A self-selecting prophecy: prevalence of burnout in surgical fellows.

BACKGROUND: Burnout has become a prominent topic, yet there are limited data on the manifestation of this phenomenon among surgical fellows. The goal of this study is to elucidate the prevalence of burnout and determine if there are protective or predisposing factors in surgical fellowship training. METHODS: A confidential electronic survey was distributed to Fellowship Council accredited fellows during the 2020-2021 academic year. Demographic information and training characteristics were queried. The fellows were then asked to complete the Maslach Burnout Inventory (MBI), Perceived Stress Scale (PSS), Short Grit Scale (SGS), Satisfaction with Life Scale (SLS), and General Self-Efficacy Scale (SE). Data were analyzed using p values of ≤ 0.05 as statistically significant. RESULTS: At the end of the survey period, 92 out of 196 (46.9%) fellowship trainees responded. 69.6% of respondents identified as men, 29.7% as international medical school graduates (IMGs), and 15.3% non-US IMGs. Based on criteria defined by the MBI, there was an 8.4% rate of burnout. Most respondents noted low stress levels (62.3%), good satisfaction with life (58.9%), a moderate amount of grit, and a high level of self-esteem. On comparative analysis, fellows with burnout had significantly higher stress levels, lower levels of satisfaction with life, and less self-esteem. CONCLUSIONS: Overall, there was a low rate of burnout among fellows. We suggest this may be reflective of a self-selecting effect, as trainees who choose to undergo additional training may be less likely to experience this syndrome. In addition, there may be a protective factor during fellowship that results from inherent mentoring, increased specialization, and autonomy. Further investigation of the predisposing factors to burnout in fellowship trainees is warranted based on the results of this study.

Investigating Factors at Play in Hepatopancreatobiliary Fellowship Selection: Beliefs versus Reality.

BACKGROUND: Selection biases affecting candidate matches to fellowship programs directly influence diversity within the surgical community. The review of selection bias has never been distinctively investigated in the Hepatopancreatobiliary (HPB) surgery community. This study seeks to (i) evaluate factors affecting selection of candidates to HPB fellowships, (ii) examine explicit biases among program directors and faculty of HPB programs in North America, and (iii) compare the demography of the HPB faculty and recently graduated fellows to general surgery residents. STUDY DESIGN: An anonymous, self-reported survey consisting of 10 sets of fictional applications was distributed to 52 faculty members, including program directors, of AHPBA-affiliated HPB fellowships in North America. The respondents had to pick a preferred candidate between two abridged, fictional HPB fellow applications and give an open-ended response as to why they picked that candidate. The applications were nearly identical with one notable characteristic of interest. Demographic information of both faculty and their recent fellows was also collected. This survey was administered and collected between February and April, 2020. RESULTS: A total of 29 fully completed responses were received, comprising a 55.7% response rate. Respondents were 72.4% male, 69.0% Caucasian, and 79.3% held US medical degrees (MD). 50.0% of respondents preferred an MD candidate to a DO candidate, and 37% preferred US graduates to foreign-trained candidates. The respondents were unanimous in stating that gender, race, and family status were not a factor in their selection process. 5.0% said they would support an LGBTQ candidate when faced with otherwise similar applicants. Seventy-six HPB fellows from the past 5 years were 76.3% male, 56.6% Caucasian, and 51.3% US graduated Doctor of Medicine (US MD). CONCLUSION: This is the first study explicitly exploring the impact of demographic factors in the HPB fellowship selection process. The respondents unanimously and explicitly stated that race and gender do not play any role in their selection process. Yet, there is stark discordance between general surgery resident demographics and HPB fellow demographics. A greater effort to promote a more diverse HPB surgery community may be needed.

Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi-Procedure Learning Curve Study Utilizing CUSUM Analysis.

BACKGROUND/OBJECTIVE: Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020. RESULTS: Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay. CONCLUSIONS: Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Hiatal Hernia After Esophagectomy: A Single-Center Retrospective Analysis of a Rare Postoperative Phenomenon.

Development of a post-esophagectomy hiatal hernia (PEHH) is a rare, but problematic, sequela with the current reported prevalence ranging up to 20%. To determine the incidence rate of PEHH at our institution, a retrospective review of all transhiatal esophagectomies performed from 2012 to 2020 was conducted. Demographic, operative, and oncologic data were collected, rates of PEHH were calculated, and characteristics of subsequent repair were reviewed and analyzed. A total of 160 transhiatal esophagectomies were included, of which four patients (2.5%) developed a PEHH at a mean of 12 months postoperatively (range: 3-28 months) with symptomatology driving the diagnosis for three patients. The limited size of our study does not allow for statistically significant determinations regarding risk factors or method of repair. The true prevalence of a hiatal defect is likely higher than reported, as clinically asymptomatic patients are not captured in our current literature.

Transduodenal resection for duodenal adenomas may be an underutilized tool - A single institution experience.

Background: Duodenal adenomas are pre-malignant lesions. Transduodenal resection and pancreaticoduodenectomy remain the only two surgical options. The optimal surgical management remains controversial between these two strategies. Methods: A retrospective review was conducted to identify patients who underwent intervention for duodenal adenomas. Patient were stratified by type of procedure, pancreaticoduodenectomy or transduodenal resection, and their demographic data as well as perioperative outcomes were compared. Results: 26 patients underwent surgery for duodenal adenomas. 11 underwent a pancreaticoduodenectomy (PD) (42.3%) and 15 underwent a transduodenal resection (TDR) (57.7%). Median operative time, median estimated blood loss, and mean length of stay were longer in the PD vs TDR group. Two patients (13.3%) in the TDR group developed recurrent adenomas. Conclusion: Transduodenal resection should be considered in patients who are suspected to harbor benign duodenal tumors. Duodenal tumors with high grade dysplasia or invasive cancer should undergo an oncologic procedure. Endoscopic surveillance appears to be indicated after transduodenal resection.

Teacher and Trainee Learning Together-Dual Console and the 3 Arms.

OBJECTIVE: The purpose of this paper is to propose a method by which the trainer and the trainee can overcome their learning curves together. DESIGN/SETTING/PARTICIPANTS: At a tertiary care facility where we have completely done away with the mandatory bedside procedure requirements, residents and fellows start all cases on the console and have graduated responsibilities assigned to them. Bedside assist cases were felt to take away from trainee precious console time when there were only on service for a limited period while providing laparoscopic skill training without any robot-specific experience. This is a cumulative experience of teaching residents and fellows under this system and its results. RESULTS: All trainees at a PG 3 level or greater were able to perform advanced hiatal dissection within 5 cases. CONCLUSIONS: The authors propose a paradigm that uses all 3 arms of the robot and a dual console system.

Advanced Gastrointestinal Surgery Fellowship Graduates Are Desirable to Current US General Surgery Practices: Results of a SSAT Sponsored Survey.

BACKGROUND: Fellowship training after surgery residency has become commonplace. The concept of an advanced gastrointestinal (AGI) surgical fellowship has been implemented through the SSAT and Fellowship Council (FC). Newer and more competitive requirements are being proposed through a taskforce inclusive of many surgical societies. This study was designed to measure the interest in hiring graduates of AGI fellowship. METHOD: This is a SSAT sponsored 20-question survey which was sent out to the Society members in general surgery practices (mix of hospital based and private) across the USA through an online electronic survey software (SurveyMonkey, Palo Alto, Ca.). Descriptive statistics were generated from aggregate survey responses. RESULTS: We had a total of 285 responses. Majority (92%) preferred hiring a surgeon who has completed a post-graduate fellowship. Type of fellowship preferred by the prospective employers varied depending on the focus and the need of the individual practice. Most important characteristic that the employers sought were references, letters of recommendation, and work ethic, followed by technical skills, and completion of fellowship. Most of the responders felt that a complex GI surgery fellowship may be an attractive qualification in prospective job candidates. CONCLUSION: Our survey showed that the majority of surgery practices in the US prefer fellowship-trained candidates as potential hires. Only a small minority (< 20%) of those surveyed felt that completing an AGI fellowship would not give prospective candidates an advantage in obtaining a job. Our results indicate a growing need for a AGI surgery fellowship.

Expectations of Hepato-Pancreato-Biliary Fellows; Do We Meet Them?

OBJECTIVE: There are 16 accredited hepatopancreatobiliary (HPB) fellowships in North America. The purpose of this study is to portray the expectations of the incoming HPB fellows about their training and its implication on their career. DESIGN: A 29-questions survey was sent out to all HPB fellows starting in August 2017. The survey was divided in 3 sections depicting background, in-training and postfellowship expectations. Descriptive statistics were generated for aggregate survey responses. SETTING: This study was performed through an online questionnaire that was sent to the participants via e-mail. The answers were processed in our offices in Methodist Richardson Medical Center, in Richardson, Texas which is a private tertiary medical center part of the Methodist Health System. PARTICIPANTS: Participants were all incoming HPB Fellows (In HPB fellowship programs accredited by the Fellowship Council) starting their fellowship in August 2017. RESULTS: We had a 94% response rate. Forty-six percent of fellows anticipate doing about 150 to 250 HPB cases during the fellowship, and all 15 fellows anticipate having at least 1 publication during fellowship. Despite that >90% of fellows believe that minimally invasive surgery (MIS) approaches will be more frequently utilized in HPB surgery, only 3/15 anticipate being able to apply MIS techniques and only 54% will be robotically trained. Interestingly the majority of fellows believe that the attending should be performing the case the first few months. CONCLUSION: The trainees believe that case volume is the most important factor for choosing a fellowship and for adequate training. Most of the fellows anticipate doing adequate number of cases but only the minority feels they will be adequately trained in MIS-robotic techniques.