Looking Across the Drape: A Novel Quality Improvement Approach to Understanding Surgeon and Anesthesiologist Burnout.

OBJECTIVE: To identify well-being threats for surgeons and anesthesiologists and develop interventions using the Quality of Life Improvement (QOLI) approach. BACKGROUND: Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs. METHODS: Anesthesia and surgery faculty in eight perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live-voting to identify well-being priorities. RESULTS: 104 perioperative faculty completed the survey. Across specialties, higher MHC-SF scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded five areas for intervention: (1) Work culture, (2) Work environment/resources, (3) Sources of fulfillment, (4) Work/life harmony, (5) Financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were OR inefficiencies/delays and excessive workload, while anesthesiologists cited understaffing and unpredictable work hours. CONCLUSIONS: Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.

Mindfulness Based Interventions for Surgeons: A Scoping Review.

OBJECTIVE: To review the evidence on mindfulness-based interventions (MBIs) for surgeons. BACKGROUND: Healthcare professionals have alarmingly high rates of burnout, yet little is known about psychological factors that support resilience. MBIs, which involve codified training in specific skills such as self-awareness, emotional regulation, and perspective-taking, have shown benefit to professionals in high stress environments, but have had limited implementation in the healthcare workplace and in surgery. To our knowledge, there has not been a scoping review of MBIs in surgery to date. METHODS: We conducted a scoping review of the evidence for the feasibility and effectiveness of MBIs for surgeons, including evidence on interventions that explicitly train mindfulness, which spans multiple cohorts and settings, utilizing different methodologies and outcome measures. RESULTS: This scoping review yielded 24 studies, including two mixed method/qualitative studies, nine randomized control trials, three non-randomized interventional studies, and eight single-arm interventional studies. CONCLUSIONS: We find that MBIs in surgery 1) are feasible in surgical contexts, with implementation science providing insights on sustainability; 2) increase mindfulness, 3) improve well-being in terms of burnout and both psychological and neurophysiological measures of stress, and 4) enhance performance as measured in executive function, surgical skills, and communication skills. These conclusions are supported by psychometric measures, observations of technical skills, and neurophysiological evidence. Future directions include studying MBIs in larger and more diverse populations, and iteratively tailoring mindfulness-based interventions to other healthcare contexts.

Investigating influential factors and mechanisms of surgical resident well-being using social network analysis.

BACKGROUND: Burnout and depression in General Surgery residents affect patient care and drive attrition. Few impactful interventions exist, in part because little is known about influential drivers and mechanistic relationships. METHODS: Residents from 16 general surgery programs completed published well-being scales in January 2021. Social network analysis demonstrated influential relationships between factors, and path analysis revealed drivers of burnout and depression. RESULTS: 300 residents completed the survey (34% response rate). Workplace demand and mindfulness influenced depressive symptoms and emotional exhaustion, mediated by perceived stress. Mindfulness increased personal accomplishment, mediated by psychological well-being (p â€‹< â€‹0.05 for all results). All mediated effects were greater than direct effects. CONCLUSIONS: This study yielded a quantitative conceptual model of mechanistic relationships affecting well-being in surgical residency, identifying stress and psychological well-being (measuring sense of purpose) as central mediators, and triangulating workplace demand and mindfulness as potentially high-yield interventional targets for reducing burnout and depression in surgical residency.

Intramuscular Administration of Tranexamic Acid in a Large Swine Model of Hemorrhage with Hyperfibrinolysis.

BACKGROUND: Traumatic injury with subsequent hemorrhage is one of the leading causes of mortality among military personnel and civilians alike. Post traumatic hemorrhage accounts for 40-50% of deaths in severe trauma patients occurring secondary to direct vessel injury or the development of trauma induced coagulopathy (TIC). Hyperfibrinolysis plays a major role in TIC and its presence increases a patient's risk of mortality. Early therapeutic intervention with intravenous (IV) tranexamic acid (TXA) prevents development of hyperfibrinolysis and subsequent TIC leading to decreased mortality. However, obtaining IV access in an austere environment can be challenging. In this study, we evaluated the efficacy of intramuscular (IM) versus IV TXA at preventing hyperfibrinolysis in a hemorrhaged swine. METHODS: Yorkshire cross swine were randomized on the day of study to receive IM or IV TXA or no treatment. Swine were sedated, intubated, and determined to be hemodynamically stable prior to experimentation. Controlled hemorrhaged was induced by the removal of 30% total blood volume. After hemorrhage, swine were treated with 1000 mg of IM or IV TXA. Control animals received no treatment. Thirty minutes post TXA treatment, fibrinolysis was induced with a 50 mg bolus of tissue plasminogen activator (tPA). Blood samples were collected to evaluate blood TXA concentrations, blood gases, blood chemistry, and fibrinolysis. RESULTS: Blood TXA concentrations were significantly different between administration routes at the early timepoints, but were equivalent by 20 minutes after injection, remaining consistently elevated for up to three hours post administration. Induction of fibrinolysis resulted in 87.18 ± 4.63% lysis in control animals, compared to swine treated with IM TXA 1.96 ± 2.66 % and 1.5 ± 0.42% lysis in the IV TXA group. CONCLUSION: In the large swine model of hemorrhage with hyperfibrinolysis, IM TXA is bioequivalent and equally efficacious in preventing hyperfibrinolysis as IV TXA administration.

Flourishing and the Prioritization of Workplace Elements in General Surgery Residents.

INTRODUCTION: To explore and begin to operationalize workplace elements that influence general surgery (GS) resident wellbeing. Tailoring workplace wellbeing interventions is critical to their success. Occupational science has revealed that a person-centered approach to identifying positive and negative workplace influences can inform tailoring while accounting for individual differences. To our knowledge, this approach has not been applied to the surgical training environment. METHODS: A national sample of GS residents from 16 Accreditation Council for Graduate Medical Education training programs ranked the importance of workplace elements via an anonymous survey. Latent profile analysis was performed to identify shared patterns of workplace element prioritization and their relation to levels of flourishing, a measure of global wellbeing. RESULTS: GS trainee respondents (n = 300, 34% response rate - average for studies with this sample population) expressed a hierarchy of workplace element importance which differed by gender and race. "Skills to manage stress" and "a team you feel a part of" were prioritized higher by non-males than males. Residents of color and residents underrepresented in medicine, respectively, prioritized "recognition of work/effort" and "skills to manage stress" more than White and overrepresented in medicine residents. Flourishing prevalence varied by 40% with small differences in the specific profile of workplace element prioritization. CONCLUSIONS: Differences in prioritization of workplace elements reveal subtle but important differences that may guide the design of wellbeing interventions for different populations within surgery.

Operationalizing the Culture of Burnout and Well-Being: Multicenter Study of Value Congruence and Flourishing in General Surgery Residency.

BACKGROUND: Value congruence (VC) is the degree of alignment between worker and workplace values and is strongly associated with reduced job strain and retention. Within general surgery residency, the impact of VC and how to operationalize it to improve workplace well-being remain unclear. STUDY DESIGN: This 2-part mixed-methods study comprised 2 surveys of US general surgery residents and qualitative interviews with program directors. In Part 1, January 2021, mixed-level surgical residents from 16 ACGME-accredited general surgery residency programs participated in survey #1. This survey was used to identify shared or conflicting perspectives on VC concerning well-being initiatives and resources. In April 2021, interviews from 8 institutions were conducted with 9 program directors or their proxies. In Part 2, May to June 2022, a similar cohort of surgical residents participated in survey #2. Unadjusted logistic and linear regression models were used in this survey to assess the association between VC and individual-level global well-being (ie flourishing), respectively. RESULTS: In survey #1 (N = 300, 34% response rate), lack of VC was an emergent theme with subthemes of inaccessibility, inconsiderateness, inauthenticity, and insufficiency regarding well-being resources. Program directors expressed variable awareness of and alignment with these perceptions. In survey #2 (N = 251, 31% response rate), higher VC was significantly associated with flourishing (odds ratio 1.91, 95% CI 1.44 to 2.52, p < 0.001). CONCLUSIONS: Exploring the perceived lack of VC within general surgery residency reveals an important cultural variable for optimizing well-being and suggests open dialogue as a first step toward positive change. Future work to identify where and how institutional actions diminish perceived VC is warranted.

Making the Financial Case for Surgical Resident Well-being: A Scoping Review.

OBJECTIVE: To conduct a scoping review of literature on financial implications of surgical resident well-being. BACKGROUND: Surgeon well-being affects clinical outcomes, patient experience, and health care economics. However, our understanding of the relationship between surgical resident well-being and organizational finances is limited. METHODS: Authors searched PubMed, Web of Science, and Embase with no date or language restrictions. Searches of the gray literature included hand references of articles selected for data extraction and reviewing conference abstracts from Embase. Two reviewers screened articles for eligibility based on title and abstract then reviewed eligible articles in their entirety. Data were extracted and analyzed using conventional content analysis. RESULTS: Twenty-five articles were included, 5 (20%) published between 2003 and 2010, 12 (48%) between 2011 and 2018, and 8 (32%) between 2019 and 2021. One (4%) had an aim directly related to the research question, but financial implications were not considered from the institutional perspective. All others explored factors impacting well-being or workplace sequelae of well-being, but the economics of these elements were not the primary focus. Analysis of content surrounding financial considerations of resident well-being revealed 5 categories; however, no articles provided a comprehensive business case for investing in resident well-being from the institutional perspective. CONCLUSIONS: Although the number of publications identified through the present scoping review is relatively small, the emergence of publications referencing economic issues associated with surgical resident well-being may suggest a growing recognition of this area's importance. This scoping review highlights a gap in the literature, which should be addressed to drive the system-level change needed to improve surgical resident well-being.

Well-Being Intervention in General Surgery: Multicenter Study of Program Director and Resident Perspectives.

BACKGROUND: Physician well-being is critical for optimal care, but rates of psychological distress among surgical trainees are rising. Although numerous efforts have been made, the perceived efficacy of well-being interventions is not well understood. STUDY DESIGN: This qualitative thematic study included online questionnaires to Program Directors (PDs) and residents at 16 ACGME-accredited General Surgery residency programs. PDs reported active well-being interventions for surgical residents or those under consideration at their institutions. Residents shared perspectives of available well-being interventions through open-ended responses. Conventional content analysis was used to analyze responses. RESULTS: Fifteen PDs, or their proxies (94% response rate), responded. Responses revealed that a majority of available well-being interventions are focused on changing the individual experience rather than the underlying workplace. PD decision-making around well-being interventions is often not based on objective data. Three hundred residents (34% response rate) responded. Of available interventions, those that increase control (eg advanced and flexible scheduling), increase support (eg mentorship), and decrease demand (eg work hour limits) were consistently identified as beneficial, but interventions perceived to increase demand (eg held during unprotected time) were consistently identified as not beneficial. Group social activities, cognitive skills training, and well-being committees were variably seen as beneficial (increasing support) or not (increasing demand). CONCLUSIONS: Our findings underscore the prevalence of individual-based well-being interventions and the paucity of system-level changes. This may explain, in part, the persistence of distress among residents despite abundant effort, highlighting the imperative for system-level transformation.

Emotional Regulation in Surgery: Fostering Well-Being, Performance, and Leadership.

Emotional regulation is increasingly gaining acceptance as a means to improve well-being, performance, and leadership across high-stakes professions, representing innovation in thinking within the field of surgical education. As one part of a broader cognitive skill set that can be trained and honed, emotional regulation has a strong evidence base in high-stress, high-performance fields. Nevertheless, even as Program Directors and surgical educators have become increasingly aware of this data, with emerging evidence in the surgical education literature supporting efficacy, hurdles to sustainable implementation exist. In this white paper, we present evidence supporting the value of emotional regulation training in surgery and share case studies in order to illustrate practical steps for the development, adaptation, and implementation of emotional regulation curricula in three key developmental contexts: basic cognitive skills training, technical skills acquisition and performance, and preparation for independence. We focus on the practical aspects of each case to elucidate the challenges and opportunities of introducing and adopting a curricular innovation into surgical education. We propose an integrated curriculum consisting of all three applied contexts for emotional regulation skills and advocate for the dissemination of such a longitudinal curriculum on a national level.

The General Surgery Residency Experience: A Multicenter Study of Differences in Wellbeing by Race/Ethnicity.

Objectives: We explored differences by race/ethnicity in regard to several factors that reflect or impact wellbeing. Background: Physician wellbeing has critical ramifications for the US healthcare system, affecting clinical outcomes, patient experience, and healthcare economics. Within surgery, literature examining the association between race/ethnicity and wellbeing has been limited and inconclusive. Methods: Residents at 16 academic General Surgery training programs completed an online questionnaire. Racial/ethnic identity, gender identity, post-graduate year (PGY) level, and gap years were self-reported. Differences by race/ethnicity in flourishing (global wellbeing) as well as factors reflecting resilience (mindfulness, personal accomplishment, workplace support, workplace control) and risk (depression, emotional exhaustion, depersonalization, stress, anxiety, workplace demand) were assessed. Results: Of 300 respondents (response rate 34%), 179 (60%) were non-male, 123 (41%) were residents of color (ROC), and 53 (18%) were from racial/ethnic groups that are underrepresented in medicine (UIM). Relative to White residents, ROC have significantly lower flourishing and higher anxiety, and these remain significant when adjusting for gender, PGY level, and gap years. Relative to residents overrepresented in medicine (OIM), UIM residents have significantly lower emotional exhaustion and depersonalization after adjusting for gender, PGY level and gap years. Conclusions: Disparities in resident wellbeing based on race/ethnicity and UIM/OIM status exist. However, the experience of ROC is not homogeneous. As part of the transformative process to address systemic racism, eliminate disparities in surgical training, and reconceptualize wellbeing as a fundamental asset for optimal surgeon performance, further understanding the specific contributors and detractors of wellbeing among different individuals and groups is critical.

Evaluation of aqueous dimethyl trisulfide as an antidote to a highly lethal cyanide poisoning in a large swine model.

BACKGROUND: Cyanide is a rapid acting, lethal, metabolic poison and remains a significant threat. Current FDA-approved antidotes are not amenable or efficient enough for a mass casualty incident. OBJECTIVE: The objective of this study is to evaluate short and long-term efficacy of intramuscular aqueous dimethyl trisulfide (DMTS) on survival and clinical outcomes in a swine model of cyanide exposure. METHODS: Anesthetized swine were instrumented and acclimated until breathing spontaneously. Potassium cyanide infusion was initiated and continued until 5 min after the onset of apnea. Subsequently, animals were treated with intramuscular DMTS (n = 11) or saline control (n = 10). Laboratory values and DMTS blood concentrations were assessed at various time points and physiological parameters were monitored continuously until the end of the experiment unless death occurred. A subset of animals treated with DMTS (n = 5) were survived for 7 days to evaluate muscle integrity by repeat biopsy and neurobehavioral outcomes. RESULTS: Physiological parameters and time to apnea were similar in both groups at baseline and at time of treatment. Survival in the DMTS-treated group was 90% and 30% in saline controls (p = 0.0034). DMTS-treated animals returned to breathing at 12.0 ± 10.4 min (mean ± SD) compared to 22.9 ± 7.0 min (mean ± SD) in the 3 surviving controls. Blood collected prior to euthanasia showed improved blood lactate concentrations in the DMTS treatment group; 5.47 ± 2.65 mmol/L vs. 9.39 ± 4.51 mmol/L (mean ± SD) in controls (p = 0.0310). Low concentrations of DMTS were detected in the blood, gradually increasing over time with no elimination phase observed. There was no mortality, histological evidence of muscle trauma, or observed adverse neurobehavioral outcomes, in DMTS-treated animals survived to 7 days. CONCLUSION: Intramuscular administration of aqueous DMTS improves survival following cyanide poisoning with no observed long-term effects on muscle integrity at the injection site or adverse neurobehavioral outcomes.

Validity evidence for flourishing as a measure of global wellbeing: a national multicenter study of academic general surgery residents.

Purpose: Physician wellbeing is critical to high-quality sustainable healthcare and optimal patient experience. Few objective measures exist to assay wellbeing (as opposed to just pathology) in surgery, or to evaluate the efficacy of wellbeing interventions. Flourishing (as measured by the Mental Health Continuum, MHC) has been suggested as a concise measure of global wellbeing in surgeons. We aimed to establish validity evidence for flourishing in a large national sample of surgical trainees, explore differences by gender and race, and confirm support for the underlying constructs. Methods: This cross-sectional study of all General Surgery residents at 16 ACGME-accredited academic programs included an online survey of published measures distributed in February 2021. The Mental Health Continuum (MHC), a three-factor model, assesses emotional, social, and psychological wellbeing and is an established metric of psychosocial thriving in non-physicians. A global score cut-off exists for flourishing which represents high wellbeing. Correlation between flourishing and established measures of risk and resilience in surgery were assessed for validity evidence. Differences by gender and race were explored. A confirmatory factor analysis (CFA) was performed to confirm the three-factor structure in surgical trainees. Results: 300 residents (60% non-male, 41% non-white) responded to the survey. For the overall group, flourishing was significantly positively correlated with all wellbeing resilience factors and negatively correlated with all risk factors. This held true for race and gender subgroups based on interaction analyses. CFA and sensitivity analysis results supported the three-factor structure. Conclusions: Our findings offer validity evidence for flourishing as a measure of global wellbeing and confirm the three-factor structure of emotional, social, and psychological wellbeing in surgical trainees. Thus, the MHC may be a concise tool for assaying wellbeing, within and across subgroups, and for assessing wellbeing intervention effectiveness within the surgery.

Flourishing as a guide to intervention: a national multicenter study of general surgery residents.

Purpose: Physician wellbeing is critical to maximize patient experience, quality of care, and healthcare value. Objective measures to guide and assess efficacy of interventions in terms of enhanced thriving (as opposed to just decreased pathology) have been limited. Here we provide early data on modifiable targets, potential interventions, and comparative impact. Methods: In this cross-sectional survey-based study of mixed-level residents at 16 academic General Surgery training programs, gender-identity, race, post-graduate year, and gap years were self-reported. Correlation between our primary outcome variable, flourishing, and measures of resilience (mindfulness, personal accomplishment [PA], workplace support, workplace control) and risk (depression, emotional exhaustion, depersonalization, perceived stress, anxiety, workplace demand) were assessed. Results: Of 891 recipients, 300 responded (60% non-male, 41% non-white). Flourishing was significantly positively correlated with all measured resilience factors and negatively correlated with all measured risk factors. In multivariable modelling, mindfulness, PA, and workplace support were positively and significantly associated with flourishing, with PA having the strongest resilience effect. Depression and anxiety were negatively and significantly associated with flourishing, with depression having the strongest risk effect. Conclusions: Our results suggest that interventions that increase mindfulness, workplace support, and PA, as well as those that decrease depression and anxiety may particularly impact flourishing (i.e., global wellbeing) in surgical trainees. These findings provide preliminary guidance on allocation of resources toward wellbeing interventions. In particular, cognitive (i.e., mindfulness) training is a feasible intervention with modest but significant association with flourishing, and potential indirect effects through influence on PA, anxiety and depression. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00014-3.

Enabling Conducting Polymer Applications: Methods for Achieving High Molecular Weight in Chemical Oxidative Polymerization in Alkyl- and Ether-Substituted Thiophenes.

Polythiophenes (PTs) constitute a diverse array of promising materials for conducting polymer applications. However, many of the synthetic methods to produce PTs have been optimized only for the prototypical alkyl-substituted example poly(3-hexylthiophene) (P3HT). Improvement of these methods beyond P3HT is key to enabling the widespread application of PTs. In this work, P3HT and two ether-substituted PTs poly(2-dodecyl-2H,3H-thieno[3,4-b][1,4]dioxine) (PEDOT-C12) and poly(3,4-bis(hexyloxy)thiophene) (PBHOT) are synthesized by the FeCl3-initiated oxidative method under different conditions. Polymerization was carried out according to a common literature procedure ("reverse addition") and a modified method ("standard addition"), which differ by the solvent system and the order of addition of reagents to the reaction mixture. Gel-permeation chromatography (GPC) was performed to determine the impact of the different methods on the molecular weights (Mw) and degree of polymerization (Xw) of the polymers relative to polystyrene standards. The standard addition method produced ether-substituted PTs with higher Mw and Xw than those produced using the reverse addition method for sterically unhindered monomers. For P3HT, the highest Mw and Xw were obtained using the reverse addition method. The results show the oxidation potential of the monomer and solution has the greatest impact on the yield and Xw obtained and should be carefully considered when optimizing the reaction conditions for different monomers.

Appendiceal neurofibroma in a patient with neurofibromatosis 1 and recurrent abdominal infections from ventriculoperitoneal shunt: a case report.

Appendiceal neurofibromas are exceedingly rare, with neither experimental nor observational data to support evidence-based diagnosis or treatment. We describe the case of a 52-year-old woman with neurofibromatosis 1 (NF1) complicated by aqueductal stenosis and resultant hydrocephalus needing a ventriculoperitoneal shunt (VPS). She presented to the emergency department with abdominal pain and was found to have abnormalities in the right hemiabdomen on cross-section imaging, also a Staphylococcus epidermidis growth at the distal portion of the VPS. She was initially treated with two rounds of intravenous antibiotics and VPS removal without improvement. She ultimately underwent an appendectomy, which revealed pathologic evidence of NF. The appendectomy was key to ruling out malignancy, addressing further symptoms and preventing future malignant transformation. This case highlights the importance of including appendiceal neurofibromas in the differential diagnoses of abdominal pain in patients with NF1.

Exploration of Individual and System-Level Well-being Initiatives at an Academic Surgical Residency Program: A Mixed-Methods Study.

Importance: Physician well-being is a critical component of sustainable health care. There are few data on the effects of multilevel well-being programs nor a clear understanding of where and how to target resources. Objective: To inform the design of future well-being interventions by exploring individual and workplace factors associated with surgical trainees' well-being, differences by gender identity, and end-user perceptions of these initiatives. Design, Setting, and Participants: This mixed-methods study among surgical trainees within a single US academic surgical department included a questionnaire in January 2019 (98 participants, including general surgery residents and clinical fellows) and a focus group (9 participants, all clinical residents who recently completed their third postgraduate year [PGY 3]) in July 2019. Participants self-reported gender (man, woman, nonbinary). Exposures: Individual and organizational-level initiatives, including mindfulness-based affective regulation training (via Enhanced Stress Resilience Training), advanced scheduling of time off, wellness half-days, and the creation of a resident-driven well-being committee. Main Outcomes and Measures: Well-being was explored using validated measures of psychosocial risk (emotional exhaustion, depersonalization, perceived stress, depressive symptoms, alcohol use, languishing, anxiety, high psychological demand) and resilience (mindfulness, social support, flourishing) factors. End-user perceptions were assessed through open-ended responses and a formal focus group. Results: Of 98 participants surveyed, 64 responded (response rate, 65%), of whom 35 (55%) were women. Women vs men trainees were significantly more likely to report high depersonalization (odds ratio [OR], 5.50; 95% CI, 1.38-21.85) and less likely to report high mindfulness tendencies (OR, 0.17; 95% CI, 0.05-0.53). Open-ended responses highlighted time and priorities as the greatest barriers to using well-being resources. Focus group findings reflected Job Demand-Resource theory tenets, revealing the value of individual-level interventions to provide coping skills, the benefit of advance scheduling of time off for maintaining personal support resources, the importance of work quality rather than quantity, and the demoralizing effect of inefficient or nonresponsive systems. Conclusions and Relevance: In this study, surgical trainees indicated that multilevel well-being programs would benefit them, but tailoring these initiatives to individual needs and specific workplace elements is critical to maximizing intervention effects.