Risk of motor vehicle collision associated with cannabis and alcohol use among patients presenting for emergency care

BACKGROUND

The objective of this study was to examine the relationship between cannabis and alcohol use and occurrence of motor vehicle collision (MVC) among patients in the emergency department (ED).

METHODS

This was a cross-sectional study of visits to EDs in Denver, CO, Portland, OR, and Sacramento, CA by drivers who were involved in MVCs and presented with injuries (cases) and non-injured drivers (controls) who presented for medical care. We obtained blood samples and measured delta-9-THC and its metabolites. Alcohol levels were determined by breathalyzer or samples taken in the course of clinical care. Participants completed a research-assistant-administered interview consisting of questions about drug and alcohol use prior to their visit, context of use, and past-year drug and alcohol use. Multiple logistic regression was used to estimate the association between MVC and cannabis/alcohol use, adjusted for demographic characteristics. We then stratified participants based on levels of cannabis use and calculated the odds of MVC across these levels, first using self-report and then using blood levels for delta-9-THC in separate models. We conducted a case-crossover analysis, using 7-day look-back data to allow each participant to serve as their own control. Sensitivity analyses examined the influence of usual use patterns and driving in a closed (car, truck, van) versus open (motorcycle, motorbike, all-terrain vehicle) vehicle.

RESULTS

Cannabis alone was not associated with higher odds of MVC, while acute alcohol use alone, and combined use of alcohol and cannabis were both independently associated with higher odds of MVC. Stratifying by level of self-reported or measured cannabis use, higher levels were not associated with higher odds for MVC, with or without co-use of alcohol; in fact, high self-reported acute cannabis use was associated with lower odds of MVC (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.05-0.65). In the case-crossover analysis, alcohol use alone or in combination with cannabis was associated with higher odds of MVC, while cannabis use alone was again associated with decreased odds of MVC.

CONCLUSIONS

Alcohol use alone or in conjunction with cannabis was consistently associated with higer odds for MVC. However, the relationship between measured levels of cannabis and MVC was not as clear. Emphasis on actual driving behaviors and clinical signs of intoxication to determine driving under the influence has the strongest rationale.

Validity of Entrustable Professional Activities in a National Sample of General Surgery Residency Programs

BACKGROUND

The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones.

STUDY DESIGN

Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings.

RESULTS

A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455).

CONCLUSIONS

Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees.

An Executive Summary of the National Trauma Research Action Plan (NTRAP)

ABSTRACT

The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

Faculty Entrustment and Resident Entrustability

Importance

As the surgical education paradigm transitions to entrustable professional activities, a better understanding of the factors associated with resident entrustability are needed. Previous work has demonstrated intraoperative faculty entrustment to be associated with resident entrustability. However, larger studies are needed to understand if this association is present across various surgical training programs.

Objective

To assess intraoperative faculty-resident behaviors and determine if faculty entrustment is associated with resident entrustability across 4 university-based surgical training programs.

Design, Setting, and Participants

This cross-sectional study was conducted at 4 university-based surgical training programs from October 2018 to May 2022. OpTrust, a validated tool designed to assess both intraoperative faculty entrustment and resident entrustability behaviors independently, was used to assess faculty-resident interactions. A total of 94 faculty and 129 residents were observed. Purposeful sampling was used to create variation in type of operation performed, case difficulty, faculty-resident pairings, faculty experience, and resident training level.

Main Outcomes and Measures

Observed resident entrustability scores (scale 1-4, with 4 indicating full entrustability) were compared with reported measures (faculty level, case difficulty, resident postgraduate year [PGY], resident gender, observation month) and observed faculty entrustment scores (scale 1-4, with 4 indicating full entrustment). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients.

Results

A total of 338 cases were observed. Cases observed were evenly distributed by faculty experience (1-5 years' experience: 67 [20.9%]; 6-14 years' experience: 186 [58%]; ≥15 years' experience: 67 [20.9%]), resident PGY (PGY 1: 28 [8%]; PGY 2: 74 [22%]; PGY 3: 64 [19%]; PGY 4: 40 [12%]; PGY 5: 97 [29%]; ≥PGY 6: 36 [11%]), and resident gender (female: 183 [54%]; male: 154 [46%]). At the univariate level, PGY (mean [SD] resident entrustability score range, 1.44 [0.46] for PGY 1 to 3.24 [0.65] for PGY 6; F = 38.92; P < .001) and faculty entrustment (2.55 [0.86]; R2 = 0.94; P < .001) were significantly associated with resident entrustablity. Path analysis demonstrated that faculty entrustment was associated with resident entrustability and that the association of PGY with resident entrustability was mediated by faculty entrustment at all 4 institutions.

Conclusions and Relevance

Faculty entrustment remained associated with resident entrustability across various surgical training programs. These findings suggest that efforts to develop faculty entrustment behaviors may enhance intraoperative teaching and resident progression by promoting resident entrustability.

Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study

OBJECTIVE

The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training.

METHODS

5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions.

RESULTS

Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level.

CONCLUSIONS

These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.

Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm

LEVEL OF EVIDENCE

Literature synthesis and expert opinion, Level V.

Integrating Surgical Palliative Care Into the Full Spectrum of Medical Education

We describe our institutional approach to incorporating surgical palliative care education into the Undergraduate Medical Education, Graduate Medical Education and Continuing Medical Education spaces as a model to help guide similarly interested educators. We had a well-established Ethics and Professionalism Curriculum, but an educational needs assessment revealed that both the residents and faculty felt that additional training in palliative care principles was crucial. We describe our full spectrum palliative care curriculum, which begins with the medical students on their surgical clerkship and continues with a 4 week surgical palliative care rotation for categorical general surgery PGY-1 residents, as well as a Mastering Tough Conversations course over several months at the end of the first year. Surgical Critical Care rotations, Intensive Care Unit debriefs after major complications, deaths, and other high-stress events are described, as is the CME domain, which includes routine Department of Surgery Death Rounds and a focus on palliative care concepts in Departmental Morbidity and Mortality conference. The Peer Support program and Surgical Palliative Care Journal Club round out our current educational endeavor. We describe our plans to create a full spectrum surgical palliative care curriculum that is fully integrated with the 5 clinical years of surgical residency, and include our proposed educational goals and year-specific objectives. The development of a Surgical Palliative Care Service is also described.

Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey

BACKGROUND

In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes.

METHODS

Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions.

CONCLUSION

This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Increased identification of cannabis use among drivers involved in motor vehicle collisions using an expanded cannabis inventory

OBJECTIVES

The objectives of this study were to implement and examine the potential capture rate of a novel instrument, the Expanded Cannabis Inventory, in a population of emergency department (ED) patients presenting after motor vehicle collisions (MVC).

METHODS

Study participants who presented to the ED after MVC were recruited from three hospitals in cannabis-legal states (Denver, CO; Portland, OR; and Sacramento, CA). Research assistants (RAs) administered the Expanded Cannabis Inventory, which includes a wide variety of products that have become readily available in states where cannabis is legal, in addition to assessments related to patient demographic characteristics, general health, cannabis attitudes, and dependency measures. RAs also obtained blood samples for delta-9-THC and metabolites.

RESULTS

Among 692 participants who provided responses to questions about cannabis use, 292 (42%) reported past-year use. Seventy-eight (27%) of those identified as using cannabis were only captured due to items in the expanded instrument. These patients were more likely to be White and were more likely to perceive daily use to be of high risk. Fewer had Cannabis Use Disorder Inventory Test (CUDIT) scores consistent with hazardous cannabis use. However, more of the patients only captured by the expanded instrument had high measured blood levels of delta-9-THC on samples obtained in the ED.

CONCLUSIONS

Changing cannabis use patterns must be reflected in our measurements for clinical practice, research, and surveillance. Instruments that are the current standard in clinical practice capture limited data and may no longer perform well enough to identify a complete cohort or to provide insight into the health behaviors of patients.

Circulating endocannabinoids and genetic polymorphisms as predictors of posttraumatic stress disorder symptom severity: heterogeneity in a community-based cohort

The endocannabinoid signaling system (ECSS) regulates fear and anxiety. While ECSS hypoactivity can contribute to symptoms of established post-traumatic stress disorder (PTSD), the role of the ECSS in PTSD development following trauma is unknown. A prospective, longitudinal cohort study of 170 individuals (47% non-Hispanic Caucasian and 70% male) treated at a level 1 trauma center for traumatic injury was carried out. PTSD symptom assessments and blood were obtained during hospitalization and at follow-up (6-8 months post injury). Serum concentrations of the endocannabinoids N-arachidonoylethanolamine (AEA) and 2-arachidonoylglycerol (2-AG) were determined at both time points and selected genetic polymorphisms in endocannabinoid genes, including rs324420 in fatty acid amide hydrolase, were assessed. For the entire sample, serum concentrations of AEA at hospitalization were significantly higher in those diagnosed with PTSD at follow-up (p = 0.030). Serum concentrations of 2-AG were significantly, positively correlated with PTSD symptom severity at follow-up only in minorities (p = 0.014). Minority participants (mostly Black/African American) also demonstrated significant, negative correlations between serum AEA concentrations and PTSD symptom severity both measured at hospitalization (p = 0.015). The A/A genotype at rs324420 was associated with significantly higher PTSD symptom severity (p = 0.025) and occurred exclusively in the Black participants. Collectively, these results are contrary to our hypothesis and find positive associations between circulating endocannabinoids and risk for PTSD. Minority status is an important modulator of the association between endocannabinoids and risk for PTSD, suggesting that the ECSS contributes to risk most significantly in these individuals and the contextual factors related to these findings should be further explored.

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.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

ABSTRACT

This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

LEVEL OF EVIDENCE

Consensus algorithm from the Western Trauma Association, Level V.

Career Advancement for Surgeon-Educators:Findings from a Modified Delphi Process

OBJECTIVES

Reward and recognition of surgical education as an academic activity remains a highly variable process between institutions. The goal of this study is to provide expert consensus definition of an academic surgical educator, with focus on criteria for academic promotion.

STUDY DESIGN AND SETTING

Following IRB approval, a Web-based modified Delphi process was used to generate prioritized academic promotion criteria for surgical educators.

PARTICIPANTS AND SETTING

Participants were recruited nationally from a pool of senior academic surgeons who are members of the Society of University Surgeons and the Society of Surgical Chairs.

RESULTS

Following a three-round modified Delphi process, the top domains of educational activity for promotion to associate professor and professor were scholarship, teaching, and administration; mentorship was also a priority category for promotion to professor. The top three activities described for promotion to Associate Professor were active participation in conferences/ departmental educational activities for medical students and residents; educational portfolio demonstrating commitment to activities as an educator; and clinical teaching excellence at their home institution. The three activities most highly scored items for promotion to Professor were mentorship of junior surgical educators; active participation in conferences/ departmental educational activities for medical students and residents; and a record of teaching excellence at the medical student and resident levels.

CONCLUSIONS

These findings demonstrate a progression from teacher to scholar to leader across a surgical educator's career, with each level incorporating and building upon the prior activities. Identification of categories and criteria may meaningfully inform best practices to be incorporated into the career development and promotion processes for surgeons on an educator academic pathway.

Surgical Trainees and The Geriatric Patient: A Scoping Review

OBJECTIVE

There is an increasing emphasis on surgical trainees learning how to appropriately provide care for the geriatric patient. We hypothesized that little published formal curriculum on the topic exists. We sought to perform a scoping review to test this hypothesis.

DESIGN

PubMed, OVID Medline, and EMBASE databases were queried from inception, supplemented by hand search of references and the grey literature. Included English language abstracts and articles described trainee perceptions of geriatric patients and/or description of dedicated geriatric curricula for trainees.

RESULTS

There were 21 included abstracts or papers, which were categorized into 8 survey-based studies, 6 descriptions of curricular design, and 7 interventional studies with pre- and post-intervention knowledge tests. General surgery residents were most frequently included. Self-rated confidence and comfort were typically higher than objective measures of resident performance in the care of geriatric patients. Residents were commonly unaware of the standardized assessment tools and recommendations that exist. Medication and delirium management were frequently-identified topics posing the widest gaps in resident knowledge.

CONCLUSION

There are few published examples of curricula on the care of geriatric patients for surgical trainees. More work is needed for the creation of specialty-specific and needs-based geriatric surgical curricula.

How I Do It a Surgical Palliative Care Rotation for Residents

To address the need for increased exposure to the essential components of Palliative Care in our residency, we created a 4 week rotation in Surgical Palliative Care for all of our categorical interns. The rotation includes time on an interdisciplinary inpatient consultative palliative care service as well as time in the outpatient clinic and in the operating room with the Surgical Palliative Care attending. Most patients who are seen and evaluated have surgical issues, allowing exposure to the fundamental aspects of palliative care as they pertain to surgical practice across the continuum of healthcare settings. Communication around serious illness, complicated decision making, complex pain and symptom management, withdrawal of life-sustaining treatment, and end-of-life care are all integral parts of the rotation. The rotation has been very favorably received by the residents, and the impact on the culture of the department has been tremendous as well. The structured approach provided, including goals and objectives and the weekly schedule, make this rotation easily replicable in other residency programs.

Teaching Palliative Care in Surgical Education

Without training in how to identify and relieve pain and suffering, surgeons miss opportunities to offer palliative services to patients. Despite explicit calls for expanding palliative care education since the 1990s, palliative care training in surgical curricula is often limited to end-of-life discussions. A growing consensus among palliative care experts suggests that formal palliative care education during surgical training should include structured communication and prognostication tools, strategies for symptom management, and an understanding of palliative care specialists' role in treating patients at all disease stages.

Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury

BACKGROUND

"Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients.

METHODS

We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress.

RESULTS

BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds.

CONCLUSION

BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members.

LEVEL OF EVIDENCE

Therapeutic, level III.

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers.

METHODS

Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence.

RESULTS

Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16).

CONCLUSION

In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury.

LEVEL OF EVIDENCE

Therapeutic, level IV; Epidemiologic, level III.

Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery: A Secondary Analysis of a Randomized Clinical Trial

Importance

For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown.

Objective

To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery.

Design, Setting, and Participants

This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018.

Interventions

Patients received a question prompt list brochure with 11 questions that they might ask their surgeon.

Main Outcomes and Measures

For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted.

Results

Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P = .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P = .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P = .22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P = .77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively.

Conclusions and Relevance

Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively.

Trial Registration

ClinicalTrials.gov Identifier: NCT02623335.

Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery: A Multisite Randomized Clinical Trial

Importance

Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict.

Objective

To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery.

Design, Setting, and Participants

This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat.

Interventions

A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit.

Main Outcomes and Measures

Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery.

Results

Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal α = .01).

Conclusions and Relevance

The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly.

Trial Registration

ClinicalTrials.gov identifier: NCT02623335.

Expressions of conflict following postoperative complications in older adults having major surgery

BACKGROUND

After serious postoperative complications, patients and families may experience conflict about goals of care.

METHODS

We performed a multisite randomized clinical trial to test the effect of a question prompt list on postoperative conflict. We interviewed family members and patients age ≥60 who experienced serious complications. We used qualitative content analysis to analyze conflict and characterize patient experiences with complications.

RESULTS

Fifty-six of 446 patients suffered a serious complication. Participants generally did not report conflict relating to postoperative treatments and expressed support for the care they received. We did not appreciate a difference in conflict between intervention and usual care. Respondents reported feeling unprepared for complications, witnessing heated interactions among team members, and a failure to develop trust for their surgeon preoperatively.

CONCLUSION

Postoperative conflict following serious complications is well described but its incidence may be low. Nonetheless, patient and family observations reveal opportunities for improvement.

Evaluation of leadership curricula in general surgery residency programs

The rapid and dynamic surgical environment requires leaders that can help guide their teams to desired outcomes while delivering patient-centered care. The need for early implementation of leadership curricula has been identified; however, most available leadership curricula are tailored for faculty and not embedded within surgery training. The ideal intervention(s) to close this gap while addressing the unique challenges of the demanding surgical training are yet to be identified. This manuscript reviews the current status of residency leadership programs and the relationship of leadership to other essential aspects for optimal training of future surgeon leaders. The use of best practice medical education frameworks is key to help guide effective and sustainable evidence-based leadership curricula. The collaboration, standardization, and publication of leadership curricula for surgery residents can serve as prototypes to address specific needs at different training institutions with the aim of equipping surgeons with the necessary leadership tools for their success.

Validation of the Injured Trauma Survivor Screen: An American Association for the Surgery of Trauma multi-institutional trial

BACKGROUND

Psychological distress is common following a traumatic injury event. The Injured Trauma Survivor Screen (ITSS) was developed at a level 1 trauma center to assess for posttraumatic stress disorder (PTSD) and major depressive episode (MDE) following admission for a traumatic injury. The ITSS sensitivity and specificity were analyzed 1 to 3 and 6 to 9 months postinjury to test the validity across trauma centers.

METHOD

Four level 1 trauma centers from the East, Midwest, South, and West in the United States recruited 375 eligible adult inpatients (excluded participants included those with moderate or severe traumatic brain injury, whose injury was self-inflicted, were noncommunicative, or were non-English speaking). Baseline sample (White/Caucasian, 63.2%; male, 62.4%; mean (SD) age, 45 (17.11) years; injured by motor vehicle collision, 42.4%) measurements were conducted during index hospitalization. At first follow-up, 69.6% (n = 261) were retained; at second follow-up, 61.3% (n = 230) were retained. Measurements included the ITSS, PTSD Checklist for DSM-5, Center for Epidemiologic Studies Depression Scale-Revised, and Clinician-Administered PTSD Scaled for DSM 5.

RESULTS

At follow-up 1, the ITSS PTSD subscale had a sensitivity of 75% and specificity of 78.8%, and the MDE subscale had a sensitivity of 80.4% and specificity of 65.6%. At follow-up 2, the PTSD subscale had a sensitivity of 72.7% and specificity of 83.1%, and the MDE subscale had a sensitivity of 76.1% and specificity of 68.3%. A combined risk group using two symptom based measures administered at baseline produced increased specificity.

CONCLUSION

The nine-item ITSS continues to be an efficient and effective risk screen for PTSD and MDE following traumatic injury requiring hospitalization. This multi-institutional validation study creates a solid foundation for further exploration of the generalizability of this screen's psychometric properties in distinct populations.

LEVEL OF EVIDENCE

Prognostic study, level III.

Association Between Medicaid Expansion and the Use of Outpatient General Surgical Care Among US Adults in Multiple States

Importance

The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient surgical care, particularly among underserved populations, remains unknown.

Objective

To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care.

Design, Setting, and Participants

This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019.

Interventions

State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act.

Main Outcomes and Measures

Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage.

Results

A total of 207 176 patients (106 395 women [51.35%] and 100 781 men [48.65%]; mean [SD] age, 45.7 [12.4] years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states.

Conclusions and Relevance

Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.

A multi-institutional study assessing general surgery faculty teaching evaluations

BACKGROUND

Resident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists.

STUDY DESIGN

Twenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful.

RESULTS

Number of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest.

CONCLUSION

There was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development.

Effective Palliative Care in the Trauma Setting

A 55-year-old man undergoes emergent exploratory laparotomy and splenectomy following a motorcycle collision. Following surgery, he is found to have a traumatic brain injury requiring decompressive craniectomy and intracranial pressure monitoring. The patient then continues to have complications throughout his hospital course. Using the American College of Surgeons Trauma Quality Improvement Program guidelines, the surgical team has early and ongoing primary palliative care discussions to foster communication and determine goals of care for the patient. As the patient deteriorates, the surgical team continues meeting with the patient's surrogate decision makers to discuss the best case and worst case scenarios regarding the patient's prognosis and expected quality of life.

Revitalizing the Patient-Surgeon Relationship: Surgical Curriculum Including the Patient Perspective

OBJECTIVE

General Surgery residents have increasing obligations that limit time with patients. This affects the patient-physician relationship, decreases meaning in work and increases burnout. Patient-Centric Resident Conferences (PCRC)¹ incorporate patients in resident didactics to promote meaning in work and improve resident confidence in counseling and consenting patients for surgery.

DESIGN

Prospective cohort study of General Surgery residents who participated in standard didactic conferences (control) and modified conferences (PCRC) between 2017 and 2019. Control conferences covered a relevant surgical topic. PCRC had shortened didactics and discussions with patients who had undergone the relevant index operation. Pre- and postconference surveys measured teaching effectiveness, confidence in counseling and consenting, and resident perception of how well the conference supported their decision to pursue surgery. Survey data was compared using chi-squared tests. Qualitative data analysis used ground theory methodology.

SETTING

This study was performed by the Department of Surgery at Oregon Health and Science University in Portland, Oregon.

PARTICIPANTS

All active General Surgery residents were asked to participate in conferences.

RESULTS

Eighty-one residents completed 136 surveys over 5 control conferences and 207 surveys over 7 PCRC. Residents reported increased confidence in counseling and consenting for surgery following control conferences (p < 0.0001) and PCRC (p < 0.0001). Residents' perception of effectiveness of teaching pathophysiology (p = 0.008) and operative steps (p = 0.013) was greater in control conferences whereas effectiveness of teaching surgical complications was greater in PCRC (p = 0.006). Resident responses indicated greater support for a surgical career following PCRC compared to control conferences (p = 0.013). Themes like "patient perspective," "impact on surgeon," and "psychological effects of surgery" were common in PCRC and rare in control conferences.

CONCLUSIONS

PCRC were associated with stronger motivations for a surgical career and included patient-centered themes, which can enhance meaning in work. These conferences complement but do not replace standard didactics.

DACC Resting State Functional Connectivity as a Predictor of Pain Symptoms Following Motor Vehicle Crash: A Preliminary Investigation

There is significant heterogeneity in pain outcomes following motor vehicle crashes (MVCs), such that a sizeable portion of individuals develop symptoms of chronic pain months after injury while others recover. Despite variable outcomes, the pathogenesis of chronic pain is currently unclear. Previous neuroimaging work implicates the dorsal anterior cingulate cortex (dACC) in adaptive control of pain, while prior resting state functional magnetic resonance imaging studies find increased functional connectivity (FC) between the dACC and regions involved in pain processing in those with chronic pain. Hyper-connectivity of the dACC to regions that mediate pain response may therefore relate to pain severity. The present study completed rsfMRI scans on N = 22 survivors of MVCs collected within 2 weeks of the incident to test whole-brain dACC-FC as a predictor of pain severity 6 months later. At 2 weeks, pain symptoms were predicted by positive connectivity between the dACC and the premotor cortex. Controlling for pain symptoms at 2 weeks, pain symptoms at 6 months were predicted by negative connectivity between the dACC and the precuneus. Previous research implicates the precuneus in the individual subjective awareness of pain. Given a relatively small sample size, approximately half of which did not experience chronic pain at 6 months, findings warrant replication. Nevertheless, this study provides preliminary evidence of enhanced dACC connectivity with motor regions and decreased connectivity with pain processing regions as immediate and prospective predictors of pain following MVC. PERSPECTIVE: This article presents evidence of distinct neural vulnerabilities that predict chronic pain in MVC survivors based on whole-brain connectivity with the dorsal anterior cingulate cortex.

Investigating Association Between Sex and Faculty Teaching Evaluation in General Surgery Residency Programs: A Multi-Institutional Study

BACKGROUND

In specialties with gender imbalance, such as general surgery, women faculty frequently receive lower teaching evaluation scores compared with men, which can affect academic advancement.

STUDY DESIGN

We collected 1 year of anonymous resident-derived faculty teaching evaluations from 21 general surgery programs, along with resident, faculty, and department leadership gender complement. A composite evaluation score was calculated for each faculty. After accounting for within-program correlations, we compared male and female scores using the cluster-adjusted t-test to describe the respective mean differences with a 95% CI. Programs were divided into quartiles based on percent female faculty, female residents, and combined total females to detect associations between female representation and faculty teaching evaluation scores.

RESULTS

The 21 programs yielded 20,187 teaching evaluations of 1,177 faculty. Women comprised 28% of the faculty, 47% of residents, 43% of program directors, and 19% of department chairs. Overall, women faculty had significantly higher evaluation scores than men (90.6% vs 89.5%, p < 0.05). Female gender was associated with higher teaching evaluation scores compared with male faculty in the lowest quartiles for all combinations of women representation.

CONCLUSIONS

This multi-institutional analysis of general surgical resident evaluations of faculty identified that female gender was associated with higher evaluation scores than men (although the difference was small). This unanticipated finding might reflect the slowly changing gender balance within general surgery and attitudes towards female faculty in a traditionally male-dominated field. Contrary to our hypothesis, female gender was associated with higher faculty evaluation scores at programs with fewer women faculty and fewer women residents.

Efficacy of a Novel Surgical Manikin for Simulating Emergency Surgical Procedures

The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among Surge-Man, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.

Identification of risk for posttraumatic stress disorder symptom clusters early after trauma

The current study examined how the injured trauma survivor screen (ITSS), a hospital-administered screener of posttraumatic stress disorder (PTSD) and depression, differentially predicted PTSD symptom cluster severity. Participants from a Level 1 trauma center (n = 220) completed the ITSS while inpatient and PTSD symptoms were assessed one-month post discharge. Perceived life threat and intentionality of injury were key predictors of avoidance, re-experiencing, and hyperarousal symptom clusters. However, negative alterations in mood and cognition cluster seemed best predicted by mood and cognitive risk factors. Therefore, the ITSS provides utility in differentially predicting symptom clusters and treatment planning after traumatic injury.

Validation of Abbreviated Four- and Eight-Item Versions of the PTSD Checklist for DSM-5 in a Traumatically Injured Sample

Rates of posttraumatic stress disorder (PTSD) are three times higher in traumatically injured populations than the general population, yet limited brief, valid measures for assessing PTSD symptom severity exist. The PTSD Checklist for DSM-5 (PCL-5) is a valid, efficient measure of symptom severity, but its completion is time consuming. Subsequently, abbreviated four- and eight-item versions were developed using the Mini-International Neuropsychiatric Interview-7 PTSD module and validated in Veteran samples. This study aimed to validate these abbreviated versions using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the gold standard for PTSD diagnosis, in a traumatically injured civilian population. Participants were 251 traumatically injured adults (M_age = 42.52 years; 69.3% male; 50.2% Caucasian) recruited from a Level 1 trauma center inpatient unit; 32.3% and 17.9% of participants experienced a motor vehicle crash or gunshot wound, respectively. The CAPS-5 and PCL-5 were administered approximately 6.5 months postinjury. We examined whether compared to the full PCL-5, the abbreviated versions would adequately differentiate between participants with and without a CAPS-5 PTSD diagnosis. The abbreviated versions were highly correlated with the total scale and showed good-to-excellent internal consistency. The diagnostic utility of the abbreviated measures was comparable to that of the total scale regarding sensitivity, suggesting they may be useful as abbreviated screening tools; however, the total scale functioned better regarding specificity. The abbreviated versions of the PCL-5 may be useful screening instruments in the long-term care of traumatic injury survivors and may be more likely to be implemented across routine clinical and research contexts.

Confidence and Competence in Volunteer Examiners of the American Board of Surgery

BACKGROUND

Previous work has demonstrated the impact of sex on the relationship between confidence and competence, with women having less confidence and less self-perceived competence. Recent recruitment of examiners by the American Board of Surgery (ABS) allowed exploration of confidence and perceived competence.

STUDY DESIGN

We solicited 23,869 eligible board-certified surgeons (4,382 women) via email to serve as examiners for the ABS General Surgery Certifying Examination (GCE). Volunteers were asked about practice and comfort examining in the 14 GCE content areas. Regression models investigated the relationship between reported practice and confidence examining.

RESULTS

There were 2,157 surgeons who volunteered, of whom 420 (19.5%) were female. Men reported practicing in a greater number of content areas than women (6.59 vs 5.36, p < 0.001) and selected more content areas in which they felt comfortable examining (7.69 vs 6.64, p < 0.001). The average male volunteer was comfortable examining in 0.70 more content areas than women, controlling for self-reported practice.

CONCLUSIONS

Men reported practicing more broadly and were more confident than women in their ability to examine across ABS Certifying Examination content areas. However, the confidence of male surgeons was not restricted to those areas in which they reported practicing. These data have important implications for training, leadership, and professional development.

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.