Poster Session III - DEI & Global Surgery
Background: A critical barrier to diversification of the medical profession is the “leaky pipeline” that perpetuates underrepresentation of racial minorities. A proposed solution to improve retention of underrepresented minorities (URMs) is the use of holistic review – a flexible and individualized approach giving balanced consideration to experiences/attributes – for selection of candidates to graduate medical education (GME) programs. Despite enthusiasm for holistic review, few studies examine its effectiveness in increasing diversity of matriculated residents. This systematic review summarizes the state of holistic review in GME and quantifies its impact on diversity.
Methods: PubMed and Embase were searched for articles published before February 10, 2023 describing the implementation of holistic review in U.S. GME programs. Articles were included if they described components of holistic review and/or compared the diversity of traditionally reviewed cohorts to those holistically reviewed. Two authors performed title/abstract screening; any disagreements were adjudicated by a third reviewer. The association between holistic review and the proportion of URMs interviewed/matriculated was assessed using random-effects meta-analysis. Additionally, components of holistic review were categorized and described.
Results: Of 201 screened abstracts, 21 articles were included. Programs’ holistic review process included use of a mission-guided approach to candidate selection, interviewer bias training, blinding of residency committee to applicant appearance/demographic information, standardization of the rank list compilation process, clear messaging about diversity/equity/inclusion (DEI) in advance of and during the interview day, programmatic DEI cultural changes, dedicated diversification of the residency committee, de-emphasis of academic metrics, focus on experiences/attributes, and special review of URM applicants. Six articles included data comparing proportions of URMs interviewed at programs using traditional vs. holistic review. There were significantly increased odds of interviewing URMs at programs using holistic review (OR 2.30 [1.19, 4.44]). Four articles presented comparative data on matriculating cohorts; holistic review was not associated with increasing odds of matriculating URMs.
Conclusion: While holistic review may improve diversity of interviewed GME cohorts, this does not translate to an increase in URMs matriculating at these programs. Further work is needed to understand what initiatives can be undertaken during the interview and ranking process to bolster the recruitment of URMs.
Background
With the rise in robotic surgery, it is important to adapt residency curricula to ensure adequate robotic surgery training and operative autonomy. This study evaluated resident and program-level factors associated with operative autonomy during robotic surgeries.
Methods
Twenty-eight chiefs submitted procedure-specific robotic surgery case logs from 2021-2023, detailing case type, console time, and case completed portions. The analysis included three procedures: pancreaticoduodenectomy (PD), hernia repairs, and colorectal surgeries, including right and left hemicolectomies and low anterior resection. Each procedure was divided into four key portions. Outcomes measured included High Resident Autonomy (HRA), defined as >50% resident case participation, and minutes at the console. Independent variables included: graduation year, pursued fellowship type, attending gender, underrepresented minority status, and hospital. Univariable and multivariable logistic regression were performed.
Results
Of the 576 cases, 57% were hernias, 30% were colorectal cases, and 13% were PD. 339 cases took place at our university hospital. Female residents were present in 60% of the cases. Male residents reported higher resident participation (83% vs. 64%) and longer console times (150 vs 120 minutes; p< 0.01). Multivariable analysis indicated female gender was associated with 74% lower odds of HRA (95% CI: 0.15 - 0.45; p<0.001) and 18 fewer minutes of console time per minute versus males (p<0.01). The 2023 cohort had significantly higher odds of HRA than the 2021 cohort (OR: 4.46, 95% CI: 2.34 - 8.51; P < 0.001) and 15 more console minutes. Compared to others, residents with aligned fellowships spent 37 more console minutes (p<0.001). No significant differences were found between attending gender, hospital and minority status. A sub-analysis by case revealed that in PD 84% of male residents reported having performed the portal dissection compared to 39% of female residents (p <0.001). Furthermore, male residents reported an average console time of 240 minutes compared to 180 minutes for female residents (p <0.001).
Conclusions
Our findings reveal significant gender disparities in self-reported operative autonomy and console time. The later cohorts showed improved training outcomes and fellowship alignment positively impacted console time. This suggests a need to refine training approaches, ensuring equity and optimizing training efficacy.
Introduction: An innovative augmented reality (AR) surgical simulator holds promise for enhancing surgical training, but a comprehensive evaluation across Kirkpatrick's pyramid levels is crucial. Kirkpatrick's pyramid, assessing training effectiveness through reactions, learning, behavior, and results, provides a structured approach to gauge the impact of such simulators. This study also aligns with the United Nations Sustainable Development Goals(SDGs), contributing to global advancements in healthcare, education, and sustainable development.
Methods: A holistic assessment of AR-based surgical simulators across Kirkpatrick's levels was conducted through multiple studies across four primary modalities. A pilot study(n=11) and a multi-center study(n=15) examined junior trainees' performance in appendectomies and vaginal cuff closures, focusing on completion time and distance traveled metrics(Level 2).
Simultaneously, we evaluated self-confidence scores before and after AR training, revealing a mean improvement of 3.82 (Likert scale, p=0.018), indicating heightened morale and skill transferability (Level 1 and 3). A health economics review demonstrated potential cost savings (Level 4). An independent systematic review of relevant literature involving 26 studies was also conducted.
Results: Significant reductions in completion time and distance traveled (p<0.001, n=6 and p<0.05, n=6, respectively) underscored skill enhancement through AR training (Level 2). This aligns with SDG 3 (Good Health and Well-being), promoting enhanced healthcare delivery through improved surgical skills and reduced procedural times (UN 2023).Improved self-confidence suggests heightened morale and skill transferability (Level 1, 3), resonating with SDG 4 (Quality Education)(UN 2023).
A health economics review highlighted potential per-patient savings of up to £455 through AR-based surgical training, demonstrating organizational benefits (Level 4). These outcomes align with SDG 9(Industry, Innovation, and Infrastructure)(UN 2023), emphasizing skill transfer as a means to achieve broader societal progress.
The novel AR-based surgical simulator yielded positive outcomes across Levels 1 to 4, elevating trainees' morale, satisfaction, confidence, and skill transferability (Level 1,3), while delivering substantial organizational savings(Level 4). These findings have the potential to extend across various specializations.
Conclusion:
AR-based surgical training significantly reduced completion time and distance traveled, indicating improved skill acquisition(Level 2). These results endorse the transformative role of AR in surgical training, aligning with Kirkpatrick's goals and Sustainable Development Goals 34, and 9.
Background:
The successful implementation of a laparoscopic simulation curriculum into surgical training requires substantial investment by training programs to ensure access to laparoscopic simulators and provide protected simulation time for trainees. While prior work has established the feasibility and efficacy of implementing various laparoscopic simulation curricula, there is still a gap in program evaluation of accessible, efficacious curricula collaboratively delivered across diverse contexts by educators and local stakeholders. We describe the implementation of a laparoscopic simulation curriculum into surgical residencies in Santiago (Chile), San Francisco (USA), and Dar es Salaam (Tanzania).
Methods:
The LAPP curriculum, consisting of 11 tasks, was implemented in three different educational centers across three continents. Data were collected on program implementation and trainees’ performance during initial and post-feedback attempts at each task, with a focus on task completion time. Implementation strategies at each site were compared and statistical analysis of trainee performance was conducted using basic descriptive statistics and analysis of variance (ANOVA) to identify inter-site differences in trainee performance.
Results:
LAPP has now been integrated into the general surgery residency at a program in Santiago Chile since 2010, San Francisco since 2022, and Dar es Salaam Tanzania since 2023. In the 2022-2023 academic year, 12, 14, and 17 residents graduated from the curriculum in Santiago, San Francisco, and Dar es Salaam, respectively. The programs in San Francisco and Dar es Salaam provide protected time for residents to complete the LAPP curriculum while residents in Santiago are required to complete the course without being provided protected time. In addition, both San Francisco and Dar es Salaam residents are provided with asynchronous feedback while residents in Santiago rely mostly on in-person feedback. Time to completion of the transfer of objects before and after completion of the LAPP curriculum significantly improved for all sites (all P<0.001), but did not differ significantly between sites (P=0.3).
Conclusion:
We have successfully implemented a laparoscopic simulation curriculum into general surgery programs across diverse contexts in the United States, Chile, and Tanzania. Implementation of this curriculum is an example of the opportunity for collaboration among training programs globally.
Introduction: Receiving feedback from someone in a position of authority can be anxiety provoking for surgery residents. Current feedback approaches in surgery are “one-size-fits-all”, at a time when our residents come from increasingly diverse cultural backgrounds. Our study examined the perspectives of surgical residents on the feedback they receive.
Methods: From February to June of 2023, we conduced 3 voluntary 45-minute multi-institutional focus groups consisting of surgical residents (n = 23), each with 6-9 participants. De-identified focus group discussions were recorded, and emerging themes were identified and analyzed.
Results: While all residents considered feedback a crucial source of learning and growth, they reported feeling anxious before and during formal feedbacks. Surgical interns, undesignated preliminary residents, female residents, international medical graduates, and residents with a non-US cultural background reported more anxiety about critical feedback, that they feel has affected their confidence, motivation, and performance. Residents with a different cultural background feel that more than half of the time the feedback provider interprets a given situation not from raw observations but from a perspective based on only their own values and culture without taking into considerations the residents’ culture.
Participants suggested the following interventions for improving feedback:
- Educate residents on how to manage stress and anxiety related to feedback
- Educate residents on how to receive negative feedback
- Educate faculty on how to provide negative feedback
- Educate both residents and faculty on the cultural dimensions of the feedback
- Feedback simulation involving both residents and faculty
- Provide residents with the option of choosing the faculty giving the formal feedback
- Involve peers in the feedback process
- Involve mentors of residents for important critical feedback
- Provide faculty with cultural mentors who can provide insights into cultural norms and feedback preferences
- Avoid feedback overload
- Provide observable feedback
- Follow-up shortly after feedback to ensure it was properly received
Conclusions: Despite feedback improvements, surgery residents continue to experience feedback anxiety, and cultural sensitivity of the current feedback approaches is lacking. Educational interventions are necessary to reduce resident feedback anxiety and train feedback providers to increase their cultural awareness.
Background:
Workplace incivilities are low-intensity behaviors that violate norms of respect. They degrade culture, diminish learning, and impair performance. Incivilities have been studied with surgical residents and attendings, but not with medical students. Understanding if and how students experience incivilities on the surgery clerkship can guide educators on how to address them.
Methods:
From Oct 2022-2023, medical students at a single institution received surveys near the end of their 12-week surgery clerkship, which could be completed at one of three sites. Items included demographics and a modified Workplace Incivility Survey that asked how frequently (1=never to 5=multiple times per week) 12 incivilities were experienced during the clerkship. Students were also asked how their perceptions of and interest in surgery changed by the end of the clerkship. An overall index of incivilities was calculated for each student by averaging the frequency of all 12 behaviors. Descriptive and bivariate statistics were performed. Content analysis of free text responses is pending.
Results:
The response rate was 83% (118/144) with 49% self-identifying as female and 58% as non-White. Of respondents, 97% experienced incivilities during the clerkship. The most frequently experienced were “receiving little attention for their opinions” (3.07±1.34, mean ± sd), “being interrupted” (2.36±1.38), and “being ignored” (2.27±1.37). The index of incivilities did not vary significantly based on gender or race. Students whose interest in a surgical career decreased by the end the clerkship had a significantly higher index than those whose interest increased or remained stable (2.13±0.86 vs. 1.70±0.58, respectively, p<0.005). Students whose perception of surgical culture worsened by the end of the clerkship had a significantly higher index compared to those whose perceptions improved or remained stable (2.12±0.71 vs. 1.68±0.59, respectively, p<0.05). Of those who had completed other clerkships, 68% reported that incivilities were more common on surgery.
Conclusions:
Medical students reported incivilities as nearly ubiquitous during the surgery clerkship. Experiencing these behaviors more frequently was associated with decreased interest in surgery and worse perceptions of surgical culture. Surgical educators should track and intervene on these behaviors during the clerkship. Other specialties should study these phenomena as well.
Background
As the Accreditation Council for Graduate Medical Education (ACGME) began to emphasize competency-based assessments to obtain information on resident progress, the American Board of Surgery (ABS) announced that in July 2023, incoming general surgery residents would be evaluated with Entrustable Professional Activities (EPAs) as their own competency-based assessment. With the shift towards competency-based assessments as a premier factor in resident advancement, this study aims to evaluate the nature of feedback provided to residents based on self-identified gender.
Methods
A single institution general surgery residency program initiated a workplace-based assessment program from August 2022 to June 2023. Residents were assigned individual, private assessment portals and encouraged to request written feedback from attendings following cases or interactions. These assessments were compiled and de-identified. Two independent reviewers (CFY and OEO) categorized the narrative feedback to determine if the feedback was personality or clinically based, actionable, and theme (positive, negative or mixed). The themes were further divided in to 6 categories (preparedness, efficiency, independence, teaching/direction to assistants, technical skills and professionalism). The feedback was then compared between those who identified as female versus male.
Results
There were 376 total assessments, 55% (205/376) were completed by female residents and 36% (171/376) male residents. Female residents received significantly more mixed (88/205, 43%) and negative feedback (51/205, 25%) versus positive (66/205, 32%), p=0.018. The feedback to females had similar themes to male residents with a trend towards females receiving less feedback regarding teaching skills (5.5% vs 10.5%, p=0.067).
Conclusions
Female residents were less likely than their male colleagues to receive positive feedback. This highlights the role implicit bias may play in the competency-based assessment era. As residency advancement comes to rely on these assessments, more bias may come to light with concerns for preferential advancement based on gender and other disparities. Additionally, this belies the importance of checking one’s implicit biases when providing these assessments.