Surgical Providers' Perceptions of the Patient Portal: Before and After the 21st Century Cures Act.

INTRODUCTION: In April 2021, the Information Blocking Rule (IBR) of the 21st Century Cures Act went into effect giving patients immediate access to notes, radiology reports, lab results, and surgical pathology. We aimed to examine changes in surgical providers' perceptions of patient portal usage before and after its implementation. METHODS: We administered a 37-question survey prior to the implementation of the IBR and a 39-question follow-up survey 3 mo later. The survey was sent to all surgeons, advanced practice providers, and clinic nurses in our surgical department. RESULTS: The response rate to pre surveys and post surveys was 33.7% and 30.7%, respectively. Providers' preference for communication via the patient portal (compared to phone or in person) regarding lab, radiology, or pathology results remained similar. While there was an increase in messages received from patients, there was no difference in the self-reported time spent on the electronic health record (EHR). Prior to the implementation of the blocking rule, 75.8% of providers believed that the portal increased workload which decreased to 57.4% on our follow-up survey. About one-third of providers screened positive for burnout before (32%) which decreased slightly (27.4%). CONCLUSIONS: Although 43.9% of providers reported the Cures Act had changed their practice, there was no difference in self-reported EHR usage, preferred method of interaction with patients, overall workload, or burnout. Initial concerns regarding the IBR's effect on job satisfaction, patient anxiety, and quality of care had lessened. Further exploration into how patients having immediate access to their EHRs has changed surgical practice is needed.

Genetic Testing for Adrenal Tumors-What the Contemporary Surgeon Should Know.

Surgical diseases of the adrenal gland include pheochromocytoma/paraganglioma, primary hyperaldosteronism, Cushing syndrome, and adrenocortical carcinoma. These conditions may be associated with familial syndromes, and genetic testing is available and recommended in most. For adrenal surgeons to be familiar with these syndromes and know when to consider referral for genetic counseling and genetic testing is important. Identification of patients with familial syndromes allows for the detection and screening of associated syndromic neoplasms, guides surgical planning and operative approach, influences recurrence and malignancy risk assessment, aids in the development of a postoperative surveillance plan, and determines the need for screening family members.

Extreme Elevation of Baseline Intraoperative Parathyroid Hormone Measurements: Should Usual Protocols Apply?

INTRODUCTION: Intraoperative parathyroid hormone (IOPTH) monitoring is routinely used to facilitate minimally invasive parathyroidectomy. Many IOPTH protocols exist for predicting biochemical cure. Some patients are found to have extremely high baseline IOPTH levels (defined in this study as >500 pg/mL), which may affect the likelihood of satisfying certain final IOPTH criteria. We aimed to discover whether clinically significant differences exist in patients with extremely high baseline IOPTH and which IOPTH protocols are most appropriately applied to these patients. MATERIALS AND METHODS: This is a retrospective review of 237 patients who underwent parathyroidectomy with IOPTH monitoring for primary hyperparathyroidism (pHPT) from 2016 to 2020. Baseline IOPTH levels, drawn prior to manipulation of parathyroid glands, were grouped into categories labeled "elevated" (>65-500 pg/mL) and "extremely elevated" (>500 pg/mL). Final IOPTH levels were analyzed to determine whether there was a >50% decrease from baseline and whether a normal IOPTH value was achieved. 6-wk postoperative calcium levels were also examined. RESULTS: Of the patients in this cohort, 76% were in the elevated group and 24% in the extremely elevated group. Male sex and higher preoperative PTH levels were correlated with higher baseline IOPTH levels. Patients with extremely elevated baseline IOPTH were less likely to have IOPTH fall into normal range at the conclusion of the case (P = 0.019), and final IOPTH levels were higher (P < 0.001), but the IOPTH was equally likely to decrease >50% from baseline. There was no difference in the mean postoperative calcium levels between the two groups at 6-wk or at longer term follow-up (mean 525 d). CONCLUSIONS: Detection of baseline IOPTH levels >500 pg/mL during parathyroidectomy performed for pHPT is not uncommon. IOPTH in patients with extremely elevated baseline levels were less likely to fall into normal range, but follow-up calcium levels were equal, suggesting that applying more stringent IOPTH criteria for predicting biochemical cure may not be appropriate for this population.

Educational Policy Development as a Leadership Experience: Inclusive Institutional Change.

Medical students have a unique opportunity to advocate for educational policies that promote best practices in undergraduate medical education. At the Geisel School of Medicine at Dartmouth, students play a crucial role in the development of medical education policies. This article describes two innovative, inclusive, and effective approaches to increase student engagement: (1) restructuring Medical Education Subcommittees to diversify student perspectives and (2) including students in a values-based design thinking approach to the development of new academic advancement and promotion and conduct policies. Through deliberate participation, medical students gain valuable skills that can be applied as future educators and academic leaders.

Qualities of excellent resident and attending teachers recognized by medical students: A qualitative analysis of nominations for surgical clerkship teaching awards.

BACKGROUND: Effective teaching positively impacts student experience during the surgical clerkship. We sought to better understand how medical students characterize excellent surgical educators and how these characteristics may differ between residents and attendings. METHODS: 289 nominations by third-year medical students for a surgical resident and attending teaching award were examined for thematic content using conventional content analysis. RESULTS: Six major themes emerged: inclusion of students, prioritizing student education, facilitating procedural involvement, utilizing effective educational methods, providing mentorship, and role modeling. Residents were more frequently commended for the first three themes, while residents and attendings were recognized equally for the latter three. CONCLUSIONS: In identifying excellent surgical educators, students emphasized the educators' roles in fostering a positive learning environment where student education is prioritized. Residents were recognized more often than attendings for a broader set of qualities valued by students. Residents as teachers training should be structured to develop these qualities.

A Diagnosis of Normocalcemic Primary Hyperparathyroidism Prompted by "Salt and Pepper" Lesions of the Calvarium.

BACKGROUND: We report a case of normocalcemic primary hyperparathyroidism, a diagnosis prompted by radiographic "salt and pepper" calvarial lesions, typically described in hypercalcemic primary hyperparathyroidism or secondary hyperparathyroidism. CASE REPORT: A 60-year-old woman noticed indentations of her scalp and presented to her primary care provider. Radiography of the calvarium demonstrated granular "salt and pepper" lesions, prompting investigation. The patient was found to have an elevated parathyroid hormone (PTH) level of 79 pg/mL (reference range, 14-54 pg/mL) and a normal albumin-corrected calcium level of 9.8 mg/dL (reference range, 8.6-10.4 mg/dL). She was referred to our endocrine clinic and described having bone aches, fevers, leg cramps, and a remote history of nephrolithiasis. Her physical examination revealed hypertension. Repeat laboratory evaluation confirmed elevated PTH and normal albumin-corrected calcium. Secondary causes of hyperparathyroidism were ruled out. Her 25-hydroxyvitamin D level was 35 ng/mL (reference range, 30-100 ng/mL), with a normal creatinine level (0.73 mg/dL; reference range, 0.5-0.99 mg/dL). The patient underwent ultrasound and sestamibi scintigraphy, with uptake in the right inferior thyroid pole. She was found to have a 6-mm parathyroid adenoma and underwent a targeted parathyroidectomy, with normalization of serum PTH. DISCUSSION: Many cases of normocalcemic primary hyperparathyroidism are diagnosed in asymptomatic patients presenting with low bone mass; however, imaging prompted this patient's evaluation. Ultimately, the calvarial lesions were thought secondary to bone resorption from increased osteoclast activity. CONCLUSION: This case highlights an atypical presentation of normocalcemic primary hyperparathyroidism in that the evaluation was precipitated by unexpected radiographic evidence of metabolic bone disease, rather than by symptoms or biochemical studies.

Trends in Diagnosis of Noninvasive Follicular Thyroid Neoplasm With Papillarylike Nuclear Features and Total Thyroidectomies for Patients With Papillary Thyroid Neoplasms.

Importance: Increasing detection of early-stage papillary thyroid neoplasms without improvements in mortality has prompted development of strategies to prevent or mitigate overtreatment. Objective: To determine adoption rates of 2 recent strategies developed to limit overtreatment of low-risk thyroid cancers: (1) a new classification, noninvasive follicular thyroid neoplasm with papillarylike nuclear features (NIFTP), and (2) hemithyroidectomy for selected papillary thyroid carcinomas (PTCs) up to 4 cm in size. Design, Setting, and Participants: This is a cross-sectional analysis of 3368 pathology records of 2 cohorts of patients from 18 hospitals in 6 countries during 2 time periods (2015 and 2019). Participating hospitals were included from the US (n = 12), Canada (n = 2), Denmark (n = 1), South Korea (n = 1), South Africa (n = 1), and India (n = 1). The records of the first 100 patients per institution for each year who underwent thyroid-directed surgery (hemithyroidectomy, total thyroidectomy, or completion thyroidectomy) were reviewed. Main Outcomes and Measures: Frequency of diagnosis of NIFTP, PTCs, and thyroidectomies during the study period. Results: Of the 790 papillary thyroid neoplasms captured in the 2019 cohort, 38 (4.8%) were diagnosed as NIFTP. Diagnosis of NIFTP was observed in the US, South Africa, and India. There was minimal difference in the total proportion of PTCs in the 2015 cohort compared with the 2019 cohort (778 [47.1%] vs 752 [44.5%]; difference, 2.6% [95% CI, -16.9% to 22.1%]). The proportion of PTCs eligible for hemithyroidectomy but treated with total thyroidectomy in the 2 cohorts demonstrated a decreasing trend from 2015 to 2019 (341 of 453 [75.3%] vs 253 of 434 [58.3%]; difference, 17.0% [95% CI, -1.2% to 35.2%]). Conclusions and Relevance: Results of this cohort study showed that the 2 mitigation strategies for preventing overtreatment of early-stage thyroid cancer have had mixed success. The diagnosis of NIFTP has only been applied to a small proportion of thyroid neoplasms compared with expected rates. However, more patients eligible for hemithyroidectomy received it in 2019 compared with 2015, showing some success with this deescalation strategy.

Using molecular testing to improve the management of thyroid nodules with indeterminate cytology: an institutional experience with review of molecular alterations.

INTRODUCTION: Molecular testing has helped clinicians and cytopathologists to further categorize indeterminate thyroid fine needle aspiration (FNA) specimens. The purpose of the present study was to evaluate the accuracy of commercially available molecular tests, review their effects on patient treatment, and correlate the molecular alterations with the histologic findings. MATERIALS AND METHODS: A pathology laboratory information system search identified thyroid FNAs performed at our institution between January 1, 2015 and June 30, 2020. The results of surgical follow-up and ancillary molecular testing were collected. We evaluated the accuracy of these tests and whether they could reduce the number of surgeries performed. RESULTS: Our laboratory information system search identified 510 cases reported as atypia of undetermined significance, 94 as suspicious for follicular neoplasm, and 44 as suspicious for follicular neoplasm, Hurthle cell type. Of the specimens, 343 had no ancillary molecular testing, 146 were sent for ThyGenX/ThyraMIR, and 136 were sent for ThyroSeq. Of the patients without molecular testing, 50.4% had undergone follow-up surgery compared with 30.8% after ThyGenX/ThyraMIR and 38.2% after ThyroSeq testing, resulting in 38.9% and 24.2% fewer surgeries and an odds ratio of 0.04 (95% confidence interval, 0.00-0.33) and 0.14 (95% confidence interval, 0.01-0.95), respectively. For ThyGenX/ThyraMIR testing, the risk of malignancy for high and moderate to high risk alterations was 80%, 28.6% for moderate and low to moderate risk alterations, and 23.1% for low risk alterations. For ThyroSeq, the risk of malignancy was 87.5% for high risk alterations, 36.8% for intermediate to high risk alterations, 27.3% for intermediate risk alterations, and 0% for low risk alterations. The areas under the curve for ThyGenX/ThyraMIR and ThyroSeq testing were 0.65 and 0.85, respectively. CONCLUSIONS: These findings suggest that, at our institution, both ThygenX/ThyraMIR and ThyroSeq can be used to effectively stratify cytology specimens based on the risk of malignancy and reduce the number of surgeries performed at our institution.

Hopes, fears, and rumors: Medical students and the general surgery clerkship.

BACKGROUND: Surgical educators have worked to manage the hopes and fears as well as the recurring rumors that plague the surgical clerkship. It is not known if this has effected change over time. METHODS: We gathered information on hopes, fears, and rumors during our clerkship orientations from 2017 to 2019 using anonymous polling software with real-time feedback. We analyzed 468 responses using qualitative content analysis. RESULTS: Students hoped for practical skills acquisition, self-improvement, and understanding the surgical profession. They feared lack of time and knowledge, burnout, mistreatment, and subjective evaluation. Rumors included negative perceptions of surgical culture work environment, and fear of mistreatment despite clerkship changes intended to allay these fears. CONCLUSION: Students starting surgery clerkships hope to gain surgical and clinical skills but concerns about surgical culture and mistreatment appear to remain unchanged despite structural improvements in the clerkship experience. Surgeons should look beyond the clerkship itself to change these perceptions.

How Much is Enough? Public Perception of Minimum Surgeon Volumes.

BACKGROUND: A large body of literature supports an association between surgical volumes and outcomes. Research on this subject has resulted in attempts to quantify minimum volume standards for specific surgeries. However, the extent to which the public takes interest in or is able to interpret surgical volume information is not known. METHODS: We designed a 38-question online survey to assess respondents' knowledge and beliefs about minimum surgical volume standards, and other factors influencing choice of surgeon. Participants, recruited through Amazon Mechanical Turk, an online crowdsourcing marketplace, were specifically asked to estimate minimum volume standards for four different operations (hernia repair, knee replacement, mitral valve repair, and Whipple) and to assess the implications of specific surgeon volumes for decision-making in two hypothetical scenarios. RESULTS: Among 2024 participants, 81% attested that surgeons should be subject to minimum volume standards. A small minority (19%) reported having prior knowledge of a link between surgeon volumes and outcomes. Respondents' mean estimates for appropriate minimum annual volumes across four operations were directly correlated with surgical complexity (5 for inguinal hernia repair, 25 for Whipple), while published minimum standards fall with increasing surgical complexity (25 for hernia repair, 5 for Whipple). These findings were validated by participants' stated intentions: 55% would proceed with a hernia repair by a surgeon with annual volume of 25, while 13% would proceed with a Whipple when annual volume was 5. CONCLUSION: The concept of minimum surgical volumes is intuitively important to the lay public. However, the general public's skewed expectations of minimum volume standards demonstrate an inability to interpret surgical volume numbers meaningfully in clinical settings without appropriate context.

Telemedicine for Surgical Consultations - Pandemic Response or Here to Stay?: A Report of Public Perceptions.

OBJECTIVE: This study aims to determine the public's perception of telemedicine surgical consultations, during the COVID-19 pandemic and beyond. SUMMARY BACKGROUND DATA: With rapid expansion and uptake of telemedicine during the pandemic, many have posited that virtual visits will endure even as in-person visits are reinstated. The public's perception of telemedicine for an initial surgical consultation has not been previously studied. METHODS: A 43-question survey assessed respondents' attitudes toward telemedicine for initial consultations with surgeons, both in the context of COVID-19 and during "normal circumstances." Participants were recruited through Amazon Mechanical Turk, an online crowd-sourcing marketplace. RESULTS: Based on 1827 analyzable responses, we found that a majority (86%) of respondents reported being satisfied (either extremely or somewhat) with telemedicine encounters. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Preferences for virtual visits decreased with increasing complexity of the surgical intervention, even during the pandemic. A majority felt that "establishing trust and comfort" was best accomplished in person, and the vast majority felt it was important to meet their surgeons before the day of surgery. CONCLUSIONS: The public views telemedicine as an acceptable substitute for in-person visits, especially during the pandemic. However, it seems that an in-person interaction is still preferred when possible for surgical consultations. If telemedicine services are to persist beyond social distancing, further exploration of its impact on the patient-surgeon relationship will be needed.

The Evolving Practice Patterns of Academic Endocrine Surgeons: A Cross-sectional Analysis of the Faculty Practice Solutions Center Database 2014 to 2017.

OBJECTIVE: To examine the evolution of an academic endocrine surgeon's practice over time. SUMMARY BACKGROUND: Amid growing recognition that surgical volume and specialization are linked to better outcomes, endocrine surgery is one of the youngest fields to develop its own formal fellowship training program. However, 3 decades after the emergence of endocrine surgery as a distinct specialty, the medical community and public still have a limited understanding of endocrine surgeons and what they do. METHODS: We performed a cross-sectional analysis of endocrine surgeons identified in the Faculty Practice Solutions Center Database from 2014 to 2017. Trends in annual number of endocrine surgeries performed, number of all surgeries performed, total work relative value units generated, and patient payer mix stratified by years of practice were evaluated. RESULTS: One hundred thirty-nine endocrine surgeons practicing in 103 institutions over 4 years were analyzed. The proportion of endocrine-specific operations increases over time. A typical academic endocrine surgeon meets the high-volume threshold for thyroidectomies early in their career, but does not reach the thresholds for parathyroidectomies or adrenalectomies until after 4 years. Increased productivity as reflected by adjusted work relative value units does increase over the first 15 years of practice, but also decreases as the proportion of endocrine-specific practice increases. The greatest proportion of endocrine surgeons' patients are insured by commercial plans (46%-50%), and payer mix is stable across all levels of practice. CONCLUSIONS: Although endocrine surgeons perform a high-volume of endocrine-specific operations, practice patterns are heterogeneous and suggest that most surgeons have to grow their endocrine-specific practice over time.

The surgical consult entrustable professional activity (EPA): Defining competence as a basis for evaluation.

BACKGROUND: The American Board of Surgery has proposed a competency-based training model, which relies on entrustable professional activities (EPAs) to assess and document competence. No data exist defining competence for surgical consultation, one of five proposed trial EPAs. METHODS: Qualitative interviews performed with 23 surgical faculty at two academic institutions. Interviews were reviewed for thematic content. RESULTS: No explicit framework is currently used to evaluate the surgical consult. Most participants currently use subjective, global performance assessment. This method often relies on information not limited to the discrete consult at hand. Competence for a discrete surgical consult can be defined by six key procedural steps and six performance traits. Five red-flag behaviors were identified that negatively impact entrustability. CONCLUSIONS: Subjective global assessment of resident performance can be problematic. We propose an objective framework for assessment, which can be used to develop an evaluation tool and inform entrustment decisions for competency-based training.

Integrating Mindfulness Into Eating Behaviors.

Food choices and eating behaviors are influenced by a wide variety of factors. However, traditional dietary advice primarily addresses health-related reasons for eating. Lifestyle medicine outcomes may be improved by helping individuals become more aware of why they eat and support individuals to increase their skills in reconciling eating for health and nonhealth purposes. Intuitive eating aims to increase individuals' awareness of why, what, and how much they eat through mindfulness. This framework and concepts such as flexible restraint can be used to teach individuals skills that may help them improve psychological well-being and manage their weight.

Association of BRAF V600E Mutation and MicroRNA Expression with Central Lymph Node Metastases in Papillary Thyroid Cancer: A Prospective Study from Four Endocrine Surgery Centers.

BACKGROUND: Studies have demonstrated an association of the BRAF(V600E) mutation and microRNA (miR) expression with aggressive clinicopathologic features in papillary thyroid cancer (PTC). Analysis of BRAF(V600E) mutations with miR expression data may improve perioperative decision making for patients with PTC, specifically in identifying patients harboring central lymph node metastases (CLNM). METHODS: Between January 2012 and June 2013, 237 consecutive patients underwent total thyroidectomy and prophylactic central lymph node dissection (CLND) at four endocrine surgery centers. All tumors were tested for the presence of the BRAF(V600E) mutation and miR-21, miR-146b-3p, miR-146b-5p, miR-204, miR-221, miR-222, and miR-375 expression. Bivariate and multivariable analyses were performed to examine associations between molecular markers and aggressive clinicopathologic features of PTC. RESULTS: Multivariable logistic regression analysis of all clinicopathologic features found miR-146b-3p and miR-146b-5p to be independent predictors of CLNM, while the presence of BRAF(V600E) almost reached significance. Multivariable logistic regression analysis limited to only predictors available preoperatively (molecular markers, age, sex, and tumor size) found miR-146b-3p, miR-146b-5p, miR-222, and BRAF(V600E) mutation to predict CLNM independently. While BRAF(V600E) was found to be associated with CLNM (48% mutated in node-positive cases vs. 28% mutated in node-negative cases), its positive and negative predictive values (48% and 72%, respectively) limit its clinical utility as a stand-alone marker. In the subgroup analysis focusing on only classical variant of PTC cases (CVPTC), undergoing prophylactic lymph node dissection, multivariable logistic regression analysis found only miR-146b-5p and miR-222 to be independent predictors of CLNM, while BRAF(V600E) was not significantly associated with CLNM. CONCLUSION: In the patients undergoing prophylactic CLNDs, miR-146b-3p, miR-146b-5p, and miR-222 were found to be predictive of CLNM preoperatively. However, there was significant overlap in expression of these miRs in the two outcome groups. The BRAF(V600E) mutation, while being a marker of CLNM when considering only preoperative variables among all histological subtypes, is likely not a useful stand-alone marker clinically because the difference between node-positive and node-negative cases was small. Furthermore, it lost significance when examining only CVPTC. Overall, our results speak to the concept and interpretation of statistical significance versus actual applicability of molecular markers, raising questions about their clinical usefulness as individual prognostic markers.

The biochemical severity of primary hyperparathyroidism correlates with the localization accuracy of sestamibi and surgeon-performed ultrasound.

BACKGROUND: Minimally invasive parathyroidectomy for primary hyperparathyroidism is dependent on preoperative localization, commonly with ultrasound and sestamibi imaging. This study sought to determine if preoperative serum calcium and parathyroid hormone (PTH) levels correlate with localization sensitivity and positive predictive value (PPV). STUDY DESIGN: This is a retrospective analysis of a prospective database of 1,910 patients with primary hyperparathyroidism from 2002 to 2013, who had surgeon-performed ultrasound and/or sestamibi for preoperative localization. The sensitivity and PPV of ultrasound and sestamibi were analyzed by degree of preoperative serum calcium and parathyroid hormone level perturbation. RESULTS: In 1,910 parathyroidectomy patients, ultrasound was localizing in 1,411 of 1,644 (86%) and sestamibi in 802 of 1,165 (69%) (p < 0.01). The PPV of ultrasound was 1,135 of 1,411 (80%) and sestamibi was 705 of 802 (88%) (p < 0.01). Using logistic regression analysis, there was statistically significant positive correlation between localization and preoperative serum calcium for both sestamibi (odds ratio [OR] 1.21 [95% CI 1.00 to 1.47; p < 0.05]) and ultrasound (OR 1.29 [95% CI 1.03 to 1.60; p < 0.05]). There was a weak, but statistically significant positive correlation of PTH with sestamibi localization (OR 1.00 [95% CI 1.00 to 1.01; p < 0.05]). There was no statistically significant correlation between the PPV and serum calcium or PTH for either study. When patients were divided into quartiles of preoperative serum calcium and PTH levels, localization rates and PPV of both ultrasound and sestamibi increased with higher calcium and PTH levels. Surgeon-performed ultrasound had higher localization rates than sestamibi, with lower calcium and PTH values. Sestamibi demonstrated higher PPV values across all quartiles. CONCLUSIONS: Surgeon-performed ultrasound and sestamibi have higher localization rates and PPV, with increasing preoperative serum calcium and PTH levels. Surgeon-performed ultrasound may be a better initial test for patients with lower calcium (<10.5 mg/dL) and PTH (<90 pg/mL) values due to significantly higher localization rates; however, a localizing sestamibi has higher PPV.