Defining Types of Leadership Within an Academic Surgery Department to Promote Change for Decreasing Rates of Burnout.

OBJECTIVES: Successful leaders influence the group they represent. Effective surgical care is tied to its leadership climate. However, most surgical providers are not attuned to their individual strengths which if known they could leverage them within their teams. This study identifies leadership types within a department of surgery which may be used to better understand and cultivate their strengths. METHODS: In 2022, 172 providers in an academic surgery department were offered the GallupTM CliftonStrengths assessment, a proprietary instrument that maps 34 strengths across 4 domains of leadership. The assessment provides a respondent with their top 5 strengths and the domain in which they naturally "lead". RESULTS: Of 172 providers, 127 (74%) completed the assessment. While providers have strengths in multiple domains, they "lead with" a specific domain. Mapped from the providers' top 10 strengths, the most common "lead with" domain for surgical providers was Executing: the ability to implement ideas and produce results. Strategic Thinking: those who are analytical and push teams forward and Relationship Building: the ability to create strong and effective teams were followed by the least common domain. Influencing: the ability to communicate ideas and lead others. Formal leaders were significantly more likely to lead with Strategic Thinking. There were no significant differences between APPs and physicians. CONCLUSION: A majority of surgical providers "lead with" the GallupTM Executing domain. Those who lead with executing skills work tirelessly to produce outcomes. Learning to leverage the strengths of our teams to create cohesion and efficiency may improve engagement and retention.

Patient and Family Mistreatment of Residents in the Surgical Learning Environment.

OBJECTIVE: Identify the frequency and types of mistreatment experienced by residents from patients and their families (P&F) and determine whether the types and frequency varied based on resident gender. DESIGN: An anonymous survey was distributed to residents to assess the types of P&F mistreatment toward residents and the association with resident gender. SETTING: The survey was distributed to the general surgery and urology programs at a large academic medical center in the mid-Atlantic. Participants: 23 of 53 residents (43% response rate) participated in the anonymous survey. Residents: 15 male residents (65%), 8 female residents (35%). Results: 12 of 23 responding residents (52%) indicated they experienced at least one form of mistreatment from P&F. Women were more likely to experience mistreatment (88% vs. 33%), with verbal assault was the most frequent (50% for female residents, 33% for male residents). Patients were more often the source than families (52% vs. 41%); verbal assault or threats of physical harm were the most common (50% for female residents, 33% for male residents). CONCLUSIONS: Residents experience mistreatment from multiple sources. This paper provides insight into the experiences of surgical residents with mistreatment from their P&F, with differences in frequency of behaviors dependent upon the perpetrator group and resident gender. Patients and their family mistreatments are likely underreported and may be more difficult to prevent. It is important to identify mitigation strategies and ensure resources are available for those residents experiencing mistreatment. A strong culture against mistreatment and providing specific resources may minimize the experience and negative effects of mistreatment.

Physician mistreatment in the clinical learning environment.

BACKGROUND: Mistreatment has been correlated with burnout and poor well-being in medical students, but data regarding residents and faculty are limited. The objective was to investigate the prevalence of mistreatment towards surgical housestaff and faculty and characterize such experiences. METHODS: In 2018, the Department of Surgery surveyed housestaff and faculty on incidents of mistreatment. RESULTS: Clinical faculty (63%) and residents (72%) completed the mistreatment survey. Excluding public embarrassment, 48% of residents and 29% of clinical faculty experienced mistreatment. Residents experienced public embarrassment and public humiliation more frequently than faculty, however faculty were subjected to racially or ethnically offensive remarks/names more frequently than residents (p < .05). Faculty within and external to their department were most cited as instigators of mistreatment. Residents experienced mistreatment most often by faculty, co-residents, and nurses. Reporting of the behaviors was low. CONCLUSIONS: Incidents of mistreatment are frequently occurring for surgical residents and faculty.

It Is Time for Zero Tolerance for Sexual Harassment in Academic Medicine.

While more women are in leadership positions in academic medicine now than ever before in U.S. history, evidence from recent surveys of women and graduating medical students demonstrates that sexual harassment continues in academic health centers. Academic medicine's ability to change its culture is hampered by victims' fear of reporting episodes of harassment, which is largely due to fear of retaliation. In this Perspective, the authors describe efforts in scientific societies to address the issue of sexual harassment and to begin to establish safe environments at national meetings. The authors contend that each institution must work to make it safe for individuals to come forward, to provide training for victims and for bystanders, and to abolish "locker room" talk that is demeaning to women.

Striving for Gender Equity in Academic Medicine Careers: A Call to Action.

Women represent approximately half of students entering medical schools and more than half of those entering PhD programs. When advancing through the academic and professional fields, however, women continually face barriers that men do not. In this Commentary, the authors offer ideas for coordinating the efforts of organizations, academic institutions, and leaders throughout the scientific and medical professions to reduce barriers that result in inequities and, instead, strive for gender parity. Specific areas of focus outlined by the authors include facilitating women's access to formal and informal professional networks, acknowledging and addressing the gender pay gap as well as the lack of research funding awarded to women in the field, and updating workplace policies that have not evolved to accommodate women's lifestyles. As academic institutions seek access to top talent and the means to develop those individuals capable of generating the change medicine and science needs, the authors urge leaders and change agents within academic medicine to address the systemic barriers to gender equity that impede us from achieving the mission to improve the health of all.

Correlation of venous thromboembolism prophylaxis and electronic medical record alerts with incidence among surgical patients.

BACKGROUND: Venous thromboembolism events are potentially preventable adverse events. We investigated the effect of interruptions and delays in pharmacologic prophylaxis on venous thromboembolism incidence. Additionally, we evaluated the utility of electronic medical record alerts for venous thromboembolism prophylaxis. METHODS: Venous thromboembolisms were identified in surgical patients retrospectively through Core Measure Venous ThromboEmbolism-6-6 and Patient Safety Indicator 12 between November 2013 and March 2015. Venous thromboembolism pharmacologic prophylaxis and prescriber response to electronic medical record alerts were recorded prospectively. Prophylaxis was categorized as continuous, delayed, interrupted, other, and none. RESULTS: Among 10,318 surgical admissions, there were 131 venous thromboembolisms; 23.7% of the venous thromboembolisms occurred with optimal continuous prophylaxis. Prophylaxis, length of stay, age, and transfer from another hospital were associated with increased venous thromboembolism incidence. Compared with continuous prophylaxis, interruptions were associated with 3 times greater odds of venous thromboembolism. Delays were associated with 2 times greater odds of venous thromboembolism. Electronic medical record alerts occurred in 45.7% of the encounters and were associated with a 2-fold increased venous thromboembolism incidence. Focus groups revealed procedures as the main contributor to interruptions, and workflow disruption as the main limitation of the electronic medical record alerts. CONCLUSION: Multidisciplinary strategies to decrease delays and interruptions in venous thromboembolism prophylaxis and optimization of electronic medical record tools for prophylaxis may help decrease rates of preventable venous thromboembolism.

Randomized controlled trials: a systematic review of laparoscopic surgery and simulation-based training.

INTRODUCTION: This systematic review was conducted to analyze the impact and describe simulation-based training and the acquisition of laparoscopic surgery skills during medical school and residency programs. METHODS: This systematic review focused on the published literature that used randomized controlled trials to examine the effectiveness of simulation-based training to develop laparoscopic surgery skills. Searching PubMed from the inception of the databases to May 1, 2014 and specific hand journal searches identified the studies. This current review of the literature addresses the question of whether laparoscopic simulation translates the acquisition of surgical skills to the operating room (OR). RESULTS: This systematic review of simulation-based training and laparoscopic surgery found that specific skills could be translatable to the OR. Twenty-one studies reported learning outcomes measured in five behavioral categories: economy of movement (8 studies); suturing (3 studies); performance time (13 studies); error rates (7 studies), and global rating (7 studies). CONCLUSION: Simulation-based training can lead to demonstrable benefits of surgical skills in the OR environment. This review suggests that simulation-based training is an effective way to teach laparoscopic surgery skills, increase translation of laparoscopic surgery skills to the OR, and increase patient safety; however, more research should be conducted to determine if and how simulation can become apart of surgical curriculum.

International women physicians' perspectives on choosing an academic medicine career.

UNLABELLED: Concerns about recruiting physicians into academic careers is an international issue. A qualitative study with United States (US) women physicians revealed insights into how, when, and why physicians choose an academic career in medicine. The current study explored international women physicians' perspectives on their career choice of academic medicine and determined if different themes emerged. We expanded the 2012 study of US women physicians by interviewing women physicians in Canada, Pakistan, Mexico, and Sweden to gain an international perspective on choosing an academic career. Interviews were thematically analyzed against themes identified in the previous study. Based on themes identified in the study of US physicians, qualitative analysis of 7 international women physicians revealed parallel themes for the following areas: Why academic medicine? Fit; People; Aspects of academic health centre environment. How the decision to enter academic medicine was made? Decision-making style; Emotionality When the decision to enter academic medicine was made? Practising physician; Fellowship; Medical student. Work-life balance, choosing academic medicine by default, serendipity, intellectual stimulation, mentors, research and teaching were among the areas specifically highlighted. CONCLUSION: Parallel themes exist regarding how, why, and when US and international women physicians choose academic medicine as a career path.

Women physicians: choosing a career in academic medicine.

PURPOSE: Despite recent efforts to understand the complex process of physician career development, the medical education community has a poor understanding of why, how, and when women physicians embark on careers in academic medicine. METHOD: In 2010, the authors phone-interviewed women physicians in academic medicine regarding why, how, and when they chose academic medicine careers. Project investigators first individually and then collectively analyzed transcripts to identify themes in the data. RESULTS: Through analyzing the transcripts of the 53 interviews, the investigators identified five themes related to why women choose careers in academic medicine: fit, aspects of the academic health center environment, people, exposure, and clinical medicine. They identified five themes related to how women make the decision to enter academic medicine: change in specialty, dissatisfaction with former career, emotionality, parental influence, and decision-making styles. The authors also identified four themes regarding when women decide to enter academic medicine: as a practicing physician, fellow, resident, or medical student. CONCLUSIONS: Choosing a career in academic medicine is greatly influenced by the environment in which one trains and by people-be they faculty, mentors, role models, or family. An interest in teaching is a primary reason women choose a career in academic medicine. Many women physicians entering academic medicine chose to do so after or during fellowship, which is when they became more aware of academic medicine as a possible career. For many women, choosing academic medicine was not necessarily an active, planned decision; rather, it was serendipitous or circumstantial.

Patient factors affecting operative times for single-incision trans-axillary robotic-assisted (STAR) thyroid lobectomy: does size matter?

BACKGROUND: Single-incision, transaxillary, robotic-assisted (STAR) thyroid lobectomy using a robotic surgical system is a novel surgical approach that is extensively described in Korean patients. Some have suggested that this experience will not translate into the American population because of differing body habitus and because the mean size of the thyroid nodules removed in Korea are <1 cm. We reviewed our experience with STAR thyroid lobectomy. METHODS: We retrospectively reviewed our prospectively collected data on consecutive cases of STAR thyroid lobectomy performed by a single surgeon. Operative times and patient outcomes were evaluated. RESULTS: Seventeen operations were performed on 15 patients. Mean total operative time was 219.3 (range, 183-256) minutes. All patients were discharged on postoperative day 1. Postoperative complications were seromas (n = 2) and cellulitis (n = 2). Operative time did not vary with the size or volume of the nodule or gland. The mean nodule diameter was 1.9 (range, 0.5-3.1) cm. The mean nodule volume and thyroid volume were 5.0 (range, 0.1-16.7) cm(3) and 20.7 (range, 11.8-45.8) cm(3), respectively. When stratified by body mass index (range, 19.6-37.8), normal versus overweight or obese, total operative time increased from 204 to 225 min, and console time from 114 to 125 min. CONCLUSIONS: STAR thyroid surgery is a feasible technique. Factors, such as mass size, specimen volume, and patient body mass index, had little effect on operative times. These differences should not hinder the adoption of this procedure in North America, because new retractor systems help to overcome them. Further evaluation of this procedure is reasonable and safe.

Virginia Commonwealth University: committed to the professional growth of women in surgery.

Academic surgery programs need to offer avenues not only to increase recruitment of women, but also to provide support so women can stay in the surgical field successfully. Virginia Commonwealth University has served to enable the growth of women surgeons in their careers. This article reviews the aspects in which this institution has provided with the necessary support for career and personal growth.

How, when, and why do physicians choose careers in academic medicine? A literature review.

PURPOSE: Medicine has different pathways in which physicians pursue their vocation. Clinical practice, research, and academia are common paths. The authors examined the literature to identify research-based factors influencing physicians to choose a career path in academic medicine. METHOD: In the fall of 2006, the authors searched the PubMed database from 1960 to 2006 using the term career academic medicine. Review of articles resulted in the identification of nine themes relating to academic medicine career paths. The authors summarized the important and relevant articles to capture what the literature contributed as a whole to the larger question, "How, when, and why do physicians choose an academic career in medicine?" RESULTS: A synthesis of articles revealed that (1) values are essential to understanding the decision to enter a career in academic medicine, (2) factors associated with academic medicine career choice include research-oriented programs, gender, and mentors and role models, (3) an obstacle to pursuing this career path is loss of interest in academic careers during residency as residents learn about factors associated with academic careers in medicine, and (4) debt may be a barrier to choosing an academic career in medicine for some individuals in some specialties. CONCLUSIONS: Despite the study findings, the larger question (stated above) remains essentially unanswered in the literature. The authors propose a call to action by various professional groups and organizations to use rigorous and complex research efforts to seek answers to this very important question.

Recapitulation of pancreatic neuroendocrine tumors in human multiple endocrine neoplasia type I syndrome via Pdx1-directed inactivation of Men1.

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal syndrome caused by mutations in the MEN1 tumor suppressor gene. Whereas the protein product of MEN1, menin, is ubiquitously expressed, somatic loss of the remaining wild-type MEN1 allele results in tumors primarily in parathyroid, pituitary, and endocrine pancreas. To understand the endocrine specificity of the MEN1 syndrome, we evaluated biallelic loss of Men1 by inactivating Men1 in pancreatic progenitor cells using the Cre-lox system. Men1 deletion in progenitor cells that differentiate into exocrine and endocrine pancreas did not affect normal pancreas morphogenesis and development. However, mice having homozygous inactivation of the Men1 in pancreas developed endocrine tumors with no exocrine tumor manifestation, recapitulating phenotypes seen in the MEN1 patients. In the absence of menin, the endocrine pancreas showed increase in cell proliferation, vascularity, and abnormal vascular structures; such changes were lacking in exocrine pancreas. Further analysis revealed that these endocrine manifestations were associated with up-regulation in vascular endothelial growth factor expression in both human and mouse MEN1 pancreatic endocrine tumors. Together, these data suggest the presence of cell-specific factors for menin and a permissive endocrine environment for MEN1 tumorigenesis in endocrine pancreas. Based on our analysis, we propose that menin's ability to maintain cellular and microenvironment integrity might explain the endocrine- restrictive nature of the MEN1 syndrome.

Intralymphatic dendritic cell vaccination induces tumor antigen-specific, skin-homing T lymphocytes.

PURPOSE: The identification of tumor antigens recognized by cytotoxic and T helper lymphocytes has led to the development of specific cancer vaccines. Immunization with tumor antigen-pulsed dendritic cells has proved effective at eliciting elevated levels of tumor antigen-specific T cells in patient blood, but objective clinical responses remain rare, suggesting that vaccine-induced T cells are not trafficking optimally to site(s) of tumor burden. Accumulating evidence from animal models suggests that route of immunization can have a substantial influence on the subsequent migration of primed, activated T cells in vivo. EXPERIMENTAL DESIGN: In a clinical trial designed to elicit more effective cytotoxic T-cell mediated antitumor responses, metastatic melanoma patients were immunized directly via a peripheral intralymphatic route with autologous dendritic cells pulsed with HLA-A*0201-restricted melanoma-associated peptide antigens derived from MART-1 and gp100. RESULTS: Within 10 days of intralymphatic dendritic cell vaccination, four of six patients developed dramatic and diffuse erythematous rashes in sun-exposed areas of skin that showed extensive T-cell infiltration. CTLs grown from rash biopsies were strongly enriched for tumor antigen-specific T cells that had elevated expression of cutaneous lymphocyte antigen and chemokine receptor-6, consistent with a skin-homing phenotype. Of note, the only patient in the study with cutaneously localized disease showed a significant regression of metastatic lesions following the development of a surrounding rash. CONCLUSIONS: The evidence presented here is consistent with immunization studies in animal models and supports the concept that T cells are "imprinted" in peripheral lymph node sites to express specific ligands and chemokine receptors that allow them to migrate to skin. Furthermore, the preferential migration of the T cells to sun-exposed cutaneous sites suggests that inflammation plays a critical role in this migration. These observations suggest that further study of the effects of immunization route and inflammation on T-cell migration in humans is warranted, and could lead to vaccination approaches that would more reliably direct trafficking of activated T cells to diverse sites of metastatic disease.

Tumor-associated endothelial cells display GSTP1 and RARbeta2 promoter methylation in human prostate cancer.

BACKGROUND: A functional blood supply is essential for tumor growth and proliferation. However, the mechanism of blood vessel recruitment to the tumor is still poorly understood. Ideally, a thorough molecular assessment of blood vessel cells would be critical in our comprehension of this process. Yet, to date, there is little known about the molecular makeup of the endothelial cells of tumor-associated blood vessels, due in part to the difficulty of isolating a pure population of endothelial cells from the heterogeneous tissue environment. METHODS: Here we describe the use of a recently developed technique, Expression Microdissection, to isolate endothelial cells from the tumor microenvironment. The methylation status of the dissected samples was evaluated for GSTP1 and RARbeta2 promoters via the QMS-PCR method. RESULTS: Comparing GSTP1 and RARbeta2 promoter methylation data, we show that 100% and 88% methylation is detected, respectively, in the tumor areas, both in epithelium and endothelium. Little to no methylation is observed in non-tumor tissue areas. CONCLUSION: We applied an accurate microdissection technique to isolate endothelial cells from tissues, enabling DNA analysis such as promoter methylation status. The observations suggest that epigenetic alterations may play a role in determining the phenotype of tumor-associated vasculature.

Gene promoter methylation in prostate tumor-associated stromal cells.

BACKGROUND: Gene expression can be silenced through the methylation of specific sites in the promoter region. This mechanism of gene silencing has an important role in the carcinogenesis of prostate and other cancers. Although tumor-associated stromal cells also exhibit changes in gene expression, promoter methylation has not been described in these cells. METHODS: Tumor epithelia, tumor-associated stroma and normal epithelia, and stroma adjacent to tumor tissues were isolated from whole-mount prostatectomy specimens (two per patient) of patients (n = 5) with localized prostate cancer and from normal epithelia and stroma from benign prostate hyperplasia specimens (two per patient) from men (n = 5) without prostate cancer by using laser capture microdissection or expression microdissection. The methylation status of three genes important in prostate carcinogenesis, GSTP1, RARbeta2, and CD44, were evaluated using quantitative methylation-sensitive polymerase chain reaction. RESULTS: GSTP1 and RARbeta2 were methylated in the tumor epithelium of all five prostate cancer patients and in the tumor-associated stroma in four of the five patients. CD44 was methylated in the tumor epithelium from four of the five patients but not in the tumor stroma. GSTP1 and RARbeta2 were methylated in normal epithelium of two and four patients, respectively, and in normal stroma of one and two patients, respectively, that were isolated from regions adjacent to the tumors and may have resulted from a tumor-field effect; CD44 methylation was not observed in normal epithelium or stroma. In contrast, normal epithelia and stroma from benign prostate hyperplasia specimens showed no promoter methylation in GSTP1, RARbeta2, or CD44. CONCLUSIONS: The observation of promoter methylation in the non-neoplastic cells of the prostate tumor microenvironment may advance our understanding of prostate cancer development and progression and lead to new diagnostic and prognostic markers and therapeutic targets.

A prospective evaluation of laparoscopic exploration with intraoperative ultrasound as a technique for localizing sporadic insulinomas.

BACKGROUND: Preoperative imaging studies localize insulinomas in less than 50% of patients. Arteriography with calcium stimulation and venous sampling (ASVS) regionalizes greater than 90% of insulinomas but requires specialized expertise and an invasive procedure. This prospective study evaluated laparoscopic exploration with IOUS compared with the other localization procedures in patients with a sporadic insulinoma. METHODS: Between March 2001 and October 2004, 14 patients (7 women and 7 men; mean age, 53) with an insulinoma were enrolled in an IRB-approved protocol. Computed tomography, magnetic resonance imaging, ultrasound scan, and arteriography with calcium stimulation and venous sampling were performed preoperatively. A surgeon, blinded to the results of the localizing studies, performed a laparoscopic exploration with intraoperative ultrasound (IOUS). At the completion of the exploration, the success of laparoscopy for localization was scored, and the tumor was resected. RESULTS: Twelve of 14 tumors were localized successfully before laparoscopy (noninvasive, 7 of 14; invasive, 11 of 14). Laparoscopic IOUS localized successfully 12 of 14 tumors. All lesions were resected, and all patients were cured (median follow-up, 36 months). CONCLUSION: Laparoscopic IOUS identified 86% of tumors. The authors consider laparoscopic IOUS to be equivalent to ASVS in localizing insulinomas. Further study is therefore warranted to determine the role of laparoscopy with IOUS in the localization and treatment algorithm for patients with sporadic insulinoma.

Simultaneous targeting of CD3 on T cells and CD40 on B or dendritic cells augments the antitumor reactivity of tumor-primed lymph node cells.

To date, molecular targets chosen for Ab activation to generate antitumor effector cells have been confined on T cells, such as TCR/CD3, CD28, CD137 (4-1BB), CD134 (OX40), and inducible costimulator. In this report we investigated the immune function of murine tumor-draining lymph node (TDLN) cells after simultaneous Ab targeting of CD3 on T cells and CD40 on APCs. Anti-CD3 plus anti-CD40-activated TDLN cells secreted significantly higher amounts of IFN-gamma, but less IL-10, compared with anti-CD3-activated cells. In adoptive immunotherapy, ligation of CD3 and CD40 resulted in the generation of more potent effector cells in mediating tumor regression. Freshly harvested TDLN cells were composed of approximately 60% CD3+ T cells, 30-35% CD19+ B cells, 5% CD11c+ dendritic cells (DC), and few CD14+ or NK cells (each <3%). CD40 was distributed predominantly on B cells and DCs. Cell depletion indicated that simultaneous targeting was toward CD3 on T cells and CD40 on APCs, respectively. Elimination of APCs completely abrogated the augmented antitumor responses induced by anti-CD40. Either B cell or DC removal partially, but significantly, reduced the therapeutic efficacy conferred by CD40 engagement. Furthermore, the immunomodulation function of anti-CD40 was associated with its capability to increase IL-12 secretion while inhibiting IL-4 production. Our study establishes a role for CD40 expressed on B cells or DCs in the costimulation of TDLN cells. Eliciting antitumor activity via simultaneous targeting of CD3 on T cells and CD40 on APCs is relevant for the design of effective T cell-based cancer immunotherapy.

The past decade of experience with isolated hepatic perfusion.

Metastatic or primary unresectable cancers confined to the liver are the sole or life-limiting component of disease for many patients with colorectal cancer, ocular melanoma, neuroendocrine tumors, or primary colangio- or hepatocellular carcinomas. Regional treatment strategies including infusional chemotherapy and local ablative therapy are under investigation, but have limitations with respect to the clinical conditions under which they can be employed. Isolated hepatic perfusion (IHP) was first clinically applied over 40 years ago, but because of its technical complexity, the attendant potential morbidity, and the lack of documented efficacy, it has not enjoyed consistent or widespread evaluation. In light of the antitumor activity with isolated limb perfusion with tumor necrosis factor (TNF) and melphalan in patients with unresectable extremity sarcoma or in transit melanoma, this regimen has been administered via IHP at several centers worldwide for patients with unresectable liver cancers. IHP with TNF and melphalan can result in significant regression of advanced refractory cancers from multiple histologies confined to the liver. Patient selection is important to ensure good results with minimal morbidity and mortality. Work to define the appropriate clinical groups is ongoing at many clinical centers.