Association between gastrointestinal symptoms and specialty care utilization among colon cancer survivors: a cohort study.

PURPOSE: Persistent gastrointestinal (GI) symptoms are frequently experienced by colon cancer survivors and may help identify patients with higher utilization of healthcare services. To assess the relationship between GI symptoms and specialty care utilization among colon cancer survivors. METHODS: A prospective longitudinal cohort study at an academic medical center of 126 adults surgically treated for stage I-IV colon cancer between February 2017 and June 2022. Participants reported GI symptoms through the EORTC QLQ-C30 and QLQ-CR29 at enrollment and as frequently as every 6 months for 5 years. Main outcome measures were visits, telephone encounters, and secure messages with a medical provider within specialty oncology clinics within 6 months after each survey completion. Generalized linear mixed regression model for repeated measurements with random trajectory for each participant was performed to estimate the associations between symptoms and healthcare use. Models were adjusted for demographics, clinical and surgical factors, and timing in relation to onset of the COVID-19 pandemic. RESULTS: In the 6 months after each survey time point, patients averaged 1.2 visits, 0.5 telephone encounters, and 3.2 patient-initiated messages. In adjusted models, those with any abdominal pain (RR 1.45; p = 0.002), buttock pain (RR 1.30; p = 0.050), or increased stool frequency (RR 1.26; p = 0.046) had more clinic visits in the following 6 months than those without these symptoms. Including these three symptoms in one model revealed that only abdominal pain was statistically significantly associated with increased clinic visits (RR 1.36; p = 0.016). Patients with any blood or mucus in stool (RR 2.46; p = 0.009) had significantly more telephone encounters, and those with any abdominal pain (RR 1.65; p = 0.002) had significantly more patient-initiated messages than those without these symptoms. CONCLUSIONS: Our findings identify GI symptoms associated with increased use of oncologic specialty care among colon cancer survivors, with abdominal pain as an important predictor of utilization. IMPLICATIONS FOR CANCER SURVIVORS: Early identification and anticipatory management of colon cancer survivors experiencing abdominal pain may decrease healthcare utilization.

An At-Home Laparoscopic Curriculum for Junior Residents in Surgery, Obstetrics/Gynecology, and Urology.

Introduction: Laparoscopic surgery requires significant training, and prior studies have shown that surgical residents lack key laparoscopic skills. Many educators have implemented simulation curricula to improve laparoscopic training. Given limited time for dedicated, in-person simulation center practice, at-home training has emerged as a possible mechanism by which to expand training and promote practice. There remains a gap in published at-home laparoscopic curricula employing embedded feedback mechanisms. Methods: We developed a nine-task at-home laparoscopic curriculum and an end-of-curriculum assessment following Kern's six-step approach. We implemented the curriculum over 4 months with first- to third-year residents. Results: Of 47 invited residents from general surgery, obstetrics/gynecology, and urology, 37 (79%) participated in the at-home curriculum, and 25 (53%) participated in the end-of-curriculum assessment. Residents who participated in the at-home curriculum completed a median of six of nine tasks (interquartile range: 3-8). Twenty-two residents (47%) responded to a postcurriculum survey. Of these, 19 (86%) reported that their laparoscopic skills improved through completion of the curriculum, and the same 19 (86%) felt that the curriculum should be continued for future residents. Residents who completed more at-home curriculum tasks scored higher on the end-of-curriculum assessment (p = .009 with adjusted R 2 of .28) and performed assessment tasks in less time (p = .004 with adjusted R 2 of .28). Discussion: This learner-centered laparoscopic curriculum provides guiding examples, spaced practice, feedback, and graduated skill development to enable junior residents to improve their laparoscopic skills in a low-stakes, at-home environment.

Identifying Novel Inhibitors of Workplace Support and the Importance of Value Congruence and Feeling Valued in General Surgery Residency Training.

OBJECTIVE: To explore residents' perceptions of workplace support inhibitors and their relationship to resident wellbeing. We aim to provide evidence-based targets to inform future work operationalizing support in surgical training. DESIGN: This is a 2-part mixed-methods cross-sectional study. Part 1 analyzed qualitative data from focus groups (April 2021-May 2022). Part 2 comprised an online survey (informed by findings in Part 1, May 2022) to assess the association between perceived workplace support (e.g. feeling valued and value congruence) and poor individual global wellbeing (e.g. languishing). SETTING: National multi-center study including 16 ACGME-accredited academic programs. PARTICIPANTS: General surgery residents at all training levels, both clinical and research years. RESULTS: 28 residents participated in the focus groups which revealed three major themes around perceived inhibitors of workplace support: lack of trust in residency program (e.g. ulterior motives), poor communication from leadership (e.g. lack of transparency, ineffective dialogue), and unfair systems in residency training (e.g. exploitation of residents, paternal leave policies). These themes emphasized the importance of feeling valued and value congruence, with the latter reflected in the form of trust and communication with leadership, a key element of worker-workplace alignment. 251 residents responded to the survey (response rate 31%, 50.6% women) which revealed that a lower sense of feeling valued and lower perceived value congruence were significantly associated with languishing. CONCLUSIONS: Our findings suggest feeling valued and value congruence (specifically, having trust and communication with leadership) are important targets for increasing workplace support in surgical training, offering evidence-based targets for future work to operationalize support in surgical training.

Investigating Workplace Support and the Importance of Psychological Safety in General Surgery Residency Training.

OBJECTIVE: Workplace interventions that increase support can mitigate burnout, improve workplace satisfaction, and increase well-being. Our aim is to provide evidence-based targets to inform future work for operationalizing support in general surgery residency. DESIGN: This is a 2-part mixed-methods cross-sectional study. Part 1 analyzed qualitative data from focus groups (April 2021-May 2022). Part 2 comprised an online survey (informed by findings in Part 1) in May 2022 to assess the association between perceived psychological safety (PS) and flourishing, as well as PS and languishing. SETTING: National multi-center study including 16 ACGME-accredited academic programs. PARTICIPANTS: General surgery residents at various training levels, in both clinical and research. RESULTS: A total of 28 residents participated in the focus groups which revealed both enhancers and inhibitors of support pertaining to PS in the workplace. Enhancers of support included those currently implemented (i.e., allyship of mentors) and those proposed by residents (i.e., nonpunitive analysis of mistakes). Inhibitors of support included both systems (i.e., wellness initiatives as a 'band-aid' for systems issues) and culture (i.e., indefatigability, stoicism). About 251 residents (31%) responded to the survey which revealed higher perception of PS was significantly associated with flourishing at the level of residency program and departmental leadership. Lower perception of PS was significantly associated with languishing at the level of residency program leadership only. CONCLUSION: Our findings highlight the promotion of PS, such as expansion of mentorship to include advocacy (advocating on a resident's behalf, recognition when mistreated) and affirmation (i.e., soliciting opinions on controversial social matters/events, recognizing different life experiences), cultural acceptance of asking for help (without being perceived as weak), formal help navigating interpersonal dynamics (i.e., guidance from senior residents), and leadership presentations and modeling to destigmatize asking for help, as a means of operationalizing workplace support to increase flourishing and decrease languishing.

Investigating First Year Surgery Residents' Expectations of Demand, Control, and Support During Training.

OBJECTIVE: To provide a more granular understanding of the expectations of general surgery interns regarding workplace demand, control, and support prior to starting training. SUMMARY/BACKGROUND DATA: General surgery (GS) interns are at highest risk for burnout and attrition. Maslach frames burnout as resulting from a mismatch between workplace expectations and reality. Occupational science demonstrates workplace demand, control, and support (DCS) as strong influencers of job strain. GS interns' realistic expectations of demands are associated with decreased likelihood of attrition, but their expectations regarding this factor are poorly understood. METHODS: Semi-structured interviews were conducted with 14 incoming surgical residents at UCSF: University of California, San Francisco (57% women, 71% non-White), exploring expectations regarding workplace DCS. Transcripts were uploaded to analytic software and coded in dyads using an iterative approach to consensus. Transcripts were thematically analyzed using inductive and deductive reasoning, applying job-demand-resource theory frameworks, and following a published 6-step approach. RESULTS: Four main themes emerged: past experiences, expected rewards, anticipated challenges, and the desire to belong. Past experiences describes the expectation to successfully cope with future stressors via self-reliance. Rewards such as professional mastery, personal growth, and sense of meaning were expected outcomes seen as balancing anticipated challenges. Anticipated challenges included low control, toxic cultural elements, and discrimination. Desire to belong (i.e., earned recognition as a peer, inclusion in an elite culture) emerged as a powerful motivator, with survival connotations for women and non-Whites. CONCLUSION: Our results suggest incoming interns overestimate the efficacy of self-reliance for coping; count on specific rewards; express realistic expectations regarding challenges; and see inclusion among surgeons as an aspiration that off-sets prolonged effort. Further study is warranted to understand expectation-reality mismatch and potential interventions to target dissonance. MINI-ABSTRACT: In this institutional study of general surgery interns, we provide a more granular understanding of the expectations of general surgery interns regarding workplace demand, control, and support prior to starting training, and how we might target "expectations-reality" mismatch and the "desire to belong" as a means of mitigating burnout and minimizing attrition from training.

Investigating influential factors and mechanisms of surgical resident well-being using social network analysis.

BACKGROUND: Burnout and depression in General Surgery residents affect patient care and drive attrition. Few impactful interventions exist, in part because little is known about influential drivers and mechanistic relationships. METHODS: Residents from 16 general surgery programs completed published well-being scales in January 2021. Social network analysis demonstrated influential relationships between factors, and path analysis revealed drivers of burnout and depression. RESULTS: 300 residents completed the survey (34% response rate). Workplace demand and mindfulness influenced depressive symptoms and emotional exhaustion, mediated by perceived stress. Mindfulness increased personal accomplishment, mediated by psychological well-being (p â€‹< â€‹0.05 for all results). All mediated effects were greater than direct effects. CONCLUSIONS: This study yielded a quantitative conceptual model of mechanistic relationships affecting well-being in surgical residency, identifying stress and psychological well-being (measuring sense of purpose) as central mediators, and triangulating workplace demand and mindfulness as potentially high-yield interventional targets for reducing burnout and depression in surgical residency.

Pretransplantation coronavirus disease 2019 vaccination requirements: A matched case-control study of factors associated with waitlist inactivation.

Numerous United States transplant centers require solid organ transplantation candidates to be vaccinated against the coronavirus disease of 2019 to be active on the United Network for Organ Sharing waiting list. This study examined characteristics of adult patients on one center's kidney transplantation waiting list whose status was inactivated due to a lack of coronavirus disease 2019 vaccination by July 1, 2022, and who did not subsequently provide proof of vaccination by August 31, 2022 (cases). Patients in the control group were retrospectively matched to patients in the case group in a 4-to-1 fashion according to age, sex, and "active" status on the waiting list. Multivariable logistic regression was performed, with race/ethnicity, primary language, health insurance, education, and Vaccine Equity Metric (VEM, a measure of health equity at the zip code level) quartile as covariates. Results revealed that patients from zip codes in the lowest VEM quartile (odds ratio [OR] 1.89; P = .02) and those insured by governmental payors (Medicare: OR, 2.00; P < .01 and Medicaid: OR, 2.89; P < .01) had higher odds of being inactivated than those from zip codes that make up the highest VEM quartile and those insured by commercial payors, respectively. These findings serve as a cautionary tale regarding universal pretransplantation vaccination requirements, which may raise equity concerns that should be considered upon policy implementation.