General Surgery Resident Participation in a Mandatory Wellness Program: Six Years Later.

INTRODUCTION: Following the approval of a resident-created physician wellness program in 2016, an initial survey demonstrated majority support for the implementation of a mandatory curriculum. The purpose of this study is to survey surgical residents about the wellness curriculum six years after implementation and re-evaluate preference for mandatory participation. METHODS: In 2016, the CORE7 Wellness Program didactic sessions were integrated into the general surgery resident education curriculum. A comparison between 2016 and 2022 resident survey results was done to examine overall approval and resident experience. RESULTS: A total of 25 general surgery residents responded to the 2022 survey which equaled to a response rate of 67.5% compared to a response rate of 87.1% in 2016. Similar to the results in 2016, there was unanimous support (100%, n = 25) in favor of the ongoing development of a general surgery wellness program. The majority of residents (88% versus 85.2% in 2016) preferred quarterly "wellness half-days" remain a mandatory component of the program. In 2016, most of the residents (50%) stated that the reason for mandatory preference for wellness half-days was ease of explanation to faculty. In 2022, the reason changed to a combination of reasons with most residents (59%) selecting ease of explanation to attendings, feeling too guilty otherwise to leave the shift, and forcing the resident to think about self-care. Complaints about taking a wellness half-day from other team members increased from 29% in 2016 to 48% in 2022. CONCLUSIONS: Six years after implementation, there is unanimous support for the mandatory components of a general surgery residency wellness curriculum. Increased perceived complaints from faculty and staff about resident wellness present an opportunity for improvement.

PAUSE: principled feature attribution for unsupervised gene expression analysis.

As interest in using unsupervised deep learning models to analyze gene expression data has grown, an increasing number of methods have been developed to make these models more interpretable. These methods can be separated into two groups: post hoc analyses of black box models through feature attribution methods and approaches to build inherently interpretable models through biologically-constrained architectures. We argue that these approaches are not mutually exclusive, but can in fact be usefully combined. We propose PAUSE ( https://github.com/suinleelab/PAUSE ), an unsupervised pathway attribution method that identifies major sources of transcriptomic variation when combined with biologically-constrained neural network models.

Effect of a behavioral intervention on anxiety and perceived performance of non-technical skills during surgical simulations.

BACKGROUND: Surgical trainees experience intrinsic stress and anxiety during high-acuity clinical situations which can negatively impact performance. Emerging data suggests that education in mindfulness-based coping techniques may improve performance. We evaluated the effects of a stress recovery intervention on novice trainees' perceived level of anxiety during an intentionally stressful simulation. METHODS: Participants were recruited from surgical intern classes over three consecutive years. All participants completed a simulation intentionally designed to evoke a stress response. Participants then completed a stress recovery intervention or received no additional training. All participants then completed a second novel simulation. RESULTS: Intervention participants had significantly higher self-reported ability to manage stress (intervention 2.4 to 3.6, p < 0.01; control 2.8 to 3.3, p = 0.06), and stop, think, and observe (intervention 2.5 to 3.7, p < 0.01; control 2.6 to 3.3, p = 0.08) during the second simulation. Both groups also had significantly lower levels of state anxiety during the second simulation as compared to the first (intervention 45.1 vs 59.3, p < 0.01; control 49.3 vs 57.4, p < 0.05). During the second simulation, trainees in both groups reported improvements in perceived abilities to: recognize stress (intervention 2.7 to 4.1, p < 0.01; control 2.9 to 3.6, p < 0.05), communicate with and lead their team (intervention 2.4 to 3.3, p < 0.05; control 2.3 to 3.3, p < 0.01), and to prioritize, plan, and prepare (intervention 2.1 to 3.1, p < 0.05; control 2.1 to 3.0, p < 0.01). CONCLUSION: Our research shows that a brief intervention was associated with a significant increase in trainee ability to both recognize internal stress and engage in proactive coping mechanisms. This research also shows that while repeated stress-inducing simulations may themselves decrease perceived anxiety levels in novice surgical trainees, training in coping strategies may potentiate this effect.

More Than Aligning Perception: Impact of an Educational Intervention on Medical Student Mistreatment Reporting.

BACKGROUND: Despite decades of reporting, rates of medical student mistreatment on the surgical clerkship remains a national issue. To understand whether misaligned perceptions about what constitutes mistreatment were leading to the high rates of reported mistreatment at our institution, we implemented an intervention designed to educate students about the unique challenges of the surgical environment and to build consensus around the definition of mistreatment. STUDY DESIGN: Medical students were recruited from the surgery clerkship to participate in a video vignette-based curriculum accompanied by a facilitated discussion. Participants completed a survey before and after the educational intervention to assess their understanding of mistreatment and their perceptions of the surgical learning environment. At the end of each clerkship block students who participated in the intervention, as well as students who did not participate, were asked to complete a questionnaire about their experiences during the clerkship. RESULTS: During 6 clerkship blocks, 53 students participated in the intervention (51% of the third-year student cohort). Students who participated in the intervention were more likely to report experiencing mistreatment or witnessing mistreatment during the clerkship. Students who participated in the intervention also reported experiencing neglect more frequently than students who did not participate. CONCLUSIONS: We found that using an educational intervention designed to align perceptions of what constitutes mistreatment in the surgical learning environment did not decrease rates of mistreatment reporting on the surgical clerkship at our institution. Students who participated in the intervention reported increased confidence in their ability to define and recognize mistreatment after the intervention, as well as increased comfort reporting mistreatment and turning to faculty with concerns about mistreatment.

Implementation of a Clinical Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department.

BACKGROUND: Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer of complexity to CD. A clinical documentation improvement (CDI) and ICD-10 training program was created for health care providers in our academic surgery department. We aimed to assess the impact of our CDI curriculum by comparing quality metrics, coding, and reimbursement before and after implementation of our CDI program. STUDY DESIGN: A CDI/ICD-10 training curriculum was instituted in September 2014 for all members of our university surgery department. The curriculum consisted of didactic lectures, 1-on-1 provider training, case reviews, e-learning modules, and CD queries from nurse CDI staff and hospital coders. Outcomes parameters included monthly documentation completion rates, severity of illness (SOI), risk of mortality (ROM), case-mix index (CMI), all-payer refined diagnosis-related groups (APR-DRG), and Surgical Care Improvement Program (SCIP) metrics. Financial gain from responses to CDI queries was determined retrospectively. RESULTS: Surgery department delinquent documentation decreased by 85% after CDI implementation. Compliance with SCIP measures improved from 85% to 97%. Significant increases in surgical SOI, ROM, CMI, and APR-DRG (all p < 0.01) were found after CDI/ICD-10 training implementation. Provider responses to CDI queries resulted in an estimated $4,672,786 increase in charges. CONCLUSIONS: Clinical documentation improvement/ICD-10 training in an academic surgery department is an effective method to improve documentation rates, increase the hospital estimated reimbursement based on more accurate CD, and provide better compliance with surgical quality measures.

Effects of Technological Advances in Surgical Education on Quantitative Outcomes From Residency Programs.

OBJECTIVES: The purpose of this article is to review the literature on current technology for surgical education and to evaluate the effect of technological advances on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification. DESIGN: A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: technology for surgical education, simulation-based surgical training, simulation-based nontechnical skills (NTS) training, ACGME Core Competencies, ABSITE scores, and ABS pass rate. RESULTS: Our initial search list included the following: 648 on technology for surgical education, 413 on simulation-based surgical training, 51 on simulation-based NTS training, 78 on ABSITE scores, and 33 on ABS pass rate. Further, 42 articles on technological advances for surgical education met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 33 of 42 and 26 of 42 publications on technological advances for surgical education showed objective improvements regarding patient care and medical knowledge, respectively, whereas only 2 of 42 publications showed improved ABSITE scores, but none showed improved ABS pass rates. Improvements in the other ACGME core competencies were documented in 14 studies, 9 of which were on simulation-based NTS training. CONCLUSIONS: Most of the studies on technological advances for surgical education have shown a positive effect on patient care and medical knowledge. However, the effect of simulation-based surgical training and simulation-based NTS training on ABSITE scores and ABS certification has not been assessed. Studies on technological advances in surgical education and simulation-based NTS training showing quantitative evidence that surgery residency program objectives are achieved are still needed.

Effect of Process Changes in Surgical Training on Quantitative Outcomes From Surgery Residency Programs.

OBJECTIVES: The purpose of this article is to review the literature on process changes in surgical training programs and to evaluate their effect on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification. DESIGN: A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: surgery residency training, surgical education, competency-based surgical education, ACGME core competencies, ABSITE scores, and ABS pass rate. RESULTS: Our initial search list included 990 articles on surgery residency training models, 539 on competency-based surgical education, 78 on ABSITE scores, and 33 on ABS pass rate. Overall, 31 articles met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 5/31, 19/31, and 6/31 articles on process changes in surgical training programs had a positive effect on patient care, medical knowledge, and ABSITE scores, respectively. ABS certification was not analyzed. The other ACGME core competencies were addressed in only 6 studies. CONCLUSIONS: Several publications on process changes in surgical training programs have shown a positive effect on patient care, medical knowledge, and ABSITE scores. However, the effect on ABS certification, and other quantitative outcomes from residency programs, have not been addressed. Studies on education strategies showing evidence that residency program objectives are being achieved are still needed. This article addresses the 6 ACGME Core Competencies.

Using Qualitative and Quantitative Assessment to Develop a Patient Safety Curriculum for Surgical Residents.

OBJECTIVE: The objective is to use qualitative and quantitative analysis to develop a patient safety curriculum for surgical residents. DESIGN: A prospective study of surgical residents using both quantitative and qualitative methods to craft a patient safety curriculum. Both a survey and focus groups were held before and 4 months after delivery of the patient safety curriculum. SETTING: The University of New Mexico Hospital, a tertiary academic medical center. PARTICIPANTS: General surgery residents, postgraduate years 1 to 5 RESULTS: Qualitative and quantitative analysis revealed areas that required attention and thus helped to mold the curriculum. Qualitative analysis after delivery of the curriculum showed positive changes in attitudes and normative beliefs toward patient safety. Specifically, attitudes and approach to quality improvement and teamwork showed improvement. Survey analysis did not show any significant change in resident perception of the environment during the time frame of this study. CONCLUSIONS: Using qualitative analysis to uncover attitudinal barriers to a safe patient environment can help to enhance the relevance and content of a patient safety curriculum for general surgery residents.

Competency champions in the clinical competency committee: a successful strategy to implement milestone evaluations and competency coaching.

OBJECTIVES: To create a clinical competency committee (CCC) that (1) centers on the competency-based milestones, (2) is simple to implement, (3) creates competency expertise, and (4) guides remediation and coaching of residents who are not progressing in milestone performance evaluations. DESIGN: We created a CCC that meets monthly and at each meeting reviews a resident class for milestone performance, a competency (by a faculty competency champion), a resident rotation service, and any other resident or issue of concern. SETTING: University surgical residency program. PARTICIPANTS: The CCC members include the program director, associate program directors, director of surgical curriculum, competency champions, departmental chair, 2 at-large faculty members, and the administrative chief residents. RESULTS: Seven residents were placed on remediation (later renamed as coaching) during the academic year after falling behind on milestone progression in one or more competencies. An additional 4 residents voluntarily placed themselves on remediation for medical knowledge after receiving in-training examination scores that the residents (not the CCC membership) considered substandard. All but 2 of the remediated/coached residents successfully completed all area milestone performance but some chose to stay on the medical knowledge competency strategy. CONCLUSIONS: Monthly meetings of the CCC make milestone evaluation less burdensome. In addition, the expectations of the residents are clearer and more tangible. "Competency champions" who are familiar with the milestones allow effective coaching strategies and documentation of clear performance improvements in competencies for successful completion of residency training. Residents who do not reach appropriate milestone performance can then be placed in remediation for more formal performance evaluation. The function of our CCC has also allowed us opportunity to evaluate the required rotations to ensure that they offer experiences that help residents achieve competency performance necessary to be safe and effective surgeons upon completion of training.

The importance of community in academic health centers.

BACKGROUND: A strong sense of community in any organization, whether it is a small business or a large academic medical center, positively impacts on productivity, efficiency, and morale and makes for an enjoyable workplace. Striking a balance between institutional interests and those of the individual is an ongoing challenge that demands vigilance on the part of faculty and administrators. A faculty comprising self-absorbed individuals, no matter how accomplished they are, will eventually devolve into dysfunction. As the emphasis on extramural grants and clinical productivity has intensified in recent years, this balance has tilted in favor of individualism at the expense of student success and community spirit. SUMMARY: This article examines factors that tend to undermine community and human behaviors that can counter these negative forces. CONCLUSIONS: If the various stakeholders in the academic health center--deans, chairpersons, faculty, students and staff--all take stock of their responsibilities and commit themselves to restoring a healthier balance between self-interest and institutional missions, beneficial returns are likely in terms of higher quality education and clinical care, increased research productivity and a more vibrant and enjoyable workplace.

Commentary: the case for expanding general surgery residencies.

Despite the significant growth in population in the United States since 1980 and societal and demographic factors such as an aging population, there has been no increase in the number of graduating general surgery residents each year, which has created a worsening shortage of general surgeons. Other factors, such as stricter duty hours requirements and an increase in the number and variety of procedures general surgeons must perform, have also contributed to this shortage. Yet, applicant demand for general surgery positions is currently strong and will increase as new medical schools are created and current medical schools expand class size. The authors of this commentary propose an expansion of the Accreditation Council for Graduate Medical Education-approved general surgery categorical resident positions as the necessary first step in addressing the current and projected shortage of general surgeons. Before this expansion of general surgery residencies can occur, impediments such as the availability of residency spots for both U.S. and international medical graduates, the availability of educational opportunities for residents in teaching hospitals, and inadequate financial resources, such as a lack of funding from the Centers for Medicare and Medicaid, must be overcome.

Ampelomyces mycoparasites from apple powdery mildew identified as a distinct group based on single-stranded conformation polymorphism analysis of the rDNA ITS region.

Pycnidial fungi belonging to the genus Ampelomyces are the most common natural antagonists of powdery mildews worldwide. During a study of the interactions between apple powdery mildew (Podosphaera leucotricha) and Ampelomyces mycoparasites, 52 new Ampelomyces isolates were obtained from P. leucotricha and, in addition, 13 new isolates from other species of the Erysiphaceae in four European countries. Their genetic diversity was screened using single-stranded conformation polymorphism (SSCP) analysis of the internal transcribed spacer (ITS) region of the ribosomal DNA (rDNA). For comparison, 24 isolates obtained from genetic resource collections or other sources were included in this study. Based on the ITS-SSCP patterns, the isolates were placed in eight groups. The isolates belonged to two types based on their growth in culture. The faster-growing and the slower-growing isolates were included in different SSCP groups. A phylogenetic analysis of the ITS sequences of representatives of these groups confirmed the results obtained with the SSCP method, and showed that the faster-growing isolates do not belong to Ampelomyces as suggested by earlier studies. All the isolates from P. leucotricha fell into a distinct SSCP group of genetically homogeneous isolates. This suggests that Ampelomyces mycoparasites which occur in apple powdery mildew are slightly different from the other Ampelomyces groups which contain mycoparasites from various powdery mildew species. This may be because the main growth period of Ampelomyces mycoparasites in apple powdery mildew is isolated in time from that of Ampelomyces isolates that occur in other species of the Erysiphaceae. P. leucotricha starts its life-cycle early in the season, usually in March-April, while most powdery mildews are active in the same environments only late in the year.

Ethnic differences in symptoms of post-traumatic stress after the Exxon Valdez oil spill.

INTRODUCTION: Previous studies have reported ethnic differences in the prevalence of post-traumatic stress disorder (PTSD), but the reasons for these differences remain unclear. HYPOTHESIS: Ethnic differences in the prevalence of PTSD may reflect ethnic differences in (1) exposure to traumatic events; (2) appraisal of such event as traumatic; and (3) culturally-determined responses to standardized diagnostic instruments, reflecting differences in cultural meanings associated with physical symptoms and idioms of distress. METHODS: Ethnic differences in risk factors and factor structures of PTSD symptoms were examined in 188 Alaskan Natives and 371 Euro-Americans exposed to the Exxon-Valdez oil spill in 1989. RESULTS: High levels of social disruption were associated with PTSD one year after the oil spill in both ethnic groups. However, low family support, participation in spill clean-up activities, and a decline in subsistence activities were significantly associated with PTSD in Alaskan Natives, but not in Euro-Americans. Factor analysis of the Diagnostic Interview Schedule PTSD subscale revealed five factors for both ethnic groups. However, the items comprising these factors were dissimilar. CONCLUSIONS: These results suggest that social disruption is sufficiently traumatic to be associated with symptoms of post-traumatic stress, but that a diagnosis of PTSD must take into consideration local interpretations of these symptoms.

Solid phase assembly of defined protein conjugates.

We have developed a solid-phase procedure for protein-protein conjugation that gives greater control over product size and composition than previous methods. Conjugates are assembled by sequential addition of activated proteins to the support under conditions suitable for maintaining the activity of the proteins. The total number of conjugate units to be prepared is fixed in the first step by the quantity of the first protein absorbed by the support. In each following step, the added protein links only to previously bound protein. The final conjugate is released to solution by cleaving the linker holding the first protein to the support. This stepwise assembly provides uniformly sized conjugates of the desired size and composition with placement of components at the desired positions within the structure. Using this approach, we have prepared a series of conjugates containing R-phycoerythrin as the central protein, with varying quantities of alkaline phosphatase and IgG with expected molecular masses ranging from 1.6 to 11.5 MDa. Size-exclusion chromatography and atomic force microscopy demonstrate homogeneity and control of the conjugate size. In an immunoassay for human thyroid stimulating hormone, the conjugates show signals consistent with their compositions.