A comprehensive analysis of leadership attributes, discrepancies, and implications for gender equity in vascular surgery.

OBJECTIVE: Well-developed leadership skills have been associated with a better understanding of health care context, increased team performance, and improved patient outcomes. Surgeons, in particular, stand to benefit from leadership development. Although studies have focused on investigating knowledge gaps and needs of surgeons in leadership roles, there is a noticeable gap in the literature concerning leadership in vascular surgery. The goal of this study was to characterize current leadership attributes of vascular surgeons and understand demographic influences on leadership patterns. METHODS: This retrospective cohort study was a descriptive analysis of vascular surgeons and their observers who took the Leadership Practices Inventory (LPI) from 2020 to 2023. The LPI is a 30-question inventory that measures the frequency of specific leadership behaviors across five practices of leadership. RESULTS: A total of 110 vascular surgeons completed the LPI. The majority of participants were White (56%) and identified as male (60%). Vascular surgeons most frequently observed the "enabling others to act" leadership practice style (8.90 ± 0.74) by all evaluators. Vascular surgeons were most frequently above the 70th percentile in the "challenge the process" leadership practice style (49%) compared with the average of other leaders worldwide. Observers rated vascular surgeons as displaying significantly more frequent leadership behaviors than vascular surgeons rated themselves in every leadership practice style (P < .01). The only demographic variable associated with a significantly increased occurrence of achieving 70th percentile across all five leadership practice styles was the male gender: a multivariable model adjusting for objective experience showed that men were at least 3.5 times more likely to be rated above the 70th percentile than women. CONCLUSIONS: Vascular surgeons under-report the frequency at which they practice leadership skills across all five leadership practice styles and should recognize their strengths of enabling others to act and challenging the process. Men are recognized as exhibiting all five leadership practices more frequently than women, regardless of current position or experience level. This observation may reflect the limited leadership positions available for women, thereby restricting their opportunities to demonstrate leadership practices as frequently or recognizably as their male counterparts.

Economic value of podiatry service in limb salvage alliance.

OBJECTIVE/BACKGROUND: Over the past decade, multidisciplinary "toe and flow" programs have gained great popularity, with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States. METHODS: An administrative database that captured monthly operating room (OR) cases, clinic encounters, in-patient volume, and total work relative value units (wRVUs) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of 3 years, there was a significant change in the number of podiatrists (from 1 to 4) within the program, whereas the clinical full-time employees for vascular surgeons remained relatively stable. RESULTS: The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of 4 years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic, and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P < .01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40%, respectively (P < .01) in the past 3 years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite the fact that that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs. CONCLUSIONS: This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrists in a vascular surgery practice is clearly demonstrated.

Ensuring equity, diversity, and inclusion in the Society for Vascular Surgery: A report of the Society for Vascular Surgery Task Force on Equity, Diversity, and Inclusion.

Diversity, equity, and inclusion represent interconnected goals meant to ensure that all individuals, regardless of their innate identity characteristics, feel welcomed and valued among their peers. Equity is achieved when all individuals have equal access to leadership and career advancement opportunities as well as fair compensation for their work. It is well-known that the unique backgrounds and perspectives contributed by a diverse workforce strengthen and improve medical organizations overall. The Society for Vascular Surgery (SVS) is committed to supporting the highest quality leadership, patient care, surgical education, and societal recommendations through promoting diversity, equity, and inclusion within the SVS. The overarching goal of this document is to provide specific context and guidance for enhancing diversity, equity, and inclusion within the SVS as well as setting the tone for conduct and processes beyond the SVS, within other national and regional vascular surgery organizations and practice settings.

Update on workforce diversity in vascular surgery.

OBJECTIVE: Creating a diverse workforce is paramount to the success of the surgical field. A diverse workforce allows us to meet the health needs of an increasingly diverse population and to bring new ideas to spur technical innovation. The purpose of this study was to assess trends in workforce diversity within vascular surgery (VS) and general surgery (GS) as compared with orthopedic surgery (OS)-a specialty that instituted a formal diversity initiative over a decade ago. METHODS: Data on the trainee pool for VS (fellowships and integrated residencies), GS, and OS were obtained from the U.S. Graduate Medical Education reports for 1999 through 2017. Medical student demographic data were obtained from the Association of American Medical Colleges U.S. medical school enrollment reports. The representation of surgical trainee populations (female, Hispanic, and black) was normalized by their representation in medical school. We also performed the χ2 test to compare proportions of residents over dichotomized time periods (1999-2005 and 2013-2017) as well as a more sensitive trend of proportions test. RESULTS: The proportion of female trainees increased significantly between the time periods for the three surgical disciplines examined (P < .001). Hispanic trainees also represented an increasing proportion of all three disciplines (P ≤ .001). The proportion of black trainees did not significantly change in any discipline between the two periods. Relative to their proportion in medical school, Hispanic trainees were well represented in all surgical specialties studied (normalized ratio [NR], 0.95-1.52: 0.95 OS, 1.00 GS, 1.53 VS fellowship, and 1.23 VS residency). Compared with their representation in medical school, women were under-represented as surgical trainees (NR: 0.32 OS, 0.82 GS, 0.56 VS fellowship, and 0.78 VS residency) as were black trainees (NR: 0.63 OS, 0.90 GS, 0.99 VS fellowship, and 0.81 VS residency). CONCLUSIONS: Although there were significant increases in the number of women and Hispanic trainees in these three surgical disciplines, only Hispanic trainees enter the surgical field at a rate higher than their proportion in medical school. The lack of an increase in black trainees across all specialties was particularly discouraging. Women and black trainees were under-represented in all specialties as compared with their representation in medical school. The data presented suggest potential problems with recruitment at multiple levels of the pipeline. Particular attention should be paid to increasing the pool of minority medical school graduates who are both interested in and competitive for surgical specialties.

The Isolated Surgeon: A Scoping Review.

BACKGROUND: Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care. METHODS: We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role. RESULTS: From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings. CONCLUSIONS: This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.

A Surgeon Badge or Text Message Sign-in Intervention Improves Operating Room Start Efficiency.

BACKGROUND: Operating room (OR) efficiency, often measured by first case on-time start (FCOTS) percentage, is an important driver of perioperative team morale and the financial success of a hospital. MATERIALS AND METHODS: In this quasi-experimental study of elective surgical procedures at a single tertiary academic hospital, an intervention requiring attending surgeon attestation of availability via SMS text message or identification badge swipe was implemented. Key measures of OR efficiency were compared before and after the change. RESULTS: FCOTS percentage increased from 61.6% to 66.9% after the intervention (P = 0.01). After adjusting for patient and procedural characteristics, postintervention period remained associated with an increased odds of an on-time start (odds ratio 1.29, P = 0.01). Additionally, procedural start times from the pre- to postintervention period were significantly improved (-0.08 min/day, P = 0.009). CONCLUSIONS: Implementation of an attending surgeon text or badge sign-in process was associated with improved FCOTS percentage and earlier procedure start times.

Teamwork at the Bench: Strategies for Collaborative Surgical Science in a Pandemic.

The Center for Basic and Translational Science was formed to address the unique challenges faced by surgeon-scientists. Shortly after its inception, COVID-19 upended research workflows at our institution. We discuss how the collaborative Center for Basic and Translational Science framework was adapted to support laboratories during the pandemic by assisting with ramp-down, promoting mentorship and community building, and maintaining research productivity.

Education Morbidity and Mortality: Reviving Intraoperative Teaching and Learning.

BACKGROUND: Using the platform of morbidity and mortality conference, we developed and executed a combined faculty-resident intervention called "Education M&M" to discuss challenges faced by both parties in the operating room (OR), identify realistic solutions, and implement action plans. This study aimed to investigate the impact of this intervention on resident OR training. MATERIALS AND METHODS: Two resident case presentations were followed by audience discussion and recommendations regarding actionable solutions aimed at improving resident OR training from an expert faculty panel. Postintervention surveys were completed by participants immediately and 2 mo later to assess perceived short and long-term impact on OR teaching and/or learning and the execution of two recommended solutions. Descriptive statistical analysis was applied. RESULTS: Immediate post-intervention surveys (n = 44) indicated that 81.8% of participants enjoyed the M&M "a lot"; 90.1% said they would use some or a lot of the ideas presented. Awareness of OR teaching/learning challenges before and after the M&M improved from 3.0 to 3.7 (P = 0.00001) for faculty and 3.0 to 3.9 for trainees (P = 0.00004). Understanding of OR teaching and/or learning approaches improved from 3.1 to 3.7 for faculty (P = 0.00004) and 2.7 to 3.9 for trainees (P = 0.00001). In 2-mo post-intervention surveys, most residents had experienced two recommended solutions (71% and 88%) in the OR, but self-reported changes to faculty behavior did not reach statistical significance. CONCLUSIONS: A department-wide education M&M could be an effective approach to enhance mutual communication between faculty members and residents around OR teaching/learning by identifying program-specific challenges and potential actionable solutions.

Evaluation of the Impact of Intraoperative Distractions on Teamwork, Stress, and Workload.

BACKGROUND: Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress. METHODS: This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured. RESULTS: Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P < 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P < 0.01 and r = 0.137, P < 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P < 0.05). CONCLUSIONS: This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen.

Data Accuracy and Predictors of High Ratings of Colon and Rectal Surgeons on an Online Physician Rating Website.

BACKGROUND: Online physician rating Web sites are used by over half of consumers to select doctors. No studies have examined physician rating Web sites for colon and rectal surgeons. OBJECTIVE: The purpose of this study was to evaluate the accuracy and rating patterns of colon and rectal surgeons on the largest physician rating Web site. DESIGN: Physician characteristics and ratings were collected from a randomly selected sample of 500 from 3043 Healthgrades "colon and rectal surgery specialists." Board certifications were verified with the American Board of Surgery and American Board of Colon and Rectal Surgery Web sites. SETTINGS: Data acquisition was completed on July 18, 2018. PATIENTS: Patients were not directly studied. MAIN OUTCOME MEASURES: The primary outcome was to assess the accuracy of Healthgrades in reporting American Board of Surgery and American Board of Colon and Rectal Surgery certification. The secondary outcome was to identify factors associated with high star ratings. RESULTS: A total of 48 (9.6%) of the 500 sampled were incorrectly identified as practicing US surgeons and excluded from subsequent analysis. Healthgrades showed 80.1% agreement with verified board certifications for American Board of Surgery and 85.4% for American Board of Colon and Rectal Surgery. The mean star rating was 4.2 of 5.0 (SD = 0.9), and 77 (21.6%) had 5-star ratings. In a multivariable logistic model (p < 0.001), 5-star rating was associated with 1 to 9 years (OR = 2.76; p = 0.04) or >40 years in practice (OR = 3.35; p = 0.04) and fewer reviews (OR = 0.88; p < 0.001). There were no significant associations with surgeon sex, age, geographic region, or board certification. LIMITATIONS: Data were limited to a single physician rating Web site. CONCLUSIONS: In the modern age of healthcare consumerism, physician rating Web sites should be used with caution given inaccuracies. More accurate online resources are needed to inform patient decisions in the selection of specialized colon and rectal surgical care. See Video Abstract at http://links.lww.com/DCR/B91. PRECISIÓN DE DATOS Y PREDICTORES DE ALTAS CALIFICACIONES DE CIRUJANOS DE COLON Y RECTO EN UN SITIO WEB DE CALIFICACIÓN MÉDICA EN LÍNEA: Más de la mitad de los consumidores utilizan los sitios web de calificación de médicos en línea para seleccionar médicos. Ningún estudio ha examinado los sitios web de calificación de médicos para cirujanos de colon y recto.Evaluar la precisión y los patrones de calificación de los cirujanos de colon y recto en el sitio web más grande de calificación de médicos.Las características y calificaciones de los médicos se obtuvieron de una muestra seleccionada al azar de 500 de 3,043 "especialistas en cirugía de colon y recto" de Healthgrades. Las certificaciones del Consejo se verificaron en los sitios web del Consejo Americano de Cirugía y del Consejo Americano de Cirugía de Colon y Recto.La adquisición de datos se completó el 18 de julio de 2018.Los pacientes no fueron estudiados directamente.El resultado primario fue evaluar la precisión de Healthgrades al informar la certificación por el Consejo Americano de Cirugía y por el Consejo Americano de Cirugía de Colon y Recto. El resultado secundario fue identificar factores asociados con altas calificaciones en estrellas.Un total de 48 (9.6%) de la muestra de 500 fueron identificados incorrectamente como cirujanos practicantes de EE. UU. y excluidos del análisis subsecuente. Healthgrades mostró un 80.1% de concordancia con las certificaciones verificadas del Consejo Americano de Cirugía y el 85.4% con el Consejo Americano de Cirugía de Colon y Recto. La calificación promedio de estrellas fue 4.2 / 5 (SD 0.9), y 77 (21.6%) tuvieron calificaciones de 5 estrellas. En un modelo logístico multivariable (p <0.001), la calificación de 5 estrellas se asoció con 1-9 años (OR 2.76, p = 0.04) o más de 40 años en la práctica (OR 3.35, p = 0.04) y menos evaluaciones (OR 0.88, p <0.001). No hubo asociaciones significativas con el género, edad, región geográfica o certificación por los Consejos del cirujano.Los datos se limitaron a un solo sitio web de calificación de médicos.En la era moderna del consumismo en atención médica, los sitios web de calificación de los médicos deben usarse con precaución debido a imprecisiones. Se necesitan recursos en línea más precisos para que las decisiones de los pacientes sean informadas en la selección de atención quirúrgica especializada de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B91. (Traducción-Dr. Jorge Silva-Velazco).

Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study.

BACKGROUND: The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports. OBJECTIVE: The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer. DESIGN: This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews. SETTINGS: The study was conducted at US medical centers. PARTICIPANTS: Colorectal surgeons were included. INTERVENTION: After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems. MAIN OUTCOME MEASURES: Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured. RESULTS: Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons. LIMITATIONS: The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only. CONCLUSIONS: Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at http://links.lww.com/DCR/B100. IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en http://links.lww.com/DCR/B100. (Traducción-Dr. Adrian E. Ortega).

The Value of the Surgeon Informatician.

Clinical informatics is an interdisciplinary specialty that leverages big data, health information technologies, and the science of biomedical informatics within clinical environments to improve quality and outcomes in the increasingly complex and often siloed health care systems. Core competencies of clinical informatics primarily focus on clinical decision making and care process improvement, health information systems, and leadership and change management. Although the broad relevance of clinical informatics is apparent, this review focuses on its application and pertinence to the discipline of surgery, which is less well defined. In doing so, we hope to highlight the importance of the surgeon informatician. Topics covered include electronic health records, clinical decision support systems, computerized order entry, data analytics, clinical documentation, information architectures, implementation science, quality improvement, simulation, education, and telemedicine. The formal pathway for surgeons to become clinical informaticians is also discussed.

We are All Asian: Society of Asian Academic Surgeons Presidential Address.

This 2019 Presidential Address for the Society of Asian Academic Surgeons was delivered on September 27, 2019. Using anecdotes from her upbringing, Dr. Jennifer Tseng offers a visionary perspective on belonging and inclusivity in academic surgery. She concludes with practical strategies for success drawn from these experiences.

Resident-Championed Quality Improvement Provides Value: Confronting Prolonged Mechanical Ventilation.

BACKGROUND: The Quality In-Training Initiative (QITI) provides hands-on quality improvement education for residents. As our institution has ranked in the bottom quartile for prolonged mechanical ventilation (PMV) according to the National Surgical Quality Improvement Program (NSQIP), we sought to illustrate how our resident-led QITI could be used to determine perioperative contributors to PMV. MATERIALS AND METHODS: The Model for Improvement framework (developed by Associates in Process Improvement) was used to target postoperative ventilator management. However, baseline findings from our 2016 NSQIP data suggested that preoperative patient factors were more likely contributing to PMV. Subsequently, a retrospective one-to-one case-control study was developed, comparing preoperative NSQIP risk calculator profiles for PMV patients to case-matched patients for age, sex, procedure, and emergent case status. Chart review determined ventilator time, 30-d outcomes, and all-cause mortality. RESULTS: Forty-five patients with PMV (69% elective) had a median ventilator time of 134 h (interquartile range 87-254). The NSQIP calculator demonstrated increased preoperative risk percentages in PMV patients when compared to case-matched patients for any complication (includes PMV), predicted length of stay, and death (all P < 0.05). Thirty-day outcomes were worse for the PMV group in categories for sepsis, pneumonia, unplanned reoperation, 30-d mortality, rehab facility discharge, and length of stay (all P < 0.05). All-cause mortality was also significantly higher for PMV patients (P < 0.05). CONCLUSIONS: Resident-led QITI projects enhance resident education while exposing opportunities for improving care. Preoperative patient factors play a larger-than-anticipated role in PMV at our institution. Ongoing efforts are aimed toward preoperative identification and optimization of high-risk patients.

Implementation of General Surgery Care into a Student-Run Free Clinic.

BACKGROUND: Student-run free clinics (SRFCs) provide medical care to uninsured, and surgical issues are often outside the normal scope of care of these clinics. The Shade Tree Clinic (STC) is an SRFC serving 300 patients with complex medical conditions. This study describes the implementation and efficacy of a General Surgery Specialty Clinic in this setting. METHODS: This descriptive study examines the demographics and referral patterns of patients seen in two pilot Specialty Clinics and other patients evaluated for general surgical issues from December 2017 to January 2020. Providers were surveyed regarding their experience in clinic. RESULTS: Twenty patients were evaluated by six general surgeons during 22 separate encounters (n = 20). Nine patients were seen in two pilot Specialty Clinics for biliary colic, hernia, hemorrhoids, anal mass, toenail lesion, surgical weight loss, and venous insufficiency. Referrals from these clinics to affiliated Vanderbilt University Medical Center included six ultrasounds; referrals to vascular surgery and podiatry clinics; and referrals for laparoscopic cholecystectomy and anal mass excision. STC also directly referred eight patients for colonoscopies and five patients for major operations through primary care clinic. Hundred percent of care was cost-free to patients. Providers reported a median satisfaction score of five with the Specialty Clinics (Very Satisfied; [4, 5]). Hundred percent of providers felt that the concerns of patients were addressed. CONCLUSIONS: A surgery specialty clinic in the setting of an SRFC is an effective way to provide surgical care to underserved populations with the potential to reduce unplanned hospital utilization.

Crucial Roles of Vascular Surgeons in Oncovascular and Non-Vascular Surgery.

OBJECTIVE: Vascular surgeons can be useful in non-vascular surgery cases, especially in oncology where complete resection is important. Such activity has been quantified at least locally, but maybe not adequately reported in a systematic manner, or studied prospectively. This study aimed to describe the roles of vascular surgeons in oncovascular surgery (OVS) and non-vascular surgery (NVS), and to analyse the yearly trends of consult surgery, early mortality and morbidity and risk factors for poor outcomes. METHODS: This study was a five year retrospective review of the role of vascular surgeons in various settings at a tertiary hospital. Electronic medical records and images were reviewed retrospectively. Between January 2014 and December 2018, the vascular surgery registry data of Seoul National University Hospital were reviewed for OVS or NVS assisted by vascular surgeons and operations primarily done by vascular surgeons. Demographic data, clinical characteristics, operative data, vascular related data and operative outcomes were collected. The operations were classified into primary surgery or consult surgery. Consult procedures were divided into planned or unplanned surgery. RESULTS: Of 564 cases, vascular surgeons performed 74 OVS as primary surgery, and retroperitoneal tumour was the most frequent diagnosis (n = 34). There were 490 intra-operative requests for a vascular surgeon's assistance, of which 109 were emergency calls. Total intra-operative consultations increased by 115.9% over five years, and the proportion of unplanned operations also increased. Unplanned assistance was most commonly requested for bleeding, whereas node dissection was the most common reason for planned surgery. The mortality rate was not different between the planned and unplanned surgery groups, but the latter showed worse outcomes in total operating time, length of hospital stay, post-operative consultations, and post-operative vascular related complications. CONCLUSION: Vascular surgeons have an essential role to play in the modern practice of cancer surgery. Oncovascular surgery enables gross resection of a tumour even in the presence of major vessel invasion. Emergency unplanned surgery had worse outcomes; therefore, pre-operative vascular consultation and multidisciplinary management are highly recommended for better patient outcomes.

The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer.

The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.

Outcomes With Overlapping Surgery at a Large Academic Medical Center.

OBJECTIVE: The aim of the study was to evaluate the efficiency and safety of overlapping surgery (OS) at a training institution by comparing it with nonoverlapping surgery (NO) with respect to operative time, mortality, readmissions, and complications. BACKGROUND: OS is the practice of an attending physician providing supervision to 2 surgeries that are scheduled at overlapping times. Recent media and government attention have raised concerns about this practice and the need for informed patient consent. METHODS: A population-based, retrospective, cohort study was conducted using data on operative procedures from January 1, 2014 to December 31, 2015 at a large tertiary academic center. Patients who had undergone surgery by attending surgeons who performed ≥10% of their cases overlapping were selected. Thirty-day mortality, readmission within 30 days, and 7 patient safety indicators (PSIs) were recorded. RESULTS: A total of 26,260 cases met our criteria for analysis for surgical time and 15,106 cases for outcomes. OS patients had an average case length of 2.18 hours compared with 1.64 hours among NO patients (P < 0.0001), a decreased risk of mortality [relative risk (RR) 0.42, 95% confidence interval (CI), 0.34-0.52, P < 0.0001), a decreased risk of readmission (RR 0.92, 95% CI, 0.86-0.98, P = 0.0148), and a decreased risk of experiencing any PSI (RR 0.67, 95% CI, 0.55-0.83, P = 0.0002). CONCLUSIONS: The present study confirms prior reports and addresses gaps in the literature regarding OS, such as the effect of resident involvement and the individual effect of OS in 13 different surgical specialties. The findings highlight the need for additional investigation and suggest that the practice of OS does not expose patients to increased risk of negative outcomes.

Effects of a Surgical Receipt Program on the Supply Costs of Five General Surgery Procedures.

BACKGROUND: Surgical supplies occupy a large portion of health care expenditures but is often under the surgeon's control. We sought to assess whether an automated, surgeon-directed, cost feedback system can decrease supply expenditures for five common general surgery procedures. MATERIALS AND METHODS: An automated "surgical receipt" detailing intraoperative supply costs was generated and emailed to surgeons after each case. We compared the median cost per case for 18 mo before and after implementation of the surgical receipt. We controlled for price fluctuations by applying common per-unit prices in both periods. We also compared the incision time, case length booking accuracy, length of stay, and postoperative occurrences. RESULTS: Median costs decreased significantly for open inguinal hernia ($433.45 to $385.49, P < 0.001), laparoscopic cholecystectomy ($886.77 to $816.13, P = 0.002), and thyroidectomy ($861.21 to $825.90, P = 0.034). Median costs were unchanged for laparoscopic appendectomy and increased significantly for lumpectomy ($325.67 to $420.53, P < 0.001). There was an increase in incision-to-closure minutes for open inguinal hernia (71 to 75 min, P < 0.001) and laparoscopic cholecystectomy (75 to 96 min, P < 0.001), but a decrease in thyroidectomy (79 to 73 min, P < 0.001). There was an increase in booking accuracy for laparoscopic appendectomy (38.6% to 55.0%, P = 0.001) and thyroidectomy (32.5% to 48.1%, P = 0.001). There were no differences in postoperative occurrence rates and length of stay duration. CONCLUSIONS: An automated surgeon-directed surgical receipt may be a useful tool to decrease supply costs for certain procedures. However, curtailing surgical supply costs with surgeon-directed cost feedback alone is challenging and a multimodal approach may be necessary.

Pancreatic Incidentalomas: A Management Algorithm for Identifying Ectopic Spleens.

BACKGROUND: Identification of incidental pancreatic lesions is increasing because of advancements in imaging. Diagnosis remains a challenge for clinicians, with intrapancreatic accessory spleens (IPAS) posing a unique dilemma. IPAS are frequently resected because of inability to exclude alternate diagnoses, subjecting patients to unnecessary risk. The purpose of this study was to examine our institutional experience with IPAS and develop a multidisciplinary algorithm to improve preoperative diagnosis. MATERIALS AND METHODS: Patients who underwent a distal pancreatectomy at a single institution from 2005 to 2018 were identified from a prospectively maintained database. Examination of final pathology for a diagnosis of IPAS yielded the final cohort. Demographics, preoperative workup, and operative course were reviewed and analyzed. A diagnostic algorithm was composed based on the consensus of a panel of expert pancreatic surgeons, a radiologist, and a pathologist. RESULTS: Ten patients of 303 patients who underwent a distal pancreatectomy were identified with a final pathology of IPAS. The average age was 54 y, 80% were white, and 60% were male. Lesions ranged in size from 7 mm to 5.1 cm in largest diameter (mean 2.2 cm). Lesions were described as round, well-marginated, and enhancing masses within the pancreatic tail. Preoperative workup was variable in terms of imaging and laboratory testing. Diagnostic workups were examined and combined with multidisciplinary input to create a diagnostic algorithm. CONCLUSIONS: Incidental pancreatic lesions like IPAS remain a diagnostic challenge for clinicians. Employing a diagnostic algorithm as proposed may aid in the distinction of malignant and premalignant pathology and prevent unwarranted pancreatic resections.