Residents Need a Dynamic Approach to Leadership Education: A Qualitative Study.

OBJECTIVE: Leadership is an essential skill for surgeons, but it is not systematically taught in residency. The objective of this study was to explore the current experiences, motivators, and perspectives on leadership training of general surgery residents. DESIGN/SETTING/PARTICIPANTS: Semi-structured focus groups were conducted with 20 general surgery residents at an academic training program. Six in-person sessions (one for each postgraduate year and research) were recorded, transcribed, and de-identified. Data were inductively coded by 2 independent researchers and analyzed thematically. Discrepancies were discussed and resolved through consensus. RESULTS: Participants described developing their leadership skills prior to residency through formal (e.g., job and military) and informal (e.g., extracurricular) experiences. Most reported that leadership development during residency occurred informally (e.g., emulating mentors, trial-and-error). Evolving responsibilities and expectations shaped residents' leadership values: junior residents focused on student and task management and adaptation to new teams; mid-level residents emphasized emotional intelligence and delivery of resident feedback; and senior residents stressed team engagement, inspiring the team, and teaching/mentoring. Major transition periods between residency levels were identified as critical times for leadership training as they allow for self-reflection, motivating residents to participate in a leadership curriculum. Employing level appropriate and immediately applicable content during this time would encourage curriculum attendance and prepare residents for new roles. CONCLUSIONS: There is a lack of formal leadership training in general surgery residency. There is an opportunity to design and implement leadership training that engages surgical residents with level-relevant content and strategies. Transition periods offer optimal timing for maximal curricula uptake.

On the Operating Table: A Student's Experience in Surgery.

The role of medical students in patient care is complex. Students suggest plans but are not responsible for enacting them. We are anticipated to make mistakes but expected to perform tasks with excellence. Regardless of the field, physicians are tasked with the responsibility and burden of making decisions. Students are at the interface between the patient and the surgical team; their interactions with the patient can be life-changing and potentially lifesaving. Choosing to not operate on patients, deemed inoperable, can be morally challenging. As students, we may not have the power to make decisions but can be present and learn from our patients.

Trauma surgeons experience compassion fatigue: A major metropolitan area survey.

INTRODUCTION: Compassion fatigue (CF), the physical, emotional, and psychological impact of helping others, is composed of three domains: compassion satisfaction (CS), secondary traumatic stress (STS), and burnout (BO). Trauma surgeons (TSs) experience work-related stress resulting in high rates of CF, which can manifest as physical and psychological disorders. We hypothesized that TSs experience CF and there are potentially modifiable systemic factors to mitigate its symptoms. METHODS: All TSs in a major metropolitan area were eligible. Personal and professional demographic information was obtained. Each participant completed six validated surveys: (1) Professional Quality of Life scale, (2) Perceived Stress Scale, (3) Multidimensional Scale of Perceived Social Support, (4) Adverse Childhood Events Questionnaire, (5) Brief Coping Inventory, and (6) Toronto Empathy Questionnaire. Compassion fatigue subscale risk scores (low, <23; moderate, 23-41; high, >41) were recorded. Linear regression analysis assessed the demographic and environmental factors association with BO, STS, and CS. Variables significant on univariate analysis were included in multivariate models to determine the independent influence on BO, STS, and CS. Significance was p ≤ 0.05. RESULTS: There were 57 TSs (response rate, 75.4% [n = 43]; White, 65% [n = 28]; male, 67% [n = 29]). Trauma surgeons experienced CF (BO, 26 [interquartile range (IQR), 21-32]; STS, 23 [IQR, 19-32]; CS, 39 [IQR, 34-45]). The Perceived Stress Scale score was significantly associated with increased BO (coefficient [coef.], 0.52; 95% confidence interval [CI], 0.28-0.77) and STS (coef., 0.44; 95% CI, 0.15-0.73), and decreased CS (coef., -0.51; 95% CI, -0.80 to -0.23) ( p < 0.01). Night shifts were associated with higher BO (coef., 1.55; 95% CI, 0.07-3.03; p = 0.05); conversely, day shifts were associated with higher STS (coef., 1.94; 95% CI, 0.32-3.56; p = 0.03). Higher Toronto Empathy Questionnaire scores were associated with greater CS (coef., 0.33; 95% CI, 0.12-0.55; p < 0.01). CONCLUSION: Trauma surgeons experience moderate BO and STS associated with modifiable system- and work-related stressors. Efforts to reduce CF should focus on addressing sources of workplace stress and promoting empathic care. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons.

BACKGROUND: A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS: We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS: Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION: Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.

Autonomy Maps: Building a Shared Mental Model for Progressive Resident Operative Autonomy on the Road to Entrustable Professional Activities (EPAs).

Our residents expressed dissatisfaction with operative autonomy and faculty feedback regarding technical skills. They reported variability among faculty regarding allowed operative autonomy. Our goals were to establish a shared mental model among residents and faculty regarding intraoperative performance expectations. We asked faculty to assign a level of expected autonomy (Zwisch scale) for various steps of common procedures according to the resident post-graduate year. Through an iterative process, the maps were standardized across service lines. The resulting "Autonomy Maps" were distributed to the faculty and residents. We held educational sessions and set expectations for use. Selected benchmarks were incorporated into resident end-of-rotation assessment forms. Initial operative case mapping identified variability in faculty expectations for a given post-graduate year and procedure. Residents reported improved satisfaction with understanding expectations regarding operative performance. Establishing autonomy benchmarks facilitated more specific feedback regarding residents' technical skills. Faculty expectations for resident operative autonomy are variable. Autonomy Maps provide structure for a shared mental model between faculty and residents for progressive operative autonomy and serve as a framework for expectations that improve resident satisfaction. Case-specific technical benchmarks are useful tools for assessing residents' technical milestones.

When public health crises collide: 5 years of pediatric firearm injury prevention opportunities.

Objectives: Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies. Patients and methods: Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths. Results: There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%. Conclusions: Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness. Level of evidence: Level III; epidemiological study type.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Bias in the trauma bay: A multicenter qualitative study on team communication.

BACKGROUND: Team communication and bias in and out of the operating room have been shown to impact patient outcomes. Limited data exist regarding the impact of communication bias during trauma resuscitation and multidisciplinary team performance on patient outcomes. We sought to characterize bias in communication among health care clinicians during trauma resuscitations. METHODS: Participation from multidisciplinary trauma team members (emergency medicine and surgery faculty, residents, nurses, medical students, emergency medical services personnel) was solicited from verified level 1 trauma centers. Comprehensive semistructured interviews were conducted and recorded for analysis; sample size was determined by saturation. Interviews were led by a team of doctorate communications experts. Central themes regarding bias were identified using Leximancer analytic software (Leximancer Pty Ltd., Brisbane, Australia). RESULTS: Interviews with 40 team members (54% female, 82% White) from 5 geographically diverse Level 1 trauma centers were conducted. More than 14,000 words were analyzed. Statements regarding bias were analyzed and revealed a consensus that multiple forms of communication bias are present in the trauma bay. The presence of bias is primarily related to sex but was also influenced by race, experience, and occasionally the leader's age, weight, and height. The most commonly described targets of bias were females and non-White providers unfamiliar to the rest of the trauma team. Most common sources of bias were White male surgeons, female nurses, and nonhospital staff. Participants perceived bias being unconscious but affecting patient care. CONCLUSION: Bias in the trauma bay is a barrier to effective team communication. Identification of common targets and sources of biases may lead to more effective communication and workflow in the trauma bay. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Addressing Surgeon Burnout Through a Multi-level Approach: A National Call to Action.

Purpose of Review: Physician burnout is an epidemic and there are unique aspects of surgery that dictate rates of burnout among general surgeons and surgical trainees. This review characterizes the scope of burnout and its drivers within the field of surgery and advocates for strategies to address burnout at the individual, institutional, and national levels. Recent Findings: Rates of burnout in surgery are increasing with higher numbers of young and female surgeons affected. Contributing factors are generally related to work-life balance, longer hours, and mistreatment in the workplace. Attempts have been made at implementing structured initiatives in an effort to combat work dissatisfaction and emotional exhaustion. Still, rates of burnout continue to increase. Summary: General surgeons and trainees are at high risk for burnout with resulting attrition, depression, and suicidal ideation. The solution to burnout must be addressed at individual, institutional, and national levels. Further research into the factors leading to surgeon burnout and enactment of effective strategies to mitigate burnout must be pursued.

Redefining trauma deserts: novel technique to accurately map prehospital transport time.

Background: Prehospital transport time has been directly related to mortality for hemorrhaging trauma patients. 'Trauma deserts' were previously defined as being outside of a 5-mile radial distance of an urban trauma center. We postulated that the true 'desert' should be based on transport time rather than transport distance. Methods: Using the Chicagoland area that was used to describe 'trauma deserts,' a sequential process to query a commercial travel optimization product to map transport times over coordinates that covered the entire urban area at a particular time of day. This produces a heat map representing prehospital transport times. Travel times were then limited to 15 minutes to represent a temporally based map of transport capabilities. This was repeated during high and low traffic times and for centers across the city. Results: We demonstrated that the temporally based map for transport to a trauma center in an urban center differs significantly from the radial distance to the trauma center. Primary effects were proximity to highways and the downtown area. Transportation to centers were significantly different when time was considered instead of distance (p<0.001). We were further able to map variations in traffic patterns and thus transport times by time of day. The truly 'closest' trauma center by time changed based on time of day and was not always the closest hospital by distance. Discussion: As the crow flies is not how the ambulance drives. This novel technique of dynamically mapping transport times can be used to create accurate trauma deserts in an urban setting with multiple trauma centers. Further, this technique can be used to quantify the potential benefit or detriment of adding or removing firehouses or trauma centers.

Association of Women Surgeons' Comprehensive Initiative for Healthy Surgical Families During Residency and Fellowship Training.

Importance: The lack of family-friendly policies continues to contribute to the underrepresentation and attrition of surgical trainees. Women in surgery face unique challenges in balancing surgical education with personal and family needs. Observations: The Association of Women Surgeons is committed to supporting surgical families and developing equitable family-friendly guidelines. Herein we detail recommendations for adequate paid parental leave, access to childcare, breastfeeding support, and insurance coverage of fertility preservation and assisted reproductive technology. Conclusions and Relevance: The specific recommendations outlined in this document form the basis of a comprehensive initiative for supporting surgical families.

Language of violence: Do words matter more than we think?

Firearm violence is a leading cause of morbidity and mortality among young adults. Identification of intervention targets is crucial to developing and implementing effective prevention efforts. Hospital Violence Intervention Programs (HVIPs) have used a multiprong social care approach to mediate the cycle of interpersonal violence. One struggle continually encountered is how to change the conversation around the future. Speech patterns have been associated with health outcomes and overall behavior modification. During violence prevention efforts, young victims of violence say things such as 'I'm living on borrowed time' and 'why should I worry about getting an education when I'll likely die soon anyway?' Such speech patterns may contribute to the cycle of violence and increase the likelihood of reinjury. Presented is a narrative review of the impact language has on health outcomes and how psychotherapy may be able to change thought patterns, alter language structure, and ultimately reduce risk of reinjury. The biopsychosocial model of health posits that a person's health is dictated by a combination of biological, psychological, and social factors. By understanding that language exists in the personal context, it can serve as both an indicator and a tool for targeted interventions. Cognitive-behavioral therapy (CBT) works by retraining thought and speech patterns to affect change in emotion, physiology, and behavior. It is proposed here that CBT could be used in the HVIPs' multidisciplinary case management model by involving trained psychotherapists. Language is an important indicator of a patient's psychological state and approach to life-changing decisions. As such, language alteration through CBT could potentially be used as a novel method of injury prevention. This concept has not before been explored in this setting and may be an effective supplement to HVIPs' success.

Understanding General Surgery Applicant Expectations and Perceptions in the Virtual Interview Process.

OBJECTIVE: The COVID-19 pandemic has played a lasting role on residency recruitment through the virtual interview process. The objective of this study was to 1) examine general surgery applicants' priorities and perceptions following pre-interview virtual open houses and 2) to assess applicant expectations and efficacy of the virtual interview day process. DESIGN/SETTING/PARTICIPANTS: This study utilized two voluntary and anonymous cross-sectional surveys administered via email to evaluate the virtual interview process of a general surgery residency program. The first was administered to registrants following completion of three open houses of various topics. The second was administered following each interview day. The post-open house survey had 78 respondents, two excluded for no open house attendance. The post-interview survey was completed by 44 applicants (62.9% response rate). RESULTS: Majority of respondents reported that attending virtual open houses made them want to apply to (90.9%) and improved their perception of the program (94.7%). Applicants who felt a sense of obligation to attend open houses (68.4%) were significantly more likely to feel that they contributed to the stress and time commitment of applications (81.8% vs 18.2%, p=0.028). Interview expectations were identified in recurrent themes: 1. Clear organization with breaks, 2. Interactive resident sessions, 3. Meetings with program leadership, 4. Additional information unavailable on other resources. The pre-interview social and interview day improved 90.2% of the applicants' perceptions of the program. The interview significantly improved applicants' ability to assess nearly all aspects of the program, notably resident camaraderie and culture (30.8% vs 97.4%, p=0.01) and strengths and weaknesses (30.8% vs 92.3%, p=0.04). CONCLUSIONS: While virtual open houses can improve applicants' perceptions and desire to apply to a program, the associated stress and obligation should be considered. Virtual interviews should provide information unavailable using other resources and provide avenues for conveying the resident culture and camaraderie.

Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study.

BACKGROUND: The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals. METHODS: Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort. RESULTS: More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27-47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02-6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07-8.01). CONCLUSION: Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.