Benchmarking Accomplishments of Leaders in American Surgery and Justification for Enhancing Diversity and Inclusion.

OBJECTIVE: To comprehensively assess the level of achievement and demographics of national surgical society presidents. BACKGROUND: Data on the accomplishments needed to rise to positions of national surgical leadership is scarce and merit alone does not always yield such opportunities. Recognizing the shortcomings of sex and ethnic diversity within academic surgical leadership, the American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and the Society of Black Academic Surgeons (SBAS) partnered to address these challenges by performing a comprehensive assessment of their presidents over the last 16 years. METHODS: ACS, ASA, AWS, and SBAS presidents' CVs, at the time of their presidential term, were assessed for demographics and scholastic achievements. Regression analyses controlling for age were performed to determine relative differences across societies. RESULTS: A total of 62 of the 64 presidents' CVs were received and assessed (97% response rate). There was a large discrepancy in the average age in years of ACS (70) and ASA (66) presidents compared to the AWS (51) and SBAS (53) presidents. For the ACS and ASA cohort, 87% were male and 83% were White, collectively. After controlling for age (52), the AWS and SBAS presidents' scholastic achievements were comparable to the ACS (and ASA) cohort in 9 and 12 of the 15 accessed metrics, respectively. CONCLUSION: The ACS and ASA presidents' CVs displayed unsurpassed scholastic achievement, and although not equivalent, both the AWS and the SBAS presidents had comparable attainment. These findings further substantiate that women and ethnic minority surgeons are deserving of additional national leadership consideration as organized medicine pursues a more diverse and reflective physician workforce.

Surgeon Experience with Parental Leave Policies Varies Based on Practice Setting.

BACKGROUND: The increase in female surgeons has resulted in scrutiny of widely variable parental leave policies. We hypothesized that academic and private practice surgeons have different experiences based on difference in workplace expectations. METHODS: A 25-question survey was disseminated via social media and through the Association of Women Surgeons social media platforms from June 1 to September 15, 2017. An analysis of attending surgeons working in the USA in an academic or private practice setting was performed. RESULTS: Of 1115 total respondents, 477 were attending surgeons practicing in the USA. Practice distribution was 34% private and 47% academic. There was no difference in marital status, work status, or the number who report having been pregnant between the groups. Compared to academic surgeons, private practice surgeons were statistically less likely to have paid leave (p < 0.001) and were more likely to continue to pay benefits while on leave (p < 0.001). Private practitioners were more likely to return to work sooner than desired due to financial (p = 0.022) and supervisor (p = 0.004) pressures and were more likely to leave a job (p = 0.01). Academic surgeons were more likely to experience a delay in job advancement (p = 0.031). On multivariate analysis, more than two pregnancies were associated with an increased risk of perception of a bias and discrimination against pregnancy in the workplace. CONCLUSIONS: Parental leave policies and attitudes vary between academic and private practice, creating unique challenges for female surgeons and different issues for family planning depending on employment model.

Ensuring Equity, Diversity, and Inclusion in Academic Surgery: An American Surgical Association White Paper.

OBJECTIVE: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery. SUMMARY OF BACKGROUND DATA: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion. METHODS: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper. RESULTS: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. CONCLUSION: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition-doing good for our patients.

Factors that Can Promote or Impede the Advancement of Women as Leaders in Surgery: Results from an International Survey.

BACKGROUND: Compared with male surgeons, women have less success advancing their careers and are underrepresented in leadership positions in surgery. The purpose of this study is to identify the qualifications necessary to become leaders in surgery and the career barriers faced by women surgeons in various cultural environments. METHODS: A survey was performed with women surgeons in Japan, USA, Finland, and Hong Kong, China, to assess various barriers faced by women surgeons in the respective countries. To develop appropriate survey tool, a preliminary questionnaire was distributed to leaders in surgery and also in various organizations worldwide. RESULTS: The response rate was 23 % with 225 of 964 survey returned. Japanese women surgeons identify lacked family support as impeding a successful surgical career. US women surgeons feel more latent gender discrimination. Finnish women surgeons are less likely to need to sacrifice work-life balance, when holding leadership positions. Women surgeons worldwide are highly motivated to develop their career and agree the percentage of women surgeons in leadership positions should be increased. CONCLUSIONS: Women surgeons in different countries perceive different challenges. We must develop strategies and should not hesitate to negotiate to overcome these issues to reach leadership positions in surgery. This may be accomplished through networking worldwide to improve current conditions and obstacles.

Assessment of surgical training.

BACKGROUND: The patient safety imperative has raised expectations regarding the responsibility of medical educators and decision makers to ensure that physicians are competent. Ensuring that trainees are ready for independent practice upon graduation is challenged by reduced work hours such that trainees spend less time in the OR and perform fewer cases than desirable. METHODS: The literature on the assessment of technical and non--technical operative skills and professionalism was reviewed in order to make recommendations to identify barriers to evaluation. DISCUSSION: Barriers to documenting performance deficiencies include uncertainty as to what should be documented, and concerns about the negative impact of critical evaluations on faculty popularity. Additional challenges include a lack of clear standards for performance and effective remediation options. CONCLUSIONS: Trainee performance should be evaluated in a rigorous, reliable and meaningful way to ensure that graduates have the skills necessary for safe, independent practice.

The attitude and perceptions of work-life balance: a comparison among women surgeons in Japan, USA, and Hong Kong China.

BACKGROUND: The objective of the present study was to explore how women surgeons manage their work-life balance in three environmental and cultural settings. METHOD: Members of the Japan Association of Women Surgeons (JAWS), the United States of America (US) based Association of Women Surgeons (AWS), and the Women's Chapter of the College of Surgeons of Hong Kong (WCHK) were surveyed. RESULTS: Among 822 women surgeons contacted, 252 responded (response rate 31.8 %; 55.5 % JAWS, 28.2 % AWS, and 25.3 % WCHK). Japanese women surgeons think that work is the number one priority, whereas US and Hong Kong China (HK) respondents think the number one priority is home life. Work satisfaction level was generally high among women surgeons in all countries; however, 19 % of US surgeons are somewhat dissatisfied with their work and 76.1 % think that men are treated more favorably than women at work. Whereas 51.6 % of Japanese women surgeons think that men are treated more favorably than women at home, at the same time they placed more importance on the role of women in the family. More than half of Japanese women surgeons are "uncertain" about their career path in the future, whereas 55.2/87.1 % of US/HK respondents are optimistic. All surgeons recommended expanding support for child rearing or nursing care during work hours, promoting a flexible work schedule and changing some of the older conventional ideas about gender role. CONCLUSIONS: It is essential to address women surgeons' concerns to enable them to have a clearer vision and a challenging career, and to be more certain about their personal and professional goals.

A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study.

OBJECTIVE: This study evaluated operative performance rating (OPR) characteristics and measurement conditions necessary for reliable and valid operative performance (OP) assessment. BACKGROUND: Operative performance is a signature surgical-practice characteristic that is not measured systematically and specifically during residency training. METHODS: Expert surgeon raters from multiple institutions, blinded to resident characteristics, independently evaluated 8 open and laparoscopic OP recordings immediately after observation. RESULTS: A plurality of raters agreed on operative performance ratings (OPRs) for all performances. Using 10 judges adjusted for rater idiosyncrasies. Interrater agreement was similar for procedure-specific and general items. Higher post graduate year (PGY) residents received higher OPRs. Supervising-surgeon ratings averaged 0.51 points (1.2 standard deviations) above expert ratings for the same performances. CONCLUSIONS: OPRs have measurement properties (reliability, validity) similar to those of other well-developed performance assessments (Mini-CEX [clinical evaluation exercise], standardized patient examinations) when ratings occur immediately after observation. OPRs by blinded expert judges reflect the level of resident training and are practically significant differences as the average rating for PGY 4 residents corresponded to a "Good" performance whereas those for PGY 5 residents corresponded to a "Very Good" performance. Supervising surgeon ratings are higher than expert judge ratings reflecting the effect of interpersonal factors on supervising surgeon ratings. Use of local and national norms for interpretation of OPRs would adjust for these interpersonal factors. The OPR system provides a practical means for measuring operative performance, which is a signature characteristic of surgical practice.

Teaching assistant cases in general surgery training - A literature review.

BACKGROUND: There is a lack of understanding of the scope and purpose of teaching assistant cases, impact on patients and safety, as well as the facilitators or barriers to resident participation in these cases. METHODS: Four databases (PubMed, Embase, Web of Science, and the Education Resources Information Center), were searched. The references of identified resources were additionally hand-searched. 10 articles were identified and considered in the literature review. RESULTS: The TA case literature focuses on case numbers and safety. The discussions of papers allude to perceived benefits of TA cases. The literature review reveals that residents are more likely to be granted TA opportunities if they show themselves worthy of entrustment. CONCLUSIONS: The work elucidates aspects of TA cases that have not previously been emphasized or highlighted. The literature review can serve to inform attending surgeons and trainees how to optimize the opportunities teaching assistant cases can afford.

Women Empowering Women: Assessing the American College of Surgeons Women in Surgery Committee Mentorship Program.

BACKGROUND: Mentorship is an important factor for career promotion and professional development. The Women in Surgery Committee developed a mentorship program that matched early career female surgeons to senior female surgeons for 1 year. We hypothesized participation in the program would empower junior surgeons by providing opportunities to network and hone skills necessary to attain their career goals. METHODS: Survey was sent 4 to 6 weeks after program completion. Statements about mentorship and value of the Women in Surgery Committee program were ranked on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Participants were compared based on frequency of encounters using Student's t-test. RESULTS: A total of 105 pairs were identified; response rate was 60%. Results reported as (mean ± SD). Participants believed mentorship was essential for young surgeons (4.5 ± 1.0), and limiting the program to female surgeons added value (4.4 ± 0.6). When compared with mentees who met less than 4 times in a year, those who met 4 or more times perceived the program as beneficial (4.4 ± 0.82, p < 0.001). Mentees who met 4 or more times in a year benefitted from creating and achieving goals (4.3 ± 0.75, p < 0.001), setting expectations (4.5 ± 0.6, p < 0.001), providing networking opportunities (4.1 ± 1.1, p < 0.05), and developing professional skills (3.9 ± 0.98). CONCLUSION: The Women in Surgery Committee Mentorship Program provides an opportunity for young female surgeons; however, perceived benefit is dependent on mentee engagement.

Evaluation of the University of Virginia Leadership in Academic Medicine Program.

BACKGROUND: Developing effective transformational leaders is essential for a diverse and complex academic medical system. The purpose of this study is to elicit faculty perspectives on their leadership skills before and after participation in a Leadership in Academic Medicine (LAM) Program. SUMMARY: The two-part study consisted of a prospective Pre- and Immediate Post-LAM Survey distributed to 32 participants in the 2008 Program and a Long-Term Post-LAM Survey distributed to 110 prior participants (2004-2007). Both surveys were designed to assess participant leadership perspectives and career outcomes. Institutional Review Board approval was obtained. Data were analyzed quantitatively and qualitatively. All participants reported improved leadership skills, but the percentages were lower for Long-Term Post-LAM participants than for the Immediate Post-LAM participants. In addition, although 58% of Immediate Post-LAM women, compared with 19% of Immediate Post-LAM men (p < .05), were actively seeking leadership roles, this was reversed in the long-term group (26% of women vs. 66% of men; p < .05). CONCLUSIONS: Although the benefits of LAM participation are sustained for some years, there is a need for reinforcement to prevent skill attrition. That lower percentages of Long-Term Post-LAM women had leadership aspirations requires further study.

Team training for surgical trainees.

Healthcare professionals work in teams but are rarely trained together. Realizing the adverse impact of poor teamwork on patient care, the Accreditation Council for Graduate Medical Education requires surgical trainees to demonstrate a mastery of teamwork-related competencies. A number of team training curricula are available in the USA, the best known of which is TeamSTEPPS - developed by the U.S. Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

The Flipped Operating Room: Establishing Best Practices in Surgical Education Using Resident-Initiated, Inquiry-Based Preoperative Briefing: Resident-Initiated Preoperative Briefing.

OBJECTIVE: We performed a pilot study of a resident-initiated, inquiry-based preoperative briefing (R-PROB) to determine the feasibility and potential impact on the educational experience. DESIGN: A prospective, qualitative pilot study was performed in a general surgery residency program. The R-PROB included pre-operative emails to faculty with case summaries, learning goals, and questions. Faculty responded by email, phone, or in-person. Semi-structured interviews were completed before and after R-PROB implementation. Interviews were transcribed, coded, and analyzed through collaboration with a mixed-methods laboratory. SETTING: An urban, university-based general surgery residency PARTICIPANTS: Ten attendings from three university affiliated hospitals based on frequency of resident interaction, variation in experience and case types were selected. Thirteen residents that worked closely with the selected attendings, ranging from Clinical Year 1-5, were then recruited to participate. RESULTS: The R-PROB was viewed overall positively and felt to be easily incorporated into the curriculum. The R-PROB significantly improved attending perception of resident preparedness. Junior residents (CY1-3) affirmed that R-PROB very strongly improved case preparation. The preoperative exchange was valued by both participants as improving communication frequency, transparency, and quality. The majority of attendings stated that the R-PROB enabled tailored teaching to each resident's level both preoperatively and in the operating room. Residents affirmed attending teaching to be more targeted towards their goals and objectives after the R-PROB. Challenges included late case assignments and minor time limitations. CONCLUSIONS: A resident-initiated, inquiry-based preoperative briefing intervention is feasible and overall positively perceived by both participants. The briefings had a positive impact on resident preparedness, bi-directional communication, and permitted focused attending teaching.

Policies and practice regarding pregnancy and maternity leave: An international survey.

BACKGROUND: As women become a larger part of the surgical workforce, policies surrounding maternity and parental leave play a role in professional practice. Little is known about leave policies worldwide. METHODS: A de novo survey distributed internationally to women surgeons assessed leave polices for surgeons, inclusive of the regulatory body or source of applicable policies, changes in surgical practice due to pregnancy, and duration of leave for both parents. RESULTS: The 1111 survey respondents in 53 different countries describe diverse policies ranging from loss of operating room privileges early in pregnancy to maintenance of full surgical schedules until term delivery. Policy creators include national governments (42.38%), employers/hospitals (60.46%), supervisors (18.06%). Self-determined (9.12%), and unknown (8.7%). Paid parental leave was available to 64.44% of women surgeons and 38.68% of partners. CONCLUSION: Maternity and parental leave policies vary markedly across the global surgical workforce with implications for professional practice.

Verification of Proficiency in Basic Skills for PGY-1 Surgical Residents: 10-Year Update.

OBJECTIVE: The American College of Surgeons and the Association of Program Directors in Surgery developed a curriculum in 2001 that involved instructional modules for 11 basic surgical skills and a standardized Verification of Proficiency (VOP) evaluation instrument. Our institution continues to employ a modified version of this curriculum and the purpose of this study was to provide a 10-year update on our VOP evaluation instrument used to assess postgraduate year 1 (PGY-1) residents on surgical skills. DESIGN: All PGY-1 surgical residents over the past 10 years at our institution have completed the American College of Surgeons/the Association of Program Directors in Surgery-adapted basic surgical skills curriculum and VOP assessment. Retrospective analysis of VOP data for all residents was subjected to statistical analysis for internal validity and level of correlation. SETTING: Department of Surgery at Southern Illinois University School of Medicine located in Springfield, Illinois. PARTICIPANTS: All PGY-1 surgical residents (per year: 4 general surgery, 3 orthopedic surgery, 2 plastic surgery, 2 urology, 2 ENT, 1 vascular surgery, and 1 neurosurgery) over the past 10 years. RESULTS: One hundred and thirty five residents underwent VOP evaluation over 10 years; 92 (68%) failed at least 1 module and 40 (30%) failed at least 2 modules. Residents who failed to demonstrate proficiency were mandated to complete remediation and retested until their scores were considered proficient. Performance on checklist items showed moderate internal consistency (⍺ ≥ 0.50) on 9 of 11 modules. Poor internal consistency (⍺ < 0.30) was noted for overall proficiency across all modules. Combined performance on checklist items and economy of time and motion demonstrated significant positive correlation (p < 0.05) with overall proficiency in every module. CONCLUSIONS: The VOP instrument offers an internally valid means of assessing distinct basic skills of PGY-1 residents at basic surgical skills. The instrument provides critical formative and summative feedback on surgical skill performance to trainees.

Needs Assessment for an American College of Surgeons Certificate in Applied Surgical Education Leadership (CASEL).

OBJECTIVE: Surgeon educators in departments of surgery play key roles in leading and advancing surgical education. Their activities include ensuring sound curricula and evaluation systems, monitoring education resources, overseeing faculty development, and providing mentorship. For more than 25 years, the American College of Surgeons (ACS) has offered a comprehensive "Surgeons as Educators" (SAE) course to address fundamental topics in surgical education. This study aims to identify future career needs of SAE graduates to inform the development of an American College of Surgeons Certificate in Applied Surgical Education Leadership program. DESIGN: An IRB exempt, anonymous electronic survey was developed to determine educational roles, career aspirations, and needs of SAE Graduates. SETTING AND PARTICIPANTS: Participants included all 763 1993-2016 SAE graduates. RESULTS: One hundred and thirty-five responses were received from 600 (22.5%) graduates with valid email addresses. Sixty (45%) respondents completed the SAE Course > 5 years prior to the study (M5YRS) and 75 (55%) within the last 5 years (L5YRS). L5YRS respondents were less likely to be full professors (8% vs. 44%) or to serve as program directors (32% vs. 57%), and more likely to be associate program directors (25% vs. 17%) or clerkship directors (40% vs. 18%). High percentages of both L5YRS and M5YRS reported not pursuing additional educational opportunities post-SAE due to time and fiscal constraints. One-fifth of respondents were unaware of additional opportunities and 19% of M5YRS versus 6% of L5YRS stated that existing programs did not meet their needs. Overall improving skills as educational leaders, developing faculty development programs, and conducting educational research were noted as priorities for future development. Differences were observed between the L5YRS and M5YRS groups. The dominant preferences for course format were full-time face-to-face (41%) or a combination of full-time face-to-face with online modules (24%). The most important considerations in deciding to pursue a certificate course were course content, and interest in advancing career and time constraints. CONCLUSIONS: An SAE graduate survey has confirmed the need for additional formal training in surgical education leadership in order to permit surgeon educators meet the demands of the changing landscape of surgical education. The needs of early career faculty may differ from those of more senior surgeon educators.

Part-time training in general surgery: results of a web-based survey.

HYPOTHESIS: The recent increase in female medical school enrollment and emphasis on lifestyle considerations for both men and women pose challenges for residency recruitment and retention. This study was designed to assess interest in part-time surgical training. We hypothesized that more women than men would be interested in this option. DESIGN: A Web-based survey soliciting demographic information and opinions about training priorities was distributed to medical students, surgery residents, fellows, and trained surgeons. Respondents were asked to express on a 5-point Likert scale interest in (and deterrents to) substituting 1 or more years of standard residency with a shorter workweek (< 80 hours but > 40 hours) in exchange for a proportionately overall longer length of training. SETTING: The survey was located on the American College of Surgeons Web site. PARTICIPANTS: Medical students (482), surgical residents (789), fellows (179), and fully trained surgeons (2858) affiliated with at least 1 of 4 major surgical societies. RESULTS: There were 4308 respondents (76% male). Of physician respondents, 9.1% had taken time out of residency for nonresearch reasons. Thirty-six percent of female and 24% of male students agreed to increased interest in surgical careers if part-time training were an option (P = .005). Twenty-five percent of female and 13% of male residents (P<.001) expressed interest in this option. Prolonged training was cited as the primary deterrent. CONCLUSIONS: Eleven percent to 36% of total male and female respondents expressed interest in pursuing part-time training. Significantly more women than men favored a part-time option.

Influences on medical student career choice: gender or generation?

HYPOTHESIS: We hypothesized that increased enrollment of female medical students and different priorities of the current generation of students would be important influences on the declining interest in surgical careers. DESIGN: Students scored statements on surgical careers on 5-point Likert scales regarding agreement and whether these statements encouraged them to pursue a career in surgery. Data were analyzed using the Mann-Whitney U test. Qualitative comments were iteratively coded using a constant comparative method. SETTING: Nine US medical schools. PARTICIPANTS: A Web-based survey on the Association for Surgical Education server was e-mailed to medical students. A total of 1300 of the 1365 respondents stated their sex. MAIN OUTCOME MEASURES: The survey asked questions pertaining to surgical life, surgical residency, surgeons as influence, equity, family, and other influences. RESULTS: A total of 680 (52%) of the 1300 respondents were male. Men and women disagreed about whether surgeons lead well-balanced lives (68% and 77%, respectively) and saw this as a deterrent. A total of 35% of women (3% men; P<.001) were discouraged by a lack of female role models. Compared with students unlikely to study surgery, lower percentages of male (74% vs 65%) and female students (85% vs 58%) likely to study surgery agreed that career choice was influenced by their decision to have a family (P=.01 for men, P<.001 for women). Of medical students who agreed that their skill sets were compatible with surgical careers, similar percentages were likely (30% men vs 24% women) and unlikely (49% men vs 54% women) to study surgery. All differences between men and women were less apparent when students likely to study surgery were compared with students unlikely to study surgery. CONCLUSIONS: The decision to have a family was a more significant influence for women than men, but family and lifestyle priorities were also important to male students, supporting our hypothesis that generation and gender are both important influences on career choices.