SAGES primer for taking care of yourself during and after the COVID-19 crisis.

COVID-19 is a pandemic which has affected almost every aspect of our life since starting globally in November 2019. Given the rapidity of spread and inadequate time to prepare for record numbers of sick patients, our surgical community faces an unforeseen challenge. SAGES is committed to the protection and care of patients, their surgeons and staff, and all who are served by the medical community at large. This includes physical health, mental health, and well-being of all involved. The fear of the unknown ahead can be paralyzing. International news media have chronicled the unthinkable situations that physicians and other health care providers have been thrust into as a result of the COVID-19 pandemic. These situations include making life or death decisions for patients and their families regarding use of limited health care resources. It includes caring for patients with quickly deteriorating conditions and limited treatments available. Until recently, these situations seemed far from home, and now they are in our own hospitals. As the pandemic broadened its reach, the reality that we as surgeons may be joining the front line is real. It may be happening to you now; it may be on the horizon in the coming weeks. In this context, SAGES put together this document addressing concerns on clinician stressors in these times of uncertainty. We chose to focus on the emotional toll of the situation on the clinician, protecting vulnerable persons, reckoning with social isolation, and promoting wellness during this crisis. At the same time, the last part of this document deals with the "light at the end of the tunnel," discussing potential opportunities, lessons learned, and the positives that can come out of this crisis.

Practical Strategies for Underrepresented Minority Recruitment in General Surgery Residency.

OBJECTIVE: To analyze the effects of diversification efforts on underrepresented minority in medicine (URiM) resident recruitment in general surgery residency at a single large southeastern United States academic institution with five categorical positions. METHODS: A retrospective review of applications from the 2016 to 2022 ACGME match cycles was conducted. In an effort to diversify resident recruitment, multiple new strategies were enacted in 2021. URiM candidates were identified via a more laborious review of individual applications to the program. In addition, a holistic review process was conducted, URiM faculty and residents were prominently featured, previous underperformance in diversity was openly addressed, and URiM applicants were contacted with follow up emails. Cohorts pre- and post-implementation of these strategies were analyzed. The proportion of URiM applicants invited, interviewed, ranked, and matched were compared. RESULTS: Pre-intervention during the 2016to 20 match cycles, URiM candidates represented 4% of total applicants invited. Post-intervention during the 2021to 22 match cycles, URiM candidates represented 27% of total applicants invited. Over the past 5 years under the present program director, 1 URiM resident of 24 (4%) matched into the categorical program. Over the past 15 years under the direction of 3 program directors, a total of 6 out of 69 matched residents (9%) identified as URiM. Post intervention, the program matched on average 30% of its incoming categorical class from URiM candidates. CONCLUSION: Recruitment and selection of diverse medical school applicants is an ongoing concern of general surgery residency program directors. Historically, URiM candidates are underrepresented in applicants selected for interview. Interventions aimed at increasing the matriculation of URiM include concentrated efforts to identify more URiM candidates for interview. However, importantly, transparency of ongoing diversity efforts and diversifying both faculty and trainees involved in the selection process may also improve general surgery URiM recruitment.

The Goalposts Have Moved: Can Surgery Residents Meet Updated Quality Benchmarks for Adenoma Detection Rate in Colonoscopy?

The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology Task Force (ACGTF) on Quality in Endoscopy released updated quality benchmarks for colonoscopy in 2015. Our initial study concluded that surgery residents could perform safe and competent screening colonoscopy within a structured endoscopy curriculum. In this follow-up study, we sought to determine whether surgery residents could achieve the increased adenoma detection rate (ADR) benchmarks endorsed by the ASGE/ACGTF. An Institutional Review Board-approved prospective analysis of colonoscopies performed by five postgraduate year 2 and 3 general surgery residents from 2013 to 2015 was completed. All colonoscopies were performed under the direct supervision of surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following ASGE/ACG quality metrics were recorded: bowel preparation quality; cecal intubation rate; polyp and ADRs; and, complications. Power analysis determined that 108 procedures were required for an 80 per cent probability of data analysis accuracy. About 135 screening and diagnostic colonoscopies were performed. Bowel prep was considered "adequate" in 90 per cent of cases. The cecum was reached independently in 95 per cent of cases. Polyp(s) were visualized and removed in 39 per cent of patients. The overall ADR was 31.8 per cent (>25%). Male ADR was 38.7 per cent (>30%). Female ADR was 26.0 per cent (>20%). Average polyp size was 8.7 mm (range: 1-22 mm). One patient was readmitted for postpolypectomy syndrome, and successfully managed nonoperatively. In conclusion, using our structured endoscopy curriculum, surgery residents achieved ADRs fully consistent with the updated benchmark values endorsed by the ASGE/ACGTF.

Quality Metrics in Surgery Resident Performance of Screening Colonoscopy.

In an attempt to further standardize surgical training, the American Board of Surgery now requires that residents provide evidence that they are certified in flexible endoscopy. This prospective study was designed to determine whether, through a structured curriculum, junior level residents could learn to conduct competent and safe screening colonoscopy (SC). An Institutional Review Board-approved prospective analysis of SC performed by five postgraduate year-2 residents during the 2012-2013 academic year was completed. All SC were performed under direct supervision of one of the two surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following metrics of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology were recorded: bowel prep quality; cecal intubation; withdrawal time; number of visualized polyps; procedural duration; final pathology; adenoma detection rate (ADR); and, complications. Power analysis revealed that 108 procedures were required for an 80 per cent probability of data analysis accuracy. (American Society for Gastrointestinal Endoscopy ASGE/American College of Gastroenterology benchmark values in parentheses): 166 colonoscopies were performed, of which 149 met inclusion criteria. Bowel prep was considered "excellent" or "good" in 90 per cent of cases. The cecum was reached in 96 per cent of cases. Mean withdrawal time was 12 minutes (≥6 minute). Average procedure time was 30 minutes (≤ 30 minute). Polyp(s) were visualized and removed in 30 per cent of patients. The overall adenoma detection rate was 22.8 per cent (>20%). The ADR for males was 29.5 per cent (>25%). The ADR for females was 18.2 per cent (>15%). Average polyp size was 7.7 mm (range: 2-25 mm). No patients were readmitted for bleeding or perforation. Within a structured learning environment, trained surgical endoscopists can teach junior level surgery residents to perform safe and competent screening colonoscopy.

Development of a web-based laparoscopic technical skills assessment and testing instrument: a pilot study.

OBJECTIVE: Current surgical training programs rely heavily on subjective assessments to measure operative proficiency, despite heavy emphasis on standardized testing as a means to rank scholastic ability. A compact laparoscopic simulator was developed with the intention to create a technical skill evaluation system that resembles standardized testing to provide the user with real-time percentile scores in a variety of skill metrics. The calculation of percentiles is only accurate if the pool of scores resembles a specific distribution (e.g., normal or log-normal distribution). We hypothesize that the grading measures provided by the simulator will follow normal or log-normal distributions. MATERIALS AND METHODS: A total of 29 surgical trainees with varying levels of laparoscopic experience were surveyed regarding their current training, proficiencies, and experience with the Fundamentals of Laparoscopic Surgery curriculum and then asked to perform a standard peg-transfer task 5 times. A proprietary device placed along the trocars of a laparoscopic box trainer was used to gather data that, when subjected to unique algorithms, gave real-time, web-based feedback to trainees on the following metrics: volume of instrument use, economy of movement, angular instrument path, instrument rotation, bimanual coordination, smoothness, time to task completion, and depth perception. Numerical data were plotted on a frequency histogram. Minitab software was used to identify if individual metrics fit a standard distribution curve. Analysis of variance was used to differentiate among 3 established physician skill levels, as a means of assessing construct validity. RESULTS: In the goodness-of-fit tests performed, angular path, depth perception, rotation, and smoothness were found to best fit a log-normal distribution (p > 0.1). Bimanual coordination was found to fit a normal distribution (p ≥ 0.067). However, both normal and log-normal distributions were rejected (p ≤ 0.01) for the metrics of time, volume, and economy of movement. After separating participants into 3 groups based on level of experience with the Fundamentals of Laparoscopic Surgery curriculum, analysis of variance showed significant differences among all group means across the 5 metrics (i.e., angular path, depth perception, rotation, smoothness, and bimanual coordination; p ≤ 0.023). CONCLUSION: A proprietary device provided quantitative assessment of laparoscopic skills, which can be used to differentiate among skill levels. Of the 8 tested metrics, 5 fit a normal or log-normal distribution, meaning the scores can statistically be ranked by percentile. Time, volume, and economy of movement did not fit desired distributions. The grading system proved to have construct validity, indicating it may be useful in the longitudinal assessment of laparoscopic skills of surgical trainees.