guide to the r1 year

GUIDETOTHER1YEAR
ZACHARYJ.KASTENBERG&DAVIDJ.WORHUNSKY
STANFORDGENERALSURGERY
2016-2017ADMINCHIEFS
WelcometoStanfordSurgery
Ø 
HistoryofandPresentDayStanfordSurgery
Ø 
Expecta:ons
Ø 
InternWardDu:es/Pa:entCare
Ø 
NightService
Ø 
DutyHours
Ø 
Schedule
Ø 
ConferenceSchedule
Ø 
Chiefs’JournalClub
Ø 
Chiefs’RoundsandSocialEvents
Ø 
BalanceinLife
HistoryofStanfordSurgery
EmileF.Holman,M.D.
Chair1926–1955
Halsted’slastresident
Broughtsurgerywest
NormanE.Shumway,M.D.
Cardiac1958–1993
Fatherofhearttransplanta:on
“Bestfirstassist”
ThomasM.Krummel,M.D.
Chair1999–2015
ECMO,Innova:on,Biodesign
6Divisions,>60faculty
DepartmentofSurgery–PresentDay
— 
6Divisions
◦  ClinicalAnatomy,GeneralSurgery,PediatricGeneralSurgery,
Plas:c&Reconstruc:veSurgery,AbdominalTransplanta:on,
VascularSurgery
MaryHawn,MD
ChairofSurgery
— 
Morethan60faculty;130adjunct/affiliatedclinical
faculty
— 
Con:nuedgrowth/upwardtrajectory
◦  NewAdult(2018)andChildren’shospitals(Summer2017)
◦  DevelopmentofSurgeryHSRProgram
MarcMelcher,MD/PhD
ProgramDirector
◦  Ac:velyrecrui:ngnewfacultyacrossalldivisions
DivisionofGeneralSurgery
— 
AcuteCareSurgery/Trauma:Drs.Badger*,Browder,Gregg,Maggio,MarksSpain,Staudenmayer,
Weiser
— 
Breast:Drs.Dirbas,Jeffrey,Wapnir,&Wheeler
— 
ColorectalRed:Drs.Shelton&Welton
— 
ColorectalWhite:Drs.Kin&Kirilcuk
— 
Hepatopancreatobiliary(HPB):Drs.Dua&Visser
— 
MinimallyInvasiveSurgery(MIS):Drs.Azagury,Lau,Morton,&Rivas
— 
SurgicalOncology1:Dr.Norton
— 
SurgicalOncology2:Dr.Poultsides
— 
SurgicalOncology3/Endocrine:Drs.Cisco&Lin
OtherSurgicalDivisions
— 
PediatricGeneralSurgery:Drs.Bruzoni,Chao,Fuchs,Hartman,Krummel,Lund,Mueller,Powell,
Sylvester,Wall
— 
Plas]c&Reconstruc]veSurgery:Drs.Chang,Cur:n,Fox,Gaudilliere,Girod,Gurtner,Helms,
Hentz,Kahn,Khosla,Lee,Longaker,Lorenz,Nazerali,Nguyen,Sen,Wan
— 
AbdominalTransplanta]on:Drs.Bonham,Busque,Concepcion,Esquivel,&Gallo
— 
VascularSurgery:Aalami,Chandra,Dalman,Harris,Lee,Lee,Mell,&Zhou
— 
ClinicalAnatomy
StanfordSurgery
— 
GroundedintheHalstediantradi:onofclinicalexcellenceandeduca:on
(embodiedbyShumway)
— 
Dedicatedtothefuture(sitsinaveryforward-lookingSiliconValley)
◦  Opportuni:esareplen:ful(clinical,academic,industry...)
— 
Internclassof2016-2017ispartofthisfuture
MarkandKrummel,ArchSurg2004
Expecta:ons
Ø 
Pa:entcareisalwaysfirst
§  Honorandprivilegetocareforourpa:ents
§  Pa:entswillbeincrediblythankful(somejusthaveuniquewaysofshowingit)
§  Howwouldyouwantyourfamilymembertreated?
Ø 
Honestyisrequired(withyourcolleagues,pa:ents,andyourselves)
Ø 
Bedependable
§  Comeearlyandcomeprepared(“Fortunefavorsthepreparedmind.”–LouisPasteur)
Ø 
Beprofessional
§  Treatotherswithrespect,supportyourcolleagues,”dressforsuccess”,completeyourworkhours/
caselogs/evalua:ons/etc.in:melymanner
Pa:entCare
— 
Whatyoudomaoers...
The
n e w e ng l a n d j o u r na l
of
m e dic i n e
special article
Variation in Hospital Mortality Associated
with Inpatient Surgery
The
n e w e ng l a n d j o u r na
l o f A.
m eGhaferi,
dic i n e
Amir
M.D., John D. Birkmeyer, M.D.,
and Justin B. Dimick, M.D., M.P.H.
tal mortality with surgery. Although rates of death
for patients who underwent inpatient surgery varLow
Medium
High
Very high
Very low
ied by a factor of nearly two
(3.5%
6.9%)
A bs
t rtoac
t across
35
hospitals, these differences could not be explained
by differences in postoperative complications. Spe30
27.6
26.9 26.9
cifically, high- and low-mortality hospitals had
Background
25 24.6
23.5
nearly identical rates of postoperative complica21.4
From the Michigan Surgical Collaborative Hospital mortality
that is associated
with among
inpatient
surgery varies widely. Reducing
tions. Conversely,
rates of death
patients
19.3
20
18.4 and18.0
18.2
for Outcomes Research
Evaluation,
17.5 of postoperative
rates
the markedly
current between
focus of payers and regulators, may
with majorcomplications,
complications varied
the Department of16.2
Surgery,
14.9 University of 14.7
hospitals
with high
overall mortality
and effective
those
15
be one approach
to reducing
mortality.
However,
management of compliMichigan, Ann Arbor. Address reprint re12.5
with
low
overall
mortality.
quests to Dr. Ghaferi at Michigan Surgi- cations once they have occurred may be equally important.
10
Although it is clinically intuitive that highcal Collaborative for Outcomes Research
mortality
hospitals would have more complicaand
Evaluation,
211
N.
Fourth
Ave.,
Suite
5
Methods
201, Ann Arbor, MI 48104, or at aghaferi@
tions, our study adds to a growing body of eviumich.edu.
We studied 84,730
who had undergone
inpatient
0
dencepatients
that complications
and mortality
are not general and vascular surgery
'')(*' )
%),)(*' )
$"
,%),
6-8
correlated
the hospital
level.the In
many ofCollege of Surgeons National
from
2005 through
2007,at using
data from
American
)(*'
)
N Engl J Med 2009;361:1368-75.
these
studies, relationships
between
complications
Surgical
Quality
Improvement
Program.
We
first
ranked hospitals according to their
Copyright © 2009 Massachusetts Medical Society.
(youhaveminimalexperienceànotreadytotrusttelephone/
Figure 1. Rates of All Complications, Major Complications, and Death
and
overall
mortality
disappear
with
risk
risk-adjusted
overall rate of death and divided themadjustinto five groups. For hospitals in
1st
RETAKE of Mortality.
Ghaferi to Hospital Quintile
AUTHOR:
after Major Complications,
According
ment, suggesting that postoperative
complications
ICM
RN/EMevalua:on)
2nd
mortality
quintile, we then assessed the incidence of overall and major
1 of 1 and major complicationseach
Although ratesREG
of Fall FIGURE:
complications
did notoverall
vary
are related more to patient factors than to quality
3rd
significantly across
hospital
mortality
quintiles,
the
rate
of
death
in
patients
CASE
Revised complications and the
of death
among patients
with
of care.9,10rate
Prompted
by difficulties
in the use
of major complications.
4-C in hospitals
with major complications
was almost Line
twice as high
EMail
with very
ARTIST: ts
mortality or complications as a marker of hospihigh overall mortality
as in those with H/T
very low H/T
overall mortality
22p3 (21.4% vs.
Enon
Combo
tal quality, Silber and colleagues popularized the
Results
12.5%, P<0.001).
use of the term “failure to rescue”— defined as
#-,$,!,.!
/*$,
Rates of death varied widely across hospital quintiles, from 3.5% in very-low-mortalafter a complication — as a measure of hos' $ & ,"-''/
ity hospitals todeath
6.9%
in very-high-mortality hospitals. Hospitals with either very high
than in the very-low-mortality hospitals for each pital quality.2,9,10 Although these studies firmly
)*
'),
'
/+-
'
Ø  Differenceinhospitalqualitybasedon“rescue”from
complica:ons(“Failuretorescue”)
Ø  Youareoureyesandears,ourfirstresponders
Ø  Answerisalwaystoevaluatethepa:ent
InternWardDu:es
— 
Sign-in,pre-rounding(numbers)
— 
LeadAMrounds
— 
Orders
— 
Dischargepa:ents
— 
Callconsultants
— 
Documenta:on
— 
Answerpages
— 
MakeindependentroundsandLeadPMrounds
— 
Maintainthelist/census
— 
Sign-out
Sign-inandPre-rounding
— 
Arriveearlyenough
Ø  Getthoroughsign-outfromnightintern
Ø  Preparecensus
Ø  Getnumbers(vitals,I/O,labs,imaging)
Ø  Photocopylistforremainderofteam
— 
Medicalstudentsexpectedtohelp
LeadAMRounds
— 
Haveaplanforleadingroundsefficiently
— 
No:fyChiefofanyurgentissuesfromthestart
— 
Pa:entpresenta:on
◦  Concise,accurate,clear
◦  Offassessmentandplan(thisishowyourlearn)
WriteOrders
— 
1stpriorityistoins:tuteplanfromAMrounds
◦  Orders
–  RunthelistwithChargeRNorbedsideRN
–  TPNàDiscusswithpharmacy
–  ImagingàDiscusswithradiologisttoensurescanperformedtoourlikening
–  PICCàDiscusswithPICCRNtoensureitgetsdone
◦  MDR(~10amwithChargeRN,CM,SW,Die:cian,etc.)
Discharges
— 
Goal:before11am
— 
Canset-updaybeforewith“Condi:onalDischarge”
◦  Earn$5gitcardsbygeungdischargesdonein:melyfashion
— 
DischargeOrders
◦  Knowwhichhomemedstoresume,whichtohold,whatrequiresnewRx
–  Confirmdischargepharmacywithpa:ent
–  Rx(triplicate)mustbeaccurate(avoidsunnecessaryphonecalls,longdrivebacktohospitalforpa:ent/family)
◦  Knowac:vity,dietary,bathingrestric:ons;woundcare;follow-upplan
–  AskyourChiefifunsure
DischargeSummaries
— 
DischargeSummaries
◦  Notasummaryofeveryeventduringtheirhospitalstay
◦  Canserveasprogressnoteforthedayifitincludesaphysicalexam
◦  Summaryofeventsyouwouldcareaboutwhenevalua:ngthatpa:entatfollow-up
–  Surgery,Complica:ons,Recovery(final“CYA”line),Finalpath,Follow-up,Physicalexam
–  Buildatemplate
Consulta:ons
— 
Callearly
◦  Berespecvul,butokaytobefirm
◦  Knowthepa:entandspecificques:onbeforecalling
Documenta:on
— 
Everypa:entrequiresanotefromaphysician(orAPP)everyday
◦  MustincludePEandA/Pforbillingpurposes
◦  MedicalstudentnotesDONOTcount;nordoesacosignedstudentnote
◦  StudentsCANNOTwriteunderyouraccount(illegalasthisisMedicarefraud)
— 
Usetemplatesfromformerinterns(can”steal”inEpic)
— 
Mustbedoneina:melyfashion
— 
Copy-forwardfunc:onisdangerous;besttoavoid
— 
UpdatetheProblemlist
Documenta:on
— 
Bespecific
◦  Billing/Codingfolkswillmessage/call/page(frustra:ngbutthefutureofmedicine)
◦  e.g.,”CKD”à“CKD,Stage4”
— 
DocumentQualityMetrics
◦  Urinarycatheter(ifyes,thenreason)
◦  Centralline(ifyes,thenreason)
◦  An:bio:cs(indica:on,length,enddate)
◦  VTEprophylaxis(orwhynot)
AnsweringPages
— 
Youareoureyesandearswhileweoperate
— 
Thisisateameffort
◦  Playwellwithothers;Donotthrowsandinthesandbox;AllIReallyNeedtoKnowI
LearnedinKindergarten
◦  Berespecvul,beprompt;“killthemwithkindness”
–  Notknowingtheanswerisnotanacceptablereasontoignorethepage
–  Answeringthepagewith“letmerunitbythechief”beoerthanignoring...
◦  Yourepresentyourteam,youraoending,yourprogram,andStanfordHospital
Follow-upDailyTasksandLeadPMRounds
— 
Useasystemthatworksforyour(checkboxes,etc.)
— 
Ensurethatlabs,imaging,studies,etc.arecompletedin:melyfashion
— 
KeepyourChiefupdatedwiththeresults
◦  Textmessageand/orcometoOR
— 
MakeindependentroundsifChiefinORlateintoevening(andupdateChief),or
— 
PrepareforPMroundseachaternoon
MaintaintheCensus
— 
Keepthelistupdated
— 
Summarylineimportantforcoveringintern/team
SignOut
— 
ACGMERequirements:
◦  Minimizetransi:onsofcare
◦  Monitoredsignout(byserviceChiefs/Fellows)
◦  Documentedprocesstoensureeffec:venessoftransi:ons
— 
IPASSSystem
SignOut-IPASS
— 
I–Illnessseverity
◦  Stable,“Watcher”,Unstable
— 
P–Pa]entsummary
◦  “44Mw/HTN,CADs/pCABG,HLDnowPOD0fromhisdistalgastrectomy.Hehasanepiduralfor
pain(managedbypain)andshouldbestrictNPOwithhisNGTtolcws;donotmanipulatehisNGT.”
— 
A–Ac]onlist
◦  “POCaround8pm,follow-uphislabs,textchiefwhenthey’reback”
— 
S–Situa]onawarenessandcon]ngencyplanning
◦  “Ifpaincontrolinadequate,callpainservice.Ifbloodpressurelow,textchief.”
— 
S–Synthesisbyreceiver
◦  Askques:ons,reiterateplan
Postopera:veChecks
— 
Requirementforeverypostopera:vepa:ent(within4-8hours)
— 
Mustdocument(ifnonoteinchart,didnothappen)
Pa:entCare-Summary
— 
Callforhelp:callearly(trustyourgut;erroronsideofpa:entsafety)
— 
Neverhesitatetocallyourchief
◦  KeepingyourchiefinthedarkisNEVERacceptable
◦  Textmessagesarefree(butifnoresponse,assumenotreceived)
◦  TextàCallàPage
— 
DonotcallyourchiefintheOR;cometotheOR(unlesspa:enttoounstabletoleave
thebedside)
◦  Iftoounstable,chiefoccupiedàcallorpageSICUchief/felloworcallRRT/CodeBlue
◦  RRTgetsyouCrisisRNandRRT;CodeBluegetsyoutheCodeTeam
— 
Documentevents/yourdecision-making(briefSOAPnotesuffices)
NightService
— 
Stanfordrosteratnight:R4,R2-Consult,R2-SICU,R1x2
— 
SafetyNet(inaddi:ontoChiefathome)
◦  UsetheR4atnight(R4/R5onSat)
–  R4isthefirststopatnight
◦  SeemsminorandR4inORàConsultR2orSICUR2
NightService
InternResponsibili]esatNight
TraumaIntern
Onc/CRS/...Intern
— 
CoversACS(trauma),thoracic,transplant
— 
CoversBreast;Colorectal;HPB;MIS;SurgOnc
1,2,&3
— 
Runsallminortraumas(97),helpswithmajor
traumas(99)
— 
Helpswithminor(97)andmajor(99)traumas
— 
Obtainface-to-facesignouteachnight
— 
Obtainface-to-facesignouteachnight
— 
Completeassignedtasks(POC,studies,etc)
— 
Completeassignedtasks(POC,studies,etc)
— 
Managealldirectadmissions(eval,H&P,staff
withChief,etc)
— 
Managealldirectadmissions(eval,H&P,staff
withChief,etc)
SurgeonTalk
Ø 
“Conserva:vemanagementofSBO”àNonopera:vemanagement
Ø 
“Outsidehospital”àReferringfacility(hopefullyhaswalls/roof)
Ø 
“Gallbladderpain”àBiliarycolic,symptoma:ccholelithiasis…
•  GallstoneswithRUQpaincanbebiliarycolic,cholecys::s,choledocholithiasis,
cholangi:s,biliarypancrea::s...
Ø 
“Painonexam”àPainisasymptom,tendernessisasign
Ø 
DoNOTauscultatebowelsounds(ifyoudo,pleasedonotsharewithanyone)
Ø 
Nosillynoun-verbs(e.g.,Coumadinize,surgerize)
Ø 
Noadding–wisetotheendoforgansystems(e.g.,Respiratory-wise,Neuro-wise)
OR
— 
CometoORearlyandoten
— 
Wewillinvolveyouasmuchaswecan
— 
Stepwiseprogression...(proveyoucanwalkbeforeweletyourun)
◦  Prac:ce,prac:ce,prac:ce
◦  ORisnottheplacetoprac:ceyourknotthrowing,howtopalmaneedledriver…
DutyHours
— 
Dutyhours
◦  100%complianceisNOTagoal,itisarequirement(reality,MedHub,ACGMEsurvey)
◦  Youreduca:onmaoers
◦  Inreality,thereisnoreasontobeoverthe80-hours,6daysperweeklimit
— 
Iden:fyproblemsearlyàconsultwithchiefearly
◦  AtextmessageFridaynightthatyouwillbeoverhoursispoorplanning
◦  Ifyouarestrugglingwithhoursandservicechiefnothelpingàemailadminchiefs
DutyHours
— 
FIRSTtrial(NEJM,2016)publishedbutnochangesyet…
Ø  80hoursperweek,averagedover4-weekperiod
Ø  1dayfreeofdutyeveryweek,averagedover4-weekperiod
•  1day=24hours
•  Allowsgoldenweekendandblackweekendaslongasitaveragesout
•  Vaca:onsmeaneverythingaveragedover3weeksinstead
Ø  PGY1:Dutyperiodmustnotexceed16hours
Ø  PGY1:Shouldhave10hours,musthave8hours,freeofdutybetweendutyperiods
Ø  PGY1:Nohomecall
Schedule
— 
EmailedoutbyJoAnn:KnowbothCallscheduleandRoundingschedule
◦  Excelspreadsheetemailedinadvance
— 
CallscheduleavailableonAmion(viaScalpelhomepage)
— 
Amionscheduleisfinal
— 
Greateffortthisyeartocompletein4-monthblocks(helpusout...)
Schedule–YourResponsibility
— 
Knowyourscheduleandiden:fyanyerrorsorpoten:alconflicts
◦  Reviewyourblockschedulewhenitisemailedoutàiden:fyerrorsearly
◦  Spendabout~10minutes;helpusout(wearedoingyouafavorbygeungitdonein4-monthblocks)
◦  Emailusifyouseearealproblem(e.g.,workingweekofvaca:on,working36straightdays...)
— 
An:cipateissuesandtroubleshoot
◦  Examples:Transi:onfromnightserviceoranightcall,vaca:oninterferingwithroundingrequirements…
◦  EmailnextservicechiefEARLYtowarnthemyouarecomingoffnights
— 
DONOTemailuswiththeproblem:
Iden]fytheproblem,offerasolu]on,andthenemailus
ScheduleIntricacies
— 
Tomeetdutyhourrequirements,youmusthave1dayoffevery7days
(averagedover4weeks)
◦  If1weekofvaca:on,thenaverageover3weeks(youdoNOTgetcreditforvaca:onweek)
◦  1dayoff=24hours
◦  IfyouareoncallSatnight(5pm)androundingSunAM(un:l8-9am):
–  Youmustleavethehospitalby9amSun(16-hourmaximum)àNOEXCEPTIONS
–  Youmustleavethehospitalby5pmFri(1dayoff)àNOEXCEPTIONS
ScheduleExample
Schedulingchanges
— 
AssumetheanswerisNO...
— 
Thatsaid,certainthingscomeupduringresidencyandasafamily,wemust
supporteachother
①  Emailusforapproval(includedates,reason,andplanforcoverageàweexpecttoyou
problem-solve)
Ø 
Thismeansyouwillhaveemailedtheinvolvedpar:estoworkoutasolu:on
②  AdminChiefswillreviewtheswitch
③  Ifapproved,wewillemailallinvolvedpar:esaswellastheadministra:on
DutyHoursandOtherRegula:ons
— 
MedHub(online:mecard)
◦  Mustbefilledouteveryweekànoexcuses
◦  Allowsustoiden:fyproblemsearly(thoughthehopeisproblemsiden:fiedbeforethis
point)
◦  Mustbefilledouthonestly
— 
ACGMEsurvey
◦  Notouropportunitytoiden:fydutyhourproblems(shouldbefixedviapersonal
accountabilityandthenviaMedHub)
SchedulingStep3
— 
YouwilltakeStep3duringyourR1year
— 
PaidforbyGMEoffice(gototheirwebsitefordetails)
— 
Scheduleyourtestbasedonyourserviceandobliga:ons.Forexample:
◦  IfonOrtho,ENT,Cardiac,Vascular:schedulewhileonAnesthesia
◦  BreastorMIS(especiallywhenthereisanR3/R5doinganelec:ve)>SurgOnc/CRS
◦  IfyouscheduleonACSday/night,we(you)willhavemajorproblems(i.e.,thisis
UNACCEPTABLE)
◦  Ifyouscheduleonaservicewhileyourcolleague(R1-R5)isonvaca:on,we(you)
willhavemajorproblems(i.e.,thisisalsoUNACCEPTABLE)
QIM&M,GrandRounds,andCoreCourse
— 
Absencesarerarelyexcused
— 
Tardinessisrarelyexcused
— 
ForGrandRounds:Siunginthebackrowisacceptableifthefrontrowsare
filled
— 
ForCoreCourse/JournalClub:Sitinthefrontrows
◦  Comeprepared
— 
ForSubspecialtyservices:YoumayaoendGenSurgCoreCourseORyour
subspecialtyconference(notboth)
— 
DoNOTdelayyourreturntooff-siteservices
Sign-inSheetforQIM&M&GrandRounds
— 
BreastInternvsMISIntern
◦  Block1:K.Perrone(MIS)orI.Chang(Breast)
— 
YOURresponsibilitytobesureitisthereby6:55,nolater,NOEXCUSES
— 
Ifvaca:on,findcoverage
Logis:cs
— 
UseStanfordemailonly
◦  WewillignoreanycorrespondencefromGmail,Yahoo,etc.
— 
AddSECURE:tosubjectofanyemailincludingpa:entinforma:on
◦  e.g.,“SECURE:pa:entupdateforweekendrounds”
Feedback
— 
Providedtoyou(resident)real]me,monthly(MedHubevals),andduring
twice-yearlyfeedbacksessionswithPDs
— 
You(resident)providefeedbackatereveryrota:on
◦  Anonymous(collatedbyGME,facultyonlyseesater6monthsorcertain“n”reached)
◦  Meaningful(changesmadeeveryyearbasedonresidentfeedback)
◦  Behonest,cri:cal,butprofessional
— 
PartoftheACGMEsurveyàsoifnotsurere:process,ask!
TipsandTrickstoSucceed
— 
Theanswerisalways“yes”
◦  Cases,clinic,consult,presenta:on,tumorboard
◦  Thiswillmakeyourlifeeasier,yourchief’slifeeasier,andyouraoending’slifeeasier
— 
Donotburnbridges
◦  Yourepresentourdepartmentandouraoendings
◦  Kill‘emwithkindness...orjust“dowhatyougetpaidfor”
— 
Read...
)
Original Investigation | PACIFIC COAST SURGICAL ASSOCIATION
Reading Habits of General Surgery Residents
and Association With American Board of Surgery
In-Training Examination Performance
Jerry 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;
StudyL.Habits
and MD,
ABSITE
Performance
General MD;
Surgery
Residents
Farin Amersi, MD; Brian R. Smith, MD; Marc
Melcher,
PhD;
M. TimothyinNelson,
Timothy
Donahue, MD; Garth Jacobsen, MD;
Tracey D. Arnell, MD; Christian de Virgilio, MD
Original Investigation Research
Study Habits and ABSITE Performance in General Surgery Residents
IMPORTANCE Few large-scale studies have quantified and characterized thea study habits of
Factor
Effect (95% CI)
P Value
surgery residents. However, studies have shown an association between American Board of
Figure 1. Residents’ Level of Satisfaction With Primary
Positive correlation
Surgery In-Training Examination (ABSITE) scores and subsequent success on the American
and Secondary Study Sources
USMLE 1 score, per 1-point
0.1
.03
Board of Surgery Qualifying and Certifying
increase examinations.
(0.02 to 0.14)
100
Source Described as
“Satisfied” or “Strongly Satisfied,” %
90
80
70
60
50
40
30
20
USMLE 2 score, per 1-point
0.3
<.001
OBJECTIVES To identify the quantity
of studying, the approach(0.19
taken
increase
to when
0.44) studying, the role
MCAT score,
per 1-point
1.2
that ABSITE preparation plays in resident
reading,
and factors associated
with ABSITE
increase
(1.3 to 2.0)
performance.
Having an equal study focus on
ABSITE and patient careb
11
(7 to 15)
.002
.009
DESIGN, SETTING, AND PARTICIPANTS An anonymous 39-item questionnaire including
Daily studying for patient care
13
.02
demographic information, past performance
onbstandardized examinations,
reading habits,
or clinical duties
(4 to 23)
as study
11 and opinions pertaining.02
and study sources during the timeSurgical
leadingtextbook
up to the
2014 ABSITE
to
sourceb
(6 to 16)
the importance of the ABSITE was administered August 1, 2014,
to August 25, 2014, to 371
Level of satisfaction with study c
<.001
surgery residents in 15 residency programs
nationwide.
material (Likert scale)
Opinion of ABSITE significance c
MAIN OUTCOMES AND MEASURES (multiple
Scores from
the 2014 ABSITE.
choice)
Negative correlation
jamasurgery.com
90
80
Research Original Investigation
70
60
50
Table 5. Predictors of ABSITE Performance on Multivariable Analysis
40
30
P Value
Effect (95% CI)a
Predictor
USMLE 2 score
0.4
(0.2-0.6)
Satisfaction with source
(P <.001)
<.001
MCAT score
Opinion of ABSITE significance
(P <.001)
0.6 (0.2-1.0)
.003
20
10
Equal study focus on ABSITE and patient care
0
6.1 (0.6-11.5)
Opinion of1ABSITE significance
2 (responses
3 9.2 (6.9-11.6)
1-4)b
Satisfaction Level or Opinion of ABSITE Importance
<.001
RESULTS A total of 273 residents (73.6%) responded tobthe survey. Seven respondents did
Prior ABSITE remediation
−26
.002
not provide their January 2014 ABSITE score, leaving 266 for statistical
analysis. Most
(−36 to −16)
Lack
of studyb,dwith a mean (SD)
−12
respondents were male (162 of 266
[60.9%]),
age of 29.8 (2.6) years.<.001
The
0
(−21 to −9)
Surgical
SESAP
ABSITE median
SCORE
numberSCORE
of minutes spent studying per month was 240 (interquartile range, 120-600
SCORE questions as primary
−14
.01
Textbook
(n = 51)
Review Book Curriculum Question Bank
b and 120 for the ABSITE (interquartile range,
minutes) for patient care or clinicalsource
duties
(−19 to −9)
(n = 254)
(n = 295)
(n = 189)
(n = 86)
30-360 minutes). One hundred sixty-four
of 266
respondents
(61.7%) reported reading .04
Internet search
engine
as
−21
Source
b
source
(−30 With
to −13)
consistently throughout the year for
patient care or clinical duties.
respect to ABSITE
Primary
focus
on
patient
care
−9
.009
72secondary
of 266 residents (27.1%) reported
reading consistently throughout the year,
The top 5 most often cited study sources indicatedpreparation,
as a primary or
when studyingb
(−14 to −5)
while
247 of 266
residents
source for the American Board of Surgery In-Training
Examination
(ABSITE)
or (92.9%) reported preparing between 1 and 8 weeks prior to the
10
Invited
Commentary
Figure
2. Correlation
Between Level of Satisfaction With Study Source
and Supplemental
Perception of ABSITE
to ABSITE Scores
contentSignificance
at
Median ABSITE Percentile Score
Table 4. Factors Associated With ABSITE Performance
.03
4
<.001
Abbreviations: ABSITE, American Board of Surgery In-Training Examination;
Respondent
level College
of satisfaction
with their
primary
or secondary
studyMedical
source, Licensing
MCAT, Medical
Admission
Test;
USMLE,
United States
whether being used for patient care or American Board of Surgery In-Training
Examination.
Examination (ABSITE) studying, had a direct positive correlation with median
a
For continuous
variables,
effect of level
1-point
increase orplaced
decrease
on ABSITE
ABSITE
percentile scores.
The perceived
of importance
on ABSITE
percentile
score.
For categorical
variables,
of variable
results
also had
a significant
effect on the
median effect
percentile
scores. presence on
median ABSITE percentile score.
b
Opinion
of ABSITEas
significance:
myagreement
score doesn’tto
matter
at all; 2, need to pass
lack
of studying
indicated1,by
the statement,
to
avoid
disciplinary
measures;
3,
want
to
do
well,
but
unlikely
affect future
“I did not prepare at all” (–12 [–21 to –9]; P < .001), use oftoSCORE
career goals; 4, must do well, they are important to achieving my career goals.
questions as a primary source (–14 [–19 to –9]; P = .01), use of
an Internet search engine as a primary source (–21 [–30 to –13];
8 - III
13
14
Ultrasound for Surgeons
Surgical Infections and Choice of Antibiotics
5
Infection
O
6
Antibiotics
O
O
15
Surgical Complications
O
16
Surgery in the Elderly
O
17
Morbid Obesity
O
18
Anesthesiology, Pain Management, & Conscious Sedation
O
19
Emerging Technology in Surgery
O
4
Infection and Antibiotics
Reading...ThereisNoSubs:tute
8
Anesthesia
O
6
Fiser's The ABSITE Review
1
History of Surgery
O
2
Ethics in Surgery
O
3
Molecular and Cell Biology
O
4
5
Mediators of the Inflammatory Response
Shock, Electrolytes, and Fluid
O
O
1
13
Cell Biology
Inflammation and Cytokines
ABSITE
Killer
ABSITE Slayer
O
32
Ethics and Professionalism
O
1
Cell Biology
O
O
9
Fluids and Electrolytes
O
2
Hematology
O
15
7
Fluids/Electrolytes/Nutrition
O
O
2
Hematology
3
Blood Products
O
Metabolism in Surgical Patients
O
10
Nutrition
O
7
Fluids/Electrolytes/Nutrition
14
Wound Healing
O
9
Wound Healing
O
O
7
Medicines and Pharmacology
O
5
Pharmacology
O
O
Wound Healing
O
9
Regenerative Medicine
O
Critical Assessment of Surgical Outcomes
O
11
Surgical Patient Safety
O
O
O
Management of Acute Trauma
O
15
Trauma
O
21
Trauma
O
O
Emergency Care of MSK Injuries
O
4
Orthopedics
O
28
Orthopedics
O
O
22
Burns
O
17
Burns
O
23
Burns
O
23
Bites and Stings
O
24
Surgical Critical Care
O
16
Critical Care
O
22
Critical Care
O
25
Bedside Surgical Procedures
O
26
The Surgeon's Role in Unconventional Civilian Disasters
O
27
Transplantation Immunology and Immunosuppression
O
4
Immunology
O
28
Transplantation of Abdominal Organs
O
12
Transplantation
O
29
Tumor Biology and Tumor Markers
O
30
Melanoma and Cutaneous Malignancies
O
11
Oncology
O
31
Soft Tissue Sarcomas
O
32
Bone Tumors
O
14
Anesthesia/Pain Management
O
7-I
Trauma - I
O
7 - II
Trauma - II
O
9-I
Surgical Critical Care - I
O
9 - II
Surgical Critical Care - II
O
10
The Immunocompromised Patient
O
13
Skin/Soft Tissue
O
12 - I
Oncology
O
12-II
Oncology
O
O
O
Transplant and Immunology
O
14
Hemostasis
O
O
24
Surgical Complications and Nutrition
O
33
Head and Neck
34
Disease of the Breast
O
19
35
Breast Reconstruction
O
36
Thyroid
O
22
8
Surgical Oncology
O
13
14
Principles of Preoperative and Operative Surgery
Ultrasound for Surgeons
Surgical Infections and Choice of Antibiotics
O
Head and Neck
Breast
Thyroid
O
O
Infection
O
6
Antibiotics
O
O
10
11
Head and Neck
Breast
O
O
The Parathyroid Glands
O
23
Parathyroid
O
38
Endocrine Pancreas
O
28
Gastrointestinal Hormones
O
39
The Adrenal Glands
O
21
Adrenal
O
40
The MEN Syndromes
O
20
Pituitary
O
12
Endocrine
O
O
1
Head and Neck
O
2-I
Breast - I
O
2 - II
Breast - II
O
O
O
6
Esophagus
Fiser's The ABSITE Review
O
29
Esophagus
ABSITE
Killer
ABSITE Slayer
O
18
Esophagus
O
8 - II
Perioperative Care - II
O
42
Hiatal Hernia and GERD
O
8 - III
Perioperative Care - III
O
43
Abdominal Wall, Umbilicus, Peritoneum, Mesenteries, Omentum,
Retroperitoneum
O
44
Hernias
O
45
Acute Abdomen
O
46
Acute Gastrointestinal Hemorrhage
O
15
Surgical Complications
O
16
Surgery in the Elderly
O
17
Morbid Obesity
O
47
Stomach
O
30
Stomach
O
14
Stomach
O
48
Small Intestine
O
35
Small Bowel
O
18
Small Intestine
O
49
The Appendix
O
18
Anesthesiology, Pain Management, & Conscious Sedation
O
50
Colon and Rectum
O
19
Emerging Technology in Surgery
O
20
Management of Acute Trauma
O
25
4
Infection and Antibiotics
O
24
8
Anesthesia
O
6
Anesthesia
O
15
Trauma
O
21
Trauma
O
Emergency Care of MSK Injuries
O
4
Orthopedics
O
28
Orthopedics
O
22
Burns
O
17
Burns
O
23
Burns
O
23
Bites and Stings
O
14
Anesthesia/Pain Management
16
Critical Care
O
25
Bedside Surgical Procedures
O
26
The Surgeon's Role in Unconventional Civilian Disasters
O
27
Transplantation Immunology and Immunosuppression
O
4
Immunology
O
28
Transplantation of Abdominal Organs
O
12
Transplantation
O
29
Tumor Biology and Tumor Markers
O
30
Melanoma and Cutaneous Malignancies
O
31
Soft Tissue Sarcomas
O
32
Bone Tumors
O
33
Head and Neck
22
Critical Care
O
Transplant and Immunology
Surgical Oncology
O
O
19
Head and Neck
O
10
Head and Neck
O
O
28
24
Breast
O
11
Breast
O
O
O
36
Thyroid
O
22
37
The Parathyroid Glands
O
38
Endocrine Pancreas
O
39
The Adrenal Glands
O
40
The MEN Syndromes
O
Thyroid
O
23
Parathyroid
O
28
Gastrointestinal Hormones
O
21
Adrenal
O
20
Pituitary
O
Trauma - II
Surgical Critical Care - I
9 - II
Surgical Critical Care - II
O
10
The Immunocompromised Patient
O
13
Skin/Soft Tissue
O
12
Fiser's The ABSITE Review
43
O
44
Hernias
O
45
Acute Abdomen
O
46
Acute Gastrointestinal Hemorrhage
O
47
Stomach
O
38
Small Intestine
O
49
The Appendix
O
50
Colon and Rectum
O
Esophagus
Endocrine
O
Oncology
O
12-II
Oncology
O
1
Head and Neck
O
2-I
Breast - I
O
2 - II
Breast - II
O
O
Hernias, Abdomen, and Surgical Technology
O
Endocrine
O
Critical Care
O
Anus
O
Hernias, Abdomen, and Surgical Technology
O
13
Abdominal Wall and Hernias
6
Burns
O
10
Critical Care
O
13
Head and Neck
O
5
Breast
O
27
Thyroid/Parathyroid
O
19
Pituitary and Adrenal Glands
O
O
SESAP 15
Review of Surgery for ABSITE and Boards
O
O
Colorectal
3 - II
Alimentary Tract
Alimentary Tract
O
11
Esophagus and Diaphragm
O
20
Retroperitoneum, Omentum, Mesentery
O
1
Abdominal Wall/Inguinal Hernias
O
23
Stomach
O
21
Small Bowel
O
4
Appendix
O
9
Colon
O
3
Anus and Rectum
O
15
Liver
O
12
Gallbladder
O
16
Pancreas
O
22
Spleen
O
26
Thoracic Surgery
O
7
Cardiac Surgery
O
O
3 - III
Alimentary Tract
O
4-I
Abdomen
O
O
18
Esophagus
13
Abdominal Wall and Hernias
14
Stomach
35
Small Bowel
O
36
Colorectal
O
18
Small Intestine
O
Head and Neck
O
5
Breast
O
Thyroid/Parathyroid
O
SESAP 15
Pituitary and Adrenal Glands
O
Review of Surgery for ABSITE and Boards
O
O
3 - II
Alimentary Tract
Alimentary Tract
O
Alimentary Tract
11
Esophagus and Diaphragm
37
Anal and Rectal
O
Anal and Rectal
O
Anus
O
The Liver
O
53
Surgical Complications of Cirrhosis and Portal HTN
O
54
Biliary System
O
32
Biliary System
O
55
Exocrine Pancreas
O
33
Pancreas
O
16
Pancreas
O
56
The Spleen
O
34
Spleen
O
17
Spleen
O
57
Chest Wall and Pleura
O
58
The Mediastinum
O
25
Thoracic
O
27
Thoracic Surgery
O
59
Lung (Including PE and TOS)
O
60
Congenital Heart Disease
O
O
O
4 - II
Liver
Abdomen
O
O
15
Hepatobiliary
O
O
O
4 - III
Abdomen
O
O
20
Retroperitoneum, Omentum, Mesentery
O
1
Abdominal Wall/Inguinal Hernias
O
O
O
O
Acquired Heart Disease-Coronary Insufficiency
O
62
Acquired Heart Disease-Valvular
O
63
Thoracic Vasculature with Emphasis on Thoracic Aorta
O
Abdomen
O
Cardiac
O
Cerebrovascular Disease
O
8
Cerebrovascular Disease
O
65
Aneurysmal Vascular Disease
O
2
Aneurysmal Disease and Vascular Trauma
O
66
Peripheral Arterial Occlusive Disease
O
18
Peripheral Arterial Disease
O
67
Vascular Trauma
O
2
Aneurysmal Disease and Vascular Trauma
O
68
Venous Disease
O
29
Venous and Lymphatic Disease
O
17
Pediatric Surgery
O
27
Vascular
O
24
Vascular
O
O
69
The Lymphatics
O
70
Access and Ports
O
71
Pediatric Surgery
O
5
Pediatric Surgery
O
25
Pediatrics
O
O
72
Neurosurgery
O
3
Neurosurgery
O
29
Neurosurgery
O
O
73
Plastic Surgery
O
18
Plastics, Skin and Soft Tissue
O
26
Plastic and Reconstructive Surgery
O
O
74
Hand Surgery
O
75
Gynecologic Surgery
O
2
Gynecology
O
30
Obstetrics and Gynecology
O
O
76
Surgery in the Pregnant Patient
O
77
Urologic Surgery
O
1
Urology
O
1
Urology
O
O
6
Statistics
O
31
Statistics
O
23
Stomach
O
O
21
Small Bowel
O
4
Appendix
O
9
Colon
O
3
Anus and Rectum
O
O
5
11
O
O
O
4-I
Colorectal
37
Colorectal
52
64
13
19
3 - III
Stomach
O
O
O
30
Burns
27
6
ABSITE
Killer
ABSITE Slayer
O
19
51
36
31
O
48
Endocrine
O
26
3-I
Abdominal Wall, Umbilicus, Peritoneum, Mesenteries, Omentum,
Retroperitoneum
38
51
61
O
29
O
O
O
Sabiston
Trauma and Shock
O
10
12 - I
O
O
O
O
8
Disease of the Breast
Hiatal Hernia and GERD
O
O
O
Breast Reconstruction
42
Trauma and Shock
O
O
Oncology
35
Trauma - I
6
11
34
O
Surgical Complications and Nutrition
O
O
3
Esophagus
28
O
O
9-I
41
O
19
21
O
O
O
7 - II
Surgical Critical Care
Surgical Infections
O
7-I
24
Surgical Complications and Nutrition
O
37
41
O
O
5
24
O
3-I
12
O
O
O
Sabiston
Perioperative Care - I
Surgical Infections
O
O
8-I
25
O
21
24
O
Hematologic Principles in Surgery
O
O
O
7
8
Legal/Ethics
Review of Surgery for ABSITE and Boards
O
6
10
SESAP 15
Anesthesia
O
20
3
Sabiston
Perioperative Care - III
O
Vascular
Problems in Related Specialties
O
O
Chiefs’JournalClub
— 
4thor5thTuesdayeachmonth,star:nginJuly
— 
CategoricalGeneralSurgeryR2Residentswilleachpresent2:mes
— 
Mustbefromindexjournals(NEJM,JAMA,Lancet,Annals,JAMASurg)
— 
Cri:calanalysisofthestudywithpowerpointslides
◦  R2willpresentandthenmoderatethediscussion(pimpingencouraged)
— 
Paperwillbeemailedout1weekprior
Chiefs’Rounds
— 
Beersandburgers
— 
4thor5thTuesdayeachmonth,star:nginJune
◦  InauguralChiefs’Rounds:June30
— 
7pm,meetatDutchGoose
— 
Departmentfunded(“con:nua:onofjournalclub”)
◦  AdminChiefswillalsochipin
SocialEvents
— 
GraemeRosenberg(R2àPDresident)
◦  MonthlyChiefs’Rounds(4th/5thTuesday)
◦  FacultySocialEvent(monthly,2ndTuesdayvsThursday,Dr.CindyKin)
◦  StanfordFootballTailgate(s)
◦  HolidayPar:es
◦  AnnualBILretreat(ropescourse,dinner)
◦  Residentvs.Facultysotballgame
◦  ResidentApprecia:onDay(Gradua:onday)
ProfessionalismCurriculum
— 
Newcurriculumstar:ngthisJuly
— 
Topicsrangefrom:
◦  FinancialPlanning
◦  TimeManagement
◦  DressforSuccess
◦  ResiliencyinResidencyandCareer
◦  Transi:onfromResidencytoPrac:ce
◦  Contractnego:a:on
BalanceinLife
— 
Endoftheday:Weareafamily
— 
Lookoutforeachother,supporteachother
— 
Mateo’schinlac
Ø 
“Itdoesn’tma?erwhatyousayyoubelieve–itonlyma?erswhatyoudo.”-RobertFulghum
Ø 
“Scienceisn’tonesuccessaFeranother.It’smostlyonesuccessinadesertoffailure.”-JudahFolkman,MD
Ø 
Evertried.EverFailed.Noma?er.TryAgain.FailAgain.FailBe?er.-SamuelBeckeo(...andTomKrummel,
MD)
Ø 
“Openingoftheabdomenisnottobeadvisedwithtoolightaheart.Thedextroushandmustnotbeallowedto
reachbeforetheimperfectjudgment.”-SirZacharyCope
Ø 
“Themanwhocandrivehimselffurtheroncetheeffortgetspainfulisthemanwhowillwin.”-RogerBannister