The Predictive Performance of General Surgery Milestones on Post-Graduation Outcomes.

OBJECTIVE: To establish whether Accreditation Council for Graduate Medical Education Milestones predict future performance of general surgery trainees. SUMMARY BACKGROUND DATA: Milestones provide bi-annual assessments of trainee progress across six competencies. It is unknown whether the Milestones predict surgeon performance after the transition to independent practice. METHODS: We performed a retrospective cohort study of surgeons with complete Milestone assessments in the fourth and fifth clinical years who treated patients in acute care hospitals within Florida, New York, and Pennsylvania, 2015-2018. To account for the multiple ways in which the Milestone assessments might predict post-graduation outcomes, we included 120 Milestones features in our elastic net machine learning models. The primary outcome was risk-adjusted patient death or serious morbidity. RESULTS: 278 general surgeons were included in the study. Milestone assessments 6-months into the fourth clinical year displayed a normal score distribution while multicollinearity and low score discrimination at the final assessment period were detected. Individual Milestones features from the Patient Care, Professionalism, and Systems-based Practice domains were most predictive of patient-related outcomes. For example, surgeons with worse patient outcomes had significantly lower scores in Patient Care 3 when compared to surgeons with better patient outcomes (High DSM, yes: 2.86 vs. no: 3.04, P=0.011). CONCLUSIONS: The Milestones features that were most predictive of better patient outcomes related to intraoperative skills, ethical principles, and patient navigation and safety, measured 12-18 months prior to graduation. The development of a parsimonious set of evidence-based Milestones that better correlate with surgeon experience could enhance surgical education.

Exploring the Experience of the Surgical Workforce During the Covid-19 Pandemic.

OBJECTIVE: To explore the impact of the Covid-19 pandemic on the stress levels and experience of academic surgeons by training status (eg, housestaff or faculty). BACKGROUND: Covid-19 has uniquely challenged and changed the United States healthcare system. A better understanding of the surgeon experience is necessary to inform proactive workforce management and support. METHODS: A multi-institutional, cross-sectional telephone survey of surgeons was conducted across 5 academic medical centers from May 15 to June 5, 2020. The exposure of interest was training status. The primary outcome was maximum stress level, measured using the validated Stress Numerical Rating Scale-11 (range 0-10). RESULTS: A total of 335 surveys were completed (49.3% housestaff, 50.7% faculty; response rate 63.7%). The mean maximum stress level of faculty was 7.21 (SD 1.81) and of housestaff was 6.86 (SD 2.06) (P = 0.102). Mean stress levels at the time of the survey trended lower amongst housestaff (4.17, SD 1.89) than faculty (4.56, SD 2.15) (P = 0.076). More housestaff (63.6%) than faculty (40.0%) reported exposure to individuals with Covid-19 (P < 0.001). Subjects reported inadequate personal protective equipment in approximately a third of professional exposures, with no difference by training status (P = 0.557). CONCLUSIONS: During the early months of the Covid-19 pandemic, the personal and professional experiences of housestaff and faculty differed, in part due to a difference in exposure as well as non-work-related stressors. Workforce safety, including adequate personal protective equipment, expanded benefits (eg, emergency childcare), and deliberate staffing models may help to alleviate the stress associated with disease resurgence or future disasters.

The Relationship Between Surgeon Gender and Stress During the Covid-19 Pandemic.

OBJECTIVE: To investigate the relationship between surgeon gender and stress during the Covid-19 pandemic. BACKGROUND: Although female surgeons face difficulties integrating work and home in the best of times, the Covid-19 pandemic has presented new challenges. The implications for the female surgical workforce are unknown. METHODS: This cross-sectional, multi-center telephone survey study of surgeons was conducted across 5 academic institutions (May 15-June 5, 2020). The primary outcome was maximum stress level, measured using the validated Stress Numerical Rating Scale-11. Mixed-effects generalized linear models were used to estimate the relationship between surgeon stress level and gender. RESULTS: Of 529 surgeons contacted, 337 surgeons responded and 335 surveys were complete (response rate 63.7%). The majority of female respondents were housestaff (58.1%), and the majority of male respondents were faculty (56.8%) (P = 0.008). A greater proportion of male surgeons (50.3%) than female surgeons (36.8%) had children ≤18 years (P = 0.015). The mean maximum stress level for female surgeons was 7.51 (SD 1.49) and for male surgeons was 6.71 (SD 2.15) (P < 0.001). After adjusting for the presence of children and training status, female gender was associated with a significantly higher maximum stress level (P < 0.001). CONCLUSIONS: Our findings that women experienced more stress than men during the Covid-19 pandemic, regardless of parental status, suggest that there is more to the gendered differences in the stress experience of the pandemic than the added demands of childcare. Deliberate interventions are needed to promote and support the female surgical workforce during the pandemic.

Regulated necrosis and failed repair in cisplatin-induced chronic kidney disease.

Cisplatin is an effective chemotherapeutic agent, but significant nephrotoxicity limits its clinical use. Despite extensive investigation of the acute cellular and molecular responses to cisplatin, the mechanisms of progression from acute to chronic kidney injury have not been explored. We used functional and morphological metrics to establish a time-point when the transition from acute and reversible kidney injury to chronic and irreparable kidney disease is clearly established. In mice administered 1 or 2 doses of intraperitoneal cisplatin separated by 2 weeks, kidney function returned toward baseline two weeks after the first dose, but failed to return to normal two weeks following a second dose. Multiphoton microscopy revealed increased glomerular epithelial and proximal tubular damage in kidneys exposed to two doses of cisplatin compared with those exposed to a single dose. In contrast, there was no evidence of fibrosis, macrophage invasion, or decrease in endothelial cell mass in chronically diseased kidneys. Pathway analysis of microarray data revealed regulated necrosis as a key determinant in the development of chronic kidney disease after cisplatin administration. Western blot analysis demonstrated activation of proteins involved in necroptosis and increased expression of kidney injury markers, cellular stress response regulators, and upstream activators of regulated necrosis, including Toll-like receptors 2 and 4. These data suggest that unresolved injury and sustained activation of regulated necrosis pathways, rather than fibrosis, promote the progression of cisplatin-induced acute kidney injury to chronic kidney disease.

Recurrence and treatment trends of pancreatic neuroendocrine tumors.

INTRODUCTION: The management of recurrent pancreatic neuroendocrine tumors has changed with improvements in both systemic and locoregional therapies. This study aims to describe the patterns of recurrence and respective treatments and evaluate the changes in multimodality treatment. METHODS: This is a single-institution retrospective study of patients diagnosed with a pancreatic neuroendocrine tumor from 2004 to 2022. The primary outcome was time to recurrence. Secondary outcomes included overall survival and therapeutic modality. Time to event probabilities were calculated using the Kaplan-Meier method; probabilities were compared using log-rank tests. Cox proportional hazards multivariable modeling with competing risks yielded subdistribution hazard ratios. RESULTS: Of 284 patients with a primary pancreatic neuroendocrine tumor, 189 underwent upfront surgical resection and were included in the analysis. Of the 182 patients with a well-differentiated G1 or G2 tumor, 44 patients (24%) experienced a recurrence. Mean time to recurrence was 57 months, with the liver as the most common site (77%, 34/44). On adjusted Cox proportional hazards modeling, only nodal positivity (subdistribution hazard ratio, 4.06; 95% confidence interval, 1.31-12.03, P = .013) was associated with a greater risk of recurrence. There was an increase in adoption of newer liver-directed and systemic therapies in the latter half of the study period, with increased use of therapies such as liver embolization and peptide receptor radionucleotide therapy for recurrences occurring after 2010. CONCLUSIONS: Of the patients with well-differentiated pancreatic neuroendocrine tumors managed with upfront surgical resection, one quarter developed recurrent disease. Nodal positivity was the most significant risk factor for recurrence. The majority of patients received multimodality therapies for recurrent disease.

Post Night Shift Education for Interns: A Pilot Program.

BACKGROUND: Night float rotations are associated with decreased feedback, educational conference attendance, and operative time. Interns are also more isolated and spend less time on teams. We therefore developed a novel post night shift initiative to address these shortcomings and examined its impact on the educational experience and sense of belonging among interns. METHODS: A program of weekly senior resident-led post night shift sessions was instituted at a university-based general surgery residency program for the first quarter of the academic year. Four interns and one senior resident participated in each session. Feedback surveys were administered. A previously validated Belonging in Surgery survey was also administered to all general surgery interns at the end of the quarter. RESULTS: Eleven interns had night float rotations within the first 3 months of the academic year. The intern feedback survey response rate was 93% (10/11). All intern respondents attended at least 3 sessions. Interns felt that the sessions increased familiarity with each other (85%) and senior residents (92%), improved clinical decision making (77%), and provided a safe space for discussion (69%). The senior resident survey response rate was 86% (n = 14). All senior residents enjoyed teaching the sessions and felt that they improved their familiarity with interns. The intern belonging survey response rate was 84% (16/19). Categorical interns had significantly higher belonging scores than preliminary interns at the end of the first quarter (mean 48.1 vs 41.6, p = 0.009). There was a trend toward decreased belonging scores for interns who had night float rotations early in the year which did not meet statistical significance (42.9 vs 47.4, p = 0.059). CONCLUSION: This novel program improved intern decision-making, familiarity with other residents, and comfort calling senior residents for assistance overnight. There was no statistically significant difference in belonging between interns who started residency on night float versus those who did not. Similar programs may help address concerns regarding missed learning opportunities and decreased sense of community during these rotations.

Longitudinal evaluation of the surgical workforce experience during the Covid-19 pandemic.

BACKGROUND: An updated examination of the surgeon experience during the Covid-19 pandemic is lacking. This study sought to describe how surgeon stress levels and sources of stress evolved over the pandemic. METHODS: An electronic survey was administered to surgeons at four academic hospitals at 6-months and 12-months following an initial telephone survey. The primary outcome was stress level and secondary outcomes were the individual stressors. Thematic analysis was applied to free text responses. RESULTS: A total of 103 and 53 responses were received at 6-months and 12-months, respectively. The mean overall stress level was 5.35 (SD 1.89) at 6-months and 4.83 (SD 2.19) at 12-months. Mean number of stressors declined from 3.77 (SD 2.39) to 2.06 (SD 1.60, P < 0.001), though the "finances" stressor increased frequency (27.2% to 34.0%). Similar qualitative themes were identified, however codes for financial and capacity challenges were more prominent at 12-months. CONCLUSIONS: The surgical workforce continues to report elevated levels of stress, though the sources of this stress have changed. Targeted interventions are imperative to protect surgeons from long-term psychological and financial harm.

Trainee Sex and Accreditation Council for Graduate Medical Education Milestone Assessments During General Surgery Residency.

Importance: In evaluating the effectiveness of general surgery (GS) training, an unbiased assessment of the progression of residents with attention to individual learner factors is imperative. Objective: To evaluate the role of trainee sex in milestone achievement over the course of GS residency using national data from the Accreditation Council for Graduate Medical Education (ACGME). Design, Setting, and Participants: This cross-sectional study evaluated female and male GS residents enrolled in ACGME-accredited programs in the US from 2014 to 2018 with reported variation in milestones performance across years in training and representation. Data were analyzed from November 2019 to June 2021. Main Outcomes and Measures: Mean reported milestone score at initial and final assessment, and predicted time-to-attainment of equivalent performance by sex. Results: Among 4476 GS residents from 250 programs who had milestone assessments at any point in their clinical training, 1735 were female (38.8%). Initially, female and male residents received similar mean (SD) milestone scores (1.95 [0.50] vs 1.94 [0.50]; P = .69). At the final assessment, female trainees received overall lower mean milestone scores than male trainees (4.25 vs 4.31; P < .001). Significantly lower mean milestone scores were reported for female residents at the final assessment for several subcompetencies in both univariate and multivariate analyses, with only medical knowledge 1 (pathophysiology, diagnosis, and initial management) common to both. Multilevel mixed-effects linear modeling demonstrated that female trainees had significantly lower rates of monthly milestone attainment in the subcompetency of medical knowledge 1, which was associated with a significant difference in training time of approximately 1.8 months. Conclusions and Relevance: Both female and male GS trainees achieved the competency scores necessary to transition to independence after residency as measured by the milestones assessment system. Initially, there were no sex differences in milestone score. By graduation, there were differences in the measured assessment of female and male trainees across several subcompetencies. Careful monitoring for sex bias in the evaluation of trainees and scrutiny of the training process is needed to ensure that surgical residency programs support the educational needs of both female and male trainees.