ASE 2024 Abstracts

Quick Shot I - Assessment

COMPARISON OF THORACIC SURGERY MILESTONE RATINGS VERSION 1.0 AND VERSION 2.0 AMONG CARDIOTHORACIC SURGERY TRAINING PATHWAYS
Chase C Marso, MD¹, Kenji Yamazaki, PhD², Sean Hogan, PhD², Alex Lekdee, MS, MBA², Jonah Thomas, MD¹, Christopher Morse, MD¹, Roy Phitayakorn, MD, MHPE¹, Dandan Chen, PhD¹; ¹Massachusetts General Hospital, ²Accreditation Council for Graduate Medical Education

Background: Cardiothoracic surgery implemented Milestones Version 1.0 in 2014 which were revised to Milestones Version 2.0 in 2021. Even though cardiothoracic surgery has multiple training pathways with variable training lengths and clinical requirements, the cardiothoracic-specific milestones are equivalent. Despite the importance of Milestones in trainees’ development and readiness for independent practice, no study has compared cardiothoracic Milestone ratings between versions and across training pathways.

Methods: Milestone ratings were obtained for cardiothoracic trainees in two-year independent residency (Y2), three-year independent residency (Y3), and six-year integrated (I6) programs from 2014-2025. Trainees were included from programs that reported ratings for both versions 1.0 and 2.0. Descriptive statistics were calculated by reporting period for each training pathway. Average milestone ratings at each reporting period and the percentage of trainees failing to achieve graduation targets (Level 4) by final reporting period were compared between versions and among training pathways using Chi-square analysis.

Results: From 2014-2018, a total of 979 residents were assessed using Milestones Version 1.0 (n=409, Y2; n=232, Y3; n=338, I6). From 2021-2025, a total of 959 assessments were completed using Milestones Version 2.0 (n=365, Y2; n=217, Y3; n=377, I6). Within each training pathway, all competency domains’ (patient care, medical knowledge, etc.) mean ratings were similar for trainees between Milestone versions. The total proportion of residents failing to achieve Level 4 milestone subcompetency ratings ranged from 11.6% to 25.2% and 8.0% to 19.2% for Version 1.0 and Version 2.0, respectively. Among training pathways, I6 programs had the lowest rate of non-achievement except for the patient care 8, patient care 9, and professionalism subcompetencies (Figure).

Conclusions: Thoracic surgery milestone ratings were similar across the transition from Version 1.0 to Version 2.0, except for select Y2 subcompetencies. A high proportion of trainees were rated as not achieving graduation targets in all subcompetencies in Version 1.0 and Version 2.0, though I6 programs had lower level 4 non-achievement than Y2 and Y3 programs. These results suggest further analysis of the CT training curricula, training length, or assessment methods may be needed to improve competency metrics by graduation.

BECOMING A TWO-HANDED SURGEON: COMPARING NON-DOMINANT HAND STRENGTH AND DEXTERITY ACROSS TRAINING LEVELS
Allan Chen, BS¹, Steven Thornton, MD², Alexandria L Soto, BS¹, Kent K Yamamoto, BS³, Cameron Reid, BS³, Kerry Gao, BA¹, Shannon Barter, MD², Katharine L Jackson, MBBS²; ¹Duke University School of Medicine, ²Duke University School of Medicine Department of Surgery, ³Duke University Thomas Lord Department of Mechanical Engineering and Materials Science

Background

Bimanual skill in the operating room is essential to the maturation of surgical trainees, but the balanced hand strength and dexterity required to achieve it lacks formal instruction. Normative data on surgeon grip strength and dexterity is limited. Establishing a baseline distribution allows educators to identify areas for improvement and assess longitudinal progress.  Understanding this baseline is the first step towards exploring how training and targeted interventions can enhance surgical performance.

Methods

A cross-sectional study was conducted among medical students (MS), surgical residents, and faculty.  Hand strength was evaluated using a hydraulic dynamometer and pinch gauge across 4 tasks (hand grip, tip pinch, key-pinch, and palmar pinch). Manual dexterity was evaluated using the Purdue Pegboard across 4 tasks (dominant, non-dominant (ND), both-hand, and assembly). Within-subject asymmetry differences were analyzed using paired t-tests, and between-group comparisons across training levels using one-way ANOVA with post-hoc Tukey  testing (α=0.05).

Results

101 participants (45 MS, 39 residents, 17 faculty) were included. For hand strength, dominant hands were stronger than ND across 3 out of 4 measures in MS and residents, and 1 out of 4 in faculty (MS: hand grip p<0.001, tip pinch p=0.007, palmar pinch p=0.004; resident: hand grip p<0.001, key-pinch p = 0.043, palmar pinch = 0.003; faculty key-pinch grip p <0.001). Absolute strength did not differ between roles for any test. Asymmetry of palmar pinch differed by training level (p=0.04), with faculty showing less dominant–ND difference. 

For dexterity,  dominant hands scored higher than ND in MS and residents (p=0.02 and p=0.001 respectively), while dominant and ND performance in faculty were similar. The difference between dominant and ND hand dexterity did not vary by training level (p=0.83). However, both-hand performance differed across groups (p=0.02), with MS outperforming residents and faculty.

Conclusions

Faculty showed greater hand symmetry in palmar pinch grip and manual dexterity. These findings establish quantitative baselines for strength and dexterity and will be used to guide our upcoming two-handed curriculum where grip, pinch, and pegboard performance will be integrated with hand endurance measures alongside a novel motion-tracking assessment of vessel clip application to evaluate how targeted training can improve bimanual skill.

A SURGICAL PALLIATIVE CARE CURRICULUM FOR GENERAL SURGERY RESIDENTS—LONG TERM FOLLOWUP
Steven T Char, MD, Taylor Kline, MD, Aurora Sullivan, MD, Noelle M Javier, MD, Celia Divino, MD; Icahn School of Medicine at Mount Sinai

INTRODUCTION:  Primary palliative care (PC) is a key facet of high quality, comprehensive surgical care, but formal PC training is not yet a required component of graduate medical education. In 2023, we instituted a yearlong PC curriculum at our institution that demonstrably increased resident confidence and competence with PC topics. The durability of these improvements, however, and the benefits of repeated exposure to the curriculum remains unknown. To assess the benefits of ongoing PC education, we re-introduced the PC curriculum this year to a new cohort of residents.

METHODS: We conducted a needs assessment to characterize baseline attitudes towards PC and knowledge of key PC topics. Attitudes were measured on a 5-point Likert scale and knowledge was assessed with a 10-question quiz. Based on the results of the needs assessment, we designed six educational modules. Modules consisted of brief didactic on a PC topic led by a surgical resident in conjunction with a PC faculty member, followed by a simulated patient encounter or practice activity. To date, two of six modules have been taught.

RESULTS: Of the 45 participants who completed the needs assessment, 16/45 (35.5%) participated in the original PC curriculum. 82.2% of participants agreed or strongly agreed that a PC curriculum is relevant to surgical residents, and 77.8% agreed or strongly agreed that they frequently provide PC as surgical residents. Participants who completed the original PC curriculum more frequently participated in PC family meetings (81.3% vs 48.3%, p=0.03) and reported higher baseline confidence with topics such as code status discussions (3.56 vs 2.86, p=0.04), goals of care meetings (3.75 vs 3.14, p=0.05), and breaking bad news (4.00 vs 3.36, p=0.01). There was no difference in performance on the knowledge assessment (77.8% vs 76.3%, p=0.59).

CONCLUSION: Compared to those without prior experience, residents who completed the original PC curriculum more frequently participated in PC meetings and reported greater confidence with several PC topics but performed no differently on the knowledge assessment, suggesting a need for continued PC education. Further work is needed to elucidate whether participation in a PC curriculum will benefit those with and without prior PC education equally.

HOW I DO IT: STARTING A VIDEO REVIEW CONFERENCE
Bailey Humphreys, MD, Gregory K Low, MD, Jonathan DeLong, MD, Andrew Russ, MD; University of Tennessee Graduate School of Medicine

Objective: To describe the development, structure, challenges, and implementation of a surgical video review conference designed to enhance technical education and team-based learning in a general surgery residency. 

Design: Descriptive study detailing the development and implementation of a surgical video review conference, with preliminary evaluation of participant perceptions using a post-session survey.  

Setting: A mid-size ACGME-accredited general surgery residency. 

Participants: Medical students, general surgery residents, and faculty. 

Results: The conference was successfully integrated into the residency schedule as a recurring, biweekly educational session. A 19-question post-conference survey was administered to participants. Ninety percent of respondents rated the conference as extremely or very valuable for their learning and professional development as surgeons. Eighty percent reported significant or some improvement in technical skills and operative decision-making. All respondents agreed that the learning environment was constructive and nonjudgmental, and one hundred percent felt the conference enhanced the faculty–resident coaching culture.  

Conclusions: A structured surgical video review conference can be feasibly implemented within a general surgery residency curriculum. We present a reproducible framework and practical steps for developing a similar initiative, along with the challenges encountered and solutions identified during implementation. Because participation was voluntary, selection bias and other limitations inherent to survey-based studies are present. However, participant feedback demonstrates that video-based review and coaching are highly valued and have strong potential to improve technical performance, operative judgment, and coaching culture within surgical training programs. Sharing this framework may assist other residencies seeking to integrate video-based education into their curricula and foster a culture of continuous improvement and team-based learning. Future studies assessing objective performance metrics and long-term educational outcomes are warranted. 

ENTRUSTMENT DECISIONS BY SURGICAL MODALITY AND POST-GRADUATE YEAR: COMPARING ROBOTIC, LAPAROSCOPIC, AND OPEN APPROACHES
Alisha C Heximer, MD¹, Jessica Santhakumar, MTM¹, Yaacov Davidow, DO¹, Olle ten Cate, PhD², Patricia O'Sullivan, PhD¹, Lan Vu, MD, MAS, FACS, FAAP¹; ¹UCSF, ²University Medical Center Utrecht

Introduction
Entrustment-supervision (ES) ratings for Entrustable Professional Activities (EPAs) are an emerging metric for assessing trainee progression in intraoperative performance and faculty entrustment decisions. As robotic-assisted surgery (RAS) becomes increasingly integrated into general surgery training, questions arise about how trainee progression differs across RAS and other surgical modalities. This study examines EPA-based ES-ratings for the intra-operative gallbladder disease EPAs (cholecystectomy) by surgical modality and post-graduate year (PGY) as a marker of trainee progression.

Methods
ES-ratings for intraoperative management of gallbladder disease were collected from a single academic general surgery program (2024–2025). Each case was categorized through narrative comment and chart review as open, laparoscopic, or robotic; intraoperative conversions from minimally invasive to open were excluded. Entrustment level (1–4: limited participation, direct supervision, indirect supervision, practice ready) was analyzed descriptively by PGY level and surgical modality. Mean entrustment ratings were compared across modalities.

Results
Two-hundred-twenty-one cholecystectomy ES-ratings were analyzed: 176 laparoscopic, 26 open, and 19 robotic. Among PGY3–5 residents, mean ES-ratings were higher for laparoscopic than for robotic cases, while PGY1–2 ratings were similar in laparoscopic and robotic ratings. Mean ES-ratings increased with PGY level in both laparoscopic and robotic cases, demonstrating parallel upward trends. Mean open case ratings were higher than mean robotic in all except PGY2 level, higher than laparoscopic in PGY1-3, and similar to laparoscopic in PGY4-5. Robotic entrustment averaged approximately 0.4 points lower than laparoscopic for cholecystectomy when all PGY levels were combined. Low variance in sub-samples resulted in no visible ‘box’ for some modality and PGY combinations.

Discussion
Despite similar trends in entrustment progression by PGY, differences between modalities suggest there are barriers to achieving higher entrustment in robotic procedures. These findings support the utility of EPAs for examining entrustment across surgical modalities and highlight the potential benefit of including modality within national EPA data collection. Modality could serve as a limitation for EPA entrustment. One could be practice ready for open and laparoscopic cholecystectomy, while not for the robotic modality. Future work may explore how case complexity and faculty experience, exposure, and training environment affect entrustment patterns across modalities.

SELF-ASSESSMENT TRENDS AMONG GENERAL SURGERY TRAINEES: INSIGHTS FROM EPA MICRO-ASSESSMENTS
Michel S Kabbash, MD¹, John L Falcone, MD, MS², Christiana M Shaw, MD, MS¹, George A Sarosi, MD¹, Jennifer H Fieber, MD¹; ¹University of Florida, ²Owensboro Health

Introduction

Self-assessment is critical in surgical training and remains a cornerstone of professional development. Our study examined the effects of general surgery residents’ training level on the quality of their self-assessment. We hypothesized that as residents progress in their training, they provide higher quality self-assessments. 

Methods

We utilized Entrustable Professional Activities (EPA) micro-assessments for gallbladder disease, appendicitis and inguinal hernia, to analyze self-evaluations of general surgery residents for the 2023-2025 academic years at an academic institution. Residents’ demographics and narrative self-assessments were extracted from the Surgery EPA application. Two independent raters evaluated the narrative self-assessments for quality using the QuAL (Quality of Assessment for Learning) rubric, to score them on a zero-to-five-point scale based on evidence, suggestion and connection. Narratives with discordant scores were evaluated by a third rater. Inter-rater reliability was assessed. Data were analyzed using descriptive statistics, correlation testing, and linear regression. We used alpha=0.05 to determine statistical significance. This study was declared exempt by the Institutional Review Board.

Results

853 self-assessments from 52 residents were analyzed for quality. 11 evaluations had discordant scores and were ranked by a third rater. Inter-rater reliability was 0.85, indicating strong consistency. Mean QuAL score was 2.48 (IQR 2,3). The average word count was 31. Resident self-entrustment by postgraduate year (PGY) is outlined in the figure. Resident’s PGY (ρ= -0.4, p=0.003) and self-entrustment ratings (ρ= -0.32, p<0.001) negatively correlated with their QuAL score. Using regression analysis, we found that self-entrustment ratings were negative predictors of QuAL score (p<0.001), while narrative feedback word count (p<0.001) and number of self-evaluations submitted (p<0.001) were positively associated with feedback quality. PGY had no effect on QuAL score (p>0.05). 

Conclusion

Our study suggests that the quality of EPA self-assessments was associated with the number of self-evaluations submitted and longer word count feedback. These findings support the need to improve residents’ self-assessment by submitting more evaluations and dictating longer feedback, so that it can function not only as a measure of perceived performance, but also as a reliable driver of self-directed learning. 

RESIDENT PERSPECTIVES ON INCORPORATING PATIENT-DERIVED FEEDBACK INTO SURGICAL RESIDENT ASSESSMENT
Tiffany R Bellomo, MD¹, Chase Marso, MD¹, Camila M Muriel, BS¹, Erick H Castaneda, BS¹, Robin Hu¹, Dandan Chen¹, Roy Phitayakorn¹, Maura Sullivan², Sophia K McKinley¹; ¹Massachusetts General Hospital, ²Keck School of Medicine

Background: While attending feedback in the operating room is highly valued, attendings rarely observe resident clinical care in other settings such as perioperative areas, wards, and the emergency department. Patients can provide unique feedback that differs from attending assessments, yet no systematic mechanism exists in surgical training to collect and deliver patient feedback to residents. This qualitative study explored resident perspectives on the acceptability and value of patient feedback.

Methods: Surgery residents at an urban, tertiary medical center were purposively recruited to reflect a diverse cohort of age, gender, and race. All semi-structured interviews regarding patient feedback were transcribed verbatim and de-identified. Transcripts were inductively analyzed using a process of conventional content analysis by a multidisciplinary research team to identify prominent themes. These themes were arranged into a framework that reflected the resident perspective on the incorporation of patient feedback into their education.

Results: All 21 residents who were invited to participate completed the interview process. Residents were on average 30 years old (SD = 2.47 years) and 48% self-identified as women. Participants represented multiple diverse racial and ethnic backgrounds, including 3 Hispanic, 6 White, 3 Black, and 12 Asian residents. We identified five major themes related to resident incorporation of patient feedback into their education: (1) Resident and surgical educator perception of what constitutes acceptable patient feedback, (2) existence of multiple threats to reliability of patient feedback, (3) patient feedback impacts resident teaching and learning dynamics, (4) patient and environmental factors can make feedback interpretation difficult, and (5) feedback collection practices may shape the content of the feedback itself (Figure 1). Residents reported heterogenous attitudes towards the actionability of patient derived feedback, the utility of a single patient evaluation, and the role of the resident as a learner versus caregiver.  

Conclusions: We developed a conceptual framework for how residents anticipate incorporating systematic patient feedback into their learning. These results can inform future processes for collection and distribution of patient feedback to surgical residents. Further studies will seek to understand perspectives from other stakeholders, including attending surgeons and patients themselves. Future work may also characterize how patient feedback influences resident progression toward independent practice.

GENERAL SURGERY RESIDENT AND FACULTY PERCEPTIONS OF AUTONOMY
Cory Fox, Danyi Wang, Tiffany K Brocke, Joel Vetter, Michael M Awad, Kerri A Ohman; Washington University - St. Louis, MO

Background: Residents and faculty often interpret intraoperative autonomy differently, with residents consistently underestimating their autonomy compared to faculty. The factors shaping these perceptions are not well defined. As resident operative autonomy has declined, this misalignment may hinder surgical training, underscoring the need for a shared understanding and clear signals of autonomy to better align expectations and evaluations.

Methods: A survey was distributed through the Association for Surgical Education to general surgery residents and attending surgeons to assess the perceived importance of nine autonomy signals on Likert scales, along with open-ended questions. Descriptive statistics, Welch’s t-tests, effect sizes (Hedges’ g), and exploratory factor analysis were performed.

Results: A total of 118 respondents (36 residents, 82 attendings) completed the survey. Internal consistency was good among residents (α=0.80) and acceptable among attendings (α=0.66). Residents and attendings differed significantly on three autonomy signals. Residents rated “fraction of the operation performed” (4.0 vs 3.5, p=0.012, g=0.53) and “being allowed to struggle” (4.4 vs 3.6, p<0.0001, g=0.84) as more important, while attendings rated “operative preparation” (3.6 vs 3.0, p=0.0008, g=–0.58) as more important. No differences were observed across training stage or years in practice. Factor analysis revealed two latent dimensions in both groups, with both clustering technical execution (fraction, portions, dissection), but residents linking autonomy to correction and attending presence, and attendings clustering pre-operative decision-making and preparation.

Conclusions: Residents and attendings differ in how they define operative autonomy. Residents prioritize independent struggle and technical performance, while attendings value preparation and pre-operative decision-making. Developing a shared framework for autonomy could better align expectations, enhance resident training, and improve faculty satisfaction.

Table: General surgery residents and attendings rated the importance of autonomy signals on a 1-5 Likert scale.