Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

Defining the Disparity: A Multi-Institutional Analysis of Factors Associated With Decreased Resident Operative Experience.

INTRODUCTION: Technical learning in surgical training is multifaceted and existing literature suggests a positive relationship between case volume and proficiency. Little is known about factors associated with a decreased volume of operative experience. This study aimed to identify resident and program factors associated with general surgery residents (GSR) in the bottom quartile of logged case volume upon program completion. METHODS: A post hoc analysis of a multicenter study was used to examine case logs for categorical GSR. Participants included graduates between 2010 and 2020 from 20 programs. Residents below and above the 25th percentile for total operative volume were compared. RESULTS: The present study includes 1343 GSR who graduated over the 11-y period. In total, 336 residents were below the 25th percentile and 1007 residents were above the 25th percentile. Those below the 25th percentile were more likely to be female (41% versus 34%, P = 0.02), identify as underrepresented in medicine (22% versus 14%, P < 0.01), and pursue fellowship (86% versus 80%, P = 0.01) compared to those above the 25th percentile. Residents below the 25th percentile were more likely to have graduated from a low volume program (55% versus 25%, P < 0.01) and from top National Institutes of Health funded institutions (57% versus 52%, P = 0.01). CONCLUSIONS: This study identified individual and program characteristics associated with lower operative volume of GSR. Understanding such characteristics will aid surgical educators to achieve better equity in training.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

"The Story I Will Never Forget": Critical Incident Narratives in Surgical Residency.

OBJECTIVE: We sought to better understand what defines a critical incident experience for the surgical trainee. SUMMARY BACKGROUND DATA: Critical incidents are formative moments stamped indelibly on one's memory that shape professional identity. The critical incident technique-using participants' narratives to identify patterns and learn from their perceptions-has been explored in some healthcare settings, but there has been no inquiry within surgery. METHODS: Surgical residents at 5 residency programs (1 community, 1 university-affiliated, 3 university) were surveyed using an online questionnaire from November to December 2020. Convenience sampling was used to identify the study population. Participants were invited to write about formative, impactful experiences in training. Interpretive description was the qualitative methodology used to locate information, analyze, and record patterns in the data. Individual responses were categorized and assessed for overlying themes. RESULTS: Overall, 28 narratives were collected from surgery residents in 3 specialties (general surgery, plastic surgery, and urology), with postgraduate year representation of post-graduate years 1 to 6. Respondents were 40% female. Nineteen of the narratives reported a negative experience. Four themes were identified from responses: 1) growth through personal self-reflection, 2) difficult interpersonal interactions, 3) positive team dynamics as a psychological safety net, and 4) supportive program cultures that promote learning. CONCLUSIONS: Critical incident narratives among surgical residents indicate that unforgettable and formative experiences-both positive and negative- occur in 4 domains: within the individual, within a relationship, among a team, and within a program. Further exploring these domains in surgical training will inform optimal educational programming to support trainee development and wellbeing.

Do General Surgery Residents Begin Specializing Before Fellowship? A Multi-Institutional Study from the US ROPE Consortium.

BACKGROUND: Single-center data suggest that general surgery residents perform more cases related to their future fellowship compared with their peers. This study aimed to determine whether this experience was true for residents across multiple programs. STUDY DESIGN: Data from graduates of 18 Accreditation Council for Graduate Medical Education (ACGME)-accredited general surgery residency programs in the US Resident OPerative Experience (ROPE) Consortium were analyzed. Residents were categorized as entering 1 of 12 fellowships or entering directly into general surgery practice. Case log operative domains were mapped to each fellowship, and analyses were performed between groups. RESULTS: Of 1,192 graduated general surgery residents, 955 (80%) pursued fellowship training whereas 235 (20%) went directly into general surgery practice. The top 3 fellowships pursued were trauma/surgical critical care (18%), vascular surgery (13%), and minimally invasive surgery (12%). Residents entering minimally invasive surgery performed the most total cases, whereas residents pursuing breast performed the least (1,209 [1,056-1,325] vs 1,091 [1,006-1,171], p < 0.01). For each fellowship type, graduates completed more total fellowship-specific cases in their future specialty compared with their peers (all p < 0.05). This association was observed for all 12 fellowships at the surgeon chief level (all p < 0.05) and for 10 of 12 fellowships at the surgeon junior level (all p < 0.05). CONCLUSIONS: General surgery residents perform more cases related to their future specialty choice compared with their peers. These data suggest that the specialization process begins during residency. This tendency among residents should be considered as general surgery residency undergoes structural redesign in the future.

How Program Directors Understand General Surgery Resident Wellness.

OBJECTIVE: Burnout among general surgery residents is prevalent. Guidance on how program directors (PDs) can effectively intervene on general surgery resident wellness is lacking. In this study, we explore how PDs learn about burnout among their residents and support their well-being. DESIGN: Semi-structured interviews were conducted with PDs. Interviews were transcribed and coded by study team dyads who utilized an inductive coding approach, and then reconciled via consensus. Interpretive description was the qualitative analytical method. SETTING: Program tours to 15 general surgery programs during the exploratory phase of the SECOND Trial. PARTICIPANTS: Fifteen general surgery PDs. RESULTS: PDs identified the utility of contextual information in understanding resident wellness and implementing program-specific resident wellness initiatives. Three themes relating to PD awareness of resident burnout and well-being were identified: (1) PDs used conventional and novel methods to collect data from multiple information sources, including residents, faculty, staff, institutional representatives, and anonymous parties. (2) These contextualized data inspired the development of responsive strategies to effect programmatic changes that improved education and wellness. (3) Barriers to acquiring and utilizing information exist, requiring careful analysis, creative problem solving, as well as persistence and dedication to resident wellness. CONCLUSIONS: Qualitative analysis of general surgery residency PDs yielded insightful knowledge about gathering and responding to information to support resident wellness, including successful strategies and areas of caution. The experience of these PDs can guide others in evaluating their wellness goals and initiatives for their own residents.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Fetus in fetu: use of intraoperative ultrasound for safe excision of a rare entity.

A prenatally diagnosed abdominal mass at 36 weeks and 0 days was further characterised by postnatal ultrasound and MRI to be likely a rare case of fetus in fetu in an otherwise healthy male. Due to close proximity to both the coeliac axis and superior mesenteric artery (SMA), surgical excision was delayed for several months. Interim CT with intravenous contrast performed at 2 months of age demonstrated the SMA travelling through the posterior aspect of the mass. Surgery proceeded at 2 months of age. Intraoperative ultrasound was used to definitively identify both the coeliac axis and SMA in order to facilitate a safe excision. The patient recovered well with an uneventful discharge to home on postoperative day 8. Pathology confirmed the diagnosis of fetus in fetu.

Identifying institutional factors in general surgery resident wellness and burnout.

BACKGROUND: Effects of the institutional macrocosm on general surgery resident wellbeing have not been well studied. We sought to identify organizational factors that impact resident wellness and burnout. METHODS: Using a modified Delphi technique, an open-ended survey and two subsequent iterations were distributed to wellness stakeholders at two institutions to identify and stratify institutional factors in six burnout domains. RESULTS: Response rates for each survey round were 29/106 (27%), 30/46 (65%) and 21/30 (70%). Top factors identified in each domain were: CONCLUSION: A modified Delphi technique prioritized institutional wellness and burnout factors. Top factors identified were compensation, vacation time, and autonomy. These results can direct future scholarship of barriers/facilitators of resident wellbeing.

Surgery clerkship offers greater entrustment of medical students with supervised procedures than other clerkships.

BACKGROUND: Medical student procedural participation is increasingly limited, creating concerns over poor preparation for internship. Inadequate experiences may also compromise patient safety. This study explores variances in procedural entrustment of medical students between core clerkships during the first clinical year. METHODS: Students completing their first clinical year were surveyed on procedure participation. Holistic entrustment decisions are complex, thus participation was used as an objective proxy for entrustment. RESULTS: 138 students responded (66% response rate); 89% (123/138) wished they had performed more procedures. Students had higher participation rates during procedural clerkships (surgery, obstetrics/gynecology). Entrustment was highest during surgery, and lowest during pediatrics. Surgery gave statistically significantly higher entrustment for subcuticular suturing (compared to obstetrics/gynecology) and nasogastric tube removal (compared to internal medicine). Entrustment was generally inversely proportional to procedure complexity within each specialty. CONCLUSIONS: Students encounter higher entrustment during procedural clerkships, especially surgery. Targeted areas for increased procedural involvement can be identified in all specialties.

Gender Disparity in Referral for Definitive Care of Malignant Pleural Effusions.

BACKGROUND: Gender disparities exist in cancer care. Malignant pleural effusions (MPEs) carry a poor prognosis and are managed by different physicians. This study sought to evaluate referral patterns and gender differences for definitive treatment and outcomes of MPE patients. MATERIALS AND METHODS: Patients diagnosed with MPE from 1999 to 2015 at a quaternary care hospital were retrospectively reviewed to obtain patient history, referral to thoracic surgery for definitive management, and outcomes. Analysis was performed using chi-squared/Fisher's exact test, logistic regression models, and multivariate analysis. RESULTS: 224/686 patients (32.7%) were referred to thoracic surgery. No survival difference existed between referral and nonreferral groups or referred patients who received or did not receive pleurodesis. 405 patients (59.0%) were women. Women were statistically significantly less likely to be referred than men (27.9% versus 39.5%, P = 0.0014). This disparity persisted when comorbidities were controlled for (P = 0.0004) and when gynecologic cancers (e.g., uterine, ovarian, but not including breast; 55 female patients) were excluded from analysis (28.9% versus 39.5%, P = 0.0049). Women had statistically significantly more thoracenteses (3.34 versus 2.19, P < 0.0001) and improved survival compared with males (median survival = 136 d versus 54; P = 0.0004). CONCLUSIONS: Gender disparity exists in referral patterns for definitive management of MPE; women are less likely to be referred than men. Women have longer survival and a greater number of thoracenteses performed, despite a lower referral rate for definitive care. Further research is needed to understand the differences in referral rates and outcomes between men and women.

Assessment of Female Medical Students' Interest in Careers in Cardiothoracic Surgery.

OBJECTIVE: Although over half of medical students are females, women comprise only 21% of cardiothoracic (CT) surgery residency applicants and 5% of the CT workforce. We sought to gain insight into female medical students' perceptions of CT surgery and identify targets to increase interest. DESIGN: A 33-question survey queried career selection factors, perceptions of CT surgery, and ways to increase interest in the field. Responses were stratified by sex and preclinical versus clinical years. SETTING: Women at 13 US medical schools were compared to men at a Midwest medical school. PARTICIPANTS: Surveys were distributed to approximately 4400 women and were completed by 372 (8.5%) women. Comparison surveys were distributed to approximately 170 preclinical men and were completed by 98 (57.6%) men. RESULTS: Preclinical woman had broad interests, whereas clinical women were more interested in primary care (p = 0.0124). Intellectual interest and lifestyle were important in specialty selection for men and women (91% versus 90%; 78% versus 86%). Although preclinical men valued perceived prestige and salary significantly more than preclinical women (39% versus 20%, p = 0.0014; 64% versus 48%, p = 0.0173), preclinical women valued caring for specific ethnicities and addressing health disparities significantly more than preclinical men (26% versus 15%, p = 0.0173; 53% versus 33%, p = 0.0019). Making family plans was cited by 83% of women as difficult if they choose to become a CT surgeon. Women thought that attaining their career interests and life goals (76%) or access to female CT surgery mentors (63%) would make the field more appealing. Over 70% of preclinical women were interested in shadowing a CT surgeon. Of these women, 12% attempted to shadow. CONCLUSIONS: Although baseline interest in CT surgery is low among women, there are many targets for increasing interest especially during preclinical years. Residency programs have the opportunity to entice women to the field by addressing their priorities of lifestyle, family planning, and addressing health disparities.

Dissociation of SHP-1 from spinophilin during platelet activation exposes an inhibitory binding site for protein phosphatase-1 (PP1).

We have recently shown that a critical regulatory node in the platelet signaling network lies immediately downstream of platelet receptors for thrombin and TxA2. This node is comprised of a scaffold protein (spinophilin, SPL), a protein tyrosine phosphatase (SHP-1), and either of the two members of the Regulators of G protein Signaling family predominantly expressed in platelets (RGS10 or RGS18). The SPL/RGS/SHP-1 complex is present in resting platelets, dissociating when thrombin or TxA2, but not ADP or collagen, activate SHP-1 and release RGS10 and RGS18 to dampen signaling. Here we demonstrate an additional regulatory role for spinophilin, showing that dissociation of SHP-1 from spinophilin is followed by an increase in the binding of spinophilin to PP1, a serine/threonine phosphatase whose binding site maps to a region close to the SHP-1 binding site. The increase in PP1 binding to spinophilin is limited to platelet agonists that cause dissociation of the complex and is selective for the α and γ isoforms of PP1. Studies in cell culture show that SHP-1 and PP1 can compete for binding to spinophilin and that binding inhibits PP1 activity since over-expression of wild type spinophilin, but not spinophilin with a disabled PP1 binding site, causes an increase in the phosphorylation of myosin light chain, a well-characterized PP1 substrate. Collectively, these results indicate that in addition to regulating RGS protein availability in resting platelets, spinophilin can serve as a time-dependent, agonist- and isoform-selective regulator of PP1, inhibiting its activity when decay of the SPL/RGS/SHP-1 complex releases SHP-1 from spinophilin, exposing a binding site for PP1.