Surgical Trainees' Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal.

BACKGROUND: Surgeon educators express concern about trainees' sense of patient ownership. We aimed to compare resident and faculty perceptions on residents' sense of personal responsibility for patient outcomes and to correlate patient ownership with resident and residency characteristics. METHODS: An anonymous electronic questionnaire surveyed 373 residents and 390 faculty at seven academic surgery residencies across the United States. We modified an established psychological ownership scale to measure patient ownership among surgical trainees. RESULTS: Respondents included 123 residents and 136 faculty (response rate 33% and 35%, respectively). Overall, 78.0% of faculty agreed that residents took personal responsibility for patient outcomes, but only 26.4% thought residents felt a similar or higher degree of patient ownership compared with themselves. Faculty underestimated the proportion of residents that routinely checked on their patients when off-duty (36.8 versus 92.6%, P < 0.001). Higher means on the patient ownership scale correlated with female sex (5.9 versus. 5.5 for males, P = 0.009), advanced post graduate year level (5.3, 5.5, 5.7, 5.8, 6.1, for post graduate year 1-5, respectively, P = 0.02), and the sense that patient outcomes affected the resident respondent's mood (5.8 versus 4.8 for those whose mood was not affected, P < 0.001). In addition, trainees who perceived better resident camaraderie (P = 0.004), faculty mentorship (P < 0.001), and that their program provided appropriate autonomy (P = 0.03) felt greater responsibility for patient outcomes. CONCLUSIONS: Most faculty agree that residents assume personal responsibility for patient outcomes, but many still underestimate residents' sense of patient ownership. Certain modifiable aspects of residency culture including camaraderie, mentorship, and autonomy are associated with patient ownership among trainees.

Standardizing quality utilization of interventional radiology treatments of blunt splenic injury: SQUIRTS study.

OBJECTIVES: Nonoperative management (NOM) of blunt splenic injury (BSI) is well accepted in appropriate patients. Splenic artery embolization (SAE) in higher-grade injuries likely plays an important role in increasing the success of NOM. We previously implemented a protocol requiring referral of all BSI grades III-V undergoing NOM for SAE. It is unknown the risk of complications as well as longitudinal outcomes. We aimed to examine the splenic salvage rate and safety profile of the protocol. We hypothesized the splenic salvage rate would be high and complications would be low. METHODS: A retrospective study was performed at our Level 1 trauma center over a 9-year period. Injury characteristics and outcomes in patients sustaining BSI grades III-V were collected. Outcomes were compared for NOM on protocol (SAE) and off protocol (no angiography or angiography but no embolization). Complications for angiographies were examined. RESULTS: Between January 2010 and February 2019, 570 patients had grade III-V BSI. NOM was attempted in 359 (63 %) with overall salvage rate of 91 % (328). Of these, 305 were on protocol while 54 were off protocol (41 no angiography and 13 angiography but no SAE). During the study period, for every grade of injury a pattern was seen of a higher salvage rate in the on-protocol group when compared to the off-protocol group (Grade III, 97 %(181/187) vs. 89 %(32/36), Grade IV, 91 %(98/108) vs. 69 %(9/13) and Grade V, 80 %(8/10 vs. 0 %(0/5). The overall salvage rate was 94 %(287) on protocol vs. 76 %(41) off protocol (p < 0.001, Cochran-Mantel-Haenszel test). Complications occurred in only 8 of the 318 who underwent angiography (2 %). These included 5 access complications and 3 abscesses. CONCLUSION: The use of a protocol requiring routine splenic artery embolization for all high-grade spleen injuries slated for non-operative management is safe with a very low complication rate. NOM with splenic angioembolization failure rate is improved as compared to non-SAE patients' at all higher grades of injury. Thus, SAE for all hemodynamically stable patients of all high-grade types should be considered as a primary form of therapy for such injuries.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. METHODS: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. RESULTS: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. CONCLUSIONS: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Improving the Culture of Safety: A Prospective Handoff Initiative from the Operating Room to the Trauma Intensive Care Unit.

A recent EAST publication emphasized the importance of handoffs to ensure safe and effective care for trauma patients. In this work, we evaluated our existing handoffs from the operating room (OR) to the trauma intensive care unit (TICU) and implemented a formal process at our level 1 trauma center. Pre and post-intervention surveys were offered to the stakeholders. Responses were recorded in a Likert scaled format and results were compared using Student's t-test with statistical significance was set to .05. 57 surveys were completed (30 pre, 27 post) and 139 handoffs occurred. There was significant improvement in "overall satisfaction" and "understanding of information expected." Standardizing an OR to intensive care unit handoff clarifies expectations and improves care team satisfaction. While future studies are needed to evaluate the impact of structured handoffs on patient outcomes, provider satisfaction likely serves as an indicator for culture shift towards safer transitions of care for injured patients.

Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients.

BACKGROUND: The early resuscitation occurs in the emergency department (ED) where intensive care unit protocols do not always extend and monitoring capabilities vary. Our hypothesis is that increased ED length of stay (LOS) leads to increased hospital mortality in patients not undergoing immediate surgical intervention. METHODS: We examined all trauma activation admissions from January 2002 to July 2009 admitted to the Trauma Service (n = 3,973). Exclusion criteria were as follows: patients taken to the operating room within the first 2 hours of ED arrival, nonsurvivable brain injury, and ED deaths. Patients spending >5 hours in the ED were not included in the analysis because of significantly lower acuity and mortality. RESULTS: Patients spent a mean of 3.2 hours ± 1 hour in the ED during their initial evaluation. Hospital mortality increases for each additional hour a patient spends in the ED, with 8.3% of the patients staying in the ED between 4 hours and 5 hours ultimately dying (p = 0.028). ED LOS measured in minutes is an independent predictor of mortality (odds ratio, 1.003; 95% confidence interval, 1.010-1.006; p = 0.014) when accounting for Injury Severity Score, Revised Trauma Score, and age. Linear regression showed that a longer ED LOS was associated with anatomic injury pattern rather than physiologic derangement. CONCLUSION: In this patient population, a longer ED LOS is associated with an increased hospital mortality even when controlling for physiologic, demographic, and anatomic factors. This highlights the importance of rapid progression of patients through the initial evaluation process to facilitate placement in a location that allows implementation of early goal directed trauma resuscitation.

Screening for Bacteremia in Trauma Patients: Traditional Markers Fall Short.

BACKGROUND: Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. MATERIALS AND METHODS: Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. RESULTS: Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. CONCLUSION: Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Surgical intensive care unit mobility is increased after institution of a computerized mobility order set and intensive care unit mobility protocol: a prospective cohort analysis.

In some populations, intensive care unit (ICU) mobility has been shown to be safe and beneficial. We gathered data on 50 nonintubated surgical patients in a 10-bed surgical ICU (SICU) who met physiologic inclusion criteria beginning in May 2008 (A group). In January 2009, we began mandatory entry of computerized mobility orders as part of a standardized ICU order set. We also created a mobility protocol for nurses in this ICU. We then collected data on 50 patients in this postintervention cohort (B group). Both groups had similar baseline characteristics. A group patients had some form of mobility orders entered in 29 patients (58%) versus 47 patients (82%) in the B group, P < 0.05. In the A group, 11 patients (22%) were mobilized; in the B group, 40 patients (80%) were mobilized, P < 0.05. In our SICU patient population, mandatory entry of computerized mobility orders as part of a standard SICU order set and establishment of an ICU mobility nursing protocol was associated with an increase in number of mobility orders entered as well as an increase in SICU patient activity. Further studies should focus on measurement of the effect of mobility interventions on patient outcomes.

Evaluation of the Performance of ACS NSQIP Surgical Risk Calculator in Emergency General Surgery Patients.

The ACS NSQIP Surgical Risk Calculator is designed to estimate the chance of an unfavorable outcome after surgery. Our goal was to evaluate the accuracy of the calculator in our emergency general surgery population. Surgical outcomes were compared to predicted risk. The risk was calculated with surgeon adjustment scores (SASs) of 1 (no adjustment), 2 (risk somewhat higher), and 3 (risk significantly higher than estimate). Two hundred and twenty-seven patients met the inclusion criteria. An SAS of 1 or 2 accurately predicted risk of mortality (5.7% and 8.5% predicted versus 7.9% actual), whereas a risk adjustment of 3 indicated significant overestimation of mortality rate (14.8% predicted). There was good overall prediction performance for most variables with no clear preference for SAS 1, 2, or 3. Poor correlation was seen with SSI, urinary tract infection, and length of stay variables. The ACS NSQIP Surgical Risk Calculator yields valid predictions in the emergency general surgery population, and the data support its use to inform conversations about outcome expectations.

Do Internal or External Characteristics More Reliably Predict Burnout in Resident Physicians: A Multi-institutional Study.

INTRODUCTION: Surgical residents have been shown to experience high rates of burnout. Whether this is influenced predominately by intrinsic characteristics, external factors, or is multifactorial has not been well studied. The aim of this study was to explore the relationship between these elements and burnout. We hypothesized that residents with higher emotional intelligence scores, greater resilience and mindfulness, and better work environments would experience lower rates of burnout. METHODS: General surgery residents at 7 sites in the US were invited to complete an electronic survey in 2019 that included the 2-item Maslach Burnout Inventory, Brief Emotional Intelligence Scale, Revised Cognitive and Affective Mindfulness Scale, 2-Item Connor-Davidson Resilience Scale, Utrecht Work Engagement Scale, and Job Resources scale of the Job Demands-Resources Questionnaire. Individual constructs were assessed for association with burnout, using multivariable logistic regression models. Residents' scores were evaluated in aggregate, in groups according to demographic characteristics, and by site. RESULTS: Of 284 residents, 164 completed the survey (response rate 58%). A total of 71% of respondents were at high risk for burnout, with sites ranging from 57% to 85% (p = 0.49). Burnout rates demonstrated no significant difference across gender, PGY level, and respondent age. On bivariate model, no demographic variables were found to be associated with burnout, but the internal characteristics of emotional intelligence, resilience and mindfulness, and the external characteristics of work engagement and job resources were each found to be protective against burnout (p < 0.001 for all). However, multivariable models examining internal and external characteristics found that no internal characteristics were associated with burnout, while job resources (coeff. -1.0, p-value <0.001) and work engagement (coeff. -0.76, p-value 0.032) were significantly protective factors. Rates of engagement overall were high, particularly with respect to work "dedication." CONCLUSIONS: A majority of residents at multiple institutions were at high risk for burnout during the study period. Improved work engagement and job resources were found to be more strongly associated with decreased burnout rates when compared to internal characteristics. Although surgical residents appear to already be highly engaged in their work, programs should continue to explore ways to increase job resources, and further research should be aimed at elucidating the mediating effect of internal characteristics on these external factors.

Live Quality Assurance: Using a Multimedia Messaging Service Group Chat to Instantly Grade Intraoperative Images.

BACKGROUND: The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS. STUDY DESIGN: We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores. RESULTS: There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement. CONCLUSIONS: An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Ad astra per aspera (Through Hardships to the Stars): Lessons Learned from the First National Virtual APDS Meeting, 2020.

OBJECTIVE: After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting. DESIGN: APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking. SETTING: The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming. PARTICIPANTS: There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally. RESULTS: There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance. CONCLUSIONS: A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.

Adrenal suppression following a single dose of etomidate for rapid sequence induction: a prospective randomized study.

BACKGROUND: The administration of etomidate for rapid sequence induction (RSI) has been linked to subsequent adrenocortical insufficiency in nontrauma patients. However, etomidate-related adrenocortical insufficiency has not been well studied in the trauma population. PURPOSE: We performed a prospective, randomized, controlled study to assess the effect of one dose of etomidate for RSI on adrenal function and its clinical significance during and after resuscitation in trauma patients. METHODS: Adult trauma patients admitted to our Level I trauma center requiring RSI were randomized to receive etomidate 0.3 mg/kg and succinylcholine 1 mg/kg (E group) or fentanyl 100 microg, midazolam 5 mg, and succinylcholine 1 mg/kg (FM group) for induction. A baseline serum cortisol level was drawn before RSI. Four to six hours after RSI, a postintubation serum cortisol level was drawn. An ACTH stimulation test was performed. RESULTS: Thirty patients were enrolled: 18 E group patients and 12 FM group patients. No statistical difference was detected between the two groups with respect to age, injury severity score, and baseline serum cortisol. Mean serum cortisol levels were significantly lower in E group patients than in FM group patients 4 to 6 hours after intubation (18.2 vs. 27.8 mug/dL, p < 0.05). Change in serum cortisol between baseline and postintubation levels was different (-12.8 mg/dL +/- 9.6 microg/dL vs. 1.1 microg/dL +/- 7.6 microg/dL, p < 0.01). Patients in the E group had an average increase in cortisol after ACTH administration of 4.2 microg/dL +/- 4.9 microg/dL vs. 11.2 microg/dL +/- 6.1 microg/dL in the FM group, p < 0.001. Patients in the E group required longer ICU lengths of stay (mean, 6.3 days vs. 1.5 days, p < 0.05), more ventilator days (mean, 28 days vs. 17 days, p < 0.01), and longer hospital lengths of stay (mean, 11.6 days vs. 6.4 days, p < 0.01). CONCLUSIONS: The use of etomidate for RSI in trauma patients led to chemical evidence of adrenocortical insufficiency and may have contributed to increased hospital and ICU lengths of stay and increased ventilator days. Further studies should be considered to evaluate the safety profile of this drug in trauma patients.

Multiple-Institution Comparison of Resident and Faculty Perceptions of Burnout and Depression During Surgical Training.

Importance: Prior studies demonstrate a high prevalence of burnout and depression among surgeons. Limited data exist regarding how these conditions are perceived by the surgical community. Objectives: To measure prevalence of burnout and depression among general surgery trainees and to characterize how residents and attendings perceive these conditions. Design, Setting, and Participants: This cross-sectional study used unique, anonymous surveys for residents and attendings that were administered via a web-based platform from November 1, 2016, through March 31, 2017. All residents and attendings in the 6 general surgery training programs in North Carolina were invited to participate. Main Outcomes and Measures: The prevalence of burnout and depression among residents was assessed using validated tools. Burnout was defined by high emotional exhaustion or depersonalization on the Maslach Burnout Inventory. Depression was defined by a score of 10 or greater on the Patient Health Questionnaire-9. Linear and logistic regression models were used to assess predictive factors for burnout and depression. Residents' and attendings' perceptions of these conditions were analyzed for significant similarities and differences. Results: In this study, a total of 92 residents and 55 attendings responded. Fifty-eight of 77 residents with complete responses (75%) met criteria for burnout, and 30 of 76 (39%) met criteria for depression. Of those with burnout, 28 of 58 (48%) were at elevated risk of depression (P = .03). Nine of 77 residents (12%) had suicidal ideation in the past 2 weeks. Most residents (40 of 76 [53%]) correctly estimated that more than 50% of residents had burnout, whereas only 13 of 56 attendings (23%) correctly estimated this prevalence (P < .001). Forty-two of 83 residents (51%) and 42 of 56 attendings (75%) underestimated the true prevalence of depression (P = .002). Sixty-six of 73 residents (90%) and 40 of 51 attendings (78%) identified the same top 3 barriers to seeking care for burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care. Conclusions and Relevance: The prevalence of burnout and depression was high among general surgery residents in this study. Attendings and residents underestimated the prevalence of these conditions but acknowledged common barriers to seeking care. Discrepancies in actual and perceived levels of burnout and depression may hinder wellness interventions. Increasing understanding of these perceptions offers an opportunity to develop practical solutions.