The 2018 reawakening and eruption dynamics of Steamboat Geyser, the world's tallest active geyser.

Steamboat Geyser in Yellowstone National Park's Norris Geyser Basin began a prolific sequence of eruptions in March 2018 after 34 y of sporadic activity. We analyze a wide range of datasets to explore triggering mechanisms for Steamboat's reactivation and controls on eruption intervals and height. Prior to Steamboat's renewed activity, Norris Geyser Basin experienced uplift, a slight increase in radiant temperature, and increased regional seismicity, which may indicate that magmatic processes promoted reactivation. However, because the geothermal reservoir temperature did not change, no other dormant geysers became active, and previous periods with greater seismic moment release did not reawaken Steamboat, the reason for reactivation remains ambiguous. Eruption intervals since 2018 (3.16 to 35.45 d) modulate seasonally, with shorter intervals in the summer. Abnormally long intervals coincide with weakening of a shallow seismic source in the geyser basin's hydrothermal system. We find no relation between interval and erupted volume, implying unsteady heat and mass discharge. Finally, using data from geysers worldwide, we find a correlation between eruption height and inferred depth to the shallow reservoir supplying water to eruptions. Steamboat is taller because water is stored deeper there than at other geysers, and, hence, more energy is available to power the eruptions.

Improving Surgical Research Capacity in Low- and Middle-Income Countries: Can Episodic Data Collection Reliably Estimate Perioperative Mortality?

OBJECTIVE: The aim of this study was to empirically determine the optimal sample size needed to reliably estimate perioperative mortality (POMR) in different contexts. SUMMARY BACKGROUND DATA: POMR is a key metric for measuring the quality and safety of surgical systems and will need to be tracked as surgical care is scaled up globally. Continuous collection of outcomes for all surgical cases is not the standard in high-income countries and may not be necessary in low- and middle-income countries. METHODS: We created simulated datasets to determine the sampling frame needed to reach a given precision. We validated our findings using data collected at Mulago National Referral Hospital in Kampala, Uganda. We used these data to create a tool that can be used to determine the optimal sampling frame for a population based on POMR rate and target POMR improvement goal. RESULTS: Precision improved as the sampling frame increased. However, as POMR increased, lower sampling percentages were needed to achieve a given precision. A total of 357 eligible cases were identified in the Mulago database with an overall POMR rate of 14%. Precision of ±10% was achieved with 34% sampling, and precision of ±25% was obtained at 9% sampling. Using simulated datasets, a tool was created to determine the minimum sample percentage needed to detect a given mortality improvement goal. CONCLUSIONS: Reliably tracking POMR does not require continuous data collection. Data driven sampling strategies can be used to decrease the burden of data collection to track POMR in resource-constrained settings.

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

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

What's it Worth?: The Costs and Benefits of an Initiative to Decrease Post-Call Fatigued Driving Among Surgery Residents.

BACKGROUND: In 2017 the ACGME enacted new regulations requiring sponsoring institutions to ensure "safe transportation options for residents who may be too fatigued to safely return home." We investigate here the impact of a pilot "Safe Ride" program designed to mitigate the risks of fatigued driving. METHODS: During a 2-month pilot period at a single university-affiliated general surgery residency with four urban clinical sites, all residents (n = 72) were encouraged to hire a rideshare (e.g., Uber, Lyft) to and from 24-h clinical shifts if they felt too fatigued to drive safely. The cost of the rideshare was fully reimbursed to the resident. The impact of this intervention was evaluated using utilization data and a post-intervention resident survey. RESULTS: A total of 16.6% of trainees utilized a rideshare at least one time. Sixty-three post-call rides were taken, predominantly by junior residents (92.4%) and for commutes greater than 15 miles (91%). The cost for the 60-day pilot was $3030. Comparing pre-intervention to post-intervention data, there was a significant improvement in the reported frequency of falling asleep or nearly asleep while driving (P < 0.001). Trainees nearly unanimously (98%) supported efforts to make the program permanent. DISCUSSION: Driving while fatigued is common among surgical residents, with increased risk among junior residents, during longer commutes and following longer shifts. A reimbursed rideshare program effectively targets these risk factors and was associated with a significant decrease in rates of self-reported fatigued driving. Future efforts should focus on strategies to promote use of reimbursed rideshare programs while remaining cost efficient.

The Impact of the Great Recession on Long-Term Services and Supports in the United States and England.

The Great Recession substantially affected most developed countries. How countries responded to the Great Recession varied greatly, especially in terms of public spending. We examine the impact of the Great Recession on long-term services and supports (LTSS) in the United States and England. Financing for LTSS in these two countries differs in important ways; by examining the two countries' financing and program structures, we learn how these factors influenced each country's response to this common external stimulus. We find that between 2006 and 2013, LTSS increased in the United States in terms of spending (17%) and number of people served; in contrast, over the same period, LTSS in England decreased in terms of spending (6%) and people served. We find that the use of earmarked LTSS funding in the United States, compared to non-earmarked funding in England, contributed to different trajectories for LTSS in the two countries. Other contributing factors included differences in service entitlements, variations in ability of state and local governments to tax, and larger macroeconomic strategies implemented to combat the recession. We analyze the implications of our findings, especially as related to the potential shift to Medicaid block grant LTSS funding in the United States.

Can dogs use vocal intonation as a social referencing cue in an object choice task?

Evidence from the literature indicates that dogs' choices can be influenced by human-delivered social cues, such as pointing, and pointing combined with facial expression, intonation (i.e., rising and falling voice pitch), and/or words. The present study used an object choice task to investigate whether intonation conveys unique information in the absence of other salient cues. We removed facial expression cues and speech information by delivering cues with the experimenter's back to the dog and by using nonword vocalizations. During each trial, the dog was presented with pairs of the following three vocal cues: Positive (happy-sounding), Negative (sad-sounding), and Breath (neutral control). In Experiment 1, where dogs received only these vocal cue pairings, dogs preferred the Positive intonation, and there was no difference in choice behavior between Negative or Breath. In Experiment 2, we included a point cue with one of the two vocal cues in each pairing. Here, dogs preferred containers receiving pointing cues as well as Negative intonation, and preference was greatest when both of these cues were presented together. Taken together, these findings indicate that dogs can indeed extract information from vocal intonation alone, and may use intonation as a social referencing cue. However, the effect of intonation on behavior appears to be strongly influenced by the presence of pointing, which is known to be a highly salient visual cue for dogs. It is possible that in the presence of a point cue, intonation may shift from informative to instructive.

Disparities in Adherence to Pediatric Diabetic Ketoacidosis Management Guidelines Across a Spectrum of Emergency Departments in the State of Indiana: An Observational In Situ Simulation-Based Study.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common presentation to an emergency department (ED), with the majority presenting to community EDs. Adherence to clinical guidelines in these EDs can reduce morbidity and mortality. Few methods to describe practice gaps for DKA management have been reported. OBJECTIVES: We hypothesized that high-fidelity in situ simulation can be used to measure and compare the quality of the care provided to pediatric patients with DKA presenting to community EDs in the state of Indiana. METHODS: This observational study examined multiprofessional teams caring for a simulated pediatric patient who presented with DKA to community EDs. The primary outcome was overall adherence to pediatric DKA guidelines as measured by a validated performance checklist. A composite adherence score (CAS) was calculated using the sum of 9 checklist performance parameters. Multivariable logistic regression was used to examine the impact of ED volume and characteristics on the scores. RESULTS: A 49 multiprofessional teams from 13 sites were enrolled. Of the 252 participants, 26 (10.3%) were physicians, 143 (56.7%) registered nurses, 25 (9.9%) respiratory therapists, and 58 (23.0%) were other. The overall CAS for all sites was 55.6% (25th, 75th interquartile range, 44.4%, 66.7%). Excessive intravenous fluid boluses were given by 53.1%, whereas 30.6% and 26.5% incorrectly administered insulin and sodium bicarbonate boluses, respectively. Only 10.2% used an appropriate intravenous fluid rate, and 57.1% performed an hourly glucose. No significant difference in the CAS was found due to pediatric ED volume or presence of an inpatient pediatric service. CONCLUSIONS: Using validated in situ simulation; we revealed high variability in adherence to the pediatric DKA management guidelines at a wide range of community EDs. A statewide education initiative focused on decreasing variation and improving adherence to pediatric DKA guidelines is necessary for patient safety.

Variations in an African Grey parrot's speech patterns following ignored and denied requests.

Communicative competence is one measure of an individual's ability to navigate conversations with social partners. The current study explored the possibility of basic communicative competence in a non-mammal speaker, a speech-using African Grey parrot. Spontaneous conversations between one Grey named Cosmo and her caregiver were recorded, from which three corpora (i.e., bodies of text) of Cosmo's vocalizations were developed: (1) Baseline: Vocalizations containing no requests, (2) Ignored Requests: Vocalizations immediately following Cosmo's caregiver ignoring Cosmo's requests, and (3) Denied Requests: Vocalizations immediately following Cosmo's caregiver denying Cosmo's requests. The distributions of social (e.g., "I love you," kiss sounds) and nonsocial (e.g., answering machine beeps, "That's squirrel") vocalizations, as well as speech and nonword vocalizations, were statistically different across the three corpora. Additionally, qualitative analysis of the datasets indicated Cosmo was persistent in repeating vocalizations when denied and ignored, and interrupted her caregiver more often when requests were denied compared to ignored. Neither repetition nor interruption occurred during the Baseline conversations. The data indicate that despite the outcome being the same (i.e., request was unmet), Cosmo treated an ignored request differently than a denied request, modifying her vocalizations in accord with the specific context. Such modification is evidence of basic communicative competence.

Dense Nonaqueous-Phase Liquid Architecture in Fractured Bedrock: Implications for Treatment and Plume Longevity.

Partitioning tracer testing was performed in discrete intervals within a fractured bedrock tetrachloroethene (PCE) dense nonaqueous-phase liquid (DNAPL) source area to assess the fracture flow field and DNAPL architecture. Results confirmed that the partitioning tracer testing was able to identify and quantify low levels of residual DNAPL along flow paths in hydraulically conductive fractures. DNAPL fracture saturations (Sn) ranged from undetectable to 0.007 (DNAPL volume/fracture volume). A comparison of the fracture flow field to the DNAPL distribution indicated that the highest value of Sn was observed in the least transmissive fracture (or fracture zone). Application of a simple ambient dissolution model showed that the DNAPL present in this low transmissivity zone would persist longer than the DNAPL present in more transmissive fractures and would persist for 200 years (in the absence of any degradation reactions). Assessment of PCE mass distribution between the rock matrix and fractures showed that, due to the presence of DNAPL, the rock matrix accounted for less than 10% of the total PCE mass. The evaluation of PCE concentration profiles in the rock matrix and the estimated diffusional flux from the rock matrix suggest that the elevated PCE groundwater concentrations observed in the fractures likely are due to the presence of the residual DNAPL sources and that removal of the residual DNAPL sources within the fractures would result in a significant decrease in dissolved PCE concentrations in the source area.

Adult activity and temperature preference drives region-wide damselfly (Zygoptera) distributions under a warming climate.

We analysed a recently completed statewide odonate Atlas using multivariate linear models. Within a phylogenetically explicit framework, we developed a suite of data-derived traits to assess the mechanistic distributional drivers of 59 species of damselflies in New York State (NYS). We found that length of the flight season (adult breeding activity period) mediated by thermal preference drives regional distributions at broad (10(5) km(2)) scales. Species that had longer adult flight periods, in conjunction with longer growing seasons, had significantly wider distributions. These intrinsic traits shape species' responses to changing climates and the mechanisms behind such range shifts are fitness-based metapopulation processes that adjust phenology to the prevailing habitat and climate regime through a photoperiod filter.

Binding of the CYK-4 subunit of the centralspindlin complex induces a large scale conformational change in the kinesin subunit.

Centralspindlin is a critical regulator of cytokinesis in animal cells. It is a tetramer consisting of ZEN-4/MKLP1, a kinesin-6 motor, and CYK-4/MgcRacGAP, a Rho GTPase-activating protein. At anaphase, centralspindlin localizes to a narrow region of antiparallel microtubule overlap and initiates central spindle assembly. Central spindle assembly requires complex formation between ZEN-4 and CYK-4. However, the structural consequences of CYK-4 binding to ZEN-4 are unclear as are the mechanisms of microtubule bundling. Here we investigate whether CYK-4 binding induces a conformational change in ZEN-4. Characterization of the structure and conformational dynamics of the minimal interacting regions between ZEN-4 and CYK-4 by continuous wave EPR and double electron-electron resonance (DEER) spectroscopy reveals that CYK-4 binding dramatically stabilizes the relative positions of the neck linker regions of ZEN-4. Additionally, our data indicate that each neck linker is similarly structured in the bound and unbound states. CYK-4 binding decreases the rate of ZEN-4-mediated microtubule gliding. These results constrain models for the molecular organization of centralspindlin.

Benefits of Resistance Training During Pregnancy for Maternal and Fetal Health: A Brief Overview.

Research demonstrates resistance training is not only safe but also beneficial for pregnant women. However, exercise recommendations for pregnant women still minimize the importance of resistance exercise and provide minimal guidance. With a large increase in strength-focused sports among women, it is critical to re-evaluate the risk/benefit ratio of these exercises and ensure the latest recommendations reflect the latest clinical research. The purpose of this review is to highlight the safety and benefits of resistance training for both maternal and fetal health, particularly focusing on recent work. Relevant research involving resistance training during pregnancy was accessed and analyzed via a quasi-systematic search. Results demonstrate that appropriate prenatal resistance training can help alleviate some of the common symptoms of pregnancy, such as fatigue, back pain, and poor mental health. Resistance exercise can assist with glucose control in gestational diabetes mellitus, as well as decrease the risk of infant macrosomia and childhood metabolic dysfunction associated with uncontrolled gestational diabetes. Resistance training can also increase the likelihood of a vaginal delivery, which is beneficial for both mother and baby. Concerning fetal health, resistance training increases uterine blood flow, decreases the risk of neonatal macrosomia, and improves cognitive function and metabolic health in childhood. As with all forms of exercise, pregnant women should avoid resistance exercises that involve the supine position for extended bouts of time, trauma (or risk of trauma) to the abdomen, ballistic movements, movements that rely heavily on balance, and conditions that prohibit appropriate temperature control. With these considerations in mind, resistance training's benefits far surpass the lack of risk to the fetus. Resistance training is a safe and effective way to improve and maintain physical fitness during pregnancy and represents no risk to fetal health and development. Thus, healthcare providers should recommend resistance training for pregnant women.

A More Comfortable Method for Hydrostatic Weighing: Head above Water at Total Lung Capacity.

Hydrostatic weighing (HW) requires full submersion with the lungs at residual volume (RV) which is uncomfortable. Therefore, the purpose of this study was to find a more comfortable way to complete HW. A HW system was used to complete three comparisons: comparison 1: change in head position (head above water vs. head below water (HAW vs. HBW)), comparison 2: change in lung volume (total lung capacity (TLC) vs. RV), and comparison 3: change in head and lung volume changes. Participants were separated by males (n = 64) and females (n = 58). Comparison 1: HAW resulted in higher mean percent body fat (PBF) than HBW (4.5% overall, 3.8% in males, 5.4% in females, p < 0.05). Comparison 2: TLC resulted in lower mean PBF than RV (5.1% overall, 5.3% in males, 4.8% in females, p < 0.05). Comparison 3: HAW@TLC resulted in significantly lower (1.5% lower, p = 0.003) mean PBF for males but was not significantly lower for females or overall (0.6% higher, p = 0.39, 0.6% lower, p = 0.18, respectively) compared to HBW@RV. In conclusion, keeping the head above water and taking a deep inhale makes HW a more enjoyable, and accessible experience for everyone while still producing accurate PBF results.

Faculty and Resident Perspectives on the Implementation of Entrustable Professional Activities in General Surgery Residency.

OBJECTIVE: This study aimed to identify what best practices facilitate implementation of Entrustable Professional Activities (EPAs) into surgical training programs. DESIGN: This is a mixed methods study utilizing both survey data as well as semi-structured interviews of faculty and residents involved in the American Board of Surgery (ABS) EPA pilot study. SETTING: From 2018 to 2020, the ABS conducted a pilot that introduced five EPAs across 28 general surgery training programs. PARTICIPANTS: All faculty members and residents at the 28 pilot programs were invited to participate in the study. RESULTS: About 117 faculty members and 79 residents responded to the survey. The majority of faculty (81%) and residents (66%) felt that EPAs were useful and were a valuable addition to training. While neither group felt that EPAs were overly time consuming to complete, residents did report difficulty incorporating them into their daily workflow (44%). Semi-structured interviews found that programs that focused on faculty and resident -development and utilized frequent reminders about the importance and necessity of EPAs tended to perform better. CONCLUSIONS: EPA implementation is feasible in general surgery training programs but requires significant effort and engagement from all levels of program personnel. As EPAs are implemented by the ABS nationally a focus on resident and faculty development will be critical to success.

Higher-order semantic structures in an African Grey parrot's vocalizations: evidence from the hyperspace analog to language (HAL) model.

Previous research has described the significant role that social interaction plays in both the acquisition and use of speech by parrots. The current study analyzed the speech of one home-raised African Grey parrot (Psittacus erithacus erithacus) across three different social contexts: owner interacting with parrot in the same room, owner and parrot interacting out of view in adjacent rooms, and parrot home alone. The purpose was to determine the extent to which the subject's speech reflected an understanding of the contextual substitutability (e.g., the word street can be substituted in context for the word road) of the vocalizations that comprised the units in her repertoire (i.e., global co-occurrence of repertoire units; Burgess in Behav Res Methods Instrum Comput 30:188-198, 1998; Lund and Burgess in Behav Res Methods Instrum Comput 28:203-208, 1996). This was accomplished via the human language model hyperspace analog to language (HAL). HAL is contextually driven and bootstraps language "rules" from input without human intervention. Because HAL does not require human tutelage, it provided an objective measure to empirically examine the parrot's vocalizations. Results indicated that the subject's vocalization patterns did contain global co-occurrence. The presence of this quality in this nonhuman's speech may be strongly indicative of higher-order cognitive skills.

Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees.

PURPOSE: Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees. METHOD: The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied. RESULTS: Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment (P = 0.27 - 0.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training, however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices. CONCLUSIONS: Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.

Oncofertility research pitfall? Recall bias in young adult cancer survivors.

Objective: To assess recall bias by evaluating how well female cancer survivors remember details regarding their cancer diagnosis, treatment, and fertility preservation (FP) counseling.Oncofertility literature cites recall bias as a pitfall of retrospective surveys, but limited data exist to quantify this bias. Design: Retrospective secondary analysis of cross-sectional survey data. Setting: Single academic medical center. Patients: Female oncology patients of reproductive age, 18-44 years old, at least 6 months past their last chemotherapy treatment. Interventions: Not applicable. Main Outcome Measures: Recall of details surrounding cancer diagnosis and chemotherapy regimens, recall of FP counseling and ovarian reserve testing, and rates of chart-documented FP counseling. Results: In total, 117 patients completed the survey, with 112 verified via chart review. When asked to report the chemotherapy regimen, 57% (64 of the 112) marked "I don't know/prefer not to say." Regarding FP, 80% (90 of the 112) denied being offered counseling. Of the 37 (33%) who had documented FP conversations, 13 (35%) did not recall mention of fertility. Only 2 of 8 patients with ovarian reserve testing recalled this being performed at their initial visit. Multivariable logistic regression revealed older age was significantly associated with not being offered FP (odds ratio [OR] 0.87). Conclusions: Our results confirm that the accuracy of oncology patients' reporting is limited by a poor recall, particularly regarding their specific chemotherapy regimen. More than 1 in 3 patients documented to have been offered FP counseling do not recall this discussion. Importantly, only one-third of cancer survivors had chart-documented FP counseling. Increased efforts are needed to ensure adequate follow-up beyond the initial visit.

Maintaining On-Task Behavior of Adolescents with Autism Spectrum Disorder in the Absence of an Instructor.

Despite the vast amount of research on increasing independence for individuals with autism spectrum disorder, there is a lack of research on techniques for fostering independent on-task behavior and accuracy in the absence of an instructor. Though increasing distance of the instructor and altering reinforcer delivery have been shown in a few studies to produce independence in the absence of an instructor, no study to date has compared the effects of systematic fading and complete removal of an instructor. In the current study, we evaluated the effects of three conditions on the on-task behavior and accuracy of adolescents with autism spectrum disorder: instructor present (instructor with participant and conditioned reinforcers delivered within session ), instructor absent (instructor not with the participant and no within-session conditioned reinforcers), and instructor fading (gradual, systematic fading of instructor and thinning of within-session conditioned reinforcers). Across all three participants, the intervention was effective in maintaining criterion levels of on-task behavior and accuracy. Responding generalized to novel instructors and remained high during maintenance evaluations for all participants. Clinicians rated the procedures as having high social validity.

Surgical Residents' Awareness of the Costs of Common Operating Room Supplies.

BACKGROUND: The Accreditation Council for Graduate Medical Education mandates that residency programs incorporate cost awareness into patient care. This presents a challenge for surgical residents because they must understand operating room costs in addition to other expenses. Trainees' understanding of operating room supply costs is not well understood. METHODS: A survey was distributed to surgical residents (N = 73) at an urban, university-based residency program. Residents estimated the costs of 21 single-use operating room items. Descriptive statistics and a regression analysis were calculated. RESULTS: The response rate was 62%. Respondents accurately estimated costs for a median of 7/21 items, with error ranging from 26% to 5438%. They substantially underestimated the three highest-cost items. Increasing post-graduate year did not improve estimation accuracy (ß = .233, P = .138). DISCUSSION: Residents have a poor understanding of single-use item costs, and this does not improve with post-graduate training, suggesting inefficiencies. There is opportunity to educate residents and ultimately decrease surgical health care costs.

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.