SAGES White Paper on the importance of diversity in surgical leadership: creating the fundamentals of leadership development (FLD) curriculum.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. METHODS: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. RESULTS: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. CONCLUSION: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery.

Palliative care in a rural surgery residency program: an educational needs assessment.

BACKGROUND: There is a deficiency of palliative care education in surgical residency programs and a lack of research on palliative care education in rural surgery residency programs. Because rural palliative care presents unique challenges due to fewer specialists and resources, we investigated potential areas of improvement in palliative care education in a rural general surgery residency program. METHODS: An anonymous survey was sent to all residents of a rural general surgery residency program. The survey assessed prior hospice/palliative care education in medical school, prior volunteering experience in palliative care, comfort with having "goals of care" discussions and delivering serious news, and perceived indications for palliative care consultation. A follow-up survey assessed attitudes and interest related to palliative care education integration in a rural surgical residency program. RESULTS: Of 17 residents, 14 (82.4%) responded to the initial survey. Four respondents (28.6%) had over a half day of palliative care education in medical school. Eight of fourteen respondents (57.1%) feel comfortable having "goals of care" discussions: 0/4 interns (0%) compared to 8/10 junior and senior residents (80%). Half of respondents feel comfortable delivering serious news: 1/4 interns (25%) compared to 6/10 junior and senior residents (60%). All respondents agreed that palliative care education is necessary. Four themes were identified in content analysis of perceived indications for palliative care consultation: future planning, deferring to the expert, patient/family education, and surgeon/trainee discomfort. The follow-up survey revealed perceived limitations in palliative care resources available in a rural surgery setting. CONCLUSIONS: These results highlight the need for formal palliative care education in a rural surgery residency program. Throughout training, residents appear to develop more comfort with "goals of care" discussions than delivering serious news. In response, we are instituting palliative care discussions during educational conference, including interactive simulations to improve communication skills, and a palliative care telemedicine elective.

Use of the Alvarado Score in Elderly Patients with Complicated and Uncomplicated Appendicitis.

The purpose of this study was to determine whether the Alvarado score is beneficial in identifying complicated versus uncomplicated acute appendicitis in elderly patients. A retrospective review was conducted of patients aged 65 years and older who underwent an appendectomy for pathologically confirmed appendicitis. A review of 310 operative reports and patient charts from October 2012 to December 2016 yielded 216 patients. Patients were grouped based on complicated versus uncomplicated appendicitis. One hundred ten patients had complicated appendicitis, whereas 106 patients were uncomplicated. Among the complicated appendicitis patients, 76.4 per cent were perforated, 38.2 per cent were gangrenous, and 34.5 per cent had an abscess. The complicated appendicitis group had a higher mean duration of symptoms (2.70 ± 3.41 days vs 2.09 ± 3.08 days, P = 0.011). Appendectomies that were open or converted to open were more likely to be associated with complicated appendicitis (75% vs 48%, P = 0.012). Mean hospital length of stay was greater in those with complicated appendicitis (5.34 ± 5.56 days vs 3.12 ± 2.86 days, P < 0.001). The two groups did not differ on mean Alvarado score (complicated = 6.96 ± 1.99 vs uncomplicated = 6.72 ± 1.85, P = 0.36). Only 62.5 per cent of patients had an Alvarado score that met the cutoff for acute appendicitis. The Alvarado score was not able to differentiate complicated from uncomplicated appendicitis in elderly patients.

A neoadjuvant strategy for pancreatic adenocarcinoma increases the likelihood of receiving all components of care: lessons from a single-institution database.

BACKGROUND: Recent studies have shown adjuvant therapy improves outcomes from pancreatic cancer (PC). This study investigates receipt and timing of PC treatments, and association with outcomes. METHODS: The analysis cohort consisted of patients with newly-diagnosed PC at a single institution over 5 years. Primary Endpoints were (i) receipt of recommended therapy, and (ii) overall survival (OS). RESULTS: Among 102 patients, 52 underwent resection. Out of 36 localized resected and 16 locally advanced resected (LAR) patients, 26 and 13, respectively, received adjuvant therapy. Six of the latter group received neoadjuvant therapy. Median OS for resected patients was 15.7 months (range 0.6-51.4), compared with 7.7 for unresected patients (range 0.4-32.0) (P < 0.001), and 14.0 months for patients with resection alone (range 0.6-24.4) vs. 16.1 for patients who also received adjuvant therapy (range 3.2-51.4) (P= 0.027). Out of 46 patients undergoing up-front resection, 33 had R0 surgical margins. For the six LAR patients undergoing neoadjuvant therapy, all margins were R0. CONCLUSION: After resection, a substantial proportion of patients do not receive adjuvant therapy, and have worse survival. In this study, neoadjuvant treatment increased both the proportion of patients receiving all components of recommended therapy and the R0 resection rate.