Patient adherence to an oral rehydration solution intervention to prevent dehydration following ileostomy creation: A qualitative study.

BACKGROUND: Patients undergoing surgery for ileostomy creation frequently experience postoperative dehydration and subsequent renal injury. The use of oral rehydration solutions (ORS) has been shown to prevent dehydration, but compliance may be variable. METHODS: Semi-structured qualitative interviews were conducted with 17 patients who received a postoperative hydration kit and dehydration education to assess barriers and facilitators to compliance with ORS kit instructions. RESULTS: Qualitative analysis revealed five themes affecting patient adherence to the ORS intervention: (1) patient's perception of the effectiveness of the ORS solution, (2) existing co-morbidities, (3) kit quality and taste of the ORS product, (4) quality of the dehydration education, and (5) social support. CONCLUSIONS: Given that patient adherence can greatly affect the success of an ORS intervention, the design of future ORS interventions should emphasize the educational component, the "patient friendliness" of the ORS kit, and ways that social supports can be leveraged to increase adherence.

Postoperative Oral Rehydration and Regimented Follow-up Decrease Readmissions After Colorectal Surgery That Includes Ileostomies.

BACKGROUND: Ileostomies constitute 15% to 43% of readmissions after colorectal surgery, often due to dehydration and acute kidney injury. Prior institutional interventions decreased readmissions but not among patients who underwent new ileostomies. OBJECTIVE: To evaluate readmissions among patients who underwent new ileostomies after postoperative oral rehydration solution and standardized clinic visits. DESIGN: Retrospective analysis of prospective database. SETTINGS: Enhanced recovery colorectal surgery service. PATIENTS: Patients who underwent new ileostomy before and after intervention. INTERVENTIONS: Postoperative oral rehydration solution and postdischarge clinic visits with review of inputs/outputs, antimotility and appliance needs, and trained nurse reeducation 4 to 7 days after discharge, 30 days postoperatively, and every 1 to 2 weeks thereafter as needed. MAIN OUTCOME MEASURES: Readmission rate due to dehydration/acute kidney injury (primary), emergency department visits, and readmission rates overall and for specific diagnoses. Analysis used univariate and weighted techniques. RESULTS: A total of 312 patients (199 preintervention; 113 postintervention) were included, with a mean age of 59.0 years. Patients were predominantly White (94.9%) and evenly split between men and women. The most common diagnosis was diverticulitis (43.3%). The most common procedure was high anterior resection (38.8%), followed by low anterior resection (16.35%). Patient and procedure characteristics were well matched between groups. Multivariate analysis demonstrated that readmission rate due to dehydration/acute kidney injury significantly decreased between pre- and postintervention study groups (45.7% vs 16.5%, p = 0.039). Emergency department visits due to dehydration/acute kidney injury (12.0% vs 1.7%, p < 0.001) and readmissions from all causes (24.33% vs 10.6%, p = 0.005) also significantly decreased. Other complications were not significantly different between groups. Average stoma output 24 hours before (776 vs 625 mL, p = 0.005) and after (993 vs 890 mL, p = 0.025) discharge was significantly decreased in the postintervention group. LIMITATIONS: Retrospective single-center study. CONCLUSIONS: An oral rehydration solution and frequent standardized postdischarge visits led by trained nursing staff decreased readmissions and emergency department visits among patients who underwent new ileostomies after colorectal surgery. See Video Abstract . LA REHIDRATACIN ORAL POSOPERATORIA Y EL SEGUIMIENTO REGLAMENTADO REDUCEN LOS REINGRESOS EN PACIENTES DE CIRUGA COLORRECTAL CON ILEOSTOMAS: ANTECEDENTES:Las ileostomías constituyen del 15 al 43% de los reingresos después de la cirugía colorrectal, a menudo debido a la deshidratación y la lesión renal aguda. Las intervenciones institucionales previas redujeron los reingresos, pero no entre los pacientes con nuevas ileostomías.OBJETIVO:Evaluar los reingresos entre pacientes con nuevas ileostomías después del uso de solución de rehidratación oral postoperatoria y visitas clínicas estandarizadas.DISEÑO:Análisis retrospectivo de base de datos prospectiva.AJUSTES:Servicio de cirugía colorrectal de recuperación mejorada.PACIENTES:Pacientes con ileostomía nueva antes y después de la intervención.INTERVENCIÓN(ES):Solución de rehidratación oral posoperatoria y visitas clínicas posteriores al alta con revisión de entradas/salidas, antimotilidad y necesidades de aparatos, y reeducación de enfermeras capacitadas 4-7 días después del alta, 30 días después de la operación y cada 1-2 semanas después, según sea necesario.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de readmisión debido a deshidratación/lesión renal aguda (primaria), tasa de urgencias y de readmisión en general y para diagnósticos específicos. El análisis utilizó técnicas univariadas y ponderadas.RESULTADOS:Se incluyeron un total de 312 pacientes (199 preintervención; 113 postintervención), con una edad media de 59,0 años. Los pacientes eran predominantemente blancos (94,9%) y se dividieron equitativamente entre hombres y mujeres. El diagnóstico más frecuente fue diverticulitis (43,3%). El procedimiento más común fue la resección anterior alta (38,8 %) seguida de la resección anterior baja (16,35 %). Las características del paciente y del procedimiento coincidieron bien entre los grupos. El análisis multivariante demostró que la tasa de reingreso debido a deshidratación/lesión renal aguda disminuyó significativamente entre los grupos de estudio antes y después de la intervención (45,7 % frente a 16,5 %, p = 0,039). Las visitas a urgencias por deshidratación/insuficiencia renal aguda (12,0 % frente a 1,7 %, p < 0,001) y los reingresos por todas las causas (24,33 % frente a 10,6 %, p = 0,005) también disminuyeron significativamente. Otras complicaciones no fueron significativamente diferentes entre los grupos. El gasto medio del estoma 24 horas antes (776 ml frente a 625 ml, p = 0,005) y después (993 ml frente a 890 ml, p = 0,025) del alta disminuyó significativamente en el grupo posterior a la intervención.LIMITACIONES:Estudio retrospectivo de centro único.CONCLUSIONES:Una solución de rehidratación oral y frecuentes visitas estandarizadas posteriores al alta dirigidas por personal de enfermería capacitado redujeron los reingresos y las visitas al servicio de urgencias entre los pacientes con nuevas ileostomías después de la cirugía colorrectal. ( Traducción-Dr. Yolanda Colorado ).

Reducing Ileostomy Readmissions: Using Implementation Science to Evaluate the Adoption of a Quality Improvement Initiative.

BACKGROUND: Translating empirical evidence into clinical practice remains challenging. Prevention of morbidity from new ileostomies may serve as an example. Despite evidence demonstrating improvements in electrolyte levels, kidney function markers, and hospital readmissions, widespread adoption of oral rehydration solutions among patients with new ileostomies has not occurred. The causes of low uptake are unknown and likely multifactorial. OBJECTIVE: We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance implementation science framework to identify barriers and facilitators in the adoption of a quality improvement initiative aimed at decreasing emergency department visits and hospital readmissions because of dehydration among patients with new ileostomies using oral rehydration solutions. DESIGN: Qualitative interviews were conducted with stakeholders based on the domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. SETTINGS: Participating community and academic hospitals across Michigan (n = 12). PATIENTS: Convenience sampling was used to recruit 25 key stakeholders, including wound, ostomy, and continence nurses; registered nurses; nurse practitioners; nurse managers; colorectal surgeons; surgery residents; physician assistants; and data abstractors (1-4 participants per site). MAIN OUTCOME MEASURES: Through qualitative content analysis, we located, analyzed, and identified patterns using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: We identified the following factors to increase the adoption of quality improvement initiatives at the provider level: 1) selection and coaching of champions, 2) broadening of multidisciplinary teams, 3) performing structured patient follow-up, and 4) addressing long-term sustainability concerns regarding cost and equity. LIMITATIONS: Limited to high-volume ileostomy surgery hospitals, did not include in-person site visits to each hospital before and after implementation, and did not consider the hospital- and patient-level factors that impact the widespread adoption of quality improvement initiatives. CONCLUSIONS: Integrating implementation science frameworks to rigorously study quality improvement initiatives may reveal the determinants of the widespread adoption of evidence-based practices. REDUCCIN DE REINGRESOS POR ILEOSTOMA USO DE LA CIENCIA DE LA IMPLEMENTACIN PARA EVALUAR LA ADOPCIN DE UNA INICIATIVA DE MEJORA DE LA CALIDAD: ANTECEDENTES:Traducir la evidencia empírica a la práctica clínica sigue siendo un desafío. La prevención de la morbilidad por nuevas ileostomías puede servir como ejemplo. A pesar de la evidencia que demuestra mejoras en los niveles de electrolitos, marcadores de función renal y reingresos hospitalarios, no se ha producido una adopción generalizada de soluciones de rehidratación oral entre pacientes con nuevas ileostomías. Las causas de la baja captación son desconocidas y probablemente multifactoriales.OBJETIVO:Empleamos Alcance, Eficacia, Adopción, Implementación y Mantenimiento, un marco de las ciencias de implementación, para identificar barreras y facilitadores en la adopción de una iniciativa de mejora de la calidad destinada a disminuir las visitas al departamento de emergencias y los reingresos hospitalarios debido a la deshidratación entre los pacientes con nuevos ileostomías utilizando soluciones de rehidratación oral.DISEÑO:Se realizaron entrevistas cualitativas con las partes interesadas basadas en los dominios del marco de Alcance, Efectividad, Adopción, Implementación y Mantenimiento.CONFIGURACIÓN:Hospitales académicos y comunitarios participantes a través de Michigan (n = 12).PARTICIPANTES:Se utilizó un muestreo por conveniencia para reclutar a 25 partes interesadas clave, incluyendo enfermeras de heridas, ostomía y continencia; enfermeras registradas; enfermeras practicantes; gerentes de enfermera; cirujanos colorrectales; residentes de cirugía; asistentes médicos; y extractores de datos (1-4 participantes por sitio).PRINCIPALES MEDIDAS DE RESULTADO:A través del análisis de contenido cualitativo, localizamos, analizamos e identificamos patrones utilizando el marco de Alcance, Eficacia, Adopción, Implementación y Mantenimiento.RESULTADOS:Identificamos los siguientes factores para aumentar la adopción de iniciativas de mejora de la calidad a nivel de proveedores: 1) selección y entrenamiento de campeones, 2) ampliación de equipos multidisciplinarios, 3) seguimiento estructurado de pacientes y 4) abordaje a largo plazo. preocupaciones de sostenibilidad con respecto al costo y la equidad.LIMITACIONES:Limitado a hospitales de cirugía de ileostomía de alto volumen, incapaz de realizar visitas en persona a cada hospital antes y después de la implementación, no considera los factores a nivel del hospital y del paciente que afectan la adopción generalizada de iniciativas de mejora de la calidad.CONCLUSIONES:La integración de marcos científicos de implementación para estudiar rigurosamente las iniciativas de mejora de la calidad puede revelar los determinantes de la adopción generalizada de prácticas basadas en la evidencia. (Traducción-Dr. Aurian Garcia Gonzalez ).

What We Talk About When We Talk About Coping: A Qualitative Study of Surgery Resident's Coping After Complications and Deaths.

OBJECTIVE: To explore how surgery residents cope with unwanted patient outcomes including postoperative complications and death. BACKGROUND: Surgery residents face a variety of work-related stressors that require them to engage in coping strategies. Postoperative complications and deaths are common sources of such stressors. Although few studies examine the response to these events and their impacts on subsequent decision-making, there has been little scholarly work exploring coping strategies among surgery residents specifically. METHODS: This study investigated the ways, in which general surgery residents cope with unwanted patient outcomes, including complications and deaths. Mid-level and senior residents (n = 28) from 14 academic, community, and hybrid training programs across the United States participated in exploratory semistructured interviews conducted by an experienced anthropologist. Interview transcripts were analyzed iteratively, informed by thematic analysis. RESULTS: When discussing how they cope with complications and deaths, residents described both internal and external strategies. Internal strategies included a sense of inevitability, compartmentalization of emotions or experiences, thoughts of forgiveness, and beliefs surrounding resilience. External strategies included support from colleagues and mentors, commitment to change, and personal practices or rituals, such as exercise or psychotherapy. CONCLUSIONS: In this novel qualitative study, general surgery residents described the coping strategies that they organically used after postoperative complications and deaths. To improve resident well-being, it is critical to first understand the natural coping processes. Such efforts will facilitate structuring future support systems to aid residents during these difficult periods.

Comparison of surgeon and pathologist total mesorectal excision grade after rectal cancer resection: A single institution analysis.

BACKGROUND: A Michigan Surgical Quality Collaborative Colorectal Cancer Project initiative sought to increase adoption of surgeon total mesorectal excision (TME) grading through standardized education and synoptic operative reporting. Our study aim was to assess initiative impact and level of agreement between surgeon and pathologist-determined TME grades. METHODS: This is a retrospective comparison of surgeon and pathologist TME grades before and after initiative implementation using a prospectively maintained enhanced recovery colorectal surgery database. RESULTS: There were 112 TMEs before, and 53 TMEs following initiative implementation. There was a significant increase in surgeon TME-grade reporting in the postinitiative period (25.0% pre- vs. 81.1% post-, p < 0.001). Pathologist TME-grade reporting was high in both time periods and there was no significant change (91.1% pre- vs. 88.7% post-, p = 0.84). Surgeon and pathologist agreement was 59.3% in the preinitiative period (Κ "minimal"   0.356) and 65.0% in the postinitiative period (Κ "moderate" = 0.605, p = 0.827). There was no significant association between clinical T-stage and surgeon or pathologist TME grade. CONCLUSION: Surgeon TME grading improves with education and synoptic operative reporting. There is only moderate agreement between surgeon and pathologist, a finding that requires further study. Organized regional initiatives are effective at implementing rectal cancer management quality improvement.

"I Wish There had been Resources": A Photo-Elicitation Study of Rectal Cancer Survivorship Care Needs.

BACKGROUND: Rectal cancer survivors experience unique, prolonged posttherapy symptoms. Previous data indicate that providers are not skilled at identifying the most pertinent rectal cancer survivorship issues. Consequently, survivorship care is incomplete with the majority of rectal cancer survivors reporting at least one unmet posttherapy need. METHODS: This photo-elicitation study combines participant-submitted photographs and minimally structured qualitative interviews to explore one's lived experiences. Twenty rectal cancer survivors from a single tertiary canter provided photographs representative of their life after rectal cancer therapy. The iterative steps informed by inductive thematic analysis were used to analyze the transcribed interviews. RESULTS: Rectal cancer survivors had several recommendations to improve their survivorship care, which fell into three major themes: (1) informational needs (e.g., more details about posttherapy side effects); (2) continued multidisciplinary follow up care (e.g., dietary support); and (3) suggestions for support services (e.g., subsidized bowel altering medications and ostomy supplies). CONCLUSIONS: Rectal cancer survivors desired more detailed and individualized information, access to longitudinal multidisciplinary follow-up care, and resources to ease the burdens of daily life. These needs may be met through the restructuring of rectal cancer survivorship care to include disease surveillance, symptom management, and support services. As screening and therapy continues to improve, providers must continue to screen and to provide services that address the physical and psychosocial needs of rectal cancer survivors.

Lack of Complete Pretreatment Staging Is Associated With Omission of Neoadjuvant Therapy for Rectal Cancer: A Statewide Study.

BACKGROUND: Standardized local staging and neoadjuvant therapy are rectal cancer management quality measures supported by the Commission on Cancer and National Accreditation Program for Rectal Cancer for the management of rectal cancer. Previous studies suggested that up to 25% of patients with stage II/III rectal cancer patients do not receive neoadjuvant therapy. We hypothesized that failure to receive neoadjuvant therapy may be caused by failure to properly stage patients before surgery. OBJECTIVE: This study aimed to determine whether lack of local rectal cancer staging is associated with underutilization of neoadjuvant therapy and to determine risk factors for omission of neoadjuvant therapy. DESIGN: Retrospective cohort study. Bivariate and multivariable analyses were performed on patient, tumor, and 30-day outcome factors associated with neoadjuvant therapy and staging. SETTINGS: hospitals participated in the Michigan Surgical Quality Collaborative Colorectal Cancer Project from January 2014 to December 2019. PATIENTS: Elective, clinical stage II/III, mid-to-low rectal cancer resections. Patients with upper rectal cancer were excluded. MAIN OUTCOME MEASURES: Percentage of patients receiving neoadjuvant therapy. RESULTS: The final cohort included 350 patients with clinical stage II/III mid or low rectal cancer-80.9% of patients who had received neoadjuvant therapy and 83.2% of patients who had MRI and/or endoscopic ultrasound. A significant association was found between receiving neoadjuvant therapy and MRI/endorectal ultrasound staging ( p < 0.0001). Eighty-seven percent of patients who had MRI/endorectal ultrasound received neoadjuvant chemoradiotherapy; 49% of patients who did not have MRI/endorectal ultrasound staging received neoadjuvant chemoradiotherapy. Multivariate analysis revealed that risk factors for the omission of neoadjuvant therapy were older age and incomplete staging. LIMITATIONS: Observational study with the possibility of unmeasured confounding variables. CONCLUSIONS: Neoadjuvant therapy is underused in patients with stage II/III rectal cancer. Omission of pretreatment staging with MRI/endorectal ultrasound is associated with omission of neoadjuvant therapy. These data suggest the need for regional and national quality improvement strategies to standardize the multidisciplinary management of rectal cancer. See Video Abstract at http://links.lww.com/DCR/B923 . LA FALTA DE ESTADIFICACIN COMPLETA PREVIA AL TRATAMIENTO SE ASOCIA CON LA OMISIN DE LA TERAPIA NEOADYUVANTE PARA EL CNCER DE RECTO UN ESTUDIO ESTATAL: ANTECEDENTES: La estadificación local estandarizada y la terapia neoadyuvante son medidas de calidad de la Comisión sobre el Cáncer y el Programa Nacional de Acreditación para el Cáncer de Recto para el tratamiento del cáncer de recto. Estudios previos sugirieron que hasta el 25% de los pacientes con cáncer de recto en estadio II/III no reciben terapia neoadyuvante. Planteamos la hipótesis de que la falla en recibir la terapia neoadyuvante puede deberse a la falla en la estadificación adecuada de los pacientes antes de la cirugía.OBJETIVO: El propósito de este estudio es determinar si la falta de estadificación local del cáncer de recto está asociada con la infrautilización de la terapia neoadyuvante y determinar los factores de riesgo para la omisión de la terapia neoadyuvante.DISEÑO: Estudio de cohorte retrospectivo. Se realizaron análisis bivariados y multivariados sobre el paciente, el tumor y los factores de resultado a los 30 días asociados con la terapia neoadyuvante y la estadificación.AJUSTE: Un total de 31 hospitales que participaron en el Proyecto Quirugico Colaborativo de Cáncer Colorrectal de Calidad de Michigan desde enero de 2014 hasta diciembre de 2019.PACIENTES: Resecciones electivas, en estadio clínico II/III, de cáncer de recto medio a bajo. Se excluyeron los pacientes con cáncer de recto superior.MEDIDA DE RESULTADO PRINCIPAL: Porcentaje de pacientes que reciben terapia neoadyuvante. Porcentaje de pacientes que reciben terapia neoadyuvante.RESULTADOS: La cohorte final fue de 350 casos con cáncer de recto medio o bajo en estadio clínico II/III. El 80,9% tenía terapia neoadyuvante y el 83,2%, resonancia magnética y/o ultrasonido endoscópico. Hubo una asociación significativa entre recibir terapia neoadyuvante y la estadificación MRI/ERUS ( p < 0,0001). El 87% de los pacientes a los que se les realizaron imágenes con MRI/ERUS recibieron NT, mientras que el 49% de los pacientes a los que no se les realizó la estadificación con MRI/ERUS tuvieron NT. El análisis multivariante reveló que los factores de riesgo para la omisión de la terapia neoadyuvante fueron la edad avanzada y la estadificación incompleta.LIMITACIONES: Estudio observacional con posibilidad de confusión de variables no medidas.CONCLUSIONES: La terapia neoadyuvante está infrautilizada en pacientes con cáncer de recto en estadio II/III. La omisión de la estadificación previa al tratamiento con MRI/ERUS se asocia con la omisión de la terapia neoadyuvante. Estos datos sugieren la necesidad de estrategias regionales y nacionales de mejora de la calidad para estandarizar el manejo multidisciplinario del cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B923 . (Traducción-Dr Yolanda Colorado ).

Management and Outcomes of Pathologic Upstaging of Clinical Stage I Rectal Cancers: An Exploratory Analysis.

BACKGROUND: Preoperative staging of clinical stage I rectal cancer can fail to diagnose T3 or nodal disease. Adjuvant treatment of these upstaged patients remains controversial. OBJECTIVE: The objective was to identify predictors of clinical stage I rectal cancer upstaging and quantify rates of local and systemic recurrence. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted using data from the United States Rectal Cancer Consortium, a registry of 1881 rectal cancer resections performed at 6 academic medical centers. PATIENTS: There were a total of 94 clinical stage I rectal cancer patients who underwent proctectomy without preoperative therapy. MAIN OUTCOME MEASURES: The primary measures were incidence of pathologic upstaging, recurrence (local and systemic), and overall survival. RESULTS: Among 94 clinical stage I patients who underwent proctectomy without preoperative therapy, 23 (24.5%) were upstaged by surgical pathology. There were 6 pT3N0 patients, 8 pT1-2N+ patients, and 9 pT3N+ patients. There were no significant differences in demographic or clinical characteristics between upstaged and nonupstaged patients. Of the 6 patients who were upstaged to T3N0 disease, none received adjuvant therapy and none developed recurrence. Of the 17 patients who were upstaged to N+ disease, 14 (82%) received adjuvant chemotherapy and 6 (35%) received adjuvant chemoradiation. None developed a local recurrence, but 4 (24%) developed systemic recurrence, and 2 (12%) died of disease over a mean of 36 months of follow-up. Among the 9 pT3N+ patients, the systemic recurrence rate was 33%, despite 8 of 9 patients receiving adjuvant fluorouracil, leucovorin, and oxaliplatin. LIMITATIONS: Small sample size hinders the ability to draw significant conclusions. CONCLUSIONS: One in 4 patients with stage I rectal cancer had unrecognized T3 or nodal disease found on operative pathology. Occult nodal disease was associated with worse outcomes, despite receiving adjuvant therapy. Systemic recurrence was more common than local recurrence. See Video Abstract at http://links.lww.com/DCR/B885 . MANEJO Y RESULTADOS DEL AUMENTO DEL ESTADIO PATOLGICO DE LOS CNCERES DE RECTO EN ESTADIO CLNICO I UN ANLISIS EXPLORATORIO: ANTECEDENTES:El estadiaje pre-operatorio del cáncer de recto en fase clínica I puede ser erróneo en el diagnóstico T3 o en la diseminación ganglionar. El tratamiento adyuvante de estos pacientes sobre-estadificados ​​sigue siendo controvertido.OBJETIVO:El identificar los factores predictivos en fase clínica I del cáncer de recto y cuantificar las tasas de recurrencia local y sistémica.DISEÑO:Estudio de cohortes retrospectivo.AJUSTE:El estudio se realizó utilizando los datos del Consorcio del Cáncer de Recto de los Estados Unidos, con un registro de 1.881 resecciones oncológicas rectales realizadas en seis centros médicos académicos.PACIENTES:Un total de 94 pacientes con cáncer de recto en fase clínica I fueron sometidos a proctectomía sin terapia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas primarias fueron la incidencia del sobre-estadiaje histopatológico, la recurrencia (local y sistémica) y la sobrevida general.RESULTADOS:De 94 pacientes en fase clínica I que se sometieron a una proctectomía sin terapia preoperatoria, 23 (24,5%) fueron sobre-estadiados ​​por la histopatología quirúrgica. Hubieron 6 pacientes pT3N0, 8 pT1-2N + y 9 pT3N +. No hubo diferencias significativas en las características demográficas o clínicas entre los pacientes sobre-estadiados ​​y los no sobre-estadiados. De los 6 pacientes que fueron sobre-estadiados en la enfermedad T3N0, ninguno de ellos recibió terapia adyuvante y ninguno recidivó. De los 17 pacientes que fueron sobre-estadiados a la enfermedad N +, 14 (82%) recibieron quimioterapia adyuvante y 6 (35%) recibieron quimio-radioterapia adyuvante. Ninguno desarrolló recidiva local, pero 4 (24%) desarrollaron recidiva sistémica y 2 (12%) murieron a causa de la enfermedad durante el seguimiento medio de 36 meses. Entre los 9 pacientes con pT3N +, la tasa de recidiva sistémica fue del 33%, a pesar de que 8 de 9 pacientes recibieron fluorouracilo, leucovorina y oxaliplatino como quimio-adyuvantes.LIMITACIONES:El tamaño pequeño de la muestra dificulta la capacidad de obtener conclusiones significativas.CONCLUSIONES:Uno de cada cuatro pacientes con cáncer de recto en estadío I presentaba enfermedad ganglionar o T3 no descrita en la histopatología operatoria. La enfermedad ganglionar oculta se asoció con peores resultados, a pesar de recibir terapia adyuvante. La recidiva sistémica fue más común que la recidiva local. Consulte Video Resumen en http://links.lww.com/DCR/B885 . (Traducción-Dr. Xavier Delgadillo ).

Parastomal Hernia Rates and Exercise After Ostomy Surgery.

BACKGROUND: Parastomal hernias are common and negatively affect patient's lives. We hypothesized that physical activity (or lack thereof) might be associated with the presence of parastomal hernia. If so, this might be an actionable target for prevention. OBJECTIVE: The objective was to determine rates of and risk factors for parastomal hernias in patients with a permanent ostomy. DESIGN: This was a retrospective cohort and survey study. Postal survey included questions about parastomal hernia, symptoms, lifestyle, and validated instruments to measure stoma quality of life and physical activity. Medical record abstraction was conducted for clinical comorbidities. SETTINGS: This study was conducted in a single large academic medical center. PATIENTS: Patients who underwent operations that included a permanent urostomy, colostomy, and/or ileostomy between 2014 and 2018 were included. MAIN OUTCOME MEASURES: Parastomal hernia (self-reported) and physical activity, measured in total metabolic equivalent-minutes/week, were our main outcome measures. RESULTS: A total of 443 of 724 patients responded (response rate, 61.2%). Two hundred twelve patients (47.9%) had urostomies, 160 (36.1%) had colostomies, and 99 (22.3%) had ileostomies. One hundred twenty-eight patients (29.7%) had a parastomal hernia, with rates of 27.1% for urostomy, 40.0% for colostomy, and 23.7% for ileostomy. There was a statistically significant association between less exercise and higher incidence of parastomal hernia (median, 579 metabolic equivalent-minutes/week for those with parastomal hernias vs 1689 metabolic equivalent-minutes/week for those without; p = 0.001). LIMITATIONS: The association between physical activity and parastomal hernia may be confounded by obesity or the possibility that patients with parastomal hernia may be limited physically by their hernia. CONCLUSIONS: Parastomal hernia rates remain high in modern surgical practice. This study shows an association between patients' physical activity and the presence of a parastomal hernia, with a higher rate among patients who exercise less. See Video Abstract at http://links.lww.com/DCR/B910 . TASAS DE HERNIA PARAESTOMAL Y EJERCICIO DESPUS DE LA CIRUGA DE OSTOMA: ANTECEDENTES:Las hernias paraostomales son complicaciones comunes después de la cirugía de ostomía y afectan la calidad de vida de los pacientes. Nuestra hipótesis es que la actividad física de los pacientes (o la falta de ella) podría estar asociada con la presencia de hernia paraostomal. Si es así, este podría ser un objetivo utilizable para la prevención.OBJETIVO:Determinar las tasas y los factores de riesgo de las hernias paraostomales en pacientes que se sometieron a una cirugía que resultó en una ostomía permanente.DISEÑO:Estudio retrospectivo de cohorte y encuesta. La encuesta postal incluyó preguntas sobre hernia paraostomal, síntomas, estilo de vida e instrumentos validados para medir la calidad de vida del paciente ostomizado y la actividad física. Se realizó la confección de gráficos para las comorbilidades clínicas.ESCENARIO:Centro médico académico de gran tamañoPACIENTES:Pacientes que se sometieron a operaciones que incluyeron una urostomía permanente, colostomía y/o ileostomía entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:La hernia paraostomal (autoinformada) y la actividad física, medidas en equivalente metabólico de actividad total-minutos/semana, fueron nuestras principales medidas de resultado. También se evaluó la calidad de vida.RESULTADOS:Un total de 443 de 724 pacientes respondieron a la encuesta (tasa de respuesta 61,2%). 212 pacientes (47,9%) tenían urostomías, 160 (36,1%) colostomías y 99 (22,3%) ileostomías. 128 pacientes (29,7%) tenían hernia paraostomal, con tasas de 27,1% para urostomía, 40,0% para colostomía y 23,7% para ileostomía. Hubo una asociación estadísticamente significativa entre menos ejercicio y una mayor incidencia de hernia paraostomal (mediana: 579 equivalentes metabólicos - minutos/semana para aquellos con hernias paraostomales versus 1689 para aquellos sin hernias; p = 0,001).LIMITACIONES:La asociación entre la actividad física y la hernia paraostomal puede confundirse con la obesidad o con el hecho de que los pacientes con hernia paraostomal pueden tener menos actividad física debido a su hernia.CONCLUSIONES:Las tasas de hernia paraostomal siguen siendo altas en la práctica quirúrgica moderna y las hernias se asocian con una peor calidad de vida. Este estudio muestra una asociación entre la actividad física de los pacientes y la presencia de una hernia paraostomal, con una tasa más alta entre los pacientes que hacen menos ejercicio. Consulte Video Resumen en http://links.lww.com/DCR/B910 . (Traducción-Dr. Felipe Bellolio ).

"Their Whole Lives Are Going To Change": A Photo-Elicitation Study of Rectal Cancer Survivorship.

BACKGROUND: Rectal cancer survivors experience persistent symptoms, which may lead to unmet needs. OBJECTIVE: This study aimed to explore the rectal cancer survivor experience and identify the impacts of treatment using photo-elicitation. DESIGN: This was a novel study in which patients were instructed to take photographs that showed aspects of life that have been challenging to deal with since undergoing treatment. Participants underwent subsequent qualitative interviews using the photographs as prompts. SETTING: The study was conducted in a cancer center in a tertiary medical center. PATIENTS: Twenty patients were included who underwent curative-intent rectal cancer treatment. MAIN OUTCOME MEASURES: Interviews were designed to explore the lived experiences of patients with rectal cancer after treatment. RESULTS: Three major themes with regard to life after rectal cancer and its treatments emerged: physical symptoms, lifestyle changes, and changes over time. Physical symptoms encompassed GI issues, ostomy difficulties, and genitourinary symptoms. Lifestyle changes included those relating to diet, social life, and hobbies as well as major life changes and finances. Finally, patients spoke of improvement during the time of symptoms and impact on daily life. LIMITATIONS: There may be bias because of the homogeneity of our study population, which may not represent the experiences of younger patients, those of lower socioeconomic status, or those who chose not to participate. Our sample was also overrepresented by patients with a complete pathologic response after neoadjuvant chemotherapy and excluded individuals with recurrence. Finally, single interviews with each individual at different points from their treatment may have resulted in recall bias. CONCLUSIONS: This photo-elicitation study provided rectal cancer survivors with a unique opportunity to share how rectal cancer treatment has impacted their lives beyond traditional metrics such as postoperative complications and long-term survival. In addition to improving preoperative counseling and expectation setting, future efforts should focus on postoperative symptom surveillance and appropriate referral when needed. See Video Abstract at http://links.lww.com/DCR/C7. SUS VIDAS ENTERAS VAN A CAMBIAR UN ESTUDIO DE OBTENCIN DE IMGENES SOBRE LA SUPERVIVENCIA AL CNCER DE RECTO: ANTECEDENTES:Los sobrevivientes de cáncer de recto experimentan síntomas persistentes, lo que puede dar lugar a necesidades no satisfechas.OBJETIVO:Explorar la experiencia de los sobrevivientes de cáncer de recto e identificar los impactos del tratamiento mediante el uso de fotoestimulación.DISEÑO:En este nuevo estudio, se instruyó a los pacientes para que tomaran fotografías que mostraran aspectos de la vida que han sido difíciles de manejar desde que se sometieron al tratamiento. Los participantes se sometieron posteriormente a entrevistas cualitativas utilizando las fotografías como estimuladores.ESCENARIO:Centro oncológico en un centro médico terciario.PARTICIPANTES:Veinte pacientes que se sometieron a tratamiento de cáncer de recto con intención curativa.PRINCIPALES MEDIDAS DE RESULTADO:Las entrevistas se diseñaron para explorar las experiencias vividas por los pacientes con cáncer de recto después del tratamiento.RESULTADOS:Surgieron tres temas principales con respecto a la vida después del cáncer de recto y sus tratamientos: síntomas físicos; cambios en el estilo de vida; y cambios en el tiempo. Los síntomas físicos abarcaron problemas gastrointestinales, dificultades de las ostomías y síntomas genitourinarios. Los cambios en el estilo de vida incluyeron aquellos relacionados con la dieta, la vida social y los pasatiempos, así como cambios importantes en la vida y las finanzas. Por último, los pacientes hablaron de una mejoría con el tiempo de los síntomas y el impacto en la vida diaria.LIMITACIONES:Puede haber sesgo debido a la homogeneidad de nuestra población de estudio, que puede no representar las experiencias de los pacientes más jóvenes, los de nivel socioeconómico más bajo o los que optaron por no participar. Nuestra muestra también estuvo sobrerrepresentada por pacientes con una respuesta patológica completa después de la quimioterapia neoadyuvante y excluyó a los individuos con recurrencia. Finalmente, las entrevistas individuales con cada paciente en diferentes puntos de su tratamiento pueden dar lugar a que los participantes experimenten un sesgo de recuerdo.CONCLUSIONES:Este estudio de obtención de fotografías brinda a los sobrevivientes de cáncer de recto una oportunidad única de compartir cómo el tratamiento del cáncer de recto ha impactado sus vidas más allá de las métricas tradicionales, como las complicaciones posoperatorias y la supervivencia a largo plazo. Además de mejorar el asesoramiento preoperatorio y el establecimiento de expectativas, los esfuerzos futuros deben centrarse en la vigilancia de los síntomas posoperatorios y la derivación adecuada cuando sea necesario. Consulte Video Resumen en http://links.lww.com/DCR/C7.

"Why would you want to do that?"Surgical Interns Reflect on Discouragement From Entering Surgical Fields.

INTRODUCTION: Decreasing numbers of medical students are choosing to pursue surgical careers. This study highlights individual experiences of surgical interns receiving discouragement from pursuing surgery as a career. METHODS: We interviewed 24 incoming surgical interns from 7 institutions and 7 surgical subspecialties about their experiences with discouragement from surgery. RESULTS: All surgical interns discussed experiencing discouragement from pursuing surgery as a career. Family, friends, the general public, and medical professionals, including surgeons, served as sources of discouragement. Reasons for discouragement fell into 3 main themes: The Surgeon and Surgical Culture, The Sacrifices, and The Sexism. Despite its pervasiveness, participants reconciled the discouragement received. DISCUSSION: Discouragement from surgery is pervasive and centered around surgeon stereotypes and perceptions of surgical culture, significant personal sacrifices required, and traditional gender-related expectations. These results highlight the importance of individual surgeons' comments on student experience and can be used to improve the perception of surgery amongst prospective interns.

A national qualitative study of surgical coaching: Opportunities and barriers for colorectal surgeons.

BACKGROUND: Surgical coaching interventions have been recommended as a method of technological skills improvement for individual surgeons and lifelong occupational learning. Patient outcomes for laparoscopic colectomy vary significantly based on surgeon experience and case volume. As surgical coaching is an emerging area, little is known about how surgeons view coaching interventions. METHODS: Semistructured interviews with 68 colorectal surgeons from across the country who were e-mail recruited from the American Society of Colon and Rectal Surgeons focused on exploring the attitudes surrounding surgical coaching programs among colorectal surgeons. Interviews were performed via telephone, audio-recorded, and transcribed verbatim with redaction of identifying information. Interviews were analyzed by iterative steps informed by thematic analysis. RESULTS: Surgeons reported the desire to participate in coaching programs to improve patient outcomes through technical skill advancement, to keep pace with surgical innovation, and to fulfill a desire for lifelong learning. However, surgeons varied in their beliefs over who should be coached, who should coach, the format of coaching, and the topics addressed in coaching. Obstacles identified included time, financial and medicolegal concerns, balance with resident education, and vulnerability. CONCLUSION: Widespread enthusiasm for surgical coaching programs exists among colorectal surgeons. However, there is variability in what surgeons believe an ideal surgical coaching program would look like. Therefore, in alignment with adult learning theory, we recommend the creation of several different models of surgical coaching to allow each surgeon to benefit from this advancement in continuous professional development.

"The captain of the ship." A qualitative investigation of surgeon identity formation.

BACKGROUND: Professional identity formation is essential to medical trainee education. Surgeons are expected to guide trainees through this process but may be unprepared as they may not understand their own professional identity. METHODS: We purposively selected 46 surgeons across Michigan to participate in semi-structured qualitative interviews intended to explore surgical decision-making in 2019. Thematic analysis was used to analyze the transcripts. RESULTS: Surgeon identity formation is a complex process influenced by factors from four domains: individual factors, interpersonal relationships, external influences, and professional experience. We found surgeon identity formation commences prior to residency training and continues to remodel long into practice. CONCLUSIONS: By understanding surgeon identity, surgeons will be prepared to help form trainees' professional identities and recognize opportunities for improvement. We believe changes, especially within the environment and community, will encourage medical students to enter surgical fields, decrease resident attrition, and promote surgeon well-being.

It's not fine: A photo-elicitation study of rectal cancer survivors' emotions and coping strategies.

BACKGROUND: Comprehensive cancer care includes supporting the psychological health of survivors who are at high risk of distress. However, little is known about the emotional experiences of rectal cancer survivors specifically. We sought to explore psychological well-being and coping strategies utilized by rectal cancer survivors. METHODS: Twenty rectal cancer survivors shared photographs of their post-treatment experiences. In follow-up interviews, participants discussed photographs' meanings and emotional experiences during their cancer journey. Transcribed interviews were analyzed using iterative steps of inductive thematic analysis. RESULTS: Emotions ranged from sadness to anxiety and fear of cancer recurrence. Coping mechanisms were grouped into 3 categories: (1) seeking support and information; (2) focus on attitudes and perspectives; and (3) distancing strategies. CONCLUSION: Our results highlight the persistent psychological impact of rectal cancer and need for additional support for survivors. Providers may help temper patients' fear of recurrence by explicitly discussing prognosis and risk of recurrence. Although multidisciplinary survivorship clinics are ideal, all cancer care providers and primary care physicians should feel empowered to screen for psychological distress and refer patients to appropriate resources when needed.

The Best Gift You Could Give a Resident: A Qualitative Study of Well-Being Resources and Use Following Unwanted Outcomes.

In recent years, there has been increasing focus on the well-being of resident physicians. Considering the persistent problem of burnout and attrition particularly among surgical trainees, this is a well-warranted and laudable area of focus. However, despite the widespread adoption of resources available to residents through individual institutions, there is little understanding of how and why these resources are engaged or not during particularly vulnerable moments, such as following an unwanted patient event including postoperative complications and deaths. Methods: This qualitative study explored access to and usage of resources to promote well-being following an unwanted patient outcome through semi-structured interviews of 28 general surgery residents from 14 residency programs across the United States, including community, academic, and hybrid programs. A qualitative descriptive approach was used to analyze transcripts. Results: Residents described 3 main types of institutional resources available to them to promote well-being, including counseling services, support from program leadership, and wellness committees. Residents also described important barriers to use for each of these resources, which limited their access and value of these resources. Finally, residents shared their recommendations for future initiatives, including additional protected time off during weekdays and regular usage of structured debrief sessions following adverse patient outcomes. Conclusions: While institutional resources are commonly available to surgery residents, there remain important limitations and barriers to use, which may limit their effectiveness in supporting resident well-being in times of need. These barriers should be addressed at the program level to improve services and accessibility for residents.

"You Remember Those Days"-A Qualitative Study of Resident Surgeon Responses to Complications and Deaths.

OBJECTIVE: Postoperative complications and deaths are unavoidable aspects of a surgical career, but little is known about the impacts of these unwanted outcomes on resident surgeons. The goal of this study was to characterize the impact of complications and deaths on surgery residents in order to facilitate development of improved support systems. DESIGN: This qualitative study was designed to explore resident surgeons' experiences with unwanted outcomes, including postoperative complications and death. Semi-structured interviews explored a range of topics related to personal experiences with unwanted outcomes. Analyses of interview transcripts were performed iteratively and informed by thematic analysis. SETTING: An anthropologist at the University of Michigan conducted interviews with general surgery residents from academic, community, and hybrid training programs across the country. PARTICIPANTS: Twenty-eight mid-level and senior residents (PGY3 and above) were recruited for participation from 14 different training programs across the United States. RESULTS: Resident surgeons described an initial period of emotional response, characterized by feelings of sadness, frustration, or grief. Simultaneously or soon afterward, interviewees described a period of intellectual response aimed at understanding how and why an outcome occurred, with the expressed goal of learning from it. Many residents described impacts to their personal lives. Several factors that influenced the duration and intensity of these responses were identified, including a sense of ownership, which was a powerful driver for improvement. CONCLUSIONS: This qualitative study provides a nuanced description of resident surgeons' responses to unwanted outcomes. While emotional responses were characterized by strong feelings, such as sadness and grief, intellectual responses were focused on learning from the events. These data may help inform the development of structured support systems by residency programs. STRUCTURED ABSTRACT: Facing post-operative complications and deaths is an unavoidable aspect of surgical training, but the impacts on surgery residents has not been well characterized. Through semi-structured interviews with general surgery residents from programs across the United States, this qualitative study explored the ways that residents respond to unwanted outcomes. Residents described an initial period of emotional response, characterized by strong feelings, often of sadness or grief. There was a subsequent or concomitant period of intellectual response, in which residents examined how and why this outcome occurred, with the goal of learning from it. A feeling of ownership was strengthened by involvement in patient care and length of rotation. In light of this detailed description of resident experiences, residency programs can foster the development of improved support for trainees as they navigate these profoundly impactful events.

Resident Perceptions of Faculty Behaviors Promoting Learner Operative Skills and Autonomy.

OBJECTIVE: To better understand the resident perceived faculty factors associated with the promotion of resident operative skill and autonomy DESIGN: Qualitative retrospective analysis utilizing anonymous open-ended comments from residents on department of surgery faculty teaching evaluations and cross references them to observed faculty entrustment scores SETTING: Single tertiary midwestern allopathic academic medical center using data obtained between January 2016-August 2019 PARTICIPANTS: Forty-six resident and fourteen faculty surgeons from general, plastic, thoracic, and vascular surgery sections. RESULTS: Themes of personal traits, the working environment created, and teaching techniques employed were identified across resident promoting attendings and resident limiting attendings. Promoting attendings employed preoperative goal setting, increased operative autonomy, and postoperative feedback while creating environments conducive to learning by promoting teamwork and collaboration. Alternatively, limiting attendings used more ineffective teaching techniques including micromanaging, lack of delegation, and treating residents as observers. Additionally, trainees described these operating room environments as stressful and strained. CONCLUSIONS: Qualitative analysis of resident teaching evaluations of attending surgeons highlights the importance of relationships between learner and teacher, the learning environment, and teaching techniques. Continuous professional development programs centered on entrustment and promoting behaviors have the potential to disseminate strategies to enhance educator skills among surgeons.

Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer.

BACKGROUND: Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique. OBJECTIVE: This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading. DESIGN: To test the effect of the program, participants completed a survey before and after participating. SETTINGS: Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project. PARTICIPANTS: Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals. MAIN OUTCOME MEASURES: Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice. RESULTS: A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar. LIMITATIONS: Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible. CONCLUSIONS: Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO. ANTECEDENTES: Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos. OBJETIVO: Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal. DISEO: Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma. MARCO: Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto. PARTICIPANTES: Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales. PRINCIPALES RESULTADOS MEDIDOS: La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido. RESULTADOS: Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea. LIMITACIONES: Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares. CONCLUSIONES: Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).

Hardship and Humanity: A Closer Qualitative Look at Surgical Training and Its Effects on Trainees From the Perspectives of Loved Ones.

OBJECTIVE: The aim of this study was to obtain novel perspectives regarding the effects that surgical training has on the well-being of trainees. SUMMARY BACKGROUND DATA: Improving trainee well-being is a national concern given high rates of burnout, depression, and suicide among physicians. Supporters of surgical trainees may offer new perspectives regarding the effects of surgical training and point to strategies to optimize trainee wellness. METHODS: This qualitative study employs semi-structured interviews of 32 support persons of trainees at a single tertiary care center with multiple surgical training programs. Interviews focused on perspectives related to supporting a surgical trainee. Interview transcripts underwent qualitative analysis with semantic and conceptual coding. Themes related to effects of training on trainee wellness are reported. RESULTS: Four themes were identified: Who Can Endure the Most Hardship?-trainee attributes and programmatic factors contribute to trainees feeling the need to constantly endure the most hardship; Consequences of Hardship-constantly enduring hardships has significant negative effects on wellness; Trainees are Humans-trainees are people with basic human needs, especially the need for worth; Research Time as Refuge-dedicated research time is treated as an oasis away from clinical hardships. CONCLUSIONS: Perspectives from support persons can offer valuable insight into the wellness needs of surgical trainees. According to support persons, surgical training profoundly negatively impacts trainee wellness. Unlike during clinical training, dedicated research time is a period during which wellness can be prioritized. Programs should provide greater attention to mitigating the negative ramifications of surgical training and promoting wellness in a longitudinal fashion throughout training.