Multiple-Institution Comparison of Resident and Faculty Perceptions of Burnout and Depression During Surgical Training

Importance

Prior studies demonstrate a high prevalence of burnout and depression among surgeons. Limited data exist regarding how these conditions are perceived by the surgical community.

Objectives

To measure prevalence of burnout and depression among general surgery trainees and to characterize how residents and attendings perceive these conditions.

Design, Setting, and Participants

This cross-sectional study used unique, anonymous surveys for residents and attendings that were administered via a web-based platform from November 1, 2016, through March 31, 2017. All residents and attendings in the 6 general surgery training programs in North Carolina were invited to participate.

Main Outcomes and Measures

The prevalence of burnout and depression among residents was assessed using validated tools. Burnout was defined by high emotional exhaustion or depersonalization on the Maslach Burnout Inventory. Depression was defined by a score of 10 or greater on the Patient Health Questionnaire-9. Linear and logistic regression models were used to assess predictive factors for burnout and depression. Residents' and attendings' perceptions of these conditions were analyzed for significant similarities and differences.

Results

In this study, a total of 92 residents and 55 attendings responded. Fifty-eight of 77 residents with complete responses (75%) met criteria for burnout, and 30 of 76 (39%) met criteria for depression. Of those with burnout, 28 of 58 (48%) were at elevated risk of depression (P = .03). Nine of 77 residents (12%) had suicidal ideation in the past 2 weeks. Most residents (40 of 76 [53%]) correctly estimated that more than 50% of residents had burnout, whereas only 13 of 56 attendings (23%) correctly estimated this prevalence (P < .001). Forty-two of 83 residents (51%) and 42 of 56 attendings (75%) underestimated the true prevalence of depression (P = .002). Sixty-six of 73 residents (90%) and 40 of 51 attendings (78%) identified the same top 3 barriers to seeking care for burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care.

Conclusions and Relevance

The prevalence of burnout and depression was high among general surgery residents in this study. Attendings and residents underestimated the prevalence of these conditions but acknowledged common barriers to seeking care. Discrepancies in actual and perceived levels of burnout and depression may hinder wellness interventions. Increasing understanding of these perceptions offers an opportunity to develop practical solutions.

Toward effective feedback: From concept to practice

Feedback is the building block of assessment and an essential component of effective teaching. In this article, we will provide a comprehensive definition of feedback and a relevant conceptual framework for learning to explain how feedback can be used to improve performance. We will discuss the process of providing feedback, and the role teacher and learner can play to make it more effective. We will also examine the misunderstandings and pitfalls around feedback, as well as generational differences that may influence its impact.

Trends in Utilization and Relative Complication Rates of Bariatric Procedures

BACKGROUND

Laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding have been popular alternatives to laparoscopic Roux-en-Y gastric bypass due to their technical ease and lower complication rates. Comprehensive longitudinal data are necessary to guide selection of the appropriate bariatric procedures for individual patients.

METHODS

We used the Truven Heath Analytics MarketScan® database between 2000 and 2015 to identify patients undergoing bariatric surgery. Kaplan-Meier and Cox proportional hazard regression analyses were performed to compare complication rates between laparoscopic gastric bypass and laparoscopic sleeve gastrectomy, as well as between laparoscopic gastric bypass and laparoscopic adjustable gastric banding.

RESULTS

256,830 individuals met search criteria. By 2015, laparoscopic sleeve gastrectomy was the most commonly performed bariatric procedure followed by laparoscopic gastric bypass and then laparoscopic adjustable gastric banding. Overall, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding had fewer complications relative to laparoscopic gastric bypass with the exceptions of heartburn, gastritis, and portal vein thrombosis following sleeve gastrectomy and heartburn and dysphagia following adjustable gastric banding.

CONCLUSION

Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure in the USA. It is reassuring that its overall postoperative complication rates are lower relative to laparoscopic gastric bypass.

Detection of low-density Plasmodium falciparum infections using amplicon deep sequencing

BACKGROUND

Deep sequencing of targeted genomic regions is becoming a common tool for understanding the dynamics and complexity of Plasmodium infections, but its lower limit of detection is currently unknown. Here, a new amplicon analysis tool, the Parallel Amplicon Sequencing Error Correction (PASEC) pipeline, is used to evaluate the performance of amplicon sequencing on low-density Plasmodium DNA samples. Illumina-based sequencing of two Plasmodium falciparum genomic regions (CSP and SERA2) was performed on two types of samples: in vitro DNA mixtures mimicking low-density infections (1-200 genomes/μl) and extracted blood spots from a combination of symptomatic and asymptomatic individuals (44-653,080 parasites/μl). Three additional analysis tools-DADA2, HaplotypR, and SeekDeep-were applied to both datasets and the precision and sensitivity of each tool were evaluated.

RESULTS

Amplicon sequencing can contend with low-density samples, showing reasonable detection accuracy down to a concentration of 5 Plasmodium genomes/μl. Due to increased stochasticity and background noise, however, all four tools showed reduced sensitivity and precision on samples with very low parasitaemia (< 5 copies/μl) or low read count (< 100 reads per amplicon). PASEC could distinguish major from minor haplotypes with an accuracy of 90% in samples with at least 30 Plasmodium genomes/μl, but only 61% at low Plasmodium concentrations (< 5 genomes/μl) and 46% at very low read counts (< 25 reads per amplicon). The four tools were additionally used on a panel of extracted parasite-positive blood spots from natural malaria infections. While all four identified concordant patterns of complexity of infection (COI) across four sub-Saharan African countries, COI values obtained for individual samples differed in some cases.

CONCLUSIONS

Amplicon deep sequencing can be used to determine the complexity and diversity of low-density Plasmodium infections. Despite differences in their approach, four state-of-the-art tools resolved known haplotype mixtures with similar sensitivity and precision. Researchers can therefore choose from multiple robust approaches for analysing amplicon data, however, error filtration approaches should not be uniformly applied across samples of varying parasitaemia. Samples with very low parasitaemia and very low read count have higher false positive rates and call for read count thresholds that are higher than current default recommendations.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux

Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.

Surgeons' expertise during critical event in laparoscopic cholecystectomy: An expert-novice comparison using protocol analysis

BACKGROUND

The purpose of this study was to examine differences in thought processes between novice and experienced surgeons when they were presented with a critical situation during laparoscopic cholecystectomy.

METHODS

A group of experienced and novice surgeons were shown a recording of a laparoscopic cholecystectomy with an intraoperative bleeding event. The think-aloud method was used to capture surgeons' thought processes. Verbal reports were recorded, transcribed and analyzed using the protocol analysis method.

RESULTS

Sixteen subjects (8 in each group) participated at two centers. Experienced surgeons demonstrated deeper comprehension of the operative field, richer mental image of future events and superior awareness of potentially dangerous situations. They also spent more time engaged in metacognitive activity.

CONCLUSIONS

This study highlights the differences and similarities between surgeons with different levels of experience during a challenging intraoperative encounter. The domains of cognition and mental image as well as metacognition appear to be key elements of surgical expertise.

Sleeve Gastrectomy: Surgical Tips

The vertical sleeve gastrectomy is a bariatric procedure that was originally described as the initial step in the biliopancreatic diversion. It demonstrated effectiveness in weight loss as a single procedure, and the laparoscopic vertical sleeve gastrectomy, as a stand-alone procedure, is now the most commonly performed bariatric surgery worldwide. Due to its relative technical ease and long-term data that have established its durability in treating obesity and its related comorbid conditions, the sleeve gastrectomy has grown in popularity among patients and surgeons. While there are variations in the technical aspects of performing a laparoscopic sleeve gastrectomy, key steps must be undertaken to produce safe and effective outcomes. This article reviews the indications for bariatric surgery, patient selection, surgical technique and tips, perioperative care and complications after sleeve gastrectomy.

The Treatment of Achalasia in Obese Patients

Epidemiological studies have demonstrated that obesity is frequently associated with esophageal motility disorders. Morbid obesity and achalasia may coexist in the same patient. The management of the morbidly obese patient with achalasia is complex and the most effective treatment remains controversial. The aim of this study is to review the pathophysiology, clinical presentation, diagnostic evaluation, and treatment of achalasia in morbidly obese patients.

EVIDENCE REVIEW

PubMed search from January 1990 to July 2017, including the following terms: achalasia, morbid obesity, bariatric, and treatment. Achalasia in the setting of morbid obesity may be successfully treated by endoscopic or surgical methods. Surgeons may choose to add a bariatric procedure, with various strategies present in the literature. A review of the present literature suggests that the preferred approach to achalasia in the morbidly obese patient is to address both disease processes simultaneously with a laparoscopic Heller myotomy and a Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is cited by most experts as the bariatric procedure of choice, given its antireflux benefits. A well-powered study, comparing the various approaches to the treatment of achalasia in the setting of morbid obesity, is required to establish a consensus.

The Treatment of Achalasia in Obese Patients

Epidemiological studies have demonstrated that obesity is frequently associated with esophageal motility disorders. Morbid obesity and achalasia may coexist in the same patient. The management of the morbidly obese patient with achalasia is complex and the most effective treatment remains controversial. The aim of this study is to review the pathophysiology, clinical presentation, diagnostic evaluation, and treatment of achalasia in morbidly obese patients. Evidence Review: PubMed search from January 1990 to July 2017, including the following terms: achalasia, morbid obesity, bariatric, and treatment. Achalasia in the setting of morbid obesity may be successfully treated by endoscopic or surgical methods. Surgeons may choose to add a bariatric procedure, with various strategies present in the literature. A review of the present literature suggests that the preferred approach to achalasia in the morbidly obese patient is to address both disease processes simultaneously with a laparoscopic Heller myotomy and a Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is cited by most experts as the bariatric procedure of choice, given its antireflux benefits. A well-powered study, comparing the various approaches to the treatment of achalasia in the setting of morbid obesity, is required to establish a consensus.

Oral Anticoagulant Use After Bariatric Surgery: A Literature Review and Clinical Guidance

Bariatric surgery may alter the absorption, distribution, metabolism, or elimination (disposition) of orally administered drugs via changes to the gastrointestinal tract anatomy, body weight, and adipose tissue composition. As some patients who have undergone bariatric surgery will need therapeutic anticoagulation for various indications, appropriate knowledge is needed regarding anticoagulant drug disposition and resulting efficacy and safety in this population. We review general considerations about oral drug disposition in patients after bariatric surgery, as well as existing literature on oral anticoagulation after bariatric surgery. Overall, available evidence on therapeutic anticoagulation is very limited, and individual drug studies are necessary to learn how to safely and effectively use the direct oral anticoagulants. Given the sparsity of currently available data, it appears most prudent to use warfarin with international normalized ratio monitoring, and not direct oral anticoagulants, when full-dose anticoagulation is needed after bariatric surgery.

Minimally Invasive Surgery Should Be the Standard of Care for Paraesophageal Hernia Repair

BACKGROUND

It is unclear if minimally invasive surgery (MIS) has been universally embraced for paraesophageal hernia (PEH) repair. The aims of this study were: (a) to assess the national utilization of MIS for PEH repair and (b) to compare the perioperative outcomes between MIS and open procedures METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2013. Adult patients (≥18 years old) who underwent PEH repair were included. Linear and logistic regression, adjusted for patient and hospital characteristics, were used to assess the effect of minimally invasive surgery on patient outcomes RESULTS: A total of 63,812 patients were included. An abdominal approach was used in 60,087 (94.2%) patients and a thoracic approach in 3725 (5.8%) cases. Between 2000 and 2013, the rate of MIS significantly increased in abdominal and thoracic procedures. Patients undergoing MIS were less likely to experience postoperative infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and had a lower inpatient mortality. In addition, MIS significantly reduced the length of hospital stay and the overall cost.

CONCLUSIONS

MIS is associated with significantly better perioperative outcomes and lower costs. These data strongly support the MIS approach as standard of care for PEH repair.

Surgery for Gastroesophageal Reflux Disease in the Morbidly Obese Patient

The prevalence of gastroesophageal reflux disease (GERD) has mirrored the increase in obesity, and GERD is now recognized as an obesity-related comorbidity. There is growing evidence that obesity, specifically central obesity, is associated with the complications of chronic reflux, including erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. While fundoplication is effective in creating a competent gastroesophageal junction and controlling reflux in most patients, it is less effective in morbidly obese patients. In these patients a bariatric operation has the ability to correct both the obesity and the abnormal reflux. The Roux-en-Y gastric bypass is the preferred procedure.

Fundoplication for Gastroesophageal Reflux Disease: Tips for Success

Gastroesophageal reflux disease affects almost 20% of the population in the United States. Today, proton pump inhibitors are the most frequently prescribed drugs, with an estimated cost of 10 billion dollars per year. Although these medications control heartburn in the majority of patients, other symptoms such as regurgitation and respiratory symptoms often are not controlled, particularly in patients with large hiatal hernias. In these patients a properly performed laparoscopic fundoplication controls esophageal and extraesophageal symptoms and avoids life-long medical therapy. Key elements for the success of a fundoplication are careful patient selection, a complete preoperative evaluation, and a properly executed operation.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan–Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m2) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial ( P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan-Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m(2)) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial (P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.