1. Perceived Impact of Resident Travel on Transplant Surgery Experience during General Surgery Residency Training Bittner JG, 1 Fryer JP, 2 Cofer JB, 3 Mellinger JD, 4 Wynn JJ, 1 Fuhrman GM, 5 Borman KR 6 Departments of Surgery, 1 Medical College of Georgia, Augusta, GA; 2 Northwestern University, Chicago, IL; 3 University of Tennessee, Chattanooga, TN; 4 Southern Illinois University, Springfield, IL; 5 Atlanta Medical Center, Atlanta, GA; 6 Abington Memorial Hospital, Abington, PA

2. Disclosures  No related conflicts of interest

3. Introduction  Current status of transplant surgery  Essential content area of residency training  Negative feedback from program directors (PDs) and residents prompted action.  High service-to-education ratio  Poor operative experience  Low educational benefit  Rare/negative interactions with attendings  Resident travel to transplant centers  Concern for equivalent educational experience  Associated costs / inconvenience

4. Introduction  RRC-S proposed to eliminate transplant as a requirement during residency training.  ABS asked the RRC-S to stay this action and requested involvement of ASTS through TAC.  ASTS issued a call to action  Involve general surgery leadership  Reevaluate the role of surgical residents on a transplant rotation  Immediately address concerns of the RRC-S  Commit to immediate and long-term educational excellence within transplant surgery

5. Purpose  To investigate the perceived impact of resident travel on transplant experience by comparing opinions of PDs who have transplant rotations at integrated (home) compared to non-integrated (away) hospitals.

6. Methods  A comprehensive survey was created on behalf of the APDS and ASTS.  Instrument was IRB-approved.  Content was validated by a focus group.  Internet-based survey  Administered anonymously via email to 251 PDs  Resent two weeks after first administration  Supported by the President of the APDS  Data analyzed using appropriate statistics  Significance set at α = 0.05

7. Results  131 of 251 PDs (52%) responded  Sample size achieves a 5.9% confidence interval assuming 50% response distribution.  Response rates by program type similar to expected distribution  University (52%)  University-affiliated/Community (31%)  Community (17%)

8. Results  University PDs represent more chief residents on average (p<0.001)  5.7 ± 1.9 University  3.7 ± 1.0 University-affiliated / Community  3.1 ± 1.1 Community  ASTS approved fellowships similar to expected distribution (p=0.439)  20% responding PDs  24% all US residency programs

9. Results  Disproportionate response from PDs with home transplant rotations  66% of PDs use integrated (home) hospitals  30% use non-integrated (away) hospitals  80% of these feel the educational needs of all residents are given equal priority  48% require resident commuting (<30 extra miles/day)  52% purchase temporary housing  43% of transplant services provide experience for visiting residents

10. Results Transplant Rotation Types Used by Program Directors in Surgery Survey Item ResponseTransplant RotationP Value Yes (%)No (%) Program Type University7014 0.009 University-affiliated/Community2347 0.016 Community739<0.001 Program Size (graduates/year) 2 – 43792<0.001 5 – 7508<0.001 > 7130 0.018 Fisher’s exact test (α = 0.05)

11. Results Transplant Rotation Types Used by Program Directors in Surgery Survey Item ResponseTransplant RotationP Value Yes (%)No (%) Resident-Faculty Interactions Good / Very Good6564 1.000 Uncertain1925 0.625 Poor / Very Poor1611 0.385 High Service:Education Ratio Agree / Strongly Agree3447 0.218 Uncertain1620 1.000 Disagree / Strongly Disagree5033 0.110 Fisher’s exact test (α = 0.05)

12. Results Transplant Rotation Types Used by Program Directors in Surgery Survey Item ResponseTransplant RotationP Value Yes (%)No (%) Operative Experience is Excellent Agree / Strongly Agree5138 0.236 Uncertain1831 0.154 Disagree / Strongly Disagree31 1.000 Educational Value Good / Very Good6158 0.840 Uncertain2725 1.000 Poor / Very Poor1217 0.564 Fisher’s exact test (α = 0.05)

13. Results Transplant Rotation Types Used by Program Directors in Surgery Survey Item ResponseTransplant RotationP Value Yes (%)No (%) Transplant Experience Should Be Required2914 0.104 Optional61 1.000 Eliminated1025 0.045 Fisher’s exact test (α = 0.05)

14. Discussion  PDs and transplant surgeons might  Decide how many residents might rotate on a transplant service with or without a fellow.  38% believed service > education  Assess ways to protect operative experience.  53% claimed experience was less than excellent.  Share accountability for education outcomes.  59% felt transplant offers a good educational value.  Address the burden of resident travel.  78% felt travel is a poor/very poor aspect.

15. Discussion  PDs and transplant surgeons might  Guarantee visiting residents are treated the same as home residents.  80% felt visiting residents have similar experience  Ensure duty-hours compliance.  71% stated rotations were compliant.  Consider making transplant optional.  60% believed transplant should become optional.

16. Discussion  ASTS action plan  Transplant programs need to:  Designate a transplant surgeon working alongside a PD to oversee the education of surgery residents  Change the transplant rotation structure to ensure residents have adequate time for education  Reeducate attending and resident surgeons about educational expectations  Establish a relevant operative experience  Create a feedback system to allow for improving the educational milieu.

17. Limitations  52% response rate  Biased toward opinions of PDs with home transplant rotations  Not possible to tell if PDs also served as transplant fellowship director  No temporal survey administration

18. Conclusions  More PDs at Community / smaller programs use away hospitals.  PDs sending residents to away hospitals face educational, logistical, and financial burdens.  Most PDs challenge the paradigm of transplant as essential content.  More PDs employing away rotations felt transplant should be eliminated.

19. Thank You!  APDS Board of Directors  ASTS administrative staff  Responding Program Directors  Bruce V. MacFadyen, Jr., MD, FACS