Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout.

OBJECTIVES: To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents. BACKGROUND SUMMARY DATA: Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood. METHODS: Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression. RESULTS: Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment. CONCLUSIONS: Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.

The role of surgical experience in patient selection, surgical quality, and outcomes in robot-assisted radical cystectomy.

BACKGROUND: Robot-assisted radical cystectomy (RARC) remains one of the most complex urological procedures. Due to regionalization of bladder cancer care, there is likely an imbalance in experience among urologists performing RARC. We sought to describe changes in patient selection, surgical quality surrogates and rates of complications in relation to surgical experience. METHODS: We retrospectively reviewed 409 consecutive patients with bladder cancer who underwent RARC between 2006 and 2017 by a single surgeon. The cohort was divided into 4 quartiles (Q1-Q4) according to surgical experience, based on the chronologic order at which RARC was performed. Baseline, perioperative and pathologic characteristics of patients were compared among the 4 groups. 30-day and 90-day complications were assessed using the Clavien-Dindo system. The association between surgical experience (quartile) and complications was assessed using multivariable logistic regression analyses. RESULTS: Median age (interquartile range [IQR] from 70-73 years), body mass index (IQR from 25 to 27 kg/m2) and preoperative glomerular filtration rate (IQR from 59 to 65 ml/min) were similar among all quartiles (all P > 0.05). Patients in Q4 had higher rates of previous abdominopelvic surgery (46.1% vs. 30.4%, P = 0.031) and American Society of Anesthesiologists score of 3 to 4 (72.3% vs. 47.1%, P = 0.003) compared to patients in Q1. Patients who underwent RARC in Q4 compared to Q1, had less estimated blood loss (250 ml vs. 350 ml, P < 0.001), shorter operative time (346 vs. 360 minutes, P < 0.001), and higher lymph node yield (22 vs. 17 nodes, P < 0.001). The 30-day and 90-day complication rates were 53% and 62%, respectively. Thirty-day complication rates were similar among all 4 quartiles (P > 0.05), but higher among patients in Q4 compared to Q1 within 90 days (74% vs. 54%, P = 0.01). On multivariable analysis, patients in Q4 were more likely to experience any 90-day complication (OR 2.03, 95%Cl 1.11-3.70) compared to Q1. CONCLUSION: Our results show that with surgical experience, more complex cases can be performed while continuing to improve surgical quality. Nonetheless, there appears to be a trade-off between the increase in complexity of cases performed with experience and accepting higher rates of complications.

Constructing Learning Curves to Benchmark Operative Performance of General Surgery Residents Against a National Cohort of Peers.

OBJECTIVE: No method or data exist to allow surgical trainees or their programs to contextualize their technical progress. The objective of this study was to create peer benchmarks for Cumulative Sum (CUSUM) charts based upon operative evaluations from a national cohort of general surgery residents. DESIGN, SETTING, PARTICIPANTS: In 2016-2018, faculty from 26 general surgery residency programs nationwide rated 328 residents' operative performance on a case-by-case basis using a validated 5-point Likert scale. An individual case was considered a "misstep" if scoring below the national median score for that procedure in that postgraduate year (PGY). We constructed 2-sided observed-expected CUSUM charts to capture each resident's cumulative performance over time relative to the national medians. Upper (failure) and lower (positive outlier) benchmarks were established based on the PGY-specific 75th percentile and median misstep rates; consistent/repeated missteps are reflected by crossing of the upper boundary. Procedures with ≤10 observations and residents who were evaluated <10 times for each PGY were excluded. RESULTS: Around 8,161 evaluations on 76 procedure types were analyzed. The individual misstep rate was lowest among PGY-3s at 13.3% and highest among PGY-4s at 28.6%. No interns had curves that crossed the failure boundary. 8.7% of PGY-2s and 8.9% of PGY-3s finished the year past the failure boundary. PGY-2s had the most positive outliers, with 28.3% of them demonstrating an outlying success performance beyond the lower boundary for at least once. PGY-5s most frequently failed, with 16.7% ever crossing the upper boundary and 11.1% remaining above it at graduation. CONCLUSIONS: CUSUM is a valid statistical approach for benchmarking individual residents' operative performance against national peers as they progress through the year in real-time. With further validation, CUSUM could be used to set progression and/or graduation standards and objectively identify residents who might benefit from remediation.

Probiotic Lactobacillus Species Strengthen Intestinal Barrier Function and Tight Junction Integrity in Experimental Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) is a serious intestinal disease that occurs in newborn infants. It is associated with major morbidity and affects 5% of all infants admitted to neonatal intensive care units. Probiotics have variable efficacy in preventing necrotizing enterocolitis. Tight junctions (TJ) are protein complexes that maintain epithelial barrier integrity. We hypothesized that the probiotics Lactobacillus rhamnosus and Lactobacillus plantarum strengthen intestinal barrier function, promote TJ integrity, and protect against experimental NEC. Both an in vitro and an in vivo experimental model of NEC were studied. Cultured human intestinal Caco-2 cells were pretreated with L. rhamnosus and L. plantarum probiotics. TJ were then disrupted by EGTA calcium switch or LPS to mimic NEC in vitro. Trans-epithelial resistance (TER) and flux of fluorescein isothiocynate dextran was measured. TJ structure was evaluated by ZO-1 immunofluorescence. In vivo effects of ingested probiotics on intestinal injury and ZO-1 expression were assessed in a rat model of NEC infected with Cronobacter sakazakii (CS). Caco-2 cells treated with individual probiotics demonstrated higher TER and lower permeability compared to untreated cells (p<0.0001). ZO-1 immunofluorescence confirmed TJ stability in treated cells. Rat pups fed probiotics alone had more intestinal injury compared with controls (p=0.0106). Probiotics were protective against injury when given in combination with CS, with no difference in intestinal injury compared to controls (p=0.21). Increased permeability was observed in the probiotic and CS groups (p=0.03, p=0.05), but not in the probiotic plus CS group (p=0.79). Lactobacillus sp. strengthened intestinal barrier function and preserved TJ integrity in an in vitro experimental model of NEC. In vivo, probiotic bacteria were not beneficial when given alone, but were protective in the presence of CS in a rat model of NEC.

Ovariectomy-Induced Osteoporosis Does Not Impact Fusion Rates in a Recombinant Human Bone Morphogenetic Protein-2-Dependent Rat Posterolateral Arthrodesis Model.

Study Design Randomized, controlled animal study. Objective Recombinant human bone morphogenetic protein-2 (rhBMP-2) is frequently utilized as a bone graft substitute in spinal fusions to overcome the difficult healing environment in patients with osteoporosis. However, the effects of estrogen deficiency and poor bone quality on rhBMP-2 efficacy are unknown. This study sought to determine whether rhBMP-2-induced healing is affected by estrogen deficiency and poor bone quality in a stringent osteoporotic posterolateral spinal fusion model. Methods Aged female Sprague-Dawley rats underwent an ovariectomy (OVX group) or a sham procedure, and the OVX animals were fed a low-calcium, low-phytoestrogen diet. After 12 weeks, the animals underwent a posterolateral spinal fusion with 1 µg rhBMP-2 on an absorbable collagen sponge. Representative animals were sacrificed at 1 week postoperative for alkaline phosphatase (ALP) and osteocalcin serum analyses. The remaining animals underwent radiographs 2 and 4 weeks after surgery and were subsequently euthanized for fusion analysis by manual palpation, micro-computed tomography (CT) imaging, and histologic analysis. Results The ALP and osteocalcin levels were similar between the control and OVX groups. Manual palpation revealed no significant differences in the fusion scores between the control (1.42 ± 0.50) and OVX groups (1.83 ± 0.36; p = 0.07). Fusion rates were 100% in both groups. Micro-CT imaging revealed no significant difference in the quantity of new bone formation, and histologic analysis demonstrated bridging bone across the transverse processes in fused animals from both groups. Conclusions This study demonstrates that estrogen deficiency and compromised bone quality do not negatively influence spinal fusion when utilizing rhBMP-2, and the osteoinductive capacity of the growth factor is not functionally reduced under osteoporotic conditions in the rat. Although osteoporosis is a risk factor for pseudarthrosis/nonunion, rhBMP-2-induced healing was not inhibited in osteoporotic rats.

Gel scaffolds of BMP-2-binding peptide amphiphile nanofibers for spinal arthrodesis.

Peptide amphiphile (PA) nanofibers formed by self-assembly can be customized for specific applications in regenerative medicine through the use of molecules that display bioactive signals on their surfaces. Here, the use of PA nanofibers with binding affinity for the bone promoting growth factor BMP-2 to create a gel scaffold for osteogenesis is reported. With the objective of reducing the amount of BMP-2 used clinically for successful arthrodesis in the spine, amounts of growth factor incorporated in the scaffolds that are 10 to 100 times lower than that those used clinically in collagen scaffolds are used. The efficacy of the bioactive PA system to promote BMP-2-induced osteogenesis in vivo is investigated in a rat posterolateral lumbar intertransverse spinal fusion model. PA nanofiber gels displaying BMP-2-binding segments exhibit superior spinal fusion rates relative to controls, effectively decreasing the required therapeutic dose of BMP-2 by 10-fold. Interestingly, a 42% fusion rate is observed for gels containing the bioactive nanofibers without the use of exogenous BMP-2, suggesting the ability of the nanofiber to recruit endogenous growth factor. Results obtained here demonstrate that bioactive biomaterials with capacity to bind specific growth factors by design are great targets for regenerative medicine.