Multi-institutional Surgical Education Interventions: A Scoping Review.

OBJECTIVE: The aim of the study was to identify and evaluate scholarship in multi-institutional interventional surgical education trials. SUMMARY BACKGROUND DATA: Most research on interventions in surgical education occurs at individual institutions. These studies typically involve a small number of learners in a unique environment, thereby limiting their generalizability. The status of multi-institutional studies in surgical education remains unknown. METHODS: We searched the Pubmed, ERIC, PsycINFO, SCOPUS, and CINAHL databases for all English language articles published from January 1, 2000 to December 31, 2015 using the keywords "medical education," "surgical education," "multi-institutional," "multi-center," and related terms. Articles published in an English language peer-reviewed journal that described an educational intervention conducted at more than one institution and involving surgeons were included. RESULTS: Of 3511 identified articles, 53 met criteria for full-text review and inclusion in this review. The median number of institutional sites was 4, with a range of 2 to 54. The 2 most common areas of focus were technical skills (43% of studies) and clinical knowledge (32% of studies). These were also the 2 most commonly measured outcomes (technical skills 32% of studies, clinical knowledge 21% of studies). Thirteen percentage of studies measured only learner attitudes and perceptions rather than learning outcomes. CONCLUSIONS: Multi-institutional surgical education studies do not uniformly incorporate characteristics of high quality research, particularly related to study design, measurable outcomes, and assessment tools used. Coordinated support, including grant funding, that addresses the challenging nature of multi-institutional surgical education research may improve the quality of these studies.

Social Belonging as a Predictor of Surgical Resident Well-being and Attrition.

OBJECTIVE: In light of the predicted shortage of surgeons, attrition from surgical residency is a significant problem. Prior data have shown that those who are happier are more productive, and those who are less well have higher rates of absenteeism. This study sought to identify the role of social belonging and its relationship to well-being and risk of attrition. DESIGN: Surgical residents were invited to participate in an online survey containing measures of social belonging (a 10-item scale adapted from previous studies), well-being (the Dupuy Psychological General Well-Being Scale, Beck Depression Inventory Short Form, and Maslach Burnout Inventory), and risk of attrition (indicated by frequency of thoughts of leaving the program). SETTING: We surveyed residents at 2 tertiary care centers, Stanford Health Care (2010, 2011, and 2015) and Washington University in St. Louis (2017). PARTICIPANTS: Categorical general surgery residents, designated preliminary residents going into 7 surgical subspecialties, and nondesignated preliminary residents were included. RESULTS: One hundred sixty-nine residents responded to the survey for a response rate of 66%. Belonging was positively correlated with general psychological well-being (r = 0.56, p < 0.0001) and negatively correlated with depression (r = -0.57, p < 0.0001), emotional exhaustion (r = -0.58, p < 0.0001), and depersonalization (r = -0.36, p < 0.0001). Further, belonging was negatively correlated with frequency of thoughts of leaving residency (r = -0.45, p < 0.0001). In regression analysis controlling for demographic variables, belonging was a significant positive predictor of psychological well-being (B = 0.95, t = 8.18, p < 0.0001) and a significant negative predictor of thoughts of leaving (B = -1.04, t = -5.44, p < 0.0001). CONCLUSIONS: Social belonging has a significant positive correlation with well-being and negative correlation with thoughts of leaving surgical training. Lack of social belonging appears to be a significant predictor of risk of attrition in surgical residency. Efforts to enhance social belonging may protect against resident attrition.

The Relationship Between Self-Efficacy and Well-Being Among Surgical Residents.

OBJECTIVE: Residency is a challenging time in the lives of physicians. In this study, we examined the relationship between general self-efficacy, defined as the belief in one's own capabilities in a variety of situations, and burnout and psychological well-being in a sample of surgical residents. DESIGN: In the context of a larger study, a cross-sectional survey was administered to residents. The survey included measures of general self-efficacy, the emotional exhaustion and personal accomplishment domains of burnout, and general psychological well-being. We examined correlations between self-efficacy and these well-being outcomes and used multivariable linear regression models that controlled for age, gender, postgraduate year, ethnicity, and the interaction between gender and self-efficacy. SETTING: We surveyed residents at Stanford Health Care, a tertiary care center, between the fall of 2010 and the spring of 2013. PARTICIPANTS: One hundred and seventy nine residents from 9 surgical subspecialties responded to the survey for a response rate of 76%. RESULTS: Residents reported high levels of self-efficacy, and over a third reported high emotional exhaustion. Eighty-nine percent of residents had average or high personal accomplishment. In adjusted regression analyses, general self-efficacy was negatively predictive of emotional exhaustion (B = -0.43, p = 0.0127) and positively predictive of personal accomplishment (B = 0.33, p = 0.0185) and general psychological well-being (B = 0.34, p = 0.0010). There was no interaction between gender and general self-efficacy in regression analyses (ps ≥ 0.6776). CONCLUSIONS: Among other factors, self-efficacy appears to be significantly predictive of resident well-being. High self-efficacy suggests that residents feel prepared and capable. Interventions to improve residents' general self-efficacy should be explored as a possible mechanism to improve well-being.

Failure to meet aerobic fitness standards among urban elementary students.

The aim of this study was to explore the relationship of aerobic fitness with the elementary school environment and student characteristics among 4th and 5th grade children attending urban public schools in St. Louis, MO, USA. This cross-sectional study was conducted during 2012-2015 and included 2381 children (mean age 10.5 y) who completed the FITNESSGRAM® 20-m Progressive Aerobic Cardiovascular Endurance Run. Healthy Fitness Zone (HFZ) was defined according to FITNESSGRAM® aerobic capacity criteria. Other student-level variables included age, race, National School Lunch Program eligibility, BMI z-score, weight status, and daily pedometer steps. School environment variables included playground features and playground safety, physical education and recess practices, and school census tract data on vacant houses and median household income. Bivariate analyses with sex stratification were used to identify student-level and school-level predictors of failure to achieve the aerobic HFZ; predictors were then included in a multivariable logistic regression model. Failure to meet the aerobic HFZ was observed among 33% of boys and 57% of girls. School environment was not predictive, but higher age and fewer daily steps were: each additional year of age was associated with 41% higher odds of failing to meet the aerobic HFZ among boys and 100% higher odds among girls. Conversely, each additional 1000 daily steps was associated with 15% (boys) and 13% (girls) lower odds of failure. Obesity posed a 60% higher risk of failure to meet HFZ among girls. These results highlight the importance of childhood physical activity opportunities, especially for girls residing in low-resource areas.

Stereotype threat and working memory among surgical residents.

BACKGROUND: Stereotype threat is a situational threat in which a member of a stereotyped group fears conforming to a negative stereotype. In this study, we examined the impact of stereotype threat on surgical performance and working memory among surgical residents. METHODS: Residents at one institution were randomized to either the threat condition or the no-threat condition. We administered the Vandenberg Mental Rotation Test and the reading span task to assess residents' mental rotation and working memory, respectively. RESULTS: 102 residents participated in this study (response rate 61%). In multivariable analysis, we found significant gender differences. Men outperformed women in mental rotation, and women outperformed men in working memory. There was no effect of condition on performance on the mental rotation or working memory test. CONCLUSIONS: No effect of condition on either test suggests that high-achieving women may be less susceptible to stereotype threat. This could be due to self-selection or adapted resilience, or women in this context may be more qualified to reach the same level of achievement as their male colleagues.

Postoperative opioid prescribing practices and the impact of the hydrocodone schedule change.

BACKGROUND: In 2014, hydrocodone was moved from Schedule III to II, thus it could no longer be "called in" to a pharmacy. We analyzed current postoperative opioid prescribing patterns and the impact of the schedule change on the type and amount prescribed. METHODS: Opioid prescriptions for common surgeries at 1 medical center from 2013 to 2016 were analyzed retrospectively. Milligram morphine equivalents prescribed before and after the schedule change were compared by t tests, and interrupted time series models and drug frequencies were compared by χ2 and Fisher exact tests. RESULTS: Data from 7,046 patients (7,361 prescriptions) after 29 different operations were analyzed. Milligram morphine equivalents prescribed for minor open procedures ranged from 211 to 342 milligram morphine equivalents, from 323 to 1297 for major open procedures, from 238 to 359 for basic laparoscopic procedures, and from 221 to 868 for complex laparoscopic procedures. Mean milligram morphine equivalents prescribed were not affected for most procedures, but over the entire population, milligram morphine equivalents prescribed began decreasing after the rule change. The percentage of hydrocodone prescriptions decreased after the rule change (from 33.8% down to 27.0%) and oxycodone and tramadol prescriptions increased. CONCLUSION: Before versus after the rule change, hydrocodone prescriptions decreased and oxycodone and tramadol prescriptions increased. Milligram morphine equivalents prescribed varied considerably across and within classes of procedures, but the schedule change did not affect mean milligram morphine equivalents prescribed for most procedures.

The relationship between perceived gender judgment and well-being among surgical residents.

BACKGROUND: Physician well-being is a significant problem. Here we explore whether one factor, a resident's concern for being judged by one's gender, influences well-being. METHODS: Over two years at one institution, we surveyed surgical residents on validated measures of well-being as well as the extent to which they felt they were judged because of their gender (gender judgment). We used correlations and linear regression to investigate the relationships between gender judgment and well-being. RESULTS: There were 193 unique respondents (87% response rate). Women had significantly more concerns about gender judgment than men (M = 2.39, SD = 0.73 vs. M = 1.46, SD = 0.62, t = -9.47, p < 0.00001). In regression analyses, gender judgment concerns were significantly associated with all three well-being outcomes (Bs -0.34, 0.50, and 0.39, respectively for well-being, emotional exhaustion, and depersonalization, all p < 0.013). CONCLUSIONS: The degree to which residents, both male and female, are concerned about being judged for their gender is significantly associated with worse well-being.

Perioperative complications of conduit urinary diversion with concomitant cystectomy for benign indications: A population-based analysis.

AIMS: Beyond single-institution case series, limited data are available to describe risks of performing a concurrent cystectomy at the time of urinary diversion for benign end-stage lower urinary tract dysfunction. Using a population-representative sample, this study aimed to analyze factors associated with perioperative complications in patients undergoing urinary diversion with or without cystectomy. METHODS: A representative sample of patients undergoing urinary diversion for benign indications was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Perioperative complications of urinary diversion with and without concomitant cystectomy were identified and coded using the International Classification of Diseases, version 9. Multivariate logistic regression models identified hospital and patient-level characteristics associated with complications of concomitant cystectomy with urinary diversion. RESULTS: There were 15,717 records for urinary diversion identified, of which 31.8% demonstrated perioperative complications: urinary diversion with concurrent cystectomy (35.0%) and urinary diversion without concomitant cystectomy (30.6%). Comparing the two groups, a concomitant cystectomy at the time of urinary diversion was significantly associated with a complication (OR = 1.23, 95%CI: 1.03-1.48). Comorbid conditions of obesity, pulmonary circulation disease, drug abuse, weight loss, and electrolyte disorders were positively associated with a complication, while private insurance and southern geographic region were negatively associated. CONCLUSIONS: A concomitant cystectomy with urinary diversion for refractory lower urinary tract dysfunction elevates risk in this population-representative sample, particularly in those with certain comorbid conditions. This analysis provides critical information for preoperative patient counseling.

Reducing health disparities by removing cost, access, and knowledge barriers.

BACKGROUND: While the rate of unintended pregnancy has declined in the United States in recent years, unintended pregnancy among teens in the United States is the highest among industrialized nations, and disproportionately affects minority teens. OBJECTIVE: Our objective of this secondary analysis was to estimate the risk of unintended pregnancy for both Black and White teens age 15-19 years when barriers to access, cost, and knowledge are removed. Our hypothesis was that the Black-White disparities would be reduced when access, education, and cost barriers are removed. STUDY DESIGN: We performed an analysis of the Contraceptive CHOICE Project database. CHOICE is a longitudinal cohort study of 9256 sexually active girls and women ages 14-45 years in the St Louis, MO, region from 2007 through 2013. Two measures of disparities were used to analyze teenage pregnancy rates and pregnancy risk from 2008 through 2013 among teens ages 15-19 years. These rates were then compared to the rates of pregnancy among all sexually active teens in the United States during the years 2008, 2009, 2010, and 2011. We estimated an absolute measure (rate difference) and a relative measure (rate ratio) to examine Black-White disparities in the rates of unintended pregnancy. RESULTS: While national rates of unintended pregnancy are decreasing, racial disparities in these rates persist. The Black-White rate difference dropped from 158.5 per 1000 in 2008 to 120.1 per 1000 in 2011; however, the relative ratio disparity decreased only from 2.6-2.5, suggesting that Black sexually active teens in the United States have 2.5 times the rate of unintended pregnancy as White teenagers. In the CHOICE Project, there was a decreasing trend in racial disparities in unintended pregnancy rates among sexually active teens (age 15-19 years): 2008 through 2009 (rate difference, 18.2; rate ratio, 3.7), 2010 through 2011 (rate difference, 4.3; rate ratio, 1.2), and 2012 through 2013 (rate difference, -1.5; rate ratio, 1.0). CONCLUSION: When barriers to cost, access, and knowledge were removed, such as in the Contraceptive CHOICE Project, Black-White disparities in unintended pregnancy rates among sexually active teens were reduced on both absolute and relative scales. The rate of unintended pregnancy was almost equal between Black and White teens compared to large Black-White disparities on the national level.

Descriptive Analysis of the 2014 Race-Based Healthcare Disparities Measurement Literature.

IMPORTANCE: There are more than 500 articles in the 2014 race-based healthcare disparities literature across a broad array of diseases and outcomes. However, unlike many other forms of research (e.g., clinical trials and systematic reviews), there are no required reporting guidelines when submitting results of disparities studies to journals. OBJECTIVE: This study describes the race-based healthcare disparities measurement literature in terms of study design, journal characteristics, generation of health disparities research, type of disparity measure used, and adherence to disparities measurement guidelines. METHODS: We searched three databases of peer-reviewed literature, PubMed, Ovid Medline, and JSTOR, for English language articles published in 2014 on racial/ethnic healthcare disparities. Studies must have quantitatively measured the difference in health outcomes between two racial/ethnic groups in order to be included. Our final sample included 266 studies from 167 medical and public health journals. FINDINGS: Only 7 % (n = 19) of articles reported both an absolute and relative measure of disparity; the majority of studies (64 %, n = 171) reported only a relative measure of effect. Most studies were published in clinical journals (74 %, n = 198), used secondary data (86 %, n = 229), and calculated black-white disparities (82 %, n = 218). The most common condition studied was cancer (25 %, n = 67), followed by a surgical procedure (18 %, n = 48). On average, articles in the sample only met 61 % of the applicable guidelines on reporting of disparities. CONCLUSIONS AND RELEVANCE: To be able to synthesize findings in the racial disparities literature (meta-analysis), there is a need for the use of consistent methods for quantifying disparities and reporting in the literature. A more consistent battery of measures and consistent reporting across studies may help speed our understanding of the origins and development of solutions to address healthcare disparities. Despite guidelines for best practices in reporting disparities, there is a lack of adherence in the current literature.

Temporal Trends in Conduit Urinary Diversion With Concomitant Cystectomy for Benign Indications: A Population-based Analysis.

OBJECTIVE: To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity for concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single-institution reports, limited data are available to describe how concurrent cystectomy is employed on a national level. MATERIALS AND METHODS: A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Using multivariate logistic regression models, we identified hospital- and patient-level characteristics associated with concomitant cystectomy with urinary diversion. RESULTS: There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (P < .001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs community hospitals), in older patients, in male patients, in the Medicare population (vs private insurance and Medicaid), and in those with certain diagnoses. CONCLUSION: There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, although the indications driving this clinical decision appear inconsistent.

Still Separate, Still Unequal: Social Determinants of Playground Safety and Proximity Disparities in St. Louis.

Physical activity among youth is shaped by the natural and built environment within which they live; however, few studies have focused on assessing playground safety and proximity in detail as part of the built environment for youth physical activity. We analyzed data on 100 publicly accessible playgrounds from Play Across St. Louis, a community-partnered study of the built environment for youth physical activity. Outcomes included overall playground safety, maintenance, and construction scores; distance to nearest playground; and distance to nearest top playground. Independent variables included neighborhood % youth, % black residents, % owner-occupied units, and % vacant units. Playgrounds in the city have varying degrees of safety and proximity. Mean overall playground safety score was 67.0 % (CI = 63.5, 70.4). Neighborhood % youth and % black residents were inversely associated with overall playground safety (p = 0.03 and p < 0.01) and maintenance (p < 0.01 and p < 0.0001). Mean distance to nearest playground was 638.1 and 1488.3 m to nearest top playground. Clusters of low safety scores were found in the northern and central areas while all high safety score clusters were found in the southern part of St. Louis. Public playground safety and proximity vary across St. Louis neighborhoods, especially by neighborhood demographics. Disparities in playground safety and proximity reveal an opportunity to develop community-wide interventions focused on playgrounds for youth activity. Further work is needed to examine the association between playground safety, proximity, and use and youth physical activity and weight.

Relationships Between Health Literacy and Genomics-Related Knowledge, Self-Efficacy, Perceived Importance, and Communication in a Medically Underserved Population.

The increasing importance of genomic information in clinical care heightens the need to examine how individuals understand, value, and communicate about this information. Based on a conceptual framework of genomics-related health literacy, we examined whether health literacy was related to knowledge, self-efficacy, and perceived importance of genetics and family health history (FHH) and communication about FHH in a medically underserved population. The analytic sample was composed of 624 patients at a primary care clinic in a large urban hospital. About half of the participants (47%) had limited health literacy; 55% had no education beyond high school, and 58% were Black. In multivariable models, limited health literacy was associated with lower genetic knowledge (ß = -0.55, SE = 0.10, p < .0001), lower awareness of FHH (odds ratio [OR] = 0.50, 95% confidence interval [CI; 0.28, 0.90], p = .020), and greater perceived importance of genetic information (OR = 1.95, 95% CI [1.27, 3.00], p = .0022) but lower perceived importance of FHH information (OR = 0.47, 95% CI [0.26, 0.86], p = .013) and more frequent communication with a doctor about FHH (OR = 2.02, 95% CI [1.27, 3.23], p = .0032). The findings highlight the importance of considering domains of genomics-related health literacy (e.g., knowledge, oral literacy) in developing educational strategies for genomic information. Health literacy research is essential to avoid increasing disparities in information and health outcomes as genomic information reaches more patients.

Racial and Ethnic Heterogeneity in Self-Reported Diabetes Prevalence Trends Across Hispanic Subgroups, National Health Interview Survey, 1997-2012.

INTRODUCTION: We examined racial/ethnic heterogeneity in self-reported diabetes prevalence over 15 years. METHODS: We used National Health Interview Survey data for 1997 through 2012 on 452,845 adults aged 18 years or older. Annual self-reported diabetes prevalence was estimated by race/ethnicity and education. We tested for trends over time by education and race/ethnicity. We also analyzed racial/ethnic and education trends in average annual prevalence. RESULTS: During the 15 years studied, diabetes prevalence differed significantly by race/ethnicity (P < .001) and by Hispanic subgroup (P < .001). Among participants with less than a high school education, the 5-year trend in diabetes prevalence was highest among Cubans and Cuban Americans (ß(5YR) = 4.8, P = .002), Puerto Ricans (ß(5YR) = 2.2, P = .06), non-Hispanic blacks (ß(5YR) = 2.2, P < .001), and non-Hispanic whites (ß(5YR) = 2.1, P < .001). Among participants with more than a high school education, non-Hispanic blacks had the highest average annual prevalence (5.5%) and Puerto Ricans had the highest 5-year trend in annual diabetes prevalence (ß(5YR) = 2.6, P = .001). CONCLUSIONS: In this representative sample of US adults, results show ethnic variations in diabetes prevalence. The prevalence of diabetes is higher among Hispanics than among non-Hispanic whites, unevenly distributed across Hispanic subgroups, and more pronounced over time and by education. Findings support disaggregation of data for racial/ethnic populations in the United States to monitor trends in diabetes disparities and the use of targeted, culturally appropriate interventions to prevent diabetes.

The pancreatic islet ß-cell-enriched transcription factor Pdx-1 regulates Slc30a8 gene transcription through an intronic enhancer.

The SLC30A8 gene encodes the zinc transporter ZnT-8, which provides zinc for insulin-hexamer formation. Genome-wide association studies have shown that a polymorphic variant in SLC30A8 is associated with altered susceptibility to Type 2 diabetes and we recently reported that glucose-stimulated insulin secretion is decreased in islets isolated from Slc30a8-knockout mice. The present study examines the molecular basis for the islet-specific expression of Slc30a8. VISTA analyses identified two conserved regions in Slc30a8 introns 2 and 3, designated enhancers A and B respectively. Transfection experiments demonstrated that enhancer B confers elevated fusion gene expression in both ßTC-3 cells and αTC-6 cells. In contrast, enhancer A confers elevated fusion gene expression selectively in ßTC-3 and not αTC-6 cells. These data suggest that enhancer A is an islet ß-cell-specific enhancer and that the mechanisms controlling Slc30a8 expression in α- and ß-cells are overlapping, but distinct. Gel retardation and ChIP (chromatin immunoprecipitation) assays revealed that the islet-enriched transcription factor Pdx-1 binds enhancer A in vitro and in situ respectively. Mutation of two Pdx-1-binding sites in enhancer A markedly reduces fusion gene expression suggesting that this factor contributes to Slc30a8 expression in ß-cells, a conclusion consistent with developmental studies showing that restriction of Pdx-1 to pancreatic islet ß-cells correlates with the induction of Slc30a8 gene expression and ZnT-8 protein expression in vivo.