Perceived stress from social isolation or loneliness among clinical and non-clinical healthcare workers during COVID-19

BACKGROUND

Workplace social isolation and loneliness have been found to result in a decline in job satisfaction and an increase in burnout among working individuals. The COVID-19 pandemic exacerbated feelings of loneliness and social isolation among healthcare workers. The majority of research on healthcare worker experiences is conducted in siloes which does not reflect the shared experiences of interprofessional teams. The purpose of this study is to understand stress from social isolation or loneliness across the entire clinical and non-clinical healthcare team over the course of the pandemic.

METHODS

Data was acquired using a cross-sectional survey distributed to healthcare workers once a year at a large academic medical center in the Southeastern United States during the COVID-19 pandemic (2020-2022). Information pertaining to job role, work location, and demographic factors was collected. Participants were also asked to assess individual well-being and resilience, in addition to reporting stress derived from various sources including job demands and social isolation or loneliness. Descriptive statistics and bivariate analyses were conducted to assess the association between stress from social isolation or loneliness and individual characteristics.

RESULTS

Stress from social isolation or loneliness was found to decrease over the survey period across all measured variables. Trainees and physician-scientists were found to report the highest rates of this stressor compared to other job roles, while Hospital-Based ICU and Non-ICU work locations reported the highest rates of loneliness and social isolation stress. Younger workers and individuals from marginalized gender and racial groups were at greater risk for stress from social isolation or loneliness.

CONCLUSIONS

Given the importance of social connections for well-being and job performance, organizations have a responsibility to create conditions and mechanisms to foster social connections. This includes establishing and reinforcing norms of behavior, and developing connection mechanisms, particularly for groups at high risk of loneliness and social isolation.

Don't Go: Examining the Relationships Between Meaning, Work Environment and Turnover Intention Across the Entire Healthcare Team

Introduction

Healthcare workers tend to have a strong sense of altruism in their work, which may be protective against turnover despite poor working conditions. Due to the increased distress noted during the pandemic, the challenges of working in healthcare and changing attitudes about work may have surpassed the protective effect of meaning and purpose in work. This study empirically examines perceived meaning in work, and specific work-related factors that contribute to employees' intent to stay and to recommend working at the organization to others as COVID-19 transitions from a pandemic to endemic phase.

Methods

Data from a survey of 4451 clinical and non-clinical healthcare workers were analyzed using regression and dominance analyses to identify specific predictors of turnover intention and net promoter score.

Results

The variables that explained the greatest contribution to variance in turnover intention from highest to lowest were burnout, trust and confidence in senior leadership, perceived organizational support, sense of belonging, and sense of recognition. The variables that explained the greatest overall contribution to variance for net promoter score from highest to lowest were perceived organizational support, trust and confidence in senior leadership, resource availability, sense of recognition, and sense of belonging. While meaning in work was associated with turnover intent, organizational and team level factors such as trust and belonging were more predictive of the outcomes.

Discussion

While meaning and purpose are important job resources, they are not sufficient to retain employees in the absence of trust, organizational support, belonging, recognition and access to necessary resources. Leaders must seek to foster environments that support trust, belonging and recognition in their retention efforts.

The Impact of a Job Crafting Intervention on Wellbeing in Health Care Leaders

BACKGROUND

Job Crafting is a strategy undertaken by highly motivated individuals to modify their own work. Educating individuals about the benefits of this approach has recently been explored in other professions as a wellbeing intervention.

OBJECTIVE

We aimed to demonstrate that a Job Crafting intervention for health care leaders would result in improved wellbeing, lower burnout, and enhanced job resources.

METHODS

Fourteen health care leaders across 6 departments at one academic medical center participated in a two-part workshop on Job Crafting between January 1, 2019 and December 31, 2020. Participants completed electronic surveys before and 4-6 weeks after the sessions. Pre- and post-intervention scores were compared using Wilcoxon signed rank sum tests.

RESULTS

Eighty-six percent of participants stated the sessions were useful and applicable to their jobs, with 93% stating they were a valuable use of time and would recommend sessions to others. Participant Job Crafting behaviors increased following the intervention, with 46% increasing structural and social resources (P = .03) and 85% decreasing Hindrance Demands (P = .02). Increased meaning in work was identified by 38% post-intervention (P = .04). No statistically significant differences were identified in Distress Scores at high risk for burnout pre- and post-intervention (86% for both), but 30% of participants had an absolute improvement (decrease) in their Distress Score.

CONCLUSIONS

A Job Crafting intervention was associated with high rates of satisfaction among participants and was successful in increasing Job Crafting behaviors and perceptions of meaningful work, but did not result in a change in risk for burnout in the short follow-up period.

The Pittman Scholar Program for junior faculty recognition at the University of Alabama at Birmingham Heersink School of Medicine

The University of Alabama at Birmingham Heersink School of Medicine established the Pittman Scholars Program in 2015 to elevate scientific impact and to support the recruitment and retention of highly competitive junior faculty. The authors examined the impact of this program on research productivity and on faculty retention. The authors evaluated publications and extramural grant awards and available demographic data for the Pittman Scholars compared to all junior faculty in the Heersink School of Medicine. From 2015 to 2021, the program awarded a diverse group of 41 junior faculty members across the institution. For this cohort, ninety-four new extramural grants were awarded and 146 grant applications were submitted since the inception of the scholar award. Pittman Scholars published a total of 411 papers during the term of the award. The faculty retention rate of the scholars was 95%, comparable to that of all Heersink junior faculty, with 2 recipients being recruited to other institutions. The implementation of the Pittman Scholars Program has been an effective strategy to celebrate scientific impact and acknowledge junior faculty members as outstanding scientists at our institution. The Pittman Scholars award allows junior faculty to use funds for their research program, publications, collaborations, and career advancement. The Pittman Scholars are recognized at local, regional, and national levels for the work they are contributing to academic medicine. The program has served as an important pipeline faculty development program and an avenue for individual recognition for research-intensive faculty.

Burnout, Moral Distress, and Compassion Fatigue as Correlates of Posttraumatic Stress Symptoms in Clinical and Nonclinical Healthcare Workers

GOAL

Research has highlighted psychological distress resulting from the COVID-19 pandemic on healthcare workers (HCWs), including the development of posttraumatic stress symptoms (PTSS). However, the degree to which these conditions have endured beyond the pandemic and the extent to which they affect the entire healthcare team, including both clinical and nonclinical workers, remain unknown. This study aims to identify correlates of PTSS in the entire healthcare workforce with the goal of providing evidence to support the development of trauma-informed leadership strategies.

METHODS

Data were collected from June to July 2022 using a cross-sectional anonymous survey in a large academic medical center setting. A total of 6,466 clinical and nonclinical employees completed the survey (27.3% response rate). Cases with at least one missing variable were omitted, for a total sample size of 4,806, the evaluation of which enabled us to understand individual, organizational, and work-related and nonwork-related stressors associated with PTSS. Data were analyzed using ordinal logistic regression and dominance analyses to identify predictors of PTSS specific to clinical and nonclinical workers.

PRINCIPAL FINDINGS

While previous studies have shown that HCWs in different job roles experience unique stressors, our data indicate that the top correlates of PTSS among both clinical and nonclinical HCWs are the same: burnout, moral distress, and compassion fatigue. These three factors alone explained 45% and 44.4% of the variance in PTSS in clinical and nonclinical workers, respectively. PTSS was also associated with a lower sense of recognition and feeling mistreated by other employees at work in the clinical workforce. Concerningly, women and sexual minorities in the clinical sample exhibited a higher incidence of PTSS. In nonclinical workers, social isolation or loneliness and lower trust and confidence in senior leadership were associated with PTSS. Nonwork-related factors, such as exhaustion from caregiving responsibilities and financial strain, were also significantly associated with PTSS. Even after controlling for discrimination at and outside of work in both samples, we found that non-White populations were more likely to experience PTSS, highlighting a deeply concerning issue in the healthcare workforce.

PRACTICAL APPLICATIONS

The primary objective of this article is to help healthcare leaders understand the correlates of PTSS across the entire healthcare team as organizations recover from the COVID-19 pandemic. Understanding which factors are associated with PTSS will help healthcare leaders develop best practices that aim to reduce HCW distress and strategies to circumvent trauma derived from future crises. Our data indicate that leaders must address the correlates of PTSS in the workforce, focusing attention on both those who work on the frontlines and those who work behind the scenes. We urge leaders to adopt a trauma-informed leadership approach to ensure that the entire healthcare workforce is recognized, supported, and cared for as each HCW plays a unique role in the care of patients.

Feeling safe versus being safe: Perceptions of safety versus actual disease exposure across the entire health care team

As supply chains experienced disruptions early in the COVID-19 pandemic, personal protective equipment (PPE) quickly became scarce. The purpose of this study was to examine the impact of perceptions of inadequate PPE, fear of COVID-19 infection, and self-reported direct COVID-19 exposure on health care workers. Data to assess distress, resilience, social-ecological factors, and work and nonwork-related stressors were collected from June to July 2020 at a large medical center. Stressors were analyzed by role using descriptive statistics and multivariate regression analysis. Our data indicate that job role influenced fear of infection and perceptions of inadequate PPE in the early phase of the COVID-19 pandemic. Perceived organizational support was also related to perceptions of inadequate PPE supply. Interestingly, work location, rather than job role, was predictive of direct COVID-19 exposure. Our data highlight a disconnect between the perception of safety in the health care setting with real risk of exposure to infectious disease. This study suggests that leaders in health care should focus on cultivating supportive organizational cultures, assessing both perceived and actual safety, and provide adequate training in safety practices may improve preparedness and organizational trust during times of both certainty and crisis particularly for clinical workers with less education and training.

Navigating Minority and Gender Discrimination, Substance Use Disorder, Financial Distress, and Workplace Politics: Lessons for Work-Life Wellness in Academic Medicine: Part 2 of 3

In this second of three manuscripts addressing a range of complex work and personal issues, the authors explore case scenarios with characters who work in the fields of general surgery, orthopedic surgery, anesthesiology, neurology, radiology, and otolaryngology. The medical specialty identifiers help inform some baseline understanding of the demands of that particular profession but are less pertinent than the specifics of each case. In this manuscript, the authors dive into the topics of navigating a lawsuit and professional burnout, personal finances, substance use disorder, demands of clinical work and workplace politics, diversity and inclusion, and dealing with major personal illness. The authors provide practical steps to help the readers deal with similar situations and provide insight to support persons on how to improve support structures.

Still Exhausted: The Role of Residual Caregiving Fatigue on Women in Medicine and Science Across the Pipeline

Understanding the impact of caregiving responsibilities on women in medicine is crucial for ensuring a healthy and intact workforce, as caregiving responsibilities have the potential to affect the careers of women in health care along the entire pipeline, from students and trainees to physicians, physician-scientists, and biomedical researchers.

An Investigation of Organizational Correlates of Distress in Non-Clinician Biomedical Researchers in the United States

Purpose

Challenges ushered by the COVID-19 pandemic led to an increased focus on the mental well-being of the healthcare workforce. Despite the important contribution non-clinician biomedical researchers make to the mission of academic medical centers, the well-being of this unique population remains understudied in the United States. The purpose of this study was to examine the individual and organizational correlates of distress among non-clinician biomedical researchers.

Methods

A survey was delivered to employees of a large academic medical center in the southeastern United States, including non-clinician biomedical researchers. Participants were asked to assess their own well-being using the validated Well-Being Index (WBI) tool, resilience, work and nonwork-related stressors and demographic descriptors. Descriptive statistics and bivariate analyses were conducted, and binary logistic regression was used to examine predictors of increased odds of overall distress.

Results

Nearly 44% of surveyed non-clinician biomedical researchers met the threshold for high distress which indicates an increased risk of suicidal ideation, turnover intention, and burnout. The major correlates of distress were at the organizational level, including perceived organizational support (OR 0.79, 95% CI 0.70-0.90), heavy workload and long hours (OR 3.25, 95% CI 1.53-6.88), inability or lack of support to take time off (OR 2.80, 95% CI 1.03-7.66) and conflict with supervisor (OR 5.03, 95% CI 1.13-22.1). While lower individual resilience (OR 0.69, 95% CI 0.54-0.88) was statistically significantly associated with greater distress, it accounted for less than 10% of the overall variance when controlling for other work-related factors.

Conclusion

These findings suggest that developing organizational interventions that address institutional support for non-clinician biomedical researchers within academic medical centers represents an important opportunity to reduce distress within this population. While emphasizing individual resiliency as an important in the pursuit of well-being, it is also the responsibility of the organization to create and foster an environment in which employees can access their own resilience.

AD Informer Set: Chemical tools to facilitate Alzheimer's disease drug discovery

Introduction

The portfolio of novel targets to treat Alzheimer's disease (AD) has been enriched by the Accelerating Medicines Partnership Program for Alzheimer's Disease (AMP AD) program.

Methods

Publicly available resources, such as literature and databases, enabled a data-driven effort to identify existing small molecule modulators for many protein products expressed by the genes nominated by AMP AD and suitable positive control compounds to be included in the set. Compounds contained within the set were manually selected and annotated with associated published, predicted, and/or experimental data.

Results

We built an annotated set of 171 small molecule modulators targeting 98 unique proteins that have been nominated by AMP AD consortium members as novel targets for the treatment of AD. The majority of compounds included in the set are inhibitors. These small molecules vary in their quality and should be considered chemical tools that can be used in efforts to validate therapeutic hypotheses, but which will require further optimization. A physical copy of the AD Informer Set can be requested on the Target Enablement to Accelerate Therapy Development for Alzheimer's Disease (TREAT-AD) website.

Discussion

Small molecules that enable target validation are important tools for the translation of novel hypotheses into viable therapeutic strategies for AD.

Physician, Nurse, and Advanced Practice Provider Perspectives on the Rapid Transition to Inpatient and Outpatient Telemedicine

Background: Many health systems transitioned rapidly to using inpatient and outpatient telemedicine during the COVID-19 pandemic. Prior research has examined clinician satisfaction and experiences with telemedicine in a siloed approach for specific provider types. Less is known about how experiences with the rapid transition to telemedicine affected the entire clinical team, and how this contributed to their overall distress. Methods: A survey was conducted within a large academic medical center in the Southeastern United States during June of 2020. The survey asked about experiences with inpatient and outpatient telemedicine and overall distress. Analysis of variance was calculated to examine differences in experiences among physicians, nurses, and advanced practice providers (APPs) with both inpatient and outpatient telemedicine. Multivariate regression analysis was conducted to determine whether reported telemedicine stressors were associated with changes in overall distress scores. Qualitative comments provided during the survey were included to illustrate the quantitative findings. Results: Of the 1130 survey respondents, 237 indicated that they used telemedicine. Telemedicine use was not statistically significantly associated with overall distress scores. The APPs indicated the greatest satisfaction with telemedicine, followed by physicians and then nurses. Team members differed on their perceptions of quality of care and safety for inpatient and outpatient telemedicine. Physicians (70%) and APPs (64%) felt safer having the option to use inpatient telemedicine, whereas only 26% of nurses reported the same. Overall, >70% of physicians and APPs would like to continue having the option to use inpatient and outpatient telemedicine in the future, whereas <50% of nurses reported the same. Discussion: These results suggest that telemedicine holds promise for providing care beyond the pandemic, and it may be a mechanism to improve flexibility, autonomy, and expand patient access. Implementation of new technologies must consider the experiences of the entire team, rather than a siloed approach to determining satisfaction with the changes.

Identification of Leadership Behaviors that Impact General Surgery Junior Residents' Well-being: A Needs Assessment in a Single Academic Center

OBJECTIVE

Emerging literature has started to link leadership with the well-being of team members; however, this link during residency training has not been studied. The objective of this study was to perform a needs assessment to identify leadership behaviors among senior residents and evaluate the impact that these behaviors have on junior residents' well-being.

DESIGN

A semi-structured question script was developed and ∼60 minute virtual focus groups were held during protected educational time, until data saturation was reached. Data analysis was performed in the tradition of grounded theory.

SETTING

This study was performed at Oregon Health & Science University, one of the largest general surgery programs.

PARTICIPANTS

Participants enrolled in the general surgery residency program from July 2020 to February 2021 were included. 35 general surgery residents participated in the focus groups.

RESULTS

Two major themes resulted from the data analysis: (1) Effective leadership behaviors and their positive consequences, and (2) Ineffective leadership behaviors and their negative consequences. Effective and ineffective leadership were characterized by the presence or absence of 6 main behaviors: supportive and empowering, team building, management skills, emotional intelligence, effective communication, and teaching. Effective and ineffective leadership positively and negatively impacted residents' well-being, individual growth, and psychological safety.

CONCLUSIONS

The results from this study identified leadership behaviors from senior residents and demonstrated that those behaviors have a significant short-term and long-term positive and negative impact on junior residents' well-being. These results fill a gap in the literature, and can serve as a guide for surgical educators to develop evidence-based leadership curricula.

Use of AD Informer Set compounds to explore validity of novel targets in Alzheimer's disease pathology

Introduction

A chemogenomic set of small molecules with annotated activities and implicated roles in Alzheimer's disease (AD) called the AD Informer Set was recently developed and made available to the AD research community: https://treatad.org/data‐tools/ad‐informer‐set/.

Methods

Small subsets of AD Informer Set compounds were selected for AD‐relevant profiling. Nine compounds targeting proteins expressed by six AD‐implicated genes prioritized for study by Target Enablement to Accelerate Therapy Development for Alzheimer's Disease (TREAT‐AD) teams were selected for G‐protein coupled receptor (GPCR), amyloid beta (Aβ) and tau, and pharmacokinetic (PK) studies. Four non‐overlapping compounds were analyzed in microglial cytotoxicity and phagocytosis assays.

Results

The nine compounds targeting CAPN2, EPHX2, MDK, MerTK/FLT3, or SYK proteins were profiled in 46 to 47 primary GPCR binding assays. Human induced pluripotent stem cell (iPSC)‐derived neurons were treated with the same nine compounds and secretion of Aβ peptides (Aβ40 and Aβ42) as well as levels of phosphophorylated tau (p‐tau, Thr231) and total tau (t‐tau) peptides measured at two concentrations and two timepoints. Finally, CD1 mice were dosed intravenously to determine preliminary PK and/or brain‐specific penetrance values for these compounds. As a final cell‐based study, a non‐overlapping subset of four compounds was selected based on single‐concentration screening for analysis of both cytotoxicity and phagocytosis in murine and human microglia cells.

Discussion

We have demonstrated the utility of the AD Informer Set in the validation of novel AD hypotheses using biochemical, cellular (primary and immortalized), and in vivo studies. The selectivity for their primary targets versus essential GPCRs in the brain was established for our compounds. Statistical changes in tau, p‐tau, Aβ40, and/or Aβ42 and blood–brain barrier penetrance were observed, solidifying the utility of specific compounds for AD. Single‐concentration phagocytosis results were validated as predictive of dose–response findings. These studies established workflows, validated assays, and illuminated next steps for protein targets and compounds.

Returning to Growth: One Academic Medical Center's Successful Five-Step Approach to Change Management

The University of Alabama at Birmingham academic medical center (UAB AMC) had achieved great success and growth during the 50 years since its founding. However, the challenging and more competitive environment of the 2000s left the UAB AMC on a downward trajectory. The UAB AMC had to overcome difficult internal cultural and structural barriers that stood in the way of the transformational change needed to remain competitive. Competition rather than collaborative and strategic financial investment were the primary cultural barriers for the UAB AMC, while people were the primary structural barrier. Leadership identified 5 steps that were critical for the transformation that occurred between 2013 and 2018: alignment of leadership; creating a compelling and credible shared vision; identifying cultural and structural barriers; creating a thoughtful, data-driven intervention; and improved communication and accountability. Following these steps enabled the UAB AMC to transform its institutional structure and culture. As a result, the UAB AMC thrived, returning to substantial growth in research and clinical care. UAB AMC School of Medicine grew by $100 million in National Institutes of Health funding and moved up 10 spots in ranking. In 2018, UAB Hospital had 10 specialties ranked by U.S. News & World Report, 7 more than in 2013. This article outlines the approach taken and provides a conceptual framework for other AMCs eager to transform their structure and culture and position themselves for growth.

Trending diversity: Reviewing four-decades of graduating fellows and the current leadership in pediatric surgery

PURPOSE

Diversity in the physician workforce remains a priority in healthcare as it has been shown to improve outcomes. Decisions for choosing specific fields in medicine are partly influenced by mentors, which tend to be the same sex or ethnicity. Females are starting to outnumber males in medical school and minorities are targeted for recruitment. We hypothesized that diversity in pediatric surgery has increased over time.

METHODS

The recently published A Genealogy of North American Pediatric Surgery was utilized to identify graduating pediatric surgery fellows from 1981 to 2018. Organization websites were used to identify past and current leaders. A web-based analysis, including online facial recognition software, was performed. A year-to-year and decade-to-decade demographic comparison was completed.

RESULTS

1217 pediatric surgery fellows graduated between 1981 and 2018. When comparing graduates from the first and last decades, an increase from 16.9% to 39.5% for female graduates was observed (p = 0.046). A significant increase in nonwhite graduates was seen for all races (p < 0.05). Representation in leadership was White and male dominant.

CONCLUSION

There was a significant increase in diversity in pediatric surgery fellowship graduates. There were increasing trends in female graduates and all nonwhite racial groups. Focusing on enhancing the pipeline and mentoring underrepresented minorities will continue to enhance this trend for the field of pediatric surgery.

LEVEL OF EVIDENCE

III; Retrospective Review.

Perforated Appendicitis during a Pandemic: The Downstream Effect of COVID-19 in Children

Introduction

Coronavirus Disease-19 (COVID-19) was declared a pandemic in March 2020. States issued stay-at-home orders and hospitals cancelled non-emergent surgeries. During this time, we anecdotally noticed more admissions for perforated appendicitis. Therefore, we hypothesized that during the months following the COVID-19 pandemic declaration, more children were presenting with perforated appendicitis.

Materials and Methods

This is a retrospective cohort study reviewing pediatric patients admitted at a single institution with acute and/or perforated appendicitis between October 2019 to May 2020. Interval appendectomies were excluded. COVID-19 months were designated as March, April, and May 2020. Additional analysis of March, April, and May 2019 was performed for comparison purposes. Analyzed data included demographics, symptoms, white blood cell count, imaging findings, procedures performed, and perforation status. Statistical analysis was performed.

Results

During the study period, 285 patients were admitted with the diagnosis of acute appendicitis with 95 patients being perforated. We identified a significant increase in perforated appendicitis cases in the three COVID-19 months compared with the preceding five months (45.6% vs 26.4%; P <0.001). In addition, a similar significant increase was identified when comparing to the same months a year prior (P = 0.003). No significant difference in duration of pain was identified (P=0.926).

Conclusion

The COVID-19 pandemic and its associated stay-at-home orders have had downstream effects on healthcare. Our review has demonstrated a significant increase in the number of children presenting with perforated appendicitis following these stay-at-home ordinances. These results demonstrate that further investigations into the issues surrounding access to healthcare, especially during this pandemic, are warranted.

PhI(OAc)2 and iodine-mediated synthesis of N-alkyl sulfonamides derived from polycyclic aromatic hydrocarbon scaffolds and determination of their antibacterial and cytotoxic activities

The development of new approaches toward chemo- and regioselective functionalization of polycyclic aromatic hydrocarbon (PAH) scaffolds will provide opportunities for the synthesis of novel biologically active small molecules that exploit the high degree of lipophilicity imparted by the PAH unit. Herein, we report a new synthetic method for C-X bond substitution that is speculated to operate via a N-centered radical (NCR) mechanism according to experimental observations. A series of PAH sulfonamides have been synthesized and their biological activity has been evaluated against Gram-negative and Gram-positive bacterial strains (using a BacTiter-Glo assay) along with a series of mammalian cell lines (using CellTiter-Blue and CellTiter-Glo assays). The viability assays have resulted in the discovery of a number of bactericidal compounds that exhibit potency similar to other well-known antibacterials such as kanamycin and tetracycline, along with the discovery of a luciferase inhibitor. Additionally, the physicochemical and drug-likeness properties of the compounds were determined experimentally and using in silico approaches and the results are presented and discussed within.

Healthcare is a Team Sport: Stress, Resilience, and Correlates of Well-Being Among Health System Employees in a Crisis

EXECUTIVE SUMMARY

While the COVID-19 pandemic has added stressors to the lives of healthcare workers, it is unclear which factors represent the most useful targets for interventions to mitigate employee distress across the entire healthcare team. A survey was distributed to employees of a large healthcare system in the Southeastern United States, and 1,130 respondents participated. The survey measured overall distress using the 9-item Well-Being Index (WBI), work-related factors, moral distress, resilience, and organizational-level factors. Respondents were also asked to identify major work, clinical, and nonwork stressors. Multivariate regression was used to evaluate associations between employee characteristics and WBI distress score. Overall, 82% of employees reported high distress (WBI ≥ 2), with nurses, clinical support staff, and advanced practice providers reporting the highest average scores. Factors associated with higher distress included increased job demands or responsibilities, heavy workload or long hours, higher frequency of moral distress, and loneliness or social isolation. Factors associated with lower distress were perceived organizational support, work control, perceived fairness of salary cuts, and resilience. Most factors significantly associated with distress-heavy workloads and long hours, increased job demands, and moral distress, in particular-were work-related, indicating that efforts can be made to mitigate them. Resilience explained a small portion of the variance in distress relative to other work-related factors. Ensuring appropriate staffing levels may represent the single largest opportunity to significantly move the needle on distress. However, the financial impact of the COVID-19 pandemic on the healthcare system may represent a barrier to addressing these stressors.

Have the Characteristics for Success as a Surgeon Changed? A Century of Perspective Through the American College of Surgeons

BACKGROUND

The Presidential Address of the American College of Surgeons (ACS) is an influential platform during the convocation for new Fellows every year. Recent work reported that most ACS presidents primarily discuss personal characteristics for success; however, these qualities were never specified. Therefore, this study aimed to identify the personal characteristics that are espoused in ACS presidential addresses as essential for success as a surgeon.

STUDY DESIGN

Thematic analysis was completed for every ACS presidential address (98 addresses between 1913 and 2019). Full-text addresses were reviewed (2 team members), personal characteristics were coded (1 team member) and then assembled into patterns and themes (3 team-members' consensus). A temporal frame was adopted in grouping these themes in that personal qualities that appeared consistently throughout this period were classified as Enduring Characteristics and those that emerged only in later years were classified as Recent Characteristics.

RESULTS

Enduring Characteristics that were present throughout the century included sincere compassion for patients; integrity; engagement (willingness to help shape the changing field at the institutional or national level); and commitment to lifelong learning. Recent Characteristics included humility and the interpersonal attributes of inclusivity and the ability to be a collaborative team leader.

CONCLUSIONS

Surgery has experienced countless paradigm shifts since 1913, and the perceived characteristics for success have similarly evolved to include more interpersonal abilities. The importance of sincere compassion for patients, integrity, engagement, and commitment to lifelong learning remained consistent for more than a century.

Moving Career Development Upstream: Evaluation of a Course for Internal Medicine Trainees Contemplating Career Pathways in Academic Medicine

OBJECTIVES

Despite training in academic medical centers, many residents and fellows lack an understanding of the different career paths in academic medicine. Without this fundamental knowledge, choosing an academic career pathway and transitioning to junior faculty is challenging. We started the Pathways in Academic Medicine course ("Pathways") to introduce residents and fellows to the wide array of academic career pathways and to expose them to the concepts and resources needed to transition successfully from trainee to junior faculty.

RESULTS

Sixty-nine medicine residents and fellows participated in Pathways programming. Surveys and focus groups revealed high satisfaction with the course sessions. Trainees indicated that Pathways helped them to envision an academic career, clarified the steps needed to pursue an academic career, and normalized common challenges.

CONCLUSIONS

Pathways is an important educational innovation that gives participants experiences to jumpstart successful careers in academic medicine. We hope that our program will serve as an example for other institutions interested in improving the trainee-to-faculty transition.

Needs Assessment for an American College of Surgeons Certificate in Applied Surgical Education Leadership (CASEL)

OBJECTIVE

Surgeon educators in departments of surgery play key roles in leading and advancing surgical education. Their activities include ensuring sound curricula and evaluation systems, monitoring education resources, overseeing faculty development, and providing mentorship. For more than 25 years, the American College of Surgeons (ACS) has offered a comprehensive "Surgeons as Educators" (SAE) course to address fundamental topics in surgical education. This study aims to identify future career needs of SAE graduates to inform the development of an American College of Surgeons Certificate in Applied Surgical Education Leadership program.

DESIGN

An IRB exempt, anonymous electronic survey was developed to determine educational roles, career aspirations, and needs of SAE Graduates.

SETTING AND PARTICIPANTS

Participants included all 763 1993-2016 SAE graduates.

RESULTS

One hundred and thirty-five responses were received from 600 (22.5%) graduates with valid email addresses. Sixty (45%) respondents completed the SAE Course > 5 years prior to the study (M5YRS) and 75 (55%) within the last 5 years (L5YRS). L5YRS respondents were less likely to be full professors (8% vs. 44%) or to serve as program directors (32% vs. 57%), and more likely to be associate program directors (25% vs. 17%) or clerkship directors (40% vs. 18%). High percentages of both L5YRS and M5YRS reported not pursuing additional educational opportunities post-SAE due to time and fiscal constraints. One-fifth of respondents were unaware of additional opportunities and 19% of M5YRS versus 6% of L5YRS stated that existing programs did not meet their needs. Overall improving skills as educational leaders, developing faculty development programs, and conducting educational research were noted as priorities for future development. Differences were observed between the L5YRS and M5YRS groups. The dominant preferences for course format were full-time face-to-face (41%) or a combination of full-time face-to-face with online modules (24%). The most important considerations in deciding to pursue a certificate course were course content, and interest in advancing career and time constraints.

CONCLUSIONS

An SAE graduate survey has confirmed the need for additional formal training in surgical education leadership in order to permit surgeon educators meet the demands of the changing landscape of surgical education. The needs of early career faculty may differ from those of more senior surgeon educators.

Sixty years of community change in the prairie-savanna-forest mosaic of Wisconsin

Biodiversity loss is a global concern, and maintaining habitat complexity in naturally patchy landscapes can help retain regional diversity. A mosaic of prairie, savanna, and forest historically occurred across central North America but currently is highly fragmented due to human land conversion. It is unclear how each habitat type now contributes to regional diversity. Using legacy data, we resurveyed savanna plant communities originally surveyed in the 1950s to compare change in savannas to that in remnant forests and prairies. Savanna community structure and composition changed substantially over the past 60 years. Tree canopy density nearly doubled and many prairie and savanna specialist species were replaced by forest and non‐native species. All three habitats gained and lost many species since the 1950s, resulting in large changes in community composition from local colonizations and extinctions. Across all three habitats, regional species extinctions matched that of regional colonization resulting in no net change in regional species richness. Synthesis—Despite considerable species turnover within savannas, many species remain within the broader prairie–savanna–forest mosaic. Both regional extinctions and colonizations were high over the past 60 years, and maintaining the presence of all three community types—prairie, savanna and forest—on the landscape is critical to maintaining regional biodiversity.

Combining community resurvey data to advance global change research

More and more ecologists have started to resurvey communities sampled in earlier decades to determine long-term shifts in community composition and infer the likely drivers of the ecological changes observed. However, to assess the relative importance of, and interactions among, multiple drivers joint analyses of resurvey data from many regions spanning large environmental gradients are needed. In this paper we illustrate how combining resurvey data from multiple regions can increase the likelihood of driver-orthogonality within the design and show that repeatedly surveying across multiple regions provides higher representativeness and comprehensiveness, allowing us to answer more completely a broader range of questions. We provide general guidelines to aid implementation of multi-region resurvey databases. In so doing, we aim to encourage resurvey database development across other community types and biomes to advance global environmental change research.

Closure of a Traumatic Esophagomediastinal Fistula in a Child by Endoscopic Fulguration and Fibrin Injection

Posttraumatic esophagomediastinal fistula is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Its management, especially in previously operated field, is controversial and several endoscopic methods are being proposed as alternatives. Ours is the first report of endoscopic fulguration and fibrin injection in successful closure of such fistula. A 9-year-old female sustained complete tracheoesophageal transection from a gunshot wound to the neck and underwent immediate primary repair. She presented nine months later with fevers and swelling over anterior neck. CT revealed air tracking posteriorly to the dorsal neck and inferiorly to the mediastinum. Considering difficulty of open surgical approach, endoscopic intervention was attempted. Posterior wall fistula was identified via microlaryngoscopy above the esophageal anastomosis. The fistula tract was de-epithelialized via a Bugbee fulgurating electrode and then sealed with fibrin glue. Consequent imaging studies demonstrated complete occlusion of the fistula. Posterior posttraumatic esophagomediastinal fistula presents a challenging scenario from a surgical standpoint, as it combines difficulty of safe approach, high rate of injury to surrounding structures, and significant postoperative recurrence rate. Endoscopic Bugbee fulguration and fibrin glue injection are a safe and effective alternative to the traditional approach.

Closure of a Traumatic Esophagomediastinal Fistula in a Child by Endoscopic Fulguration and Fibrin Injection

Posttraumatic esophagomediastinal fistula is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Its management, especially in previously operated field, is controversial and several endoscopic methods are being proposed as alternatives. Ours is the first report of endoscopic fulguration and fibrin injection in successful closure of such fistula. A 9-year-old female sustained complete tracheoesophageal transection from a gunshot wound to the neck and underwent immediate primary repair. She presented nine months later with fevers and swelling over anterior neck. CT revealed air tracking posteriorly to the dorsal neck and interiorly to the mediastinum. Considering difficulty of open surgical approach, endoscopic intervention was attempted. Posterior wall fistula was identified via microlaryngoscopy above the esophageal anastomosis. The fistula tract was de-epithelialized via a Bugbee fulgurating electrode and then sealed with fibrin glue. Consequent imaging studies demonstrated complete occlusion of the fistula. Posterior posttraumatic esophagomediastinal fistula presents a challenging scenario from a surgical standpoint, as it combines difficulty of safe approach, high rate of injury to surrounding structures, and significant postoperative recurrence rate. Endoscopic Bugbee fulguration and fibrin glue injection are a safe and effective alternative to the traditional approach.

The pace of plant community change is accelerating in remnant prairies

Patterns of biodiversity are changing rapidly. "Legacy studies" use historical data to document changes between past and present communities, revealing long-term trends that can often be linked to particular drivers of ecological change. However, a single pair of historical samples cannot ascertain whether rates of change are consistent or whether the impact and identity of drivers have shifted. Using data from a second resurvey of 47 Wisconsin prairie remnants, we show that the pace of community change has increased with shifts in the strength of particular drivers. Annual rates of local colonization and extinction accelerated by 129 and 214%, respectively, between 1950 and 1987 and between 1987 and 2012. Two anthropogenic drivers-patch area and fire history-increased in importance between these periods. As the strength and number of anthropogenic forces increase, rates of biodiversity change are likely to accelerate in other ecosystems as well.

TspanC8 Tetraspanins and A Disintegrin and Metalloprotease 10 (ADAM10) Interact via Their Extracellular Regions: EVIDENCE FOR DISTINCT BINDING MECHANISMS FOR DIFFERENT TspanC8 PROTEINS

A disintegrin and metalloprotease 10 (ADAM10) is a ubiquitously expressed transmembrane metalloprotease that cleaves the extracellular regions from its transmembrane substrates. ADAM10 is essential for embryonic development and is implicated in cancer, Alzheimer, and inflammatory diseases. The tetraspanins are a superfamily of 33 four-transmembrane proteins in mammals, of which the TspanC8 subgroup (Tspan5, 10, 14, 15, 17, and 33) promote ADAM10 intracellular trafficking and enzymatic maturation. However, the interaction between TspanC8s and ADAM10 has only been demonstrated in overexpression systems and the interaction mechanism remains undefined. To address these issues, an antibody was developed to Tspan14, which was used to show co-immunoprecipitation of Tspan14 with ADAM10 in primary human cells. Chimeric Tspan14 constructs demonstrated that the large extracellular loop of Tspan14 mediated its co-immunoprecipitation with ADAM10, and promoted ADAM10 maturation and trafficking to the cell surface. Chimeric ADAM10 constructs showed that membrane-proximal stalk, cysteine-rich, and disintegrin domains of ADAM10 mediated its co-immunoprecipitation with Tspan14 and other TspanC8s. This TspanC8-interacting region was required for ADAM10 exit from the endoplasmic reticulum. Truncated ADAM10 constructs revealed differential TspanC8 binding requirements for the stalk, cysteine-rich, and disintegrin domains. Moreover, Tspan15was the only TspanC8 to promote cleavage of the ADAM10 substrate N-cadherin, whereas Tspan14 was unique in reducing cleavage of the platelet collagen receptor GPVI. These findings suggest that ADAM10 may adopt distinct conformations in complex with different TspanC8s, which could impact on substrate selectivity. Furthermore, this study identifies regions of TspanC8s and ADAM10 for potential interaction-disrupting therapeutic targeting.

Routine utilization of single-incision pediatric endosurgery (SIPES): a 5-year institutional experience

BACKGROUND

Single-incision pediatric endosurgery (SIPES) allows operation through one access site, eliminating the multiple sites traditionally used. There are few large series evaluating the versatility of SIPES. The purpose of this study is to review a 5-year single-institution experience with routine SIPES use.

PATIENTS AND METHODS

This is an Institutional Review Board-approved retrospective analysis of prospectively collected data. All SIPES cases from March 2009 to December 2013 were included. Our database contains demographics, procedure type, operative duration, estimated blood loss, instance of added ports or conversion to open, complications, and follow-up duration.

RESULTS

Of 1322 SIPES operations performed, most (82.1%) were appendectomies and cholecystectomies. Of 871 (66%) patients seen in follow-up, with a median duration of 26 days, 53 (6.1%) experienced postoperative complications. Forty-two cases (4.8%) were surgical-site infections, of which 4 required drainage. Less frequent complications that required operative intervention include recurrent inguinal hernia (n=4), umbilical hernia (n=3), intraabdominal abscess (n=1), bleeding (n=1), abdominal compartment syndrome (n=1), bowel obstruction (n=1), stitch granuloma (n=1), and persistent postoperative pain (n=1).

CONCLUSIONS

Operative times and complication rates are comparable to those in prior reported multiport laparoscopic series, allowing safe integration of SIPES into the routine of a surgical practice for most common procedures.

Note: pneumatically modulated liquid delivery with feedback control

We present the design and characterization of a pneumatically driven liquid delivery system using an embedded microcontroller with feedback control capable of maintaining a stable, constant flow rate over several hours of operation. Flow rates with relative standard deviations less than 1% were achieved and compared to a typical laboratory syringe pump.

Using the hidden curriculum to teach professionalism during the surgery clerkship

BACKGROUND

It has been shown that medical student professionalism is influenced by the hidden curriculum, although the extent to which this occurs during the surgery clerkship is unknown. Furthermore, the processes within the hidden curriculum have been used to teach professionalism to medical students, but this strategy has not been used during the surgery clerkship. The purpose of this study was to review a 2-year experience with a surgery clerkship instructional session where the hidden curriculum was used to teach professionalism to medical students.

STUDY DESIGN

Medical student essays were analyzed to evaluate the influence of the hidden curriculum on their ideas about professionalism and to identify specific behaviors that they regarded as professional and unprofessional. The instructional session was evaluated using the average satisfaction session ratings and through an analysis of medical student session evaluation comments.

RESULTS

Seventy-five percent of medical students reported that their ideas about professionalism changed. This change involved their general concepts about professionalism, identifying specific behaviors that they planned to adopt or avoid, or developing opinions about the professionalism of surgeons. The average satisfaction rating was consistently high throughout the study period, and the most helpful session feature was reported as the opportunity to share and discuss their observations.

CONCLUSIONS

The hidden curriculum has a substantial influence on the development of professionalism of medical students during the surgery clerkship. It was possible to illuminate and use the hidden curriculum to create an instructional session devoted to professionalism for medical students on the surgery clerkship.

Engaging medical students in the feedback process

BACKGROUND

There are potential advantages to engaging medical students in the feedback process, but efforts to do so have yielded mixed results. The purpose of this study was to evaluate a student-focused feedback instructional session in an experimental setting.

METHODS

Medical students were assigned randomly to either the intervention or control groups and then assigned randomly to receive either feedback or compliments. Tests of knowledge, skills, and attitudes were given before and after the intervention.

RESULTS

There was a significant gain of knowledge and skill in the group that received instruction. Satisfaction was higher after compliments in the control group but higher after feedback in the instructional group. There was no change in the subject's willingness to seek feedback.

CONCLUSIONS

A student-focused component should be carefully included as part of an overall effort to improve feedback in surgical education. The role of medical student attitudes about feedback requires further investigation.

Paying the extinction debt in southern Wisconsin forest understories

The lack of long-term baseline data restricts the ability to measure changes in biological diversity directly and to determine its cause. This hampers conservation efforts and limits testing of basic tenets of ecology and conservation biology. We used a historical baseline survey to track shifts in the abundance and distribution of 296 native understory species across 82 sites over 55 years in the fragmented forests of southern Wisconsin. We resurveyed stands first surveyed in the early 1950s to evaluate the influence of patch size and surrounding land cover on shifts in native plant richness and heterogeneity and to evaluate changes in the relative importance of local site conditions versus the surrounding landscape context as drivers of community composition and structure. Larger forests and those with more surrounding forest cover lost fewer species, were more likely to recruit new species, and had lower rates of homogenization than smaller forests in more fragmented landscapes. Nearby urbanization further reduced both alpha and beta understory diversity. Similarly, understory composition depended strongly on local site conditions in the original survey but only weakly reflected the surrounding landscape composition. By 2005, however, the relative importance of these factors had reversed such that the surrounding landscape structure is now a much better predictor of understory composition than are local site conditions. Collectively, these results strongly support the idea that larger intact habitat patches and landscapes better sustain native species diversity and demonstrate that humans play an increasingly important role in driving patterns of native species diversity and community composition.