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Although it seems natural that surgical trainees would learn from demonstrations of a correct performance, evidence outside of surgical education has suggested that error-focused examples may promote error detection and improved procedural task performance. We hypothesized that feedback through error-focused videos would improve procedural learning more than correct-focused videos.We conducted a randomized controlled trial of video feedback comparing error-focused versus correct-focused examples. The participants were interviewees at our general surgery residency program in December 2020. All of the interviewees performed suturing and knot tying tasks on their interview day (baseline), with 70 common errors identified. For each error, we created an instructional feedback video in two formats: one video demonstrating the error and another demonstrating correct performance. The study participants received feedback videos based on baseline performance errors, with the format randomly assigned. Two blinded raters assessed the baseline and postintervention performances.Thirty-seven interviewees enrolled and 17 submitted postintervention videos. The postintervention mean performance scores were significantly higher (P = .02) in the error-focused than the correct-focused example group (suturing [maximum score 18]: 16.9 vs 13.9 [difference 2.9; 95% CI 0.7, 5.1]; knot-tying [maximum score 24]: 21.6 vs 17.8 [difference 3.8; 95% CI 0.5, 7.0]). We found no between-group differences in performance time ([error-focused versus correct-focused] suturing: 246 vs 256 s; knot-tying: 170 vs 138 s; P = .08). Mean satisfaction with feedback was similar between groups (error-focused: mean = 5.3 versus correct-focused: mean = 5.2, out of 7; P = .95).Feedback that highlights errors is associated with better learning of surgical skills than feedback demonstrating correct performance, confirming our hypothesis.

The main consideration during residency recruitment is identifying applicants who will succeed during residency. However, few studies have identified applicant characteristics that are associated with competency development during residency, such as the Accreditation Council for Graduate Medical Education milestones. As mini multiple interviews (MMIs) can be used to assess various competencies, we aimed to determine if simulated surgical skills MMI scores during a general surgery residency interview were associated with Accreditation Council for Graduate Medical Education milestone ratings at the conclusion of intern year.Retrospective cohort study. Interns' Step 1 and 2 clinical knowledge (CK) scores, interview day simulated surgical skills MMI overall score, traditional faculty interview scores, average overall milestone ratings in the spring of residency, and intern American Board of Surgery In-Training Examination (ABSITE) percentile scores were gathered. Two multiple linear regression were performed analyzing the association between Step 1, Step 2 CK, MMI, and traditional faculty interview scores with (1) average overall milestone rating and (2) ABSITE percentile scores, controlling for categorical/preliminary intern classification.One academic medical center PARTICIPANTS: General surgery interns matriculating in 2020-2021 RESULTS: Nineteen interns were included. Multiple linear regression revealed that higher overall simulated surgical skills MMI score was associated with higher average milestone ratings (β = .45, p = 0.03) and higher ABSITE score (β = .43, p = 0.02) while neither Step 1, Step 2 CK, nor faculty interview scores were significantly associated with average milestone ratings.Surgical residency programs invest a tremendous amount of effort into training residents, thus metrics for predicting applicants that will succeed are needed. Higher scores on a simulated surgical skills MMIs are associated with higher milestone ratings 1 year into residency and higher intern ABSITE percentiles. These results indicate a noteworthy method, simulated surgical skills MMIs, as an additional metric that may select residents that will have early success in residency.

To investigate the steps faculty surgeons take upon experiencing intraoperative error and synthesize these actions to offer a framework for coping with errors.While intraoperative errors are inevitable, formal training in error recovery is insufficient and there are no established curricula that teach surgeons how to deal with the intraoperative error. This is problematic because insufficient error recovery is detrimental to both patient outcomes and surgeon psychological well-being.We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with faculty surgeons from 3 hospitals. Surgeons described recent experiences with intraoperative error. Interviews were transcribed and coded. Analysis allowed for development of themes regarding responses to errors and coping strategies.Twenty-seven surgeons (30% female) participated. Upon completion of the analysis, themes emerged in 3 distinct areas: (1) Exigency, or a need for training surgical learners how to cope with intraoperative errors, (2) Learning, or how faculty surgeons themselves learned to cope with intraoperative errors, and (3) Responses, or how surgeons now handle intraoperative errors. The latter category was organized into the STOPS framework: Intraoperative errors could produce STOPS: Stop, Talk to your Team, Obtain Help, Plan, Succeed.This study provides both novel insight into how surgeons cope with intraoperative errors and a framework that may be of great use to trainees and faculty alike.

In 2022, United States Medical Licensing Examination (USMLE) Step 1 scores will become pass/fail. This may be problematic, as residency programs heavily rely on USMLE Step 1 scores as a metric when determining interview invitations. This study aimed to assess candidate application metrics associated with USMLE Step 1 scores to offer programs new cues for stratifying applicants.Retrospective cohort study analyzing interviewed applicants to one general surgery residency program in 2019 and 2020. Applicant data analyzed included USMLE Step 1 scores, number of publications, clerkship scores, letter of recommendation scores (out of 2, scored by 0.25 interval), interview overall score (out of 5, scored by integer level), and standardized question score (out of 10). Each year, applicant's answers to one standardized behavioral question during their interview were scored by interviewers.Tertiary medical center, academic general surgery residency program.Interviewed applicants at one general surgery residency program whose applications contained complete demographic information (203 out of 247).Multiple Linear Regression revealed that higher surgical clerkship (β = 0.19, p = 0.006) and higher standardized interview question (β = 0.32, p0.001) scores were positively associated with applicant USMLE Step 1 score (F[7, 195] = 6.61, p0.001, R2 = 0.19). Letter of recommendation score, number of peer reviewed publications, gender, race, and applicant type (preliminary/categorical) were not associated with USMLE Step 1 scores.With USMLE Step 1 scores transitioning to pass/fail, surgical residency programs need new selection heuristics. Surgery clerkship scores and standardized behavioral questions answered by applicants prior to the interview could provide a holistic view of applicants and help programs better stratify candidates without USMLE Step 1 scores.

Background Higher workload is associated with burnout and lower performance. Therefore, we aim to assess shift-related factors associated with higher workload on EGS, ICU, and trauma surgery services. Methods In this prospective cohort study, faculty surgeons and surgery residents completed a survey after each EGS, ICU, or trauma shift, including shift details and a modified NASA-TLX. Results Seventeen faculty and 12 residents completed 174 and 48 surveys after working scheduled 12-h and 24-h shifts, respectively (response rates: faculty – 62%, residents – 42%). NASA-TLX was significantly increased with a higher physician subjective fatigue level. Further, seeing more consults or performing more operations than average significantly increased workload. Finally, NASA-TLX was significantly higher for faculty when they felt their shift was more difficult than expected. Conclusions Higher volume clinical responsibilities and higher subjective fatigue levels are independently associated with higher workload. Designing shift coverage to expand on busier days may decrease workload, impacting burnout and shift performance.

Background There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement. Methods We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD. Results Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5 g/dL) ( P = .03) and duodenal ulcers ( P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29 days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, Discussion Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

OBJECTIVE The virtual interview season has challenged general surgery residency programs to recruit applicants through the loss of visiting clerkships, tours, and time with residents. Webinars, increased informal resident and faculty sessions, and live-narrated video tours are potential solutions. This study aimed to assess the effectiveness of these elements in virtually showcasing a residency program during the virtual interview season. DESIGN/SETTING Prospective applicants to one general surgery residency program (Mayo Clinic in Rochester, Minnesota) were invited to attend six webinars: Program Overview, Simulation Education, Diversity, Resident Life, Mingle with Residents, and Last-Minute Q&A. An anonymous survey was sent to all registered participants of the webinars. Interviewees participated in a preinterview social hour with resident and faculty and a live-narrated video tour of our facilities during their interview. A second anonymous survey was sent to all interviewees. PARTICIPANTS Webinars – 33% of 159 unique registrants surveyed participated. Interviews – 46% of 109 interviewees surveyed participated. RESULTS Average satisfaction with the webinars was 9.4/10. Overall, 98% of attendees felt that the webinars gave them a “feel” for the program. Attendees found the Last-Minute Q&A webinar and Program Overview to be most useful. For resident-led webinars, 100% of attendees felt that themed break-out rooms were effective. Average satisfaction with the interviews was 4.4/5. Interviewees rated access to faculty and residents highly (4.4/5 and 4.5/5, respectively). 98% of interviewees found the live-narrated video tour helpful. CONCLUSIONS A webinar curriculum can be effective in virtual residency recruitment, as prospective applicants developed a good understanding of the resident program after participating. Further, live-narrated video tours and purposefully incorporating several avenues for informal conversations with residents and faculty can successfully address applicant concerns about virtual interviews.

Objective We describe the feasibility of transitioning simulated skills assessments during general surgery interviews from an in-person to virtual format. Design/Setting Technical and nontechnical skill multiple mini-interviews (MMIs) were performed virtually and assessed for 109 applicants during virtual general surgery interviews over 2 days at a tertiary academic medical center. Results We demonstrate the feasibility of virtually assessing general surgery residency applicants’ technical and non-technical skills. Using a virtual MMI format during general surgery interviews, we assessed communication, emotional intelligence, anatomical knowledge, interpretation of medical tests, knot tying, and suturing. Four tasks (communication, emotional intelligence , anatomical knowledge, and interpretation of tests) were assessed synchronously by trained general surgery interns. Applicants submitted a recording of themselves performing knot tying and suturing tasks, which were asynchronously assessed after the interview day. Applicants rated the MMI experience highly (4.3/5) via postinterview day survey and the majority of applicants felt that station objectives were met in the virtual format. Conclusions We report a successful experience implementing technical and nontechnical virtual MMIs with capacity for 120 applicants during general surgery residency interviews. In the midst of a COVID-19 pandemic, the ability to assess surgical leaners virtually is essential. Virtual skills assessments may provide a more comprehensive picture of applicants and enable residency programs to better assess residents when gathering in person is not feasible.

Objective This study aims to characterize changes in the total operative cases logged by general surgery residents across three residency programs. Design Retrospective cohort study. De-identified case logs, divided by institution and post graduate year (PGY) level, were obtained from the general surgery training programs at three academic hospitals. Total cases logged were calculated over the pandemic period (start: beginning of residency, end: May 31st, 2020) and the control period (start: beginning of residency, end: May 31st, 2019). Setting Three academic tertiary hospitals (Mayo Clinic – Arizona, Mayo Clinic – Florida, and Mayo Clinic – Rochester) Participants All general surgery residents at these three hospitals, including 25 residents at Mayo Clinic – Arizona in both the pandemic and control period, 16 and 15 residents at Mayo Clinic – Florida in the control and pandemic period, respectively, and 81 and 77 residents at Mayo Clinic – Rochester in the control and pandemic period, respectively. Results Only PGY 4 general surgery residents at Mayo Clinic – Rochester had a decrease in operative cases logged in the pandemic period (759 cases on average compared to 1010 cases, p = 0.005), with no other changes in operative cases logged noted. Conclusions While elective cases were postponed secondary to the COVID-19 pandemic for around 1 month in the spring of 2020, the decrease in elective cases did not greatly impact overall resident operative cases logged for residents in three general surgery residency programs.

Physician burnout has been demonstrated at high rates among surgeons. Research has shown that physicians experiencing burnout have higher rates of depression, substance abuse, attrition, and medical errors. Surgical culture often promotes self-reliance; however, lacking social connections may worsen burnout. Therefore, we aimed to determine if struggling to develop a professional or personal community is associated with worsened burnout in surgeons.We conducted a survey of surgical residents and faculty at seven institutions in the United States in the spring of 2021. Variables measured included mentorship experience, presence of a social community outside work, burnout levels (Professional Fulfillment Index [PFI], 15: high professional fulfillment, 75: low professional fulfillment), average weekly hours worked over the previous 2 mo, and demographics (race, gender, and role: faculty or resident).A total of 218 participants completed the survey (50% residents and 54% male). Participants' PFI scores were an average of 36.29/75, indicating poor professional fulfillment (standard deviation [SD] = 11.80). A multiple linear regression revealed that struggling to find a mentor (β = 0.20, P = 0.004) and not having a social community exterior to the hospital (β = -0.25, P 0.001) were independently associated with significantly higher PFI scores (P 0.001, RStruggling to find a mentor and a lack of social community outside of work are associated with higher levels of burnout in this multi-institutional study. These findings suggest that targeting an improved support for building professional and personal relationships may be a strategy for improving burnout levels in both faculty and resident surgeons.

Objectives Peripheral intravenous (IV) cannulation is the most common procedure performed in the emergency department (ED). Elastic tourniquets (ETs) and blood pressure cuffs (BPCs) are frequently used for venodilation. Although BPCs lead to increased venodilation and decreased compressibility, it is unclear whether this translates into a meaningful patient-centered outcome. This study aimed to determine whether one method is superior for success on the first attempt. Methods This was a prospective, single-blinded, randomized controlled trial in the ED of a tertiary care center. A convenience sample of adult patients was randomly assigned to an ET or BPC with a cover concealing the type of tourniquet. The primary outcome was success rate on the first attempt. Secondary outcomes were number of attempts, number of providers, and rate of rescue techniques. Results Of the 121 patients enrolled, 119 qualified for analysis. In the ET group, 42 of 59 patients (71%) had successful IV cannulation on first attempt compared with 43 of 60 (72%) in the BPC group (P = .95). The number of attempts (P = .87), number of nurses (P = .67), and use of rescue techniques (P = .32) did not differ significantly. A history of difficult IV access and site other than the antecubital vein were associated with decreased success. Conclusions ETs and BPCs performed similarly in providing venodilation for successful peripheral IV cannulation. History of difficult IV access and IV site are important factors in determining the likelihood of success.

Background To describe the effect of the COVID-19 pandemic on emergency general surgery operative volumes during governmental shutdowns secondary to the pandemic and characterize differences in disease severity, morbidity, and mortality during this time compared to previous years. Methods This retrospective cohort study compares patients who underwent emergency general surgery operations at a tertiary hospital from March 1st to May 31st of 2020 to 2019. Average emergent cases per day were analyzed, comparing identical date ranges between 2020 (pandemic group) and 2019 (control group). Secondary analysis was performed analyzing disease severity, morbidity, and mortality. Results From March 1st to May 31st, 2020, 2.5 emergency general surgery operations were performed on average daily compared to 3.0 operations on average daily in 2019, a significant decrease ( P = .03). No significant difference was found in presenting disease severity, morbidity, or mortality between the pandemic and control groups. Discussion This study demonstrates a decrease of 65% in emergency general surgery operations during governmental restrictions secondary to the COVID-19 pandemic. This decrease in operations was not associated with worse disease severity, morbidity, or mortality.

Background The COVID-19 pandemic affected graduate medical education (GME) by decreasing elective procedures and disrupting didactic learning activities in 2020. Editorials have hypothesized that resident physicians worked fewer hours, therefore losing valuable experience, but we are not aware of studies that have objectively assessed changes in hours worked. Objective This study aims to identify differences secondary to the COVID-19 pandemic in resident work hours across all specialties at 3 geographically dispersed, integrated academic hospitals in a large sponsoring institution. Methods We obtained de-identified work hour data from all residency programs at Mayo Clinic in Arizona, Florida, and Minnesota. Resident work hours were compared between 2020 and 2019 from March to May. Results Work hours for 1149 and 1118 residents during the pandemic and control periods respectively were compared. Decreases in resident work hours were seen, with the largest decrease demonstrated in April 2020 when 19 of 43 programs demonstrated significantly decreased work hours. Residents worked more hours from home in April 2020 compared to the previous year (Arizona: mean 1 hour in 2019 vs 5.2 hours in 2020, P Conclusions The COVID-19 pandemic was associated with a decrease in work hours in some, but not all, specialties. The decrease in on-site work was only partially offset by an increased number of hours worked from home.

This chapter discusses a particular example taken from one of South American’s largest Indian groups. A clear-cut distinction between the two usages, however, is impossible, the universe of time and space somehow merging into a single conceptual unit. The world of the Matapuqenians is confined by the boundaries of the valley. These boundaries are not only of a geographical nature but are closely associated with what Andeanists have called ‘the vertical zonation of the Andean ecology’. The traditional view of pacha is contained in the interrelationships of the vertical zones of the valley slopes. In the Pincos Valley a single family can, and indeed must, have plots of land in the various crop-zones: the lower-lying wheat and barley fields, the most favoured maize fields, and, at the top range, the numerous plots for the cultivation of tubers. The division of labour between the sexes underlines the principles inherent in the bilateral kinship system.

The prevalence of atrial fibrillation (AF) is significantly higher in adults with congenital heart disease (ACHD) compared to patients without congenital heart disease (CHD). As AF in ACHD patients might have significant hemodynamic consequences, rhythm control is particularly desirable but rarely achieved by antiarrhythmic drugs. The aim of this study was to investigate safety and long-term outcome of AF ablation in ACHD patients. All ACHD patients (n = 46) that underwent AF ablation at our centre from 2013 to 2017 were included in the study. CHD was classified as simple (46%), moderate (41%) or complex (13%). The majority of patients (61%) suffered from persistent AF (paroxysmal AF 39%). Persistent AF was present in 57% of patients with simple, in 58% of patients with moderate and 83% of patients with complex CHD. All patients underwent radiofrequency (RF) ablation on uninterrupted oral anticoagulation. Pulmonary vein isolation (PVI) was performed in patients with paroxysmal AF, whereas patients with persistent AF underwent PVI and ablation of complex fractionated atrial electrograms (CFAE). No major complications occurred. Single-procedure success after 18 months off antiarrhythmic drugs was 61% for paroxysmal AF and 29% for persistent AF (p = 0.003). Multiple procedures (mean 2.1 ± 1.4) increased long-term success to 82% for paroxysmal AF and 48% for persistent AF (p = 0.05). Long-term ablation success was 64% for simple, 62% for moderate and 50% for complex CHD patients. AF ablation in ACHD patients is feasible and safe regardless of CHD complexity. Success rates in patients with paroxysmal AF are high and comparable to patients without CHD. In ACHD patients with persistent AF, success rates of ablation are markedly reduced which might be due to a different and/or more extensive (bi-)atrial substrate. In the cohort of complex ACHD patients with persistent AF as the dominant AF type, long-term success of AF ablation is limited.

Introduction: The COVID-19 pandemic forced general surgery residency programs to conduct virtual interviews, limiting traditional evaluation of applicants. We piloted a novel, completely virtual simulated skills assessment for interviewees. We aimed to assess feasibility of virtual skill assessments and determine whether differing domains of skills were successfully assessed. Methods: During their interview, applicants to 1 general surgery residency program in 2020 completed a simulated surgical skills test assessing suturing, knot tying, anatomy, interpretation of chest x-ray and arterial blood gas, emotional intelligence through a challenging standardized patient interaction, and communication through a Lego building task. Applicants were scored on each station and assigned a quartile ranking (1 through 4) based on their relative scores. Results: Surgical skills were assessed in 109 general surgery applicant interviews. A principal components factor analysis was conducted on the 6 items with varimax rotation, Kaiser-Meyer-Olkin = 0.57, all Kaiser-Meyer-Olkin values for individual items > 0.5. Three factors had eigenvalues > 1 and in combination explained 66.38% of the data. The clustered items for the same factor suggest that factor 1 represents medical knowledge and the ability to convey it, factor 2 represents technical skills, and factor 3 represents emotional intelligence. See Table 1 for factor loadings after rotation. Conclusion: As we consider a new era of virtual resident interviews, this research provides evidence that a large group of applicants can undergo a completely virtual skills assessment and that these 6 items likely assess a broad range of domains: medical knowledge, technical skills, and nontechnical skills. [Formula presented]

Background Few studies have evaluated surgical outcomes in long-term follow-up for patients undergoing Laparoscopic Ventral Hernia Repair (LVHR). Methods A retrospective review of long-term follow-up of LVHR patients (2002–2005) at a single institution. Results Sixty-three patients (37 males; mean age = 63, mean BMI = 33, 41% for recurrence) underwent LVHR. Mean operative time was 164 min. Mean hospital stay was 3.7 days. Short- and long-term complications occurred in 19% and 44% of patients, respectively. Mean follow-up was 12.4 years. Recurrent hernias were noted in 15 patients. Seroma formation occurred in 14 patients; small bowel obstruction occurred in 10 patients. Five patients developed mesh infection. Use of PTFE mesh, longer operative time, and a larger hernia defect were risk factors for mesh infection (p Conclusions Long-term outcomes for patients undergoing LVHR are fraught with complications (44%) and a considerable risk of hernia recurrence (23%).

In Peru, land invasions have played an informal yet prominent role in implementing agrarian reform. In the southern Andes, peasant mobilization and land takeover were used as a means to circumvent a stalled expropriation process. Strategic lessons learned in agrarian settings have application on the margins of cities as well. New “urban areas” created out of expropriated hacienda lands in Cuzco were initiated by spontaneous occupancy which gradually became regulated and standardized in predictable ways. Administrative planning becomes a response to land takeover, playing a retrospective role in situations in which internal kinds of development already are unfolding. State permissiveness towards illegal occupancy is a carefully courted prize, not to be taken for granted. Nevertheless, residents invest years of effort in building their homes and neighborhoods, in the hope of eventually prevailing, despite contradictory and frustrating experiences with changing policies and bureaucratic encounters.

L'A. traite la question des papiers d'identite et de l'espace bureaucratique au Perou. La demande et le renouvellement de toute une serie de documents personnels obligent les individus a parcourir et a reparcourir les marches des rues et des bâtiments officiels de Cuzco, au sud des montagnes du Perou. Ces deplacements, facilement observables, s'inscrivent dans un milieu urbain tres inhabituel caracterise par un feuillete complexe d'espaces administratifs Inca, coloniaux, republicains et contemporains. Au cours de ce processus ou l'Etat construit ces differentes modalites d'identification, un enseignement physique de la citoyennete se voit dispense dans cette interaction spatiale avec les bureaux. La participation active et l'acceptation plus ou moins consentie a effectuer ces peregrinations documentaires legitime la presence de l'Etat et sa domination de la scene urbaine. D'un cote, les citoyens sont ainsi crees par ces differentes sequences d'identification bureaucratique tandis que, de l'autre, la presence de l'Etat s'impose progressivement par l'entremise du mouvement dynamique effectue par ceux qui se trouvent engages dans ce processus d'identification. En meme temps qu'il interiorise l'espace bureaucratique, le deplacement du corps est interiorise par lui.

Synopsis In this article, the author discusses the use of the public/private dichotomy, a prevalent model used in the analysis of women's role in society. She calls for a refining of the concept and questions its applicability in the analysis of the particular social organization of the Quechua Indians of highland Peru. The Quechua community under discussion is characterized by a village organization based largely on bilateral kinship affiliation. In the household unit, the means of production are held individually by both husband and wife and the division of labour, where it exists, is complementary and not exclusive. The basic attitude to individual ownership coupled with economic inter-dependence, marks the relationship between the sexes as one of mutual respect and competition. In this context the public and private spheres are indistinguishable and the model is rejected. Instead the Quechua concept of yanantin is suggested as a more fitting model for the understanding of women's role in that society.