Importance of Diversity, Equity, and Inclusion in the Hepatopancreatobiliary Workforce.

Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician-patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship.

Checking Our Blind Spots: Examining Characteristics of Interviewees Versus Matriculants to a Hepatopancreatobiliary Surgical Fellowship Program.

OBJECTIVE: Racial and gender biases exist within academic surgery; bias negatively impacts patient care, reimbursement, student training, and staff retention. Few studies have investigated the potential for bias in surgical fellowship recruitment. We aimed to compare the racial and gender diversity at our hepatopancreatobiliary (HPB) surgery fellowship program to nationwide standards. We further aimed to investigate differences in the demographics of resident interviewees versus matriculants to our HPB fellowship. DESIGN: Retrospective review. SETTING: North American HPB fellowship training programs. PARTICIPANTS: Mayo Clinic's HPB surgery fellowship interviewees and North American HPB surgery fellowship graduates from 2013 to 2020. RESULTS: When compared to general surgery residency graduates during the study period (in 2019), a lower proportion of North American HPB surgery fellowship graduates were female (26% HPB fellowship graduates vs. 43.1% residents, p = 0.005), with no difference in proportion of racially under-represented in medicine (rURM) HPB fellowship graduates (10.7%) compared to rURM proportion of general surgery residents nationally (14.5%). There was an upward trend in female representation among North American HPB fellowship graduates from 11% in 2013 to 32% in 2020, but proportions of rURM HPB fellows remained steadily low. When comparing HPB interviewees at our institution to national general surgery residents, no differences were observed in proportions of female (34.4% interviewees vs. 43.1% residents, p = 0.17) or rURM (interviewees = 6.8%, residents = 14.5%, p = 0.09) applicants. Additionally, there was no significant difference between the proportion of female or rURM interviewees and matriculants to our HPB program. CONCLUSIONS: While fewer female graduating surgeons are pursuing HPB fellowship training than male graduates, this gender gap has narrowed over time. In contrast, the national percentage of rURM HPB fellowship graduates has remained low, mirroring stagnant proportions of rURM surgical residency graduates. When comparing HPB fellowship interviewees at our own institution to North American fellowship graduates, we observed similar proportions of female interviewees but lower proportions of rURM interviewees. Locally, these data will drive process change toward more intentional examination of our interview selection process. Nationally, more work is needed to increase the racial diversity of surgical residency and fellowship trainees to best reflect and serve our diverse patient populations.

Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology.

BACKGROUND: The feasibility of remote perioperative telemonitoring of patient-generated physiologic health data and patient-reported outcomes in a high risk complex general and urologic oncology surgery population is evaluated. METHODS: Complex general surgical/urologic oncology patients wore a pedometer, completed ePROs (electronic patient-reported outcome surveys) and record their vitals (weight, pulse, pulse oximetry, blood pressure, and temperature) via a telehealth app platform. Feasibility (% adherence) was assessed as the primary outcome measure. RESULTS: Twenty-one patients with a median age 58 (32-82) years were included. The readmission rate was 33% and the incidence of ≥Grade 3a morbidity was 24%. Adherence to vital sign and ePRO measurements was 95% before surgery, 91% at discharge, and 82%, 68%, and 64% at postdischarge d2, 7, 14, and 30, respectively. There was significant worsening of mobility, self-care and usual daily activity at postdischarge d2 compared to preoperative baseline (p < 0.05). Median daily preoperative steps taken by patients with

Academic Productivity in Hepatopancreatobiliary Surgeons: Identifying Benchmarks Associated With Rank in North America.

BACKGROUND: Academic achievement is an integral part of the promotion process; however, there are no standardized metrics for faculty or leadership to reference in assessing this potential for promotion. The aim of this study was to identify metrics that correlate with academic rank in hepatopancreaticobiliary (HPB) surgeons. MATERIALS AND METHODS: Faculty was identified from 17 fellowship council accredited HPB surgery fellowships in the United States and Canada. The number of publications, citations, h-index values, and National Institutes of Health (NIH) funding for each faculty member was captured. RESULTS: Of 111 surgeons identified, there were 31 (27%) assistant, 39 (35%) associate, and 41 (36%) full professors. On univariate analysis, years in practice, h-index, and a history of NIH funding were significantly associated with a surgeon's academic rank (P < .05). Years in practice and h-index remained significant on multivariate analysis (P < .001). DISCUSSION: Academic productivity metrics including h-index and NIH funding are associated with promotion to the next academic rank.

The impact of financial toxicity in gastrointestinal cancer patients.

BACKGROUND: Biopsychosocial distress screening is a critical component of comprehensive cancer care. Financial issues are a common source of distress in this patient population. This study uses a biopsychosocial distress screening tool to determine the factors associated with financial toxicity and the impact of these stressors on gastrointestinal cancer patients. METHODS: A 48-question, proprietary distress screening tool was administered to patients with gastrointestinal malignancies from 2009 to 2015. This validated, electronically-administered tool is given to all new patients. Responses were recorded on a 5-point Likert scale from 1 (not a problem) to 5 (very severe problem), with responses rated at ≥3 indicative of distress. Univariate and multivariate logistic regressions were used to analyze the data. RESULTS: Most of the 1,027 patients had colorectal (50%) or hepatobiliary (31%) malignancies. Additionally, 34% of all patients expressed a high level of financial toxicity. Age greater than 65 (odds ratio: 0.63, 95% confidence interval: 0.47-0.86, P < .01), college education (odds ratio: 0.53, 95% confidence interval: 0.38-0.73, P < .0001), being partnered (odds ratio: 0.61, 95% confidence interval: 0.44-0.84, P < .01), and annual income greater than $40,000 (odds ratio: 0.27, 95% confidence interval: 0.19-0.38, P < .0001) were all protective against financial toxicity on univariate analysis. Also, heavy tobacco use was associated significantly with increased distress on univariate analysis (odds ratio: 2.79, 95% confidence interval: 1.38-5.78, P < .01). With the exception of partnered status (odds ratio: 1.18, 95% confidence interval: 0.76-1.85, P = .46), all these variables retained their significant association with financial toxicity in the multivariate model. CONCLUSION: Financial toxicity impacts a large number of cancer patients. Further study of at-risk populations may identify patients who would benefit from pre-emptive education and counseling interventions as part of their routine cancer care.

Minimally invasive distal pancreatectomy and the cost of conversion.

BACKGROUND: Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS: A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS: There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS: Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.

Academic productivity in surgical oncology: Where is the bar set for those training the next generation?

BACKGROUND AND OBJECTIVES: Promotion and tenure are important milestones for academic surgical oncologists. The aim of this study was to quantify academic metrics associated with rank in surgical oncologists training the next generation. METHODS: Faculty were identified from accredited surgical oncology fellowships in the United States. Scopus was used to obtain the number of publications/citations and h-index values. The National Institutes of Health (NIH) RePORT website was used to identify funding history. RESULTS: Of the 319 surgeons identified, complete rank information was obtained for 308. The majority of faculty were men (70%) and only 11% of full professors were women. The median h-index values were 7, 17, and 39 for assistant, associate, and full professors, respectively. While 50% of full professors had a history of NIH funding, only 26% had RO1s and 20% had current NIH funding. Using multivariate analysis, years in practice, h-index, and a history of NIH funding were associated with academic rank (P < .05). CONCLUSION: Objective benchmarks, such as the median h-index and NIH funding, provide additional insights for both junior faculty and leadership into the productivity needed to attain promotion to the next academic rank for surgical oncologists.

Development of an international online learning platform for hepatopancreatobiliary surgical training: a needs assessment.

BACKGROUND: The Americas Hepato-Pancreato-Biliary Association (AHPBA) and the Australian and New Zealand Hepatic, Pancreatic and Biliary Association (ANZHPBA) are developing an online distance learning curriculum to facilitate an interactive didactic experience for hepatopancreatobiliary (HPB) fellows in the operationalization of existing HPB fellow curricula. Two needs assessment surveys were carried out to identify the optimal structure and process for deployment in fellow education. METHODS: A 22-question survey querying fellows' learning styles and current and anticipated use of learning tools was disseminated electronically to 38 North American and Australasian HPB fellows. A follow-up 20-question survey was administered to assess fellows' feelings regarding online content. RESULTS: Response rates were 55% (n = 21) for the first survey and 42% for the second (n = 16). In the first survey, 67% of respondents claimed familiarity with the required HPB curriculum, and 43% indicated dissatisfaction with current personal study strategies. A total of 62% (n = 13) reported studying with focused clinical relevance versus using a prescribed curriculum (n = 1, 5%). Fellows anticipated participating using online tools once (n = 10, 48%) or two or three times (n = 5, 24%) per week. Most respondents (n = 18, 86%) would meaningfully follow one or two discussions per month. The second survey identified themes for improvement such as discussion topics of interest, avoidance of holiday timing and mandatory participation. CONCLUSIONS: An international online distance learning format is an appealing mechanism for improved dissemination and operationalization of the established HPB fellow curricula. Fellows will engage in interactive discussions monthly. Controversial topics or those requiring complex decision making are best suited to this learning format.