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Figure.  A Conceptual Framework of the Domains of the Surgical Learning Environment Associated With Perceived Preparedness for Practice
A Conceptual Framework of the Domains of the Surgical Learning Environment Associated With Perceived Preparedness for Practice
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Hu  YY, Ellis  RJ, Hewitt  DB,  et al.  Discrimination, abuse harassment, and burnout in surgical residency training.   N Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759 PubMedGoogle ScholarCrossref
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Tevis  SE, Rogers  AP, Carchman  EH, Foley  EF, Harms  BA.  Clinically competent and fiscally at risk: impact of debt and financial parameters on the surgical resident.   J Am Coll Surg. 2018;227(2):163-171.e7. doi:10.1016/j.jamcollsurg.2018.05.002 PubMedGoogle ScholarCrossref
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Zhu  Y, Goldstone  AB, Woo  YJ.  Integrated thoracic surgery residency: current status and future evolution.   Semin Thorac Cardiovasc Surg. 2019;31(3):345-349. doi:10.1053/j.semtcvs.2019.04.002 PubMedGoogle ScholarCrossref
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Damewood  RB, Blair  PG, Park  YS, Lupi  LK, Newman  RW, Sachdeva  AK.  “Taking training to the next level”: the American College of Surgeons Committee on Residency Training survey.   J Surg Educ. 2017;74(6):e95-e105. doi:10.1016/j.jsurg.2017.07.008 PubMedGoogle ScholarCrossref
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Kiguchi  M, Leake  A, Switzer  G, Mitchell  E, Makaroun  M, Chaer  RA.  Perceptions of society for vascular surgery members and surgery department chairs of the integrated 0 + 5 vascular surgery training paradigm.   J Surg Educ. 2014;71(5):716-725. doi:10.1016/j.jsurg.2014.02.005 PubMedGoogle ScholarCrossref
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Peterson  LA, Avise  J, Goldman  MP,  et al.  Perceptions of integrated vascular surgery fellowship graduates among community vascular surgeons.   Ann Vasc Surg. 2016;30:118-22.e1, 2. doi:10.1016/j.avsg.2015.10.006PubMedGoogle ScholarCrossref
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Pellegrini  CA.  Surgical education in the United States: navigating the white waters.   Ann Surg. 2006;244(3):335-342. doi:10.1097/01.sla.0000234800.08200.6c PubMedGoogle ScholarCrossref
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Sealy  WC.  Halsted is dead: time for change in graduate surgical education.   Curr Surg. 1999;56:34-39. doi:10.1016/S0149-7944(99)00005-7 Google ScholarCrossref
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Debas  HT, Bass  BL, Brennan  MF,  et al; American Surgical Association Blue Ribbon Committee.  American Surgical Association Blue Ribbon Committee report on surgical education: 2004.   Ann Surg. 2005;241(1):1-8. doi:10.1097/01.sla.0000150066.83563.52 PubMedGoogle ScholarCrossref
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Abruzzo  D, Sklar  DP, McMahon  GT.  Improving trust between learners and teachers in medicine.   Acad Med. 2019;94(2):147-150. doi:10.1097/ACM.0000000000002514 PubMedGoogle ScholarCrossref
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Mullins  CH, MacLennan  P, Wagle  A, Chen  H, Lindeman  B.  Repeat attending exposure influences operative autonomy in endocrine surgical procedures.   J Surg Educ. 2020;77(6):e71-e77. doi:10.1016/j.jsurg.2020.08.035PubMedGoogle ScholarCrossref
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    Original Investigation
    March 24, 2021

    A Framework for Understanding the Association Between Training Paradigm and Trainee Preparedness for Independent Surgical Practice

    Author Affiliations
    • 1Division of Vascular Surgery, Department of Surgery, University of Utah, Salt Lake City
    • 2Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison
    • 3Department of Medical Education, University of Illinois at Chicago, Chicago
    JAMA Surg. 2021;156(6):535-540. doi:10.1001/jamasurg.2021.0031
    Key Points

    Question  What factors are associated with surgical trainees’ perception of their preparedness for independent practice, and what are the differences between different training paradigms?

    Findings  In this qualitative study of 22 recent graduates and program directors of graduate surgical training programs, 4 key domains were identified as factors that affect perception of preparedness for independent surgical practice: the structure of the training program, characteristics of the individual trainee, relationships between trainees and faculty members, and the clinical material and culture of the organization where the training occurs.

    Meaning  Results of this study were used to create a framework for evaluating and improving existing residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains.

    Abstract

    Importance  The sociopolitical and cultural context of graduate surgical education has changed considerably over the past 2 decades. Although new structures of graduate surgical training programs have been developed in response and the comparative value of formats are continually debated, it remains unclear how different time-based structural paradigms are preparing trainees for independent practice after program completion.

    Objective  To investigate the factors associated with trainees’ and program directors’ perception of trainee preparedness for independent surgical practice.

    Design, Setting, and Participants  This qualitative study used an instrumental case study approach and obtained information through semistructured interviews, which were analyzed using open-and-focused coding. Participants were recent graduates and program directors of vascular surgery training programs in the United States. The 2 training paradigms analyzed were the integrated vascular surgery residency program (0 + 5, with 0 indicating that the general surgery training experiences are fully integrated into the 5 years of overall training and 5 indicating the total number of years of training) and the traditional vascular surgery fellowship program (5 + 2, with 5 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training). All graduates completed their training in 2018. All interviews were conducted between July 1, 2018, and September 30, 2018.

    Main Outcomes and Measures  A conceptual framework to inform current and ongoing efforts to optimize graduate surgical training programs across specialties.

    Results  A total of 22 semistructured interviews were completed, involving 7 graduates of 5 + 2 programs, 9 graduates of 0 + 5 programs, and 6 vascular surgery program directors. Of the 22 participants, 15 were men (68%). Participants described 4 interconnected domains that were associated with trainees’ perceived preparedness for practice: structural, individual, relational, and organizational. Structural factors included the overall and vascular surgery–specific time spent in training, whereas individual factors included innate technical skills, confidence, maturity, and motivation. Faculty-trainee relationships (or relational factors) were deemed important for building trust and granting of autonomy. Organizational factors included features of the local organization, including patient population, case volume, and case mix.

    Conclusions and Relevance  Findings suggest that restructuring training paradigms alone is insufficient to address the issue of trainees’ perceived preparedness for practice. A framework was created from the results for evaluating and improving residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains associated with preparedness.

    Introduction

    The landscape of graduate surgical education has changed considerably over the past 2 decades. Trainees no longer experience complete immersion in the practice of surgery, with work-hour regulations limiting their exposure to the full course of individual patient care.1-3 Advances in technology and treatment options have resulted in ever-increasing information to learn and technical skills to master. Demands from accrediting bodies for competency-based training have further complicated long-standing time-based training models.4-6 Increasing attention has been paid to trainee well-being, burnout, and fiscal responsibility related to duration of training.7,8 This radically altered learning environment has called into question whether the traditional training models of 5 to 7 years of general surgery residency, plus fellowship for more than 80% of graduates, continue to meet the needs of trainees.9

    In addition to the impact of an altered learning environment, and perhaps in response to it, new surgical training paradigms have been developed and implemented in a variety of specialties.10,11 These new paradigms, particularly integrated types, have made substantial changes to the structure of surgical training with a focus on the amount of time spent in training and the allocation of that time to general surgery and subspecialty experiences.

    The surgical community has debated the relative merits of these different models, with persistent skepticism regarding shortened paradigms.12,13 It remains unclear, however, whether the structural changes inherent in these new models have addressed the challenges of preparing graduates for independent practice in the context of the current learning environment. The goal of this qualitative study was to investigate the factors associated with trainees’ and program directors’ perception of trainee preparedness for independent surgical practice.

    Methods

    Qualitative interviews are particularly well-suited for investigations that aim to explore individuals’ perspectives. We chose to use a semistructured interview technique to elicit participants’ views about their preparedness for independent surgical practice.14 The institutional review boards of the University of Utah and University of Illinois, Chicago deemed this study exempt from review because the identity of the participants was anonymized. Verbal informed consent was obtained from all participants.

    Setting and Participants

    To investigate how the structure of graduate surgical training programs impacts the perceived learner preparedness for practice, we adopted an instrumental case study approach, which enabled the exploration of a broad concept through the examination of a particular representative case.15Quiz Ref ID We recruited graduates from integrated vascular surgery residency programs (0 + 5, with 0 indicating that the general surgery training experiences are fully integrated into the 5 years of overall training and 5 indicating the total number of years of training) and from traditional vascular surgery fellowship programs (5 + 2, with 5 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training) as well as vascular surgery program directors to participate in the study. The Association of Program Directors in Vascular Surgery directory was used to identify all 2018 graduates of the 0 + 5 and 5 + 2 programs.

    To ensure that participants would be able to comment on both training paradigms, we used a purposive sampling strategy, with a focus on graduates of institutions with both the 0 + 5 and 5 + 2 programs and program directors with experience directing both paradigms. Invitations to participate, along with a consent cover letter, were emailed to 41 graduates from 0 + 5 programs, 45 graduates from 5 + 2 programs, and 35 program directors. Participation was voluntary, and all who responded to the recruitment email were included in the analysis.

    Data Collection and Analysis

    We used prominent themes in the literature on preparedness for practice to inform the semistructured interview guides, which were then piloted and refined for content and clarity (eAppendices 1 and 2 in the Supplement). One of us (B.K.S.), a vascular surgeon who completed the 0 + 5 program and served as an associate program director of a 5 + 2 program for 2 years, conducted all of the interviews between July 1, 2018, and September 30, 2018. Interview length ranged from 20 to 45 minutes, and all interviews were audio-recorded and transcribed. Identifying information on participants was removed at transcription.

    We used the thematic and analytic approach of open-and-focused coding, with the help of NVivo software, version 12 (QSR International), for data management and analysis.16 With an inductive approach, we developed a codebook or set of focused codes from the initial analytical categories. These focused codes were used to code the full data set. Initial and integrative memos were shared among the study team members throughout the data analysis phase to minimize bias and ensure reflexivity during the development of the analytic model. Data collection and analysis continued until thematic saturation was achieved.

    Results

    Twenty-two semistructured interviews were completed with 7 graduates of 5 + 2 programs, 9 graduates of 0 + 5 programs, and 6 vascular surgery program directors. Participants were from 18 vascular surgery training programs across the United States. Of the 22 participants, 15 were men (68%) and 7 were women (32%). Recent graduates and program directors described factors associated with trainee preparation for practice, focusing on the quantity and quality of time in training as well as the differences in 2 program structures (0 + 5 vs 5 + 2). Although this emphasis on the structural domain was unsurprising given that structure was a key difference between the programs, the participants identified 3 additional domains as important contributors to preparedness: individual, relational, and organizational.

    Structural Domain

    Participants described various structural features of vascular surgery training programs that played a role in graduates’ preparedness. These features focused on the overall as well as the vascular surgery–specific quantity of time in training. Vascular-focused time was described as being of greater educational value by graduates of the 0 + 5 program, whereas graduates of the 5 + 2 program largely emphasized the benefit of more time in training overall. Participants generally agreed that there is a point of diminishing returns, when additional time in training is no longer beneficial.

    Many graduates of the 5 + 2 program discussed that the length of time in training was beneficial because “the sheer number of cases is valuable in that when stuff becomes critical, or when all the responsibility is on you, you can just react.” Quiz Ref IDThe longer duration of training provided by the 5 + 2 structure affords an opportunity for a higher volume of both operative cases and other clinical experiences, which contribute to the development of preparedness. Inasuch as case volume is a surrogate for competence, graduates from the 5 + 2 program believed that the structure of their training optimized their technical skills, enabling them to perform more repetitions of operative skills, whether for general or vascular surgical cases.

    Graduates of the 0 + 5 program also emphasized the importance of time in training; however, their focus was on how that time was spent, or the vascular-specific quantity of time. Increased exposure to vascular surgery was believed to be important: “the volume of vascular cases is really beneficial because a lot of the cases we do are not really standard, and there is a lot of decision-making and different ways to attack it.”

    In general, program directors shared the perspective of graduates from the 0 + 5 program, opining that “according to experience, the [0 + 5 trainees] are more prepared because they’ve been thinking about the same problems and types of problems for 5 years.” Another program director said, “[The 0 + 5 residents] have been exposed to us for multiple years and involved in the discussions about why, when, [and] how, because we encouraged them to challenge us on a regular basis.” Similar to responses from the graduates of the 0 + 5 program, program directors emphasized the value of spending more time gaining a deeper understanding of longitudinal patient care.

    Individual Domain

    Participants believed that individual factors had a role in trainees’ preparedness for practice, independent of the structure of the training program that they completed, suggesting that trainees with particular strengths or weaknesses would experience similar successes and challenges in either training paradigm. Individual factors included trainees’ innate technical ability, confidence, maturity, and motivation for self-directed learning.

    When discussing a 5 + 2 program trainee who struggled with lack of confidence, 1 program director remarked, “it was more of an individual thing, I think, than anything else. And my guess is that if [the trainee] had come through the 0 + 5 program they would have had confidence issues as well.” This program director articulated that individuals carry a set of traits that are unique to them and are not a result of the structure of their training program. Similarly, a graduate of the 0 + 5 program discussed trainees’ confidence: “I feel like there’s still going to be differences even when people train for the same amount of time, in their amount of confidence, just based on their personality.”

    Many participants commented that innate abilities were associated with preparedness, with 1 program director noting that “there are people who are gifted and people who are not. I think there is individual variation, and it depends on the person.” In addition, participants often specified that individual skills superseded the type of training paradigm they completed. Another program director suggested that “there are people from both paradigms that are fantastic and are independent and have confidence and are technically great. And then there are people…from both training models that are a little more timid.” This program director highlighted that excellent surgeons have come from both training paradigms, suggesting that individual factors play a role in preparedness, outside of the structure of the program completed. Participants also acknowledged this phenomenon: “Some people are just going to be more naturally comfortable and more naturally gifted, and another year or 2 is really a waste of time for them because they’re already at that point where they should be.…I think it’s more of an individual issue than it is what type of program you come from.” As this graduate explained, the increased time spent in the 5 + 2 program may not be necessary for every trainee, given that some have innate technical skills that can be developed faster.

    Relational Domain

    Quiz Ref IDParticipants described the role of faculty and trainee relationships in trainees’ perceived preparedness for practice. Relational factors that were discussed included the development of trust between faculty and trainees as well as granting autonomy on the basis of trusting relationships. The long-term structure of the 0 + 5 program was described as supporting the development of strong relationships, although this was frequently described as a challenge within the shorter 5 + 2 program.

    As faculty members develop relationships with trainees, they are better able to judge trainees’ competence and entrust them to function autonomously, both in clinical decision-making and operating. One graduate of the 0 + 5 program explained that faculty members who got to know the trainees “know where your skills are…and, in turn, they give you more autonomy. I do think having that longer-term relationship helped.” The increased autonomy that is granted through these trusting teacher-learner relationships was noted as critical to improving trainees’ confidence during their preparation to practice independently.

    On the other hand, graduates of the 5 + 2 program expressed frustration about having to reestablish relationships with new faculty in their fellowship program within a short period. This situation was particularly frustrating to those who recently experienced the pinnacle of these teacher-learner relationships and concomitant autonomy, such as chief general surgery residents. One graduate of the 5 + 2 program explained, “you're just getting to know [faculty]. All they know is what you’re like on paper and what your [general surgery] faculty said, but it's different than just starting de novo and entrusting someone you're meeting for the first time in the operating room as a first-year fellow. I think you start over a little bit.” Although faced with this likely limitation of the 5 + 2 structure, graduates believed that they ultimately were able to overcome this challenge.

    Organizational Domain

    Participants highlighted the importance of organizational factors, such as operative case mix and case volume, regional patient population, and faculty niches and expertise, in preparedness for practice. These factors reflect the clinical material, culture, and learning opportunities that are available to the residents and fellows at the organization in which they are training, regardless of the training paradigm.

    Organizations offer a variety of clinical training sites that provide different patient populations and clinical learning opportunities. Regardless of the structure of the program, the opportunity to train in multiple practice settings was a component of trainees’ perceptions of preparedness. Program directors agreed, with 1 emphasizing that he was “very cognizant of making sure [my trainees] see [vascular surgery] in different cities, different settings, and different practices.” Notably, the program director continued that “you can do more of that in 5 years,” suggesting that the 0 + 5 structure presents more learning opportunities at different sites.

    Differences in patient populations were also noted to impact the clinical learning material and therefore trainees’ perception of preparedness for different aspects of vascular patient care. One participant commented on the prevalence of obesity in the patient population: “where I'm going to practice, obesity is rampant, and where I did my fellowship it wasn't…so I think that's something I'll probably struggle with.”

    Recent graduates frequently referenced whether their training program was “open [surgery] heavy” or had an “endovascular bias,” which was a factor in their perception of preparedness to carry out these technical skills. Graduates described being more confident in particular skills as a result of the preferences and practice patterns of the faculty at their organizations as well as the volume of cases in either open or endovascular surgery. One 0 + 5 graduate said, “We [did] complex [endovascular] aneurysm repair, so I feel pretty comfortable doing complex aortic endo work. As far as peripheral goes, I think that our institution as a whole, we’re very quick to jump to a bypass.” Greater confidence in one or the other skill set was not expressed by graduates from the 0 + 5 program compared with graduates from the 5 + 2 program. Quiz Ref IDBoth groups referred to their local organization as a bigger factor in their technical skill preparedness than their training paradigm.

    Interplay of Domains

    The 4 domains (structural, individual, relational, and organizational) were closely interrelated and each had implications for the other. For example, participants discussed the interplay between time in training (structural factor) and individual characteristics (individual factor), believing that different trainees (individual factor) required more or less time (structural factor) to reach the same level of proficiency. Likewise, organizational features, such as the local patient population and available case mix (organizational factor), were associated with trainees’ confidence (individual factor) after graduation. The quantity of time spent in training (structural factor) was also deemed as a substantial factor in faculty-trainee relationships (relational factor).

    Ultimately, although participants addressed the pros and cons of the different training structures, most expressed that individual, relational, and organizational domains served to balance out the structural differences. One 0 + 5 program graduate said, “I feel like [the program differences] probably all comes out kind of a wash.” Findings from the comparison of the 2 different training structures suggest that individual, relational, and organizational factors had implications for learning in a way that yielded similar outcomes, or preparedness, for trainees from both programs.

    Discussion

    This study explored the factors in the perception of preparedness for practice. Our findings revealed the complexities of graduate surgical training structures as well as the interconnectedness of individual, relational, and organizational domains in practice preparedness, as perceived by both the graduates themselves and their program directors.

    The current time-based structure of graduate surgical training has been largely unchanged since the 1930s, but this structure has come under intense scrutiny within the past 2 decades.17,18 Recommendations for change have focused on restructuring many aspects of the graduate surgical education system.19Quiz Ref ID Findings from this study suggest that this focus on program structure is insufficient to address the concerns over trainees’ perceived preparedness for practice. Participants’ belief that “it all comes out in the end” (which means that graduates of both training paradigms are equally well prepared) indicates that structure is not the only factor to consider in addressing preparedness concerns. From a structural standpoint, improving how the time in training is used, rather than increasing the amount of time in training, appears more likely to impact preparedness.

    The importance of strong faculty-trainee relationships in preparing graduates for practice cannot be overstated. As teacher-learner relationships develop, bidirectional trust is established. Faculty members gradually build trust in their trainees’ decision-making abilities and technical skills, and trainees trust their faculty as competent and professional teachers who have the trainees’ best interests in mind.20 Consistent with previous studies, this study found that both faculty and trainees described trust as essential to enabling trainee autonomy; subsequently, autonomous experiences were described as major contributors to feelings of preparedness.21,22 Trusting relationships develop with time and repeated exposure, which implies that available time and longitudinal engagement are important.22-24 Participants in the present study agreed that the longitudinal engagement between faculty and trainees in the 0 + 5 program was a substantial advantage of this paradigm. This finding suggests that faculty and trainees alike should pay attention to focused and deliberate development of relationships within the 5 + 2 paradigm.

    We used the results of this study to develop a framework for understanding and optimizing graduate surgical training programs across specialties (Figure). This framework recommends the consideration of the organizational, individual, and relational domains of training programs, in addition to the structural domain, to support trainees in becoming independent surgeons.

    Recommendations for Use of the Framework

    We propose 2 important applications of the framework described herein: (1) evaluation and continuous quality improvement of existing residency and fellowship programs, and (2) development of graduate surgical training paradigms to meet the needs of learners in today’s clinical learning environment.

    We recommend that programs map the data that they collect from their annual program evaluations to the 4 domains in the framework. Although we anticipate that many organizational factors (such as operative case mix and volume) and structural factors (such as the rotation schedule and time allotment for different activities) are currently included in their evaluations, it is likely that relational and individual factors are not included. New evaluation tools may be needed to assist programs in understanding these factors, which are critical to establishing a good learning environment and ensuring trainees’ preparedness for practice.

    As surgical education leaders and organizations continue to deliberate on paradigms that optimize graduate surgical training, they must consider the association between different structural paradigms and the other 3 domains in the framework. Adjusting the structure of general surgery residency training to the 3 + 3 (with 3 indicating the number of years of general surgery training and 3 indicating the number of years of vascular surgery training) or the 4 + 2 (with 4 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training) program, among others, may impact the development of strong faculty-trainee relationships, which could have either favorable or detrimental outcomes for trainee autonomy and confidence. Different program structures may be better suited to different organizations, depending on the local patient population, case volume, and case mix. Furthermore, individual learners may thrive within different structures, depending on the overall summation of the learning environment as these different factors interact. Through more complex interaction effects, different training models may be better suited to different combinations of organizational contexts and individuals, suggesting that a menu of options may be the best approach to meeting the needs of programs and learners going forward.

    Limitations

    This study has several limitations. First, respondent selection bias may have resulted in a sample that is not representative of the general population of vascular surgery graduates and program directors. Future studies should explore the unique experiences of residents and fellows who have struggled during training. Second, we recruited participants who had recently graduated and had not yet begun their independent surgical practice. Interviews with those who have been in practice may have provided different insights. Third, this study included a relatively small sample of surgeons in 1 specialty. Although this small sample size may raise questions of generalizability to other specialties, the case study approach provided an opportunity to explore a phenomenon of interest and thus was ideal for the development of a framework.

    Conclusions

    As surgical education leaders continue to consider restructuring graduate surgical training, they must also consider the implications of individual, relational, and organizational domains for the learning environment and, ultimately, trainees’ preparedness for practice. Findings from this study suggest that restructuring the training paradigms alone is insufficient to address the issue of trainees’ perceived preparedness. The results of this study were used to create a framework that could be applied to evaluating and improving existing residency and fellowship programs as well as to developing graduate surgical training paradigms that incorporate all 4 domains. Because the program structure is only 1 domain in trainees’ perceived preparedness, the surgical community should exercise caution in making assumptions about a surgeon’s preparedness on the basis of training paradigm alone.

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    Article Information

    Accepted for Publication: December 30, 2020.

    Published Online: March 24, 2021. doi:10.1001/jamasurg.2021.0031

    Corresponding Author: Brigitte K. Smith, MD, MHPE, Division of Vascular Surgery, Department of Surgery, University of Utah, 30 N 1900 E, SOM#3C344, Salt Lake City, UT 84132 (brigitte.smith@hsc.utah.edu).

    Author Contributions: Dr Smith had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Smith, Yudkowsky, Hirshfield.

    Acquisition, analysis, or interpretation of data: Smith, Rectenwald, Hirshfield.

    Drafting of the manuscript: Smith.

    Critical revision of the manuscript for important intellectual content: All authors.

    Administrative, technical, or material support: Smith.

    Supervision: Smith, Rectenwald, Hirshfield.

    Conflict of Interest Disclosures: None reported.

    Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of the APDVS.

    Additional Contributions: The Association of Program Directors in Vascular Surgery (APDVS) provided contact information for the recruitment of study participants.

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