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Moral injury in healthcare is characterized as the lasting psychological, biological, and social impact on providers which occurs following an adverse patient outcome. Moral injury can contribute to second victim syndrome and lasting psychological harm. While many surgeons face moral injury due to patient acuity and the potential for intraoperative or post operative complications, the transplant ecosystem compounds the impact of moral injury. Institutional blame placed on the transplant surgeon following a post-transplant death or graft loss is magnified by public reporting. Centers whose outcomes fall below threshold levels are subject to regulatory citation and financial loss. Moral injury can also result in risk aversion, limiting access to transplant for higher risk candidates and reduced acceptance of marginal organs hurting donor families. Strategies to increase resilience, reduce accusation and blame, and focus on system quality improvement are vital to mitigate the impact of moral injury on transplant professionals. The transplant community must proactively work to reduce Moral Injury to protect surgeons, ensure access to life saving transplant procedures, and avoid unnecessary organ offer declines.
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Neutrophils are vital to both the inflammatory cascade and tissue repair after an injury. Neutrophil heterogeneity is well established but there is less evidence for significant, different functional roles for neutrophil subsets. OLFM4 (Olfactomedin-4) is expressed by a subset of neutrophils, and high expression of OLFM4 is associated with worse outcomes in patients with sepsis and acute respiratory distress syndrome. We hypothesized that an increased number of OLFM4+ neutrophils would occur in trauma patients with worse clinical outcomes. To test this, we prospectively enrolled patients who suffered a blunt traumatic injury. Blood was collected at the time of admission, Day 3, and Day 7 and analyzed for the percentage of neutrophils expressing OLFM4. We found that a subset of patients who suffered blunt traumatic injury upregulated their percentage of OLFM4+ neutrophils. Those who upregulated their OLFM4 had an increased length of stay, days in the ICU, and ventilator days. A majority of these patients also suffered from hemorrhagic shock. To establish a potential role for OLFM4+ neutrophils, we used a murine model of hemorrhagic shock because mice also express OLFM4 in a subset of neutrophils. These studies demonstrated that wild type mice had higher concentrations of cytokines in the plasma and myeloperoxidase in the lungs compared with OLFM4-null mice. In addition, we used an anti-OLFM4 antibody, which when given to wild type mice led to the reduction of myeloperoxidase in the lungs of mice. These findings suggest that OLFM4+ neutrophils are a unique subset of neutrophils that affect the inflammatory response after tissue injury.
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Fator Estimulador de Colônias de Granulócitos/metabolismo , Neutrófilos/metabolismo , Choque Hemorrágico/metabolismo , Regulação para Cima/fisiologia , Adulto , Animais , Citocinas/metabolismo , Modelos Animais de Doenças , Feminino , Humanos , Inflamação/metabolismo , Pulmão/metabolismo , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Pessoa de Meia-Idade , Peroxidase/metabolismo , Estudos Prospectivos , Sepse/metabolismoRESUMO
Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.
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Esgotamento Profissional , Cirurgiões , Esgotamento Profissional/etiologia , Bolsas de Estudo , Humanos , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
Morbid obesity is a barrier to kidney transplant in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (SG) is an increasingly considered intervention, but the safety and long-term outcomes are uncertain. We reviewed prospectively collected data on patients with ESRD and chronic kidney disease (CKD) undergoing SG from 2011 to 2018. There were 198 patients with ESRD and 45 patients with CKD (stages 1-4) who met National Institutes of Health guidelines for bariatric surgery and underwent SG; 72% and 48% achieved a body mass index of ≤ 40 and ≤ 35 kg/m2 , respectively. The mean percentages of total weight loss and excess weight loss were 18.9 ± 10.8% and 38.2 ± 20.3%, respectively. SG reduced hypertension (85.8% vs 52.1%), decreased antihypertensive medication use (1.6 vs 1.0) (P < .01 each), and reduced incidence of diabetes (59.6% vs 32.5%, P < .01). Of the 71 patients with ESRD who achieved a body mass index of ≤ 40 kg/m2 , 45 were waitlisted and received a kidney transplant, whereas 10 remain on the waitlist. Mortality rate after SG was 1.8 per 100 patient-years, compared with 7.3 for non-SG. Patients with stage 3a or 3b CKD exhibited improved glomerular filtration rate (43.5 vs 58.4 mL/min, P = .01). In conclusion, SG safely improves transplant candidacy while providing significant, sustainable effects on weight loss, reducing medical comorbidities, and possibly improving renal function in stage 3 patients.
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Gastrectomia , Falência Renal Crônica/complicações , Obesidade Mórbida/cirurgia , Adulto , Idoso , Feminino , Seguimentos , Gastrectomia/métodos , Humanos , Falência Renal Crônica/mortalidade , Falência Renal Crônica/cirurgia , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/mortalidade , Estudos Prospectivos , Tempo para o Tratamento , Resultado do Tratamento , Listas de Espera , Redução de PesoRESUMO
Simultaneous liver-kidney transplantation (SLKT) is indicated for patients with end-stage liver disease (ESLD) and concurrent renal insufficiency. En bloc SLKT is an alternative to traditional separate implantations, but studies comparing the two techniques are limited. The en bloc technique maintains renal outflow via donor infrahepatic vena cava and inflow via anastomosis of donor renal artery to donor splenic artery. Comparison of recipients of en bloc (n = 17) vs traditional (n = 17) SLKT between 2013 and 2017 was performed. Recipient demographics and comorbidities were similar. More recipients of traditional SLKT were dialysis dependent (82.4% vs 41.2%, P = .01) with lower baseline pretransplant eGFR (14 vs 18, P = .01). En bloc SLKT was associated with shorter kidney cold ischemia time (341 vs 533 minutes, P < .01) and operative time (374 vs 511 minutes, P < .01). Two en bloc patients underwent reoperation for kidney allograft inflow issues due to kinking and renal steal. Early kidney allograft dysfunction (23.5% in both groups), 1-year kidney graft survival (88.2% vs 82.4%, P = 1.0), and posttransplantation eGFR were similar between groups. In our experience, the en bloc SLKT technique is safe and feasible, with comparable outcomes to the traditional method.
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Transplante de Rim , Transplante de Fígado , Sobrevivência de Enxerto , Humanos , Rim , FígadoAssuntos
Antivirais/administração & dosagem , Seleção do Doador/normas , Hepatite B/prevenção & controle , Transplante de Fígado/normas , Complicações Pós-Operatórias/prevenção & controle , Viremia/diagnóstico , Aloenxertos/provisão & distribuição , Aloenxertos/virologia , Consenso , DNA Viral/sangue , DNA Viral/isolamento & purificação , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Seguimentos , Sobrevivência de Enxerto , Hepatite B/diagnóstico , Hepatite B/transmissão , Hepatite B/virologia , Antígenos de Superfície da Hepatite B/sangue , Antígenos de Superfície da Hepatite B/isolamento & purificação , Vírus da Hepatite B/imunologia , Vírus da Hepatite B/isolamento & purificação , Humanos , Fígado/virologia , Transplante de Fígado/efeitos adversos , Doadores Vivos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/virologia , Guias de Prática Clínica como Assunto , Resultado do Tratamento , Viremia/transmissão , Viremia/virologiaRESUMO
BACKGROUND: The prevalence of burnout and depression among abdominal transplant surgeons has been well described. However, the incidence of early-career transplant surgeons leaving the field is unknown. The objective of this study was to quantify the incidence of attrition among early-career abdominal transplant surgeons. METHODS: A custom database from the Organ Procurement and Transplantation Network with encrypted surgeon-specific identifiers was queried for transplant surgeons who entered the field between 2008 and 2019. Surgeons who experienced attrition, defined as not completing a subsequent transplant after a minimum of 5, were identified. Surgeon-specific case volumes, case mix, and recipient outcomes were modeled to describe their association with attrition. RESULTS: Between 2008 and 2018, 496 abdominal transplant surgeons entered the field and performed 76,465 transplant procedures. A total of 24.4% (n = 121) experienced attrition, with a median time to attrition of 2.75 years. Attrition surgeons completed fewer kidney (7 vs 21, P < .01), pancreas (0.52 vs 1.43, P < .01), and liver transplants (1 vs 4, P < .01) in their first year of practice. Attrition surgeons completed a smaller proportion of their transplant center's volume (9% vs 18%, P < .01) and were less likely to participate in pediatric transplants (26.5% vs 52.5%, P < .01) and living donor kidney transplants (64.5% vs 84.5%, P < .01). On multivariable analysis, performing fewer kidney (odds ratio: 0.98, 95% confidence interval: 0.98-0.99) and liver transplants (odds ratio: 0.98, 95% confidence interval: 0.97-0.98) by year 5 and completing a smaller proportion of their centers' volume (odds ratio: 0.96, 95% confidence interval: 0.94-0.98) were associated with attrition. Furthermore, attrition surgeons had worse allograft and patient survival for liver transplant recipients (both log-rank P < .01). CONCLUSION: This investigation was the first to quantify the high incidence of attrition experienced by early-career abdominal transplant surgeons and its association with surgeon-specific case volumes, case mix, and worse recipient outcomes. These findings suggested the abdominal transplant workforce is struggling to retain their fellowship-trained surgeons.
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Esgotamento Profissional , Cirurgiões , Criança , Humanos , Sobrevivência de Enxerto , Incidência , Transplante de Rim , Transplante de Fígado , Obtenção de Tecidos e Órgãos , Esgotamento Profissional/epidemiologiaRESUMO
BACKGROUND: Liver transplant recipients with persistent renal dysfunction may be prioritized on the kidney transplant waitlist based on the Organ Procurement and Transplantation Network "safety-net" policy implemented in 2017. The aim of this study was to evaluate the utilization of kidney transplant and posttransplant outcomes, of liver transplant recipients with persistent renal dysfunction before and after implementation of the Organ Procurement and Transplantation Network kidney safety-net policy and standardization of simultaneous liver-kidney requirements. METHODS: Using the United Network for Organ Sharing database from January 2015 to March 2019, outcomes of liver transplant recipients listed for kidney transplant and the subset who received kidney after liver transplants were compared before and after policy implementation. RESULTS: Liver transplant recipients listed for kidney transplant increased from 58 to 200, and kidney after liver transplants increased from 29.3% to 42.5% after safety-net policy implementation. Post-policy kidney after liver transplants received more local organs (91.8% vs 70.6%, P = .03) and trended toward shorter waitlist time (47 [17-123] vs 84 [37-226] days, P = .051). The pre- and post-policy cohorts had similar (P > .05) kidney donor profile index (0.43 [0.27-0.69] vs 0.42 [0.28-0.58]) and delayed graft function (11.8% vs 14.1%). Patient, kidney graft, and liver graft survival were similar (P > .05) between pre and post-policy cohorts. Patient and kidney graft survival were similar between kidney after liver transplants and propensity score-matched kidney transplant alone recipients. Patient, kidney, and liver graft survival were similar between kidney after liver transplants and propensity score-matched simultaneous liver-kidney transplant recipients. CONCLUSION: This study demonstrates that after Organ Procurement and Transplantation Network "safety-net" policy implementation, there has been an increase in liver transplant recipients with renal dysfunction who are listed for and undergo kidney transplant with excellent short-term results.
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Nefropatias , Obtenção de Tecidos e Órgãos , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Políticas , Fatores de RiscoRESUMO
OBJECTIVE: Recent initiatives have emphasized the importance of diversity, equity, and inclusion in academic surgery. Racial/ethnic disparities remain prevalent throughout surgical training, and the "diversity pipeline" in resident recruitment and retention remains poorly defined. METHODS: Data was retrospectively collected using two separate datasets. The Association of American Medical Colleges database was used to obtain demographic data on US medical school graduates. The US Graduate Medical Education annual report was used to obtain demographic data on surgical residents. Wilcoxon signed-rank test was used to compare racial/ethnic distribution within surgical residency programs with graduating medical students. Linear regression analysis was performed to analyze population trends over time. RESULTS: The study population included 184,690 surgical residents from 2011 to 2020. Nine resident cohorts were created according to surgical specialty - general surgery, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, cardiothoracic surgery, urology, and vascular surgery. Among surgical programs, White residents were overrepresented in 8 of 9 specialties compared to the concurrent graduating medical student class for all years (p < 0.01 each, no difference in ophthalmology). Black residents were underrepresented in 8 of 9 specialties (p < 0.01 each, no difference in general surgery). Asian representation was mixed among specialties (4 overrepresented, 1 equal, 4 underrepresented), as was Hispanic representation (5 overrepresented, 4 equal) (p < 0.01 each). CONCLUSIONS: These data suggest that racial/ethnic disparities are inherent to the process of recruitment and retention of surgical residents. Efforts to improve the "diversity pipeline" should focus on mentorship and development of minority medical students and creating an equitable learning environment.
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Internato e Residência , Cirurgia Plástica , Educação de Pós-Graduação em Medicina , Humanos , Grupos Minoritários , Estudos Retrospectivos , Cirurgia Plástica/educação , Estados UnidosRESUMO
BACKGROUND: Integrated thoracic surgery (I-6) programs have become popular over traditional general surgery (GS) pathways since their inception in 2007. However the effect of I-6 programs on GS resident training remains unknown. The purpose of this study was to evaluate the effect of I-6 programs on the thoracic operative experience of co-located GS residents. METHODS: Thoracic surgery cases recorded by residents in GS programs co-located with I-6 programs until 2019 were analyzed. Cases were reviewed 5 years before (TSR-5) through 5 years after (TSR-5) the matriculation of the first thoracic resident in the co-located I-6 program. To contextualize the overall trends in the field Accreditation Council for Graduate Medical Education GS resident case logs from 1990 to 2018 were analyzed and total thoracic surgery cases recorded. Statistical analysis was performed with linear regression. RESULTS: Residents in 19 GS programs with co-located I-6 programs showed an increase in total thoracic cases from 3710 to 4451 (Δ/year of +85.05 cases a year; P = .03) balanced by an increase in GS residents from 107 to 126 (Δ/year of +1.45; P = .01) with no significant overall change in the median thoracic operative case volume (31.00 at both thoracic residency before and after 5 years). Nationally from 1990 to 2018 there was no change in the total thoracic operative experience for GS graduates. CONCLUSIONS: The introduction of I-6 programs did not negatively impact thoracic operative experience for residents in co-located GS programs. Adequate training of both I-6 and GS residents at the same institution is feasible.
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Cirurgia Geral/educação , Internato e Residência/organização & administração , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Cirurgia Torácica/educação , Estados UnidosRESUMO
BACKGROUND: Diversity in surgery has been shown to improve mentorship and patient care. Diversity has improved among general surgery (GS) trainees but is not the case for departmental leadership. We analyzed the race and gender distributions across leadership positions at academic GS programs. METHODS: Academic GS programs (n = 118) listed by the Fellowship and Residency Electronic Interactive Database Access system were included. Leadership positions were ascertained from department websites. Gender and race were determined through publicly provided data. RESULTS: Ninety-two (79.3%) department chairs were white and 99 (85.3%) were men. Additionally, 88 (74.6%) program directors and 34 (77.3%) vice-chairs of education were men. A higher proportion of associate program directors were women (38.5%). Of 787 division-chiefs, 73.4% were white. Only trauma had >10% representation from minority surgeons. Women represented >10% of division chiefs in colorectal, thoracic, pediatric, and plastic/burn surgery. CONCLUSION: Diversity among GS trainees is not yet reflected in departmental leadership. Effort is needed to improve disparities in representation across leadership roles.
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Centros Médicos Acadêmicos/organização & administração , Docentes de Medicina/estatística & dados numéricos , Grupos Minoritários/estatística & dados numéricos , Diretores Médicos/estatística & dados numéricos , Centro Cirúrgico Hospitalar/organização & administração , Centros Médicos Acadêmicos/estatística & dados numéricos , Diversidade Cultural , Etnicidade/estatística & dados numéricos , Bolsas de Estudo/organização & administração , Bolsas de Estudo/estatística & dados numéricos , Feminino , Cirurgia Geral/educação , Cirurgia Geral/organização & administração , Cirurgia Geral/estatística & dados numéricos , Humanos , Internato e Residência/organização & administração , Internato e Residência/estatística & dados numéricos , Liderança , Masculino , Médicas/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Estados UnidosRESUMO
OBJECTIVES: The operative experience of today's general surgery (GS) residents are changing. The Surgical Council on Resident Education (SCORE) was founded to provide a standardized, competency-based curriculum. We set out to evaluate resident operative experience in core and advanced operations. DESIGN: Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 2010 to 2018 were reviewed. Operative volume data for 344 operations were extracted and analyzed. Operations were designated as core, advanced, or undefined as listed by SCORE, and stratified as GS or subspecialty. SETTING: National analysis utilizing ACGME operative log reports. PARTICIPANTS: All graduating general surgery residents between 2010 and 2018. RESULTS: A total of 10,118 residents completed GS training with an average of 1121.5 ± 29.3 total cases. Core operations comprised 80.5% of total volume while advanced comprised only 8.0%. The total core experience increased (+7.0 cases/year), while total advanced experience decreased (-1.4 cases/year) (p < 0.01 each). Compositional analysis among core operations revealed an increase in 9/13 GS domains and a decrease in 8/10 subspecialty domains (all p < 0.05). CONCLUSIONS: There has been an increase in core operative experience with a concurrent decrease in advanced operative experience of graduating GS residents. These findings highlight the continued narrowing of the operative experience for trainees, with increasing focus on GS and less on subspecialty domains. Ongoing efforts to look beyond operative volume to ensure competency of graduates will prove beneficial.
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Cirurgia Geral , Internato e Residência , Acreditação , Competência Clínica , Educação de Pós-Graduação em Medicina , Cirurgia Geral/educação , Humanos , Carga de TrabalhoRESUMO
BACKGROUND: Surgical residencies have implemented boot-camps for early acquisition of basic technical skills for interns. However, educators worry that retention is poor. We hypothesized that a structured boot-camp curriculum would improve skills. METHODS: Interns underwent eight boot-camp sessions at the beginning of residency. Interns completed pre-, post-boot-camp, and end-of-year skills assessments, as well as post-boot camp and end-of-year porcine procedure labs. Proficiency was measured on a 5-point scale and by completion time. RESULTS: After boot-camp, interns improved all domains of knot-tying. Median time decreased for skin-closure (8.3 vs 9.9 min, p < 0.01), peg transfer (57 vs 87 s, p < 0.01), intracorporeal (178 vs 300 s, p < 0.01), and extracorporeal knot-tying (140 vs 259 s, p < 0.01). At the end-of-year assessment, interns exhibited retention of all skills and improved in knot-tying and central line skills. During the retention porcine lab, interns progressed basic but not complex skills. CONCLUSIONS: An eight-week boot-camp effectively improved technical skills among surgery interns. Interns retained all skills and improved upon techniques frequently practiced during intern year.
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Competência Clínica , Cirurgia Geral/educação , Internato e Residência , Procedimentos Cirúrgicos Operatórios/educação , Cateterismo Venoso Central , Avaliação Educacional , Feminino , Humanos , Internato e Residência/métodos , Internato e Residência/organização & administração , Laparoscopia/educação , Masculino , Retenção Psicológica , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/normas , Técnicas de Sutura/educação , Técnicas de Fechamento de Ferimentos/educaçãoRESUMO
BACKGROUND: General surgery was once the gateway into a career in surgery. Over time, surgical subspecialties developed separate residency programs, and recently, integrated programs have emerged. It is unknown what impact the presence of surgical subspecialties and integrated programs have had on general surgery. Our objective was to evaluate match trends and quantify competitiveness of the general surgery, integrated programs, and surgical subspecialties matches. METHODS: National Residency Matching Program match data and applicant characteristics from 2010 through 2020 were analyzed for US senior allopathic applicants. Integrated programs were defined as plastic and vascular surgery, and surgical subspecialties were defined as otolaryngology, orthopedic surgery, and neurosurgery. Trends were evaluated using linear regression, programs were compared on 10 metrics by Wilcoxon rank-sum tests, and a logistic regression was used to rank each specialty match. RESULTS: The number of US senior applicants per position to integrated programs decreased and approached that of general surgery and surgical subspecialties, but the median number of applicants per position to general surgery was lower than to surgical subspecialties or integrated programs (1.21 interquartile range). Our logistic regression showed United States Medical Licensing Examination scores, research experience, Alpha Omega Alpha Honor Society membership, and graduation from a top medical school to be the most important factors in the match, and our weighted rank score found general surgery (2.85) to be less competitive than surgical subspecialties (1.92) or integrated programs (1.17). CONCLUSION: Throughout the last decade, integrated programs and surgical subspecialties have matched more competitive applicants based on the most significant predictors of the match. Moving forward, it is important that general surgery strives to attract the best and brightest out of medical school.
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Escolha da Profissão , Educação de Pós-Graduação em Medicina/organização & administração , Cirurgia Geral/educação , Internet , Internato e Residência/métodos , Seleção de Pessoal/métodos , Procedimentos Cirúrgicos Operatórios/educação , Humanos , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: Advances in surgical training have led to the recent emergence of surgical education research. While the importance of surgical education research is well recognized, not all surgical journals are publishing these works. The objective of this study was to analyze the volume and types of surgical education publications in general surgery and surgical subspecialty journals. DESIGN: A PubMed search string was developed to identify surgical education publications in general surgery (GS, nâ¯=â¯10) and surgical subspecialty (SS, nâ¯=â¯16) journals from 2015 to 2019. Publications were catalogued into 7 categories: curriculum and/or teaching, trainee assessment, program evaluation, wellness and/or burnout, resident research, case outcomes with resident involvement, and other. Journals were also categorized by impact factor into 3 groups. Statistical analysis was performed using linear regression and Wilcoxon rank-sum to analyze differences in education publication number and percent between GS and SS journals, as well as between different impact factor groups. RESULTS: The median proportion of surgical education publications was 1.2% (IQR 0.3-2.8%) of total publications for journals queried. The highest proportion of surgical education publications by a journal was 13.9%. All other journals had median ≤ 5.5%. GS journals had a significantly higher median percent of surgical education publications than SS journals (2.9% [IQR 1.7-4.8%] vs 0.5% [IQR 0.0-1.4%] p < 0.01). Additionally, no significant differences were found for number of surgical education publications when journals were categorized by IF (p > 0.05). CONCLUSIONS: Education research is an important component of the surgical literature, with similar publication rates among journals of different impact factors. Publication volume is higher among general surgery than surgical subspecialty journals. With the ever-changing paradigm of surgical training, a rigorous scientific approach is needed to ensure effective training of future surgeons. Subspecialty journals should promote surgical education research to further understand and develop training in their field.
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Currículo , Projetos de Pesquisa , PublicaçõesRESUMO
BACKGROUND: Chronic pancreatitis (CP) is associated with poor quality of life. Total pancreatectomy with islet autotransplantation (TPIAT) has traditionally been reserved for patients with refractory disease. We hypothesized TPIAT would lead to decreased costs and resource utilization after operation in children. METHODS: Retrospective review of 39 patients who underwent TPIAT at a single children's hospital was performed. All inpatient admissions, imaging, endoscopic procedures, and operations were recorded for the year prior to and following operation. Costs were determined from Centers for Medicare and Medicaid Services. RESULTS: Median hospital admissions before operation was 5 (IQR:2-7) and decreased to 2 (IQR:1-3) after (p < 0.01). Median total cost for the year before operation was $36,006 (IQR:$19,914-$47,680), decreasing to $24,900 postoperatively (IQR:$17,432-$44,005, p = 0.03). Removing cost of TPIAT itself, total cost was further reduced to $10,564 (IQR:$3096-$29,669, p < 0.01). CONCLUSION: In children with debilitating CP, TPIAT has favorable impact on cost reduction, hospitalizations, and invasive procedures. Early intervention at a specialized pancreas center of excellence should be considered to decrease future resource utilization and costs among children.
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Recursos em Saúde/economia , Transplante das Ilhotas Pancreáticas/economia , Pancreatectomia/economia , Pancreatite Crônica/cirurgia , Analgésicos Opioides/uso terapêutico , Criança , Controle de Custos , Feminino , Humanos , Masculino , Cadeias de Markov , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Transplante AutólogoRESUMO
OBJECTIVE: Living kidney donation is a unique operation, as healthy patients are placed at risks inherent with major surgery without physical benefit. The ethical implications associated with any morbidity make it a high-stakes procedure. Fellowships are faced with the dilemma of optimizing fellow training in this demanding procedure while providing safe outcomes to donors. The Laparoscopic Living Donor Nephrectomy (LDN) Workshop is a resource that can provide intense instruction to help bridge the training deficit. Our aim was to examine the course's effectiveness in improving fellows' skill and confidence related to implementing LDN into future practice. METHODS: From 2017 to 2018, 36 abdominal transplant surgery fellows participated in a 2-day workshop consisting of live surgery observation, cadaver lab, and didactic sessions. Surveys were completed precourse, postcourse, and at 3-month postcourse follow-up. RESULTS: Preworkshop, 61% of participants reported less than 50% confidence in independent performance of LDN. Following workshop completion, 95% reported improved confidence. At 3-month follow-up, there was a 30% (p < 0.05) increase in median confidence level. Immediately following the course, 67% reported improved ability to analyze kidneys prior to donation, 74% changed the way donor candidates were evaluated, and 67% reported enhanced ability to risk stratify donors. Eighty-five percent felt it strengthened operative techniques with 70% implementing new diagnostic treatments and surgical strategies. Seventy percent of participants felt it improved their communication with colleagues and 67% had enhanced communication with patients. These trends were maintained at 3-month follow-up. CONCLUSION: These results indicated that the LDN Workshop improves confidence and increases fellows' skillset in a high-stakes procedure. The LDN Workshop is a useful adjunct to fellowship training to optimize successful, efficient, and safe performance of a demanding procedure in a uniquely healthy donor population.
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Bolsas de Estudo , Laparoscopia , Cadáver , Competência Clínica , Comunicação , Endoscopia , Humanos , NefrectomiaRESUMO
BACKGROUND: Interest in surgery has declined for two decades. This study aimed to evaluate the impact of one's interest in surgery on career choice. METHODS: Students who completed the surgical clerkship (2016-2017) were invited to complete surveys assessing rotation experience, learning style, burnout, and grit. Students were grouped according to interest or no interest in surgery after the clerkship. RESULTS: Surveys were completed by 62 students of whom 51.6% reported an interest in surgery. No minority students expressed interest compared with Caucasian (51.1%) and Asian (71.4%) students (pâ¯=â¯0.02). Disinterested students had higher emotional exhaustion (EE, 20 vs 25, pâ¯=â¯0.03). There was no difference in clerkship grade between groups (86.3% vs 85.3%, pâ¯=â¯0.56). Students who matched into surgery had lower EE and higher grit. CONCLUSIONS: Interest in surgery was not associated with improved clerkship performance. Disinterested students had higher EE, suggesting interest may play a role in adapting to clerkship challenges.
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Escolha da Profissão , Estágio Clínico/organização & administração , Competência Clínica , Educação de Graduação em Medicina/organização & administração , Cirurgia Geral/educação , Estudantes de Medicina/psicologia , Adaptação Psicológica , Adulto , Atitude do Pessoal de Saúde , Feminino , Humanos , Masculino , Estudantes de Medicina/estatística & dados numéricos , Inquéritos e Questionários , Análise e Desempenho de Tarefas , Adulto JovemRESUMO
BACKGROUND: How burnout changes during general surgery residency remains unknown. METHODS: From 2015 to 2018, general surgery residents completed the Maslach Burnout Inventory and Grit Scale. Statistical analyses were adjusted for repeated measures and compared to the incoming intern level. RESULTS: Fifty-five residents participated in this study. Burnout rates varied by program level, with an increased risk occuring in the third clinical year (ORâ¯=â¯11.7, pâ¯=â¯0.03). Emotional exhaustion (EE) peaked during the first and third clinical years, depersonalization (DP) peaked during the first and second clinical years, and personal achievement (PA) reached a nadir during the third clinical year (all pâ¯<â¯0.05). Residents with burnout had lower grit scores compared to those without burnout (3.71 vs 4.02, pâ¯<â¯0.01). Increasing grit was linearly associated with decreasing EE, decreasing DP, and increasing PA (all pâ¯<â¯0.05). CONCLUSIONS: Burnout varies throughout surgical residency, and grit is inversely related to burnout.