Practical Guide to Curricular Development Research.

This Guide to Statistics and Methods provides an overview of performing curricular development research.

Work relative value units undervalue the clinical effort associated with teaching cases: An ACS-NSQIP analysis.

PURPOSE: Work-relative-value-units (wRVUs) are a core metric of faculty effort but do not account for the additional work associated with intraoperative teaching. This study introduces and assesses an indexed effort, wRVU per minute (wRVU index). We hypothesize that there is a significant decrease in the calculated wRVU index among teaching cases. METHODS: We queried the ACS-NSQIP database for 7 core Emergency General Surgery procedures and records were stratified into teaching vs non-teaching, and emergent vs non-emergent procedures. We utilized multivariable generalized linear models to determine factors associated with increased operative time and decreased wRVU index. RESULTS: Data were available for 953,967 cases from 2005 to 2010. For all cases, teaching vs non-teaching, the median wRVU index was 0.16 vs 0.21 (p â€‹< â€‹0.001). There was a positive association between teaching cases and decreased wRVU index for all cases. CONCLUSION: The wRVU index was 24% lower for teaching cases when compared to non-teaching cases despite controlling for patient-specific factors. This finding highlights the need for further evaluation of the current wRVU framework.

Outcomes of Concurrent Ventral Hernia Repair and Cholecystectomy Compared to Ventral Hernia Repair Alone.

Introduction It has been suggested that hernia repair with concomitant cholecystectomy increases the risk of postoperative complications due to potential mesh contamination. This study compares postoperative outcomes and complications between patients who underwent ventral hernia repair (VHR) with and without concomitant cholecystectomy (CCY). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, from 2005 to 2019, we queried patients who underwent ventral hernia repairs using the current procedural terminology (CPT) codes 49652-49657 (laparoscopic) and 49560-49566 (open), with or without cholecystectomy. The ACS NSQIP is a prospective, systematic study of patients who underwent major general surgical procedures aggregating data from over 200 hospitals. Cases involving additional concomitant procedures were excluded. Primary outcomes of interest were 30-day mortality, length of stay, readmission, return to operating room (OR), and postoperative complications. The odds ratio for primary outcomes was calculated using multivariable binomial logistic regression to control for patient risk factors. Results In total, 167586 cases were identified, 165,758 ventral hernia repairs alone, and 1,828 ventral hernia repairs with concomitant cholecystectomy. There was no difference in 30-day mortality, length of stay, readmission, return to the operating room, or postoperative complications between groups. Patients who underwent simultaneous VHR/CCY when compared to those who had VHR alone, had no differences in the rate of surgical site infections (1.86% vs. 1.97%, P = 0.57) or sepsis (0.82% vs. 0.41%, P = 0.10).  Conclusion In a large national sample, there is no significant difference in postoperative outcomes, specifically infection-related complications, when comparing VHR along with concurrent VHR/CCY. Our findings suggest no increased risks for patients undergoing concurrent ventral hernia repair and cholecystectomy. Hence, surgeons might consider this combined approach to offer the best value-based care, especially when it could eliminate the need for a second operation and the risk of infection is low. Prospective studies with more procedural-specific information for hernia repairs and indications for cholecystectomy are needed however it is likely safe to perform both procedures during the same setting in cholecystectomy cases lacking signs of acute infection.

Bullying in Orthopaedic Surgery: A Survey of US Orthopaedic Trainees and Attending Surgeons.

INTRODUCTION: Bullying is a notable problem in surgery, creating a hostile environment for surgeons and trainees, and may negatively affect patient care. However, specific details regarding bullying in orthopaedic surgery are lacking. The primary aim of this study was to determine the prevalence and nature of bullying within orthopaedic surgery in the United States. METHODS: A deidentified survey was developed using the survey created by the Royal College of Australasian Surgeons and the validated Negative Acts Questionnaire-Revised survey tool. This survey was distributed to orthopaedic trainees and attending surgeons in April 2021. RESULTS: Of the 105 survey respondents, 60 (60.6%) were trainees and 39 (39.4%) were attending surgeons. Although 21 respondents (24.7%) stated they had been bullied, 16 victims (28.1%) did not seek to address this behavior. Perpetrators of bullying were most commonly male (49/71, 67.2%) and the victims' superior (36/82, 43.9%). Five bullying victims (8.8%) reported the behavior, despite 46 respondents (92.0%) stating that their institution has a specific policy against bullying. CONCLUSION: Bullying behavior occurs in orthopaedic surgery, with perpetrators being most commonly male and the victims' superiors. Despite the fact that an overwhelming majority of institutions have policies against bullying, the reporting of such behavior is lacking.

Factors Potential Patients Deem Important for Decision-Making in High-Risk Surgical Scenarios.

BACKGROUND: Surgical futility and shared decision-making to proceed with high-risk surgery are challenging for patients and surgeons alike. It is unknown which factors contribute to a patient's decision to undergo high-risk and potentially futile surgery. The clinical perspective, founded in statistical probabilities of survival, could be misaligned with a patient's determination of worthwhile surgery. This study assesses factors most important to patients in pursuing high-risk surgery. STUDY DESIGN: Via anonymous survey, lay participants recruited through Amazon's Mturk were presented high-risk scenarios necessitating emergency surgery. They rated factors (objective risk and quality-of-life domains) in surgical decision-making (0 = not at all, 4 = extremely) and made the decision to pursue surgery based on clinical scenarios. Repeated observations were accounted for via a generalized mixed-effects model and estimated effects of respondent characteristics, scenario factors, and likelihood to recommend surgery. RESULTS: Two hundred thirty-six participants completed the survey. Chance of survival to justify surgery averaged 69.3% (SD = 21.3), ranking as the highest determining factor in electing for surgery. Other factors were also considered important in electing for surgery, including the average number of days the patient lived if surgery were and were not completed, functional and pain status after surgery, family member approval, and surgery cost. Postoperative independence was associated with proceeding with surgery (p < 0.001). Recommendations by patient age was moderated by respondent age (p = 0.002). CONCLUSION: Patients highly value likelihood of survival and postoperative independence in shared decision-making for high-risk surgery. It is important to improve the understanding of surgical futility from a patient's perspective.

Impact of bowel preparation on elective colectomies for diverticulitis: analysis of the NSQIP database.

BACKGROUND: Recent data based on large databases show that bowel preparation (BP) is associated with improved outcomes in patients undergoing elective colorectal surgery. However, it remains unclear whether BP in elective colectomies would lead to similar results in patients with diverticulitis. The purpose of this study was to investigate whether bowel preparation affected the surgical site infections (SSI) and anastomotic leakage (AL) in patients with diverticulitis undergoing elective colectomies. STUDY DESIGN: We identified 16,380 diverticulitis patients who underwent elective colectomies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy targeted database (2012-2017). Multivariate logistic regression models were employed to investigate the impact of different bowel preparation strategies on postoperative complications, including SSI and AL. RESULTS: In the identified population, a total of 2524 patients (15.4%) received no preparation (NP), 4715 (28.8%) mechanical bowel preparation (MBP) alone, 739 (4.5%) antibiotic bowel preparation (ABP) alone, and 8402 (51.3%) MBP + ABP. Compared to NP, patients who received any type of bowel preparations showed a significantly decreased risk of SSI and AL after adjustment for potential confounders (SSI: MBP [OR = 0.82, 95%CI: 0.70-0.96], ABP [0.69, 95%CI: 0.52-0.92]; AL: MBP [OR = 0.66, 95%CI: 0.51-0.86], ABP [0.56, 95%CI: 0.34-0.93]), where the combination type of MBP + ABP had the strongest effect (SSI:OR = 0.58, 95%CI:0.50-0.67; AL:OR = 0.46, 95%CI:0.36-0.59). The significantly decreased risk of 30-day mortality was observed in the bowel preparation of MBP + ABP only (OR = 0.32, 95%CI: 0.13-0.79). After the further stratification by surgery procedures, patients who received MBP + ABP showed consistently lower risk for both SSI and AL when undergoing open and laparoscopic surgeries (Open: SSI [OR = 0.51, 95%CI: 0.37-0.69], AL [OR = 0.47, 95%CI: 0.25-0.91]; Laparoscopic: SSI [OR = 0.58, 95%CI: 0.47-0.72, AL [OR = 0.49, 95%CI: 0.35-0.68]). CONCLUSIONS: MBP + ABP for diverticulitis patients undergoing elective open or laparoscopic colectomies was associated with decreased risk of SSI, AL, and 30-day mortality. Benefits of MBP + ABP for diverticulitis patients underwent robotic surgeries warrant further investigation.

Does Surgeon Specialty Make a Difference in Ventral Hernia Repair With the Component Separation Technique?

Background Abdominal wall reconstruction (AWR) has evolved with the continued advent of new techniques such as component separation (CS). General (GS) and plastics surgeons (PS) are trained to perform this procedure. Differences in patient population and clinical outcomes between specialties are unknown. Methods Using a national database, patients who underwent incisional/ventral hernia repair managed with CS were grouped according to the primary specialty. Patient demographics, perioperative details, and postoperative complications were compared, and the risk factors associated with clinical outcomes were analyzed.  Results A total of 4,088 patients were identified. PS operated more often in the inpatient setting, and patients had a higher prevalence of hypertension and clean-contaminated wounds. Hypertension and being operated by a PS were associated with an increased risk of needing a blood transfusion after CST. Conclusion CS surgical outcomes are similar and comparable specialties. Primary specialty does not affect postoperative complications or 30-day mortality after CS.

Characterization of Laryngotracheal Fractures and Repairs: A TQIP Study.

OBJECTIVES: Laryngotracheal trauma is poorly studied and associated with serious morbidity and mortality. This study reports features associated with laryngotracheal fractures, and factors associated with laryngeal fracture repair. STUDY DESIGN: Retrospective database study SETTING: American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP®) METHODS: ACS-TQIP® 2014-2015 participant user data files were queried for laryngotracheal fractures using the International Classification of Diseases (ICD) 9th edition encodings. Demographic, diagnostic and procedure characteristics were analyzed with univariate chi-squared analysis and multivariate logistic regression. RESULTS: We extracted 635 cases of laryngotracheal injury, with a median Injury Severity Score of 16 (IQR: 10 - 25). Most were caused unintentionally (65.7%), followed by assault (28.8%). Blunt trauma (79.5%) was more common than penetrating trauma (20.0%). These trends were upheld in the subgroup of repaired fractures, which made up 12.6% (80/635) of cases. The median length of hospital stay was 6 days (IQR: 3 - 13) in all fractures and 10 days (IQR: 6 - 14) in the subgroup of repaired fractures, while the median length of ICU stay was 4 days (IQR: 2 - 9) in all fractures and 4.5 (IQR: 6 - 14.3) in the subgroup of repaired fractures. Cut/pierce injuries (OR: 4.7, P < 0.001) and ISS (OR: 0.97, pP = 0.026) significantly affected rate of laryngeal fracture repair. CONCLUSION: Laryngotracheal fractures are uncommon but serious injuries. Our results show that penetrating causes of injuries have the shortest time to repair, and that a higher ISS score is negatively associated with repair.

Diversity efforts in surgery: Are we there yet?

INTRODUCTION: We aimed to assess and quantify recent efforts of surgical departments in achieving diversity, equity and inclusion. METHODS: Chairs of surgery at US hospitals were identified from a database maintained by the Association of Women Surgeons and surveyed to assess diversity, equity and inclusion efforts. RESULTS: A total of 226 surveys were sent out with a 22.6% response rate. Across all survey respondents, only 28.2% of surgeons were female and 24.4% were URiM, with no programs reporting any non-binary surgeons. In the last 3 years, 95.8% programs reported an increase in female surgeons, while only 75.5% programs reported an increase in URiM surgeons. Program size made no difference in diversity across race or gender. DISCUSSION: Recent recruitment efforts are bringing change to departments of surgery. Retaining diverse faculty, ensuring equity in promotions, and giving every faculty the opportunity to thrive is essential to fostering diversity, equity and inclusion in surgery.

Bullying of vascular surgery trainees.

OBJECTIVE: Bullying is defined as the perception of negative actions in which the target has difficulty in defending themself. Bullying can include verbal, physical, and psychological force used to influence the target's behavior. We sought to understand the factors associated with bullying identified in vascular surgery trainees and the barriers to reporting. METHODS: An anonymous electronic survey consisting of demographic information and validated scales for bullying (negative acts questionnaire - revised [NAQ-R]), social support, and grit was sent to vascular surgery trainees in the United States. The respondents who had reported experiencing bullying were compared with those who had not been bullied. RESULTS: Of the 516 trainees invited, 132 (26%) completed the survey. Of these 132 trainees, 63 (48%) reported having been bullied or witnessing a fellow trainee being bullied in the previous 6 months, with 42 (32%) reporting having been bullied. Gender, marital status, paradigm of vascular training, grit level, and social support did not predict for the receipt of bullying, although those in the highest quartile of grit showed a trend toward lower NAQ-R scores (P = .06). As expected, the trainees that reported having experienced bullying had had higher NAQ-R scores (P < .0001). No trainee reported daily bullying; however, 52% reported bullying "now and then" or several times a week. The most common perpetrator was their direct superior surgeon, although 12 (29%) had reported bullying from co-residents and 6 (14%) had reported bullying from patients. Of the 42 trainees who had reported experiencing bullying, 15 (36%) did not address the bullying behavior. The most common barriers to reporting bullying identified were fear of loss of support from their supervisor (48%), loss of reputation (45%), and effect on career choices (43%). Of those who reported addressing the behavior, 56% reported that the behavior had continued. Of the 132 respondents, 70 (53%) reported no knowledge of institution-specific policies to address bullying in their program. The most common reasons identified for why bullying might occur in vascular training programs were "high stress environments" and "learned behavior" from others. CONCLUSIONS: Our results indicate that bullying occurs for a significant number of vascular trainees. However, we did not find any clearly identified factors predictive of who will experience bullying. Trainees with higher grit might experience less bullying or be more likely to have a lower perception of bullying behavior. Further research is needed to determine the effects of bullying on vascular trainees.

Evidence-based Guidelines on the Use of Virtual Surgical Education Pertaining to the Domains of Cognition and Curriculum, Psychomotor Skills Training, and Faculty Development and Mentorship.

OBJECTIVE: To identify, categorize, and evaluate the quality of literature, and to provide evidence-based guidelines on virtual surgical education within the cognitive and curricula, psychomotor, and faculty development and mentorship domains. SUMMARY OF BACKGROUND DATA: During the coronavirus disease 2019 pandemic, utilizing virtual learning modalities is expanding rapidly. Although the innovative methods must be considered to bridge the surgical education gap, a framework is needed to avoid expansion of virtual education without proper supporting evidence in some areas. METHODS: The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual education and to build evidence-based guidelines by utilizing the SiGN methodology. We identified patient/problem-intervention-comparison-outcome-style questions, conducted systematic literature reviews using PubMed, EMBASE, and Education Resources information Center databases. Then we formulated evidence-based recommendations, assessed the quality of evidence using Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle-Ottawa Scale for Education, and Kirkpatrick ratings, and conducted Delphi consensus to validate the recommendations. RESULTS: Eleven patient/problem-intervention-comparison-outcome-style questions were designed by the expert committees. After screening 4723 articles by the review committee, 241 articles met inclusion criteria for full article reviews, and 166 studies were included and categorized into 3 domains: cognition and curricula (n = 92), psychomotor, (n = 119), and faculty development and mentorship (n = 119). Sixteen evidence-based recommendations were formulated and validated by an external expert panel. CONCLUSION: The evidence-based guidelines developed using SiGN methodology, provide a set of recommendations for surgical training societies, training programs, and educators on utilizing virtual surgical education and highlights the area of needs for further investigation.

Independent Operating by General Surgery Residents: An ACS-NSQIP Analysis.

OBJECTIVE: Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time. DESIGN: We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications. SETTING: The ACS-NSQIP database. PARTICIPANTS: Patients undergoing one of 7 emergency general surgery operations. RESULTS: Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality. CONCLUSION: Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes.

Characterizing Epidemiology and Associated-Factors of Adolescent Sports-Related Traumas Using Trauma Quality Improvement Program.

ABSTRACT: Sports-related injuries contribute to a considerable proportion of pediatric and adolescent craniofacial trauma, which can have severe and longstanding consequences on physical and mental health. The growing popularity of sports within this at-risk group warrants further characterization of such injuries in order to enhance management and prevention strategies. In this study, the authors summarized key trends in 1452 sports-related injuries among individuals aged 16 to 19 using the American College of Surgeon's Trauma Quality Improvement Program database from 2014 to 2016. The authors observed a preponderance of injuries associated with skateboarding, snowboarding, and skiing, with significantly higher percentages of traumatic brain injuries among skateboarding-related traumas. Notably, we observed that traumatic brain injurie rates were slightly higher among subjects who wore helmets. Intensive care unit durations and hospital stays appeared to vary by sport and craniofacial fracture. Altogether, this study contributes to the adolescent sports-related injuries and craniofacial trauma literature.