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White EM, Esposito AC, Yoo PS. Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees. Acad Med 2023:00001888-990000000-00702. [PMID: 38113443 DOI: 10.1097/acm.0000000000005587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PURPOSE Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees. METHOD The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied. RESULTS Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment (P = 0.27 - 0.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training, however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices. CONCLUSIONS Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.
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Affiliation(s)
- Erin M White
- E.M. White is a general surgery resident, Yale University-Yale New Haven Hospital, New Haven, Connecticut; ORCID: https://orcid.org/0000-0001-9679-0243
| | - Andrew C Esposito
- A.C. Esposito is a general surgery resident, Yale University-Yale New Haven Hospital, New Haven, Connecticut; ORCID: https://orcid.org/0000-0003-1845-9349
| | - Peter S Yoo
- P.S. Yoo is associate professor of surgery and residency program director, Yale University-Yale New Haven Hospital, New Haven, Connecticut; https://orcid.org/0000-0003-3840-1697
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Coppersmith NA, Chung M, Esposito AC, Flom E, Dent DL, Morris-Wiseman L, Rosenkranz KM, Terhune KP, Yoo PS. How Did We Get Here and Where Are We Going? Career Trajectories of United States General Surgery Residency Program Directors. J Surg Educ 2023; 80:1653-1662. [PMID: 37355404 DOI: 10.1016/j.jsurg.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/15/2023] [Accepted: 05/29/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE To develop the future of United States (US) surgical education leadership, surgical trainees and early career faculty who aspire to become program directors (PDs) must understand the potential career pathways and requisite skills and experience to become a general surgery residency PD. The objective of this study was to understand the demographics, career experiences, and professional satisfaction of US PDs in general surgery. DESIGN An anonymous, cross-sectional survey utilizing a novel instrument. SETTING An electronic survey distributed to US general surgery PDs between June and November 2022 PARTICIPANTS: PDs of US general surgery residency programs. A list of the Accrediting Council for Graduate Medical Education (ACGME)-accredited general surgery PDs was created from the ACGME list from the 2022 to 23 academic year. RESULTS The survey achieved a response rate of 46.2% (159/344). Only 32.1% of PDs identified as female and 67.3% identified as male with 1 respondent preferring not to identify their gender. PDs were White or Caucasian (68.6%), Asian (13.8%), and Black (3.7%); 4.4% were Hispanic or Latino. Only 83.7% of PDs completed fellowship training. PDs have been in the role for an average of 5.5 ± 4.9 years. The PDs were compensated for an average of 54.7% (±14.9% SD, 0%-100% range) of their time towards clinical duties. They were compensated on average for 35.7% (±12.6%, 0%-100%) of effort for residency-related administrative duties. Only 5% of PDs had obtained or were enrolled in an education-related degree. Only 55.4% of PDs had received formal surgical education training in teaching and assessment. 54.1% of PDs were interested in obtaining a more senior leadership position in the future. Most PDs (38.4%) expect to serve as PD for 5 to 8 years in total. Overall, the majority of PDs were very satisfied (29.6%) or satisfied (51.6%) professionally; similarly 28.9% were very satisfied and 48.4% satisfied personally. CONCLUSIONS This study represents the most up-to-date characterization of the personal, academic, and career-related features of current surgical residency PDs across the US. PDs enjoy a high degree of professional and personal satisfaction and most aspire to increasing leadership within their organizations. Compared to prior data, PDs have become more diverse in terms of both gender and race over time. Opportunities exist for increased mentorship of aspiring and current PDs as well as increased training in teaching and assessment.
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Affiliation(s)
| | - Mark Chung
- Yale College, Yale University, New Haven, Connecticut
| | - Andrew C Esposito
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Emily Flom
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel L Dent
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | | | - Kari M Rosenkranz
- Department of Surgery, Geisel School of Medicine, Hanover, New Hampshire
| | - Kyla P Terhune
- Department of Surgery, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Peter S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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White EM, Hernandez A, Coppersmith NA, Esposito AC, Paranjpe AA, Yoo PS. Surgical Residents' Awareness of the Costs of Common Operating Room Supplies. Am Surg 2023; 89:4640-4643. [PMID: 36113130 DOI: 10.1177/00031348221126953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education mandates that residency programs incorporate cost awareness into patient care. This presents a challenge for surgical residents because they must understand operating room costs in addition to other expenses. Trainees' understanding of operating room supply costs is not well understood. METHODS A survey was distributed to surgical residents (N = 73) at an urban, university-based residency program. Residents estimated the costs of 21 single-use operating room items. Descriptive statistics and a regression analysis were calculated. RESULTS The response rate was 62%. Respondents accurately estimated costs for a median of 7/21 items, with error ranging from 26% to 5438%. They substantially underestimated the three highest-cost items. Increasing post-graduate year did not improve estimation accuracy (β = .233, P = .138). DISCUSSION Residents have a poor understanding of single-use item costs, and this does not improve with post-graduate training, suggesting inefficiencies. There is opportunity to educate residents and ultimately decrease surgical health care costs.
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Affiliation(s)
- Erin M White
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alee Hernandez
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Andrew C Esposito
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ashwini A Paranjpe
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Esposito AC, Mongiu A. Management of Anal Incontinence With Implantable Sacral Neuromodulation. Dis Colon Rectum 2023; 66:758-762. [PMID: 36989061 DOI: 10.1097/dcr.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Affiliation(s)
- Andrew C Esposito
- Division of Colon and Rectal Surgery, Department of Surgery, Yale University, New Haven, Connecticut
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Esposito AC, Coppersmith NA, White EM, Papageorge MV, DiSiena M, Hess D, LaFemina J, Larkin AC, Miner TJ, Nepomnayshy D, Palesty J, Rosenkranz KM, Seymour NE, Trevisani G, Whiting J, Oliveira KD, Longo WE, Yoo PS. Update on the Financial Well-Being of Surgical Residents in New England. J Am Coll Surg 2023; 236:953-960. [PMID: 36622076 DOI: 10.1097/xcs.0000000000000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being. STUDY DESIGN A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort. RESULTS Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans. CONCLUSIONS Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.
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Affiliation(s)
- Andrew C Esposito
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
| | - Nathan A Coppersmith
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
| | - Erin M White
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
| | - Marianna V Papageorge
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
| | - Michael DiSiena
- Berkshire Medical Center, Department of Surgery, Pittsfield, MA (DiSiena)
| | - Donald Hess
- Boston Medical Center, Department of Surgery, Boston, MA (Hess)
| | - Jennifer LaFemina
- the University of Massachusetts Chan Medical School, Department of Surgery, Worcester, MA (LaFemina, Larkin)
| | - Anne C Larkin
- the University of Massachusetts Chan Medical School, Department of Surgery, Worcester, MA (LaFemina, Larkin)
| | - Thomas J Miner
- Rhode Island Hospital, Warren Alpert Medical School, Department of Surgery, Providence, RI (Miner)
| | - Dmitry Nepomnayshy
- Lahey Hospital and Medical Center, Department of Surgery, Burlington, MA (Nepomnayshy)
| | - John Palesty
- Saint Mary's Hospital, Department of Surgery, Waterbury, CT (Palesty)
| | - Kari M Rosenkranz
- Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, NH (Rosenkranz)
| | - Neal E Seymour
- Baystate Health, Department of Surgery, Springfield, MA (Seymour)
| | - Gino Trevisani
- the University of Vermont Medical Center, Department of Surgery, Burlington, VT (Trevisani)
| | - James Whiting
- Maine Medical Center, Department of Surgery, Portland, ME (Whiting)
| | - Kristin D Oliveira
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
| | - Walter E Longo
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
| | - Peter S Yoo
- From the Yale School of Medicine, Department of Surgery, New Haven, CT (Esposito, Coppersmith, White, Papageorge, Oliveira, Longo, Yoo)
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Esposito AC, Coppersmith NA, Flom EA, Chung M, Reddy V, Leeds I, Longo W, Pantel H, Yoo PS, Mongiu A. So You Want to be a Program Director? Career Paths of Colon and Rectal Surgery Residency Program Directors. J Surg Educ 2023; 80:588-596. [PMID: 36658062 DOI: 10.1016/j.jsurg.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/11/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The trajectory of colon and rectal surgery residency program director (PD) career paths has not been well described, leaving those who aspire for the position with minimal guidance. The goal of this study is to characterize their career paths in the United States. By understanding their experiences, the path to train and educate the next generation of colon and rectal surgeons as a PD will be better illuminated. STUDY DESIGN This study was an anonymous, cross-sectional survey of all junior and senior colon and rectal surgery residency PDs in the United States during April and May of 2022. PDs were divided into junior and senior PDs. Results were compared using 2-sided independent t-tests and Kruskall-Wallis tests. RESULTS Of 65 colon and rectal surgery PDs, 48% (31/65) completed the survey which encompassed demographics, leadership, education, research, and time utilization. Participants were primarily white and male, although increased female representation was identified among the junior PDs (50%). Junior PDs were also more likely to hold associate or assistant professor positions at time of appointment (p = 0.01) and a majority of all PDs (64%) previously or currently held a leadership position in a national or regional surgical association. When appointed, senior PDs reported increased teaching time. CONCLUSIONS This multi-institutional analysis of colon and rectal surgery residency PDs identified a trend towards equal gender representation and diversity amongst upcoming junior PDs. All respondents were appointed to PD from within the institution. Other key experiences included previous leadership roles and associate or assistant professor positions at time of appointment. While it is impossible to create a single recommended template for every aspiring colon and rectal surgery educator to advance to a PD position, this study provides guideposts along that career path.
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Affiliation(s)
- Andrew C Esposito
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | | | - Emily A Flom
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Vikram Reddy
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Yale School of Management, Yale University, New Haven, Connecticut
| | - Ira Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Walter Longo
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Haddon Pantel
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Division of Transplant Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anne Mongiu
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Esposito AC, Zhang Y, Nagarkatti N, Laird WD, Coppersmith NA, Reddy V, Leeds I, Mongiu A, Longo W, Hao RM, Pantel H. Do Cultures From Percutaneously Drained Intra-abdominal Abscesses Change Treatment? A Retrospective Review. Dis Colon Rectum 2023; 66:451-457. [PMID: 36538708 DOI: 10.1097/dcr.0000000000002644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Routinely obtaining intraoperative cultures for abdominal infections is not a currently recommended evidence-based practice. Yet, cultures are frequently sent from these infections when they are managed by image-guided percutaneous drains. OBJECTIVE This study aimed to determine the utility of cultures from percutaneously drained intra-abdominal abscesses. DESIGN Retrospective medical record review. SETTING Single university-affiliated institution. PATIENTS Inpatients with an intra-abdominal abscess secondary to diverticulitis or appendicitis between 2013 and 2021 managed with image-guided percutaneous drain, excluding those with active chemotherapy, HIV, or solid organ transplant, were included in the study. MAIN OUTCOME MEASURES Frequency culture data from percutaneous drains changed antimicrobial therapy. RESULTS There were 221 patients who met the inclusion criteria. Of these, 56% were admitted for diverticulitis and 44% for appendicitis. Patients were 54% female and had a median age of 62 years (range, 18-93), and 14% were active smokers. The median length of hospitalization was 8 days (range, 1-78) and the median antibiotics course was 8 days (range, 1-22). Culture data from percutaneous drains altered antimicrobial therapy in 8% of patients (16/211). A culture was obtained from 95% of drains, with 78% of cultures with growth. Cultures grew multiple bacteria in 66% and mixed variety without speciation in 13%. The most common pathogen was the Bacteroides family at 33% of all bacteria. The most common empiric antibiotic regimens were ceftriaxone used in 33% of patients and metronidazole used in 40% of patients. Female sex ( p = 0.027) and presence of bacteria with any antibiotic resistance ( p < 0.01) were associated with higher likelihood of cultures influencing antimicrobial therapy. LIMITATIONS Retrospective and single institution's microbiome. CONCLUSIONS Microbiology data from image-guided percutaneous drains of abdominal abscesses altered antimicrobial therapy in 8% of patients, which is lower than reported in previously published literature on cultures obtained surgically. Given this low rate, similar to the recommendation regarding cultures obtained intraoperatively, routinely culturing material from drains placed in abdominal abscesses is not recommended. See Video Abstract at http://links.lww.com/DCR/C64 . LOS CULTIVOS DE ABSCESOS INTRA ABDOMINALES DRENADOS PERCUTNEAMENTE CAMBIAN EL TRATAMIENTO UNA REVISIN RETROSPECTIVA ANTECEDENTES:La obtención rutinaria de cultivos intra-operatorios para infecciones abdominales no es una práctica basada en evidencia actualmente recomendada. Sin embargo, con frecuencia se envían cultivos de estas infecciones cuando se manejan con drenajes percutáneos guiados por imágenes.OBJETIVO:Determinar la utilidad de los cultivos de abscesos intra-abdominales drenados percutáneamente.DISEÑO:Revisión retrospectiva de gráficos.ESCENARIO:Institución única afiliada a la universidad.PACIENTES:Pacientes hospitalizados con absceso intra-abdominal secundario a diverticulitis o apendicitis entre 2013 y 2021 manejados con drenaje percutáneo guiado por imagen, excluyendo aquellos con quimioterapia activa, VIH o trasplante de órgano sólido.PRINCIPALES MEDIDAS DE RESULTADO:Los datos de cultivo de frecuencia de los drenajes percutáneos cambiaron la terapia antimicrobiana.RESULTADOS:Hubo 221 pacientes que cumplieron con los criterios de inclusión. De estos, el 56% ingresaron por diverticulitis y el 44% por apendicitis. El 54% de los pacientes eran mujeres, tenían una edad media de 62 años (18-93) y el 14% eran fumadores activos. La duración de hospitalización media fue de 8 días (rango, 1-78) y la mediana del curso de antibióticos fue de 8 días (rango, 1-22). Los datos de cultivo de drenajes percutáneos alteraron la terapia antimicrobiana en el 7% (16/221) de los pacientes. Se obtuvo cultivo del 95% de los drenajes, con un 79% de cultivos con crecimiento. Los cultivos produjeron múltiples bacterias en el 63% y variedad mixta sin especiación en el 13%. El patógeno más común fue la familia Bacteroides con un 33% de todas las bacterias. El régimen de antibiótico empírico más común fue ceftriaxona y metronidazol, utilizados en el 33% y el 40% de los pacientes, respectivamente. El sexo femenino ( p = 0,027) y la presencia de bacterias con alguna resistencia a los antibióticos ( p < 0,01) se asociaron con una mayor probabilidad de que los cultivos influyeran en la terapia antimicrobiana.LIMITACIONES:Microbioma retrospectivo y de una sola institución.CONCLUSIONES:Los datos microbiológicos de los drenajes percutáneos guiados por imágenes de los abscesos abdominales alteraron la terapia antimicrobiana en el 7% de los pacientes, que es inferior a la literatura publicada previamente sobre cultivos obtenidos quirúrgicamente. Dada esta baja tasa, similar a la recomendación sobre cultivos obtenidos intraoperatoriamente, no se recomienda el cultivo rutinario de material de drenajes colocados en abscesos abdominales. Consulte Video Resumen en http://links.lww.com/DCR/C64 . (Traducción-Dr. Mauricio Santamaria.
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Affiliation(s)
- Andrew C Esposito
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Yuqi Zhang
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Nupur Nagarkatti
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Nathan A Coppersmith
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Vikram Reddy
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Yale School of Management, Yale University, New Haven, Connecticut
| | - Ira Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anne Mongiu
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Walter Longo
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ritche M Hao
- Section of Infectious Disease, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Haddon Pantel
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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White EM, Esposito AC, Kurbatov V, Wang X, Caty MG, Laurans M, Yoo PS. How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education. J Surg Educ 2022; 79:e181-e193. [PMID: 36253332 DOI: 10.1016/j.jsurg.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/24/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among. SETTING Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals. PARTICIPANTS Clinical faculty within the Department of Surgery. RESULTS A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care. CONCLUSIONS Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.
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Affiliation(s)
- Erin M White
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Vadim Kurbatov
- Yale University School of Medicine, Department of Surgery, Department of Genetics, New Haven, Connecticut
| | - Xujun Wang
- Yale University School of Medicine, Department of Genetics, New Haven, Connecticut
| | - Michael G Caty
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Maxwell Laurans
- Yale University School of Medicine, Department of Neurosurgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut.
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Esposito AC, Brandt WS, Coppersmith NA, White EM, Chung M, Rujeedawa T, Yoo PS. Learning Environment is the Prevailing Factor in Surgical Residents' Favorite Rotations. J Surg Educ 2022; 79:1454-1464. [PMID: 35907699 DOI: 10.1016/j.jsurg.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Understand the characteristics of residents' favorite rotations to improve the ability of educators to maximize positive learning experiences. DESIGN Novel cross-sectional survey developed through thematic analysis of focus groups with residents using 4-point Likert scales ranked from "Not at all important" to "Extremely important." SETTING Single university-affiliated urban hospital PARTICIPANTS: Clinical surgical residents BACKGROUND: Resident assessments of learning experiences vary between rotations leading to the development of "favorite" rotations. MATERIALS AND METHODS A novel survey instrument containing 31 characteristics divided into 4 thematic categories was developed following analysis of surgical resident focus groups. Clinical surgical residents were asked how important each characteristic was for determining their favorite rotation on a 4-point Likert Scale from "not at all important" to "extremely important." Two-sided independent sample T-tests were used. RESULTS The response rate was 59% (33/56) with proportional representation of postgraduate levels. Overall, 67% (22/33) of residents reported their favorite rotation was in their preferred specialty, 70% (23/33) reported their favorite rotation required >70 hours per week in the hospital, and 97% (32/33) of residents reported their favorite rotation required <2 days of clinic. Overall, the average ranking of the categories from most to least important was content (mean = 2.84, SD = 0.48), learning environment (mean = 2.67, SD = 0.57), working environment (mean = 2.38, SD = 0.56), and accomplishment (mean = 2.31, SD = 0.57). The only category with a statistically significant difference between junior and senior resident was content with seniors ranking it most important (mean = 3.35, SD = 0.93) compared to junior residents who ranked it least important (mean = 2.21, SD = 1.25), p = 0.01. Personal characteristics such as "Attendings cared about my learning" (mean = 3.56, SD = 0.50) and "I felt good at my job" (mean = 3.45, SD = 0.67), tended to be more important than structural characteristics such as "call schedule" (mean = 2.71, SD = 0.86), "formal didactics" (mean = 2.67, SD = 1.04), and "work-life balance" (mean = 2.70, SD = 0.99). CONCLUSIONS This study demonstrates a novel understanding of the factors that contribute to resident preferences for certain rotations. Junior and senior residents attribute importance differently, which may provide the basis for level-appropriate improvements. Personal factors tended to be more contributory than structural factors, highlighting additional dimensions to examine when considering how to optimize certain rotations.
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Affiliation(s)
- Andrew C Esposito
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Whitney S Brandt
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Erin M White
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Peter S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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10
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Coppersmith NA, Esposito AC, Yoo PS. The Potential Application of Mindset Theory to Surgical Education. J Surg Educ 2022; 79:845-849. [PMID: 35474256 DOI: 10.1016/j.jsurg.2022.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/24/2022] [Accepted: 03/19/2022] [Indexed: 06/14/2023]
Abstract
Mindset theory proposes that individuals hold a range of beliefs regarding the malleability of attributes such as intellect and skill. Within surgery, mindset theory has been discussed as a way of understanding achievement in both the cognitive and technical aspects of learning surgery. A review of the literature reveals a limited body of research that has addressed the mindsets of surgeons or by extension, tied those mindsets to outcomes. Within health professions education, mindset theory has been studied more broadly, but the benefits of mindset theory are largely assumed and drawn from education research regarding children and adolescents. Though mindset theory has gained traction, there has been debate regarding the traits associated with growth and fixed mindsets. The strongest evidence from primary and secondary education shows that low socioeconomic status and academically at-risk students can benefit the most from mindset interventions, and these findings may extend to surgical learning as well. Mindset theory offers an interesting lens to better understand surgical education, but more research is needed to characterize the mindsets of surgeons and understand how these mindsets influence performance and outcomes.
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Affiliation(s)
- Nathan A Coppersmith
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew C Esposito
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
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11
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Esposito AC, White EM, Rohde SC, Chilakamarry S, Yoo PS. Effect of Surgical Team Communication on Adherence to Opioid Discharge Guidelines in Post-Operative Inpatients. J Surg Educ 2022; 79:740-744. [PMID: 34933817 DOI: 10.1016/j.jsurg.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/17/2021] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Current opioid prescribing guidelines state that post-operative inpatients who do not receive opioids in the 24 hours preceding discharge do not require an opioid prescription on discharge. This study was designed to assess providers' understanding of opioid discharge guidelines and explore drivers of adherence. DESIGN An electronic survey was released which assessed knowledge of opioid discharge guidelines and probed surgical team communication. Kruskal-Wallis tests were used to determine differences between provider types. Spearman's correlation evaluated relationships between estimated and observed adherence to guidelines. SETTING Yale New-Haven Hospital, (tertiary, university-based) PARTICIPANTS: Surgical residents, advanced practice providers (APPs) and attendings who discharged inpatients with opioids between November 2017-August 2019 RESULTS: The response rate was 36% (90/253), including 36% (49/136) of residents, 23% (13/56) of APPs, and 46% (28/61) of attendings. Seventy eight percent of participants believed patients who met the guideline should "never" or "sometimes" receive opioids on discharge. There was a significant difference between attending preferences and what residents (H22 = 202.7, p = 0.0001) and APPs (H22 = 24.6, p = 0.003) believed were the attending's preferences. Eleven percent of attendings preferred their patients to "most of the time" or "always" receive opioids on discharge, while 45% of residents and 54% of APPs reported the same. Overall, 57% of attendings reported they "most of the time" or "always" communicated their discharge preferences while 12% of residents (H22 = -20.4, p = 0.0003) and 8% of APPs (H22 = -23.5, p = 0.003) reported the same. There was no correlation between all groups' estimated adherence to the guidelines and observed adherence (rs = 0.135, p = 0.206). CONCLUSIONS This study demonstrates that surgical residents, APPs, and attendings are aware of the guideline but breakdowns in communication between the attending and the surgical team may contribute to deviation from this guideline. Improving communication may lead to improved adherence to post-operative opioid discharge prescribing guidelines.
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Affiliation(s)
- Andrew C Esposito
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Erin M White
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Peter S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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12
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Esposito AC, Yoo PS, Lipman JM. Video Coaching: A National Survey of Surgical Residency Program Directors. J Surg Educ 2022; 79:708-716. [PMID: 34952818 DOI: 10.1016/j.jsurg.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/16/2021] [Accepted: 11/27/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Video coaching has been demonstrated to improve resident and attending skills and is overwhelmingly well received by the participants. However, misperceptions about its utility among those who do not use video coaching may be a barrier to widespread implementation. DESIGN Cross-sectional web-based survey SETTING: National survey PARTICIPANTS: Surgical program director members of the Association of Program Directors of Surgery STUDY DESIGN: The survey was developed via a deductive approach after a literature review and was piloted with surgical attendings and residents. All Likert scale were averaged and comparisons between groups was performed via independent t-tests. RESULTS There were 52 responses from PDs. 27/52(51.9%) PDs reported their program supported video coaching of residents. PDs from residences with video coaching programs were more likely to believe that video coaching was useful in identifying their own strengths and weakness (p = 0.005), was a useful adjunct for resident feedback (p = 0.024), and a personal library of video recordings would be helpful (p = 0.015) when compared to PDs from residencies without video coaching. Programs without video coaching were more likely to believe barriers to implementation included it being ineffective (p = 0.024) and that the technology was unavailable (p = 0.006). Over 50% of respondents from both groups believed expense, difficulty with set up, time required, and patient privacy were "Very" or "Extremely" likely to be barriers to implementation. CONCLUSIONS This is the first national survey of PDs regarding the use of video coaching. Residency programs without video coaching may underestimate the utility of video coaching in training surgical residents.
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Affiliation(s)
- Andrew C Esposito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
| | - Peter S Yoo
- Yale School of Medicine, Department of Surgery, Division of Transplant Surgery, New Haven, Connecticut
| | - Jeremy M Lipman
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
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13
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Esposito AC, Coppersmith NA, White EM, Yoo PS. Video Coaching in Surgical Education: Utility, Opportunities, and Barriers to Implementation. J Surg Educ 2022; 79:717-724. [PMID: 34972670 DOI: 10.1016/j.jsurg.2021.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/30/2021] [Accepted: 12/04/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE This review discusses the literature on Video-Based Coaching (VBC) and explores the barriers to widespread implementation. DESIGN A search was performed on Scopus and PubMed for the terms "operation," "operating room," "surgery," "resident," "house staff," "graduate medical education," "teaching," "coaching," "assessment," "reflection," "camera," and "video" on July 27, 2021, in English. This yielded 828 results. A single author reviewed the titles and abstracts and eliminated any results that did not pertain to operative VBC or assessment. All bibliographies were reviewed, and appropriate manuscripts were included in this study. This resulted in a total of 52 manuscripts included in this review. SETTING/PARTICIPANTS Original, peer-reviewed studies focused on VBC or assessment. RESULTS VBC has been both subjectively and objectively found to be a valuable educational tool. Nearly every study of video recording in the operating room found that subjects, including surgical residents and seasoned surgeons alike, overwhelmingly considered it a useful, non-redundant adjunct to their training. Most studies that evaluated skill acquisition via standardized assessment tools found that surgical residents who underwent a VBC program had significant improvements compared to their counterparts who did not undergo video review. Despite this evidence of effectiveness, fewer than 5% of residency programs employ video recording in the operating room. Barriers to implementation include significant time commitments for proposed coaching curricula and difficulty with integration of video cameras into the operating room. CONCLUSIONS VBC has significant educational benefits, but a scalable curriculum has not been developed. An optimal solution would ensure technical ease and expediency, simple, high-quality cameras, immediate review, and overcoming entrenched surgical norms and culture.
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Affiliation(s)
- Andrew C Esposito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | | | - Erin M White
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
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14
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Papageorge MV, DeWane MP, Esposito AC, Oliveira K, Longo W, Yoo PS. Making leadership a priority in surgical residency. Am J Surg 2022; 224:641-642. [DOI: 10.1016/j.amjsurg.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/07/2021] [Accepted: 01/19/2022] [Indexed: 11/26/2022]
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15
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Esposito AC, Lipman JM. Video Coaching: A National Survey of Surgical Residency Program Directors. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Esposito AC, Jacobs D, Olino K. ASO Author Reflections: The Utility of Overall Survival as an Outcome in the Study of Merkel Cell Carcinoma. Ann Surg Oncol 2021; 29:425-426. [PMID: 34523003 DOI: 10.1245/s10434-021-10791-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Andrew C Esposito
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel Jacobs
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kelly Olino
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
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17
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White EM, Rohde SC, Ruzgar NM, Chan SM, Esposito AC, Oliveira KD, Yoo PS. Characterizing the social media footprint of general surgery residency programs. PLoS One 2021; 16:e0253787. [PMID: 34191853 PMCID: PMC8244871 DOI: 10.1371/journal.pone.0253787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/14/2021] [Indexed: 12/15/2022] Open
Abstract
Background The medical community has increasingly embraced social media for a variety of purposes, including trainee education, research dissemination, professional networking, and recruitment of trainees and faculty. Platform choice and usage patterns appear to vary by specialty and purpose, but few studies comprehensively assess programs’ social media presence. Prior studies assessed general surgery departments’ Twitter use but omitted additional social media platforms and residency-specific accounts. Objective This study sought to broadly characterize the social media footprint of U.S. general surgery residency programs. Methods Using a protocolized search of program websites, social media platforms (Twitter, Facebook, Instagram, LinkedIn), and internet search, cross-sectional data on social media usage in March 2020 were collected for programs, their affiliated departments, their program directors (PDs), and their assistant/associate PDs (APDs). Results 318 general surgery residency programs, 313 PDs, and 296 APDs were identified. 47.2% of programs had surgery-specific accounts on ≥1 platform. 40.2% of PDs and APDs had ≥1 account on Twitter and/or LinkedIn. Program type was associated with social media adoption and Twitter utilization, with lower usage among university-affiliated and independent programs (p<0.01). Conclusions Most general surgery residencies, especially non-university-based programs, lacked any department or residency accounts across Twitter, Facebook, and Instagram by March 2020. These findings highlight opportunities for increased social media engagement and act as a pre-pandemic baseline for future investigations of how the shift to virtual trainee education, recruitment, conferences, and clinical care affect social media use.
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Affiliation(s)
- Erin M. White
- Department of Surgery, Yale University, New Haven, Connecticut, United States of America
| | - Stefanie C. Rohde
- School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Nensi M. Ruzgar
- School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Shin Mei Chan
- School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Andrew C. Esposito
- Department of Surgery, Yale University, New Haven, Connecticut, United States of America
| | - Kristin D. Oliveira
- Department of Surgery, Yale University, New Haven, Connecticut, United States of America
| | - Peter S. Yoo
- Department of Surgery, Yale University, New Haven, Connecticut, United States of America
- * E-mail:
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18
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White EM, Shaughnessy MP, Esposito AC, Slade MD, Korah M, Yoo PS. Surgical Education in the Time of COVID: Understanding the Early Response of Surgical Training Programs to the Novel Coronavirus Pandemic. J Surg Educ 2021; 78:412-421. [PMID: 32768380 PMCID: PMC7381939 DOI: 10.1016/j.jsurg.2020.07.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/21/2020] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Describe the early impact of the COVID-19 pandemic on general surgery residency training nationwide. DESIGN A 31-question electronic survey was distributed to general surgery program directors. Qualitative data underwent iterative coding analysis. Quantitative data were evaluated with summary statistics and bivariate analyses. PARTICIPANTS Eighty-four residency programs (33.6% response rate) with representation across US geographic regions, program affiliations, and sizes. RESULTS Widespread changes were observed in the surgical training environment. One hundred percent of programs reduced the number of residents on rounds and 95.2% reduced the size of their in-hospital resident workforce; on average, daytime staffing decreased by nearly half. With telehealth clinics (90.5%) and remote inpatient consults (26.2%), both clinical care and resident didactics (86.9%) were increasingly virtual, with similar impact across all program demographics. Conversely, availability of some wellness initiatives was significantly higher among university programs than independent programs, including childcare (51.2% vs 6.7%), housing (41.9% vs 13.3%), and virtual mental health services (83.7% vs 53.3%). CONCLUSIONS Changes in clinical care delivery dramatically reduced in face-to-face learning opportunities for surgical trainees during the COVID-19 pandemic. While this effect had equal impact across all program types, sizes, and geographies, the same cannot be said for wellness initiatives. Though all programs initiated some strategies to protect resident health, the disparity between university programs and independent programs may be cause for action.
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Affiliation(s)
- Erin M White
- Department of Surgery, Yale University, New Haven, Connecticut
| | | | | | - Martin D Slade
- Occupational Health & Environmental Medicine, Yale University, New Haven, Connecticut
| | - Maria Korah
- School of Medicine, Yale University, New Haven, Connecticut; Department of Surgery, Stanford University, Stanford, California
| | - Peter S Yoo
- Department of Surgery, Yale University, New Haven, Connecticut.
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19
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White EM, Miller SM, Esposito AC, Yoo PS. "Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent. J Surg Educ 2020; 77:e47-e51. [PMID: 32753261 DOI: 10.1016/j.jsurg.2020.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations. DESIGN This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature. CONCLUSIONS We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.
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Affiliation(s)
- Erin M White
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
| | - Samuel M Miller
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
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20
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Ward WH, Goel N, Ruth KJ, Esposito AC, Lambreton F, Sigurdson ER, Meyer JE, Farma JM. Predictive Value of Leukocyte- and Platelet-Derived Ratios in Rectal Adenocarcinoma. J Surg Res 2018; 232:275-282. [PMID: 30463730 DOI: 10.1016/j.jss.2018.06.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/30/2018] [Accepted: 06/19/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Advances in treatment of rectal cancer have improved survival, but there is variability in response to therapy. Recent data suggest the utility of the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in predicting survival. Our aim was to examine these ratios in rectal cancer patients and determine whether any association exists with overall survival (OS). METHODS Using prospectively maintained institutional data, a query was completed for clinical stage II-III rectal adenocarcinoma patients treated from 2002 to 2016. We included patients who had a complete blood count collected before neoadjuvant chemoradiation (pre-CRT) and again before surgery (post-CRT). The LMR, NLR, and PLR were calculated for the pre-CRT and post-CRT time points. Potential cutpoints associated with OS differences were determined using maximally selected rank statistics. Survival curves were compared using log-rank tests and were adjusted for age and stage using Cox regression. RESULTS A total of 146 patients were included. Cutpoints were significantly associated with OS for pre-CRT ratios but not for post-CRT ratios. Within the pretreatment group, a "low" (<2.86) LMR was associated with decreased OS (log-rank P = 0.004). In the same group, a "high" (>4.47) NLR and "high" PLR (>203.6) were associated with decreased OS (log-rank P < 0.001). With covariate adjustment for age, and separately for final pathologic stage, the associations between OS and LMR, NLR, and PLR each retained statistical significance. CONCLUSIONS If obtained before the start of neoadjuvant chemoradiation, LMR, NLR, and PLR values are accurate predictors of 5-y OS in patients with locally advanced rectal adenocarcinoma.
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Affiliation(s)
- William H Ward
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| | - Neha Goel
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Karen J Ruth
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Andrew C Esposito
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Fernando Lambreton
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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21
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Esposito AC, Crawford J, Sigurdson ER, Handorf EA, Hayes SB, Boraas M, Bleicher RJ. Omission of radiotherapy after breast conservation surgery in the postneoadjuvant setting. J Surg Res 2017; 221:49-57. [PMID: 29229152 DOI: 10.1016/j.jss.2017.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 08/01/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Breast conservation therapy (BCT) consists of breast conservation surgery (BCS) and radiotherapy (RT). Neoadjuvant chemotherapy (NACT) can downstage tumors, broadening BCS eligibility in patients requiring mastectomy. However, tumor downstaging does not obviate need for RT. This study evaluated factors that predict RT omission after NACT and BCS. METHODS The National Cancer Database was queried for women with unilateral, clinical stage II-III breast cancer, treated with NACT and BCS between 2008 and 2012. Patients not receiving RT after NACT and BCS were identified. A subgroup analysis was performed eliminating patients for whom RT was recommended but not received. RESULTS Among 10,220 patients meeting study eligibility, 974 (9.53%) did not receive RT after BCS. Predictors of RT omission included older age, insurance status, facility type, facility region, more recent year of diagnosis, receptor status unknown, human epidermal growth factor receptor 2 status positive or unknown, and positive margins. Factors increasing the likelihood of RT receipt included cN3 disease, receptor positivity, and primary downstaging. Race, Hispanicity, education, income, comorbidities, rural versus urban setting, histology, grade, and nodal stage change were not associated with RT omission. When excluding the 314 patients for whom RT was recommended but not received, age, Medicaid insurance, facility type, facility region, receptor status unknown, human epidermal growth factor receptor 2 status unknown, and positive margins were predictors of RT omission. CONCLUSIONS Race, comorbidities, and socioeconomic status were not predictors of RT omission. It remains unclear whether omission of RT in some cases is due to lack of physician knowledge. Further efforts are needed to ensure that physicians and patients recognize that RT is a vital and required part of BCT, even after NACT.
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Affiliation(s)
- Andrew C Esposito
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - James Crawford
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elin R Sigurdson
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elizabeth A Handorf
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Shelly B Hayes
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Marcia Boraas
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard J Bleicher
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
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22
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Oh KJ, Savulionyte GE, Uohara MY, Owen-Simon NL, Esposito AC, Dachert SR, Das A, Strauss DM. Analysis of Malpractice Litigation and Ethics in Medical Student Education: Results from Four National Legal Databases. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Esposito AC. Surgical management of a free-floating iris cyst in the anterior chamber. Am J Ophthalmol 1965; 60:924-5. [PMID: 5844920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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25
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