statistical significance was evaluated on numerically scored items by applying the Mann-Whitney U test to median values expressed with interquartile ranges, comparing resident and faculty responses.Scoring system responses from faculty and residents were generally similar. The merger was seen as neutral to positive in its impact on academic issues, but it had more negative effects on issues related to overall program atmosphere and morale. Statistically significant differences between resident and faculty responses were noted in 2 areas: teaching conference timing and overall program effectiveness in preparing for practice. Both of these areas were more favorably impacted by the merger from the residents' perspective, and more negatively as judged by the faculty (p < 0.05). Written commentary by both groups similarly emphasized areas of academic strengthening as a positive effect of the merger, and relationship and morale issues as being more negatively impacted.As reflected by resident and faculty perceptions, program mergers may provide opportunities to strengthen and enhance the academic and clinical foundation of residency. This may, however, occur at the expense of morale and relational issues, which may be negatively impacted by program administrative and geographic expansion.     

Factors affecting choice of surgical residency training program

BACKGROUND: A significant problem facing American surgery today is the lack of participation from women and minorities. In 1995 and 1996, 15.1 and 15.8% of United States general surgical residency graduates were women. Of our 71 graduates in the last 12 years, 38% were women. The aim of this study was to identify the factors influencing our residents' choice of training program and the reasons why our program has a high percentage of female graduates. METHODS: Between 1989 and 2000, 27 women and 44 men completed general surgical training at our university and 44/71 (59%) responded to our survey. The age at residency completion was 34 +/- 2.2 years for men and 33.9 +/- 2.8 years for women. Fifty-five percent of men and 30% of women went on to fellowship training; and 36% of men and 20% of women are in academia. RESULTS: Factors influencing our graduates' selection of training program are: Only 23% of men had a female faculty as their mentor, whereas 90% of women had a male faculty as their mentor during training. Only 59% of men but 80% of women (P < 0.05) agreed that female medical students need role models of successful female faculty members. Fifty-five percent of men and 45% of women would encourage a female medical student to choose surgery as a career, but 82% of men and 50% of women would encourage a male medical student to do so. Ninety-one percent of men and 85% of women would choose surgery as a career again. CONCLUSIONS: A surgical residency training program with strong leadership, good clinical experience, and high resident morale will equally attract both genders. Women may pay more attention to the program's gender mix and geographic location.     

Measuring medical education and curriculum during orthopedic surgical residency

BACKGROUND: Evaluating residency programs requires objective assessment tools, but few are readily available. The purpose of this study was to measure education by correlating resident test scores with several measurements of educator performance. MATERIALS AND METHODS: The study group included residents and educators from a single residency program. We performed a retrospective analysis of scores from the Orthopaedic In-Training Examination collected during a 6-year period. Resident examination scores were indexed by dividing program averages by national averages to determine yearly score trends and then were correlated with educator attendance and teaching hours. Subspecialty scores were ranked to gauge residency strengths and weaknesses. Teaching hours devoted to subspecialties were compared with test scores to measure curricular emphases and to appraise teaching efficiency. RESULTS: Yearly average examination scores were proportional to national averages (P < 0.001). However, of 3436 possible educator-score associations, only 15 scores correlated highly (r > 0.9) with educators, and only 26 were significant (P < 0.05). Trend analysis put subspecialty scores in yearly perspective. Ranking was inaccurate until scores were indexed to the national average. In 2002, the distribution of 238 teaching hours ranged from 4 to 48 h for subspecialties, and 9 of 12 subspecialties were emphasized disproportionately to the examination. Teaching efficiency varied more than 10-fold by subspecialty. CONCLUSIONS: The creation of a score index helped to identify and address imbalances between teaching hours devoted to subspecialties and resident needs as evidenced by low In-Training examination scores. The present study improved educator accountability by correlating measurements of teaching and learning.     

The importance of teaching surgical history in a general surgery residency program

Because we recently realized our department had a shortcoming in teaching surgical history to our residents, which resulted in near total ignorance of the history of their chosen specialty, we decided to poll all the general surgery residency program directors in the United States regarding the teaching of surgical history. Questionnaires were mailed to 265 programs and 159 (60%) responded. Of this group, 149 (94%) reported that they were convinced that the study of surgical history had an important place in surgical education. However, only 19 of the reporting programs (12%) indicated that they had a formal program for teaching surgical history. With our departmental failing with regard to teaching surgical history, reinforced by the results of our poll, we opted to improve the teaching of history to surgical residents. We began a bimonthly, relatively informal surgical history session with presentations by residents and faculty. This has renewed interest in the history of our specialty of residents and faculty alike. We urge all programs to incorporate a similar surgical history format to benefit the program, but especially to benefit the residents.     

Impact of a surgical oncologist on general surgery residency training program

BACKGROUND: To assess the impact of adding a surgical oncologist to our faculty we examined the operative experience in our program before and after the addition. METHODS: Operative case numbers reported to the American Board of Surgery over a 10-year period were analyzed. This time period encompassed 5 years before and after the addition of a surgical oncologist to our faculty. All defined category case numbers were examined using t test analysis. Significance was defined as a P value of less than 0.05. RESULTS: The overall caseload increased in the time period after the faculty addition. There was a statistically significant increase in skin/soft tissue, breast, esophagus, small intestine, large intestine, live, spleen, and endocrine cases. No statistical significance was seen in head/neck, stomach, pancreas, and biliary cases. CONCLUSIONS: The addition of a surgical oncologist to our faculty coincides with a statistically significant increase in areas of skin/soft tissue, breast, esophagus, small intestine, large intestine, liver, spleen, and endocrine. Other areas not statistically significant may reflect referral patterns or this particular oncologist's preferences of practice.     

A new residency program for Japanese surgical specialties

Medical education, in general, should be a continuous and life-long persistent training for the purposes to be reached through the education of humanity and medical techniques which are the arts based on the sciences whichever originated from the western or eastern world histories. These training started from the student life through the termination of medical profession, especially in the field of surgery, the medical doctors are the only existence to be allowed to insult human body even for the purpose of treatment. These facts should be learned through well-trained experienced teachers with ethics, theories and evidence based medicine. The new training curriculum for 5 years program of the surgical specialties in Japan has built up and started just two years ago to be successful supported not only by medical teachers but also by the government and civilian economical foundations. A sort of national board of medical specialties is necessary system to develop general medical care system with effective specializations.     

Challenges during the implementation of a laparoscopic skills curriculum in a busy general surgery residency program

The purpose of this article is to describe our experience with the incorporation of a proficiency-based laparoscopic skills curriculum in a busy surgical training program that aims to improve the technical proficiency of residents. The curriculum has a cognitive component and a manual skills component and is adjusted to resident training level. It is based on the Fundamentals of Laparoscopic Surgery program and includes basic laparoscopic virtual-reality tasks of the Lap Mentor simulator (Simbionix USA Corp., Cleveland, Ohio). Training occurs in weekly 1-hour sessions until expert-derived performance goals are achieved. Maintenance training ensures skill retention. Performance is assessed with objective metrics and is supported with feedback and an award system. Resident workload is assessed at regular intervals. Knowledge tests and manual skills tests are administered at the beginning and end of the academic year to assess resident performance improvement and curriculum effectiveness. Resident attendance rates and training progress are monitored continuously, and training sessions are adjusted to individual needs. Our curriculum has been implemented for several months. Our experience so far suggests that it is imperative to have dedicated supervising personnel and dedicated training time in the busy week of the surgical resident to ensure attendance. Our next step is to incorporate the 20 modules of the new Association of Program Directors in Surgery (ADPS)/American College of Surgeons (ACS) national skills curriculum into our skills training program, to expand its cognitive component by incorporating additional procedural videos, and to adapt scenario-based training on trauma and critical care on human patient simulators.     

Patient safety curriculum for surgical residency programs: results of a national consensus conference

BACKGROUND: The American College of Surgeons (ACS) and the Accreditation Council for Graduate Medical Education (ACGME) are committed to promoting patient safety through education. In view of the critical role of residents in the delivery of safe patient care, the ACS and ACGME sponsored jointly a national consensus conference to initiate the development of a curriculum on patient safety that may be used across all surgical residency programs. CONCLUSIONS: National leaders in surgery with expertise in surgical care and surgical education, patient safety experts, medical educators, key stakeholders from national organizations, and surgical residents were invited to participate in the conference. Attendees considered patient safety issues within the context of the 6 core competencies defined by the ACGME and American Board of Medical Specialties (ABMS). Discussions resulted in the development of a curriculum matrix that includes listings of patient safety topics, teaching and learning strategies, and assessment methods. Guidelines for implementation and dissemination are also provided. The curriculum content underscores the need to create an organizational culture of safety and focuses on both individuals and systems. Individual residency programs may prioritize the curriculum content based on their specific needs. The ACS and ACGME will pursue development of educational modules to address the curriculum content, disseminate helpful information, and assist in implementation of new educational interventions. This effort has the potential to positively impact residency education in surgery, help surgical program directors address the core competencies, and enhance patient safety.