The Role of Race and Gender in the Career Experiences of Black/African American Academic Surgeons: A Survey of the Society of Black Academic Surgeons and a Call to Action.

OBJECTIVE: To determine the role of race and gender in the career experience of Black/AA academic surgeons and to quantify the prevalence of experience with racial and gender bias stratified by gender. SUMMARY OF BACKGROUND DATA: Compared to their male counterparts, Black/African American women remain significantly underrepresented among senior surgical faculty and department leadership. The impact of racial and gender bias on the academic and professional trajectory of Black/AA women surgeons has not been well-studied. METHODS: A cross-sectional survey regarding demographics, employment, and perceived barriers to career advancement was distributed via email to faculty surgeon members of the Society of Black American Surgeons (SBAS) in September 2019. RESULTS: Of 181 faculty members, 53 responded (29%), including 31 women (58%) and 22 men (42%). Academic positions as a first job were common (men 95% vs women 77%, P = 0.06). Men were more likely to attain the rank of full professor (men 41% vs women 7%, P = 0.01). Reports of racial bias in the workplace were similar (women 84% vs men 86%, not significant); however, reports of gender bias (women 97% vs men 27%, P < 0.001) and perception of salary inequities (women 89% vs 63%, P = 0.02) were more common among women. CONCLUSIONS AND RELEVANCE: Despite efforts to increase diversity, high rates of racial bias persist in the workplace. Black/AA women also report experiencing a high rate of gender bias and challenges in academic promotion.

Surgical autonomy: A resident perspective and the balance of teacher development with operative independence.

BACKGROUND: This study aims to understand the perspectives of operative autonomy of surgical residents at various postgraduate levels. METHODS: Categorical general surgery residents at a single academic residency were invited to participate in focus groups to discuss their opinions and definitions of operative autonomy. Employing constructivist thematic analysis, focus groups were audio recorded, transcribed, and inductively analyzed using a constant comparative technique. RESULTS: Twenty clinical surgical residents participated in 6 focus groups. Overarching themes identified include autonomy as a dynamic, progressive path to operative independence and the complex interaction of resident-as-teacher development and operative autonomy. Four within operative case themes were intrinsic factors, extrinsic factors, autonomy promoting or inhibiting behaviors, and the relationship between residents and attendings. CONCLUSION: Residents define operative autonomy as a progressive and dynamic pathway to operative independence. Teacher development is viewed as both an extension beyond operative independence and potentially in conflict with their colleagues' development.

Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

BACKGROUND: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.

Surgical Translational Research May Be Forward or Reverse.

The classic concept of translational research can be described as a bench-to-bedside approach. Reverse translational research, bedside-to-benchtop, also may have a place. Under some circumstances, innovative clinicians may develop new techniques in advance of basic science research. A recent example of the success of reverse translational research is shoulder superior capsular reconstruction. Theoretically, new surgical techniques are ideally first tested ex vivo, but this does not guarantee clinical success, and in some cases, experienced, specialized surgeon-scientists can modify existing techniques and perform novel interventions with little risk to patients. Benefits of reverse translational research include a shorter time from innovation to application, and real, not theoretical, determination of clinical outcome. If a reverse approach is warranted, strict adherence to bioethical principles is required, including cooperation with ethics committees, institutional review boards, trial registration, and informed consent. Translational research can be bidirectional.

Restricted access to innovative surgical technique related to a specific training, is it ethical? Example of the PIPAC procedure. A systematic review and an experts survey.

OBJECTIVE: Using the example of Pressurized Intra Peritoneal Aerosol Chemotherapy (PIPAC), we analyse the development model of this procedure and provide an ethical analysis of the involvement of the industry in a new development. SUMMARY BACKGROUND DATA: In the case of breakthrough innovation, medical training is essential for safe use of the new procedure. In some cases, pharmaceutical companies decide to organise this training. But when it becomes the only training opportunity to use the device, scientists and clinicians could be exposed to a conflict of interest? METHODS: We performed a literature review of PIPAC publications using the STROBE criteria. Then, we conducted interviews with an expert panel to analyse the ethical impact of involvement of the industry in the development of the PIPAC procedure. RESULTS: The number of publications has increased every year since the first publication in Germany, where the technology was developed in 2013. The scientific production was of good quality, with a mean STROBE score of 18.2 ± 2.4 out of 22 points. Ten of the 33 included studies declared a conflict of interest. From the interviews, the main axe concerning the implication of the industry was the training model. The company had decided that only trained and approval surgeon could perform the PIPAC procedure. All four interviewed practitioners agreed that it was initially a good way to implement the procedure safely, but later they felt uncomfortable about the control and validation by the industry. CONCLUSION: Based on the growing number of published papers from a growing number of international centres, the controlled training model is not limiting. However, the different levels of conflict of interest complicate transparency, and we postulated that this development model is limited to the beginning of the procedure diffusion. CLINICALTRIAL. GOV REGISTRATION: NCT04341337.

Surgical ethics: a framework for surgeons, patients, and society.

The practice of surgery is based on the technical capabilities of the surgeon (techne), their knowledge (episteme) and their capacity of judgment (phronesis). Surgeons face situations that call into question moral choices and face ethical difficulties in their daily practice. In fact, innovation is increasing, and as operations become more complex and the risks become greater, the tools necessary to approach an ethically challenging surgical case become more important. Surgical ethics can be distinguished from other medical ethics fields because of its unique characteristics and goals. Ethics lie at the core of professionalism: a proficient surgeon is considered to be not only competent to perform the art and science of surgery as traditionally understood, but also to be ethically and morally reliable. The principlism and the four-box model approaches to clinical ethics could serve as a guide to the surgical ethics discussion. There are five categories of experience and relationships that are especially important in surgery-rescue, proximity, ordeal, aftermath and presence. Ethical reasoning should help surgeons to gives answers to the questions: What should be done? Has the right decision in this situation been made? The following article is presented with the intent of encouraging thought and dialogue about ethical considerations relevant to the practice of surgery. For that reason, we will first define the scope of surgical ethics, then we will present the main ethical issues faced by surgeons and how surgeons deal with them. Finally, I will show the implications of the development of surgery ethics for patients, surgeons and society.

Reconceptualizing Ethics Through Morbidity and Mortality Rounds.

BACKGROUND: Surgeons face ethical tensions daily, yet ethics education continues to prove challenging. Two possible reasons for these challenges may be the different conceptions of knowledge between technical training vs those that underpin ethical practice, and the potential devaluing of ethics as a focus for education given false assumptions about its inherent nature. This study implemented and evaluated an innovation meant to prioritize and contextualize ethics in surgical learning and practice. STUDY DESIGN: After implementation of Ethics Morbidity and Mortality (M&M) rounds as an educational intervention, a qualitative evaluation consisted of interviews with 12 residents and 9 faculty. Analysis was informed by principles of constructivist grounded theory and the theoretical framework of Habermas' 3 types of knowledge: technical, practical, and emancipatory. For comparative purposes, analysis was conducted of how participants described ethics and ethics education and learning in relation to the traditional ethics teaching model vs the M&Ms. RESULTS: In the traditional model, ethics teaching was seen as disconnected from real life, and not valuable. Within M&Ms, ethics was viewed as integral to practice, engaging, valuable, and relevant. In the traditional model, ethics principles were seen as acquired through role modeling and as a fixed part of character. Within M&Ms, ethics principles were seen as learnable and transformable parts of identity. CONCLUSIONS: Traditional teaching of surgical ethics may result in physicians armed with knowledge, but unable to apply it. Our findings suggest that incorporating ethics into M&Ms allows not only learning the tools of ethics, but the knowledge that ethical principles were becoming integrated into professional identity.

Surgery during COVID-19 crisis conditions: can we protect our ethical integrity against the odds?

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients' outcome within the constraints of pandemic management and its long-term outlook.

What do patients want? Surgical informed-consent and patient-centered care - An augmented model of information disclosure.

The ideal moral standard for surgical informed-consent calls upon surgeons to carry out a disclosure dialogue with patients so they have as full as possible an understanding of the procedure before they sign the informed-consent form. This study is the first to empirically explore patient preferences regarding disclosure dialogue. Twelve Israelis who underwent life-saving surgeries participated in a narrative study. Three themes emerged from the analysis: objectification of patients, anxiety provoking processes and information, and lack of information that was essential for patients. Findings contribute to existing debates among surgeons regarding the scope and importance of some disclosure components. Analysis led to our formulation of an augmented subjective model of information disclosure that participants prefer, which extends beyond the immediate present of the surgery to the period after discharge, and until return to routine. Surgeons should be aware of patient preferences in disclosure, and gaps between perceptions of surgeons, and preferences and needs of patients.

Surgical ethics: a framework for surgeons, patients, and society

Summary The practice of surgery is based on the technical capabilities of the surgeon (techne), their knowledge (episteme) and their capacity of judgment (phronesis). Surgeons face situations that call into question moral choices and face ethical difficulties in their daily practice. In fact, innovation is increasing, and as operations become more complex and the risks become greater, the tools necessary to approach an ethically challenging surgical case become more important. Surgical ethics can be distinguished from other medical ethics fields because of its unique characteristics and goals. Ethics lie at the core of professionalism: a proficient surgeon is considered to be not only competent to perform the art and science of surgery as traditionally understood, but also to be ethically and morally reliable. The principlism and the four-box model approaches to clinical ethics could serve as a guide to the surgical ethics discussion. There are five categories of experience and relationships that are especially important in surgery-rescue, proximity, ordeal, aftermath and presence. Ethical reasoning should help surgeons to gives answers to the questions: What should be done? Has the right decision in this situation been made? The following article is presented with the intent of encouraging thought and dialogue about ethical considerations relevant to the practice of surgery. For that reason, we will first define the scope of surgical ethics, then we will present the main ethical issues faced by surgeons and how surgeons deal with them. Finally, I will show the implications of the development of surgery ethics for patients, surgeons and society.

Talking About Ethical Issues in Surgery-Results of a Novel Online Pilot Curriculum.

OBJECTIVES: Surgical ethics has been suggested as a distinct field of study apart from clinical ethics due to a unique practice type and treatment dynamic. At our institution, most if not all teaching of clinical ethics is undertaken by nonsurgical faculty. We introduced a novel online Surgical Ethics Program (SEO) in a pilot form (SEO-P) for initial presentation to learners in our environment. The overall goal of our educational intervention was to enhance knowledge, understanding and appreciation for surgical ethics in medical students and to evaluate our curriculum. SETTING: SEO-P was undertaken over a 4-week period in 2018 with 9 fourth-year medical students enrolled in a surgery elective at our institution. These learners all had career plans in general surgery or a surgical subspecialty. There was 3 weeks of content: (1) background in clinical ethics as it applies to surgical practice, (2) surgical consents and autonomy, and (3) the impaired physician. All pilot learners were evaluated with: (1) postprogram final exam assessment (compared to preprogram knowledge base test), (2) self-reflection essay of ethical practice in surgery, (3) evaluation of 2 case studies, and (4) an assessment of participation in online discussion forums. Postprogram survey of the learners was also undertaken in an anonymous fashion. RESULTS: Four of 9 or 44.4% of students scored greater than or equal to 80% on the postprogram knowledge assessment test. A preprogram knowledge-based examination of all learners yielded a mean and standard deviation of 57.1 ± 6.0%. Postprogram knowledge-based test with mean and standard deviation was 78.8 ± 15%. This was a statistically significant increase in scores (p = 0.004; t test). All 9 passed the course with a mean final summative course grade of 95.2 ± 3.2%. From the postprogram evaluation survey, all 7 students who responded felt that the SEO-P would help them become an "ethical" practitioner. Surprisingly, only half of the learners (57.1%) thought "technology used to support the SEO Course (i.e., the chosen curriculum management system) was effective in conducting the course." CONCLUSIONS: We set forth to use "web-based" technology to enhance exposure of medical students in our institution to surgical ethics. Hence, we designed our pilot curriculum to be a completely online offering. We feel that the utilization of the surgical voice, that is a surgical ethics curriculum developed by surgeons to explore surgically related clinical ethical issues, is an essential theme and goal of our program. Future challenges will be to present this voice in an effective manner with either an improved curriculum delivery system or by potentially utilizing a blended approach.

Fetal Repair of Open Neural Tube Defects: Ethical, Legal, and Social Issues.

Open neural tube defects or myelomeningoceles are a common congenital condition caused by failure of closure of the neural tube early in gestation, leading to a number of neurologic sequelae including paralysis, hindbrain herniation, hydrocephalus and neurogenic bowel and bladder dysfunction. Traditionally, the condition was treated by closure of the defect postnatally but a recently completed randomized controlled trial of prenatal versus postnatal closure demonstrated improved neurologic outcomes in the prenatal closure group. Fetal surgery, or more precisely maternal-fetal surgery, raises a number of ethical issues that we address including who the patient is, informed consent, surgical innovation and equipoise as well maternal assumption of risk. As the procedure becomes more widely adopted into practice, we suggest close monitoring of new fetal surgery centers, in order to ensure that the positive results of the trial are maintained without increased risk to both the mother and fetus.

Ethical Issues Encountered During the Medical Student Surgical Clerkship.

BACKGROUND: Data regarding ethical issues encountered by medical students during the surgical clerkship are sparse. Identification of such issues facilitates development of an ethics curriculum that ensures student preparation for issues most frequently encountered on the surgical rotation. To better understand these issues, we performed content analysis of reflections written by medical students about ethical issues encountered during their surgical clerkship. MATERIALS AND METHODS: All medical students on the surgical clerkship at a university hospital from 4/2017 to 6/2018 submitted a written reflection regarding an ethical issue encountered during the clerkship. Two investigators performed content analysis of each reflection. References to ethical principles (beneficence, nonmaleficence, justice, autonomy) were tabulated. Ethical issues were classified into main categories and subcategories, based on a modified version of a previously published taxonomy. RESULTS: 134 reflections underwent content analysis. Nonmaleficence was the most frequently mentioned ethical principle. 411 specific ethical issues were identified. Ethical issues were distributed across ten main categories: decision-making (28%), communication among health care team members (14%), justice (12%), communication between providers, patients, and families (9%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student-specific issues (5%), documentation (1%), and miscellaneous/other (8%). We identified two ethical issues infrequently discussed in previous reports: delivery of efficient yet high-quality care and poor communication between services/consultants. CONCLUSIONS: Students encounter diverse ethical issues during their surgical clerkships. Ethical and contextual considerations related to these issues should be incorporated into a preclinical/clinical surgical ethics curriculum to prepare students to understand and engage the challenges they face during the clerkship.