- Email: [email protected]
Surgical resident perspective on deceased donor organ procurement
The American Journal of Surgery (2015) 209, 1090-1094
Surgical Education
Surgical resident perspective on deceased donor organ procurement Adena J. Osband, M.D.*, David A. Laskow, M.D. Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
KEYWORDS: Organ procurement; Organ donation; Surgical education
Abstract BACKGROUND: Deceased donor organ procurement provides unparalleled opportunity for surgical residents with extensive surgical exposure. We hypothesize that surgical residents regard organ donation positively and organ procurement enhances their education. METHODS: We conducted an institutional review board approved anonymous national survey to evaluate organ procurement experiences and attitudes of general surgical residents. RESULTS: Three hundred ninety-seven residents representing all postgraduate years responded, with 97% completion rate. Organ procurement increased with training level (92% seniors vs 53% interns). Over 85% agree organ procurement is a good educational and operative experience, and 73% believe that it will benefit their future surgical career. About 68% agree that organ procurement provided knowledge of anatomy and exposures; under 10% felt organ procurement could be duplicated with simulation. Presence of transplant program did not affect attitudes or experience. Eighty-eight percent women versus77% men plan to donate their own organs. CONCLUSION: Results indicate that surgical residents value organ procurement, and it remains an essential encounter that applies to general surgery. Ó 2015 Elsevier Inc. All rights reserved.
As surgical training becomes more time limited, focus should be centered on maximizing resident benefit from every single operative experience. Deceased donor organ procurement provides a unique opportunity in many ways. The operation itself is extensive, with an expansive lesson in anatomy not provided in any other setting.1,2 The exposures and techniques used in procurement may be of significant help in operations and surgical disciplines other than transplantation.1,3 The potential for increased operative experience at an earlier stage in training clearly exists during procurement. In addition, the chance to learn to work
closely and simultaneously with other surgical teams is not a frequent occurrence in general surgery. At this time, there is active debate regarding the need for a transplant surgery rotation as part of general surgical training.4 Although the extent and applicability of the organ procurement experience both educationally and surgically are not surprising to most who have participated, this concept has not been extensively studied or quantified. In addition, there is little in the literature regarding surgical residents’ attitudes toward organ donation overall, despite their active involvement in the process.5,6
The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-732-253-3699; fax: 11-732-4487319. E-mail address: [email protected] Manuscript received January 31, 2014; revised manuscript May 22, 2014
Methods
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.08.039
The 23-question anonymous survey was administered through Survey Monkey (Fig. 1). Distribution of the survey was done by the US general surgery program directors, who
A.J. Osband and D.A. Laskow
Surgical residents & organ procurement
1091
approved. Statistical analysis was performed using unpaired t test.
Results
Figure 1
The 23 question survey and answer choices.
were sent the link electronically and were asked to forward it to their residents. Answers were multiple choice or evaluated on a 5-point Likert scale, with responses ranging from strongly agree to strongly disagree. Opportunity for additional comment was provided for each answer. Prior to national distribution, the questionnaire was validated by a group of surgeons and a pilot study at a single institution. The study and survey were institutional review board
Three hundred ninety-seven residents responded to the survey, with a 97% completion rate. Assuming all program directors distributed the survey, this represents a 7% response rate. All postgraduate years are represented, with each year comprising 13% to 25% of the population (Fig. 2). The sex breakdown is roughly equal, with 57% men and 43% women. Self-reported race demonstrates 76% Caucasian, 4% African American, 3% Hispanic, and 17% other. All regions of the United States are represented, but the southwest only comprises 4%. Eighty-seven percent of the respondents have already rotated on the transplant service. Fifty-eight percent have not yet attended organ procurement during residency, but 23% did prior to residency (Fig. 3). A total of 29% have never participated in organ procurement. Organ procurement involvement correlated with postgraduate year, with 100% of the chiefs having participated during residency. Over 80% of all respondents, and 100% of those with experience (organ procurement R 1), agree or strongly agree that organ procurement is both a good educational and operative experience (Table 1). Each senior resident considers procurement to have provided knowledge of anatomy and exposures; only one feels that procurement did not impact his approach to other operations. Most of those with neutral opinion on this question have not yet had experience, and only 22% would not like more experience. In fact, 60% of those who have already done over 10 want further opportunity to participate. Seventy-three percent of respondents believe their future careers will benefit from their procurement experience. Of those who have done organ procurement, only 6% disagree that the experience will positively benefit their future as a surgeon. There is a clear association between experience and perceived impact on future career. Regardless of sex and race, residents feel that organ procurement is a valuable experience, both technically and educationally. Few residents believe that the organ procurement experience can be duplicated with either simulation or another currently performed operation. Over 70% of respondents are interested in donation, and the majority would donate a relative’s organs if the decision were theirs to make (Table 1). Seventy-six percent would consider live donation for a known recipient, and 23% would entertain altruistic donation. Experience does not correlate with willingness to donate. Seventy-eight percent of men and 88% of women report plans to donate their organs (P 5 .01). Remarkably, 77% of both men and women have signed donor cards. Although nearly all the men have indicated their wishes with a signed donor card, a number of the women who profess interest in organ donation do not yet have signed donor cards.
1092
The American Journal of Surgery, Vol 209, No 6, June 2015
Figure 2
Distribution across postgraduate years.
There is no difference in accepting an organ if one needed a transplant, with regard to sex or experience. Respondents are equally likely to accept an organ from a living or deceased donor. More women than men (16 vs 8) report negative association with organ procurement (P 5 .01), though there is no correlation with experience. Only 12 individuals report religious concerns and 5 report ethical concerns. Many of those with negative associations or concerns have not yet actually
Figure 3
participated in organ procurement. Their concerns about organ procurement did not correlate with negative attitude toward donation.
Comment Organ donation rates are unquestionably tied to education.7 Many studies have documented misperceptions and
Distribution of organ procurement resident experience.
A.J. Osband and D.A. Laskow Table 1
Surgical residents & organ procurement
1093
Representative survey results, listed as percentages of total responses
Organ procurement is a good educational experience Organ procurement is a good operative experience Organ procurement can be duplicated with simulator Organ procurement can be duplicated with other operations Organ procurement provides knowledge anatomy and exposure Organ procurement impacts approach to other operations Organ procurement will benefit future surgical career Ethical concerns Religious concerns Negative association License signed for organ donation Plan to donate organs Would donate relative’s organs Would consider live donation Would accept transplant (deceased donor) Would accept transplant (live donor)
attitudes of various healthcare professionals toward organ donation in various countries.6,8–11 The common conclusion of these studies is that people in general favor organ donation and that some education is lacking. Not surprisingly, an international survey of transplant professionals showed that 88% felt public education would positively impact organ donation worldwide.7 Unfortunately, despite many countries undertaking public education initiatives, consent rates remain low.12 Ideally, this instruction would target not just the public, but specifically medical personnel. Three studies surveying medical students revealed that some education is still lacking even for those pursing medicine, and as anticipated, increased education was associated with increased willingness to donate.8–10 Interestingly, few of these studies of medical personnel have targeted those in surgical training. Surgical residents are uniquely positioned in dealing with organ procurement, as they participate in the care of potential donors in the trauma and intensive care realms, and also rotate on the transplant service. In addition, they may care for patients who die before an appropriate organ is able to be transplanted. A study published in 2009 surveyed medical students, surgical residents, and attending surgeons at 2 academic medical centers.5 That survey included 41 surgical residents, with similar findings to our survey with respect to rates of organ procurement experience, objections, and willingness to donate organs. Regrettably that article noted that most of the individuals with resistance to donation cited the organ procurement procedure as the dominant reason. In contrast, our study demonstrated that increased experience was associated with more positive attitude toward organ donation. And despite more negative association with organ procurement, more women plan to donate their organs, perhaps because of a distinction between the procedure itself and the concept of organ donation. This discrepancy further highlights the need for
Agree (strongly agree and agree)
Neutral (undecided)
Disagree (strongly disagree and disagree)
88 87 9 15 68 42 73 3 1 6 77 83 81 76 90 88
8 8 24 26 26 46 21 0 0 0 0 12 13 19 7 9
4 5 67 59 6 12 6 97 99 94 23 5 6 5 3 3
emphasis on education and advocacy. In this highly educated group, it was also surprising to find a reasonable percentage that remain undecided. Involving surgical residents in organ procurement provides them an opportunity to learn about the entire process of brain death and organ donation. A clear limitation of this study involves its distribution. After being validated by all residents at a single general surgery program, it was sent out nationally. Because of the inability to contact each surgical resident directly, we were dependent on program directors to e-mail the survey link to their residents and encourage participation. This obviously resulted in a smaller response than desired, but we do believe the information we received to be worthwhile and applicable to many programs. As reflected in the survey responses, most ambivalence toward organ procurement is present in the inexperienced. Clearly, those who have participated value its educational benefits and understand the applications to nontransplant surgery. A previous study illustrated this point with regard to vascular exposure teaching for senior residents, and a subsequent letter to the editor questioned further study on this subject.1,2 Since that initial small study years ago, this is the only project quantifying the impact of organ procurement exposure. A study reporting use of a cadaver laboratory in surgical residency supports our study’s finding of the inferiority of simulation.13 Based on this survey, many residency programs have no formal system in place to enable resident participation in organ procurement. The shift toward less open operative experience during general surgery residency will only continue, and organ procurement may be part of the solution.14,15 Our study clearly emphasizes the global applicability of organ procurement experience beyond a career in transplant surgery. It would therefore seem imperative that residency programs enable and facilitate organ procurement participation.
1094 In summary, general surgical residents greatly value the surgical experience of deceased donor organ procurement and have a positive attitude toward donation. The benefits of organ procurement experience are not limited to procurement itself or transplant surgery. Further advocacy is needed in the transplant and general surgical arenas to keep procurement experience a vital part of surgical residency training.
References 1. Ahmed N, Chung R. Multiple organ procurement: a tool for teaching operative technique of major vascular control. J Trauma 2008;65: 1093–4. 2. Ball CG, Dixon E, Kirpatrick AW. The utility of organ procurement procedures for operative trauma training. J Trauma 2009;67:1128. 3. Schwartz JJ, Thiesset HF, Bohn JA, et al. Perceived benefits of a transplant surgery experience to general surgery residency training. J Surg Educ 2012;69:371–84. 4. Fryer JP, Magee JC. Optimizing the surgical residents’ educational experience on transplant surgery. J Surg Educ 2009;66:196–200. 5. Hobeika MJ, Simon R, Malik R, et al. US surgeon and medical student attitudes toward organ donation. J Trauma 2009;67:372–5. 6. Rios A, Conesa C, Ramirez P, et al. Attitudes of resident doctors toward different types of organ donation in a Spanish transplant hospital. Transplant Proc 2006;38:869–74.
The American Journal of Surgery, Vol 209, No 6, June 2015 7. Oz MC, Kherani AR, Rowe A, et al. How to improve organ donation: results of the ISHLT/FACT poll. J Heart Lung Transplant 2003;22: 389–410. 8. Najafizadeh K, Shiemorteza M, Jamali M, et al. Attitudes of medical students about brain death and organ donation. Transplant Proc 2009; 41:2707–10. 9. Mekahli D, Liutkus A, Fargue S, et al. Survey of first-year medical students to assess their knowledge and attitudes toward organ transplantation and donation. Transplant Proc 2009;41:634–8. 10. Schaeffner ES, Windisch W, Freidel K, et al. Knowledge and attitude regarding organ donation among medical students and physicians. Transplantation 2004;77:1714–8. 11. Reddy AVR, Guleria S, Khazanchi RK, et al. Attitude of patients, the public, doctors, and nurses toward organ donation. Transplant Proc 2003;35:18. 12. Irving MJ, Tong A, Jan S, et al. Factors that influence the decision to be an organ donor: a systematic review of the qualitative literature. Nephrol Dial Transplant 2012;27:2526–33. 13. Lewis CE, Peacock WJ, Tillou A, et al. A novel cadaver-based educational program in general surgery training. J Surg Educ 2012;69: 693–8. 14. Gunter JW, Simmons JD, Mitchell ME, et al. A solution to the decreased resident exposure to open operations in the era of minimally invasive surgery and restricted duty hours may be with organ procurement and transplantation surgery. J Surg Educ 2012;69:575–9. 15. McCoy AM, Gasevic E, Szlabick RE, et al. Are open abdominal procedures a thing of the past? An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ 2013;70:683–9.
Surgical Education
Surgical resident perspective on deceased donor organ procurement Adena J. Osband, M.D.*, David A. Laskow, M.D. Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
KEYWORDS: Organ procurement; Organ donation; Surgical education
Abstract BACKGROUND: Deceased donor organ procurement provides unparalleled opportunity for surgical residents with extensive surgical exposure. We hypothesize that surgical residents regard organ donation positively and organ procurement enhances their education. METHODS: We conducted an institutional review board approved anonymous national survey to evaluate organ procurement experiences and attitudes of general surgical residents. RESULTS: Three hundred ninety-seven residents representing all postgraduate years responded, with 97% completion rate. Organ procurement increased with training level (92% seniors vs 53% interns). Over 85% agree organ procurement is a good educational and operative experience, and 73% believe that it will benefit their future surgical career. About 68% agree that organ procurement provided knowledge of anatomy and exposures; under 10% felt organ procurement could be duplicated with simulation. Presence of transplant program did not affect attitudes or experience. Eighty-eight percent women versus77% men plan to donate their own organs. CONCLUSION: Results indicate that surgical residents value organ procurement, and it remains an essential encounter that applies to general surgery. Ó 2015 Elsevier Inc. All rights reserved.
As surgical training becomes more time limited, focus should be centered on maximizing resident benefit from every single operative experience. Deceased donor organ procurement provides a unique opportunity in many ways. The operation itself is extensive, with an expansive lesson in anatomy not provided in any other setting.1,2 The exposures and techniques used in procurement may be of significant help in operations and surgical disciplines other than transplantation.1,3 The potential for increased operative experience at an earlier stage in training clearly exists during procurement. In addition, the chance to learn to work
closely and simultaneously with other surgical teams is not a frequent occurrence in general surgery. At this time, there is active debate regarding the need for a transplant surgery rotation as part of general surgical training.4 Although the extent and applicability of the organ procurement experience both educationally and surgically are not surprising to most who have participated, this concept has not been extensively studied or quantified. In addition, there is little in the literature regarding surgical residents’ attitudes toward organ donation overall, despite their active involvement in the process.5,6
The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-732-253-3699; fax: 11-732-4487319. E-mail address: [email protected] Manuscript received January 31, 2014; revised manuscript May 22, 2014
Methods
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.08.039
The 23-question anonymous survey was administered through Survey Monkey (Fig. 1). Distribution of the survey was done by the US general surgery program directors, who
A.J. Osband and D.A. Laskow
Surgical residents & organ procurement
1091
approved. Statistical analysis was performed using unpaired t test.
Results
Figure 1
The 23 question survey and answer choices.
were sent the link electronically and were asked to forward it to their residents. Answers were multiple choice or evaluated on a 5-point Likert scale, with responses ranging from strongly agree to strongly disagree. Opportunity for additional comment was provided for each answer. Prior to national distribution, the questionnaire was validated by a group of surgeons and a pilot study at a single institution. The study and survey were institutional review board
Three hundred ninety-seven residents responded to the survey, with a 97% completion rate. Assuming all program directors distributed the survey, this represents a 7% response rate. All postgraduate years are represented, with each year comprising 13% to 25% of the population (Fig. 2). The sex breakdown is roughly equal, with 57% men and 43% women. Self-reported race demonstrates 76% Caucasian, 4% African American, 3% Hispanic, and 17% other. All regions of the United States are represented, but the southwest only comprises 4%. Eighty-seven percent of the respondents have already rotated on the transplant service. Fifty-eight percent have not yet attended organ procurement during residency, but 23% did prior to residency (Fig. 3). A total of 29% have never participated in organ procurement. Organ procurement involvement correlated with postgraduate year, with 100% of the chiefs having participated during residency. Over 80% of all respondents, and 100% of those with experience (organ procurement R 1), agree or strongly agree that organ procurement is both a good educational and operative experience (Table 1). Each senior resident considers procurement to have provided knowledge of anatomy and exposures; only one feels that procurement did not impact his approach to other operations. Most of those with neutral opinion on this question have not yet had experience, and only 22% would not like more experience. In fact, 60% of those who have already done over 10 want further opportunity to participate. Seventy-three percent of respondents believe their future careers will benefit from their procurement experience. Of those who have done organ procurement, only 6% disagree that the experience will positively benefit their future as a surgeon. There is a clear association between experience and perceived impact on future career. Regardless of sex and race, residents feel that organ procurement is a valuable experience, both technically and educationally. Few residents believe that the organ procurement experience can be duplicated with either simulation or another currently performed operation. Over 70% of respondents are interested in donation, and the majority would donate a relative’s organs if the decision were theirs to make (Table 1). Seventy-six percent would consider live donation for a known recipient, and 23% would entertain altruistic donation. Experience does not correlate with willingness to donate. Seventy-eight percent of men and 88% of women report plans to donate their organs (P 5 .01). Remarkably, 77% of both men and women have signed donor cards. Although nearly all the men have indicated their wishes with a signed donor card, a number of the women who profess interest in organ donation do not yet have signed donor cards.
1092
The American Journal of Surgery, Vol 209, No 6, June 2015
Figure 2
Distribution across postgraduate years.
There is no difference in accepting an organ if one needed a transplant, with regard to sex or experience. Respondents are equally likely to accept an organ from a living or deceased donor. More women than men (16 vs 8) report negative association with organ procurement (P 5 .01), though there is no correlation with experience. Only 12 individuals report religious concerns and 5 report ethical concerns. Many of those with negative associations or concerns have not yet actually
Figure 3
participated in organ procurement. Their concerns about organ procurement did not correlate with negative attitude toward donation.
Comment Organ donation rates are unquestionably tied to education.7 Many studies have documented misperceptions and
Distribution of organ procurement resident experience.
A.J. Osband and D.A. Laskow Table 1
Surgical residents & organ procurement
1093
Representative survey results, listed as percentages of total responses
Organ procurement is a good educational experience Organ procurement is a good operative experience Organ procurement can be duplicated with simulator Organ procurement can be duplicated with other operations Organ procurement provides knowledge anatomy and exposure Organ procurement impacts approach to other operations Organ procurement will benefit future surgical career Ethical concerns Religious concerns Negative association License signed for organ donation Plan to donate organs Would donate relative’s organs Would consider live donation Would accept transplant (deceased donor) Would accept transplant (live donor)
attitudes of various healthcare professionals toward organ donation in various countries.6,8–11 The common conclusion of these studies is that people in general favor organ donation and that some education is lacking. Not surprisingly, an international survey of transplant professionals showed that 88% felt public education would positively impact organ donation worldwide.7 Unfortunately, despite many countries undertaking public education initiatives, consent rates remain low.12 Ideally, this instruction would target not just the public, but specifically medical personnel. Three studies surveying medical students revealed that some education is still lacking even for those pursing medicine, and as anticipated, increased education was associated with increased willingness to donate.8–10 Interestingly, few of these studies of medical personnel have targeted those in surgical training. Surgical residents are uniquely positioned in dealing with organ procurement, as they participate in the care of potential donors in the trauma and intensive care realms, and also rotate on the transplant service. In addition, they may care for patients who die before an appropriate organ is able to be transplanted. A study published in 2009 surveyed medical students, surgical residents, and attending surgeons at 2 academic medical centers.5 That survey included 41 surgical residents, with similar findings to our survey with respect to rates of organ procurement experience, objections, and willingness to donate organs. Regrettably that article noted that most of the individuals with resistance to donation cited the organ procurement procedure as the dominant reason. In contrast, our study demonstrated that increased experience was associated with more positive attitude toward organ donation. And despite more negative association with organ procurement, more women plan to donate their organs, perhaps because of a distinction between the procedure itself and the concept of organ donation. This discrepancy further highlights the need for
Agree (strongly agree and agree)
Neutral (undecided)
Disagree (strongly disagree and disagree)
88 87 9 15 68 42 73 3 1 6 77 83 81 76 90 88
8 8 24 26 26 46 21 0 0 0 0 12 13 19 7 9
4 5 67 59 6 12 6 97 99 94 23 5 6 5 3 3
emphasis on education and advocacy. In this highly educated group, it was also surprising to find a reasonable percentage that remain undecided. Involving surgical residents in organ procurement provides them an opportunity to learn about the entire process of brain death and organ donation. A clear limitation of this study involves its distribution. After being validated by all residents at a single general surgery program, it was sent out nationally. Because of the inability to contact each surgical resident directly, we were dependent on program directors to e-mail the survey link to their residents and encourage participation. This obviously resulted in a smaller response than desired, but we do believe the information we received to be worthwhile and applicable to many programs. As reflected in the survey responses, most ambivalence toward organ procurement is present in the inexperienced. Clearly, those who have participated value its educational benefits and understand the applications to nontransplant surgery. A previous study illustrated this point with regard to vascular exposure teaching for senior residents, and a subsequent letter to the editor questioned further study on this subject.1,2 Since that initial small study years ago, this is the only project quantifying the impact of organ procurement exposure. A study reporting use of a cadaver laboratory in surgical residency supports our study’s finding of the inferiority of simulation.13 Based on this survey, many residency programs have no formal system in place to enable resident participation in organ procurement. The shift toward less open operative experience during general surgery residency will only continue, and organ procurement may be part of the solution.14,15 Our study clearly emphasizes the global applicability of organ procurement experience beyond a career in transplant surgery. It would therefore seem imperative that residency programs enable and facilitate organ procurement participation.
1094 In summary, general surgical residents greatly value the surgical experience of deceased donor organ procurement and have a positive attitude toward donation. The benefits of organ procurement experience are not limited to procurement itself or transplant surgery. Further advocacy is needed in the transplant and general surgical arenas to keep procurement experience a vital part of surgical residency training.
References 1. Ahmed N, Chung R. Multiple organ procurement: a tool for teaching operative technique of major vascular control. J Trauma 2008;65: 1093–4. 2. Ball CG, Dixon E, Kirpatrick AW. The utility of organ procurement procedures for operative trauma training. J Trauma 2009;67:1128. 3. Schwartz JJ, Thiesset HF, Bohn JA, et al. Perceived benefits of a transplant surgery experience to general surgery residency training. J Surg Educ 2012;69:371–84. 4. Fryer JP, Magee JC. Optimizing the surgical residents’ educational experience on transplant surgery. J Surg Educ 2009;66:196–200. 5. Hobeika MJ, Simon R, Malik R, et al. US surgeon and medical student attitudes toward organ donation. J Trauma 2009;67:372–5. 6. Rios A, Conesa C, Ramirez P, et al. Attitudes of resident doctors toward different types of organ donation in a Spanish transplant hospital. Transplant Proc 2006;38:869–74.
The American Journal of Surgery, Vol 209, No 6, June 2015 7. Oz MC, Kherani AR, Rowe A, et al. How to improve organ donation: results of the ISHLT/FACT poll. J Heart Lung Transplant 2003;22: 389–410. 8. Najafizadeh K, Shiemorteza M, Jamali M, et al. Attitudes of medical students about brain death and organ donation. Transplant Proc 2009; 41:2707–10. 9. Mekahli D, Liutkus A, Fargue S, et al. Survey of first-year medical students to assess their knowledge and attitudes toward organ transplantation and donation. Transplant Proc 2009;41:634–8. 10. Schaeffner ES, Windisch W, Freidel K, et al. Knowledge and attitude regarding organ donation among medical students and physicians. Transplantation 2004;77:1714–8. 11. Reddy AVR, Guleria S, Khazanchi RK, et al. Attitude of patients, the public, doctors, and nurses toward organ donation. Transplant Proc 2003;35:18. 12. Irving MJ, Tong A, Jan S, et al. Factors that influence the decision to be an organ donor: a systematic review of the qualitative literature. Nephrol Dial Transplant 2012;27:2526–33. 13. Lewis CE, Peacock WJ, Tillou A, et al. A novel cadaver-based educational program in general surgery training. J Surg Educ 2012;69: 693–8. 14. Gunter JW, Simmons JD, Mitchell ME, et al. A solution to the decreased resident exposure to open operations in the era of minimally invasive surgery and restricted duty hours may be with organ procurement and transplantation surgery. J Surg Educ 2012;69:575–9. 15. McCoy AM, Gasevic E, Szlabick RE, et al. Are open abdominal procedures a thing of the past? An analysis of graduating general surgery residents’ case logs from 2000 to 2011. J Surg Educ 2013;70:683–9.