National Trends in General Surgery Resident Exposure to Complex Oncology-Relevant Cases.

OBJECTIVE: To evaluate trends in surgical resident exposure to complex oncologic procedures in order to determine whether additional fellowship training is necessary. DESIGN: An observational study of national Accreditation Council for Graduate Medical Education case log statistical reports was conducted to determine the average number of cases for selected oncology-relevant procedures completed during training. Linear regression and Cusick trend tests were used to assess temporal trends with the null hypothesis assuming an estimated slope of zero. Instrumental variable estimation was used to study the effect of duty-hour restrictions on oncologic cases per year. SETTING: United States general surgery residency training programs. PARTICIPANTS: Graduating surgical residents completing their training between 2000 and 2016. RESULTS: Across the study interval, mean case volume was 950.6 ± 29.7 (standard deviation) cases with 38.9 ± 3.1 complex oncologic cases per graduating resident. Decreasing trends were noted for average exposure to lymphadenectomies (-7.8 cases/decade; 95% confidence interval [CI] -8.8 to -6.8) and low rectal procedures (-0.9 cases/decade; 95% CI -1.2 to -0.6). There was no clinically important change in complex soft-tissue resections and foregut cases. A significant increase was seen in number of hepatopancreaticobiliary procedures (+3.9 cases/decade; 95% CI 3.1-4.7). Using instrumental variable estimation, there was a modest decline in cancer-relevant cases by 5.0 cases/decade (95% CI 4.5-5.6), while there was an increase in 38.5 total cases/decade (95% CI 10.4-66.7) associated with duty-hour restrictions. CONCLUSIONS: Case numbers for several complex oncologic procedures remain low, justifying a need for further fellowship training depending on individual resident experience.

Residents in distress: an exploration of assistance-seeking and reporting behaviors.

BACKGROUND: This study explores assistance-seeking and reporting behaviors in surgical residents faced with stressful circumstances. METHODS: Three surgical societies distributed a multiple choice, free-text response survey to residents. RESULTS: One hundred sixty-four residents (39% male) responded; 58% of women (43% men) were married; and 22% of men (7% women) were international medical graduates. Residents' dominant action to colleagues' concerning behavior was to approach him/her directly. Women were more likely to report colleagues' unpredictable behavior toward staff (28% vs 10%, P < .05), alcohol on breath at work (53% vs 32%, P = nonsignificant), and personal hygiene deterioration (15% vs 2%, P < .05) to an authority. Men were more likely to ignore frequent interpersonal conflicts and illnesses. CONCLUSIONS: Male and female surgery residents adopt different strategies in dealing with perceived distress in their colleagues. These impact their response to signs of impairment. Educators should consider sex while providing residents with an understanding of their role in the recognition of personal impairment and that of their peers.

Surgeons in Difficulty: An Exploration of Differences in Assistance-Seeking Behaviors between Male and Female Surgeons.

BACKGROUND: Physician burnout is associated with diminished ability to practice with requisite skill and safety. Physicians are often reluctant to seek help for an impaired colleague or for impairment that affects their own ability to practice. To better support surgeons in difficulty, we explored sex differences in assistance-seeking behaviors under stress. STUDY DESIGN: Surgeons in 3 national societies completed an IRB-approved anonymous multiple-choice and free-text response survey. Responses were explored with the general linear model using item-specific continuous and categorical methods. STUDY DESIGN: Two hundred and twelve surgeons (n = 79 [37.3%] male, n = 133 [63%] female) responded. Although men and women worked similar hours (p > 0.05), women worked more clinical (p < 0.01) and fewer administrative hours (p < 0.01) in later age (F = 7.88; degrees of freedom [df] 4/145; p < 0.01). Women were less satisfied with work-life balance, as identified by aggregate variables related to emotional/decisional partnership, non-work-related chore support, and personal fulfillment (F = 15.29; df 3/16; p < 0.01), but change jobs less frequently (F = 4.23; df 1/201; p < 0.05). Males are more likely to seek help from colleagues (chi-square 107.5; p < 0.01) or friends (chi-square 123.8; p < 0.01) and women are more likely to seek support from professional counselors (chi-square 146.8; p < 0.01). Almost one-third of surgeons would ignore behaviors that adversely impact well being and could result in potential personal or patient safety. CONCLUSIONS: The differences between the assistance-seeking and reporting behaviors of male and female surgeons in distress could have implications for identification and treatment of this population. These findings can be used to develop educational activities to teach surgeons how to effectively handle these challenging situations.

Hemorrhoids and fistulas: new solutions to old problems.

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

Teaching and Assessing Colorectal Surgery Residents in the Age of ACGME Competencies: Pieces of the Whole.

Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.

Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools.

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

Health-related information gathering practices in breast and colorectal specialty clinics: the end of the electronic divide?

BACKGROUND: Health-related information can help patients understand their disease process and make informed decisions. We hypothesize that with the increased availability of Web-based resources, sociodemographic factors no longer impact Internet use among patients. METHODS: Study-specific surveys were administered to a convenience cohort of patients seen in the breast and colorectal specialty clinics at a single academic institution between August 2008 and February 2009. RESULTS: One hundred ninety-four surveys were returned (response rate 80%). Median age was 53 years (range 19-88) with 131 (75%) females. Twenty-six percent of patients were college graduates and 59% reported an annual income greater than $50,000. There was no association between Internet use and age, gender, income, or educational level. CONCLUSION: Web-based information is being increasingly used by patients irrespective of their demographic characteristics. These resources can therefore be used to educate patients about their disease, treatment options, and health maintenance.

Utilization of bovine acellular dermal matrix for abdominal wall reconstruction: a retrospective case series.

Abdominal wall reconstruction using nonabsorbable synthetic material can be challenging due to the risk for bacterial colonization and subsequent complications. Bioprosthetic materials are a safe alternative that can facilitate soft tissue reconstruction, including abdominal wall repair. To assess the short-term outcomes of using a bovine acellular dermal matrix in contaminated postsurgical wounds, charts of all patients who were managed using the bovine acellular dermal matrix between November 2006 and July 2007 were reviewed. Six related procedures were performed in five patients: two men and three women, median age 61 years (range 50 to 66 years), median body mass index 35 kg/m2 (range 28 to 51 kg/m2). Patients underwent parastomal hernia repair and anterior abdominal wall reconstruction (one patient), reinforcement of colostomy site (one patient), and repair of large anterior abdominal wall defects following bowel resection (three patients). Clinical follow-up was complete on all patients until December 2008. Three of the five patients did not develop any wound-related complications during a median follow-up of 10 months (range 9 to 17 months). The two patients who developed complications (2 months and 10 days postoperatively, respectively) had a body mass index of 42 and 51, respectively, and multiple comorbidities. The authors' initial experience with bovine acellular dermal matrix for various soft tissue reconstruction suggests the product is safe when used in uninfected wounds. Further experience is required to determine the effectiveness, complication profile, and feasibility of using this bioprosthesis in clinical practice and to evaluate its use in infected wounds.

Anal fissure.

Anal fissure is a common problem, vexing to both patients and physicians. The historical mainstay of therapy has been some method of partial division of the internal anal sphincter with the serious potential complication of fecal incontinence. Nonsurgical treatment methods were therefore pursued, producing healing rates less than that seen after surgical therapy but none of the morbidity of surgery. This article summarizes accepted methods of modern medical and surgical therapy for anal fissure and offers a rationale for treatment type selection.

Practice parameters for the surgical treatment of ulcerative colitis.

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised).

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Practice parameters for the management of rectal cancer (revised).

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.