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Objective: Mobile phone-based paging systems have become increasingly common for communication within hospitals. Surgical interns receive the most pages, and our aim is to objectively quantify and evaluate this burden to allow for targeted improvement., Design: We performed a retrospective review of our institutions mobile phone-based paging system data (Halo Health, Cincinnati, OH) from July 2019 to September 2019., Setting: Carolinas Medical Center, Charlotte, NC, USA., Participants: Seven general surgery postgraduate year (PGY) 1 residents., Results: Forty-five thousand eight hundred and one messages met inclusion criteria, with 27,397 messages received and 18,404 sent. PGY 1 residents each received an average of 48 ± 41 messages per shift, with 8 ± 17 messages per day while off-duty. Night shifts averaged more messages than day shifts (80 ± 39 vs 38 ± 32, p < 0.0001), and had more shifts with high message volume (30% vs 11%, p = 0.0005). Evaluating the total number of messages received per minute of the day, the largest number of high-volume message intervals (21) occurred during patient handoff (1700-1900 hours). Most messages were sent by nursing staff (55.8%), followed by medical providers (38.2%)., Conclusions: PGY 1 residents receive a large number of pages using a messaging application, with many occurring at critical times. Residents received a higher volume of pages on night shifts, during patient handoff, and while off-duty. Since most pages are from nursing staff, targeted education and preventative actions may help decrease the volume of pages during these critical times., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Electronic health records (EHRs) are an integral part of the medical system and are used in all aspects of care. Despite multiple advantages of an EHR, concerns exist over the amount of time that residents spend on computers rather than in direct patient care. This study aims to quantify the time a general surgery resident spends on the EHR during their training., Design/participants: Active usage time data from our institution's EHR were extracted for 34 unique general surgery residents from October 2014 to June 2019. Career time on the EHR was calculated and a "work month" was defined as a 4-week period of 80 hours per week., Setting: Carolinas Medical Center, Charlotte, NC., Results: Total career EHR usage for a general surgery resident was 2512 continuous hours, corresponding to 31.4 work weeks or 7.9 work months. In total, 7133 charts were opened with an average of 20.5 minutes on the EHR per patient chart. Career time spent on specific tasks included: chart review 10.6 work weeks, documentation 10.4 work weeks, and order entry 5.4 work weeks. The total number of orders entered were 57,739 and total number of documents created were 9222. EHR time in all aspects, patient charts opened, documents created, and number of orders entered decreased as postgraduate year increased., Conclusions: This is the first study quantifying the total time a general surgery resident spends on the EHR during their clinical training. Total EHR time equated to nearly 8 work months. General surgery residents spend considerable time on the EHR and this underscores the importance of implementing methods to improve EHR efficiency and maximize time for clinical training., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Time spent on the Electronic Health Record (EHR) influences surgical residents' clinical availability. Objective data assessing EHR usage among surgical residents are lacking and necessary., Design/participants: Active EHR usage data for 70 surgical residents were collected from April 2015 through April 2016. Active EHR usage was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. Usage data of different specialties, interns (PGY 1), juniors (PGY 2, 3), and seniors (PGY 4, 5) were compared., Setting: Carolinas Medical Center, Charlotte, NC., Results: Interns spent more time than juniors on total EHR activities per day (134.5 vs 105.5 minutes, p < 0.001) and juniors spent more time per day than seniors (105.5 vs 78.7 minutes, p < 0.001). Among different EHR activities per patient, interns spent greater time than juniors on chart review (8.1 vs 6.2 minutes, p < 0.001), documentation (9.0 vs 6.5 minutes, p < 0.001), and orders (3.6 vs 3.0 minutes, p < 0.001). Juniors spent the same time as seniors on chart review (6.2 vs 6.5 minutes, p = 0.2). Juniors spent more time than seniors on documentation (6.5 vs 5.2 minutes, p < 0.001) and orders (3.0 vs 2.7 minutes, p < 0.05). Comparing EHR activities per patient among different specialties, General Surgery residents spent more time than Orthopedic residents on total EHR time (19.9 vs 15.9 minutes, p < 0.001), chart review (6.8 vs 5.7 minutes, p < 0.001), documentation (6.3 vs 5.6 minutes, p < 0.001), and orders (3.6 vs 2.6 minutes, p < 0.001). General Surgery residents spent less time than OB/GYN residents on total EHR time (19.9 vs 22 minutes, p < 0.01), chart review (6.8 vs. 7.5 minutes, p < 0.05), and documentation (6.3 vs 7.6 minutes, p < 0.001), but more time on orders (3.6 vs 2.9 minutes, p < 0.001)., Conclusions: These are the first reported objective findings on surgical resident use of the EHR and may provide an opportunity for improvement in EHR training and usage., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Accreditation Council for Graduate Medical Education (ACGME) requires diversity in residency. The self-identified race/ethnicities of general surgery applicants, residents, and core teaching faculty were assessed to evaluate underrepresented minority (URM) representation in surgery residency programs and to determine the impact of URM faculty and residents on URM applicants' selection for interview or match., Study Design: Data from the 2018 application cycle were collated for 10 general surgery programs. Applicants without a self-identified race/ethnicity were excluded. URMs were defined as those identifying as black/African American, Hispanic/Latino/of Spanish origin, and American Indian/Alaskan Native/Native Hawaiian/Pacific Islander-Samoan. Statistical analyses included chi-square tests and a multivariate model., Results: Ten surgery residency programs received 9,143 applications from 3,067 unique applicants. Applications from white, Asian, Hispanic/Latino, black/African American, and American Indian applicants constituted 66%, 19%, 8%, 7% and 1%, respectively, of those applications selected to interview and 66%, 13%, 11%, 8%, and 2%, respectively, of applications resulting in a match. Among programs' 272 core faculty and 318 current residents, 10% and 21%, respectively, were identified as URMs. As faculty diversity increased, there was no difference in selection to interview for URM (odds ratio [OR] 0.83; 95% CI 0.54 to 1.28, per 10% increase in faculty diversity) or non-URM applicants (OR 0.68; 95% CI 0.57 to 0.81). Similarly, greater URM representation among current residents did not affect the likelihood of being selected for an interview for URM (OR 1.20; 95%CI 0.90 to 1.61) vs non-URM applicants (OR 1.28; 95% CI 1.13 to 1.45). Current resident and faculty URM representation was correlated (r = 0.8; p = 0.005)., Conclusions: Programs with a greater proportion of URM core faculty or residents did not select a greater proportion of URM applicants for interview. However, core faculty and resident racial diversity were correlated. Recruitment of racially/ethnically diverse trainees and faculty will require ongoing analysis to develop effective recruitment strategies., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Diversity is an ill-defined entity in general surgery training. The Accreditation Council for Graduate Medical Education recently proposed new common program requirements including verbiage requiring diversity in residency. "Recruiting" for diversity can be challenging within the constraints of geographic preference, type of program, and applicant qualifications. In addition, the Match process adds further uncertainty. We sought to study the self-identified racial/ethnic distribution of general surgery applicants to better ascertain the characteristics of underrepresented minorities (URM) within the general surgery applicant pool., Design: Program-specific data from the Electronic Residency Application Service was collated for the 2018 medical student application cycle. Data were abstracted for all participating programs' applicants and those selected to interview. Applicants who did not enter a self-identified race/ethnicity were excluded from analysis. URM were defined as those identifying as Black/African American, Hispanic/Latino/of Spanish origin, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander-Samoan. Appropriate statistical analyses were accomplished., Setting: Ten general surgery residency programs-5 independent programs and 5 university programs., Participants: Residency applicants to the participating general surgery residency programs., Results: Ten surgery residency programs received 10,312 applications from 3192 unique applicants. Seven hundred and seventy-eight applications did not include a self-identified race/ethnicity and were excluded from analysis. The racial/ethnic makeup of applicants in this study cohort was similar to that from 2017 to 2018 Electronic Residency Application Service data of 4262 total applicants to categorical general surgery. Programs received a median of 1085 (range: 485-1264) applications each and altogether selected 617 unique applicants for interviews. Overall, 2148 applicants graduated from US medical schools, and of those, 595 (28%) were offered interviews. The mean age of applicants was 28.8 ± 3.8 years and 1316 (41%) were female. Hispanic/Latino/of Spanish origin, Black, and American Indian/Alaskan Native/Hawaiian/Pacific Islander-Samoan applicants constituted 12%, 8%, and 1% of total applicants, but only 8%, 6%, and 1% of those selected for interview. Overall, 29% of applicants had United States Medical Licensing Examination (USMLE) Step 1 scores ≤220; 37 (6%) of those selected for interviews had a USMLE Step 1 score of ≤220. A higher proportion of URM applicants had USMLE scores ≤220 compared to White and Asian applicants. Non-white self-identification was a significant independent predictor of a lower likelihood of interview selection. Female gender, USMLE Step 1 score >220, and graduating from a US medical school were associated with an increased likelihood of being selected to interview., Conclusions: URM applicants represented a disproportionately smaller percentage of applicants selected for interview. USMLE Step 1 scores were lower among the URM applicants. Training programs that use discreet USMLE cutoffs are likely excluding URM at a higher rate than their non-URM applicants. Attempts to recruit racially/ethnically diverse trainees should include program-level analysis to determine disparities and a focused strategy to interview applicants who might be overlooked by conventional screening tools., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Prior studies demonstrate a high prevalence of burnout and depression among surgeons. Limited data exist regarding how these conditions are perceived by the surgical community., Objectives: To measure prevalence of burnout and depression among general surgery trainees and to characterize how residents and attendings perceive these conditions., Design, Setting, and Participants: This cross-sectional study used unique, anonymous surveys for residents and attendings that were administered via a web-based platform from November 1, 2016, through March 31, 2017. All residents and attendings in the 6 general surgery training programs in North Carolina were invited to participate., Main Outcomes and Measures: The prevalence of burnout and depression among residents was assessed using validated tools. Burnout was defined by high emotional exhaustion or depersonalization on the Maslach Burnout Inventory. Depression was defined by a score of 10 or greater on the Patient Health Questionnaire-9. Linear and logistic regression models were used to assess predictive factors for burnout and depression. Residents' and attendings' perceptions of these conditions were analyzed for significant similarities and differences., Results: In this study, a total of 92 residents and 55 attendings responded. Fifty-eight of 77 residents with complete responses (75%) met criteria for burnout, and 30 of 76 (39%) met criteria for depression. Of those with burnout, 28 of 58 (48%) were at elevated risk of depression (P = .03). Nine of 77 residents (12%) had suicidal ideation in the past 2 weeks. Most residents (40 of 76 [53%]) correctly estimated that more than 50% of residents had burnout, whereas only 13 of 56 attendings (23%) correctly estimated this prevalence (P < .001). Forty-two of 83 residents (51%) and 42 of 56 attendings (75%) underestimated the true prevalence of depression (P = .002). Sixty-six of 73 residents (90%) and 40 of 51 attendings (78%) identified the same top 3 barriers to seeking care for burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care., Conclusions and Relevance: The prevalence of burnout and depression was high among general surgery residents in this study. Attendings and residents underestimated the prevalence of these conditions but acknowledged common barriers to seeking care. Discrepancies in actual and perceived levels of burnout and depression may hinder wellness interventions. Increasing understanding of these perceptions offers an opportunity to develop practical solutions.

Purpose: Timely performance evaluation and feedback are critical to resident development. However, formulating and delivering this information disrupts physician workflow, leading to low participation. This study was designed to determine if a locally developed smartphone platform would integrate regular evaluation into daily processes and thus increase faculty participation in timely resident evaluation., Methods: Formal, documented resident operative and patient interaction evaluations were compiled over an 8-month study period. The study was divided into two 4-month phases. No changes to the existing evaluation methods were made during Phase 1. Phase 2 began after a washout period of 2 weeks and coincided with the launch of a smartphone-based platform. The platform uses a combination of Likert scale questions and the Dreyfus model of skill acquisition to describe competence levels in technical and nontechnical skills. The instrument inflicts minimal effect on surgeon workflow, with the aim of integrating resident evaluation into daily processes. The number of different faculty members performing evaluations, resident level (postgraduate year), type of interaction or procedure, and competency data were compiled. All evaluations were tracked by the program director as they were automatically uploaded into a database. Faculty members were introduced to the new platform at the beginning of Phase 2, and previous methods of evaluation continued to be encouraged and were considered valid throughout both phases of the study. Data were analyzed using Fisher exact test for specific PGY level, and chi-square test was used for overall program analysis. Statistical significance was set at p < 0.05., Results: Total faculty engagement, that is, number of faculty members completing evaluations, increased from 13% (5/38) in Phase 1 to 53% (20/38) in Phase 2. During Phase 1, all evaluations consisted of online forms through the department's established system or e-mails to the program director. Evaluations were completed in 0.9% (15/1599) of cases residents completed in Phase 1 versus 12% (217/1812) of those in Phase 2. During Phase 2, evaluations were conducted exclusively using the new platform. This was done based on participant's choice. Total numbers of residents and core faculty members did not change between Phases 1 and 2., Conclusions: A smartphone-based platform can be created with existing technology at no cost. It is adaptable and can be updated in real-time and can employ validated scales to build an evaluation portfolio for learners assessing technical and nontechnical skills. Furthermore, and perhaps most importantly, it can be designed to integrate into existing workflow patterns to increase faculty participation., (Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means (P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation (P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation (P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Introduction: The purpose of this study was to analyze the effect of residents on patient outcomes in laparoscopic ventral hernia repair (LVHR).We hypothesized that increasing postgraduate year (PGY) level would correlate with better outcomes., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2011 for elective LVHR. Attending only cases were used as the control, and resident cases were stratified into junior (PGY 1-3), chief (4-5), and fellow (6+) cases. Standard statistical tests and multivariate regression controlling for age, body mass index, Charlson comorbidity index, smoking, functional status, and inpatient cases were performed for trainee involvement and PGY level., Results: There were 6,841 ventral hernia repairs that met inclusion criteria: 2,773 attending and 4,068 resident cases. There were 1,644 junior, 1,983 chief, and 441 fellow cases. Patients were similar between the attending and resident groups. The resident group had a higher rate of inpatient cases, general complications, longer operative time, and hospital length of stay. After controlling for confounders in multivariate analysis, only operative time was significantly different; resident cases were 17.7 min longer (CI 15.0-20.6; p < 0.001). There was no significant difference in the rate of wound or major complications, readmission, reoperation, or mortality between attending and resident cases. Demographics were not significantly different between the PGY level strata. On multivariate regression by PGY level with attending alone as the reference, only operative time was significantly different. Juniors (15.7 min, CI 12.2-19.2), chiefs (18.0 min, CI 14.7-21.3), and fellows (24.9 min, CI 19.1-30.7) had significantly longer cases than attending alone; all p < 0.001., Conclusion: Trainee involvement during LVHR does not change the clinical outcomes for patients as compared to those performed by an attending only. Operative time is significantly longer with increasing PGY level, perhaps indicating the complexity of the operation or increasing trainee involvement as primary surgeon. However, patient care does not suffer, affirming the current surgical training curriculum is appropriate.

Background: Our objective was to compare the value of porcine versus cadaveric models for procedural training of general surgery residents outside the operating room (OR)., Methods: Two procedural workshops for general surgery residents based on the American College of Surgeons/Association of Program Directors in Surgery national skills curriculum were administered. During each workshop, 7 surgery faculty taught 16 residents level-appropriate operative procedures on 4 training models (2 cadaver torsos; 2 pigs). Participants compared the 2 models at the end of the workshops using a 10-point Likert scale and indicated their training model preference. Ratings were compared using a paired t test., Results: Among the 39 participants (9 faculty and 30 residents) who provided ratings, the porcine models were rated lower for anatomic relevance (6.8 ± 2.1 vs 9.1 ± 1.5; P < .01) but higher for tissue handling (8.4 ± 1.3 vs 7.2 ± 2.0; P < .01) and ability to dissect/identify planes (8.6 ± 1.2 vs 6.7 ± 2.4; P < .01) compared with the cadavers. There were no differences in perceived similarity to live patient surgery and overall value of the 2 models for training (7.2 ± 2.2 vs 6.9 ± 2.5 and 8.5 ± 1.6 vs 8.5 ± 1.5, respectively). There were no differences between resident and faculty ratings. Eight (20%) participants preferred the porcine model for training, 5 (13%) the cadaveric model, 16 (41%) both, and 10 (26%) indicated differences in preference based on operative procedure. Participants rated highly the overall quality and value of these procedural workshops for their learning (8.4 ± 1.1)., Conclusion: Based on resident and faculty evaluations, both porcine and cadaveric models are deemed necessary and valuable for procedural training outside the OR. Such skills workshops should be incorporated into the surgical curriculum., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objectives: The Association of Program Directors in Surgery/American College of Surgeons national skills curriculum provides residency programs with a great educational tool for their residents. Our objective was to assess the feasibility, value, and cost required to administer a procedural workshop for general surgery residents based on phase II of the national skills curriculum., Design, Setting, and Participants: Surgery faculty instructed residents on a variety of level-appropriate surgical procedures during a procedural workshop using 4 training models (2 cadaver torsos and 2 pigs). The educational value of the workshop, the quality of teaching, the instruction and feedback received, and the training models used were evaluated by participants on a 10-point Likert scale. Resident performance and workshop cost were also assessed., Results: Seven faculty instructed 16 residents (postgraduate year 1-4) on 23 surgical procedures (median 4 procedures per resident). Participants rated the overall value of the workshop as 8 (range, 7-10). Residents rated the quality of teaching as 9 (range, 6-10) and the quality of instruction and feedback received as 8.5 (range, 6-10). Overall resident performance was rated as 8 (range, 5-10) by faculty. The factors most positively impacting the quality of the workshop were reported to be the close interaction between residents and faculty, the training models, and the protected time. Sixty-eight percent of participants indicated that both cadaver and pig models were necessary for this course, and all participants believed that such workshops should be part of the general surgery curriculum. Overall cost reached just under $10,000 excluding supplies and faculty time., Conclusions: The feasibility of a cadaveric and animal-based procedural workshop for surgery residents based on phase II of the national skills curriculum was demonstrated. While very resource-intensive and costly, the educational value of this workshop was rated highly by residents and faculty because of their close interaction in a relaxed environment. Such workshops should be incorporated into the surgical curriculum., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Since the institution of Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions, conflicting evidence exists regarding the impact on resident case volume with most data from single-institution studies. We examined the effect of restrictions on national resident operative experience. After permission from the ACGME, we reviewed the publicly available national resident case log data (1999 through 2008) maintained on the ACGME web site (www.acgme.org), including total major cases with subanalysis of the ACGME-specified categories. The mean cases per resident were compared before (1999 to 2003) and after (2003 to 2008) restrictions. After the implementation of duty hour restrictions, the mean number of total cases per resident significantly decreased (949 +/- 18 vs 911 +/- 14, P = 0.004). Subanalysis showed a significant increase in alimentary tract (217 +/- 7 vs 229 +/- 3, P = 0.004), skin/soft tissue (31 +/- 3 vs 36 +/- 1, P = 0.01), and endocrine (26 +/- 2 vs 31 +/- 2, P = 0.006) cases. However, we observed a significant decrease in head and neck (21 +/- 0.3 vs 20 +/- 0.3, P = 0.01), vascular (164 +/- 29 vs 126 +/- 5, P = 0.01), pediatric (41 +/- 1 vs 37 +/- 2, P = 0.006), genitourinary (10 +/- 2 vs 7 +/- 1, P = 0.004), gynecologic surgery (5 +/- 1 vs 3 +/- 0.6, P = 0.002), plastics (16 +/- 0.3 vs 15 +/- 0.7, P = 0.03), and endoscopy (91 +/- 3 vs 82 +/- 2, P < 0.001) procedures. Analysis of the ACGME-compiled national data confirms that duty hour restrictions have significantly impacted resident operative experience. Importantly, experience in specialty areas, including vascular and endoscopy, appears to have been sacrificed for consolidation of resources into general surgery services as indicated by the increase in alimentary tract and endocrine cases. These findings raise the following question: Is the era of truly broad-based general surgery training coming to an end?