Lack of Racial and Ethnic Diversity in Surgical Education, as Reflected by Skin Tone in General Surgery Textbooks

INTRODUCTION

Disparity in healthcare is an important and timely topic. One example of such disparity appears to be the disproportionate use of lighter skin tone illustrations in medical and surgical educational material.1 Visual representation of pathology in instructional material is one key element that informs decision making in surgical disease and could contribute to disparity in outcomes in underrepresented tonal groups. Our hypothesis is that visual examples (illustrations) of clinical pathology in major surgical texts are biased in that they are heavily weighted to Caucasian skin tones and therefore fail to accurately represent the racial distribution of patients in the United States population.

METHODS

Images from 4 commonly used general surgery textbooks were screened independently by 2 reviewers from Maimonides Medical Center and SUNY (State University of New York) Downstate College of Medicine. Human photographic and cartoon images (where skin tone could be determined), with adequate skin shown, were included. These images were assigned a Fitzpatrick skin photo type (FP) score (1-6). The distribution of images among the 6 FP categories were compared to the expected distribution of images in the United States population, as described from a previous National Health and Nutrition Examination Survey (NHANES). Differences in distribution were compared using a chi-squared test, with p-value <0.05 considered as statistically significant.

RESULTS

There were 556 total images deemed adequate for assessment from the 4 textbooks chosen. 169 from Sabiston, 61 from Mulholland and Greenfield, 177 from Schwartz, and 149 from ACS. About 539 of these images (96.9%) were depictions of patients with light skin tone (FP scores 1-3.) while less than 4% of images were of dark-skinned individuals (FP score between 4 and 6.) An FP score 1 accounted for most images, comprising 477 images (86.1%). There was a 1.8% analytical discrepancy noted between the textbook reviewers. The distribution on the general US population (NHANES) is: FP score 1: 1.6%, FP score 2: 33.1%, FP score 3: 47.8%, FP score 4: 4.9%, FP score 5: 3.6%, FP score 6: 9.0%.

CONCLUSIONS

Screening of commonly used general surgery textbooks showed a significant lack of diversity in image-based skin tone representation when compared to the United States population at large. The overwhelming majority of images were of light skin tones. Improving diversity of imagery in educational material, such as basic textbooks, might help reduce observed disparities in outcomes among surgical patients in the future.

Prevalence and Source Tracing of PFAS in Shallow Groundwater Used for Drinking Water in Wisconsin, USA

Samples from 450 homes with shallow private wells throughout the state of Wisconsin (USA) were collected and analyzed for 44 individual per- and polyfluoroalkyl substances (PFAS), general water quality parameters, and indicators of human waste as well as agricultural influence. At least one PFAS was detected in 71% of the study samples, and 22 of the 44 PFAS analytes were detected in one or more samples. Levels of PFOA and/or PFOS exceeded the proposed Maximum Contaminant Levels of 4 ng/L, put forward by the U.S. Environmental Protection Agency (EPA) in March 2023, in 17 of the 450 samples, with two additional samples containing PFHxS ≳ 9 ng/L (the EPA-proposed hazard index reference value). Those samples above the referenced PFAS levels tend to be associated with developed land and human waste indicators (artificial sweeteners and pharmaceuticals), which can be released to groundwater via septic systems. For a few samples with levels of PFOA, PFOS, and/or PFHxS > 40 ng/L, application of wastes to agricultural land is a possible source. Overall, the study suggests that human waste sources, septic systems in particular, are important sources of perfluoroalkyl acids, especially ones with ≤8 perfluorinated carbons, in shallow groundwater.

The Standardized Video Interview: How Does It Affect the Likelihood to Invite for a Residency Interview?

BACKGROUND

The Association of American Medical Colleges instituted a standardized video interview (SVI) for all applicants to emergency medicine (EM). It is unclear how the SVI affects a faculty reviewer's decision on likelihood to invite an applicant (LTI) for an interview.

OBJECTIVES

The objective was to determine whether the SVI affects the LTI.

METHODS

Nine Accreditation Council of Graduate Medication Education (ACGME)-accredited EM residency programs participated in this prospective, observational study. LTI was defined on a 5-point Likert scale as follows: 1 = definitely not invite, 2 = likely not invite, 3 = might invite, 4 = probably invite, 5 = definitely invite. LTI was recorded at three instances during each review: 1) after typical screening (blinded to the SVI), 2) after unblinding to the SVI score, and 3) after viewing the SVI video.

RESULTS

Seventeen reviewers at nine ACGME-accredited residency programs participated. We reviewed 2,219 applications representing 1,424 unique applicants. After unblinding the SVI score, LTI did not change in 2,065 (93.1%), increased in 85 (3.8%) and decreased in 69 (3.1%; p = 0.22). In subgroup analyses, the effect of the SVI on LTI was unchanged by United States Medical Licensing Examination score. However, when examining subgroups of SVI scores, the percentage of applicants in whom the SVI score changed the LTI was significantly different in those that scored in the lower and upper subgroups (p < 0.0001). The SVI video was viewed in 816 (36.8%) applications. Watching the video did not change the LTI in 631 (77.3%); LTI increased in 106 (13.0%) and decreased in 79 (9.7%) applications (p = 0.04).

CONCLUSIONS

The SVI score changed the LTI in 7% of applications. In this group, the score was equally likely to increase or decrease the LTI. Lower SVI scores were more likely to decrease the LTI than higher scores were to increase the LTI. Watching the SVI video was more likely to increase the LTI than to decrease it.

Standardized Video Interviews Do Not Correlate to United States Medical Licensing Examination Step 1 and Step 2 Scores

Introduction

In 2017, the Standardized Video Interview (SVI) was required for applicants to emergency medicine (EM). The SVI contains six questions highlighting professionalism and interpersonal communication skills. The responses were scored (6–30). As it is a new metric, no information is available on correlation between SVI scores and other application data. This study was to determine if a correlation exists between applicants’ United States Medical Licensing Examination (USMLE) and SVI scores. We hypothesized that numeric USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores would not correlate with the SVI score, but that performance on the Step 2 Clinical Skills (CS) portion may correlate with the SVI since both test communication skills.

Methods

Nine EM residency sites participated in the study with data exported from an Electronic Residency Application Service (ERAS®) report. All applicants with both SVI and USMLE scores were included. We studied the correlation between SVI scores and USMLE scores. Predetermined subgroup analysis was performed based on applicants’ USMLE Step 1 and Step 2 CK scores as follows: (≥ 200, 201–220, 221–240, 241–260, >260). We used linear regression, the Kruskal-Wallis test and Mann-Whitney U test for statistical analyses.

Results

1,325 applicants had both Step 1 and SVI scores available, with no correlation between the overall scores (p=0.58) and no correlation between the scores across all Step 1 score ranges, (p=0.29). Both Step 2 CK and SVI scores were available for 1,275 applicants, with no correlation between the overall scores (p=0.56) and no correlation across all ranges, (p=0.10). The USMLE Step 2 CS and SVI scores were available for 1,000 applicants. Four applicants failed the CS test without any correlation to the SVI score (p=0.08).

Conclusion

We found no correlation between the scores on any portion of the USMLE and the SVI; therefore, the SVI provides new information to application screeners.

Fate of five pharmaceuticals under different infiltration conditions for managed aquifer recharge

Infiltration of treated wastewater (TWW) to recharge depleted aquifers, often referred to as managed aquifer recharge, is a solution to replenish groundwater resources in regions facing water scarcity. We present a mass balance approach to infer the amounts of five pharmaceuticals (carbamazepine, diclofenac, fenoprofen, gemfibrozil, and naproxen) degraded in column experiments based on concentrations of pharmaceuticals in the aqueous and solid (sorbed) phases. Column experiments were conducted under three different conditions: continuous infiltration, wetting and drying cycles, and wetting and drying cycles with elevated concentrations of antibiotics (which may reduce microbially aided degradation of other compounds). A mass balance comparing pharmaceutical mass in the water phase over the 16-month duration of the experiments to mass sorbed to the soil was used to infer the mass of pharmaceuticals degraded. Results show sorption as the main attenuation mechanism for carbamazepine. About half of the mass of diclofenac was degraded with wetting and drying cycles, but no significant degradation was found for continuous infiltration, while 32% of infiltrated mass sorbed. Fenoprofen was degraded in the shallow and aerobic part of the soil, but degradation appeared to cease beyond 27 cm depth. Gemfibrozil attenuated through a combination of degradation and sorption, with slight increases in attenuation with depth from both mechanisms. Naproxen degraded progressively with depth, resulting in attenuation of >90% of the mass. In the column with elevated concentrations of antibiotics, the antibiotics attenuated to about 50% or less of inflow concentrations by 27 cm depth and within this zone, less degradation of the other compounds was observed.

The addition of metronomic chemotherapy does not improve outcome for canine splenic haemangiosarcoma

OBJECTIVES

To determine whether the addition of metronomic chemotherapy improved outcome for dogs with splenic haemangiosarcoma treated with splenectomy and adjuvant maximum tolerated dose chemotherapy.

MATERIALS AND METHODS

Medical records were examined retrospectively for dogs with splenic haemangiosarcoma that had undergone splenectomy followed by anthracycline-based chemotherapy. Thirty-nine dogs underwent splenectomy followed by maximum tolerated dose chemotherapy with an anthracycline, cyclophosphamide, or both (Group 1). Twenty-two dogs underwent splenectomy followed by adjuvant maximum tolerated dose chemotherapy with an anthracycline, cyclophosphamide, or both, plus metronomic chemotherapy (Group 2). Dogs in both groups were further separated into those treated with either maximum tolerated dose anthracycline or maximum tolerated dose anthracycline and cyclophosphamide.

RESULTS

Median progression-free survival was 165 days and median overall survival time was 180 days in Group 1. Median progression-free survival was 185 days and median overall survival time was 212 days in Group 2. In both groups, the overall survival was shorter in dogs that had received maximum tolerated dose cyclophosphamide.

CLINICAL SIGNIFICANCE

The addition of metronomic to maximum tolerated dose chemotherapy protocols does not appear to improve outcome in dogs with splenic haemangiosarcoma treated with splenectomy and maximum tolerated dose chemotherapy.

Novel methods reveal that parallelism contributes to the functional vertical slot dimension in ceramic and metal brackets

OBJECTIVES:

To validate a novel method for measuring the clinically relevant bracket slot and use these methods to test the hypothesis that various metal injection molded (MIM) and esthetic ceramic injection molded (CIM) brackets have a bracket slot accuracy within 1 mil (0.001") of their reported slot dimension.

MATERIALS AND METHODS:

A Nikon iNEXIV-VMA-2520 laser microscope was used to measure slots of six series of CIM brackets and two series of MIM brackets via a vision measuring system of 256 gray levels to capture each edge of the slot, largely taking out human subjectivity. This system had a maximum permissible error of 2 + 8 L/1000 μm with a point resolution of 0.1 μm and was estimated to be more accurate than previous methods by a factor of 10. The video image for each bracket was autofocused by a blinded operator, and 40 point-to-line measurements were calculated along the clinical slot and averaged.

RESULTS:

Vertical slot dimension varied from series to series and within the series of brackets. Three of six CIM and two of three MIM brackets had a statistically significant mean slot size 0.001 inches larger than reported. The reported precision of these CIM brackets, as determined from standard deviation, varied from series to series.

CONCLUSIONS:

A novel system that incorporates parallelism into analysis of vertical bracket slot dimension was described. When the entire clinically relevant slot was considered, MIM and CIM brackets had similar precision but were significantly oversized, with contribution from a nonparallel, likely diverging, vertical slot dimension.

Abstract P6-03-03: Not presented

This abstract was not presented at the symposium.

Geographical differences in survival of dogs with non-Hodgkin lymphoma treated with a CHOP based chemotherapy protocol

BACKGROUND

In humans geographical differences in the incidence and presentation of various cancers have been reported. However, much of this information has not been collected in veterinary oncology.

AIM

The purpose of this study was to determine if a geographic difference in progression free survival exists for dogs with lymphoma treated within the US.

MATERIALS AND METHODS

Medical records of 775 cases of canine lymphoma from 3 US regions (west, south and north), treated with CHOP chemotherapy, were retrospectively evaluated. Cases were collected from referral institutions and were required to have received at least one doxorubicin treatment and have follow up information regarding time to progression.

RESULTS

Significant differences in sex (p = 0.05), weight (p = 0.049), stage (p < 0.001), immunophenotype (p = <0.001), and number of doxorubicin doses (p = 0.001) were seen between regions. Upon univariate analysis, progression free survival (PFS) differed by region (p = 0.006), stage (p = 0.009), sub-stage (p = 0.0005), and immunophenotype (p = 0.001). A multivariable Cox regression model showed that dogs in the western region had a significantly shorter PFS when compared to the south and east.

CONCLUSION

PFS was significantly affected by stage, sub-stage and phenotype.

Abstract P5-03-03: A blood-based proteomic Videssa® breast assay performs comparably in women with dense and non-dense breasts

Breast density is associated with reduced imaging sensitivity and specificity for breast cancer (BC). Women with dense breasts are at a four- to six-fold increased risk of developing BC. A biochemical approach that is not affected by density would provide an additional tool to health-care professionals who are managing women with dense breasts and suspicious imaging findings. Videssa® Breast, a combinatorial proteomic biomarker assay, comprised of Serum Protein Biomarkers (SPBs) and Tumor –Associated Autoantibodies (TAAbs) integrated with clinical characteristic data to produce one diagnostic score that reliably detects BC was recently developed as an adjunctive tool to imaging. The goal of this study was to determine whether the diagnostic performance of Videssa® Breast was impacted by breast density.

Provista-001 enrolled 351 participants under the age of 50 years with no prior history of breast biopsy, and Provista-002 cohort one enrolled 210 participants under the age of 50 years with no history of breast biopsy within six months; all participants were assessed as BI-RADS 3 or 4. Breast density status was retrospectively obtained for participants; the four American College of Radiology breast density categories (a, b, c, and d) used for clinical reporting were applied. Serum was collected and tested with Videssa® Breast. Women were categorized into Dense, which included categories c and d, and Non-dense, which included categories a and b, groups.

To understand the performance of Videssa® Breast in women with dense breasts, the clinical sensitivity, specificity, NPV and PPV were evaluated in the dense and non-dense groups from the comprehensive Provista-001 and Provista-002 set (n=545). Of these 545, breast density information was available for 454; 62.6% (n=284) were categorized as having dense breasts and 37.4% (n=170) were categorized as having non-dense breasts. The sensitivity of Videssa® Breast in the non-dense and dense groups was 92.3% and 88.9%, respectively, and the specificity in the non-dense and dense groups was 86.6% and 81.2%, respectively. No significant differences were observed in the sensitivity (p=1.0) or specificity (p=0.1783) of Videssa® Breast in detecting BC in participants with non-dense breasts compared to those with dense breasts. The NPV in both groups exceeded 99%; the PPV was similar across groups.

In summary, this study demonstrates that Videssa® Breast has comparable performance in women with dense and non-dense breasts. Videssa® Breast demonstrates high sensitivity and specificity for detecting BC (Grades I through III), irrespective of density status. Videssa® breast provides an additional tool for health-care providers when women with dense breasts present with challenging imaging findings. In addition, Videssa® breast provides assurance to a woman with dense breasts that she does not have BC, potentially reducing further anxiety in this higher risk patient population.

Citation Format: Silver M, Tran Q, Gordon K, Benson KL, Henderson MC, Letsios E, Mulpuri R, Reese DE. A blood-based proteomic Videssa® breast assay performs comparably in women with dense and non-dense breasts [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-03.

Teaching the Emergency Department Patient Experience: Needs Assessment from the CORD-EM Task Force

Introduction

Since the creation of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction (PS) scores, patient experience (PE) has become a metric that can profoundly affect the fiscal balance of hospital systems, reputation of entire departments and welfare of individual physicians. While government and hospital mandates demonstrate the prominence of PE as a quality measure, no such mandate exists for its education. The objective of this study was to determine the education and evaluation landscape for PE in categorical emergency medicine (EM) residencies.

Methods

This was a prospective survey analysis of the Council of Emergency Medicine Residency Directors (CORD) membership. Program directors (PDs), assistant PDs and core faculty who are part of the CORD listserv were sent an email link to a brief, anonymous electronic survey. Respondents were asked their position in the residency, the name of their department, and questions regarding the presence and types of PS evaluative data and PE education they provide.

Results

We obtained 168 responses from 139 individual residencies, representing 72% of all categorical EM residencies. This survey found that only 27% of responding residencies provide PS data to their residents. Of those programs, 61% offer simulation scores, 39% provide third-party attending data on cases with resident participation, 37% provide third-party acquired data specifically about residents and 37% provide internally acquired quantitative data.

Only 35% of residencies reported having any organized PE curricula. Of the programs that provide an organized PE curriculum, most offer multiple modalities; 96% provide didactic lectures, 49% small group sessions, 47% simulation sessions and 27% specifically use standardized patient encounters in their simulation sessions.

Conclusion

The majority of categorical EM residencies do not provide either PS data or any organized PE curriculum. Those that do use a heterogeneous set of data collection modalities and educational techniques. American Osteopathic Association and Accreditation Council for Graduate Medical Education residencies show no significant differences in their resident PS data provision or formal curricula. Further work is needed to improve education given the high stakes of PS scores in the emergency physician’s career.