INTRODUCTION!

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The American University of Beirut Medical Center (AUBMC) was
established in 1867 and has been providing the highest standard of care
in Lebanon and the Middle East since, being the only hospital in the
region that has all of JCA, Magnet and CAP accreditations. Surgery at
AUBMC, extends to many fields like General Surgery, Neurosurgery,
Urosurgery, Plastic Surgery, and Orthopedic surgery, where medical
graduates from all over the Arab world pursue their education. !
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AUBMC is currently working to be ACGME-I certified, which
requires strict adherence to their conditions, and this has been an extra
burden on our residents who already have a very demanding training [1]
(Bunch WH, Dvonch VM, Storr CL, Storr CL, Baldwin DC Jr, Hughes
PH. The stresses of the surgical residency. J Surg Res.
1992;53:268-271). !
. Amongst ACGME-I objectives is to limit shifts to 80 hours a week
(https://www.acgme.org/acgmeweb/tabid/363/Publications/Papers/
PositionPapers/HighlightsItsStandardsonResidentDutyHours-.aspx
ACGME website) and to emphasise on trainees education, which is
very promising on the long run, but for now, residents are still struggling
to accommodate with this accreditation http://www.acgme-i.org/Portals/
0/Specialties/GeneralSurgery/GeneralSurgery.pdf ), as they are being
more strictly supervised and are expected to meet ACGME-I
requirements very strictly (http://applications.emro.who.int/imemrf/
Sultan_Qaboos_Univ_Med_J/
Sultan_Qaboos_Univ_Med_J_2013_13_2_198_201.pdf ARTICLE ON
ACGME ADVANTAGE LONG RUN) . On top of the clinical care,
paperwork, and assistance in the operation room, surgical trainee have
to continue their medical education in order to master a body of
knowledge and information necessary for their practice. This education
continues for the rest of their career, but is most pronounced during their
residency, and most of it consists of self learning not accounted for in
their schedule (look for smthng to support that). This is one tangible
obstacle our resident are facing, where their surgical education is limited
by time. !
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We have to acknowledge the effect of time on their level of energy
which can potentially jeopardise patients care, the effect of time on their
personal and social life, as it is highly encouraged that surgical residents
get married after the end of their training. (A Survey of Residents and Faculty
Regarding Work Hour Limitations in Surgical Training Programs!

Mark J. Niederee, MD; Jason L. Knudtson, MD; Matthew C. Byrnes, MD; Stephen D.
Helmer, PhD; R. Stephen Smith, MD) This is an important issue at AUBMC that

must be further evaluated to improve the quality of surgical training.

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Moreover, communication between the residents and the
physicians is not well established due to their hectic schedule, which
limits major issues in their training, like surgical education (poor
communication). Since we have little information on this topic, it is of our
interest to undergo a detailed study, collecting the biggest amount of
data reflecting this reality accurately, and possibly linking several
variables together in order to optimise surgical residency programs and
residents education.!
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On further notice, AUBMC has been housing patients from all over
the Arab world with increased load in the past decade, due to the wars
in Iraq and Syria,with around 35,000 admissions a year, 50,000 visits at
the emergency department, 255,000 private clinic visits and 28,809
outpatient department visits yearly Table 1. The numbers in Table 1
clearly show the high flux this institution handles, and the great
responsibility it holds. Hence, the surgical residency programs which
accounts for a great amount of patients care, and work on the floors and
operation room, is to be further assessed and ameliorated in order to
maximise the training provided and improve the healthcare system in
Lebanon and the Middle East. ((maybe could find another institution in
ME to compare with)!

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METHODS!
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Out of 67 surveys sent , 57 were answered and 51 were
completed. 36% were PGY1, 21% PGY2, 19% PGY3, 11% PGY4 and
13% PGY5 Figure 1, with a 93% percentage of males participant and
only 7% of females Figure 2. 65% were in a general surgery program,
7% in Urosurgery, 18% in Orthopedic surgery, 6%in Plastic surgery and
4% in Neurosurgery Figure 3.
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This is a survey of hundred and four questions approved by the
Institutional Review Board review, divided into seven groups, where
each group focuses on a subject of interest concerning our residents.!
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The first group, involves nineteen questions regarding residents
studying methods and habits. A second group of thirteen questions will
entail residents satisfaction regarding their salaries and facilities
provided by the hospital,then eight questions will be consecrated for

residents opinions and involvement in the operation room. In the fourth

group, fifteen questions to reflect the interaction between the residents
and attending, and the assessment of physicians by residents are
asked. The fifth group involves eleven questions about education
outside AUBMC like interest in fellowship and electives abroad. The
sixth group of eleven questions assess residents opinions and
satisfaction regarding the workload, then nine questions will focus on
wether residents are trained to face important situations not specific for
a surgical education, like adequate communication skills, end of life
ethics and nausea and vomiting management. At last a set of eighteen
questions will include questions regarding research facilities and
residents interest and involvement in research.!
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This is a completely voluntary survey, sent by an email to all
AUBMC surgical residents containing a URL link, linking them to the
survey. The first question involves a consent form where whomever
wants to participate should agree. The consent form assures
participants that this an entirely anonymous survey (the name of the
participant is not required for completion) that will take around 15-20
minutes, and that responses are gathered on a surver system website
run by AUBMC itself (Limesurvey) that will ensure that all the data
collected will remain secured in the surver and only people working on
this study will have access to the results through the web.The consent
also states that !
participants will not receive payment for their participation, that they may
withdraw at any time without consequences, and that the collected
information will only be used in favour of our residents.!
! In this current study we will not use all groups of questions
mentioned above as we will be focusing on the education and workload
of our residents. Groups 1, 3, 5, 7 and 8 will be included and further
analysed individually and in respect to each other.!
RESULTS!
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Only two participants reported having children, both being in the
26-30 age group one of them PGY1 the other PGY2, and 76% of
residents agree with the statement Is your personal life adversly
affected because of the workload with 62% agreeing that workload
hours be limited. 70% of residents are working more than 80 hours a
week with 4 days off a month on average, and 56% reported that the
workload is affecting their performance Figure 4. Despite these
constraints, 90% of surgical residents would choose surgery again.! !

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Regarding studying hours, 87% of residents reported studying
between 1 to 2 hours a day and around 11% studying 3-4 hours a day,
and only one resident reporting studying more than 4 hours Figure 5.
Most of them use surgery text books, peer reviewed journals, e-book,
and other internet sources equally with no specific preference for one
over another. !
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Most study on their day off, and data show that residents prefer
studying on pre-call than post call and less preferably during the call.
78% usually study at home, 11% at the library, 2% at the office, another
3%at a coffee shop and 6% in the on call room Figure 6. Moreover, 16%
of our residents are completely dissatisfied with the number of hours
they study outside work, 45% are somewhat dissatisfied, 35% were
somewhat satisfied and 4% were completely satisfied Figure 7, while
most of them were somewhat satisfied with the study material currently
used, but are also willing to try another type of study material and to
enrol in a trial comparing study methods. Almost all residents agree that
increasing the fund of knowledge, performing oral exams, and improving
patient care would motivate them to study more, whereas opinions on
disciplinary actions were variable with 48% of participants considering
disciplinary actions not important versus 52% agreeing on the opposite.!
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When asked about the number of surgeries they scrubbed in the
prior month, 27% answered 1-5, 18% scrubbed in 6-10 surgeries,
9%between 11 and 15 and around 46% did scrub more than 15 times
Figure 8. There was a positive correlation between the year of
residency and the number of times residents scrubbed, as this would be
expected, since juniors are more busy working on the floors, and when
they attend surgeries they are more likely to be second assistants than
seniors. Figure 9 82% have read about the case prior to the procedure,
78% have discussed the case with team while only 65% discussed it
with the attending and most residents report being overly supervised
during surgeries. This is another weakness in our program that stems
from poor communication between residents and attendings,having as
consequences inadequate pre operative learning and the inability of
residents to build confidence when performing in the operation room as
they are overly supervised, but this is an issue to be also looked upon
from the attendings perspective, since patients safety and care is of
higher priority than education and residents supervising should be strict
to avoid mistakes. Adding to that, 60% of residents state, that attending
never or rarely give spontaneous presentations, and this also confirms

that there is poor interaction between attendings and residents, but

there is adequate teaching in the clinics, as cases are most of the time
discussed in clinics.!
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The majority of residents stated that they are moderately to well
trained in communicating with hospice care, management of
constipation nausea and vomiting terminal dyspnea, non oral feedings in
end of life care, pain assessment and management, end of life ethics
and communication, but 39% stated that they are not trained to manage
terminal delirium. Figure 10!
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All residents responded yes when asked if interested in doing an
international elective during their training. Only 25% have done an
elective abroad, mainly in the US and 90% of the electives were not
arranged by the department. Most residents report that the aspect of
international surgery they are interested in is learning and operating
rather than teaching or just traveling Figure 11. On the other hand their
main factor that impediments an international elective is the cost of the
elective and secondly the lack of time and opportunity Figure 12. This
raises the idea of wether or not an elective abroad should be part of the
training, with possible financial support. Concerning research, also all
residents acknowledge its importance, and most of them agree that
research will be part of their long-term career Figure 13. Unlike the
electives, 76% have been involved in research, mainly clinical, but only
42% were once authors on any of the publications, and about 60% of
residents have completed CITI (The Collaborative Institutional Training
Initiative) Figure 14.

DISCUSSION!

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In this study of surgical residents of all post graduate years, we
have pointed out several problems regarding surgical training.!
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First of all, the majority of residents report having a high workload
affecting their performance and personal lives.(IN COMPARISON TO)
Taking a closer look at this issue, there is negative correlation between
the year of residency and dissatisfaction regarding the workload. (THIS
CAN BE REINFORCED BY A PAPER TOO)This can stem from many
reasons, as that more advanced residents are more used to this lifestyle
and no longer feel the pressure and acknowledge the importance of this
harsh training. Or just simply that they are about to finish their training
and would not see it fair if younger residents had an easier path than

theirs. Anyways, AUBMC will have to adhere at some point to the 80

hours a week policy, required for the ACGME I accreditation, which will
probably resolve this issue. (Studying the Effects of ACGME Duty Hours
Limits on Resident Satisfaction: Results From VA Learners' Perceptions
SURVEY!
Kashner, T. Michael PhD, JD; Henley, Steven S. MS; Golden, Richard
M. PhD; Byrne, John M. DO; Keitz, Sheri A. MD, PhD; Cannon, Grant W.
MD; Chang, Barbara K. MD, MA; Holland, Gloria J. PhD; Aron, David C.
MD; Muchmore, Elaine A. MD; Wicker, Annie; White, Halbert PhD)!
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The second point worth to notice is the amount of studying, and
the unsatisfactory education, according to our residents. (THIS IS ALSO
A PROBLEM IN ))As part of the solution most of them agreed that
improving the fund of education, and doing well on oral exams would
motivate them to study more and better. (ORAL EXAM PAPERS) It is
also clear that the lack of interactions between attendings and residents
affects education. (HOW LESS INTERACTION AFFECT EDUCATION
PAPER)This can be justified by noting that residents spend much time
working on the floors, teaching students, leaving them less time for
learning and interaction with their superiors. Or it can be due to the tight
schedule of attendings. This is to be further assessed with educational
specialist, but as far as we know from this survey, routine oral exams
and improving the focus on education should resolve this matter. This is
also part of the ACGME I accreditation that requires at least 15 hours a
week for education, and It is the responsibility of attendings, to organise
more conferences and talks in favour of this regulation.(15 hours
education policy reference)!
In parallel to the results of our survey, We would like to add that
general surgery residents have been required to present the Absite
exam yearly since 2011. This is a 5 hours exam of 250 questions,
testing residents on the topics covered by the SCORE curriculum
lectures, including General Surgery topics, Radiology, Anesthesiology,
Ethics, Biostatistics and basic science too (REFER TO THE WEBSITE).
In fact AUBMC introduced ACS weekly core curriculum to their program
in 2011, which had its equivalent SCORE modules assigned, and then
adopted the SCORE curriculum in 2013. In addition to that, ATLS
(Advanced Trauma Life Support) program was started in 2010 by Dr.
Georges Abi-Saad and other surgeons, where interns, residents and
attending all across Lebanon were welcomed to attend this three 3 days
certified course, and they have to pass an oral and written exam for
certification (REFER AND TALK ABT improvement )))) The Fellowship

and Residency Research Program (FRRP) was implemented in

2011/2012 academic year where research has become a requirement in
the residency program (TALK ABT T]IT TOO))). All these internationally
recognised and standardised educational projects were a leap in the
improvement of the surgical department at AUBMC. !
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When comparing the score of our residents in the Absite exam with
the international average Tables 2, 3,4 and 5, we were able to have a
better and more objective view on the level of education of our residents
(imPORTANC OF ABSITE>>>). According to these datas, PGYI AUBMC
residents had average scores higher than the international averages in
all four years (2011,2012,2013,2014), but other AUBMC residents
scored lower than the international average, most of the time. On the
other hand, there was no significant change in AUBMC residents score
after the introduction of SCORE modules. These results can be
interpreted as the improvement of the quality of education of residents
from year to year, as newer residents score better than their seniors;
relatively, although not directly related to SCORE lecture implementation
to the program.!
Another point to mention, is the electives abroad that all residents
with no exceptions, consider useful. But electives are not part of the
curriculum. AUBMC should consider the addition of organised electives
in their curriculum, since it would be of great experience for our
residents who highly recommend it, and would improve the quality of
work at AUBMC due to the experience granted abroad. (elective abroad
benefits in comparison)))))!
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In research, data shows that about half the resident who were
once involved in research did not get their names as primary authors in
any of their publication. This is problematic, since it is important for them
to have their names in the publication to gain credibility regionally and
abroad, especially needed for their fellowship.Since FRRP
implementation in the residency program, research is starting to get
more organised which will make it more fair on behalf of our residents.
(FRRP EFFECT ON RESEARCH FOR RESIDENTS))!
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At last, Regarding the work in the operation rooms, residents
report being over supervised. But as discussed earlier this one question
is not enough to evaluate this issue, since we need the perspective of
the primary physician who is in charge of the surgery, as he holds all
responsibilities towards the patients and is in charge of teaching
residents surgical skills. (OR AND RESIDENTS INVOLVEMENT)!

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survey dh_dhSummary.pdf). Accessed August 28, 2006.!

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Discussion risk are minimal.!

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]1.!

Bunch WH, Dvonch VM, Storr CL, Storr CL, Baldwin DC Jr,
Hughes PH. The stresses of the surgical residency. J Surg Res.
1992;53:268-271. !

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! 1.! Marks DR. Resident work hours revisited. Internist. 1993;34:31-32.
PATIENT CARE!

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2 The ACGMEs approach to limit resident!
duty hours: the common standards and activities!
to promote adherence. Available at: (http://www.!
acgme.org/acWebsite/dutyHours/!
dh_dhSummary.pdf). Accessed August 28, 2006!

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Accreditation Council for Graduate Medical Education. Report of the
ACGME work
group on resident duty hours [ACGME Web site]. Available at: http://
www.acgme
.org/dutyhours/wkgroupreport611.pdf. Accessed October 12, 2002. !