Surgical Infection Society Curriculum Development Symposium: An Overview

Abstract

Hospital-acquired infections, sepsis, and critically ill patients cost the healthcare system billions of dollars every year. Many factors contribute to these problems, and the remedies are multifactorial. Education is an important component in resolving many of the issues related to better combating the economic, social, and personal costs associated with surgical infections. The Surgical Infection Society (SIS) convened a symposium to begin a dialogue on how the SIS can facilitate a better understanding of how to educate the surgical infection professionals and trainees. The following report summarizes the presentations and commentary presented at the 2013 Annual Meeting.

Recent reports estimate that the attributable cost of hospital-acquired infections approaches 10 billion dollars annually in this country [1]. Moreover, sepsis and its sequelae result in excess deaths worldwide. These issues need urgent attention in all domains: Medical policy, practice, and education. Surgical practitioners need a sound, broad-based understanding of surgically relevant infections, risks, preventions, and treatments. While there is general consensus regarding surgical infections, little agreement exists, however, on what should be included in a curriculum.

The Acute Care Surgery and Education and Awards Committees of the Surgical Infection Society (SIS) conducted a targeted needs assessment to determine the need for and components of a surgical infection curriculum. At the Annual Meeting in 2013, a panel convened by the Education and Awards Committee reviewed adult learning principles, acute care surgical and surgical expert opinions, and summarized the key findings followed by audience feedback. The key findings include: (1) Adult learning concepts are critical for surgical infection curriculum delivery; (2) generational trends may modify traditional methods; and (3) surgical infection experts agree that core concepts are needed for specialized fellowships (i.e., acute care surgery), and general surgical infectious disease training offers learning opportunities for surgeons and others began medical school. The SIS will take these findings and refine a surgical infection curriculum. The following sections highlight the key findings from the symposium.

Principles of Adult Learning

In this section, we discuss principles that affect the way adults learn, gain knowledge, as well as generational characteristics that influence learning. We consider the adult learner to include those in Undergraduate Medical Education (medical school), Graduate Medical Education (residency, fellowship), and Continued Medical Education (lifelong learning). What each generation expects from society and values from life affects their approach to education, to learning, and to giving and receiving evaluation. Understanding these values and expectations allows the educator to create teaching methods that best fit the learner's needs.

In 1910, the Flexner Carnegie Foundation-sponsored report revolutionized and set a standard for how medical education was best delivered [2]. A century later, Cooke, Irby, and O'Brien [3], once again sponsored by the Carnegie Foundation, highlighted the modern stresses on medical education and proposed changes. Noting that medical knowledge is expanding exponentially, Cooke, Irby, and O'Brien [3] stated, “…fields…tend to grow through division and multiplication rather than through synthesis and simplification. New domains…new topics …and new specializations are added to the canon…Yet medical students are expected to learn…and somehow to connect, combine, and integrate them within their own understandings and… identities.” While the authors were specifically commenting about medical and resident education, the same is true wherever on the learning spectrum the physician learner is located.

Adult learner motivation

In the lexicon of educators, pedagogy is the art and science of education with its inherent instructional strategies and philosophies. The word, as derived from Greek, essentially means, “to lead the child.” Malcolm Knowles [4] made six assumptions behind the motivation of adult learners when integrating the work of his academic predecessors from multiple disciplines including philosophy, sociology, and social psychology, as well as clinical and developmental psychology. In contrast to pedagogy and to highlight the unique needs of adult learners, Knowles coined the term “andragogy,” or “man-leading.” To summarize:

• Adults learn when they know why they are learning something (Need to Know).

• Experience, including error, is the foundation for learning (Foundation).

• Adult learners are self-responsible and want to be participants in educational planning and evaluation (Self-concept).

• Interest to learn is highest when the topic is relevant to work or life (Readiness).

• Adult learning considers complete problems in context and not small bits of content (Orientation).

• Adult learners respond to internal motivators rather than external incentives (Motivation).

These principles of adult learning underlie common medical school education methods such as problem-based learning, experiential learning, case-based education, etc. Although written before Knowles' principles were known, the fact that the original Flexner report endorsed third and fourth year medical student experiential learning with real, hospitalized patients suggests that such concepts resonated with learners and educators even before they were codified by educational researchers. Likewise, it is not surprising that Cooke, Irby, and O'Brien [5] describe the current medical learning environment in terms of adult learning principles. “Learning is progressive and developmental….Learning is participatory….Learning is situated and distributed.”

Generational characteristics

As residents, we despised it when someone said, “When I was a resident…” But later in our careers, it is improbable that we have not yearned for the way things were. Such generational differences are inevitable. Sociologists have defined characteristics of different generations that may influence the way each learns. It is also important to recognize that the descriptions of each generation are broad, the starting and ending dates may vary depending on sources, and that there is continuity of characteristics between the end of one generation and beginning of another. Notwithstanding, understanding generational tendencies can give insight to teachers and learners and highlight methods to break down instructional and learning barriers.

The most senior in our surgical community were members of the generation known as The Builders who number approximately 56 million. The Builders were raised with memories, if not experience, of the Great Depression and the New Deal. They experienced World War II and the Korean War and were often educated on the GI Bill. They value authority, hard work, personal honor, and delayed gratification. In the workplace, they would frequently work for the same company their entire career [6,7].

Next in line are the 80 million Baby Boomers, generally born between 1946 and 1964. They experienced social stability early, followed by significant changes in the late 1960s with the emergence of the Civil Rights and Women's Rights movements, Vietnam, and the escalating Cold War. They experienced the transition of broadcast entertainment and news from radio to television, on which they witnessed and rapidly mimicked social changes such as rock music and fashion trends. Their personal identities are inextricably linked to their professional identities, which frequently supersede the former. They want perpetual health, youth, and wealth. They consider the purpose of technology to expand their work capacity [6,7].

Following the Boomers is Generation X consisting of the 38 million persons born between 1965 and 1977. This generation is characterized by personal and social uncertainty. They experienced the Persian Gulf War, the Challenger Explosion, the emergence of human immunodeficiency virus/acquired immunodeficiency syndrome, and corporate downsizing. They were the latchkey kids of Boomer parents pre-occupied by their own generational proclivities. Alone at home, they watched MTV, played video games, and learned about computers. Broadly, they desire balance in life and consider that the purpose of technology is to enable that balance [6,7].

Current members of Generation Y, sometimes referred to as the Millennials, are the youngest of today's adult medical learners. Like their predecessors, they have known social and political uncertainty, but at a more intense level. They have grown with global terrorism and witnessed great tragedies such as the attacks of 9/11 and Columbine shootings broadcast incessantly to multiple televisions in their homes. Cell phones, computers, and the Internet have always existed. Technology is integral to all aspects of life.

They were raised in highly structured and protected environments with tight schedules and referees who enforced the rules of the game to which there were no losers. They have close relationships with their parents and project the same familiarity with their work supervisors and teachers. They are used to receiving feedback and even demand it as part of their education, yet they can become demoralized if it is perceived as too negative or if not sandwiched between the positive. They value teamwork, diversity, and non-denominational spirituality. In the workplace, they want their work and their person to be immediately valued and rewarded. They want to know why they are doing something [6 –9].

If we compare generational characteristics with the principles of adult learning, we find that the generational characteristics of today's younger medical learners may be more in synchrony with principles of adult learning. Based on their close relationships with teachers and parents and their desire for feedback, they are prepared to be participants in their education and evaluation. Because they want to know the reason for a task or job, they connect to the Need to Know and Foundation principles. As generation gaps are inevitable between teachers and learners, understanding generational tendencies can influence learning goals and objectives, teaching methods, and evaluation tools, ultimately to improve the teaching and learning experience and expectations of all.

Determining a Core Curriculum in Surgical Infections for Fellowship Training in Acute Care Surgery using the Delphi Technique

Emergency department visits by older, sicker, and uninsured patients, many with surgical emergencies, are more common and require a continuous workforce of surgical specialists to respond, evaluate, operate, and deliver critical care [2,3]. Unfortunately, emergency departments are having greater difficulties assuring specialist coverage [4,5]. In response, many hospitals have abandoned the traditional model of surgeon coverage for urgent care, which relied on non-trauma surgeons taking home call, in favor of having their trauma programs absorb emergency surgery [6,7].

This new model of Acute Care Surgery (ACS), a combination of trauma surgery, broad-based emergency surgery, and surgical critical care, has been championed by the American Association for the Surgery of Trauma (AAST) and a number of other trauma and surgical societies [8]. Data are accumulating that ACS services, particularly for time-dependent surgical pathology, streamlines and improves the processes of delivering care and yields better outcomes [9 –13].

How to deliver this care most appropriately and train the future generations of ACS surgeons that will provide it has yet to be defined [14 –16]. Few studies have identified the characteristics of these programs that are deterministic of improved outcomes. Yet, in the wake of optimistic data, particularly those suggesting financial and educational benefits, many institutions are creating ACS programs [17 –19]. These data serve as the impetus to create ACS fellowships, which now are accredited by AAST. In light of the importance of this field for the provision of care to complex, acutely ill, and resource intensive patients, we sought to determine by consensus of expert opinion a set of core topics in those areas of surgical infection considered to be fundamental to the core curriculum of ACS.

Results

We invited 86 experts from 26 states to participate. A total of 145 initial topics were proposed in five categories and submitted to the experts for consensus evaluation: Biology of Sepsis (n = 17); Risk, Prevention, and Prophylaxis (n = 10); Thorax (n = 31); Abdomen (n = 31); and Soft Tissue Infections (n = 8). Thirty-one final criteria were considered important (mean priority score >4) by consensus in the final round. The mean priority scores ranged from 4.08 to 4.73, and the standard deviation was less than 1 in 30 (97%). The final rank order of these 31 most important topics is listed in Table 1.

Table 1.

Demographic Characteristics of Respondents to Surgical Infection Society Curriculum Development Survey

Variable	N = 135^ (%)*
Gender
Male	92 (74)
Female	32 (26)
Age
<35	43 (33)
35–44	31 (24)
45–54	28 (21)
55–64	21 (16)
≥65	8 (6)
Academic rank
Assistant Professor	27 (21)
Associate Professor	31 (24)
Professor	63 (49)
Do not have one	7 (5)
Other	2 (2)
Post-graduate year
<7	36 (27)
≥7	99 (73)
Type of hospital
University	103 (81)
Community	4 (3)
Community with affiliation	11 (9)
Other	10 (8)
Level of trauma center
None	8 (6)
Level I	100 (78)
Level II	10 (8)
Level III/IV	7 (6)
Other	3 (2)
What type of city
Small (<0.5 M)	25 (19)
Mid-size (0.5–1 M)	40 (31)
Large (>1M)	64 (50)

Values may not add up to total number of respondents because of missing values.

Topics concerning Soft Tissue Infections received the highest priority, comprising four of the top 10 (40%) topics. Six of the seven (86%) topics in Risk, Prevention, and Prophylaxis included in round two comprised 19% of the final 31 topics considered fundamental for ACS training. Topics in the Thoracic (n = 3) and Abdominal infection (n = 3) completed the top 10 highest-ranking filters. They comprised eight (26%) and six (19%), respectively, of the final 31 important topics. Six (19%) topics in the Biology of Sepsis were included in the final 31 most important topics. Five (63%) of eight in Soft Tissue Infection included in the second round were in the final 31 most important topics, however.

Discussion

With the emergence of the field of ACS and the recent development of subspecialty ACS fellowship training, we considered it a priority to develop a core curriculum that standardizes training. Here we have identified 31 topics spanning five aspects of surgical training that represent a consensus of experts in ACS within the United States. Our results emphasize the importance of knowledge, rather than procedural training, regarding surgical infections, because 23 of 31 (74%) and 8 of the top 10 (80%) topics focused on knowledge. Of these 20, six (30%) focused on the basic Biology of Sepsis, including metabolism, physiology, pathophysiology, pharmacokinetics, and pharmacodynamics.

These topics are fundamental in medical school education, but they are not emphasized in subsequent residency and fellowship training. Five procedures were considered fundamental: Ultrasonography, tracheostomy, bronchoscopy, esophagoscopy, and enteral access. Although exposure to each procedure is acquired during surgical residency, it is clear that the acquisition of additional expertise, specific to surgical infections and ACS, is needed.

Although it was not our objective to obtain universal agreement on the topics proposed, there was general consensus as to which criteria were important. All 31 topics were considered very or most important (i.e., priority score >4). The standard deviation of the mean priority score was less than 1 in 30 (97%) of these final topics. We believe that the large number of topics developed by this panel reflects the lack of interaction between participants and an unbiased, consensus opinion of ACS experts.

The rapidly changing paradigm in surgical management and training with increasing sub-specialization, a shift toward minimally invasive techniques, a perceived decline in the general surgical training concerning basic surgical infectious diseases, all combined with advances and increased complexity of the treatment of acutely ill patients undergoing surgical procedures make the establishment of an identified skill set in Surgical Infectious Diseases of considerable importance. Within the constraints imposed by the limitations described above, this list of topics represents the most important aspects of surgical infections that merit consideration for incorporation into a core curriculum of ACS training. This information will assist our societal and institutional colleagues in the development of ACS fellowships that optimize the training of future ACS surgeons.

A Brief Needs Assessment of Core Curriculum from SIS Experts

The Education and Awards Committee of the SIS embarked on a formal curriculum development process to address the development of a surgical curriculum. Unlike the previous focus on acute care training, the group wanted to focus its understanding on the array of audiences that may need more information regarding surgical infections. This committee assumed that surgical infections were significant, costly, and imposed considerable morbidity and mortality. Thus, there exists a significant need for better understanding and education for the long-term goal of improved public health.

Methods

The Children's Hospital Los Angeles Committee on Clinical Investigations approved the following study. The SIS Education and Awards Committee met monthly by conference call to organize the curriculum development as described by Kern et al [28] (Table 2 ). Although exposure to diverse surgical topics is acquired during surgical residency, it is clear that the acquisition of additional expertise, specific to surgical infectious and ACS, is needed [20 –27]. Problem identification and general needs assessment were performed, because each Committee member was asked to identify key surgical infection-related topics and established peer-reviewed resources for surgical infection information.

Table 2A.

Level of Agreement for the Inclusion of Each Topic Area by Academic Rank

Topic area	Disagree	Agree
Surgical site infection: Principles and practice	-
Assistant Professor	-	2 (11)
Associate Professor	-	6 (33)
Professor	-	9 (50)
Other	-	1 (6)
Pre-operative antimicrobial management, such as colorectal surgery, non-CRS, and trauma
Assistant Professor	-	4 (18)
Associate Professor	-	6 (27)
Professor	-	9 (41)
Other	-	3 (14)
Intra-operative antimicrobial management
Assistant Professor	-	9 (26)
Associate Professor	1 (50)	8 (24)
Professor	-	16 (47)
Other	1 (50)	1 (3)
Complications of antimicrobial usage
Assistant Professor	1 (100)	6 (22)
Associate Professor	-	6 (22)
Professor	-	15 (56)
Other	-	-
Timing of antimicrobial administration
Assistant Professor	-	8 (27)
Associate Professor	1 (100)	9 (30)
Professor	-	11 (37)
Other	-	2 (7)
Outpatient antimicrobials: route and duration
Assistant Professor	3 (19)	11 (22)
Associate Professor	7 (44)	9 (18)
Professor	5 (31)	27 (54)
Other	1 (6)	3 (6)
Surgical management infection, such as debridement, role of VAC, and wound care
Assistant Professor	1 (50)	5 (17)
Associate Professor	-	9 (31)
Professor	-	15 (52)
Other	1 (50)
Care of the patient with septic shock, including antibiotic stewardship
Assistant Professor	-	3 (16)
Associate Professor	-	4 (21)
Professor	-	11 (58)
Other	-	1 (5)
Hyperbaric management of a patient with infection
Assistant Professor	9 (20)	9 (24)
Associate Professor	15 (34)	6 (16)
Professor	18 (41)	21 (55)
Other	2 (5)	2 (5)
Urinary tract infections in the critically ill, including funguria, and management of chronic indwelling catheters
Assistant Professor	1 (10)	10 (21)
Associate Professor	2 (20)	14 (29)
Professor	4 (40)	23 (48)
Other	3 (30)	1 (2)
Diagnosis of pneumonia
Assistant Professor	1 (50)	11 (30)
Associate Professor	-	8 (22)
Professor	1 (50)	15 (40)
Other	-	3 (8)
Patient with fever, including workup and empiric vs. prophylaxis
Assistant Professor	2 (50)	9 (24)
Associate Professor	-	8 (21)
Professor	2 (50)	19 (50)
Other	-	2 (5)
Surgical microbiology
Assistant Professor	1 (25)	8 (22)
Associate Professor	2 (50)	9 (24)
Professor	1 (25)	18 (49)
Other	-	2 (5)
Surgical Immunology
Assistant Professor	-	10 (20)
Associate Professor	3 (75)	12 (23)
Professor	1 (25)	27 (53)
Other	-	2 (4)
Intra-abdominal infection
Assistant Professor	-	5 (22)
Associate Professor	1 (100)	8 (35)
Professor	-	9 (39)
Other	-	1 (4)
Peri-rectal abscess and pilonidal abscess
Assistant Professor	3 (23)	8 (20)
Associate Professor	3 (23)	12 (30)
Professor	5 (38)	18 (45)
Other	2 (16)	2 (5)
Clostridium difficile enterocolitis
Assistant Professor	1 (50)	5 (19)
Associate Professor	-	10 (38)
Professor	1 (50)	9 (35)
Other	-	2 (8)
Burn wound infection
Assistant Professor	2 (17)	12 (25)
Associate Professor	3 (25)	13 (27)
Professor	4 (33)	21 (44)
Other	3 (25)	-
Fungal infection of surgical significance
Assistant Professor	-	11 (24)
Associate Professor	1 (50)	12 (27)
Professor	1 (50)	20 (44)
Other	-	2 (4)
Viral infection of surgical significance
Assistant Professor	1 (6)	13 (27)
Associate Professor	7 (41)	10 (21)
Professor	7 (41)	22 (46)
Other	2 (12)	3 (6)
Cardiothoracic infection
Assistant Professor	5 (28)	14 (26)
Associate Professor	5 (28)	15 (28)
Professor	7 (39)	22 (41)
Other	1 (6)	2 (4)
Head-neck infections
Assistant Professor	4 (31)	15 (26)
Associate Professor	4 (31)	16 (27)
Professor	4 (31)	25 (43)
Other	1 (8)	2 (3)
Vascular infections
Assistant Professor	4 (50)	14 (25)
Associate Professor	1 (12)	15 (27)
Professor	3 (37)	23 (42)
Other		3 (5)
Urologic infections
Assistant Professor	4 (29)	13 (23)
Associate Professor	3 (21)	13 (23)
Professor	4 (29)	29 (52)
Other	3 (21)	1 (2)
Bone and joint infections
Assistant Professor	7 (33)	11 (21)
Associate Professor	5 (24)	15 (28)
Professor	6 (29)	27 (51)
Other	3 (14)
Obstetric and gynecologic infections
Assistant Professor	9 (32)	10 (21)
Associate Professor	6 (21)	14 (29)
Professor	10 (36)	23 (48)
Other	3 (11)	1 (2)
Necrotizing enterocolitis
Assistant Professor	4 (20)	8 (19)
Associate Professor	4 (20)	12 (29)
Professor	10 (50)	19 (45)
Other	1 (10)	3 (7)
Central nervous system infections
Assistant Professor	8 (32)	11 (21)
Associate Professor	4 (16)	17 (33)
Professor	8 (32)	23 (44)
Other	5 (20)	1 (2)
Agents of bioterrorism
Assistant Professor	5 (16)	7 (14)
Associate Professor	10 (32)	12 (24)
Professor	13 (42)	27 (55)
Other	3 (10)	3 (6)
Microbial translocation, probiotics, prebiotics, and selective gut decontamination
Assistant Professor	1 (8)	12 (20)
Associate Professor	3 (35)	15 (25)
Professor	7 (58)	29 (49)
Other	1 (8)	3 (5)
Antimicrobial pharmacology
Assistant Professor	1 (25)	12 (24)
Associate Professor	1 (25)	13 (26)
Professor	2 (50)	23 (47)
Other	-	1 (2)

Non-CRS = non-colorectal surgery; VAC = vaccum-assisted closure.

Table 2B.

Level of Agreement for the Inclusion of Each Topic Area by Gender

Tarea	Disagree	Agree
Surgical site infection: Principles and practice
Male	-	14 (82)
Female	-	3 (18)
Pre-operative antimicrobial management, such as colorectal surgery, non-CRS, and trauma
Male	-	12 (57)
Female	-	9 (43)
Intra-operative antimicrobial management
Male	2 (100)	23 (70)
Female	-	10 (30)
Complications of antimicrobial usage
Male	-	18 (69)
Female	1 (100)	8 (31)
Timing of antimicrobial administration
Male	1 (100)	20 (67)
Female	-	10 (33)
Outpatient antimicrobials: route and duration
Male	10 (71)	38 (78)
Female	4 (29)	11 (22)
Surgical management infection, such as debridement, role of VAC, and wound care
Male	1 (50)	20 (77)
Female	1 (50)	6 (23)
Care of the patient with septic shock, including antibiotic stewardship
Male	-	14 (78)
Female	-	4 (22)
Hyperbaric management of a patient with infection
Male	31 (74)	22 (63)
Female	11 (26)	13 (37)
Urinary tract infections in the critically ill, including funguria, and management of chronic indwelling catheters
Male	6 (67)	35 (78)
Female	3 (33)	10 (22)
Diagnosis of pneumonia
Male	1 (50)	25 (76)
Female	1 (50)	8 (24)
Patient with fever, including workup and empiric vs. prophylaxis
Male	1 (33)	27 (79)
Female	2 (67)	7 (21)
Surgical microbiology
Male	2 (50)	24 (67)
Female	2 (50)	12 (33)
Surgical Immunology
Male	3 (75)	35 (70)
Female	1 (25)	15 (30)
Intra-abdominal infection
Male	1 (100)	13 (59)
Female	-	9 (41)
Peri-rectal abscess and pilonidal abscess
Male	8 (80)	28 (70)
Female	2 (20)	12 (30)
Clostridium difficile enterocolitis
Male	2 (100)	15 (65)
Female	-	8 (35)
Burn wound infection
Male	7 (78)	31 (66)
Female	2 (22)	16 (34)
Fungal infection of surgical significance
Male	2 (100)	28 (68)
Female	-	13 (32)
Viral infection of surgical significance
Male	12 (75)	32 (71)
Female	4 (25)	13 (29)
Cardiothoracic infection
Male	12 (75)	36 (71)
Female	4 (25)	15 (29)
Head-neck infections
Male	8 (73)	39 (70)
Female	3 (27)	17 (30)
Vascular infections
Male	4 (57)	37 (71)
Female	3 (43)	15 (29)
Urologic infections
Male	8 (61)	39 (74)
Female	5 (38)	14 (26)
Bone and joint infections
Male	13 (65)	37 (73)
Female	7 (35)	14 (27)
Obstetric and gynecologic infections
Male	21 (81)	32 (68)
Female	5 (19)	15 (32)
Necrotizing enterocolitis
Male	15 (79)	29 (72)
Female	4 (21)	11 (27)
Central nervous system infections
Male	19 (79)	31 (62)
Female	5 (21)	19 (38)
Agents of bioterrorism
Male	25 (83)	33 (72)
Female	5 (17)	13 (28)
Microbial translocation, probiotics, prebiotics, and selective gut decontamination
Male	9 (75)	42 (74)
Female	3 (25)	15 (26)
Antimicrobial pharmacology
Male	2 (50)	33 (72)
Female	2 (50)	13 (28)

Non-CRS = non-colorectal surgery; VAC = vaccum-assisted closure.

Initial curriculum topics were collected by the committee chairman, and a finalized draft document prepared (Table 3). This final draft document was then presented to the SIS membership as an electronic survey. The SIS membership ranked the importance of the topics on a four-point scale: (1) Strongly Disagree; (2) Disagree; (3) Agree; (4) Strongly Agree. Topics that achieved a 75% “Agree or Strongly Agree” were considered important topics for a surgical infection curriculum. Descriptive data were compiled by an Excel spreadsheet and presented as percentage of respondents.

Table 3.

Target Audience For Each Topic Area By Academic Rank

Topic area	Professional	Trainee	Medical Student	Public
Surgical site infection: Principles and practice
Assistant Professor	20 (26)	18 (23)	15 (21)	6 (22)
Associate Professor	16 (21)	18 (23)	18 (25)	4 (15)
Professor	35 (45)	36 (47)	36 (50)	16 (59)
Other	6 (8)	5 (6)	3 (4)	1 (4)
Pre-operative antimicrobial management, such as colorectal surgery, non-CRS, and trauma
Assistant Professor	19 (26)	17 (23)	13 (25)	4 (50)
Associate Professor	16 (22)	18 (24)	13 (25)	1 (12)
Professor	34 (46)	35 (47)	25 (48)	3 (37)
Other	5 (7)	4 (5)	1 (2)	-
Intra-operative antimicrobial management
Assistant Professor	19 (25)	16 (21)	8 (24)	-
Associate Professor	17 (22)	19 (25)	10 (30)	1 (100)
Professor	35 (45)	35 (47)	14 (42)	-
Other	6 (8)	5 (7)	1 (3)	-
Complications of antimicrobial usage
Assistant Professor	18 (24)	16 (22)	14 (21)	7 (23)
Associate Professor	17 (22)	16 (22)	16 (24)	7 (23)
Professor	35 (46)	35 (49)	32 (48)	15 (48)
Other	6 (8)	5 (7)	5 (7)	2 (96)
Timing of antimicrobial administration
Assistant Professor	19 (25)	16 (22)	6 (15)	-
Associate Professor	17 (22)	19 (26)	9 (22)	1 (25)
Professor	35 (46)	33 (45)	23 (56)	3 (74)
Other	5 (7)	5 (7)	3 (7)	-
Outpatient antimicrobials: route and duration
Assistant Professor	19 (26)	16 (23)	11 (22)	4 (19)
Associate Professor	15 (21)	15 (22)	12 (24)	8 (38)
Professor	33 (46)	32 (47)	23 (46)	9 (43)
Other	5 (7)	5 (7)	4 (8)	-
Surgical management infection, such as debridement, role of VAC, and wound care
Assistant Professor	19 (25)	15 (20)	10 (22)	2 (50)
Associate Professor	17 (22)	19 (26)	13 (29)	1 (25)
Professor	35 (45)	35 (47)	20 (44)	1 (25)
Other	6 (8)	5 (7)	2 (4)	-
Care of the patient with septic shock, including antibiotic stewardship
Assistant Professor	19 (25)	17 (23)	12 (25)	1 (100)
Associate Professor	18 (22)	18 (24)	11 (23)	-
Professor	37 (46)	35 (47)	22 (46)	-
Other	6 (7)	5 (7)	3 (6)	-
Hyperbaric management of a patient with infection
Assistant Professor	14 (25)	9 (19)	2 (13)	2 (40)
Associate Professor	13 (23)	13 (28)	7 (47)	2 (40)
Professor	26 (46)	21 (45)	5 (33)	-
Other	4 (7)	4 (8)	1 (7)	1 (20)
Urinary tract infections in the critically ill, including funguria, and management of chronic indwelling catheters
Assistant Professor	18 (24)	17 (23)	12 (29)	2 (67)
Associate Professor	16 (22)	17 (23)	11 (26)	-
Professor	35 (47)	35 (47)	18 (43)	1 (33)
Other	5 (7)	5 (7)	1 (2)	-
Diagnosis of pneumonia
Assistant Professor	18 (24)	16 (21)	13 (21)	1 (12)
Associate Professor	17 (22)	19 (25)	15 (24)	3 (37)
Professor	36 (47)	35 (47)	30 (48)	3 (37)
Other	5 (7)	5 (7)	4 (6)	1 (12)
Patient with fever, including workup and empiric vs. prophylaxis
Assistant Professor	17 (24)	17 (23)	13 (21)	1 (33)
Associate Professor	18 (25)	18 (25)	16 (25)	1 (33)
Professor	33 (46)	34 (47)	29 (46)	-
Other	4 (6)	4 (5)	5 (8)	1 (33)
Surgical microbiology
Assistant Professor	18 (25)	17 (24)	12 (25)	3 (75)
Associate Professor	15 (21)	16 (22)	13 (27)	1 (75)
Professor	33 (46)	34 (47)	20 (42)	-
Other	6 (8)	5 (7)	3 (6)	-
Surgical Immunology
Assistant Professor	17 (25)	17 (24)	12 (25)	1 (50)
Associate Professor	13 (19)	16 (23)	12 (25)	1 (50)
Professor	32 (47)	32 (46)	22 (46)	-
Other	6 (9)	5 (7)	2 (4)	-
Intra-abdominal infection
Assistant Professor	18 (24)	17 (23)	14 (24)	3 (60)
Associate Professor	16 (22)	18 (24)	14 (24)	-
Professor	34 (46)	35 (47)	26 (45)	2 (40)
Other	6 (8)	5 (7)	4 (7)	-
Perirectal abscess and pilonidal abscess
Assistant Professor	17 (26)	16 (22)	12 (22)	5 (62)
Associate Professor	14 (21)	18 (25)	11 (20)	1 (12)
Professor	30 (46)	34 (47)	28 (52)	1 (12)
Other	4 (6)	4 (6)	3 (6)	1 (12)
Clostridium difficile enterocolitis
Assistant Professor	19 (24)	17 (22)	13 (21)	5 (23)
Associate Professor	16 (20)	19 (25)	15 (25)	6 (27)
Professor	37 (47)	35 (46)	30 (49)	10 (45)
Other	6 (8)	5 (7)	3 (5)	1 (5)
Burn wound infection
Assistant Professor	18 (29)	17 (23)	9 (24)	4 (100)
Associate Professor	11 (17)	17 (23)	9 (24)	-
Professor	31 (49)	35 (47)	17 (46)	-
Other	3 (5)	5 (7)	2 (5)	-
Fungal infection of surgical significance
Assistant Professor	18 (25)	16 (22)	8 (25)	-
Associate Professor	16 (22)	17 (24)	9 (28)	1 (100)
Professor	33 (46)	33 (46)	13 (41)	-
Other	5 (7)	5 (7)	2 (6)	-
Viral infection of surgical significance
Assistant Professor	17 (25)	15 (23)	5 (17)	-
Associate Professor	14 (20)	16 (25)	8 (27)	1 (100)
Professor	34 (49)	29 (45)	14 (47)	-
Other	4 (6)	5 (8)	3 (10)	-
Cardiothoracic infection
Assistant Professor	16 (26)	14 (21)	9 (28)	3 (75)
Associate Professor	11 (18)	16 (23)	8 (25)	1 (25)
Professor	31 (50)	33 (48)	13 (41)	-
Other	4 (6)	5 (7)	2 (6)	-
Head-neck infections
Assistant Professor	16 (26)	14 (21)	9 (26)	1 (50)
Associate Professor	11 (18)	16 (24)	8 (23)	1 (50)
Professor	30 (50)	32 (48)	15 (44)	-
Other	4 (7)	5 (7)	2 (6)	-
Vascular infections
Assistant Professor	16 (26)	14 (21)	11 (32)	2 (67)
Associate Professor	11 (18)	16 (24)	7 (21)	1 (33)
Professor	31 (50)	32 (48)	13 (38)	-
Other	4 (6)	5 (6)	3 (9)	-
Urologic infections
Assistant Professor	16 (27)	14 (21)	10 (27)	2 (50)
Associate Professor	11 (18)	16 (25)	8 (22)	1 (25)
Professor	29 (48)	32 (49)	16 (43)	-
Other	4 (7)	3 (5)	3 (8)	1 (25)
Bone and joint infections
Assistant Professor	16 (27)	14 (21)	11 (31)	2 (50)
Associate Professor	10 (17)	16 (25)	8 (22)	1 (25)
Professor	30 (50)	32 (49)	14 (39)	-
Other	4 (7)	3 (5)	3 (8)	1 (25)
Obstetric and gynecologic infections
Assistant Professor	16 (28)	14 (23)	11 (30)	3 (43)
Associate Professor	10 (17)	15 (24)	8 (22)	1 (14)
Professor	28 (48)	30 (48)	15 (40)	2 (29)
Other	4 (7)	3 (5)	3 (8)	1 (14)
Necrotizing enterocolitis
Assistant Professor	18 (29)	16 (23)	12 (30)	1 (50)
Associate Professor	12 (19)	18 (26)	9 (22)	1 (50)
Professor	29 (46)	30 (43)	16 (40)	-
Other	4 (6)	5 (7)	3 (7)	-
Central nervous system infections
Assistant Professor	16 (26)	14 (22)	10 (25)	1 (25)
Associate Professor	12 (20)	15 (24)	11 (27)	2 (50)
Professor	29 (47)	31 (49)	16 (40)	-
Other	4 (7)	3 (5)	3 (7)	1 (25)
Agents of bioterrorism
Assistant Professor	16 (24)	14 (24)	10 (23)	7 (27)
Associate Professor	11 (17)	13 (22)	12 (27)	9 (35)
Professor	34 (51)	28 (47)	19 (43)	8 (31)
Other	4 (8)	4 (7)	3 (7)	2 (8)
Microbial translocation, probiotics, prebiotics, and selective gut decontamination
Assistant Professor	17 (24)	15 (21)	12 (31)	4 (67)
Associate Professor	16 (22)	18 (26)	12 (31)	1 (17)
Professor	33 (47)	32 (46)	12 (31)	-
Other	6 (8)	5 (7)	3 (8)	1 (17)
Antimicrobial pharmacology
Assistant Professor	18 (26)	15 (21)	13 (23)	1 (100)
Associate Professor	14 (20)	17 (24)	14 (25)	-
Professor	32 (46)	34 (48)	25 (45)	-
Other	6 (9)	5 (7)	4 (7)	-

Non-CRS = non-colorectal surgery; VAC = vaccum-assisted closure.

Results

The active members (n = 455) of the SIS were e-mailed on two separate occasions with an internet-based link to the survey of topics (Table 1). One hundred ninety-nine (43.7%) members began the survey, 135 (29.7%) completed the demographics, 103 (22.6%) answered the questions regarding the curriculum content, and 84 (18.5%) answered the questions regarding curriculum content and the target audience (Professional vs. Trainee vs. Student vs. Public). There were three times more male respondents than female (74.2% vs. 25.8%) and a decreasing incidence of respondents with increasing age (<35 years: 32.8%; 35–44 years: 23.7%; 45–54 years: 21.4%; 55–64 years: 16.0; >65 years: 6.1%). The majority of respondents had attained the academic rank of professor (48.5%), and three-quarters had been in practice more than seven years. More than 80% of respondents were university faculty, 78% worked at Level I trauma centers, and half (49.6%) practiced in cities greater than 1 million in population (Table 1).

All respondents agreed that surgical site infections and care of the patient with septic shock (including antibiotic stewardship) should be included in the curriculum (Table 2 ). Although most topics received at least an 80% approval rating, specialty-specific infections such as obstetric and gynecologic infections (78%), bone and joint infections (78%), necrotizing enterocolitis (76%), central nervous system infections (75%), and agents of bioterrorism (75%) fell below this threshold. Hyperbaric management (44%) of a patient with infection was not thought to be necessary for a comprehensive surgical infections curriculum (Table 2 ).

Survey respondents took advantage of the option to suggest uncovered topics (Table 2 ). These included infection-related topics such as necrotizing soft tissue infections, prions, implant-related infections, and risk factors for failure of source control. Guideline-related topics and basic science-related topics were also mentioned (Table 2 ).

Discussion

This pilot study was limited in a few but important ways. First, the respondents may not represent the broadest views of the SIS. We found that many of these respondents were senior members. Because our intent was to get a broad set of topics reviewed, the final subject matter may need additional refinement.

Future Directions

The SIS Education and Awards Committee will continue to refine the subject matter topics and establish clear educational objectives. Further work will be needed in delineating educational strategies. Finally, the surgical infection curriculum will be vigorously evaluated after implementation and adjusted accordingly.