Managing Resident Mental Health: Prevention is Better than Cure.

OBJECTIVE: There is a high prevalance of burnout and mental health illness among trainees. Through structured meetings, Program Directors (PDs) have an opportunity to screen and aid residents that may be affected by mental health concerns. However, barriers to this process exist. This study sought to evaluate the perspectives of PDs regarding mental health screening for trainees. DESIGN: A 13-item survey-based study. SETTING: Electronic distribution of the survey was performed via three individualized requests sent via e-mail to PDs. PARTICIPANTS: PDs of 5 ACGME specialties, including Internal Medicine, Pediatrics, Emergency Medicine, General Surgery, and Psychiatry were invited to participate. RESULTS: In total, 595 PDs responded to the survey (response rate = 40.0%) In general, PDs expressed dissatisfaction with the management of burnout and mental health. Most PDs supported periodic screening of residents for burnout (87.0%) and mental health (73.9%). For a resident that could screen positive for mental illness, most PDs were concerned about the possibility of harm to a patient (70.7%) and implications for future licensing (65.7%). Only 30.2% of PDs currently use some form of standardized screening to identify residents struggling with mental health and burnout concerns. CONCLUSION: The majority of PDs across 5 ACGME specialties support the use of periodic screening of residents for burnout and mental health. However, concerns exist regarding such screening such as the implications for future licensing. Additional work needs to be done to address PD concerns and destigmatizate mental health wellbeing and care among trainees.

Resident Mental Health and Burnout: Current Practices and Perspectives of Urology Program Directors.

OBJECTIVE: To understand perspectives of urology program directors (PDs) regarding the management and screening of resident mental health and burnout. METHODS: After piloting and survey validation, an IRB-exempt 14 question survey was distributed to PDs of all 145 ACGME accredited urology residency programs. Statistical significance was determined using an alpha value of 0.05 and response plurality was determined by non-overlapping 95% confidence intervals. RESULTS: A total of 72 PDs completed the survey (response rate = 49.6%). The majority of PDs (59.7%) do not use standardized screening for resident burnout or mental health. A statistically significant proportion of PDs agreed to implementing periodic mental health (75.0%, 95% CI [65.0%-75.0%]) and burnout (87.6%, 95% CI [79.9%-95.1%]) screening. Female PDs were more likely to agree to implementing mental health screening compared to male PDs (female=94.4% vs male=68.5%; P =.03). If mental health screening was implemented and a resident tested positive, PDs were most concerned about harm to a patient (72.2%, 95% CI [61.9-82.6]) and implications of a positive screen on future licensing and practice (55.6%, 95% CI [44.1-67.0]). CONCLUSION: Although the majority of urology PDs believe residents should be periodically screened for burnout and mental health, most do not currently screen their trainees. If mental health screening was implemented, PDs expressed concern about patient harm and challenges associated with future licensing. Our survey results suggest opportunities for improving management of resident burnout and mental health.

Outcomes of Immediate Implant-Based Mastectomy Reconstruction in Women with Previous Breast Radiotherapy.

BACKGROUND: The objective of this study was to determine whether women with a history of radiation therapy before mastectomy experience a risk for postoperative complications and patient-reported outcomes similar to those of women undergoing postmastectomy radiation therapy in the setting of immediate implant reconstruction. METHODS: The cohort included patients undergoing immediate implant reconstruction at 11 centers across North America. Women were categorized into three groups: prior breast conservation therapy, postmastectomy radiation therapy, and no radiation therapy. Mixed effect logistic regressions were used to analyze the effects of radiation therapy status on complication rates and patient-reported outcomes. RESULTS: ONE THOUSAND FIVE HUNDRED NINETY-FOUR: patients were analyzed, including 84 women with prior breast conservation therapy, 329 women who underwent postmastectomy radiation therapy, and 1181 women with no history of radiation therapy. Compared with postmastectomy radiation therapy, breast conservation was associated with lower rates of all complications and major complications (OR, 0.65; 95 percent CI, 0.37 to 1.14; p = 0.13; and OR, 0.61; 95 percent CI, 0.33 to 1.13; p = 0.12). These differences were not statistically significant. Rates of reconstructive failure between the two cohorts were comparable. Before reconstruction, satisfaction with breasts was lowest for women with prior breast conservation therapy (p < 0.001). At 2 years postoperatively, satisfaction with breasts was lower for women with postmastectomy radiation therapy compared with breast conservation patients (p = 0.007). CONCLUSIONS: Higher postoperative complication rates were observed in women exposed to radiation therapy regardless of timing. Although women with prior breast conservation experienced greater satisfaction with their breasts and fewer complications when compared to women undergoing postmastectomy radiation therapy, there was a similar risk for reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The influence of reconstruction choice and inclusion of radiation therapy on functional shoulder biomechanics in women undergoing mastectomy for breast cancer.

PURPOSE: The functional implications of reconstructing the breast mound with a latissimus dorsi (LD) flap or placing an implant under the pectoralis major (PM) muscle is complicated by potential comorbidities from disinserting these muscles and adjuvant radiotherapy. We utilized novel robot-assisted measures of shoulder stiffness and strength to dissociate how breast reconstruction choice and inclusion of radiation therapy impact shoulder morbidity in post-mastectomy reconstruction patients. METHODS: Shoulder strength and stiffness were collected from 10 irradiated LD flap breast reconstruction patients, 14 two-stage subpectoral implant reconstruction patients (subpectoral), and 10 irradiated deep inferior epigastric perforator (DIEP) flap patients an average of 659 days post-reconstruction. Univariate ANOVAs examined surgical group differences in strength and stiffness. RESULTS: There were main effects of surgical group on vertical adduction, vertical abduction, and internal rotation strength. The LD flap group was significantly weaker than the subpectoral group in all measures and significantly weaker than the DIEP group during vertical adduction. There was also a main effect of surgical group on vertical adduction stiffness, where the LD group exhibited significantly reduced stiffness while producing vertical adduction torque. No significant differences between the subpectoral and DIEP groups existed for any measure of shoulder strength or stiffness. CONCLUSIONS: Disinsertion of the LD, not the disinsertion of the PM or radiotherapy, contributes to strength deficits following LD flap breast reconstructions. The combined disinsertion of the PM and LD compromises shoulder stability in the vertical plane. Shoulder function should be a focal point of the surgical decision-making process and postsurgical care.

Surgical correction of gynecomastia: a geometric approach.

Many techniques are available for surgical correction of gynecomastia. In this article, we describe a technique based on geometrical principles that is simple to execute, effective, highly reproducible, and relies less on intuition of the surgeon.