See One, Do One, Improve One's Wellness: Resident Autonomy in US General Surgery Programs, A Mixed-methods Study.

OBJECTIVE: We sought to examine the factors associated with resident perceptions of autonomy and to characterize the relationship between resident autonomy and wellness. BACKGROUND: Concerns exist that resident autonomy is decreasing, impacting competence. METHODS: Quantitative data were collected through a cross-sectional survey administered after the 2020 ABSITE. Qualitative data were collected through interviews and focus groups with residents and faculty at 15 programs. RESULTS: Seven thousand two hundred thirty-three residents (85.5% response rate) from 324 programs completed the survey. Of 5139 residents with complete data, 4424 (82.2%) reported appropriate autonomy, and these residents were less likely to experience burnout [odds ratio (OR) 0.69; 95% CI 0.58-0.83], suicidality (OR 0.69; 95% CI 0.54-0.89), and thoughts of leaving their programs (OR 0.45; 95% CI 0.37-0.54). Women were less likely to report appropriate autonomy (OR 0.81; 95% CI 0.68-0.97). Residents were more likely to report appropriate autonomy if they also reported satisfaction with their workload (OR 1.65; 95% CI 1.28-2.11), work-life balance (OR 2.01; 95% CI 1.57-2.58), faculty engagement (OR 3.55; 95% CI 2.86-4.35), resident camaraderie (OR 2.23; 95% CI, 1.78-2.79), and efficiency and resources (OR 2.37; 95% CI 1.95-2.88). Qualitative data revealed that (1) autonomy gives meaning to the clinical experience of residency, (2) multiple factors create barriers to autonomy, and (3) autonomy is not inherent to the training paradigm, requiring residents to learn behaviors to "earn" it. CONCLUSION: Autonomy is not considered an inherent part of the training paradigm such that residents can assume that they will achieve it. Resources to function autonomously should be allocated equitably to support all residents' educational growth and wellness.

Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative.

BACKGROUND: The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN: The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS: Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS: This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.

Assessing Resident Well-Being After the ABSITE: A Bad Time to Ask?

Assess the association of residents' exam performance and transient emotions with their reports of burnout, suicidality, and mistreatment. Background: An annual survey evaluating surgical resident well-being is administered following the American Board of Surgery In-Training Examination (ABSITE). One concern about administering a survey after the ABSITE is that stress from the exam may influence their responses. Methods: A survey was administered to all general surgery residents following the 2018 ABSITE assessing positive and negative emotions (scales range from 0 to 12), as well as burnout, suicidality over the past 12 months, and mistreatment (discrimination, sexual harassment verbal/emotional or physical abuse) in the past academic year. Multivariable hierarchical regressions assessed the associations of exam performance and emotions with burnout, suicidality, and mistreatment. Results: Residents from 262 programs provided complete responses (N = 6987, 93.6% response rate). Residents reported high mean positive emotion (M = 7.54, SD = 2.35) and low mean negative emotion (M = 5.33, SD = 2.43). While residents in the bottom ABSITE score quartile reported lower positive and higher negative emotion than residents in the top 2 and 3 quartiles, respectively (P < 0.005), exam performance was not associated with the reported likelihood of burnout, suicidality, or mistreatment. Conclusions: Residents' emotions after the ABSITE are largely positive. Although poor exam performance may be associated with lower positive and higher negative emotion, it does not seem to be associated with the likelihood of reporting burnout, suicidality, or mistreatment. After adjusting for exam performance and emotions, mistreatment remained independently associated with burnout and suicidality. These findings support existing evidence demonstrating that burnout and suicidality are stable constructs that are robust to transient stress and/or emotions.

Validation study of the ACS NSQIP surgical risk calculator for two procedures in Japan.

INTRODUCTION: The ACS NSQIP Surgical Risk Calculator (SRC) assesses risk to support goal-concordant care. While it accurately predicts US outcomes, its performance internationally is unknown. This study evaluates SRC accuracy in predicting mortality following low anterior resection (LAR) and pancreaticoduodenectomy (PD) in NSQIP patients and accuracy retention when applied to native Japanese patients (National Clinical Database, NCD). METHODS: NSQIP (41,260 LAR; 15,114 PD) and NCD cases (61,220 LAR; 27,901 PD) from 2015 to 2017 were processed through the SRC mortality model. Country-specific calibration and discrimination were assessed with and without an intercept correction applied to the Japanese data. RESULTS: The SRC exhibited acceptable calibration for LAR and PD when applied to NSQIP data but miscalibration for NCD data. A simple correction to the model intercept, motivated by lower mortality rates in the Japanese data, successfully remediated the miscalibration. CONCLUSIONS: The SRC may inaccurately predict surgical risk when applied to the native Japanese population. An intercept correction method is suggested when miscalibration is encountered; it is simple to implement and may permit effective international use of the SRC.

Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout.

OBJECTIVES: To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents. BACKGROUND SUMMARY DATA: Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood. METHODS: Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression. RESULTS: Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment. CONCLUSIONS: Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.

Development of a conceptual model for understanding the learning environment and surgical resident well-being.

BACKGROUND: Surgeon burnout is linked to poor outcomes for physicians and patients. Several conceptual models exist that describe drivers of physician wellness generally. No such model exists for surgical residents specifically. METHODS: A conceptual model for surgical resident well-being was adapted from published models with input gained iteratively from an interdisciplinary team. A survey was developed to measure residents' perceptions of their program. A confirmatory factor analysis (CFA) tested the fit of our proposed model construct. RESULTS: The conceptual model outlines eight domains that contribute to surgical resident well-being: Efficiency and Resources, Faculty Relationships and Engagement, Meaning in Work, Resident Camaraderie, Program Culture and Values, Work-Life Integration, Workload and Job Demands, and Mistreatment. CFA demonstrated acceptable fit of the proposed 8-domain model. CONCLUSION: Eight distinct domains of the learning environment influence surgical resident well-being. This conceptual model forms the basis for the SECOND Trial, a study designed to optimize the surgical training environment and promote well-being.

The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon.

The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons' (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.

Enhancing the American College of Surgeons NSQIP Surgical Risk Calculator to Predict Geriatric Outcomes.

BACKGROUND: The American College of Surgeons (ACS) NSQIP Surgical Risk Calculator (SRC) plays an important role in risk prediction and decision-making. We sought to enhance the existing ACS NSQIP SRC with functionality to predict geriatric-specific outcomes and assess the predictive value of geriatric-specific risk factors by comparing performance in outcomes prediction using the traditional ACS NSQIP SRC with models that also included geriatric risk factors. STUDY DESIGN: Data were collected from 21 ACS NSQIP Geriatric Surgery Pilot Project hospitals between 2014 and 2017. Hierarchical regression models predicted 4 postoperative geriatric outcomes (ie pressure ulcer, delirium, new mobility aid use, and functional decline) using the traditional 21-variable ACS NSQIP SRC models and 27-variable models that included 6 geriatric risk factors (ie living situation, fall history, mobility aid use, cognitive impairment, surrogate-signed consent, and palliative care on admission). RESULTS: Data from 38,048 patients 65 years or older undergoing 197 unique operations across 10 surgical subspecialties were used. Stable model discrimination and calibration between developmental and validation datasets confirmed predictive validity. Models with and without geriatric risk factors demonstrated excellent performance (C statistic >0.8) with inclusion of geriatric risk factors improving performance. Of the 21 ACS NSQIP variables, CPT code, COPD, age, functional dependence, sex, disseminated cancer, diabetes, and sepsis were the strongest risk predictors, and impaired cognition, fall history, and mobility aid use were the strongest geriatric predictors. CONCLUSIONS: The ACS NSQIP SRC can predict 4 unique outcomes germane to geriatric surgical patients, with improvement of predictive capability after accounting for geriatric risk factors. Augmentation of ACS NSQIP SRC can enhance shared decision-making to improve the quality of surgical care in older adults.