Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Development and Validation of a Novel Literature-Based Method to Identify Disparity-Sensitive Surgical Quality Metrics.

BACKGROUND: Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed. STUDY DESIGN: Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%). RESULTS: The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points). CONCLUSIONS: Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.

Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus.

BACKGROUND: In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care. STUDY DESIGN: An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used. RESULTS: We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature. CONCLUSION: There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.

Lived Experiences of Surgical Residents During the COVID-19 Pandemic: A Qualitative Assessment.

OBJECTIVE: As the COVID-19 pandemic dynamically changes our society, it is important to consider how the pandemic has affected the training and wellness of surgical residents. Using a qualitative study of national focus groups with general surgery residents, we aim to identify common themes surrounding their personal, clinical, and educational experiences that could be used to inform practice and policy for future pandemics and disasters. DESIGN: Six 90-minute focus groups were conducted by a trained qualitative researcher who elicited responses on six predetermined topics. De-identified transcripts and audio recordings were later analyzed by two independent researchers who organized responses to each topic into themes. SETTING: Focus groups were conducted virtually and anonymously. PARTICIPANTS: General surgery residents were recruited from across the country. Demographic information of potential participants was coded, and subjects were randomly selected to ensure a diverse group of participants. RESULTS: The impact of the COVID-19 pandemic on residents' clinical, educational, and personal experiences varied depending on the institutional response of the program and the burden of COVID-19 cases geographically. Many successes were identified: the use of telehealth and virtual didactics, an increased sense of camaraderie amongst residents, and flexibility in scheduling. Many challenges were also identified: uncertainty at work regarding personal protective equipment and scheduling, decreased case volume and educational opportunities, and emotional trauma and burnout associated with the pandemic. CONCLUSIONS: These data gathered from our qualitative study highlight a clear, urgent need for thoughtful institutional planning and policies for the remainder of this and future pandemics. Residency programs must ensure a balanced training program for surgical residents as they attempt to master the skills of their craft while also serving as employed health care providers in a pandemic. Furthermore, a focus on wellness, in addition to clinical competency and education, is vital to resident resilience and success in a pandemic setting.

Setting a National Agenda for Surgical Disparities Research: Recommendations From the National Institutes of Health and American College of Surgeons Summit.

Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health-National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients' care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities.

Torso Computed Tomography Can Be Bypassed after Thorough Trauma Bay Examination of Patients Who Fall from Standing.

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.

Can routine trauma bay chest x-ray be bypassed with an extended focused assessment with sonography for trauma examination?

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

The diverse surgeons' initiative: longitudinal assessment of a successful national program.

BACKGROUND: The Diverse Surgeons Initiative (DSI) is a program that was created to provide underrepresented minority surgical residents with the clinical knowledge and minimally invasive surgical skills necessary to excel in surgical residency and successfully transition into surgical practice. The early success of the graduates of the program has been published; however, a more longitudinal assessment of the program was suggested and warranted. This study provides a 5-year follow-up of the 76 physicians that participated in the DSI from 2002 to 2009 to determine if the trend toward fellowship placement and academic appointments persisted. Additionally, this extended evaluation yields an opportunity to assess these young surgeons' professional progress and contributions to the field. STUDY DESIGN: The most current professional development and employment information was obtained for the 76 physicians that completed the DSI from 2002 to 2009. The percentage of DSI graduates completing surgical residency, obtaining subspecialty fellowships, attaining board certification, receiving fellowship in the American College of Surgeons, contributing to the peer-reviewed literature, acquiring academic faculty positions, and ascending to professional leadership roles were calculated and compared with the original assessment. RESULTS: Of the 76 DSI graduates, 99% completed general surgery residency. Of those eligible, 87% completed subspecialty fellowships; 87% were board certified; 50% received fellowship in the American College of Surgeons; 76% had contributed to the peer-reviewed literature; 41% had obtained faculty positions; and 18% held local, regional, or national professional leadership positions. CONCLUSIONS: This longitudinal analysis has revealed sustained success of the DSI in preparing underrepresented minority residents to excel in their training and transition into practice, obtain postsurgical fellowships, acquire faculty appointments, and contribute to the advancement of the field of surgery.

How much and what type: analysis of the first year of the acute care surgery operative case log.

BACKGROUND: A case log was created by the American Association for the Surgery of Trauma Acute Care Surgery (ACS) committee to track trainee operative experiences, allowing them to enter their cases in the form of Current Procedural Terminology (CPT) codes. We hypothesized that the number of cases an ACS trainee performed would be similar to the expectations of a fifth-year general surgery resident and that the current list of essential and desired cases (E/D list) would accurately reflect cases done by ACS trainees. METHODS: The database was queried from July 1, 2011, to June 30, 2012. Trainees were classified as those in American Association for the Surgery of Trauma-accredited fellowships (ACC) and those in ACS fellowships not accredited (non-ACC). CPT codes were mapped to the E/D list. Cases entered manually were individually reviewed and assigned a CPT code if possible or listed as "noncodable." To compensate for nonoperative rotations and noncompliance, case numbers were analyzed both annually and monthly to estimate average case numbers for all trainees. In addition, case logs of trainees were compared with the E/D list to assess how well it reflected actual trainee experience. RESULTS: Eighteen ACC ACS and 11 non-ACC ACS trainees performed 16.4 (12.6) cases per month compared with 15.7 (14.2) cases for non-ACC ACS fellows (p = 0.71). When annualized, trainees performed, on average, 195 cases per year. Annual analysis led to similar results. The E/D list captured only approximately 50% of the trainees' operative experience. Only 77 cases were categorized as pediatric. CONCLUSION: ACS trainees have substantial operative experience averaging nearly 200 major cases during their ACS year. However, high variability exists in the number of essential or desirable cases being performed with approximately 50% of the fellows' operative experience falling outside the E/D list of cases. Modification of the fellows' operative experience and/or the rotation requirements seems to be needed to provide experience in E/D cases.

Integrating cultural competency and humility training into clinical clerkships: surgery as a model.

BACKGROUND: Cultural competency is gaining recognition as an essential strategy by which to address health care disparities. A closer examination of medical school curriculums was undertaken to determine how the need for cultural competency and humility (CCH) training in medical education is being addressed. METHODS: A MEDLINE review of published literature regarding CCH training in medical education was performed. Additionally, key informant interviews with influential faculty members from prominent medical institutions were completed. RESULTS: Many academic medical institutions recognize the need for CCH and have successfully integrated it into the first 2 years of their curriculums. However, there seems to be a uniform deficit in CCH training in the third and fourth years of their education. CONCLUSIONS: Recognizing the need for CCH training during the third and fourth years of medical education, we explored the issues inherent to the integration of CCH training in clinical education. Using surgery as a model, we established a set of recommendations to assist clerkship directors and curriculum committees in their efforts to ensure CCH training in the last 2 years of medical education.