The Blue Ribbon Committee II Report and Recommendations on Surgical Education and Training in the United States: 2024.

OBJECTIVE: An expert panel made recommendations to optimize surgical education and training based on the effects of contemporary challenges. BACKGROUND: The inaugural Blue Ribbon Committee (BRC I) proposed sweeping recommendations for surgical education and training in 2004. In light of those findings, a second BRC (BRC II) was convened to make recommendations to optimize surgical training considering the current landscape in medical education. METHODS: BRC II was a panel of 67 experts selected on the basis of experience and leadership in surgical education and training. It was organized into subcommittees which met virtually over the course of a year. They developed recommendations, along with the Steering Committee, based on areas of focus and then presented them to the entire BRC II. The Delphi method was chosen to obtain consensus, defined as ≥80% agreement among the panel. Cronbach α was computed to assess the internal consistency of 3 Delphi rounds. RESULTS: Of the 50 recommendations, 31 obtained consensus in the following aspects of surgical training (# of consensus recommendation/# of proposed): Workforce (1/5); Medical Student Education (3/8); Work Life Integration (4/6); Resident Education (5/7); Goals, Structure, and Financing of Training (5/8); Education Support and Faculty Development (5/6); Research Training (7/9); and Educational Technology and Assessment (1/1). The internal consistency was good in Rounds 1 and 2 and acceptable in Round 3. CONCLUSIONS: BRC II used the Delphi approach to identify and recommend 31 priorities for surgical education in 2024. We advise establishing a multidisciplinary surgical educational group to oversee, monitor, and facilitate implementation of these recommendations.

Operative Team Familiarity and Specialization at an Academic Medical Center.

OBJECTIVE: To propose a framework for quantification of surgical team familiarity. BACKGROUND: Operating room (OR) teamwork quality is associated with familiarity among team members and their individual specialization. We describe novel measures of OR team familiarity and specialty experience. METHODS: Surgeon-scrub (SS) and surgeon-circulator (SC) teaming scores, defined as the pair's proportion of interactions relative to the surgeon's total cases in the preceding 6 months were calculated between 2017 and 2021 at an academic medical center. Nurse service-line (SL) experience scores were defined as the proportion of a nurse's cases performed within the given specialty. SS, SC, and nurse-SL scores were analyzed by specialty, case urgency, robotic approach, and surgeon academic rank. Two-sample Kolmogorov-Smirnov tests were used to determine heterogeneity between distributions. RESULTS: A total of 37,364 operations involving 150 attending surgeons and 222 nurses were analyzed. Median SS and SC scores were 0.08 (interquartile range: 0.03-0.19) and 0.06 (interquartile range: 0.03-0.13), respectively. Higher margin SLs, senior faculty rank, elective, and robotic cases were associated with greater SS, SC, and nurse-SL scores ( P <0.001). CONCLUSIONS: These novel measures of teaming and specialization illustrate the low levels of OR team familiarity and objectively highlight differences that necessitate a deliberate evaluation of current OR scheduling practices.

Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond.

OBJECTIVE: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Defining the "Tipping Point" to Success as a Surgeon-scientist: An Analysis of Applicants and Awardees of the American College of Surgeons Jacobson Promising Investigator Award.

BACKGROUND: Since 2005, the American College of Surgeons has administered the Jacobson Promising Investigator Award (JPIA), which recognizes surgeon-scientists at the "tipping point" of their research careers. OBJECTIVE: We retrospectively reviewed JPIA applicants to identify factors associated with selection for the award and future research success. METHODS: Profiles were reviewed for all applicants between 2008 and 2018, at the time of application and as of 2019. Web of Science and NIH Reporter metrics were also reviewed for each applicant. RESULTS: Eleven of 97 applicants were selected for the JPIA. At the time of application, awardees were more likely to have extramural (NIH K-award) versus intramural (KL2) or other career development award funding (55% vs 33%, P = 0.03) and more publications [median 70 (interquartile range, IQR 55-100) vs 40 (IQR 22-67), P = 0.03]. Post-application, JPIA awardees were more likely to achieve a higher h-Index and m-quotient compared to nonawardees (P < 0.001 for both). All JPIA recipients received new NIH funding post-award, including 82% with R01 funding, compared to 23% of nonselected applicants (P < 0.0001). Over $48 million from NIH was awarded to JPIA recipients since 2008, representing a 147-fold return on investment. CONCLUSIONS: Selection for the JPIA is associated with previous extramural NIH K award and, on average, 70 peer-reviewed publications at the time of application. Receipt of the JPIA is associated with a high rate of subsequent NIH R01 funding and publication metrics. The JPIA is an excellent indicator of "tipping point" success in academic surgery and demonstrates the huge potential impact of philanthropic support on early career surgeon-investigators.

Association of Surgeon Representation on NIH Study Sections With Receipt of Funding by Surgeon-scientists.

OBJECTIVE: Our goal was to evaluate the relationship between surgeon representation on NIH study sections and success in grant funding. SUMMARY OF BACKGROUND DATA: NIH funding for surgeon-scientists is declining. Prior work has called for increased surgeon participation in the grant review process as a strategy to increase receipt of funding by surgeon-scientists. METHODS: A retrospective review of surgeon (primary department: General, Urology, Orthopedic, Ophthalmology, Otolaryngology, Neurosurgery) representation on NIH study sections and receipt of funding was performed using NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) and 2019 Blue Ridge Institute for Medical Research data. NIH chartered study section panels and ad hoc reviewers for each 2019 review date were also obtained. RESULTS: In 2019, 9239 individuals reviewed in at least 1 of the 168 study sections [190 (2.1%) surgeons, 64 (0.7%) standing members, 126 (1.4%) ad-hoc]. Most surgeons on study sections were male (65%) professors (63%). Surgeons most commonly served on bioengineering, technology, and surgical sciences (29.6% surgeons), diseases and pathophysiology of the visual system (28.3%), and surgery, anesthesiology and trauma (21%). In 2019, 773 surgeons received 1235 NIH grants (>$580 M) out of a total of 55,012 awards (2.2%). Funded surgeons were predominantly male (79%), White (68%), non-Hispanic (97%), full professors (50%), and 43% had additional advanced degrees (MPH/PhD/MBA). surgery, anesthesiology and trauma, diseases and pathophysiology of the visual system, and bioengineering, technology, and surgical sciences were the most common study sections that reviewed funded grants to surgeon-scientists. Ninety-two surgeons both received grant funding and served on study section. Study sections with higher surgeon representation were more likely to fund surgeon-scientists (P < 0.001). CONCLUSIONS: Surgeon representation on NIH study sections is strongly associated with receipt of funding by surgeon-scientists. Increasing NIH study section representation by surgeons may help to preserve the surgeon-scientist phenotype.

Moral determinants of health: An overview of disparities in healthcare.

Healthcare disparities are a serious problem that shorten the lives of many Americans, even after accounting for social, cultural, and economic factors and correcting for confounders such as the lack of medical insurance and access to healthcare, black Americans and other minority groups receive worse medical care and experience worse outcomes as a result. Healthcare does not occur in a vacuum; surgeons cannot serve our patients' needs isolated in a bubble and cocooned from larger societal concerns. Although disparities rooted in race likely have the greatest negative effects on our patients' health, plenty of groups exist that have not historically received equal opportunities and acceptance within the surgical world. Despite now accounting for more than one half of all medical graduates, women remain underrepresented in leadership positions, and the gender pay gap has remained significant in all branches of medicine. It will require active, multifaceted, and sustained effort to increase diversity, equity, and inclusion in academic surgery. We have described the steps that can be taken within surgical departments and in national surgical societies to recruit, retain, and foster a diverse surgical workforce and to develop a more inclusive culture within surgery and surgical training.

Pain resolution and glucose control in pediatric patients with chronic pancreatitis after total pancreatectomy with islet auto-transplantation.

BACKGROUND: Chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) in pediatric patients are strongly associated with genetic mutations and lead to pan-parenchymal disease refractory to medical and endoscopic treatment. Our aim was to assess pain resolution and glucose control in patients with CP and ARP following total pancreatectomy with islet auto-transplantation (TPIAT). METHODS: We retrospectively analyzed prospectively collected clinical data of 12 children who developed CP and ARP and underwent TPIAT when 21 years old or younger at the University of Chicago between December 2009 and June 2020. Patients with recurrent or persistent abdominal pain attributed to acute or chronic pancreatic inflammation and a history of medical interventions attempted for the relief of pancreatic pain were selected by a multi-disciplinary team for TPIAT. We followed patients post-operatively and reported data for pre-TPIAT, post-operative day 75, and yearly post-TPIAT. RESULTS: All 12 patients experienced complete resolution of pancreatic pain. The overall insulin-independence rate after 1 year was 66% (8/12) and 50% (3/6) at 4 years. Shorter duration of CP/ARP pre-TPIAT, higher mass of islets infused, and lower BMI, BMI percentile, and BSA were associated with insulin-independence post-TPIAT. CONCLUSIONS: TPIAT is a viable treatment option for pediatric patients with CP and ARP. Pediatric patients undergoing TPIAT for CP achieved resolution of pancreatic-type pain and reduced opioid requirements. The majority were able to achieve insulin-independence which was associated with lower pre-TPIAT BMI and higher islet mass transplanted (i.e., over 2000 IEQ/kg), the latter of which can be achieved by earlier TPIAT. LEVEL OF EVIDENCE: Treatment study, Level IV.

Wetland Compensation and Landscape Change in a Rapidly Urbanizing Context.

While there are regulatory requirements that regulators should assess the impact of landscape-scale changes on the success of US Clean Water Act wetland compensatory mitigation sites, these requirements are poorly specified and very little work has been done to characterize how landscape change impacts CWA compensation sites. We created a rapid assessment method with both site-based and landscape-scale components, and used it to assess a population of wetland compensation sites in suburban St. Paul, Minnesota in 1997. We resampled the sites in 2010. The watersheds of these 22 compensation sites are characterized by rapid urbanization, the increase in impervious surfaces, and the loss of agriculture. This has resulted in extreme hydrographs at compensation sites and a fragmenting landscape context of more and smaller undeveloped patches. The ecosystem services provided by these compensation sites in 2010 are not significantly different than in 1997, indicating resilience in the face of landscape change, but not showing a trajectory of improvement. Reference sites were established for each ecosystem service, but two reference sites declined dramatically; results point to the importance of understanding ongoing landscape change even at benchmark sites. Compensation sites are typically located in rapidly changing and fragmenting landscapes, and understanding the relationship between landscape and compensation site will be important to ensuring appropriate compensation for impacts regulated by the Clean Water Act.

Determining vegetation metric robustness to environmental and methodological variables.

Land managers need reliable metrics for assessing the quality of restorations and natural areas and prioritizing management and conservation efforts. However, it can be difficult to select metrics that are robust to sampling methods and natural environmental differences among sites, while still providing relevant information regarding ecosystem changes or stressors. We collected herbaceous-layer vegetation data in wetlands and grasslands in four regions of the USA (the Midwest, subtropical Florida, arid southwest, and coastal New England) to determine if commonly used vegetation metrics (species richness, mean coefficient of conservatism [mean C], Floristic Quality Index [FQI], abundance-weighted mean C, and percent non-native species cover) were robust to environmental and methodological variables (region, site, observer, season, and year), and to determine adequate sample sizes for each metric. We constructed linear mixed effects models to determine the influence of these environmental and methodological variables on vegetation metrics and used metric accumulation curves to determine the effect of sample size on metric values. Species richness and FQI varied among regions, and year and observer effects were also highly supported in our models. Mean C was the metric most robust to sampling variables and stabilized at less sampling effort compared to other metrics. Assessment of mean C requires sampling a small number of quadrats (e.g. 20), but assessment of species richness or FQI requires more intensive sampling, particularly in species-rich sites. Based on our analysis, we recommend caution be used when comparing metric values among sites sampled in different regions, different years, or by different observers.

Wetland compensation and its impacts on ß-diversity.

The anthropogenic degradation of natural ecological communities can cause biodiversity loss in the form of biotic homogenization (i.e., reduced ß-diversity). Biodiversity offsetting practices, such as compensatory wetland mitigation, may inadvertently cause biotic homogenization if they produce locally homogenous or regionally recurring communities. The fact that compensation wetlands often resemble degraded wetlands suggests that potential impacts to ß-diversity are likely. Yet, it is unknown how high-quality, low-quality (degraded), and compensation wetlands compare in terms of ß-diversity. We compared the ß-diversity of high-quality, low-quality, and compensation wetlands at local and regional scales. ß-diversity was quantified as the average distance to group centroids in multivariate space based on pairwise comparisons of community composition. The local spatial structure of ß-diversity was assessed using species turnover across plots. Indicator species analysis was used to describe compositional differences potentially contributing to differences in ß-diversity. Overall, the ß-diversity of compensation sites did not differ from high-quality or low-quality natural wetlands. However, compensation wetlands had a high degree of internal turnover along the hydrological gradient, which culminated in homogenous zones in the wettest areas. Compared to high-quality wetlands, low-quality wetlands had significantly lower ß-diversity at local scales, but significantly greater ß-diversity at regional scales. Indicator species results showed that compensation wetlands were distinguished by low conservation value species typically found in old fields and waste areas. This analysis also indicated that the invasive grass Phalaris arundinacea was indicative of low-quality and compensation wetlands. This species is likely contributing to differing patterns of ß-diversity between high-quality and low-quality wetlands. These results indicate that conclusions regarding ß-diversity depend on scale and scope of analysis. Particularly, the unique architecture of compensation wetlands makes conclusions regarding within-site ß-diversity dependent on the observer's position along the hydrological gradient. Additionally, while we conclude that compensation wetlands are not contributing to biotic homogenization at the regional scale, these wetlands are distinct from both high-quality and low-quality wetlands in their composition and structure. Therefore, assessments of the overall success of wetland mitigation programs should acknowledge the reality of these differences.

Assessment of simple indices based on a single fasting blood sample as a tool to estimate beta-cell function after total pancreatectomy with islet autotransplantation - a prospective study.

We investigated six indices based on a single fasting blood sample for evaluation of the beta-cell function after total pancreatectomy with islet autotransplantation (TP-IAT). The Secretory Unit of Islet Transplant Objects (SUITO), transplant estimated function (TEF), homeostasis model assessment (HOMA-2B%), C-peptide/glucose ratio (CP/G), C-peptide/glucose creatinine ratio (CP/GCr) and BETA-2 score were compared against a 90-min serum glucose level, weighted mean C-peptide in mixed meal tolerance test (MMTT), beta score and the Igls score adjusted for islet function in the setting of IAT. We analyzed values from 32 MMTTs in 15 patients after TP-IAT with a follow-up of up to 3 years. Four (27%) individuals had discontinued insulin completely prior to day 75, while 6 out of 12 patients (50%) did not require insulin support at 1-year follow-up with HbA1c 6.0% (5.5-6.8). BETA-2 was the most consistent among indices strongly correlating with all reference measures of beta-cell function (r = 0.62-0.68). In addition, it identified insulin independence (cut-off = 16.2) and optimal/good versus marginal islet function in the Igls score well, with AUROC of 0.85 and 0.96, respectively. Based on a single fasting blood sample, BETA-2 score has the most reliable discriminant value for the assessment of graft function in patients undergoing TP-IAT.

Primary systemic therapy in resectable pancreatic ductal adenocarcinoma using mFOLFIRINOX: A pilot study.

BACKGROUND AND OBJECTIVES: Surgery followed by gemcitabine and/or a fluoropyrimidine is standard therapy for resectable PDAC. mFOLFIRINOX (oxaliplatin 85 mg/m2 , irinotecan 180 mg/m2 , leucovorin 400 mg/m2 Day 1, 5-FU 2400 mg/m2 × 48 h IV, peg-filgrastim 6 mg SQ day 3, every 14 days) has substantial activity in metastatic PDAC. We wished to determine the tolerability/efficacy of peri-operative mFOLFIRINOX in resectable PDAC. METHODS: Patients with resectable PDAC (ECOG PS 0/1) received four cycles of mFOLFIRINOX pre- and post-surgery. The primary endpoint was completion of preoperative chemotherapy plus resection. Secondary endpoints included completion of all therapy, R0 resection, treatment related toxicity, PFS, and OS. RESULTS: Twenty-one patients enrolled: median age 62 (47-78); 20/21 (95%) completed four cycles of preoperative mFOLFIRINOX; response by RECIST was 1 CR, 3 PR, 16 SD; 17/21 (81%) completed resection, 16/21 (76%) R0; 14/21 (66%) completed four cycles of postoperative mFOLFIRINOX. Grade 3 and 4 toxicity occurred in 23% and 14% patients pre-operatively, 26% and 6.0% post-operatively. Nine patients are alive with median follow-up of 27.7 (3.1-47.1) months. CONCLUSIONS: PST using mFOLFIRINOX in resectable PDAC is feasible and tolerable. R0 resection rate is high and survival promising, requiring longer follow-up and larger studies for definitive assessment.

Outcomes of Concurrent Operations: Results From the American College of Surgeons' National Surgical Quality Improvement Program.

OBJECTIVE: To determine whether concurrently performed operations are associated with an increased risk for adverse events. BACKGROUND: Concurrent operations occur when a surgeon is simultaneously responsible for critical portions of 2 or more operations. How this practice affects patient outcomes is unknown. METHODS: Using American College of Surgeons' National Surgical Quality Improvement Program data from 2014 to 2015, operations were considered concurrent if they overlapped by ≥60 minutes or in their entirety. Propensity-score-matched cohorts were constructed to compare death or serious morbidity (DSM), unplanned reoperation, and unplanned readmission in concurrent versus non-concurrent operations. Multilevel hierarchical regression was used to account for the clustered nature of the data while controlling for procedure and case mix. RESULTS: There were 1430 (32.3%) surgeons from 390 (77.7%) hospitals who performed 12,010 (2.3%) concurrent operations. Plastic surgery (n = 393 [13.7%]), otolaryngology (n = 470 [11.2%]), and neurosurgery (n = 2067 [8.4%]) were specialties with the highest proportion of concurrent operations. Spine procedures were the most frequent concurrent procedures overall (n = 2059/12,010 [17.1%]). Unadjusted rates of DSM (9.0% vs 7.1%; P < 0.001), reoperation (3.6% vs 2.7%; P < 0.001), and readmission (6.9% vs 5.1%; P < 0.001) were greater in the concurrent operation cohort versus the non-concurrent. After propensity score matching and risk-adjustment, there was no significant association of concurrence with DSM (odds ratio [OR] 1.08; 95% confidence interval [CI] 0.96-1.21), reoperation (OR 1.16; 95% CI 0.96-1.40), or readmission (OR 1.14; 95% CI 0.99-1.29). CONCLUSIONS: In these analyses, concurrent operations were not detected to increase the risk for adverse outcomes. These results do not lessen the need for further studies, continuous self-regulation and proactive disclosure to patients.

An Assessment of Long-Term Compliance with Performance Standards in Compensatory Mitigation Wetlands.

Under the US Clean Water Act, wetland restoration is used to compensate for adverse impacts to wetlands. Following construction, compensation wetlands are monitored for approximately 5 years to determine if they comply with project-specific performance standards. Once a compensation site complies with performance standards, it is assumed that the site will continue to meet standards indefinitely. However, there have been few assessments of long-term compliance. We surveyed, in 2012, 30 compensation sites 8-20 years after restoration to determine whether projects continued to meet performance standards. Additionally, we compared floristic quality of compensation sites to the quality of adjacent natural wetlands to determine whether wetland condition in compensation sites could be predicted based on the condition of nearby wetlands. Compensation sites met, on average, 65% of standards during the final year of monitoring and 53% of standards in 2012, a significant decrease in compliance. Although forested wetlands often failed to meet standards for planted tree survival, the temporal decrease in compliance was driven by increasing dominance by invasive plants in emergent wetlands. The presumption of continued compliance with performance standards after a 5-year monitoring period was not supported. Wetlands restored near better quality natural wetlands achieved and maintained greater floristic quality, suggesting that landscape context was an important determinant of long-term restoration outcomes. Based on our findings, we recommend that compensation wetlands should be monitored for longer time periods, and we suggest that nearby or adjacent natural wetlands provide good examples of reasonably achievable restoration outcomes in a particular landscape.

National-Level Wetland Policy Specificity and Goals Vary According to Political and Economic Indicators.

Growing recognition of the importance of wetlands to human and ecosystem well-being has led countries worldwide to implement wetland protection policies. Different countries have taken different approaches to wetland protection by implementing various policies, including territorial exclusion, market-based offsetting, and incentive programs for land users. Our objective was to describe the relationship between components of national-level wetland protection policies and national characteristics, including natural resource, economic, social, and political factors. We compiled data on the wetland policies of all 193 countries recognized by the U.N. and described the relationships among wetland policy goals and wetland protection mechanisms using non-metric multidimensional scaling. The first non-metric multidimensional scaling axis strongly correlated with whether a country had a wetland-specific environmental policy in place. Adoption of a comprehensive, wetland-specific policy was positively associated with degree of democracy and a commitment to establishing protected areas. The second non-metric multidimensional scaling axis defined a continuum of policy goals and mechanisms by which wetlands are protected, with goals to protect wetland ecosystem services on one end of the spectrum and goals to protect biodiversity on the other. Goals for protecting ecosystem services were frequently cited in policy documents of countries with agriculture-based economies, whereas goals associated with wetland biodiversity tended to be associated with tourism-based economies. We argue that the components of a country's wetland policies reflect national-level resource and economic characteristics. Understanding the relationship between the type of wetland policy countries adopt and national-level characteristics is critical for international efforts to protect wetlands.

Variation and Acquisition of Complex Techniques: Pancreaticoduodenectomy.

Background Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between techniques. We used pancreaticoduodenectomy as a model to catalogue variability between surgeons and investigate factors that affect fellows' acquisition of techniques. Materials and methods Semistructured interviews and operative note analysis were conducted to determine techniques of 5 attending surgeons, and these data were mapped to identify variations. Identical interviews and questioning were completed with 4 fellowship graduates whose practice includes pancreaticoduodenectomy. Results All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were 21 surgical step data points that differed. Of 5 surgeons, 4 were unable to identify colleagues' techniques. Fellows reported adopting techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Residency training did not strongly influence their choice of technique; however, senior partners after fellowship did influence technique. Conclusions The number of variants of pancreaticoduodenectomy based on granular, step-by-step differences is larger than previously described. Results hint that variation may be furthered by the fact that surgeons are not aware of the techniques used by colleagues. Fellows choose techniques based on factors not directly related to their own outcomes but rather mentor factors. Whether fellows adopt techniques that will be optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.