Surgeon proficiency gain and survival after gastrectomy for gastric adenocarcinoma: A population-based cohort study.

OBJECTIVE: Quality of surgery is essential for survival in gastric adenocarcinoma, but studies examining surgeons' proficiency gain of gastrectomies are scarce. This study aimed to reveal potential proficiency gain curves for surgeons operating patients with gastric cancer. METHODS: Population-based cohort study of patients who underwent gastrectomy for gastric adenocarcinoma in Sweden between 2006 and 2015 with follow-up throughout 2020. Data were retrieved from national registries and medical records. Risk prediction models were used to calculate outcome probabilities, and risk-adjusted cumulative sum curves were plotted to assess differences (change points) between observed and expected outcomes. The main outcome was long-term (>3-5 years) all-cause mortality after surgery. Secondary outcomes were all-cause mortality within 30 days, 31-90 days, 91 days to 1 year and>1-3 years of surgery, resection margin status, and lymph node yield. RESULTS: The study included 261 surgeons and 1636 patients. The>3- to 5-year mortality was improved after 20 cases, and decreased from 12.4% before to 8.6% after this change point (p = 0.027). Change points were suggested, but not statistically significant, after 22 cases for 30-day mortality, 28 cases for 31- to 90-day mortality, 9 cases for 91-day to 1-year mortality, and 10 cases for>1- to 3-year all-cause mortality. There were statistically significant improvements in tumour-free resection margins after 28 cases (p < 0.005) and greater lymph node yield after 13 cases (p < 0.001). CONCLUSIONS: This study reveals proficiency gain curves regarding long-term survival, resection margin status, and lymph node yield in gastrectomy for gastric adenocarcinoma, and that at least 20 gastrectomies should be conducted with experienced support before doing these operations independently.

Characterizing Moral Injury and Distress in US Military Surgeons Deployed to Far-Forward Combat Environments in Afghanistan and Iraq.

Importance: Moral injury and distress (MID), which occurs when individuals have significant dissonance with their belief system and overwhelming feelings of being powerless to do what is believed to be right, has not been explored in the unique population of military surgeons deployed far forward in active combat settings. Deployed military surgeons provide care to both injured soldiers and civilians under command-driven medical rules of engagement (MROE) in variably resourced settings. This practice setting has no civilian corollary for comparison or current specific tool for measurement. Objective: To characterize MID among military surgeons deployed during periods of high casualty volumes through a mixed-methods approach. Design, Setting, and Participants: This qualitative study using convergent mixed methods was performed from May 2020 to October 2020. Participants included US military surgeons who had combat deployments to a far-forward role 2 treatment facility during predefined peak casualty periods in Iraq (2003-2008) and Afghanistan (2009-2012), as identified by purposeful snowball sampling. Data analysis was performed from October 2020 to May 2021. Main Outcomes and Measures: Measure of Moral Distress for Healthcare Professionals (MMD-HP) survey and individual, semistructured interviews were conducted to thematic saturation. Results: The total cohort included 20 surgeons (mean [SD] age, 38.1 [5.2] years); 16 (80%) were male, and 16 (80%) had 0 or 1 prior deployment. Deployment locations were Afghanistan (11 surgeons [55%]), Iraq (9 surgeons [45%]), or both locations (3 surgeons [15%]). The mean (SD) MMD-HP score for the surgeons was 104.1 (39.3). The primary thematic domains for MID were distressing outcomes (DO) and MROE. The major subdomains of DO were guilt related to witnessing horrific injuries; treating pregnant women, children, and US soldiers; and second-guessing decisions. The major subdomains for MROE were forced transfer of civilian patients, limited capabilities and resources, inexperience in specialty surgical procedures, and communication with command. Postdeployment manifestations of MID were common and affected sleep, medical practice, and interpersonal relationships. Conclusions and Relevance: In this qualitative study, MID was ubiquitous in deployed military surgeons. Thematic observations about MID, specifically concerning the domains of DO and MROE, may represent targets for further study to develop an evaluation tool of MID in this population and inform possible programs for identification and mitigation of MID.

For the People and the Profession.

In 1982 Dean Warren delivered the presidential address "Not for the Profession… For the People" in which he identified substandard surgical residency programs graduating residents who were unable to pass American Board of Surgery exams. Drs. Warren and Shires as members of the independent ACGME began to close the substandard programs in order to improve surgical care for average Americans i.e. "for the people". By 2003 these changes dramatically reduced the failure rate for the ABS exams and trained good surgeons who could operate independently however the residents were on duty for every other or every third night. In 2003 the ACGME mandated duty hour restrictions in order improve resident wellness and improve the training environment for the profession. However, work hour restrictions reduced the time surgical residents spent in the hospital environment primarily when residents had more autonomy and had exposure to emergency cases which degraded readiness for independent practice. Surgical educators in the 2 decades after the work hour restrictions have improved techniques of training so graduates could not only pass the board exams but also be prepared for independent practice. Surgical residency training has improved by both the changes implemented by the independent ACGME in 1981 and by the work hour restrictions mandated in 2003. Five recommendations are made to ensure that Dr Warren's culture of excellence in surgical training continues in an environment that enhances wellbeing of the trainee i.e. "For the People and the Profession".

Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale.

BACKGROUND: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES: Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Industry Payments to Plastic Surgeons, 2013 to 2018: Who's Getting Paid?

BACKGROUND: The Physician Payments Sunshine Act of 2010 mandated that all industry payments to physicians be publicly disclosed. To date, industry support of plastic surgeons has not been longitudinally characterized. The authors seek to evaluate payment trends from 2013 to 2018 and characteristics across plastic surgeon recipients of industry payments. METHODS: The authors cross-referenced those in the 2019 American Society of Plastic Surgeons member database with Centers for Medicare & Medicaid Services Open Payments database physician profile identification number indicating industry funds received within the study period. We categorized surgeons by years since American Board of Plastic Surgery certification, practice region, and academic affiliation. RESULTS: A sum of $89,436,100 (247,614 payments) was received by 3855 plastic surgeons. The top 1 percent of earners (n = 39) by dollar amount received 52 percent of industry dollars to plastic surgeons; of these, nine (23 percent) were academic. Overall, 428 surgeons (11 percent) were academic and received comparable dollar amounts from industry as their nonacademic counterparts. Neither geographic location nor years of experience were independent predictors of payments received. The majority of individual transactions were for food and beverage, whereas the majority of industry dollars were typically for royalties or license. CONCLUSIONS: Over half of all industry dollars transferred went to just 1 percent of American Society of Plastic Surgeons members receiving payments between 2013 and 2018. Considerable heterogeneity exists when accounting for payment subcategories.

Vascular and Endovascular Surgical Procedural Skills Training: Survey of Vascular Surgery Program Directors About Extracurricular Vascular Surgical Educational Courses for Vascular Trainees.

BACKGROUND: Over the past decade, there has been an increase in the number of Vascular Surgery Educational Courses (VSEC) provided by academic institutions, regional and national vascular surgical societies, as well as industry partners. Each course has its own curriculum and how these curricula align with the modern needs of vascular surgery trainees are unclear. As such, there is a lack of unified content, syllabus, and trainee evaluations/feedback of these courses. The Education Committee for the Association for Program directors in Vascular Surgery (APDVS) was tasked to survey vascular surgery Program directors (PDs) and Associate Program directors (APDs) across the country to investigate the educational value, utility, and feedback provided from these VSEC. METHODS: A comprehensive list of vascular surgery educational courses across the country was generated. A 21-question survey was constructed and forwarded to all members of APDVS. The survey was directed at obtaining data from the vascular surgery program director/associate program directors about their understanding of the VSEC and what they valued as critical for their trainees. In addition, we sought to gauge the feedback provided by these courses to the vascular surgery trainees, and their PD/APDs. RESULTS: The survey was sent to 170 active members of APDVS with an overall response rate of 41%. The majority of the respondents 57 (81%) were PDs. Of all the PD/APDs, 5 (7%) reported that they knew of less than 5 such programs, 26 (37%) reported knowledge of 6-10 courses, 20 (29%) reported 11-20 courses, and 19 (27%) reported knowing more than 20 such programs. 49 (70%) of those surveyed reported that their trainees benefit from these courses. Statisticallysignificant factors impacting the decision to make adjustments to the individual training program included PGY-5 residents attending the educational courses, feedback from VSEC, and positive feedback from trainees attending the courses (all P < 0.05). When asked about their wants of VSEC, 35% desired mock oral exams, and 31% looked for cadaver dissections. Of the 24 PD/APD's who made adjustments to their program based on the feedback from the educational programs, those who held the title for 5-10 years were the most willing to make any changes 13 (54%), and those with more than ten years of experience 2 (8%), were the least willing to make any changes (P < 0.05). The majority of the PD/APDs 32 (46%) felt that the regional societal meetings are the best place to hold educational courses. 38 (55%) of PD/APD's received no feedback from the VSEC course directors. 41 (59%) of the programs provide some financial support for their trainees to attend these courses and 65 (92%) of the PD/APDs suggest that industry partners should provide the financial support for attending VSEC. CONCLUSIONS: This unique survey explores the attitude of vascular surgery educators about outside vascular surgery educational courses offered by various groups and industry. It is important to create standardized curricula for vascular surgery educational courses with collaborative oversight by educational/simulation key opinion leaders, PD/APD's, course directors and industry partners. Exploring benchmarks for standardization of the curricula offered by these outside educational opportunities would streamline the needs of our vascular surgery trainees and minimize time away from home institutions. Feedback identifying vascular trainees' strengths and areas for improvement to PD/APDs would be of great educational value and is currently a missed opportunity.

Expertise-based design in surgical trials: a narrative review.

Randomized controlled trials (RCTs) are the most robust study design for evaluating the safety and efficacy of a therapeutic intervention. However, their internal validity are at risk when evaluating surgical interventions. This review summarizes existing expertise- based trials in surgery and related methodological concepts to guide surgeons performing this work. We provide caseloads required to reach the learning curve for various surgical interventions and report criteria for expertise from published and unpublished expertise-based trials. In addition, we review design and implementation concepts of expertise-based trials, including recruitment of surgeons, crossover, ethics, generalizability, sample size and definitions for learning curve. Several RCTs have used an expertise-based design. We found that the majority of definitions used for expertise were vague, heterogeneous, and inconsistent across trials evaluating the same surgical intervention. Statistical methods exist to adjust for the learning curve; however, there is limited guidance. We developed the following criteria for surgical expertise for future trials: 1) decide on the proxy to be used for the learning curve, and 2) assess eligible surgeons by comparing their performance to the previously defined expertise criteria.

Variation in Surgeon Proficiency Scores and Association With Digit Replantation Outcomes.

Importance: Risk-adjusted variation in surgeon outcomes has been traditionally explained by surgeon volume and hospital infrastructure, yet it is unclear how a surgeon's operative proficiency directly contributes to their patients' outcomes. Objective: To assess the variation of surgeons' operative proficiency and investigate its association with surgical outcomes. Design, Setting, and Participants: This case series was a retrospective analysis of all digit replantations and revascularizations at a single US university medical center between January 2000 and August 2020. Surgeons were assigned a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Surgeon proficiency scores were then used to determine associations with outcomes from subsequent cases. The expected difficulty of each case was calculated using a novel scoring system that applied pooled relative risks from a meta-analysis of risk factors for replantation and revascularization failure. Exposures: Digit replantation and revascularization. Main Outcomes and Measures: Digit survival at 1-month follow up (case success) and number of complications. Results: A total of 145 patients and 226 digits were treated by 11 surgeons with training in hand or microsurgery (mean [SD] age, 41.9 [15.2] years; 204 [90%] men); there were 116 replantations and 110 revascularizations. Surgeon proficiency scores ranged from 1.3 to 5.7, with a mean (SD) of 3.4 (1.4). Case success rates among surgeons varied from 20.0% to 90.5%, with a mean (SD) of 64.9%. Higher proficiency scores were associated with fewer case failures: each point increase was associated with 40% decreased odds of failure (odds ratio, 0.60; 95% CI, 0.38-0.94). Every 3-point increase in proficiency score was associated with 1 less complication (effect estimate, -0.29; 95% CI, -0.56 to 0.02). Surgeon proficiency score had a greater association with case failure than surgeon volume (16.7% vs 12.0%). The final model's association with case failure had an area under the receiver operating characteristics curve of 0.93. Conclusions and Relevance: Operative proficiency varied widely among practicing surgeons and accounted for 17% of estimative ability for success of digit replantation and revascularization. Greater surgeon proficiency was associated with better outcomes, indicating that the value of surgical care may be optimized by improving surgeon proficiency.

Beyond the operating room: do hospital characteristics have an impact on surgical site infections after colorectal surgery? A systematic review.

BACKGROUND: Hospital characteristics have been recognized as potential risk factors for surgical site infection for over 20 years. However, most research has focused on patient and procedural risk factors. Understanding how structural and process variables influence infection is vital to identify targets for effective interventions and to optimize healthcare services. The aim of this study was to systematically review the association between hospital characteristics and surgical site infection in colorectal surgery. MAIN BODY: A systematic literature search was conducted using PubMed, Scopus and Web of Science databases until the 31st of May, 2021. The search strategy followed the Participants, Exposure/Intervention, Comparison, Outcomes and Study design. The primary outcome of interest was surgical site infection rate after colorectal surgery. Studies were grouped into nine risk factor typologies: hospital size, ownership affiliation, being an oncological hospital, safety-net burden, hospital volume, surgeon caseload, discharge destination and time since implementation of surveillance. The STROBE statement was used for evaluating the methodological quality. A total of 4703 records were identified, of which 172 were reviewed and 16 were included. Studies were published between 2008 and 2021, and referred to data collected between 1996 and 2016. Surgical site infection incidence ranged from 3.2 to 27.6%. Two out of five studies evaluating hospital size adjusted the analysis to patient and procedure-related risk factors, and showed that larger hospitals were either positively associated or had no association with SSI. Public hospitals did not present significantly different infection rates than private or non-profit ones. Medical school affiliation and higher safety-net burden were associated with higher surgical site infection (crude estimates), while oncological hospitals were associated with higher incidence independently of other variables. Hospital caseload showed mixed results, while surgeon caseload and surveillance time since implementation appear to be associated with fewer infections. CONCLUSIONS: Although there are few studies addressing hospital-level factors on surgical site infection, surgeon experience and the implementation of a surveillance system appear to be associated with better outcomes. For hospitals and services to be efficiently optimized, more studies addressing these variables are needed that take into account the confounding effect of patient case mix.

NASA-TLX assessment of workload in resident physicians and faculty surgeons covering trauma, surgical intensive care unit, and emergency general surgery services.

BACKGROUND: Higher workload is associated with burnout and lower performance. Therefore, we aim to assess shift-related factors associated with higher workload on EGS, ICU, and trauma surgery services. METHODS: In this prospective cohort study, faculty surgeons and surgery residents completed a survey after each EGS, ICU, or trauma shift, including shift details and a modified NASA-TLX. RESULTS: Seventeen faculty and 12 residents completed 174 and 48 surveys after working scheduled 12-h and 24-h shifts, respectively (response rates: faculty - 62%, residents - 42%). NASA-TLX was significantly increased with a higher physician subjective fatigue level. Further, seeing more consults or performing more operations than average significantly increased workload. Finally, NASA-TLX was significantly higher for faculty when they felt their shift was more difficult than expected. CONCLUSIONS: Higher volume clinical responsibilities and higher subjective fatigue levels are independently associated with higher workload. Designing shift coverage to expand on busier days may decrease workload, impacting burnout and shift performance.

Are we producing general surgeons who are ready for community or rural practice?

Summary: General surgery remains a broad and unclearly defined specialty in small and medium-sized communities, where general surgeons perform more subspecialty and non-core procedures than their urban counterparts. It is unclear what specific procedures are being performed or whether today's residents are being trained to meet community needs. We surveyed the members of the British Columbia (BC) Surgical Society and found that only 3% of BC's surgeons believe today's graduates are "definitely prepared" for a broad-based community practice. We also identified several non-core procedures performed more frequently by general surgeons in small and medium-sized communities. General surgery residency is narrowing its focus despite the fact that community general surgeons are maintaining a broad-based practice. To meet the needs of smaller communities, residency programs need to address the discrepancies that exist between the emphasis within the current training structure and the practice of our community surgeons.