guidetothe r1 year - stanford...

GUIDE TO THE R1YEAR

STANFORD GENERAL SURGERY2017-2018

WelcometoStanfordSurgery

Ø HistoryofandPresentDayStanfordSurgery

Ø Expectations

Ø InternWardDuties/PatientCare

Ø NightService

Ø DutyHours

Ø Schedule

Ø ConferenceSchedule

Ø Chiefs’JournalClub

Ø Chiefs’RoundsandSocialEvents

Ø BalanceinLife

HistoryofStanfordSurgery

EmileF.Holman,M.D.Chair1926– 1955

Halsted’slastresidentBroughtsurgerywest

NormanE.Shumway,M.D.Cardiac1958– 1993

Fatherofhearttransplantation“Bestfirstassist”

ThomasM.Krummel,M.D.Chair1999– 2015

ECMO,Innovation,Biodesign6Divisions,>60faculty

DepartmentofSurgery– PresentDay

MaryHawn,MDChairofSurgery

MarcMelcher,MD/PhDProgramDirector

� 6Divisions

◦ ClinicalAnatomy,GeneralSurgery,PediatricGeneralSurgery,Plastic&ReconstructiveSurgery,AbdominalTransplantation,VascularSurgery

� Morethan60faculty;130adjunct/affiliatedclinicalfaculty

� Continuedgrowth/upwardtrajectory

◦ NewAdult(2018)andChildren’shospitals(Summer2017)

◦ DevelopmentofSurgeryHSRProgram

◦ Activelyrecruitingnewfacultyacrossalldivisions

DivisionofGeneralSurgery

� AcuteCareSurgery/Trauma:Drs.Badger*,Browder,Maggio,Spain,Staudenmayer,Weiser,Nassar

� Breast:Drs.Dirbas &Wapnir

� ColorectalRed/White:Drs.Shelton,Morris,Kin&Kirilcuk – divisionTBD

� Hepatopancreatobiliary(HPB):Drs.Dua&Visser

� MinimallyInvasiveSurgery(MIS):Drs.Azagury,Lau,Morton,&Rivas

� SurgicalOncology1:Dr.Norton

� SurgicalOncology2:Dr.Poultsides

� SurgicalOncology3/Endocrine:Drs.Cisco,Lin,Wheeler

OtherSurgicalDivisions

� PediatricGeneralSurgery:Drs.Bruzoni,Chao,Fuchs,Hartman,Krummel,Lund,Mueller,Powell,

Sylvester,Wall

� AbdominalTransplantation:Drs.Bonham,Busque,Concepcion,Esquivel,Gallo,Melcher

� VascularSurgery:Aalami,Chandra,Dalman,Harris,Lee,&Mell

� Plastic&ReconstructiveSurgery

� ClinicalAnatomy

Additionaltrainingsites

� LucillePackardChildren’sHospital(LPCH)� PaloAltoVeteransHospital(PAVA)� ValleyMedicalCenter(VMC)� Kaiser(R2-R5only)

StanfordSurgery

� GroundedintheHalstedian traditionofclinicalexcellenceandeducation(embodiedbyShumway)

� Dedicatedtothefuture(sitsinaveryforward-lookingSiliconValley)

◦ Opportunitiesareplentiful(clinical,academic,industry...)

� YOUarepartofthisfuture

MarkandKrummel,ArchSurg 2004

Expectations

Ø Patientcareisalways first§ Honorandprivilegetocareforourpatients

§ Patientswillbeincrediblythankful(somejusthaveuniquewaysofshowingit)

§ Howwouldyouwantyourfamilymembertreated?

Ø Honestyisrequired(withyourcolleagues,patients,andyourselves)

Ø Bedependable

§ Comeearlyandcomeprepared(“Fortunefavorsthepreparedmind.”– LouisPasteur)

Ø Beprofessional

§ Treatotherswithrespect,supportyourcolleagues,”dressforsuccess”,completeyourworkhours/caselogs/evaluations/etc.intimelymanner

PatientCare

� Whatyoudomatters...

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

n engl j med 361;14 nejm.org october 1, 20091368

special article

Variation in Hospital Mortality Associated with Inpatient Surgery

Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, M.D., M.P.H.

From the Michigan Surgical Collaborative for Outcomes Research and Evaluation, the Department of Surgery, University of Michigan, Ann Arbor. Address reprint re-quests to Dr. Ghaferi at Michigan Surgi-cal Collaborative for Outcomes Research and Evaluation, 211 N. Fourth Ave., Suite 201, Ann Arbor, MI 48104, or at [email protected].

N Engl J Med 2009;361:1368-75.Copyright © 2009 Massachusetts Medical Society.

A bs tr ac t

BackgroundHospital mortality that is associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of compli-cations once they have occurred may be equally important.

MethodsWe studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. We first ranked hospitals according to their risk-adjusted overall rate of death and divided them into five groups. For hospitals in each overall mortality quintile, we then assessed the incidence of overall and major complications and the rate of death among patients with major complications.

ResultsRates of death varied widely across hospital quintiles, from 3.5% in very-low-mortal-ity hospitals to 6.9% in very-high-mortality hospitals. Hospitals with either very high mortality or very low mortality had similar rates of overall complications (24.6% and 26.9%, respectively) and of major complications (18.2% and 16.2%, respectively). Rates of individual complications did not vary significantly across hospital mortality quin-tiles. In contrast, mortality in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low over-all mortality (21.4% vs. 12.5%, P<0.001). Differences in rates of death among patients with major complications were also the primary determinant of variation in overall mortality with individual operations.

ConclusionsIn addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the time-ly recognition and management of complications once they occur.

The New England Journal of Medicine Downloaded from nejm.org on September 18, 2015. For personal use only. No other uses without permission.

Copyright © 2009 Massachusetts Medical Society. All rights reserved.

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

n engl j med 361;14 nejm.org october 1, 20091372

than in the very-low-mortality hospitals for each major complication. The largest differences in mortality after major complications between high-mortality hospital and low-mortality hospitals were observed in patients with stroke (46.4% vs. 22.5%, P<0.05), deep wound infection (7.1% vs. 3.2%, P<0.05), and septic shock (46.2% vs. 28.7%, P<0.001).

Analyses that were restricted to patients who underwent the five operations associated with the most perioperative deaths (colectomy, abdominal aortic-aneurysm repair, lower-extremity bypass, and above-knee and below-knee amputation) yield-ed virtually identical results (Table 3). For exam-ple, with colectomy, rates of death varied from 2.5% to 5.6%. The incidence of postoperative com-plications was very similar between the very-high-mortality hospitals and the very-low-mortality hos-pitals. In contrast, rates of death after a major complication were markedly higher in very-high-mortality hospitals than in very-low-mortality hos-pitals (20.4% vs. 11.4%, P<0.001).

Discussion

The results of this study provide new insights into the mechanisms underlying variations in hospi-

tal mortality with surgery. Although rates of death for patients who underwent inpatient surgery var-ied by a factor of nearly two (3.5% to 6.9%) across hospitals, these differences could not be explained by differences in postoperative complications. Spe-cifically, high- and low-mortality hospitals had nearly identical rates of postoperative complica-tions. Conversely, rates of death among patients with major complications varied markedly between hospitals with high overall mortality and those with low overall mortality.

Although it is clinically intuitive that high-mortality hospitals would have more complica-tions, our study adds to a growing body of evi-dence that complications and mortality are not correlated at the hospital level.6-8 In many of these studies, relationships between complications and overall mortality disappear with risk adjust-ment, suggesting that postoperative complications are related more to patient factors than to quality of care.9,10 Prompted by difficulties in the use of mortality or complications as a marker of hospi-tal quality, Silber and colleagues popularized the use of the term “failure to rescue”— defined as death after a complication — as a measure of hos-pital quality.2,9,10 Although these studies firmly established the importance of failure to rescue, they had certain limitations. The investigators used administrative data, which limited their abil-ity to account fully for illness severity. The use of administrative data may also result in an inaccu-rate ascertainment of postoperative complications. Our study builds on these original studies with the use of highly detailed, prospective clinical data, ensuring both adequate risk adjustment and accu-rate ascertainment of postoperative complications.

Our study had several limitations. First, the National Surgical Quality Improvement Program does not collect information on all possible post-operative complications. For example, complica-tions that are unique to individual operations, such as anastomotic leak for bowel operations, are not recorded. The complications that were included in the database were initially selected for their ap-plicability across the many general and vascular surgical procedures being sampled. Therefore, we may have underestimated the degree to which some important complications vary across hospi-tals. Second, hospitals in the database may not be representative of all hospitals in the United States, a possibility that would threaten the generalizabil-ity of our findings. Although the database includes

22p3

35

25

30

20

15

5

10

0

AUTHOR:

FIGURE:

JOB:

4-CH/T

RETAKEICM

CASE

EMail LineH/TCombo

Revised

REG F

Enon

1st2nd3rd

Ghaferi

1 of 1

10-01-09

ARTIST: ts

36114 ISSUE:

Very low Low Medium High Very high

24.6

27.6

23.5

26.9 26.9

16.218.4

14.9

18.0 18.2

12.514.7

17.519.3

21.4

Figure 1. Rates of All Complications, Major Complications, and Death after Major Complications, According to Hospital Quintile of Mortality.

Although rates of all complications and major complications did not vary significantly across hospital mortality quintiles, the rate of death in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low overall mortality (21.4% vs. 12.5%, P<0.001).

The New England Journal of Medicine Downloaded from nejm.org on September 18, 2015. For personal use only. No other uses without permission.

Copyright © 2009 Massachusetts Medical Society. All rights reserved.

Ø Differenceinhospitalqualitybasedon“rescue”fromcomplications(“Failuretorescue”)

Ø Youareoureyesandears,ourfirstresponders

Ø Answerisalways toevaluatethepatient

(youhaveminimalexperienceà notreadytotrusttelephone/RN/EMevaluation)

InternWardDuties

� Sign-in,pre-rounding(numbers)

� LeadAMrounds

� Orders

� Dischargepatients

� Callconsultants

� Documentation

� Answerpages

� MakeindependentroundsandLeadPMrounds

� Maintainthelist/census

� Sign-out

Sign-inandPre-rounding

� Arriveearlyenough

Ø Getthoroughsign-outfromnightintern

Ø Preparecensus

Ø Getnumbers(vitals,I/O,labs,imaging)– discusswithyourchiefwhatshouldbewrittendown/format

Ø Photocopylistforremainderofteam

Ø Bottomline:YOU needtoknowwhat’sgoingonwithyourpatients

� Medicalstudentsexpectedtohelp– it’syourjobtohelpthemhelpyou

LeadAMRounds

� Haveaplanforleadingroundsefficiently

� NotifyChiefofanyurgentissuesfromthestart

� Patientpresentation

◦ Concise,accurate,clear– remember,wearesurgeons

◦ Makeanassessmentandpresentaplan(thisishowyourlearn)

WriteOrders

� 1st priorityistoinstituteplanfromAMrounds

◦ Orders– talkingtopeoplestillmatters

� GettheminEPIC

� RunthelistwithChargeRNorbedsideRN

� TPNà Discusswithpharmacy

� Imagingà Discusswithradiologisteverytimetoensurescanperformedtoourlikening

� PICCà DiscusswithPICCRNtoensureitgetsdone

◦ MDR(~10amwithChargeRN,CM,SW,Dietician,etc.)

Discharges

� Goal:before11am

� Canset-updaybeforewith“ConditionalDischarge”

� DischargeOrders

◦ Knowwhichhomemedstoresume,whichtohold,whatrequiresnewRx

� Planahead– askyourchiefaboutthisthenightbeforeoronAMroundssoitdoesn’tholdthingsup

� Confirmdischargepharmacywithpatient

� Rx(triplicate)mustbeaccurate(avoidsunnecessaryphonecalls,longdrivebacktohospitalforpatient/family)

◦ Knowactivity,dietary,bathingrestrictions;woundcare;follow-upplan

DischargeSummaries

� DischargeSummaries

◦ Notasummaryofeveryeventduringtheirhospitalstay

◦ Canserveasprogressnoteforthedayifitincludesaphysicalexam

◦ Summaryofeventsyou wouldcareaboutwhenevaluatingthatpatientatfollow-up

� Surgery,Complications,Recovery(final“CYA”line),Finalpath,Follow-up,Physicalexam

� Useatemplate

Consultations

� Callearly

◦ Berespectful,butokaytobefirm– ifyourchiefaskedyoutocalltheconsult,theanswerisYES,wedowantthemtoactuallyseethepatientandleaveanote.Nodebate.

◦ Knowthepatientandspecificquestionbeforecalling

Documentation

� Every patientrequiresanotefromaphysician(orAPP)every day

◦ MustincludePEandA/P

◦ MedicalstudentnotesDONOTcount;nordoesacosignedstudentnote

◦ StudentsCANNOTwriteunderyouraccount(illegalasthisisMedicarefraud)

� Usetemplates(can”steal”fromotherresidentsinEpic)

� Mustbedoneinatimelyfashion(butpatientcarecomefirst)

� Copy-forwardfunctionisdangerous;besttoavoid

� UpdatetheProblemlist

Documentation

� Bespecific

◦ Billing/Codingfolkswillmessage/call/page(frustratingbutthefutureofmedicine)

◦ e.g.,”CKD”à “CKD,Stage4”

� DocumentQualityMetrics– theseactuallyhelpushelppatients!

◦ Urinarycatheter(ifyes,thenreason)

◦ Centralline(ifyes,thenreason)

◦ Antibiotics(indication,length,enddate)

◦ VTEprophylaxis(orwhynot)

AnsweringPages

� Youareoureyesandearswhileweoperate

� Thisisateameffort

◦ BEPROFESSIONAL.Anythingelseisunacceptable.

◦ Playwellwithothers;Donotthrowsandinthesandbox;AllIReallyNeedtoKnowILearnedinKindergarten

◦ Berespectful,beprompt;“killthemwithkindness”

� Notknowingtheanswerisnotanacceptablereasontoignorethepage

� Answeringthepagewith“letmerunitbythechief”betterthanignoring...

◦ Yourepresentyourteam,yourattending,yourprogram,andStanfordHospital

Follow-upDailyTasksandLeadPMRounds

� Useasystemthatworksforyour(checkboxes,etc.)

� Ensurethatlabs,imaging,studies,etc.arecompletedintimelyfashion(again–talkingtopeopleinpersonisbestforthis)

� KeepyourChiefupdatedwiththeresults

◦ cometoORand/ortext

� MakeindependentroundsifChiefinORlateintoevening(andupdateChief),or

� PrepareforPMroundseachafternoon

MaintaintheCensus

� Keepthelistupdated

� Summarylineimportantforcoveringintern/team

SignOut

� ACGMERequirements:

◦ Minimizetransitionsofcare

◦ Monitoredsignout (byserviceChiefs/Fellows)

◦ Documentedprocesstoensureeffectivenessoftransitions

� IPASSSystem

SignOut- IPASS� I– Illnessseverity◦ Stable,“Watcher”,Unstable

� P– Patientsummary◦ “44Mw/HTN,CADs/pCABG,HLDnowPOD0fromhisdistalgastrectomy.Hehasanepiduralfor

pain(managedbypain)andshouldbestrictNPOwithhisNGTtolcws; donotmanipulatehisNGT.”

� A– Actionlist◦ “POCaround8pm,follow-uphislabs,textchiefwhenthey’reback”

� S– Situationawarenessandcontingencyplanning◦ “Ifpaincontrolinadequate,callpainservice.Ifbloodpressurelow,textchief.”

� S– Synthesisbyreceiver◦ Askquestions,reiterateplan

PostoperativeChecks

� Requirementforeverypostoperativepatient(within4-8hours)

� Mustdocument(ifnonoteinchart,didnothappen)

◦ Doesnotneedtobeanovel!

PatientCare- Summary� Callforhelp:callearly(trustyourgut;erroronsideofpatientsafety)

� Neverhesitatetocallyourchief

◦ KeepingyourchiefinthedarkisNEVERacceptable

◦ Textmessagesarefree(butifnoresponse,assumenotreceived).Textà Callà Page

� DonotcallyourchiefintheOR;cometotheOR(unlesspatienttoounstabletoleavethebedside)

◦ Iftoounstable,chiefoccupiedà callorpageSICUchief/felloworcallRRT/CodeBlue

◦ RRTgetsyouCrisisRNandRRT;CodeBluegetsyoutheCodeTeam

� Documentevents/yourdecision-making(briefSOAPnotesuffices)

� ANYJUNIORORSENIORRESIDENTSHOULDHELPYOUIFYOUASK– YOUARENEVERALONE!!!

NightService

� Stanfordrosteratnight:R4,R2-Consult,R2-SICU,R1x2

� SafetyNet(inadditiontoChiefathome)

◦ UsetheR4atnight(R4/R5onSat)

� R4isthefirststopatnight

◦ SeemsminorandR4inORà ConsultR2orSICUR2

NightService

InternResponsibilitiesatNight

TraumaIntern– “TripleTs”

� CoversACS(trauma),thoracic,transplant

� Runs/documentationforallminortraumas(97),helpswithmajortraumas(99)

� Obtainface-to-facesignout eachnight

� Completeassignedtasks(POC,studies,etc)

� Managealldirectadmissions(eval,H&P,staffwithChief,etc)

Onc/CRS/...Intern– “the9s”� CoversBreast; Colorectal(x2);HPB;MIS;Surg

Onc 1,2,&3,Vascular

� Helpswithminor(97)andmajor(99)traumas

� Obtainface-to-facesignout eachnight

� Completeassignedtasks(POC,studies,etc)

� Managealldirectadmissions(eval,H&P,staffwithChief,etc)

NightService

Pearlstoliveby:

� Beconcerned.Assumetheworst.

� Understandhowyourbestplanwillfail.

� Seethepatient.Inperson.DON’TBELAZY.

� Communicateearlyandasoftenasneeded.

� Askforhelp.

� Itisbettertowakeupthechiefovernightthantobewokenupbythechiefthenextday…Trustus.

Trauma

� It’sateameffort� Onnightsandweekends,BOTHinternsshouldhavetraumaIDsturnedonandplanonhelpingwithnewtraumaactivationsunlessotherwisedetained(runtraumas,scribe,etc)

� Themoreyouwatch,themoreyoulearn� Mastertheprimaryandsecondarysurvey!� ATLS:getthebook/app/podcast– whateverittakes� Traumamanual

SurgeonTalk

Ø “ConservativemanagementofSBO”à Nonoperative management

Ø “Outsidehospital”à Referringfacility(hopefullyhaswalls/roof)

Ø “Gallbladderpain”à Biliarycolic,symptomaticcholelithiasis…

• GallstoneswithRUQpaincanbebiliarycolic,cholecystitis,choledocholithiasis,cholangitis,biliarypancreatitis...

Ø “Painonexam”à Painisasymptom,tendernessisasign

Ø DoNOTauscultatebowelsounds(ifyoudo,pleasedonotsharewithanyone)

Ø Nosillynoun-verbs(e.g.,Coumadinize,surgerize)

Ø Noadding–wisetotheendoforgansystems(e.g.,Respiratory-wise,Neuro-wise)

OR

� CometoORearlyandoften

� Wewillinvolveyouasmuchaswecan

� Youcanlearnatonwatchingsurgery

� Stepwiseprogression...(proveyoucanwalkbeforeweletyourun)

◦ Practice,practice,practice

◦ ORisnottheplacetopracticeyourknotthrowing,howtopalmaneedledriver…

DutyHours

� Dutyhours

◦ 100%complianceisNOTagoal,itisarequirement (reality,MedHub,ACGMEsurvey)

◦ Youreducationmatters

◦ Inreality,thereisnoreasontobeoverthe80-hours,6daysperweeklimit

� Identifyproblemsearlyà consultwithchiefearly

◦ AtextmessageFridaynightthatyouwillbeoverhoursispoorplanning

◦ Ifyouarestrugglingwithhoursandservicechiefnothelpingà emailadminchiefs

◦ Thisisasharedresponsibilitythattakescommunicationandplanning!!

DutyHours

Ø 80hoursperweek,averagedover4-weekperiod

Ø 1dayfreeofdutyeveryweek,averagedover4-weekperiod

• 1day=24hours

• Allowsgoldenweekendandblackweekendaslongasitaveragesout

• Vacationsmeaneverythingaveragedover3weeksinstead

Ø PGY1:Abletodo24hshifts

Ø PGY1:Shouldhave10hours,musthave8hoursfreeofdutybetweendutyperiods

Ø PGY1:Nohomecall

Schedule

� KnowbothCallschedule andRoundingschedule

� CallscheduleavailableonAmion (viaScalpelhomepage)

� Amion scheduleisfinal

� Wewilltrytocompletethesewellaheadoftime(helpusout...)

Schedule– YourResponsibility

� Knowyourscheduleandidentifyanyerrorsorpotentialconflicts

◦ Reviewyourblockschedulewhenitispostedà identifyerrorsearly

◦ Spendabout~10minutes; helpusout (wearetryinghardtohelpyoubygettingitdoneearly)

◦ Emailusifyouseeareal problem(e.g.,workingweekofvacation,working36straightdays...)

� Anticipateissuesandtroubleshoot– andCOMMUNICATE

◦ Examples:Transitionfromnightserviceoranightcall,vacationinterferingwithroundingrequirements…

◦ EmailnextservicechiefEARLYtowarnthemyouarecomingoffnights

� DONOTemailuswiththeproblem:

Identifytheproblem,offerasolution,andthenemailus

ScheduleIntricacies

� Tomeetdutyhourrequirements,youmust have1dayoffevery7days(averagedover4weeks)

◦ If1weekofvacation,thenaverageover3weeks (youdoNOTgetcreditforvacationweek)

◦ 1dayoff=24hours

◦ IfyouareoncallSatnightandroundingSunday:

� YoumustleavethehospitalearlyenoughonFrinighttohave24hoffà NOEXCEPTIONS

ScheduleExample

Schedulingchanges

� AssumetheanswerisNO.

� Thatsaid,certainthingscomeupduringresidency.Wegetthroughthistogether

① Emailusforapproval(includedates,reason,andplanforcoverageà weexpecttoyouproblem-solve)

Ø Thismeansyouwillhaveemailedtheinvolvedpartiestoworkoutasolution

Ø Unlessit’sanemergency,thisshouldbedoneONEWEEKINADVANCE

② AdminChiefswillreviewtheswitch

③ Ifapproved,wewillemailallinvolvedpartiesaswellastheadministration

Schedulingchanges

� Aboutrotationsorvacations:adminchiefs

� Emergencies:adminchiefsandservicechiefs

� Daytodayschedulerequests(ONEWEEKINADVANCE)

◦ Stanford:servicechiefsforROUNDING,adminchiefsforCALL

◦ LPCH:R3

◦ VA:R4

◦ VMC:TanyaJohnsonandservicechiefs(R4/R5)

DutyHoursandOtherRegulations

� MedHub (onlinetimecard)

◦ Mustbefilledouteveryweekà noexcuses

◦ Allowsustoidentifyproblemsearly(thoughthehopeisproblemsidentifiedbeforethispoint)

◦ Mustbefilledouthonestly

� ACGMEsurvey

◦ Notouropportunitytoidentifydutyhourproblems(shouldbefixedviapersonalaccountabilityandthenviaMedHub)

SchedulingStep3

� YouwilltakeStep3duringyourR1year

� PaidforbyGMEoffice(gototheirwebsitefordetails)

� Scheduleyourtestbasedonyourserviceandobligations.Forexample:◦ IfonOrtho,ENT,Cardiac,Vascular:schedulewhileonAnesthesia

◦ BreastorMIS(especiallywhenthereisanR3/R5doinganelective)>SurgOnc/CRS

◦ UNACCEPTABLETIMETOSCHEDULE:� ACSDay/Night

� WhenR1-R5onserviceisonvacation

QIM&M,GrandRounds,andCoreCourse

� Absencesarerarely excused

� Tardinessisrarely excused

� ForGrandRounds:Sittinginthebackrowisacceptableifthefrontrowsarefilled

� ForCoreCourse/JournalClub:Sitinthefrontrows

◦ Comeprepared

� ForSubspecialtyservices:YoumayattendGenSurgCoreCourseOR yoursubspecialtyconference(notboth)

� DoNOT delayyourreturntooff-siteservices

Sign-inSheetforQIM&M

� Mondaymornings

� BreastInternvsMISIntern

� YOURresponsibilitytobesureitisthereby6:55,nolater,NOEXCUSES

� Ifvacation,findcoverage

Logistics

� UseStanfordemailonly

� AddSECURE:tosubjectofanyemailincludingpatientinformation

◦ e.g.,“SECURE:patientupdateforweekendrounds”

Feedback

� Providedtoyou(resident)realtime,monthly(MedHub evals),andduringtwice-yearlyfeedbacksessionswithPDs

� You(resident)providefeedbackaftereveryrotation

◦ Anonymous (collatedbyGME,facultyonlyseesafter6monthsorcertain“n”reached)

◦ Meaningful(changesmadeeveryyearbasedonresidentfeedback)

◦ Behonest,critical,butprofessional

� PartoftheACGMEsurveyà soifnotsurere:process,ask!

TipsandTrickstoSucceed

� Theanswerisalways“yes”◦ Cases,clinic,consult,presentation,tumorboard

◦ Thiswillmakeyourlifeeasier,yourchief’slifeeasier,andyourattending’slifeeasier

� Donotburnbridges◦ Yourepresentourdepartmentandourattendings

◦ Kill‘em withkindness...orjust“dowhatyougetpaidfor”

◦ Aschiefs,wearenotinterestedincleaningupyourinterpersonalmesses.BEPROFESSIONAL.

� Read...

Copyright 2015 American Medical Association. All rights reserved.

Reading Habits of General Surgery Residentsand Association With American Board of SurgeryIn-Training Examination PerformanceJerry J. Kim, MD; Dennis Y. Kim, MD; Amy H. Kaji, MD, PhD; Edward D. Gifford, MD; Christopher Reid, MD; Richard A. Sidwell, MD;Mark E. Reeves, MD, PhD; Thomas H. Hartranft, MD; Kenji Inaba, MD; Benjamin T. Jarman, MD; Chandrakanth Are, MD; Joseph M. Galante, MD;Farin Amersi, MD; Brian R. Smith, MD; Marc L. Melcher, MD, PhD; M. Timothy Nelson, MD; Timothy Donahue, MD; Garth Jacobsen, MD;Tracey D. Arnell, MD; Christian de Virgilio, MD

IMPORTANCE Few large-scale studies have quantified and characterized the study habits ofsurgery residents. However, studies have shown an association between American Board ofSurgery In-Training Examination (ABSITE) scores and subsequent success on the AmericanBoard of Surgery Qualifying and Certifying examinations.

OBJECTIVES To identify the quantity of studying, the approach taken when studying, the rolethat ABSITE preparation plays in resident reading, and factors associated with ABSITEperformance.

DESIGN, SETTING, AND PARTICIPANTS An anonymous 39-item questionnaire includingdemographic information, past performance on standardized examinations, reading habits,and study sources during the time leading up to the 2014 ABSITE and opinions pertaining tothe importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371surgery residents in 15 residency programs nationwide.

MAIN OUTCOMES AND MEASURES Scores from the 2014 ABSITE.

RESULTS A total of 273 residents (73.6%) responded to the survey. Seven respondents didnot provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Mostrespondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. Themedian number of minutes spent studying per month was 240 (interquartile range, 120-600minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range,30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported readingconsistently throughout the year for patient care or clinical duties. With respect to ABSITEpreparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year,while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to theexamination. Univariate analysis (with results reported as effect on median ABSITE percentilescores [95% CIs]) identified the following factors as positively correlated with ABSITE scores:prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-pointincrease: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior MedicalCollege Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), highopinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), dailystudying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). Onmultivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCATscore (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), andhaving an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5];P = .03) were identified as positive predictors of ABSITE performance.

CONCLUSIONS AND RELEVANCE Most residents reported reading consistently for patient carethroughout the year. Daily studying and textbook use were associated with higher ABSITEscores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attituderegarding the importance of the ABSITE results, were independent predictors of ABSITEperformance.

JAMA Surg. doi:10.1001/jamasurg.2015.1698Published online July 15, 2015.

Invited Commentary

Supplemental content atjamasurgery.com

Author Affiliations: Authoraffiliations are listed at the end of thisarticle.

Corresponding Author: Christian deVirgilio, MD, Department of Surgery,Harbor–University of California at LosAngeles Medical Center, 1000 WCarson St, Torrance, CA 90502([email protected]).

Research

Original Investigation | PACIFIC COAST SURGICAL ASSOCIATION

(Reprinted) E1


Downloaded From: http://archsurg.jamanetwork.com/ by a STANFORD Univ Med Center User on 08/06/2015


Predictors on Multivariable AnalysisBased on significance from univariate analysis, the followingvariables were entered into multivariable linear regression analy-sis: USMLE 1 and 2 scores, MCAT scores, prior ABSITE remedia-tion, opinion of ABSITE’s significance, use of clinical textbook,use of SCORE questions, whether reading was clinically focused,having an equal study focus on ABSITE and patient care, as wellas potential within-program resident correlations.

Multivariable analysis identified 4 independent predictorsof ABSITE performance, all with a positive correlation (with re-sults reported as effect on median ABSITE percentile scores [95%CIs]): USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001),MCAT score (0.6 [0.2-1.0]; P = .003), having an equal study focuson ABSITE and patient care or clinical duties (6.1 [0.6-11.5]; P =.03), and perceived ABSITE significance (9.2 [6.9-11.6]; P < .001)(Table 5). Of these predictors, resident perception of the impor-tance of the ABSITE results seemed to have the most significanteffect, with a 9.2–percentile point increase in ABSITE score foreach increase in perceived level of significance (of 4 levels).

DiscussionThis study reviewed perceptions, attitudes, and study habits of266 residents at 15 general surgery residency programs across theUnited States. Respondents reported a median of 480 minutesspent studying in total for any reason each month (median forpatient care, 240 minutes; for ABSITE, 120 minutes). Most resi-dents (61.7%) reported consistently studying throughout the yearfor patient care, while only 27.1% reported consistent year-roundstudying for the ABSITE. Overall, residents expressed a desire toperform well on the ABSITE and a lack of motivation was rarelycited as a barrier to preparation. Specific factors associated withsuccess were identified on univariate analysis. These factors in-cluded a history of high performance on standardized testing(MCAT and USMLE 2), studying on a daily basis, use of a surgi-caltextbook,andahighlevelofsatisfactionwiththestudysourcebeing used. However, multivariable analysis showed that the ef-fect of resident perception of how important the ABSITE resultswere for achieving future goals was particularly strong. Indeed,these perceptions likely set the foundation on which ABSITE-

related study habits and strategies are built. Therefore, it is notsurprising that daily studying and textbook use are not indepen-dent predictors of performance, as these variables are probablyclosely linked to the attributes that lead to high ABSITE perfor-mance in the first place. Interestingly, the overall minutes permonth spent studying or having taken an ABSITE preparatorycourse did not correlate with scores.

Currently, a comprehensive assessment of surgical resi-dents’ study habits is lacking. Previous studies assessing sur-gery residents’ study patterns have focused on ABSITE-related preparation7,8 and have not necessarily distinguishedbetween preparation for clinical duties vs for ABSITE. Fur-thermore, the sample sizes of these studies have been small,generally less than 60 residents. A larger-scale study investi-gating the use of various study sources was conducted by Glasset al,9 with 773 respondents. However, that study did not quan-tify the amount of studying, and associations with respect toABSITE performance were not investigated. Therefore, thequestion of how much residents study and how their time isdistributed with respect to study materials and ABSITE prepa-ration has not previously been answered.

There is mounting evidence suggesting that ABSITE scoresplay a meaningful role in achieving future career goals. A 2008study showed that scoring below the 35th percentile on theABSITE on more than 1 occasion was predictive of failing theABS-QE.3 Furthermore,scoringbelowthe25thpercentilewaspre-dictive of failing both the ABS-QE and the Certifying Examina-tion (CE) in that study. A subsequent retrospective review of 607surgical residents further validated these findings and showedthat scoring below the 35th percentile on the ABSITE at any pointwas predictive of failing both the ABS-QE and ABS-CE.4 A morerecent study reviewing more than 6000 residents’ ABSITE, ABS-QE, and ABS-CE scores concluded that high ABSITE scores arehighly predictive of success on the ABS-QE, but low ABSITEscoreswerelessreliableinpredictingsubsequentABS-QEfailure.5Given the literature, ABSITE scores clearly have a distinct asso-ciationwithperformanceontheABSexaminations.Furthermore,a survey-based study of 148 surgical fellowship program direc-tors across all subspecialties ranked the ABSITE as the third mostimportant component of acceptance to a fellowship, behind let-tersofrecommendationandresidencyprogramattended.6 Inthatreport, the ABSITE was noted to carry greater weight with fellow-ship directors than did publications. Given the increasing num-ber of general surgery graduates entering fellowship programs,the importance of the ABSITE is likely to become more relevantto current surgical residents.

Despite its significance, residents currently are not knowl-edgeable about how to best prepare for the ABSITE. In 2014,Simpson-Camp and colleagues10 showed that residents wereunable to accurately predict their ABSITE performance imme-diately prior to, or even after taking the examination. Most resi-dents overestimated their performance. This overestimationreflects the poor understanding possessed by residents of whatconstitutes adequate vs inadequate preparation. To exacer-bate the matter, contemporary studies on the topic have as-sessed factors that are not necessarily under the control of resi-dents. Programmatic factors assessed include weekly readingassignments and quizzes administered by the program11 and

Table 5. Predictors of ABSITE Performance on Multivariable Analysis

Predictor Effect (95% CI)a P ValueUSMLE 2 score 0.4 (0.2-0.6) <.001

MCAT score 0.6 (0.2-1.0) .003

Equal study focus on ABSITE and patient care 6.1 (0.6-11.5) .03

Opinion of ABSITE significance (responses1-4)b

9.2 (6.9-11.6) <.001

Abbreviations: ABSITE, American Board of Surgery In-Training Examination;MCAT, Medical College Admission Test; USMLE, United States Medical LicensingExamination.a For continuous variables, effect of 1-point increase or decrease on ABSITE

percentile score. For categorical variables, effect of variable presence onmedian ABSITE percentile score.

b Opinion of ABSITE significance: 1, my score doesn’t matter at all; 2, need to passto avoid disciplinary measures; 3, want to do well, but unlikely to affect futurecareer goals; 4, must do well, they are important to achieving my career goals.

Research Original Investigation Study Habits and ABSITE Performance in General Surgery Residents

E6 JAMA Surgery Published online July 15, 2015 (Reprinted) jamasurgery.com




Figure 1. Although rapid-access Internet sources (search en-gine, PubMed, and peer-reviewed Internet sources) were notchosen as often as formal review materials, they were ratedwith the highest satisfaction levels, with 94.3% to 97.1% of resi-dents indicating “satisfied” or “strongly satisfied.” Those usinga surgical textbook (n = 254) also indicated “satisfied” or“strongly satisfied” 92.9% of the time.

Factors Associated With ABSITE PerformanceFactors positively associated with ABSITE scores on univari-ate analysis included (with results reported as effect on me-dian ABSITE percentile scores [95% CIs]) prior USMLE 1 and 2scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03;USMLE 2, 0.3 [0.19-0.44], P < .001), prior MCAT scores (per1-point increase, 1.2 [1.3-2.0]; P = .002), having an equal studyfocus on ABSITE and patient care (11 [7-15]; P = .009), dailystudying for patient care or clinical duties (13 [4-23]; P = .02),use of a surgical textbook (11 [6-16]; P = .02), level of satisfac-tion with study materials, and perceived ABSITE significance(Table 4). Factors negatively correlated with ABSITE scores in-cluded prior ABSITE remediation (–26 [–36 to –16]; P = .002),

lack of studying as indicated by agreement to the statement,“I did not prepare at all” (–12 [–21 to –9]; P < .001), use of SCOREquestions as a primary source (–14 [–19 to –9]; P = .01), use ofan Internet search engine as a primary source (–21 [–30 to –13];P = .04), and primary focus on patient care or clinical dutieswhen studying (–9 [–14 to –5]; P = .009).

The positive correlation exhibited between level of satisfac-tion and perception of ABSITE significance to ABSITE percentilescores was especially strong (Figure 2). Respondent level of sat-isfaction with their primary or secondary source, whether beingused for patient care or ABSITE studying, had a direct positivecorrelation with median ABSITE percentile scores (P < .001). Fur-thermore, the perceived level of importance placed on ABSITEresults (possible responses: 1, “my ABSITE score doesn't matterto me at all;” 2, “I just need to pass to avoid disciplinary mea-sures;” 3, “I want to do well, but don’t feel it will significantlyaffect my career goals;” and 4, “I must do well because it is im-portant in achieving future career goals”) had a significant effecton the median percentile score (P < .001). Despite the strong cor-relation that satisfaction with source material had on ABSITEscores, use of an Internet search engine (top satisfaction level[97.1%])actuallyhadadetrimentaleffectonABSITEperformance.

Factors without a significant association with ABSITEscores included age, sex, having children at home, specialtyinterest, use of an ABSITE review book, having taken anABSITE preparatory course, adhering to a year-round studyschedule, and average length of study sessions. In addition,research year status was also not associated with ABSITEscores.

Barriers to StudyingThe most commonly cited barrier to studying was residentwork hours (85 responses [32.0%]), followed by the desire tospend time with a significant other or spouse (67 [25.2%]). Lackof motivation was chosen least often as a significant barrier tostudying (25 [9.4%]).

Table 4. Factors Associated With ABSITE Performance

Factor Effect (95% CI)a P ValuePositive correlation

USMLE 1 score, per 1-pointincrease

0.1(0.02 to 0.14)

.03

USMLE 2 score, per 1-pointincrease

0.3(0.19 to 0.44)

<.001

MCAT score, per 1-pointincrease

1.2(1.3 to 2.0)

.002

Having an equal study focus onABSITE and patient careb

11(7 to 15)

.009

Daily studying for patient careor clinical dutiesb

13(4 to 23)

.02

Surgical textbook as studysourceb

11(6 to 16)

.02

Level of satisfaction with studymaterial (Likert scale)

c <.001

Opinion of ABSITE significance(multiple choice)

c <.001

Negative correlation

Prior ABSITE remediationb −26(−36 to −16)

.002

Lack of studyb,d −12(−21 to −9)

<.001

SCORE questions as primarysourceb

−14(−19 to −9)

.01

Internet search engine assourceb

−21(−30 to −13)

.04

Primary focus on patient carewhen studyingb

−9(−14 to −5)

.009

Abbreviations: ABSITE, American Board of Surgery In-Training Examination;MCAT, Medical College Admission Test; SCORE, Surgical Council on ResidentEducation; USMLE, United States Medical Licensing Examination.a For continuous variables, effect of 1-point increase or decrease on ABSITE

percentile score. For categorical variables, effect of variable presence onmedian ABSITE percentile score.

b This is a categorical dichotomous variable. Medians were compared usingnonparametric tests, and data are reported in whole numbers.

c Variable is neither continuous nor categorical dichotomous, and results areshown graphically in Figure 2.

d Those in agreement with the statement “I did not prepare at all.”

Figure 2. Correlation Between Level of Satisfaction With Study Sourceand Perception of ABSITE Significance to ABSITE Scores

90

80

70

60

30

50

10

20

40

0

Med

ian

ABSI

TE P

erce

ntile

Sco

re

Satisfaction Level or Opinion of ABSITE Importance

Satisfaction with source (P <.001)Opinion of ABSITE significance (P <.001)

1 2 3 4

Respondent level of satisfaction with their primary or secondary study source,whether being used for patient care or American Board of Surgery In-TrainingExamination (ABSITE) studying, had a direct positive correlation with medianABSITE percentile scores. The perceived level of importance placed on ABSITEresults also had a significant effect on the median percentile scores.

Study Habits and ABSITE Performance in General Surgery Residents Original Investigation Research

jamasurgery.com (Reprinted) JAMA Surgery Published online July 15, 2015 E5




[82.0%]) read on a weekly or daily basis (Table 2). When ex-trapolated from the frequency and duration of self-reported

studying, the median number of minutes studied per monthfor clinical duties was 240 (interquartile range, 120-600 min-utes). The most often cited primary study sources used for pa-tient care or clinical duties included a surgical textbook (139[52.3%]), SCORE curriculum (43 [16.2%]), and an ABSITE re-view book (40 [15.0%]).

Reading Strategies Pertaining to ABSITEFifty-six residents (21.1%) reported adhering to a year-roundABSITE study schedule and 40 (15.0%) reported studyingdaily for the ABSITE (Table 3). Many residents reportedstudying sporadically (91 [34.2%]) or once weekly (106[39.8%]). The average length of time spent during eachstudy session varied, but most residents indicated studysessions up to 30 minutes (74 [27.8%]) or between 31 and 60minutes (116 [43.6%]). The median number of minutesspent studying per month for the ABSITE was 120 (inter-quartile range, 30-360 minutes) when extrapolated from thefrequency and duration of study sessions. An ABSITEreview book was the most often selected primary studysource (126 [47.4%]). When asked about perceived impor-tance of the ABSITE, most respondents indicated a desire toperform well on the examination by responding, “I want todo well, but don’t feel it will significantly affect my careergoals” (148 [55.6%]), followed by “I must do well because it isimportant in achieving future career goals” (96 [36.1%]). Fi-nally, when asked about the timing of ABSITE preparation, 187respondents [70.3%] indicated “agree” or “strongly agree” tothe statement, “I prepared by reading regularly for 1-2 monthsbefore the ABSITE.” Fifteen residents (5.6%) agreed with thestatement, “I did not prepare at all.”

Responses given when asked to rate the level of satisfac-tion with primary and secondary study sources are shown in

Table 3. Reading Strategies Pertaining to ABSITE

Question Respondentsa

Did you follow a year-round ABSITE reading schedule?

Yes 56 (21.1)

How frequently did you read for ABSITE?b

None 3 (1.1)

Sporadically 91 (34.2)

Monthly 25 (9.4)

Weekly 106 (39.8)

Daily 40 (15.0)

What was the average length of study sessions?c

1-30 min 74 (27.8)

31-60 min 116 (43.6)

61-90 min 23 (8.6)

91-120 min 37 (13.9)

>120 min 12 (4.5)

Median (IQR) No. of minutes studied per monthfor ABSITEd

120 (30-360)

Describe your focus or goal when studyingb

My primary focus is preparing for ABSITE 49 (18.4)

My primary focus is on patient care or clinical duties 153 (57.5)

My focus is equally weighted for focused for both 63 (23.7)

What was your primary ABSITE study source?b

ABSITE review book 126 (47.4)

SCORE question bank 44 (16.5)

SCORE curriculum 37 (13.9)

Surgical textbook 25 (9.4)

Print question book 9 (3.4)

Material provided by my residency program 8 (3.0)

Smartphone application 2 (0.8)

SESAP 14 (5.3)

What is your opinion of the ABSITE results?b

My score doesn’t matter at all 5 (1.9)

Need to pass to avoid disciplinary measures 16 (6.0)

Want to do well, but unlikely to affect future careergoals

148 (55.6)

Must do well, they are important to achieving mycareer goals

96 (36.1)

How prepared were you for ABSITE?e

Not at all 15 (5.6)

Read 1-2 wk prior to the examination 60 (22.6)

Read 1-2 mo prior to the examination 187 (70.3)

Read consistently throughout the year 72 (27.1)

Abbreviations: ABSITE, American Board of Surgery In-Training Examination;IQR, interquartile range; SCORE, Surgical Council on Resident Education; SESAP,Surgical Education and Self-Assessment Program.a Data are presented as number (percentage) of respondents unless otherwise

indicated.b One respondent did not report this variable.c Four respondents did not report this variable.d Minutes of studying per month were extrapolated for each respondent based

on their study frequency and length of study sessions.e Likert Scale used: 1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree.

Numbers given are those responding as 3 or 4.

Figure 1. Residents’ Level of Satisfaction With Primaryand Secondary Study Sources

100

50

40

60

70

80

90

30

20

10

0

Sour

ce D

escr

ibed

as

“Sat

isfie

d” o

r “St

rong

ly S

atis

fied,

” %

Source

SCOREQuestion Bank

(n = 86)

SCORECurriculum

(n = 189)

ABSITEReview Book

(n = 295)

SESAP(n = 51)

SurgicalTextbook(n = 254)

The top 5 most often cited study sources indicated as a primary or secondarysource for the American Board of Surgery In-Training Examination (ABSITE) orpatient care (4 sources cited by each respondent). SCORE indicates SurgicalCouncil on Resident Education; SESAP, Surgical Education and Self-AssessmentProgram.

Research Original Investigation Study Habits and ABSITE Performance in General Surgery Residents

E4 JAMA Surgery Published online July 15, 2015 (Reprinted) jamasurgery.com



Chiefs’JournalClub

� OrganizedbyDrs.Mazer andBrubaker

� ALLresidentsparticipate,duringcorecoursetime

� CategoricalGeneralSurgeryR2Residentswillpresent

� Criticalanalysisofthestudieswithpowerpoint slides◦ R2willpresent,followedbydiscussion

� Followedbyongoing‘discussion’onTuesdayevenings– notatwork!

SocialEvents

◦ Post- JournalClubTuesdayevenings

◦ StanfordFootballTailgate(s)

◦ HolidayParties

◦ AnnualBILretreat

◦ Residentvs.Facultysoftballgame

◦ ResidentAppreciationDay(Graduationday)

◦ GraemeRosenberg(PDresident)

ProfessionalismCurriculum

� Topicsrangefrom:

◦ FinancialPlanning

◦ TimeManagement

◦ DressforSuccess

◦ ResiliencyinResidencyandCareer

◦ TransitionfromResidencytoPractice

◦ Contractnegotiation

BalanceinLife

� Classandwholeprogramsessions

� Evolvingeachyear

� Endoftheday: Weareafamily

� Lifekeepshappeningduringresidency

� Lookoutforeachother,supporteachother

� Mentalandphysicalhealthneedsactivemanagementandcare

Ø “Itdoesn’tmatterwhatyousayyoubelieve– itonlymatterswhatyoudo.”- RobertFulghum

Ø “Scienceisn’tonesuccessafteranother.It’smostlyonesuccessinadesertoffailure.”- JudahFolkman,MD

Ø Evertried.EverFailed.Nomatter.TryAgain.FailAgain.FailBetter.- SamuelBeckett(...andTomKrummel,MD)

Ø “Openingoftheabdomenisnottobeadvisedwithtoolightaheart.Thedextrous handmustnotbeallowedtoreachbeforetheimperfectjudgment.”- SirZacharyCope

Ø “Themanwhocandrivehimselffurtheroncetheeffortgetspainfulisthemanwhowillwin.”- RogerBannister

guidetothe r1 year - stanford...

Documents