Disrupting the Fellowship Match: COVID-19 and the Applicant Arms Race.

Resident and fellow selection carried out via "the Match" has historically relied upon in-person interviews to evaluate and rank candidates. However, the COVID-19 pandemic has required fellowship matches and the upcoming Main Residency Match® to become wholly virtual. The 2020 pediatric surgery match offers a unique case study in the benefits and shortcomings of a virtual process and begins a much-needed conversation regarding opportunities for innovation in candidate selection. For many candidates, the application cycle imposes considerable costs - financial, professional, and personal - which have only escalated over time. We draw on our experience from the most recent match cycle to discuss limitations of the traditional Match® and suggest potential solutions to improve the subspecialty interview process moving forward.

The digital surgeon: How big data, automation, and artificial intelligence will change surgical practice.

Exponential growth in computing power, data storage, and sensing technology has led to a world in which we can both capture and analyze incredible amounts of data. The evolution of machine learning has further advanced the ability of computers to develop insights from massive data sets that are beyond the capacity of human analysis. The convergence of computational power, data storage, connectivity, and Artificial Intelligence (AI) has led to health technologies that, to date, have focused on diagnostic areas such as radiology and pathology. The question remains how the digital revolution will translate in the realm of surgery. There are three main areas where the authors believe that AI could impact surgery in the near future: enhancement of training modalities, cognitive enhancement of the surgeon, and procedural automation. While the promise of Big Data, AI, and Automation is high, there have been unanticipated missteps in the use of such technologies that are worth considering as we evaluate how such technologies could/should be adopted in surgical practice. Surgeons must be prepared to adopt smarter training modalities, supervise the learning of machines that can enhance cognitive function, and ultimately oversee autonomous surgery without allowing for a decay in the surgeon's operating skills.

Stanford's Biodesign Innovation program: Teaching opportunities for value-driven innovation in surgery.

The Stanford Biodesign Innovation process, which identifies meaningful clinical needs, develops solutions to meet those needs, and plans for subsequent implementation in clinical practice, is an effective training approach for new generations of healthcare innovators. Continued success of this process hinges on its evolution in response to changes in healthcare delivery and an ever-increasing demand for economically viable solutions. In this article, we provide perspective on opportunities for value-driven innovation in surgery and relate these to value-related teaching elements currently integrated in the Stanford Biodesign process.

Three-dimensionally printed surface features to anchor endoluminal spring for distraction enterogenesis.

Spring-mediated distraction enterogenesis has been studied as a novel treatment for short bowel syndrome (SBS). Previous approaches are limited by multiple surgeries to restore intestinal continuity. Purely endoluminal devices require a period of intestinal attachment for enterogenesis. The purpose of this study is to modify the device to prevent premature spring migration in a porcine model. Two models were created in juvenile mini-Yucatan pigs for the placement of three-dimensionally printed springs. (1) Two Roux-en-y jejunojenostomies with two Roux limbs were made. A spring with bidirectional hooked surface features was placed in one Roux limb and a spring with smooth surface was placed in the other Roux limb. (2) The in-continuity model had both hooked and smooth surface springs placed directly in intestinal continuity. Spring location was evaluated by weekly radiographs, and the intestine was retrieved after 2 to 4 weeks. Springs with smooth surfaces migrated between 1 to 3 weeks after placement in both porcine models. Springs with bidirectional hooked surface features were anchored to the intestine for up to 4 weeks without migration. Histologically, the jejunal architecture showed significantly increased crypt depth and muscularis thickness compared to normal jejunum. Bidirectional features printed on springs prevented the premature migration of endoluminal springs. These novel spring anchors allowed for their endoluminal placement without any sutures. This approach may lead to the endoscopic placement of the device for patients with SBS.

Innovation within a university setting.

Elisabeth K. Wynne, MD, completed her undergraduate degree in bioengineering and is currently a surgical resident in training at the University of Washington. From 2014-2016, she served as a Biodesign Fellow at Stanford University. She plans to pursue a career of innovation as an academic surgeon. Thomas M. Krummel, MD, is the Emile Holman Professor and Chair Emeritus of the Department of Surgery at Stanford University School of Medicine. Throughout his career, Dr Krummel has been a pioneer and an innovator. For >12 years, he has partnered with Dr Paul Yock to co-direct the Stanford Biodesign program, which is designed to teach innovation at the emerging frontiers of engineering and biomedical sciences. Dr Krummel is Chairman of the Fogarty Institute for Innovation Board of Directors, and President of the International Scientific Committee at Institut de Recherche contre les Cancers de l'Appareil Digestif - IRCAD at the University of Strasbourg and is a frequent consultant to the medical device industry.

Biodesign process and culture to enable pediatric medical technology innovation.

Innovation is the process through which new scientific discoveries are developed and promoted from bench to bedside. In an effort to encourage young entrepreneurs in this area, Stanford Biodesign developed a medical device innovation training program focused on need-based innovation. The program focuses on teaching systematic evaluation of healthcare needs, invention, and concept development. This process can be applied to any field of medicine, including Pediatric Surgery. Similar training programs have gained traction throughout the United States and beyond. Equally important to process in the success of these programs is an institutional culture that supports transformative thinking. Key components of this culture include risk tolerance, patience, encouragement of creativity, management of conflict, and networking effects.

Outcomes from a postgraduate biomedical technology innovation training program: the first 12 years of Stanford Biodesign.

The Stanford Biodesign Program began in 2001 with a mission of helping to train leaders in biomedical technology innovation. A key feature of the program is a full-time postgraduate fellowship where multidisciplinary teams undergo a process of sourcing clinical needs, inventing solutions and planning for implementation of a business strategy. The program places a priority on needs identification, a formal process of selecting, researching and characterizing needs before beginning the process of inventing. Fellows and students from the program have gone on to careers that emphasize technology innovation across industry and academia. Biodesign trainees have started 26 companies within the program that have raised over $200 million and led to the creation of over 500 new jobs. More importantly, although most of these technologies are still at a very early stage, several projects have received regulatory approval and so far more than 150,000 patients have been treated by technologies invented by our trainees. This paper reviews the initial outcomes of the program and discusses lessons learned and future directions in terms of training priorities.

Symbiotic or parasitic? A review of the literature on the impact of fellowships on surgical residents.

OBJECTIVE: We conducted a systematic review of published literature to gain a better understanding of the impact of advanced fellowships on surgical resident training and education. BACKGROUND: As fellowship opportunities rise, resident training may be adversely impacted. METHODS: PubMed, MEDLINE, Scopus, BIOSIS, Web of Science, and a manual search of article bibliographies. Of the 139 citations identified through the initial electronic search and screened for possible inclusion, 23 articles were retained and accepted for this review. Data were extracted regarding surgical specialty, methodology, sample population, outcomes measured, and results. RESULTS: Eight studies retrospectively compared the eras before and after the introduction of a fellowship or trended data over time. Approximately half used data from a single institution, whereas the other half used some form of national data or survey. Only 3 studies used national case data. Fourteen studies looked at general surgery, 6 at obstetrics-gynecology, 2 at urology, and 1 at otolaryngology. Only one study concluded that fellowships have a generally positive impact on resident education, whereas 9 others found a negative impact. The remaining 13 studies found mixed results (n = 6) or minimal to no impact (n = 7). CONCLUSIONS: The overall impact of advanced surgical fellowships on surgical resident education and training remains unclear, as most studies rely on limited data of questionable generalizability. A careful study of the national database of surgery resident case logs is essential to better understand how early surgical specialization and fellowships will impact the future of general surgery education.

Submucosal endoscopic myotomies for esophageal lengthening: a novel minimally invasive technique with feasibility study.

BACKGROUND: Replacement conduits carry significant morbidity in long gap esophageal atresia. Surgical myotomies can lengthen the esophagus, but have not gained widespread adoption due to long-term dilatation. The aim of this study is to assess the feasibility of an emerging minimally invasive technique of submucosal endoscopic myotomy for esophageal lengthening. METHODS: Bilateral submucosal lengthening endoscopic myotomies (BSLEM) were performed in three swine. Circular esophageal muscle fibers were selectively divided in a bilateral 3 cm longitudinal pattern. Ex-vivo tensile testing was performed on the BSLEM and compared with three circular myotomies, three spiral myotomies, and three controls. RESULTS: BSLEM was completed in all cases with one esophageal microperforation. The mean operating time was 38 minutes. Over physiologic force ranges of 0 to 100 g, the percentage esophageal elongation was significantly different among the four groups (p<0.05). Spiral myotomy enabled the maximal lengthening among the techniques. BSLEM enabled lengthening significantly greater than controls, but less than both types of surgical myotomy. CONCLUSIONS: BSELM is feasible and allows significant esophageal lengthening. Unlike surgical myotomies, BSELM enables selective division of circular fibers to potentially preserve perfusion near the anastomosis and prevent long-term dilatation. Studies are ongoing to characterize the ideal pattern of selective endoscopic myotomy and long-term effects.

Applying a structured innovation process to interventional radiology: a single-center experience.

PURPOSE: To determine the feasibility and efficacy of applying an established innovation process to an active academic interventional radiology (IR) practice. MATERIALS AND METHODS: The Stanford Biodesign Medical Technology Innovation Process was used as the innovation template. Over a 4-month period, seven IR faculty and four IR fellow physicians recorded observations. These observations were converted into need statements. One particular need relating to gastrostomy tubes was diligently screened and was the subject of a single formal brainstorming session. RESULTS: Investigators collected 82 observations, 34 by faculty and 48 by fellows. The categories that generated the most observations were enteral feeding (n = 9, 11%), biopsy (n = 8, 10%), chest tubes (n = 6, 7%), chemoembolization and radioembolization (n = 6, 7%), and biliary interventions (n = 5, 6%). The output from the screening on the gastrostomy tube need was a specification sheet that served as a guidance document for the subsequent brainstorming session. The brainstorming session produced 10 concepts under three separate categories. CONCLUSIONS: This formalized innovation process generated numerous observations and ultimately 10 concepts to potentially to solve a significant clinical need, suggesting that a structured process can help guide an IR practice interested in medical innovation.