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Confounding by indication is a critical challenge in evaluating the effectiveness of surgical interventions using observational data. The threat from confounding is compounded when using medical claims data due to the inability to measure risk severity. If there are unobserved differences in risk severity across patients, treatment effect estimates based on methods such a multivariate regression may be biased in an unknown direction. A research design based on instrumental variables offers one possibility for reducing bias from unobserved confounding compared to risk adjustment with observed confounders. This study investigates whether a physician’s preference for operative care is a valid instrumental variable for studying the effect of emergency surgery. We review the plausibility of the necessary causal assumptions in an investigation of the effect of emergency general surgery (EGS) on inpatient mortality among adults using medical claims data from Florida, Pennsylvania, and New York in 2012–2013. In a departure from the extant literature, we use the framework of stochastic monotonicity which is more plausible in the context of a preference-based instrument. We compare estimates from an instrumental variables design to estimates from a design based on matching that assumes all confounders are observed. Estimates from matching show lower mortality rates for patients that undergo EGS compared to estimates based in the instrumental variables framework. Results vary substantially by condition type. We also present sensitivity analyses as well as bounds for the population level average treatment effect. We conclude with a discussion of the interpretation of estimates from both approaches.

RA was dramatically reduced following the intervention. A custom designed process to identify candidates most likely to succeed substantially improved resident retention in a demanding academic training program.

In evaluating the effectiveness of general surgery (GS) training, an unbiased assessment of the progression of residents with attention to individual learner factors is imperative.OBJECTIVE To evaluate the role of trainee sex in milestone achievement over the course of GS residency using national data from the Accreditation Council for Graduate Medical Education (ACGME). DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study evaluated female and male GS residents enrolled in ACGME-accredited programs in the US from 2014 to 2018 with reported variation in milestones performance across years in training and representation. Data were analyzed from November 2019 to June 2021. MAIN OUTCOMES AND MEASURESMean reported milestone score at initial and final assessment, and predicted time-to-attainment of equivalent performance by sex. RESULTS Among 4476 GS residents from 250 programs who had milestone assessments at any point in their clinical training, 1735 were female (38.8%). Initially, female and male residents received similar mean (SD) milestone scores (1.95 [0.50] vs 1.94 [0.50]; P = .69). At the final assessment, female trainees received overall lower mean milestone scores than male trainees (4.25 vs 4.31; P < .001). Significantly lower mean milestone scores were reported for female residents at the final assessment for several subcompetencies in both univariate and multivariate analyses, with only medical knowledge 1 (pathophysiology, diagnosis, and initial management) common to both. Multilevel mixed-effects linear modeling demonstrated that female trainees had significantly lower rates of monthly milestone attainment in the subcompetency of medical knowledge 1, which was associated with a significant difference in training time of approximately 1.8 months.CONCLUSIONS AND RELEVANCE Both female and male GS trainees achieved the competency scores necessary to transition to independence after residency as measured by the milestones assessment system. Initially, there were no sex differences in milestone score. By graduation, there were differences in the measured assessment of female and male trainees across several subcompetencies. Careful monitoring for sex bias in the evaluation of trainees and scrutiny of the training process is needed to ensure that surgical residency programs support the educational needs of both female and male trainees.

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