Simulating success: Applying EPA assessments to simulation in surgical education.

Entrustable professional activities are a competency-based evaluation framework which was deployed by the American Board of Surgery in 2023 to evaluate general surgical residents and provide a path to independent practice. Entrustable professional activity microassessments are based on 18 conditions which are core to being a practicing general surgeon, and most include multiple phases of care, such as preoperative care, intraoperative care, and postoperative care. These evaluations are an amalgam of all the clinical competencies, including medical knowledge and patient care skills.

Resident and Fellow Performance and Supervision in Surgical Oncology Procedures.

Background: Previous research has highlighted concerns among trainees and attendings that general surgery training and fellowship are inadequately preparing trainees for practice. Providing trainees with supervision that matches their proficiency may help bridge this gap. We sought to benchmark operative performance and supervision levels among senior surgery residents (post-graduate year 4 or 5) and fellows performing general surgical oncology procedures.

Decision-Making Confidence of Clinical Competency Committees for Entrustable Professional Activities.

Importance: A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs' clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known.

Objective: To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions.

Faculty and Resident Perspectives on the Implementation of Entrustable Professional Activities in General Surgery Residency.

Objective: This study aimed to identify what best practices facilitate implementation of Entrustable Professional Activities (EPAs) into surgical training programs.

Design: This is a mixed methods study utilizing both survey data as well as semi-structured interviews of faculty and residents involved in the American Board of Surgery (ABS) EPA pilot study.

Setting: From 2018 to 2020, the ABS conducted a pilot that introduced five EPAs across 28 general surgery training programs.

Validity of Entrustable Professional Activities in a National Sample of General Surgery Residency Programs.

Background: The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees.

Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention.

Background: Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs.

Study Design: An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes.

Resident Operative Autonomy and Attending Verbal Feedback Differ by Resident and Attending Gender.

Objectives: This study tests the null hypotheses that overall sentiment and gendered words in verbal feedback and resident operative autonomy relative to performance are similar for female and male residents.

Background: Female and male surgical residents may experience training differently, affecting the quality of learning and graduated autonomy.

Methods: A longitudinal, observational study using a Society for Improving Medical Professional Learning collaborative dataset describing resident and attending evaluations of resident operative performance and autonomy and recordings of verbal feedback from attendings from surgical procedures performed at 54 US general surgery residency training programs from 2016 to 2021.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.

Objective: The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country.

Increased Preoperative Stress Test Utilization is Not Associated With Reduced Adverse Cardiac Events in Current US Surgical Practice.

Objective: To measure the frequency of preoperative stress testing and its association with perioperative cardiac events.

Background: There is persistent variation in preoperative stress testing across the United States. It remains unclear whether more testing is associated with reduced perioperative cardiac events.

A narrative review of ergonomic problems, principles, and potential solutions in surgical operations.

Background: Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions.

Resource use for cholecystectomy with versus without cholangiography: A multicenter, propensity-matched analysis.

Background: Intraoperative cholangiography may allow for earlier identification of common bile duct injury and choledocholithiasis. The role of intraoperative cholangiography in decreasing resource use related to biliary pathology remains unclear. This study tests the null hypothesis that there is no difference in resource use for patients undergoing laparoscopic cholecystectomy with versus without intraoperative cholangiography.

Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback.

Background: Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy.

Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial.

Background: There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events.

Methods: A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants.

Postoperative Clostridium difficile infection has a differential procedure-specific association with surgical outcomes in contemporary United States practice.

Background: The Centers for Disease Control and Prevention has made the prevention of in-hospital Clostridium difficile infection a priority. However, whether there is a differential impact of Clostridium difficile on surgical patients remains undefined. Therefore, we quantified the procedure-specific association between postoperative Clostridium difficile and surgical outcomes to define opportunities for targeted quality improvement.

A simulation curriculum for laparoscopic common bile duct exploration, balloon sphincterotomy, and endobiliary stenting: Associations with resident performance and autonomy in the operating room.

Background: Laparoscopic common bile duct exploration is safe and effective for managing choledocholithiasis, but laparoscopic common bile duct exploration is rarely performed, which threatens surgical trainee proficiency. This study tests the hypothesis that prior operative or simulation experience with laparoscopic common bile duct exploration is associated with greater resident operative performance and autonomy without adversely affecting patient outcomes.

Methods: This longitudinal cohort study included 33 consecutive patients undergoing laparoscopic common bile duct exploration in cases involving postgraduate years 3, 4, and 5 general surgery residents at a single institution during the implementation of a laparoscopic common bile duct exploration simulation curriculum.

Does Complexity Equal Anything?

We present a new infinite class of gravitational observables in asymptotically anti-de Sitter space living on codimension-one slices of the geometry, the most famous of which is the volume of the maximal slice. We show that these observables display universal features for the thermofield-double state: they grow linearly in time at late times and reproduce the switchback effect in shock wave geometries. We argue that any member of this class of observables is an equally viable candidate as the extremal volume for a gravitational dual of complexity.

Routine Radiologic Assessment for Anastomotic Leak Is Not Necessary in Asymptomatic Patients After Esophagectomy for Esophageal Cancer.

Background: Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy.

A Phased Approach: The General Surgery Experience Adopting Entrustable Professional Activities in the United States.

Entrustable professional activities (EPAs) have been increasingly used as an assessment framework to formally capture the myriad ad hoc entrustment decisions that occur on a daily basis in clinical settings with learners present. Following the definition of Core EPAs for Entering Residency by the Association of American Medical Colleges in 2014, the American Board of Surgery (ABS) began to explore the utility of EPAs as a framework to support competency-based resident education within general surgery in 2016. As the complement of EPAs drafted for a specialty serve to define the core tasks of a professional within that discipline, initial efforts to define the entire scope of general surgery were fraught with difficulty as no commonly accepted definition of a general surgeon currently exists.

Objective predictors of intern performance.

Background: Residency programs select medical students for interviews and employment using metrics such as the United States Medical Licensing Examination (USMLE) scores, grade-point average (GPA), and class rank/quartile. It is unclear whether these metrics predict performance as an intern. This study tested the hypothesis that performance on these metrics would predict intern performance.

Racial Disparity in Liver Transplantation Listing.

Background: Previous studies have demonstrated disparities in transplantation for women, non-Caucasians, the uninsured or publicly insured, and rural populations. We sought to correlate transplant center characteristics with patient access to the waiting list and liver transplantation. We hypothesized that liver transplant centers vary greatly in providing equitable access to the waiting list and liver transplantation.