A machine learning framework for optimizing obesity care by simulating clinical trajectories and targeted interventions.

OBJECTIVE: This study aimed to determine the important clinical management bottlenecks that contribute to underuse of weight loss surgery (WLS) and assess risk factors for attrition at each of them. METHODS: A multistate conceptual model of progression from primary care to WLS was developed and used to study all adults who were seen by a primary care provider (PCP) and eligible for WLS from 2016 to 2017 at a large institution. Outcomes were progression from each state to each subsequent state in the model: PCP visit, endocrine weight management referral, endocrine weight management visit, WLS referral, WLS visit, and WLS. RESULTS: Beginning with an initial PCP visit, the respective 2-year Kaplan-Meier estimate for each outcome was 35% (n = 2063), 15.6% (n = 930), 6.3% (n = 400), 4.7% (n = 298), and 1.0% (n = 69) among 5876 eligible patients. Individual providers and clinics differed significantly in their referral practices. Female patients, younger patients, those with higher BMI, and those seen by trainees were more likely to progress. A simulated intervention to increase referrals among PCPs would generate about 49 additional WLS procedures over 3 years. CONCLUSIONS: This study discovered novel insights into the specific dynamics underlying low WLS use rates. This methodology permits in silico testing of interventions designed to optimize obesity care prior to implementation.

Intern Experience Reflects Information Gathered During the Virtual Interview Process.

OBJECTIVE: The onset of the coronavirus 2019 (COVID-19) pandemic brought many changes to the residency application process including transitioning to a virtual interview platform, which continues today. The transition brought many concerns from general surgery applicants about their ability to obtain adequate information about a program virtually. We sought to characterize how information presented by programs during the first ever virtual interview cycle matched the experience of general surgery interns after training at a program for 1 year. DESIGN, SETTING, AND PARTICIPANTS: In May of 2022, a survey was distributed to 243 program directors who were asked to forward it to their general surgery categorical interns who matched during the 2021 virtual match cycle. Demographics, resources used to determine an impression of a program, and correlations between information presented virtually and what was subsequently experienced as an intern were collected. RESULTS: Forty-six program directors confirmed forwarding the survey to their categorical interns. A total of 102 general surgery interns completed the survey. Most interns (88.2%) agreed that their experience matched expectations based on information received through the virtual interview process and 98% of interns were satisfied with their experience at their training program. Interviews with faculty (40.0%), residents (68.0%) and the program web site (29.0%) were the top 3 resources used to create the most accurate impression of a program. Interns felt they were well informed during the virtual interview experience about support from fellow residents (84.3%), culture (73.0%), surgical volume (72.5%), and intern operative experience (71.6%). In addition, 65.7% of participants thought they were able to obtain a good understanding of the program's culture from the virtual process. However, 16.7% thought that their program unintentionally misrepresented aspects of the training program. CONCLUSIONS: The faculty and residency interviews were the most important factors in program ranking and most participants agreed that their virtual interview experience matched their expectations during their intern year. Most interns felt they were able to obtain a good understanding of the program's culture from the virtual process. In addition, a majority of interns felt well informed during the interview on aspects ranging from surgical volume, autonomy, and work hours to support from faculty and residents. If virtual interviews are to continue, residents can be satisfied that information gathered virtually will match the reality of their training. Programs should continue to make every effort to present their program realistically.

Our Efforts to Create a Welcoming Surgical Residency for LGBTQ Trainees.

OBJECTIVE: To provide a more welcoming environment for LGBTQ residents. DESIGN: This paper is based upon the authors experience creating a training program welcoming to LGBTQ residents. SETTING: University General Surgery Training Program. PARTICIPANTS: Surgical Residents and Surgical Faculty. RESULTS: Over a 9 year period, our residency has made intentional efforts to welcome LGBTQ applicants and support LGBTQ residents. We now have a residency in which over 25% of our residents identify as LGBTQ. CONCLUSIONS: We see opportunities for other residencies to signal to applicants and trainees that they are welcome and celebrated for who they are.

Update on the Financial Well-Being of Surgical Residents in New England.

BACKGROUND: Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being. STUDY DESIGN: A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort. RESULTS: Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans. CONCLUSIONS: Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

An Interval Look at the Transplant Surgery Pipeline: Insights from General Surgery Residents' Operative Experience Using ACGME Operative Logs from 2000 to 2021.

OBJECTIVE: Given the declining number of US graduates pursuing transplant surgery as well as regulatory changes regarding transplant rotations for surgical residents, this study examined the transplant surgery operative volume of residents over the past 20 years. DESIGN: Retrospective analysis of the ACGME database of general surgery operative logs from academic year (AY) 1999-2000 to AY 2020-2021; data was categorized into time periods relative to regulatory changes: Period 1 (1999-2010) and Period 2 (2011-2021). SETTING/PARTICIPANTS: All ACGME-accredited general surgery residency programs in the US. FINDINGS: On average, the proportion of transplant cases to all total major cases was about 1% and did not change during the study period (p=0.61). Each graduating resident completed an average of 10.0 ± 11.0 cases during Period 1 and 10.8 ± 12.0 cases during Period 2, representing a statistically but unlikely clinically significant increase (p=0.008). Renal transplants comprised more than 50% of each resident's operative experience in transplant surgery. The proportion of resident involvement in all renal and liver transplantations nationally did not change during the study period, ranging from 34.5-42.9% for renal and 13.8-22.4% for liver. CONCLUSIONS: Resident volume in transplant surgery has largely remained consistent over the past 20 years, suggesting that changes in operative volume are unlikely driving declining interest in transplant surgery fellowship among US trainees.

The Association Between Virtual Interviewing and Geographical Distribution of Matched Residency Programs for General Surgery Applicants.

OBJECTIVE: Due to the COVID-19 pandemic, the Coalition for Physician Accountability's work group on Medical Students in the class of 2021 made the recommendation in May of 2020 that the upcoming residency recruitment cycle be conducted virtually. This flexibility may have allowed applicants to apply and interview at programs with less regard to geography, knowing that travel costs of interviewing would not be a factor. Alternatively, applicants who interviewed virtually could choose to remain in a close proximity to their home institutions where they likely have a greater comfort level and familiarity with the community both personally and professionally. We examine the distribution of applicants matched at general surgery residency programs in 2021 to those in 2020 to see if there was a change in geographic variability. DESIGN: Retrospective review of general surgery residents SETTING: United States general surgery residency programs PARTICIPANTS: 2153 PGY1 categorical general surgery residents who were interviewed virtually and PGY2 categorical general surgery residents who interviewed in-person, who also attended residency programs and medical schools located in the continental United States with publicly accessible residency websites containing necessary biographical information. RESULTS: A total of 2153 residents were included; 1124 in their PGY1 and 1029 in their PGY2. Average distance from attended medical school to matched program (634.2 vs 662.5), percentage of matched programs within 500 miles of attended medical school (57.3 vs 55.7), average price of flight, when available, from attended medical school to matched program (222.8 vs 230.4), and percentage of attended medical schools with non-stop flight to matched program (42.9 vs 42.9) did not significantly differ between PGY1 and PGY2 residents. CONCLUSIONS: The decision to adopt virtual interviewing practices compared to previous in-person interviews did not significantly alter the geographical distribution of students' matched programs. The distance from medical school to the matched program, flight availability, and flight pricing remained comparable between residents interviewed in-person and residents interviewed virtually.

Comparison of weight loss outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy in a racially mixed urban patient population.

BACKGROUND: National data show a trend favoring laparoscopic sleeve gastrectomy (SG) over Roux-en-Y gastric bypass (RYGB). Published data demonstrating the differences in weight loss between the two procedures are mixed. OBJECTIVE: In this retrospective study using clinical data from 2010 to 2020, we compared the clinical and demographic characteristics of patients undergoing either SG or RYGB to evaluate their long-term weight loss outcomes. SETTING: University hospital in the United States. METHODS: A total of 3329 patients were identified in our institutional Metabolic and Bariatric Surgery Accreditation and Quality Improvement database using Current Procedural Terminology codes for either RYGB or SG. A general linear model was used for baseline characteristics. Logistic regression was used for factors favoring RYGB versus SG. A multivariable linear mixed model was used for weight-trajectory analysis. Cox regression was used for a cumulative hazard ratio of 10% weight regained from nadir. RESULTS: Factors favoring RYGB were diagnoses of type 2 diabetes and gastroesophageal reflux disease, Hispanic ethnicity, and surgeon's preference. SG was favored among Black patients and smokers. RYGB was associated with more weight loss at all time points. The risk of weight regain was significantly higher after SG versus RYGB. CONCLUSIONS: The bariatric procedure choice is significantly influenced by race, medical history, and surgeon's experience. RYGB results in a significantly more durable weight loss compared with SG regardless of race or other stratification factors.

Frequency and Characteristics of Social Media Use among General Surgery Trainees.

INTRODUCTION: With increased social isolation due to COVID-19, social media has been increasingly adopted for communication, education, and entertainment. We sought to understand the frequency and characteristics of social media usage among general surgery trainees. MATERIALS AND METHODS: General surgery trainees in 15 American training programs were invited to participate in an anonymous electronic survey. The survey included questions about demographics, frequency of social media usage, and perceptions of risks and benefits of social media. Univariate analysis was performed to identify differences between high users of social media (4-7 h per week on at least one platform) and low users (0-3 h or less on all platforms). RESULTS: One hundred fifty-seven of 591 (26.6%) trainees completed the survey. Most respondents were PGY3 or lower (75%) and high users of social media (74.5%). Among high users, the most popular platforms were Instagram (85.7%), YouTube (85.1%), and Facebook (83.6%). YouTube and Twitter were popular for surgical education (77.3% and 68.2%, respectively). The most reported benefits of social media were improving patient education and professional networking (85.0%), where high users agreed more strongly about these benefits (P = 0.002). The most reported risks were seeing other residents (42%) or attendings (17%) with unprofessional behavior. High users disagreed more strongly about risks, including observing attendings with unprofessional behavior (P = 0.028). CONCLUSIONS: Most respondents were high users of social media, particularly Instagram, YouTube, and Facebook. High users incorporated social media into their surgical education while perceiving more benefits and fewer risks of social media.

Creating a Welcoming Surgery Residency Training Program for LGBTQ Trainees.

General Surgery residencies have been perceived as unwelcoming to lesbian, gay, bisexual, transgender, and queer (LGBTQ) applicants. Historically, applicants have been reluctant to reveal their LGBTQ status when interviewing for residency positions and LGBTQ surgery residents are more likely to consider leaving their residency. Despite the increased acceptance in society and calls for diversity by governing bodies, there is a perception that the field of surgery is lagging behind. In this article, we summarize the recent literature concerning LGBTQ status in surgery residencies and the impact it has on students and trainees. We then review the recent calls to action to remedy the identified shortcomings. We then share what has been done by our surgery residency, which has been successful in recruiting LGBTQ-identifying residents and summarize recommendation for moving forward.

Update on the Personal and Professional Well-Being of Surgical Residents in New England.

BACKGROUND: Surgical culture has shifted to recognize the importance of resident well-being. This is the first study to longitudinally track regional surgical resident well-being over 5 years. STUDY DESIGN: An anonymous cross-sectional, multi-institutional survey of New England general surgery residents using novel and published instruments to create three domains: health maintenance, burnout, and work environment. RESULTS: Overall, 75% (15 of 20) of programs participated. The response rate was 44% (250 of 570), and 53% (133 of 250) were women, 94% (234 of 250) were 25 to 34 years old, and 71% (178 of 250) were in a relationship. For health maintenance, 57% (143 of 250) reported having a primary care provider, 26% (64 of 250) had not seen a primary care provider in 2 years, and 59% (147 of 250) endorsed being up to date with age-appropriate health screening, but only 44% (109 of 250) were found to actually be up to date. Only 14% (35 of 250) reported exercising more than 150 minutes/week. The burnout rate was 19% (47 of 250), with 32% (81 of 250) and 25% (63 of 250) reporting high levels of emotional exhaustion and depersonalization, respectively. For program directors and attendings, 90% of residents reported that they cared about resident well-being. Eighty-seven percent of residents believed that it was acceptable to take time off during the workday for a personal appointment, but only 49% reported that they would personally take the time. CONCLUSIONS: The personal health maintenance of general surgery residents has changed little over the past five years, despite an overwhelming majority of residents reporting that attendings and program directors care about their well-being. Further study is needed to understand the barriers to improvement of resident wellbeing.

The impact of English proficiency on outcomes after bariatric surgery.

BACKGROUND: Several studies demonstrated language that discordant care between may lead to mixed outcomes and increased use of hospital-resources. In the setting of bariatric surgery, which relies heavily on intensive pre-operative and post-operative counseling, we hypothesized that patients with LEP would have less favorable outcomes compared to English-proficient (EP) patients. METHODS: All patients 18 years and older, who underwent laparoscopic sleeve gastrectomy (SG) or laparoscopic gastric bypass (LGBP) from January 2013 to December 2017 were included. Language proficiency was determined by chart review for the use of an interpreter at least once during the study period. Outcomes of interest at 30-days and 1 year included: emergency department (ED) visits, readmission, length of stay (LOS), chief-complaint on readmission, and post-operative complications. Additionally, comorbidity remission and weight loss at one year was recorded. RESULTS: A total of 671 patients were categorized as LEP (40%) and spoke 6 unique languages. Within the 1 year post-operative period, EP patients presented to the ED more than LEP patients (23% vs. 14% p < 0.001). After multivariable regression for potential confounders this difference persisted; adjusted OR = 0.65 (95% CI 0.43-0.95; p = 0.029). However, despite more frequent ED visits by EP patients, there was no significant difference in readmission within one year; adjusted OR = 0.94 (95% CI 0.56-1.55; p = 0.50). Both groups demonstrated similar successful weight loss at 1 year: EP-31.85% (LGBP) and - 28.02% (SG) vs. LEP-30.17% (LGBP) and - 28.36% (SG). EP and LEP patients also had similar remission of obesity-related comorbidities. CONCLUSION: There were no differences in outcomes following bariatric surgery when comparing patients with limited English proficiency to those who are proficient in English. Bariatric surgical care can be delivered in a safe and effective manner with equivalent outcomes between patients who are and are not English-language proficient.

Application of the Caprini Risk Assessment Model to Select Patients for Extended Thromboembolism Prophylaxis After Sleeve Gastrectomy.

BACKGROUND: The Caprini risk assessment model is a well-validated tool that identifies patients who would benefit from extended venous thromboembolism (VTE) prophylaxis beyond hospital discharge. VTE, particularly portal mesenteric vein thrombosis (PMVT), is a potentially devastating complication of laparoscopic sleeve gastrectomy (LSG); therefore, we sought to examine whether the model can be safely applied to LSG patients. We hypothesized that its use can minimize the incidence of postoperative VTE, including PMVT, without increasing the likelihood of bleeding complications. MATERIALS AND METHODS: We conducted a retrospective chart review of those patients who underwent LSG at our institution from 2010 and 2018, at which time the Caprini risk assessment model was already our institutional standard. We determined the patients' Caprini scores at the time of discharge and whether patients at high risk of VTE were discharged from hospital on extended courses of VTE prophylaxis. We also recorded if bleeding complications or VTE events occurred in the first 180 days after LSG. RESULTS: Six hundred thirty-eight patients underwent LSG, including 521 (81.7%) women, with an average preoperative body mass index (BMI) of 44.4 kg/m2 (SD 6.8). One hundred fifty-eight (24.8%) patients had Caprini scores that warranted extended courses of VTE prophylaxis beyond hospital discharge. Three patients (0.47%) developed a postoperative VTE, but no patient developed PMVT. No bleeding complications were observed among patients who received extended VTE prophylaxis. CONCLUSION: The Caprini risk assessment model can effectively identify patients after LSG who might benefit from extended courses of VTE prophylaxis. Extended VTE prophylaxis does not seem to confer increased bleeding risk in this patient population.

Structuring Research Rotations to Facilitate Surgery Residents' Academic Productivity.

OBJECTIVE: We sought to enhance opportunities for general surgery residents to conduct research during residency without having to take dedicated time out of clinical training. To this end, we created structured research rotations to facilitate and support resident research. DESIGN: Research blocks of four week's duration were introduced for categorical interns and post-graduate year (PGY) 4 residents. Interns had no clinical responsibilities during their research blocks while PGY 4 residents shadowed their mentor in the clinical setting. Research projects were developed and prepared in advance to maximize productivity during the research rotation. SETTING: General surgery residency program at an urban, academic, safety-net, tertiary care hospital PARTICIPANTS: Categorical general surgery interns and PGY 4 general surgery residents RESULTS: The research rotations were first offered in the 2019 to 2020 academic year (AY). 10 interns and 11 PGY 4 residents have since completed the rotations; of the PGY 4 residents, 6 had not previously taken any time off for research activities. Research projects varied between residents and focused on basic science, clinical outcomes, quality improvement, and education. CONCLUSIONS: Through establishment of dedicated research rotations, we were able to increase resident engagement in a variety of research activities. We provide a simple model for training programs seeking increased research engagement and productivity for their residents without extending training time.

Impact of fellow compared to resident assistance on outcomes of minimally invasive surgery.

INTRODUCTION: As fellowship training after general surgery residency has become increasingly common, the impact on resident education must be considered. Patient safety and procedure outcomes are often used as justification by attendings who favor fellows over residents in certain minimally invasive surgery (MIS) operations. The aim of the present study was to compare the impact of trainee level on the outcomes of selected MIS operations to determine if giving preference to fellows on grounds of outcomes is warranted. METHODS: Patients who underwent elective laparoscopic hiatal hernia repair (LHHR), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic splenectomy (LS), laparoscopic cholecystectomy (LC), or laparoscopic ventral hernia repair (LVHR) with assistance of a general surgery chief resident or fellow were identified from the American College of Surgeon's National Surgical Quality Improvement Program database (2007-2012). Patients were matched 1:1 based on propensity score for the odds of undergoing operations assisted by a fellow. RESULTS: 5145 patients underwent LHHR, 1396 LSG, 9656 LRYGB, 863 LS, 13,434 LC, and 3069 LVHR. Fellows assisted in 41.7% of LHHR, 49.2% of LSG, 56.4% of LRYGB, 25.7% of LS, 17.1% of LC, and 27.0% of LVHR cases. After matching, overall and severe complication rates were comparable between cases performed with assistance of a fellow or chief resident. Median operative time was longer for LSG, LRYGB, and LC when a fellow assisted. CONCLUSIONS: Surgical outcomes were similar between fellow and chief resident assistance in MIS operations, arguing that increased resident participation in basic and complex laparoscopic operations is appropriate without compromising patient safety.