Women in Surgery Italia: National Survey Assessing Gender-Related Challenges.

BACKGROUND: In 2019, women accounted for 46% of surgical residents. Despite the international debate on gender disparities, no literature regarding the experience in Italy is available. The aim of this survey study was to assess satisfaction among female surgeons in Italy, and determine whether they encounter gender-based discrimination. STUDY DESIGN: An anonymous, 83-item web-based survey was distributed among female surgeons working in Italy, from November 18 to December 31, 2020. Gender equity, satisfaction, and factors associated with higher satisfaction and work-life balance were explored. RESULTS: There were 3,242 volunteer respondents, 1,833 of whom completed at least 50% of the specific questions and were included in the study. Approximately 54% of female Italian surgeons reported being satisfied with their job, but only 34% with their work-life balance. Among residents, 67% thought they were not adequately trained. The majority of respondents were responsible for most of the housekeeping (60%) and childcare duties (53%), regardless of their partner's workload, and 62% reported that gender affects the way they are treated at work, with most of them experiencing microaggressions. Sexual harassment was common (59%), but only 10% of women reported it. CONCLUSIONS: Most Italian female surgeons are satisfied with their professional choice. However, they face gender discrimination, including incidents of sexual harassment and microaggression. Due to the fact that half of surgeons working in Italian hospitals will be females in the next few years, actions are urgently required to build a culture that supports a gender-neutral environment.

Firearm Storage Practices of US Members of the American College of Surgeons.

BACKGROUND: As a part of its firearm injury prevention action plan, the American College of Surgeons (ACS) surveyed the entire US ACS membership regarding individual members' knowledge, experience, attitudes, degree of support for ACS Committee on Trauma (COT) firearm programs, and degree of support for a range of firearm injury prevention policies. This survey included questions regarding members' prevalence of firearm ownership, type of firearm(s) owned, type of firearm(s) in the home, personal reasons for firearm ownership, and methods of firearm/ammunition storage. STUDY DESIGN: An email invitation to participate in an anonymous, 23-item survey on firearms was sent to all US ACS members (n = 54,761) by a contracted survey research firm. Cross tabulation of questionnaire items by demographic characteristics and chi-square analyses were performed with statistical significance p < 0.05. RESULTS: The overall response rate was 20.4% (11,147/54,761). Forty-two percent of respondents keep firearms in their home (82% long guns, 82% handguns; 32% high-capacity magazine fed, semi-automatic rifles); 75% keep guns for self-defense/protection, 73% for target shooting; 39% store firearms unlocked, and 32% store guns unlocked and loaded. Results vary by practice/training location, practice type, military experience, sex, age, presence of children in the home, level of training, and race/ethnicity. CONCLUSIONS: A significant percentage of ACS members keep firearms in their home, and nearly one-third store firearms in an unlocked and loaded fashion. Safe storage is a basic tenet of responsible firearm ownership. These data present opportunities for engaging surgeons in efforts to improve safe firearm storage.

Evaluation of Deep Learning Models for Identifying Surgical Actions and Measuring Performance.

Importance: When evaluating surgeons in the operating room, experienced physicians must rely on live or recorded video to assess the surgeon's technical performance, an approach prone to subjectivity and error. Owing to the large number of surgical procedures performed daily, it is infeasible to review every procedure; therefore, there is a tremendous loss of invaluable performance data that would otherwise be useful for improving surgical safety. Objective: To evaluate a framework for assessing surgical video clips by categorizing them based on the surgical step being performed and the level of the surgeon's competence. Design, Setting, and Participants: This quality improvement study assessed 103 video clips of 8 surgeons of various levels performing knot tying, suturing, and needle passing from the Johns Hopkins University-Intuitive Surgical Gesture and Skill Assessment Working Set. Data were collected before 2015, and data analysis took place from March to July 2019. Main Outcomes and Measures: Deep learning models were trained to estimate categorical outputs such as performance level (ie, novice, intermediate, and expert) and surgical actions (ie, knot tying, suturing, and needle passing). The efficacy of these models was measured using precision, recall, and model accuracy. Results: The provided architectures achieved accuracy in surgical action and performance calculation tasks using only video input. The embedding representation had a mean (root mean square error [RMSE]) precision of 1.00 (0) for suturing, 0.99 (0.01) for knot tying, and 0.91 (0.11) for needle passing, resulting in a mean (RMSE) precision of 0.97 (0.01). Its mean (RMSE) recall was 0.94 (0.08) for suturing, 1.00 (0) for knot tying, and 0.99 (0.01) for needle passing, resulting in a mean (RMSE) recall of 0.98 (0.01). It also estimated scores on the Objected Structured Assessment of Technical Skill Global Rating Scale categories, with a mean (RMSE) precision of 0.85 (0.09) for novice level, 0.67 (0.07) for intermediate level, and 0.79 (0.12) for expert level, resulting in a mean (RMSE) precision of 0.77 (0.04). Its mean (RMSE) recall was 0.85 (0.05) for novice level, 0.69 (0.14) for intermediate level, and 0.80 (0.13) for expert level, resulting in a mean (RMSE) recall of 0.78 (0.03). Conclusions and Relevance: The proposed models and the accompanying results illustrate that deep machine learning can identify associations in surgical video clips. These are the first steps to creating a feedback mechanism for surgeons that would allow them to learn from their experiences and refine their skills.

Higher Surgeon Procedure Volume Is Associated with Improved Hemodialysis Vascular Access Outcomes.

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.

Classification of Intermediate and Novice Surgeons' Skill Assessment Through Performance Metrics.

Background. Endoscopic surgeries have become an alternative for open procedures whenever possible. For such types of operations, surgeons are required to gain several skills, whose development needs hands-on practice. Accordingly, gaining these skills today is a challenge for surgical education programs. Despite the development of several technology-enhanced training environments, there are still problems to better integrate these technologies into educational programs. For an appropriate integration, it is critical to assess the skill levels and adapt the training content according to the trainees' requirements. In the literature, there exist several methods for assessing these skill levels. However, there are still problems in practice for objective and repetitive assessment. Methods. The present study aims to estimate the skill levels of participants in surgical training programs in an objective manner by collecting experimental data from residents in an endoscopic surgical simulation environment and gathering performance metrics. Results. It is shown that, by comparing the results of a number of classification algorithms for the best accuracy estimation and feature set, the "novice" and "intermediate" skill levels can be estimated with an accuracy of 86%. Conclusions. The outcomes help surgical educators and instructional system designers to better assess the skill levels of the trainees and guide them accordingly. In addition, objective assessments as highlighted in this study can be beneficial when designing technology-enhanced adaptive learning environments.

Combining Metrics From Clinical Simulators and Sensorimotor Tasks Can Reveal the Training Background of Surgeons.

BACKGROUND: Skill assessment in surgery traditionally has relied on the expert observation and qualitative scoring. Our novel study design demonstrates how analysis of performance in sensorimotor tasks and bench-top surgical simulators can provide inferences about the technical proficiency as well as the training history of surgeons. METHODS: We examined metrics for basic sensorimotor tasks in a virtual reality interface as well as motion metrics in clinical scenario simulations. As indicators of the training level, we considered survey responses from surgery residents, including the number of postgraduation years (PGY, four levels), research years (RY, three levels), and clinical years (CY, three levels). Next, we performed a linear discriminant analysis with cross-validation (90% training, 10% testing) to relate the training levels to the selected metrics. RESULTS: Using combined metrics from all stations, we found greater than chance predictions for each survey category, with an overall accuracy of 43.4 ± 2.9% for identifying the level for post-graduate years, 79.1 ± 1.0% accuracy for research training years, and 64.2 ± 1.0% for clinical training years. Our main finding was that combining metrics from all stations resulted in more accurate predictions than using only sensorimotor or clinical scenario tasks. In addition, we found that metrics related to the ability to cope with changes in the task environment were the most important predictors of training level. CONCLUSIONS: These results suggest that each simulator-type provided crucial information for evaluating surgical proficiency. The methods developed in this paper could improve evaluations of a surgeon's clinical proficiency as well as training potential in terms of basic sensorimotor ability.

Assessing bimanual motor skills with optical neuroimaging.

Measuring motor skill proficiency is critical for the certification of highly skilled individuals in numerous fields. However, conventional measures use subjective metrics that often cannot distinguish between expertise levels. We present an advanced optical neuroimaging methodology that can objectively and successfully classify subjects with different expertise levels associated with bimanual motor dexterity. The methodology was tested by assessing laparoscopic surgery skills within the framework of the fundamentals of a laparoscopic surgery program, which is a prerequisite for certification in general surgery. We demonstrate that optical-based metrics outperformed current metrics for surgical certification in classifying subjects with varying surgical expertise. Moreover, we report that optical neuroimaging allows for the successful classification of subjects during the acquisition of these skills.

Positive Impact of an Aortic Center Designation.

BACKGROUND: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center. METHODS: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals. RESULTS: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016. CONCLUSIONS: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation.

Objective Assessment of Surgical Technical Skill and Competency in the Operating Room.

Training skillful and competent surgeons is critical to ensure high quality of care and to minimize disparities in access to effective care. Traditional models to train surgeons are being challenged by rapid advances in technology, an intensified patient-safety culture, and a need for value-driven health systems. Simultaneously, technological developments are enabling capture and analysis of large amounts of complex surgical data. These developments are motivating a "surgical data science" approach to objective computer-aided technical skill evaluation (OCASE-T) for scalable, accurate assessment; individualized feedback; and automated coaching. We define the problem space for OCASE-T and summarize 45 publications representing recent research in this domain. We find that most studies on OCASE-T are simulation based; very few are in the operating room. The algorithms and validation methodologies used for OCASE-T are highly varied; there is no uniform consensus. Future research should emphasize competency assessment in the operating room, validation against patient outcomes, and effectiveness for surgical training.

Using Contact Forces and Robot Arm Accelerations to Automatically Rate Surgeon Skill at Peg Transfer.

OBJECTIVE: Most trainees begin learning robotic minimally invasive surgery by performing inanimate practice tasks with clinical robots such as the Intuitive Surgical da Vinci. Expert surgeons are commonly asked to evaluate these performances using standardized five-point rating scales, but doing such ratings is time consuming, tedious, and somewhat subjective. This paper presents an automatic skill evaluation system that analyzes only the contact force with the task materials, the broad-bandwidth accelerations of the robotic instruments and camera, and the task completion time. METHODS: We recruited N = 38 participants of varying skill in robotic surgery to perform three trials of peg transfer with a da Vinci Standard robot instrumented with our Smart Task Board. After calibration, three individuals rated these trials on five domains of the Global Evaluative Assessment of Robotic Skill (GEARS) structured assessment tool, providing ground-truth labels for regression and classification machine learning algorithms that predict GEARS scores based on the recorded force, acceleration, and time signals. RESULTS: Both machine learning approaches produced scores on the reserved testing sets that were in good to excellent agreement with the human raters, even when the force information was not considered. Furthermore, regression predicted GEARS scores more accurately and efficiently than classification. CONCLUSION: A surgeon's skill at robotic peg transfer can be reliably rated via regression using features gathered from force, acceleration, and time sensors external to the robot. SIGNIFICANCE: We expect improved trainee learning as a result of providing these automatic skill ratings during inanimate task practice on a surgical robot.

Willingness to Pay for Cataract Surgery Provided by a Senior Surgeon in Urban Southern China.

PURPOSE: To study willingness to pay for cataract surgery and surgical service provided by a senior cataract surgeon in urban Southern China. METHODS: This study was a cross-sectional willingness-to-pay (WTP) interview using bidding formats. Two-hundred eleven persons with presenting visual impairment in either eye due to cataract were enrolled at a tertiary eye hospital. Participants underwent a comprehensive eye examination and a WTP interview for both surgery and service provided by a senior surgeon. Demographic information, socioeconomic status and clinical data were recorded. RESULTS: Among 211 (98% response rate) persons completing the interview, 53.6% were women and 80.6% were retired. About 72.2% had a monthly income lower than 1000 renminbi (US $161). A total of 189 (89.6%) were willing to pay for cataract and the median amount of WTP was 6000 renminbi (US$968). And 102 (50.7%) were willing to pay additional fees for surgery performed by a senior surgeon, and the median amount of WTP was 500 renminbi (US$81). In regression models adjusting for age and gender, persons with preexisting eye diseases other than cataract, were more likely to pay for cataract surgery and service provided by a senior surgeon (P = 0.04 for both). CONCLUSIONS: In urban China, cataract patients, especially those with preexisting eye conditions, are willing to pay additional fees for a senior surgeon. Moving to a system where the price of cataract surgery is proportional to the consultant' skill and expertise is possible and may have a potential impact on waiting list and quality of eye care. Further studies are needed to examine the impact of such pricing system on attitudes and choices of cataract patients.