Perceived Impact of Resident Travel on Transplant Surgery Experience during General Surgery Residency Training

Bittner JG,1 Fryer JP,2 Cofer JB,3 Mellinger JD,4 Wynn JJ,1 Fuhrman GM,5 Borman KR6

Departments of Surgery, 1Medical College of Georgia, Augusta, GA; 2Northwestern University, Chicago, IL; 3University of Tennessee,

Chattanooga, TN; 4Southern Illinois University, Springfield, IL; 5Atlanta Medical Center, Atlanta, GA; 6Abington Memorial Hospital, Abington, PA

Disclosures

No related conflicts of interest

Introduction

Current status of transplant surgeryEssential content area of residency

trainingNegative feedback from program

directors (PDs) and residents prompted action.High service-to-education ratioPoor operative experienceLow educational benefitRare/negative interactions with attendingsResident travel to transplant centers

Concern for equivalent educational experienceAssociated costs / inconvenience

Introduction

RRC-S proposed to eliminate transplant as a requirement during residency training.

ABS asked the RRC-S to stay this action and requested involvement of ASTS through TAC.

ASTS issued a call to actionInvolve general surgery leadershipReevaluate the role of surgical residents on

a transplant rotationImmediately address concerns of the RRC-SCommit to immediate and long-term

educational excellence within transplant surgery

Purpose

To investigate the perceived impact of resident travel on transplant experience by comparing opinions of PDs who have transplant rotations at integrated (home) compared to non-integrated (away) hospitals.

Methods

A comprehensive survey was created on behalf of the APDS and ASTS.Instrument was IRB-approved.Content was validated by a focus group.Internet-based survey

Administered anonymously via email to 251 PDs

Resent two weeks after first administrationSupported by the President of the APDS

Data analyzed using appropriate statisticsSignificance set at α = 0.05

Results

131 of 251 PDs (52%) respondedSample size achieves a 5.9% confidence

interval assuming 50% response distribution.

Response rates by program type similar to expected distributionUniversity (52%)University-affiliated/Community (31%)Community (17%)

Results

University PDs represent more chief residents on average (p<0.001)5.7 ± 1.9 University3.7 ± 1.0 University-affiliated /

Community3.1 ± 1.1 Community

ASTS approved fellowships similar to expected distribution (p=0.439)20% responding PDs24% all US residency programs

Results

Disproportionate response from PDs with home transplant rotations66% of PDs use integrated (home)

hospitals30% use non-integrated (away)

hospitals80% of these feel the educational needs of

all residents are given equal priority48% require resident commuting (<30 extra

miles/day)52% purchase temporary housing

43% of transplant services provide experience for visiting residents

ResultsTransplant Rotation Types Used by Program Directors in Surgery

Survey Item Response Transplant Rotation P Value

Yes (%) No (%)

Program Type

University 70 14 0.009

University-affiliated/Community 23 47 0.016

Community 7 39 <0.001

Program Size (graduates/year)

2 – 4 37 92 <0.001

5 – 7 50 8 <0.001

> 7 13 0 0.018

Fisher’s exact test (α = 0.05)

ResultsTransplant Rotation Types Used by Program Directors in Surgery

Survey Item Response Transplant Rotation P Value

Yes (%) No (%)

Resident-Faculty Interactions

Good / Very Good 65 64 1.000

Uncertain 19 25 0.625

Poor / Very Poor 16 11 0.385

High Service:Education Ratio

Agree / Strongly Agree 34 47 0.218

Uncertain 16 20 1.000

Disagree / Strongly Disagree 50 33 0.110

Fisher’s exact test (α = 0.05)

ResultsTransplant Rotation Types Used by Program Directors in Surgery

Survey Item Response Transplant Rotation P Value

Yes (%) No (%)

Operative Experience is Excellent

Agree / Strongly Agree 51 38 0.236

Uncertain 18 31 0.154

Disagree / Strongly Disagree 31 31 1.000

Educational Value

Good / Very Good 61 58 0.840

Uncertain 27 25 1.000

Poor / Very Poor 12 17 0.564

Fisher’s exact test (α = 0.05)

ResultsTransplant Rotation Types Used by Program Directors in Surgery

Survey Item Response Transplant Rotation P Value

Yes (%) No (%)

Transplant Experience Should Be

Required 29 14 0.104

Optional 61 61 1.000

Eliminated 10 25 0.045

Fisher’s exact test (α = 0.05)

Discussion

PDs and transplant surgeons mightDecide how many residents might

rotate on a transplant service with or without a fellow.38% believed service > education

Assess ways to protect operative experience.53% claimed experience was less than

excellent.Share accountability for education

outcomes.59% felt transplant offers a good

educational value.Address the burden of resident travel.

78% felt travel is a poor/very poor aspect.

Discussion

PDs and transplant surgeons mightGuarantee visiting residents are treated

the same as home residents.80% felt visiting residents have similar

experienceEnsure duty-hours compliance.

71% stated rotations were compliant.Consider making transplant optional.

60% believed transplant should become optional.

Discussion

ASTS action planTransplant programs need to:

Designate a transplant surgeon working alongside a PD to oversee the education of surgery residents

Change the transplant rotation structure to ensure residents have adequate time for education

Reeducate attending and resident surgeons about educational expectations

Establish a relevant operative experienceCreate a feedback system to allow for

improving the educational milieu.

Limitations

52% response rateBiased toward opinions of PDs

with home transplant rotationsNot possible to tell if PDs also

served as transplant fellowship director

No temporal survey administration

Conclusions

More PDs at Community / smaller programs use away hospitals.

PDs sending residents to away hospitals face educational, logistical, and financial burdens.

Most PDs challenge the paradigm of transplant as essential content.

More PDs employing away rotations felt transplant should be eliminated.

Thank You!

APDS Board of Directors

ASTS administrative staff

Responding Program Directors

Bruce V. MacFadyen, Jr., MD, FACS