Attributions and perpetrators of incivility in academic surgery.

Purpose: Although incivility has been described in other specialties, little is known about the attributes and perpetrators of it in academic surgery. The goal of this study was to identify attributes and commonly associated perpetrators of incivility experienced by trainees and faculty at academic surgery programs in the U.S. Methods: A web-based survey including the Workplace Incivility Scale (WIS) and questions regarding attributions and perpetrators of incivility was sent to trainees and faculty at academic institutions across the U.S. In addition to descriptive statistics, multivariable regression models were built to determine the impact of perpetrator type and number on overall incivility scores. Results: We received 367 of 2,661 (13.8%) responses. Top three reasons for incivility were surgery hierarchy (50.1%), respondent's gender (33.8%) and intergenerational differences (28.1%). Faculty (58.6%), patients (36.8%), and nursing staff (31.9%) were the most reported parties responsible for incivility. Female surgeons reported experiencing incivility more frequently from all three top responsible parties (i.e., faculty, patients, and nurses) when compared to other gender identities. Additionally, those who reported faculty (ß = 0.61, 95%CI 0.39-0.82) or nurses (ß = 0.23, 95%CI 0.009-0.45) as perpetrators of incivility reported an increase in overall incivility scores. Conclusions: Incivility in surgery is frequently attributed to surgery hierarchy, gender, and intergenerational differences. Surgical trainees and faculty reported that faculty, patients, and nurses were the most commonly identified as responsible for uncivil events in the surgical workforce. Exposure to a greater variety of perpetrators of incivility increases overall levels of incivility, emphasizing the importance of eliminating incivility from all sources. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00129-1.

Incivility, Work Withdrawal, and Organizational Commitment Among US Surgeons.

OBJECTIVE: To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment. BACKGROUND: Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large. METHODS: Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment. RESULTS: There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (ß = 0.504, 95% CI: 0.341-0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (ß = 0.178, 95% CI: 0.153-0.203). CONCLUSIONS: Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large.

Terminal Schwann Cells Are Essential for Neuromuscular Junction Function and Recovery after Nerve Injury.

BACKGROUND: Terminal Schwann cells (tSCs), nonmyelinating glial cells at the neuromuscular junction (NMJ), are integral to NMJ development, function, remodeling, and response to injury. It is essential to understand their requirement for NMJ function. In this study, the authors assessed consequences of immune-mediated tSC ablation in adult S100 -GFP mice of both sexes in homeostasis and after nerve injury. METHODS: The authors examined NMJ morphology and function in the extensor digitorum longus muscle during homeostasis at post-tSC ablation days 3, 14, and 42 and after peroneal nerve transection and immediate repair at 3 and 6 weeks after nerve injury and tSC ablation (postinjury and ablation). RESULTS: tSC ablation resulted in significant decreases ( P < 0.05) in tSC numbers per NMJ and end plate fragmentation. NMJ innervation and EDL tetanic force were significantly decreased at post-tSC ablation day 14 ( P < 0.05) and tSCs reestablished their NMJ coverage at post-tSC ablation day 42. After nerve injury, motor end plate fragmentation increased ( P < 0.01) with tSC ablation compared with injured control mice. NMJ reinnervation and extensor digitorum longus tetanic force were significantly reduced ( P < 0.001), even at 6 weeks postinjury and ablation, compared with control mice. CONCLUSION: These results add to the understanding that tSCs, with their proregenerative potential, help maintain NMJ integrity in homeostasis and are necessary for NMJ reinnervation after peripheral nerve injury. CLINICAL RELEVANCE STATEMENT: Terminal Schwann cells are integral for efficient NMJ recovery after nerve injury. This cell population may provide a novel therapeutic target to improve outcomes for patients with nerve injuries; additional investigation is warranted.

Long-term Health Outcomes of New Persistent Opioid Use After Surgery Among Medicare Beneficiaries.

OBJECTIVE: We examined long-term health outcomes associated with new persistent opioid use after surgery and hypothesized that patients with new persistent opioid use would have poorer overall health outcomes compared with those who did not develop new persistent opioid use after surgery. BACKGROUND: New persistent opioid use is a common surgical complication. Long-term opioid use increases risk of mortality, fractures, and falls; however, less is known about health care utilization among older adults with new persistent opioid use after surgical care. METHODS: We analyzed claims from a 20% national sample of Medicare beneficiaries ≥65 years undergoing surgery between January 1, 2009, and June 30, 2019. We estimated associations between new persistent use and subsequent health events between 6 and 12 months after surgery, including mortality, serious fall/fall-related injury, and respiratory or opioid/pain-related readmission/emergency department (ED) visits using a Cox proportional hazards model to estimate mortality and multivariable logistic regression for the remaining outcomes, adjusting for demographic/clinical characteristics. Our primary outcome was mortality within 6 to 12 months after surgery. Secondary outcomes included falls and readmissions or ED visits (respiratory, pain related/opioid related) within 6 to 12 months after surgery. RESULTS: Of 229,898 patients, 6874 (3.0%) developed new persistent opioid use. Compared with patients who did not develop new persistent opioid use, patients with new persistent opioid use had a higher risk of mortality (hazard ratio 3.44, CI, 2.99-3.96), falls [adjusted odds ratio (aOR): 1.21, 95% CI, 1.05-1.39], and respiratory-related (aOR: 1.67, 95% CI, 1.49-1.86) or pain-related/opioid-related (aOR: 1.68, 95% CI, 1.55-1.82) readmissions/ED visits. CONCLUSIONS: New persistent opioid use after surgery is associated with increased mortality and poorer health outcomes after surgery. Although the mechanisms that underlie this risk are not clear, persistent opioid use may also be a marker for greater morbidity requiring more care in the late postoperative period. Increased awareness of individuals at risk for new persistent use after surgery and close follow-up in the late postoperative period is critical to mitigate the harms associated with new persistent use.

"The Story I Will Never Forget": Critical Incident Narratives in Surgical Residency.

OBJECTIVE: We sought to better understand what defines a critical incident experience for the surgical trainee. SUMMARY BACKGROUND DATA: Critical incidents are formative moments stamped indelibly on one's memory that shape professional identity. The critical incident technique-using participants' narratives to identify patterns and learn from their perceptions-has been explored in some healthcare settings, but there has been no inquiry within surgery. METHODS: Surgical residents at 5 residency programs (1 community, 1 university-affiliated, 3 university) were surveyed using an online questionnaire from November to December 2020. Convenience sampling was used to identify the study population. Participants were invited to write about formative, impactful experiences in training. Interpretive description was the qualitative methodology used to locate information, analyze, and record patterns in the data. Individual responses were categorized and assessed for overlying themes. RESULTS: Overall, 28 narratives were collected from surgery residents in 3 specialties (general surgery, plastic surgery, and urology), with postgraduate year representation of post-graduate years 1 to 6. Respondents were 40% female. Nineteen of the narratives reported a negative experience. Four themes were identified from responses: 1) growth through personal self-reflection, 2) difficult interpersonal interactions, 3) positive team dynamics as a psychological safety net, and 4) supportive program cultures that promote learning. CONCLUSIONS: Critical incident narratives among surgical residents indicate that unforgettable and formative experiences-both positive and negative- occur in 4 domains: within the individual, within a relationship, among a team, and within a program. Further exploring these domains in surgical training will inform optimal educational programming to support trainee development and wellbeing.

Opioid Coprescribing with Sedatives after Implant-Based Breast Reconstruction.

BACKGROUND: Skeletal muscle relaxants and benzodiazepines are thought to mitigate against postoperative muscle contraction. The Centers for Disease Control and Prevention and the Food and Drug Administration warn against coprescribing them with opioids because of increased risks of overdose and death. The authors evaluated the frequency of coprescribing of opioids with skeletal muscle relaxants or benzodiazepines after implant-based reconstruction. METHODS: The authors examined health care claims to identify women (18 to 64 years old) who underwent implant-based breast reconstruction between January of 2008 and June of 2019 to determine the frequency of coprescribing, factors associated with coprescribing opioids and skeletal muscle relaxants or benzodiazepines, and the impact on opioid refills within 90 days of reconstruction. RESULTS: A total of 86.7 percent of women ( n = 7574) who had implant-based breast reconstruction filled an opioid prescription perioperatively. Of these, 27.7 percent of women filled prescriptions for opioids and benzodiazepines, 14.4 percent for opioids and skeletal muscle relaxants, and 2.4 percent for opioids, benzodiazepines, and skeletal muscle relaxants. Risk factors for coprescribing opioids and benzodiazepines included use of acellular dermal matrix, immediate reconstruction, and history of anxiety. Women who filled prescriptions for opioids and skeletal muscle relaxants, opioids and benzodiazepines, and opioids with skeletal muscle relaxants and benzodiazepines were significantly more likely to refill opioid prescriptions, even when controlling for preoperative opioid exposure. CONCLUSIONS: Nearly half of women filled an opioid prescription with a benzodiazepine, skeletal muscle relaxant, or both after implant-based breast reconstruction. Coprescribing of opioids with skeletal muscle relaxants may potentiate opioid use after surgery and should be avoided given the risks of sedation. Identifying strategies that avoid sedatives to manage pain after breast reconstruction is critical to mitigate high-risk prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Influence of faculty diversity on resident diversity across surgical subspecialties.

BACKGROUND: Disparities among women and individuals from racial/ethnic minority groups persist in surgical specialties at all training levels. We hypothesized that these populations are underrepresented in surgical specialties, and that diversity in faculty is correlated with diversity in trainees. METHODS: Linking aggregate data from the Association of American Medical Colleges (AAMC) Faculty Roster and the Graduate Medical Education (GME) Track databases, we evaluated self-reported gender and racial/ethnic composition of faculty and residents across six surgical specialties. RESULTS: Programs with more women faculty had significantly greater numbers of women residents. Programs with more faculty from racial/ethnic minority groups were significantly associated with greater numbers of residents from racial/ethnic minority groups. From 2001 to 2017, the proportion of women residents, women faculty, and faculty from racial/ethnic minority groups increased across all specialties; however, the proportion of residents from racial/ethnic minority groups remained unchanged. CONCLUSIONS: In surgical specialties, diversity among faculty and trainees are correlated. However, the proportion of residents from racial/ethnic minority groups has remained unchanged, even among programs with the highest proportion of faculty from racial/ethnic minority groups.

Identifying Strategies for Struggling Surgery Residents.

BACKGROUND: Struggling residents are not uncommon in general surgery. Early identification of these residents and effective remediation remain imperfect. MATERIALS AND METHODS: We performed a survey of program directors (PD) across all general surgery residencies. Survey questions included the following: demographic information about the program and PD, 10 vignettes about hypothetical residents struggling in various ACGME milestones to assess how PDs would address these deficiencies, and self-reported PD preparedness and availability of resources to support struggling residents. RESULTS: In total, we received 82 responses to our survey. All PDs who participated in our study reported having struggling residents in their program. The three most common ways struggling residents are identified were faculty word-of-mouth, formal evaluations such as milestones and ABSITE performance, and resident word-of-mouth. Over 18% of PDs reported having little to no relevant training in addressing the needs of a struggling resident, and 65.9% of PDs did not feel that their program had 'completely adequate' resources to address these needs. In the majority of cases, PDs offer mentorship with themselves or other faculty as a remediation strategy with infrequent use of other resources. CONCLUSIONS: Strategies to identify struggling residents and remediation strategies varied widely across programs. Diversifying remediation approaches should be considered for more effective remediation.

A Simple Brochure Improves Disposal of Unused Opioids: An Observational Cross-Sectional Study.

BACKGROUND: We evaluated the effectiveness of a simple, low-cost educational brochure in improving disposal rates of unused opioids after outpatient upper extremity surgery. METHODS: This cross-sectional study enrolled eligible adult patients from a peripheral nerve clinic between November 2017 and September 2018. Patients either received or did not receive the educational brochure, which outlined a simple method to dispose of unused opioids and completed a survey at 2 weeks after surgery. We compared the proportion of patients who disposed of unused opioids after surgery between the group that had received the brochure and the group that had not. Categorical data were analyzed with χ2 test, proportions data with binomial tests, and numerical data with Mann-Whitney U test, all with a significance level of P < .05. RESULTS: There were 339 survey respondents. Nineteen patients who did not meet inclusion criteria were excluded. Of the 320 remaining patients, 139 received the brochure and 181 did not. An additional 55 patients were excluded due to preoperative opioid use. Overall, 35.3% of recipients and 38.3% of those who did not receive the brochure used all of their prescribed opioid medication (P = .625; confidence interval = -14.6%-8.8%). Among patients with unused opioid medication, a significantly higher proportion of brochure recipients disposed of the medicine compared with those who did not receive the brochure (46.7% vs 19.6%, P < .001). CONCLUSIONS: Distribution of an educational brochure significantly improved disposal of unused opioids after surgery. This easily implemented intervention can improve disposal of unused opioids and ultimately decrease excess opioids available for diverted use in the community.

Preoperative Opioid Use and Readmissions Following Surgery.

OBJECTIVE: To assess the association between preoperative opioid exposure and readmissions following common surgery. SUMMARY BACKGROUND DATA: Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown. METHODS: We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type. RESULTS: Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29). CONCLUSIONS: Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.

Contralateral prophylactic mastectomy and implications for breast reconstruction.

Contralateral prophylactic mastectomy (CPM) rates have continued to rise in the United States, impacting all stakeholders including plastic and reconstructive surgeons. Multiple factors may be influencing this trend, including patient decision-making characteristics, knowledge about breast cancer disease and prognosis, advances in genetic testing and enhanced imaging capabilities, sociodemographic factors, and access to specialty surgical services such as breast reconstruction. In this review, the authors shed light on the current state of CPM and summarize the literature analyzing its increasing prevalence in the United States, as well as outline future directions for study and dissemination of knowledge from providers to patients surrounding this important and complex treatment decision.

Opioid Use among Adolescents Undergoing Surgical Repair of Facial Trauma.

BACKGROUND: New persistent opioid use has been quantified among adults undergoing surgery; less is known about the risk among adolescents. The authors examine new persistent opioid use in opioid-naive adolescent patients who underwent operative repair of facial fractures. METHODS: Using the IBM MarketScan Commercial Database, the authors performed a retrospective analysis of patients aged 11 to 17 years who underwent facial fracture repair between 2006 and 2015. The incidences of prolonged opioid use and potentially inappropriate opioid prescriptions were determined. RESULTS: Of 4892 patients, 78.5 percent filled a prescription. Among these patients, 7.9 percent had prolonged opioid use. Significant risk factors included older age (i.e., age 15 to 17 years) (OR, 1.579; 95 percent CI, 1.173 to 2.126 compared to younger patients), multiple comorbidities (OR, 3.005; 95 percent CI, 1.193 to 7.568), mandible fracture (OR, 1.614; 95 percent CI, 1.213 to 2.146), and multiple fractures (OR, 1.542; 95 percent CI, 1.002 to 2.372). Overall, 24.1 percent received a potentially inappropriate opioid prescription. Mandible fracture repair was associated with increased risk (OR, 2.753; 95 percent CI, 2.275 to 3.331) of potentially inappropriate opioid prescription. CONCLUSIONS: Nearly one in 12 adolescents met criteria for prolonged opioid use; nearly one in four received a potentially inappropriate opioid prescription. Significant risk factors included mandible fracture, older age, multiple comorbidities, and multiple fractures. Like adults, many adolescents are at high risk for potentially inappropriate opioid prescriptions and prolonged opioid use following surgical repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Women in Leadership and Their Influence on the Gender Diversity of Academic Plastic Surgery Programs.

BACKGROUND: Women seldom reach the highest leadership positions in academic plastic surgery. Contributing factors include lack of female role models/mentors and lack of gender diversity. Studies show that female role models and mentors are critical for recruiting and retaining female surgeons and that gender diversity within organizations more strongly influences women's career choices. The authors therefore sought to determine the current gender diversity of academic plastic surgery programs and investigate influences of gender and leadership on program gender composition. METHODS: A cross-sectional study of U.S. plastic surgery residency programs was performed in December of 2018. Genders of the leadership were collected, including medical school dean, department of surgery chair, department/division of plastic surgery chair/chief, plastic surgery program director, plastic surgery faculty, and plastic surgery residents. Gender relationships among these groups were analyzed. RESULTS: Ninety-nine residency programs were identified (79 integrated with or without independent and 20 independent). Women represented a smaller proportion of academic plastic surgeons in more senior positions (38 percent residents, 20 percent faculty, 13 percent program directors, and 8 percent chairs). Plastic surgery chair gender was significantly correlated with program director gender, and plastic surgery faculty gender was significantly associated with plastic surgery resident gender. Although not statistically significant, female plastic surgery chair gender was associated with a 45 percent relative increase in female plastic surgery residents. CONCLUSIONS: Women in leadership and gender diversity influence the composition of academic plastic surgery programs. Gender disparity exists at all levels, worsening up the academic ladder. Recruitment, retention, and promotion of women is critical, as such diversity is required for continued progress in innovation and problem-solving within plastic surgery.

Comparing Nipple-sparing Mastectomy to Secondary Nipple Reconstruction: A Multi-institutional Study.

OBJECTIVE: The primary aim of this study was to compare patient-reported outcomes (PROs) of women who underwent immediate implant-based breast reconstruction (IBBR) after receiving either: (1) nipple-sparing mastectomy (NSM) or (2) simple mastectomy with subsequent nipple reconstruction (SNR). BACKGROUND: The goal of post-mastectomy breast reconstruction is to restore body image and quality-of-life after mastectomy, but removal of the nipple-areolar complex may have its own negative psychosocial consequences. NSM may have increased in popularity due to its perceived oncologic safety in many women and to reports of superior aesthetic results with this technique. Despite the increased utilization of NSM, few studies have evaluated the impact of NSM on PROs and complications in women undergoing immediate IBBR. METHODS: We performed a secondary analysis of the Mastectomy Reconstruction Outcomes Consortium study, a multicenter, prospective cohort study that recruited patients between February 2012 and July 2015. The primary aim of this study was to compare PROs as measured by BREAST-Q scores between women who underwent IBBR after NSM versus SNR. The secondary aim was to compare complication rates. Mixed-effects regression models controlled for demographic and clinical covariates. RESULTS: Of the 600 women in the study, 286 (47.7%) underwent NSM. After controlling for baseline patient characteristics, we found no significant differences in satisfaction with breast, psychosocial well-being, physical well-being or sexual well-being between women undergoing NSM versus SNR. Mastectomy type was not a significant predictor of complications or reconstructive failure. CONCLUSIONS: Despite reports of superior aesthetics for NSM over simple mastectomy with nipple reconstruction in immediate IBBR, we found no significant differences at 2 years after reconstruction in patient satisfaction, quality-of-life, or complication rates.

Macrophage-Derived Vascular Endothelial Growth Factor-A Is Integral to Neuromuscular Junction Reinnervation after Nerve Injury.

Functional recovery in the end target muscle is a determinant of outcome after peripheral nerve injury. The neuromuscular junction (NMJ) provides the interface between nerve and muscle and includes non-myelinating terminal Schwann cells (tSCs). After nerve injury, tSCs extend cytoplasmic processes between NMJs to guide axon growth and NMJ reinnervation. The mechanisms related to NMJ reinnervation are not known. We used multiple mouse models to investigate the mechanisms of NMJ reinnervation in both sexes, specifically whether macrophage-derived vascular endothelial growth factor-A (Vegf-A) is crucial to establishing NMJ reinnervation at the end target muscle. Both macrophage number and Vegf-A expression increased in end target muscles after nerve injury and repair. In mice with impaired recruitment of macrophages and monocytes (Ccr2-/- mice), the absence of CD68+ cells (macrophages) in the muscle resulted in diminished muscle function. Using a Vegf-receptor 2 (VegfR2) inhibitor (cabozantinib; CBZ) via oral gavage in wild-type (WT) mice resulted in reduced tSC cytoplasmic process extension and decreased NMJ reinnervation compared with saline controls. Mice with Vegf-A conditionally knocked out in macrophages (Vegf-Afl/fl; LysMCre mice) demonstrated a more prolonged detrimental effect on NMJ reinnervation and worse functional muscle recovery. Together, these results show that contributions of the immune system are integral for NMJ reinnervation and functional muscle recovery after nerve injury.SIGNIFICANCE STATEMENT This work demonstrates beneficial contributions of a macrophage-mediated response for neuromuscular junction (NMJ) reinnervation following nerve injury and repair. Macrophage recruitment occurred at the NMJ, distant from the nerve injury site, to support functional recovery at the muscle. We have shown hindered terminal Schwann cell (tSC) injury response and NMJ recovery with inhibition of: (1) macrophage recruitment after injury; (2) vascular endothelial growth factor receptor 2 (VegfR2) signaling; and (3) Vegf secretion from macrophages. We conclude that macrophage-derived Vegf is a key component of NMJ recovery after injury. Determining the mechanisms active at the end target muscle after motor nerve injury reveals new therapeutic targets that may translate to improve motor recovery following nerve injury.