Surgeon Sex and Health Care Costs for Patients Undergoing Common Surgical Procedures.

Importance: Prior research has shown differences in postoperative outcomes for patients treated by female and male surgeons. It is important to understand, from a health system and payer perspective, whether surgical health care costs differ according to the surgeon's sex. Objective: To examine the association between surgeon sex and health care costs among patients undergoing surgery. Design, Setting, and Participants: This population-based, retrospective cohort study included adult patients undergoing 1 of 25 common elective or emergent surgical procedures between January 1, 2007, and December 31, 2019, in Ontario, Canada. Analysis was performed from October 2022 to March 2023. Exposure: Surgeon sex. Main Outcome and Measure: The primary outcome was total health care costs assessed 1 year following surgery. Secondarily, total health care costs at 30 and 90 days, as well as specific cost categories, were assessed. Generalized estimating equations were used with procedure-level clustering to compare costs between patients undergoing equivalent surgeries performed by female and male surgeons, with further adjustment for patient-, surgeon-, anesthesiologist-, hospital-, and procedure-level covariates. Results: Among 1 165 711 included patients, 151 054 were treated by a female surgeon and 1 014 657 were treated by a male surgeon. Analyzed at the procedure-specific level and accounting for patient-, surgeon-, anesthesiologist-, and hospital-level covariates, 1-year total health care costs were higher for patients treated by male surgeons ($24 882; 95% CI, $20 780-$29 794) than female surgeons ($18 517; 95% CI, $16 080-$21 324) (adjusted absolute difference, $6365; 95% CI, $3491-9238; adjusted relative risk, 1.10; 95% CI, 1.05-1.14). Similar patterns were observed at 30 days (adjusted absolute difference, $3115; 95% CI, $1682-$4548) and 90 days (adjusted absolute difference, $4228; 95% CI, $2255-$6202). Conclusions and Relevance: This analysis found lower 30-day, 90-day, and 1-year health care costs for patients treated by female surgeons compared with those treated by male surgeons. These data further underscore the importance of creating inclusive policies and environments supportive of women surgeons to improve recruitment and retention of a more diverse and representative workforce.

Association between patient-surgeon gender concordance and mortality after surgery in the United States: retrospective observational study.

OBJECTIVE: To determine whether patient-surgeon gender concordance is associated with mortality of patients after surgery in the United States. DESIGN: Retrospective observational study. SETTING: Acute care hospitals in the US. PARTICIPANTS: 100% of Medicare fee-for-service beneficiaries aged 65-99 years who had one of 14 major elective or non-elective (emergent or urgent) surgeries in 2016-19. MAIN OUTCOME MEASURES: Mortality after surgery, defined as death within 30 days of the operation. Adjustments were made for patient and surgeon characteristics and hospital fixed effects (effectively comparing patients within the same hospital). RESULTS: Among 2 902 756 patients who had surgery, 1 287 845 (44.4%) had operations done by surgeons of the same gender (1 201 712 (41.4%) male patient and male surgeon, 86 133 (3.0%) female patient and female surgeon) and 1 614 911 (55.6%) were by surgeons of different gender (52 944 (1.8%) male patient and female surgeon, 1 561 967 (53.8%) female patient and male surgeon). Adjusted 30 day mortality after surgery was 2.0% for male patient-male surgeon dyads, 1.7% for male patient-female surgeon dyads, 1.5% for female patient-male surgeon dyads, and 1.3% for female patient-female surgeon dyads. Patient-surgeon gender concordance was associated with a slightly lower mortality for female patients (adjusted risk difference -0.2 percentage point (95% confidence interval -0.3 to -0.1); P<0.001), but a higher mortality for male patients (0.3 (0.2 to 0.5); P<0.001) for elective procedures, although the difference was small and not clinically meaningful. No evidence suggests that operative mortality differed by patient-surgeon gender concordance for non-elective procedures. CONCLUSIONS: Post-operative mortality rates were similar (ie, the difference was small and not clinically meaningful) among the four types of patient-surgeon gender dyads.

Template for a program tailored ACS/APDS phase 1 curriculum: From needs assessment to implementation.

BACKGROUND: The Phase 1 ACS/APDS skills curriculum standardizes intern training. Despite this, institutional implementation varies and is nationally low. We aimed to use Kern's six-steps to tailor this to our program, providing a framework to improve implementation. METHODS: Problem identification and general needs assessment were performed. Targeted needs assessment (TNA) of incoming interns ('interns'), current residents, and attendings determined perceived importance of skills and intern's previous experience and confidence. Educational strategies were developed. Learner knowledge was assessed before and after modules, deficiencies identified enabled employment of active learning strategies. Modular and curricular evaluations were completed. RESULTS: TNA determined all interns had been taught knot tying and suturing, and were most confident with suturing, knot tying, and urethral catheterization. Educational strategies included simulation and lectures. Evaluations demonstrated improvement in test scores (pre-v post-) and skills confidence on curricula completion. CONCLUSION: Our framework utilizes institutional resources and expertise while focusing on determining existing knowledge, skill, and technical deficiencies of learners. This approach demonstrated improvement in knowledge and confidence, and could improve implementation rates of the Phase 1 curriculum.

Independent Operating by General Surgery Residents: An ACS-NSQIP Analysis.

OBJECTIVE: Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time. DESIGN: We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications. SETTING: The ACS-NSQIP database. PARTICIPANTS: Patients undergoing one of 7 emergency general surgery operations. RESULTS: Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality. CONCLUSION: Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes.

How learning preferences and teaching styles influence effectiveness of surgical educators.

BACKGROUND: Effective surgical educators have specific attributes and learner-relationships. Our aim was to determine how intrinsic learning preferences and teaching styles affect surgical educator effectiveness. METHODS: We determined i) learning preferences ii) teaching styles and iii) self-assessment of teaching skills for all general surgery attendings. All general surgical residents in our program completed teaching evaluations of attendings. RESULTS: Multimodal was the most common learning preference (20/28). Although the multimodal learning preference appears to be associated with more effective educators than kinesthetic learning preferences, the difference was not statistically significant (80.0% versus 66.7%, p = 0.43). Attendings with Teaching Style 5 were more likely to have a lower "professional attitude towards residents" score on SETQ assessment by residents (OR 0.33 (0.11, 0.96), p = 0.04). Attendings rated their own "communication of goals" (p < 0.001), "evaluation of residents" (p = 0.04) and "overall teaching performance" (p = 0.01) per STEQ domains as significantly lower than the resident's assessment of these cofactors. CONCLUSION: Identification of factors intrinsic to surgical educators with high effectiveness is important for faculty development. Completion of a teaching style self-assessment by attendings could improve effectiveness.

Public perceptions of general surgery resident training and assessment.

BACKGROUND: Patients play a crucial role in surgical training, but little is known about the public's knowledge of general surgery training structure or opinion of resident assessment. Our aim was to evaluate the public's knowledge of general surgery training and assessment processes. METHODS: We administered an anonymous, electronic survey to US adult panelists using SurveyGizmo. We used Dillman's Tailored Design Method to optimize response rate. Questions pertained to demographics, knowledge of general surgery training structure, and opinions regarding resident assessment. Outcome measures included public knowledge of the structure of general surgery residency and the perceptions of resident assessment. Univariate and multivariate statistics were used as appropriate. RESULTS: Survey response rate was 93% (2005 of 2148). Respondents had nationally representative demographics. Most respondents had health insurance (87%). Sixty-one percent of respondents believed that 100% of hospitals trained residents. Age <40 years, Black race (odds ratio 1.48 [95% confidence interval (CI) 1.11-1.96]), working in a hospital/health care field (odds ratio 1.49 [95% CI 1.12-1.97]), and having a family member/close acquaintance working in a hospital/health care field (odds ratio 1.53 [95% CI .20-1.94]) were associated with this belief. There was a preference to obtain online information about medical training (30% television [TV] shows, 24% Internet searches, 5% social media). Eighty percent of respondents felt that resident self-assessment and patient assessment of residents was "important" or "essential" when considering readiness for independent practice. CONCLUSION: The US public has limited knowledge of general surgery training and competency assessment. Public educational strategies may help inform patients about the structure of training and assessment of trainees to improve engagement of these important stakeholders in surgical training.

Public Perceptions of General Surgery Residency Training.

OBJECTIVE: Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety. DESIGN: This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training. CONCLUSIONS: Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.

Public Perception of General Surgery Resident Autonomy and Supervision.

BACKGROUND: Despite patients being important stakeholders in surgical training, little is known about the public's perception of trainee participation in surgical care. This study evaluates the public's perception of surgical resident autonomy and supervision. STUDY DESIGN: An anonymous electronic survey was sent to adult panelists older than 18 years in the US using SurveyGizmo. The design of the survey used Dillman's Tailored Design Method to optimize response rate. Participants completed surveys including demographic characteristics and perceptions toward general surgery resident autonomy. Univariable and multivariable analyses were used as appropriate. RESULTS: Survey response rate was 93% (2,005 of 2,148). Demographic characteristics including age, gender, race or ethnicity, and highest level of education were nationally representative. Most respondents (87%) had health insurance. On multivariable logistic regression analysis, factors associated with participants who would never allow a resident to perform any portion of the operation include: female gender (odds ratio [OR] 1.58; 95% CI, 1.28 to 1.95), no health insurance (OR 1.38; 95% CI, 1.03 to 1.84), Black race (OR 1.82; 95% CI, 1.38 to 2.41), and Hispanic ethnicity (OR 1.49; 95% CI, 1.03 to 2.15). Participants who were younger than 50 years (OR 1.57; 95% CI, 1.24 to 1.98), male (OR 1.90; 95% CI, 1.56 to 2.32), of Black race (OR 1.45; 95% CI, 0.10 to 1.91), Hispanic ethnicity (OR 1.49; 95% CI, 1.05 to 2.11), working in healthcare (OR 2.18; 95% CI, 1.67 to 2.86), or insured (OR 1.46; 95% CI, 1.07 to 1.99) were more likely to believe that resident involvement increases complications. CONCLUSIONS: Among survey participants broadly representing the US population, resident participation in operations is not universally accepted. Public perception of surgical resident autonomy and supervision is important, as GME continues to evolve to address readiness for independent practice.

Comparison of laparoscopy versus mini-laparotomy for jejunostomy placement in patients with gastric adenocarcinoma.

BACKGROUND: Optimal nutrition is challenging for patients with gastric and gastroesophageal adenocarcinoma and often requires feeding tube placement prior to preoperative therapy. Feeding jejunostomy (FJ) placement via mini-laparotomy is technically easier to perform than laparoscopic FJ. The purpose of this study was to compare outcomes in patients with gastric adenocarcinoma undergoing laparoscopic versus mini-laparotomy FJ placement. METHODS: A retrospective cohort study was performed of patients with gastric adenocarcinoma receiving laparoscopic versus mini-laparotomy FJ at a single tertiary referral center from 2000 to 2018. 30-day outcomes included complications, conversion to laparotomy, reoperation, length of stay, and readmission. RESULTS: A total of 656 patients met the inclusion criteria and were studied. The majority of patients were male (68.1%) with a mean age of 60.6 years. The difference in surgical approach remained relatively stable over time. Overall, 82 (12.5%) patients experienced complications, and three (0.5%) patients died postoperatively. While readmission and conversion to open laparotomy did not differ between groups, overall complications (10.5% vs. 20.8%, p = 0.002), Clavien-Dindo ≥ 3 complications (4.0% vs. 8.9%, p = 0.021), length of stay (4.1 vs. 5.6 days, p < 0.001), and reoperation (0.9% vs. 4.0%, p = 0.002) favored the laparoscopic over mini-laparotomy group. CONCLUSION: The current study helps clarify the risk of FJ placement in patients with gastric adenocarcinoma requiring nutritional support. Laparoscopic FJ placement has lower overall morbidity and length of stay compared to mini-laparotomy. However, caution is needed in preventing and identifying the rare causes of postoperative mortality that may be associated with laparoscopic FJ placement.

Institution-specific utilization of the American College of Surgeons/Association of Program Directors operative skills curriculum: From needs assessment to implementation.

BACKGROUND: The American College of Surgeons/Association of Program Directors in Surgery operative skills curriculum standardizes training. However, simulation resources are variable with curriculum implementation institution dependent. Our aim was to use Kern's six steps of curricular development to demonstrate how to tailor the American College of Surgeons/Association of Program Directors in Surgery Phase 2 curriculum to program specific needs. METHODS: Problem identification and general needs assessment was performed. Targeted needs assessment of general surgery residents and attendings was conducted to determine perceived importance of operative skills and residents' confidence with these skills and attendings perceptions of deficiencies in technical skills using the Objective Structured Assessment of Technical Skills criteria. Educational strategies were developed dependent on program resources. The program was piloted between 2018 to 2019 and implemented in the 2019 to 2020 academic year. Assessment of resident technical skills and resident or faculty teaching skills was performed for each session. Resident confidence with procedures was assessed using the Zwisch scale before and after modules. Curricular evaluations were completed by residents after each module. RESULTS: The previous curriculum did not comprehensively cover Phase 2 modules and was not tailored to the needs of residents. Targeted needs assessment revealed differences in prioritization of learning for techniques by seniority (most important operation for faculty: laparoscopic cholecystectomy, postgraduate year 4 and 5: laparoscopic partial colectomy, interns: open inguinal/femoral hernia repair). Faculty identified technical skills on which to focus (ie, interns' knowledge of a specific procedure, postgraduate year 4 and 5 flow of the operation and forward planning). Educational strategies employed included wet and dry lab simulations and online materials. Residents reported increased procedural confidence after curriculum completion. CONCLUSION: This comprehensive implementation of the American College of Surgeons/Association of Program Directors in Surgery Phase 2 skills curriculum effectively used resources and expertise of an institution and focused on the knowledge and technical deficiencies of the target learners. Improvement in learner confidence was demonstrated by this approach.

A Template for Curriculum Development to Teach Complex Surgical or Endoscopic Techniques With Logistical Challenges.

OBJECTIVE: The current, unprecedented pace of change in medicine challenges healthcare professionals to stay up-to-date. To more effectively disseminate new surgical or endoscopic techniques a modern paradigm of training is required. Our aim was to develop a curricular framework for complex techniques that provide logistical challenges to training in order to increase safe, effective use. We use colonic endoscopic submucosal dissection (cESD) as an example. DESIGN: Curriculum development followed a multistep process representing best practice in training and education. First, a Clinical Needs Assessment established the demand for/sustainability of training. A Training Needs Analysis then identified the knowledge, skills, and attitudes required to perform cESD. A modified Delphi process defined desired learner characteristics, identified indications/contraindications to cESD, and developed a procedural task list. A pilot simulation program gathered feedback from cESD faculty experts and learners. Finally, a Behavioral Observation Scale was developed as a clinical assessment tool to assess procedural performance. SETTING: The Houston Methodist Institute for Technology, Innovation and Education. PARTICIPANTS: The first Curriculum Design Summit engaged 11 clinical SMEs, 4 education and training SMEs, 3 market development SMEs, and 1 medical device research and design engineer. The second Curriculum Design Summit engaged 10 clinical SMEs, 4 education and training SMEs, and 4 market development SMEs. We also engaged 12 Learner SMEs at both hands-on pilot courses who currently are training to perform cESD. RESULTS: Desired learner criteria were defined (e.g., in practice >2 years, available case volume ≥25/year) to ensure ability and motivation of learners. Lesions were classified by (1) suitability for cESD (Clinical T1N0M0, Paris 0-IIa +1s  > 2 cm, 0-IIc + IIa, 0-IIc), and (2) suitability for trainee experience level. A comprehensive cESD task list was constructed and an assessment tool created based on SME review of key characteristics (e.g., comprehensiveness and usability). CONCLUSION: We describe a comprehensive framework to develop educational curricula for complex surgical/endoscopic techniques with logistical challenges. To illustrate the sustainability of this training model and impact on patient outcomes, we plan to further develop and implement this program nationally.

What embodies an effective surgical educator? A grounded theory analysis of resident opinion.

BACKGROUND: Effective surgical education is key to resident professional and personal development. There is little literature defining or assessing effective surgical educators and no common definition of effectiveness in use. The opinion of surgical residents has never been qualitatively studied. Our aim was to determine what general surgery residents perceive as qualities of effective surgical educators. METHODS: A qualitative and quantitative study of general surgery senior residents (postgraduate year [PGY]-4 and -5) at a single tertiary academic institution was performed. In-depth semistructured interviews were conducted with all senior residents to determine the overall opinion of effective educators. Thematic analysis was performed using grounded theory. Participants completed a Likert-based survey to determine which qualities of an effective educator were (1) most critical and (2) had been most commonly encountered during training. Institutional review board approval was obtained. RESULTS: Data saturation occurred after 13 interviews (7 PGY-4, 6 PGY-5). Interviewees described attitudes, behaviors, and cognitions essential for effective surgical educators. They described important attributes of the trainee-trainer relationship and learning environment. On quantitative analysis, excellent communication, promoting a positive learning climate, timely constructive feedback, and technical expertise were ranked as most critical. Residents most often encountered educators with excellent communication, who fostered a positive learning climate, with clinical and technical expertise, and who provided leadership or mentorship. CONCLUSION: General surgery residents believe effective educators recognize the importance of communication and a positive learning environment, are able to adapt to the learner or environment, have clinical and technical expertise, and form a bond with their learner. This framework can inform faculty development programs to improve surgical education.

The Current Evidence for Defining and Assessing Effectiveness of Surgical Educators: A Systematic Review.

BACKGROUND: Surgical educator effectiveness is valued but lacks an operational definition. Clearly defining attributes consistent with effective surgical educators allows for the development of professional activities directed to nurture these qualities. Our aim was to identify the literature defining qualities of an effective surgical educator, and tools to measure effectiveness. METHODS: We searched PubMed, Medline, Scopus and Academic Search Complete for English language articles from 1 July 2009-1 July 2019. Two reviewers screened all abstracts for relevance and read full text of selected articles to identify included studies. Inclusion criteria were description/definition of an effective surgical educator or description of assessment/measurement of effectiveness in surgical educators. Data extracted included: study design, participants, definition/description of qualities of an effective surgical educator, qualitative or quantitative methods to assess surgical educators. RESULTS: Initial search identified 8086 articles. Of these, 2357 articles were excluded as duplicates and 5729 abstracts screened with 5638 excluded due to irrelevance. Full text review was performed for 91 articles to assess eligibility, 23 met inclusion criteria. The majority (74%) did not clearly define an effective surgical educator. Themes from six studies that determined important qualities include: communication, leadership skills, professionalism, respect, positive learning climate, and brief-intraoperative teaching-debrief model. One validated assessment tool was identified. CONCLUSIONS: There is little published work defining or assessing effective surgical educators. Establishment of a positive learning climate and excellent communication skills continue to be important qualities that define surgical educator effectiveness.

A Systematic Review of Educational Mobile-Applications (Apps) for Surgery Residents: Simulation and Beyond.

INTRODUCTION: The number of mobile-applications (Apps) increases daily. The regulation of App content is minimal yet surgical residents use these in daily educational practice. Surgical educators must be aware of the quality, efficacy, and validity of Apps available to effectively educate residents. The aim of this review was to determine the quality, efficacy, and validity evidence for educational Apps used by surgical residents. MATERIALS AND METHODS: We searched PubMed, Embase, and ERIC for articles published before September 1, 2019. Controlled vocabulary and natural language describing Apps/surgical residents were used. Two reviewers evaluated abstracts for inclusion. INCLUSION CRITERIA: studies measuring the quality, efficacy, or validity of educational Apps for surgical residents. Data was extracted from full text of included articles: study design, participants, App investigated, App development, evidence for efficacy, or validity of App. RESULTS: Initial search identified 278 articles. 64 articles were duplicates and 214 articles were screened. A further 156 were excluded with 58 full text articles assessed for eligibility. Forty-five were included in analysis. Simulation (9/45) and Feedback (15/45) Apps were the most commonly studied in surgical residents. These were the main Apps that provided validity evidence for their use in education. CONCLUSION: Surgical education is evolving as educational technology becomes more prevalent. To be effective as surgical educators we must understand and appropriately use available tools. Of the educational Apps studied (21 Apps in 8 categories), only 3 categories reported validity evidence. Future studies should take care to measure validity and efficacy of educational Apps for surgical education to ensure quality control.

Perceptions on gender disparity in surgery and surgical leadership: A multicenter mixed methods study.

BACKGROUND: Our objective was to identify perceptions of the environment for women in surgery among 4 academic institutions. METHODS: Faculty surgeons and senior surgery residents were randomly selected to participate in a parallel study with concurrent quantitative and qualitative data collection. Outcomes were perceptions of the environment for women in surgery. Measures included semi-structured interviews, survey responses, and responses to scenarios. RESULTS: Saturation was achieved after 36 individuals were interviewed: 14 female (8 faculty, 6 residents) and 22 male (18 faculty, 4 residents) surgeons. Men (100%) and women (86%) reported gender disparity in surgery and identified 6 major categories which influence disparity: definitions of gender disparity, gaps in mentoring, family responsibility, disparity in leave, unequal pay, and professional advancement. Overall 94% of participants expressed concerns with gaps in mentoring, but 64% of women versus 14% of men reported difficulties finding role models who faced similar obstacles. Over half (53%) reported time with loved ones as their biggest sacrifice to advance professionally. Both female and male respondents expressed system-based biases favoring individuals willing to sacrifice family. A global subconscious bias against the expectations, abilities, and goals of female surgeons were perceived to impede promotion and advancement. CONCLUSION: Both female and male surgeons report substantial gender-based barriers in surgery for women. Despite improvements, fundamental issues such as lack of senior role models, limited support for surgeons with families, and disparities in hiring and promotion persist. This is an opportunity to make substantive changes to the system and eliminate barriers for women joining surgery, advancing their careers, and achieving their goals in a timely fashion.

Financial implications of telemedicine visits in an academic endocrine surgery program.

BACKGROUND: Telemedicine is an emerging medium for the delivery of ambulatory care, but the reimbursement profile of telemedicine visits in the surgical setting has not been well studied. METHODS: A retrospective assessment of telemedicine encounters for thyroid and parathyroid conditions occurring from April 2015 to April 2017 was performed. Financial reimbursement from commercial payers for new and established patient visits were compared between telemedicine visits and in-person visits. Patient "savings" in terms of travel distance and drive time were calculated. RESULTS: A total of 290 telemedicine encounters were conducted; 7% were initial consultations, 47% were postoperative visits, and 45% were follow-up visits. The median patient age was 57 years. The median round-trip travel distance saved was 123.6 miles with estimated drive time of 2.4 hours per encounter. In 2% of cases, a second in-person visit within the 90-day global period occurred after a postoperative telemedicine encounter. Charges were filed for 67 encounters. The initial unpaid claims rate was 6%, which was consistent with the unpaid claims rate for in-person visits. The charge-to-collection ratio was comparable to that of in-person visits. There was a higher ratio of level 2 visits in the telemedicine encounters. Over the study period, 70 clinic hours were liberated via the use of telemedicine. CONCLUSION: Endocrine surgery telemedicine visits have the same level for level reimbursement profile as in-person visits. Down-coding and elimination of components of in-office physical examinations may lead to modest decreases in overall reimbursement. Other advantages include reallocation of clinic resources and decreased travel burden for patients.

Ensuring Equity, Diversity, and Inclusion in Academic Surgery: An American Surgical Association White Paper.

OBJECTIVE: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery. SUMMARY OF BACKGROUND DATA: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion. METHODS: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper. RESULTS: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. CONCLUSION: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition-doing good for our patients.