Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees

PURPOSE

Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees.

METHOD

The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied.

RESULTS

Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment (P = 0.27 - 0.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training, however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices.

CONCLUSIONS

Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.

Sexual Harassment in Surgery-Is Operating Room Culture the Culprit?

BACKGROUND

Sexual harassment is a known problem in surgical training and a focus of growing attention in recent years. However, the environments where sexual harassment in surgical training most commonly takes place are not yet described.

METHODS

An anonymous, voluntary, electronic survey was distributed to surgical trainees, and all programs nationally were invited to participate.

RESULTS

Sixteen general surgery training programs elected to participate, and the survey achieved a response rate of 30%. 48.9% of respondents reported experiencing sexual harassment. The most common location for harassment was in the operating room (OR) (74% of harassed respondents). The second most common location for harassment was the wards (67.4% of harassed respondents). In the OR, attendings and nurses were the most common harassers. The most common harassment in the OR was being called a sexist slur or intimate nickname.

DISCUSSION

Surgical trainees report that the OR was the most common location for trainee harassment. Given that harassment is most commonly perpetrated by both attendings and nurses, harassment in surgical training may not entirely be due to hierarchies but may also be attributed to a flawed and permissive OR culture. Surgical training programs should vigilantly eliminate the circumstances that permit sexual harassment in the OR.

Misperceptions and Missed Opportunities: A Qualitative Analysis of Barriers to Evaluating Surgical Teachers

OBJECTIVE

Teaching skills can be improved with written evaluations from learners. In addition to this primary purpose, teaching assessments are used in other aspects of faculty development including appointments, advancement and in some cases, compensation. Surgical trainees' willingness to provide meaningful assessments of their teachers is variable but the reasons for this are ill-defined. This study aims to elucidate surgical residents' perceptions regarding barriers to providing useful feedback to their teachers.

DESIGN

A qualitative, semi-structured confidential interview approach was used. A demographically diverse cohort of surgical residents in an urban university-based program was invited to participate. Interviews explored experiences and perceptions of teaching assessments. Specific attention was paid to understand perceptions of barriers; topics including utility, anonymity, time burden, and others were explored. Interviews were transcribed verbatim with identifiers removed from transcripts before analysis. All data was double coded to ensure accuracy with the development of a codebook until thematic exhaustion was reached.

SETTING

Yale New Haven Hospital is an academic, university-based medical center with approximately 70 residents in the general surgery program and approximately 170 surgical faculty.

PARTICIPANTS

A total of 21 residents completed individual or small group interviews. A theoretically driven sampling technique was used to recruit participants and maximize diversity. Individuals with varying backgrounds including PGY year, gender, age, IMG status, race, academic rank, research background and surgical division were asked to participate.

RESULTS

A total of 21 residents completed individual or small group interviews. Coding and analysis revealed 4 principal motifs: (1). Process- The process to complete assessment instruments is time-consuming and cumbersome to complete during the busy and acute surgical workday while failing to accurately address important aspects of surgical teaching. (2). Utility- Respondents reported uncertainty as to the downstream utility of the assessments, and a lack of confidence that the assessments would be used for faculty growth and improvement. (3). Resident Standing- Respondents described a lack of training, knowledge, skills, and empowerment to assess their teachers. (4). Perceived Consequences- Residents noted concern for identification, future autonomy, and other potential negative career consequences due to small resident sample sizes, recognizable experiences with attendings, and perceived power dynamics.

CONCLUSIONS

This study elucidates the perceptions of surgical trainees regarding barriers to providing feedback and assessments of their faculty. Although limited to a single-institution study, residents observed the current system does not allow for honest and accurate evaluations of surgical teachers. The extensive overlap between motifs highlights the need for a holistic approach to address these interconnected themes before teaching evaluations can be honest and productive. Importantly, it is also the first to identify residents' perceived lack of skill and sense of disempowerment to provide constructive faculty assessment. Due to the limited scope of the single-institution study, further verification and studies are needed to improve the quality of faculty feedback and assessment of surgical teachers.

How Did We Get Here and Where Are We Going? Career Trajectories of United States General Surgery Residency Program Directors

OBJECTIVE

To develop the future of United States (US) surgical education leadership, surgical trainees and early career faculty who aspire to become program directors (PDs) must understand the potential career pathways and requisite skills and experience to become a general surgery residency PD. The objective of this study was to understand the demographics, career experiences, and professional satisfaction of US PDs in general surgery.

DESIGN

An anonymous, cross-sectional survey utilizing a novel instrument.

SETTING

An electronic survey distributed to US general surgery PDs between June and November 2022 PARTICIPANTS: PDs of US general surgery residency programs. A list of the Accrediting Council for Graduate Medical Education (ACGME)-accredited general surgery PDs was created from the ACGME list from the 2022 to 23 academic year.

RESULTS

The survey achieved a response rate of 46.2% (159/344). Only 32.1% of PDs identified as female and 67.3% identified as male with 1 respondent preferring not to identify their gender. PDs were White or Caucasian (68.6%), Asian (13.8%), and Black (3.7%); 4.4% were Hispanic or Latino. Only 83.7% of PDs completed fellowship training. PDs have been in the role for an average of 5.5 ± 4.9 years. The PDs were compensated for an average of 54.7% (±14.9% SD, 0%-100% range) of their time towards clinical duties. They were compensated on average for 35.7% (±12.6%, 0%-100%) of effort for residency-related administrative duties. Only 5% of PDs had obtained or were enrolled in an education-related degree. Only 55.4% of PDs had received formal surgical education training in teaching and assessment. 54.1% of PDs were interested in obtaining a more senior leadership position in the future. Most PDs (38.4%) expect to serve as PD for 5 to 8 years in total. Overall, the majority of PDs were very satisfied (29.6%) or satisfied (51.6%) professionally; similarly 28.9% were very satisfied and 48.4% satisfied personally.

CONCLUSIONS

This study represents the most up-to-date characterization of the personal, academic, and career-related features of current surgical residency PDs across the US. PDs enjoy a high degree of professional and personal satisfaction and most aspire to increasing leadership within their organizations. Compared to prior data, PDs have become more diverse in terms of both gender and race over time. Opportunities exist for increased mentorship of aspiring and current PDs as well as increased training in teaching and assessment.

Surgical Residents' Awareness of the Costs of Common Operating Room Supplies

BACKGROUND

The Accreditation Council for Graduate Medical Education mandates that residency programs incorporate cost awareness into patient care. This presents a challenge for surgical residents because they must understand operating room costs in addition to other expenses. Trainees' understanding of operating room supply costs is not well understood.

METHODS

A survey was distributed to surgical residents (N = 73) at an urban, university-based residency program. Residents estimated the costs of 21 single-use operating room items. Descriptive statistics and a regression analysis were calculated.

RESULTS

The response rate was 62%. Respondents accurately estimated costs for a median of 7/21 items, with error ranging from 26% to 5438%. They substantially underestimated the three highest-cost items. Increasing post-graduate year did not improve estimation accuracy (β = .233, P = .138).

DISCUSSION

Residents have a poor understanding of single-use item costs, and this does not improve with post-graduate training, suggesting inefficiencies. There is opportunity to educate residents and ultimately decrease surgical health care costs.

Update on the Financial Well-Being of Surgical Residents in New England

BACKGROUND

Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being.

STUDY DESIGN

A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort.

RESULTS

Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans.

CONCLUSIONS

Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

So You Want to be a Program Director? Career Paths of Colon and Rectal Surgery Residency Program Directors

BACKGROUND

The trajectory of colon and rectal surgery residency program director (PD) career paths has not been well described, leaving those who aspire for the position with minimal guidance. The goal of this study is to characterize their career paths in the United States. By understanding their experiences, the path to train and educate the next generation of colon and rectal surgeons as a PD will be better illuminated.

STUDY DESIGN

This study was an anonymous, cross-sectional survey of all junior and senior colon and rectal surgery residency PDs in the United States during April and May of 2022. PDs were divided into junior and senior PDs. Results were compared using 2-sided independent t-tests and Kruskall-Wallis tests.

RESULTS

Of 65 colon and rectal surgery PDs, 48% (31/65) completed the survey which encompassed demographics, leadership, education, research, and time utilization. Participants were primarily white and male, although increased female representation was identified among the junior PDs (50%). Junior PDs were also more likely to hold associate or assistant professor positions at time of appointment (p = 0.01) and a majority of all PDs (64%) previously or currently held a leadership position in a national or regional surgical association. When appointed, senior PDs reported increased teaching time.

CONCLUSIONS

This multi-institutional analysis of colon and rectal surgery residency PDs identified a trend towards equal gender representation and diversity amongst upcoming junior PDs. All respondents were appointed to PD from within the institution. Other key experiences included previous leadership roles and associate or assistant professor positions at time of appointment. While it is impossible to create a single recommended template for every aspiring colon and rectal surgery educator to advance to a PD position, this study provides guideposts along that career path.

How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education

OBJECTIVE

To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among.

SETTING

Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals.

PARTICIPANTS

Clinical faculty within the Department of Surgery.

RESULTS

A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care.

CONCLUSIONS

Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.

Learning Environment is the Prevailing Factor in Surgical Residents' Favorite Rotations

OBJECTIVE

Understand the characteristics of residents' favorite rotations to improve the ability of educators to maximize positive learning experiences.

DESIGN

Novel cross-sectional survey developed through thematic analysis of focus groups with residents using 4-point Likert scales ranked from "Not at all important" to "Extremely important."

SETTING

Single university-affiliated urban hospital PARTICIPANTS: Clinical surgical residents BACKGROUND: Resident assessments of learning experiences vary between rotations leading to the development of "favorite" rotations.

MATERIALS AND METHODS

A novel survey instrument containing 31 characteristics divided into 4 thematic categories was developed following analysis of surgical resident focus groups. Clinical surgical residents were asked how important each characteristic was for determining their favorite rotation on a 4-point Likert Scale from "not at all important" to "extremely important." Two-sided independent sample T-tests were used.

RESULTS

The response rate was 59% (33/56) with proportional representation of postgraduate levels. Overall, 67% (22/33) of residents reported their favorite rotation was in their preferred specialty, 70% (23/33) reported their favorite rotation required >70 hours per week in the hospital, and 97% (32/33) of residents reported their favorite rotation required <2 days of clinic. Overall, the average ranking of the categories from most to least important was content (mean = 2.84, SD = 0.48), learning environment (mean = 2.67, SD = 0.57), working environment (mean = 2.38, SD = 0.56), and accomplishment (mean = 2.31, SD = 0.57). The only category with a statistically significant difference between junior and senior resident was content with seniors ranking it most important (mean = 3.35, SD = 0.93) compared to junior residents who ranked it least important (mean = 2.21, SD = 1.25), p = 0.01. Personal characteristics such as "Attendings cared about my learning" (mean = 3.56, SD = 0.50) and "I felt good at my job" (mean = 3.45, SD = 0.67), tended to be more important than structural characteristics such as "call schedule" (mean = 2.71, SD = 0.86), "formal didactics" (mean = 2.67, SD = 1.04), and "work-life balance" (mean = 2.70, SD = 0.99).

CONCLUSIONS

This study demonstrates a novel understanding of the factors that contribute to resident preferences for certain rotations. Junior and senior residents attribute importance differently, which may provide the basis for level-appropriate improvements. Personal factors tended to be more contributory than structural factors, highlighting additional dimensions to examine when considering how to optimize certain rotations.

The Potential Application of Mindset Theory to Surgical Education

Mindset theory proposes that individuals hold a range of beliefs regarding the malleability of attributes such as intellect and skill. Within surgery, mindset theory has been discussed as a way of understanding achievement in both the cognitive and technical aspects of learning surgery. A review of the literature reveals a limited body of research that has addressed the mindsets of surgeons or by extension, tied those mindsets to outcomes. Within health professions education, mindset theory has been studied more broadly, but the benefits of mindset theory are largely assumed and drawn from education research regarding children and adolescents. Though mindset theory has gained traction, there has been debate regarding the traits associated with growth and fixed mindsets. The strongest evidence from primary and secondary education shows that low socioeconomic status and academically at-risk students can benefit the most from mindset interventions, and these findings may extend to surgical learning as well. Mindset theory offers an interesting lens to better understand surgical education, but more research is needed to characterize the mindsets of surgeons and understand how these mindsets influence performance and outcomes.

Effect of Surgical Team Communication on Adherence to Opioid Discharge Guidelines in Post-Operative Inpatients

OBJECTIVE

Current opioid prescribing guidelines state that post-operative inpatients who do not receive opioids in the 24 hours preceding discharge do not require an opioid prescription on discharge. This study was designed to assess providers' understanding of opioid discharge guidelines and explore drivers of adherence.

DESIGN

An electronic survey was released which assessed knowledge of opioid discharge guidelines and probed surgical team communication. Kruskal-Wallis tests were used to determine differences between provider types. Spearman's correlation evaluated relationships between estimated and observed adherence to guidelines.

SETTING

Yale New-Haven Hospital, (tertiary, university-based) PARTICIPANTS: Surgical residents, advanced practice providers (APPs) and attendings who discharged inpatients with opioids between November 2017-August 2019 RESULTS: The response rate was 36% (90/253), including 36% (49/136) of residents, 23% (13/56) of APPs, and 46% (28/61) of attendings. Seventy eight percent of participants believed patients who met the guideline should "never" or "sometimes" receive opioids on discharge. There was a significant difference between attending preferences and what residents (H²₂ = 202.7, p = 0.0001) and APPs (H²₂ = 24.6, p = 0.003) believed were the attending's preferences. Eleven percent of attendings preferred their patients to "most of the time" or "always" receive opioids on discharge, while 45% of residents and 54% of APPs reported the same. Overall, 57% of attendings reported they "most of the time" or "always" communicated their discharge preferences while 12% of residents (H²₂ = -20.4, p = 0.0003) and 8% of APPs (H²₂ = -23.5, p = 0.003) reported the same. There was no correlation between all groups' estimated adherence to the guidelines and observed adherence (r_s = 0.135, p = 0.206).

CONCLUSIONS

This study demonstrates that surgical residents, APPs, and attendings are aware of the guideline but breakdowns in communication between the attending and the surgical team may contribute to deviation from this guideline. Improving communication may lead to improved adherence to post-operative opioid discharge prescribing guidelines.

Video Coaching: A National Survey of Surgical Residency Program Directors

OBJECTIVE

Video coaching has been demonstrated to improve resident and attending skills and is overwhelmingly well received by the participants. However, misperceptions about its utility among those who do not use video coaching may be a barrier to widespread implementation.

DESIGN

Cross-sectional web-based survey SETTING: National survey PARTICIPANTS: Surgical program director members of the Association of Program Directors of Surgery STUDY DESIGN: The survey was developed via a deductive approach after a literature review and was piloted with surgical attendings and residents. All Likert scale were averaged and comparisons between groups was performed via independent t-tests.

RESULTS

There were 52 responses from PDs. 27/52(51.9%) PDs reported their program supported video coaching of residents. PDs from residences with video coaching programs were more likely to believe that video coaching was useful in identifying their own strengths and weakness (p = 0.005), was a useful adjunct for resident feedback (p = 0.024), and a personal library of video recordings would be helpful (p = 0.015) when compared to PDs from residencies without video coaching. Programs without video coaching were more likely to believe barriers to implementation included it being ineffective (p = 0.024) and that the technology was unavailable (p = 0.006). Over 50% of respondents from both groups believed expense, difficulty with set up, time required, and patient privacy were "Very" or "Extremely" likely to be barriers to implementation.

CONCLUSIONS

This is the first national survey of PDs regarding the use of video coaching. Residency programs without video coaching may underestimate the utility of video coaching in training surgical residents.

Video Coaching in Surgical Education: Utility, Opportunities, and Barriers to Implementation

OBJECTIVE

This review discusses the literature on Video-Based Coaching (VBC) and explores the barriers to widespread implementation.

DESIGN

A search was performed on Scopus and PubMed for the terms "operation," "operating room," "surgery," "resident," "house staff," "graduate medical education," "teaching," "coaching," "assessment," "reflection," "camera," and "video" on July 27, 2021, in English. This yielded 828 results. A single author reviewed the titles and abstracts and eliminated any results that did not pertain to operative VBC or assessment. All bibliographies were reviewed, and appropriate manuscripts were included in this study. This resulted in a total of 52 manuscripts included in this review.

SETTING/PARTICIPANTS

Original, peer-reviewed studies focused on VBC or assessment.

RESULTS

VBC has been both subjectively and objectively found to be a valuable educational tool. Nearly every study of video recording in the operating room found that subjects, including surgical residents and seasoned surgeons alike, overwhelmingly considered it a useful, non-redundant adjunct to their training. Most studies that evaluated skill acquisition via standardized assessment tools found that surgical residents who underwent a VBC program had significant improvements compared to their counterparts who did not undergo video review. Despite this evidence of effectiveness, fewer than 5% of residency programs employ video recording in the operating room. Barriers to implementation include significant time commitments for proposed coaching curricula and difficulty with integration of video cameras into the operating room.

CONCLUSIONS

VBC has significant educational benefits, but a scalable curriculum has not been developed. An optimal solution would ensure technical ease and expediency, simple, high-quality cameras, immediate review, and overcoming entrenched surgical norms and culture.

Transplant Fellowship and Presenting at a Transplant-Specific Conference

INTRODUCTION

The ASTS implemented a task force in 2018 to increase residents' interest in careers in organ transplantation. National meetings offer important experiences that can increase interest. The present study examines an association that exists between presenting at a major transplant surgery meeting and a trainee's likelihood of pursuing a career in transplant surgery.

METHODS

All abstracts from the ASTS State of the Art Winter Symposium from 2010 to 2019 were evaluated. Using a combination of internet-based resources, it was determined if the presenter was a resident, what year of residency they were in, and if that individual went into a transplant fellowship.

RESULTS

1544 abstracts were reviewed and 133 were presented by residents. Out of residents that presented, 68.4% (54/79) were senior residents and 31.6% (25/79) were junior residents. Of senior residents, 66.7% (36/54) went into transplant fellowships, while only 20.0% (5/25) of junior residents went into transplant fellowships. Being a senior resident when presenting was statistically significant for pursuing a transplant fellowship (P = .000113).

DISCUSSION

Senior residents who present at ASTS SAWS are likely to pursue a transplant surgery fellowship. Junior residents who present are less likely to pursue transplantation, and this represents an opportunity to improve the engagement of young surgeons in the specialty.

Residency Program Use of Social Media in the COVID-19 Era: An Applicant's Perspective

General surgery residency programs' use of social media has exploded since early spring 2020, as it became clear that the COVID-19 pandemic would prevent away rotations and in-person interviews. Faced with the prospect of ranking programs they cannot visit, applicants are becoming reliant on programs' use of social media to showcase program culture, now a key recruitment tool. However, proper etiquette for applicant engagement with programs' social media accounts is unclear. Who administers these accounts - residents, program directors, program coordinators, or marketing staff? The subjectivity of criteria for "potentially unprofessional" content may pose disproportionate risks to female applicants and applicants of color. From this applicant's perspective, programs' recent use of social media has been informative and humanizing. It is our hope that departments, programs, and residents continue to post on social media throughout the application cycle. However, we applicants would benefit from clear guidance and expectations as to how to engage with residency programs via social media.

Characterizing the social media footprint of general surgery residency programs

Background

The medical community has increasingly embraced social media for a variety of purposes, including trainee education, research dissemination, professional networking, and recruitment of trainees and faculty. Platform choice and usage patterns appear to vary by specialty and purpose, but few studies comprehensively assess programs’ social media presence. Prior studies assessed general surgery departments’ Twitter use but omitted additional social media platforms and residency-specific accounts.

Objective

This study sought to broadly characterize the social media footprint of U.S. general surgery residency programs.

Methods

Using a protocolized search of program websites, social media platforms (Twitter, Facebook, Instagram, LinkedIn), and internet search, cross-sectional data on social media usage in March 2020 were collected for programs, their affiliated departments, their program directors (PDs), and their assistant/associate PDs (APDs).

Results

318 general surgery residency programs, 313 PDs, and 296 APDs were identified. 47.2% of programs had surgery-specific accounts on ≥1 platform. 40.2% of PDs and APDs had ≥1 account on Twitter and/or LinkedIn. Program type was associated with social media adoption and Twitter utilization, with lower usage among university-affiliated and independent programs (p<0.01).

Conclusions

Most general surgery residencies, especially non-university-based programs, lacked any department or residency accounts across Twitter, Facebook, and Instagram by March 2020. These findings highlight opportunities for increased social media engagement and act as a pre-pandemic baseline for future investigations of how the shift to virtual trainee education, recruitment, conferences, and clinical care affect social media use.

Driving Safety Among Surgical Residents in the Era of Duty Hour Restrictions

OBJECTIVE

Fatigued driving is a known contributor to adverse motor vehicle events (AMVEs), defined as crashes and near misses. Surgical trainees work long and irregular hours; the safety of work-related driving since the introduction of work hour regulations has not yet been studied in this population. We aimed to assess the impact of fatigue on driving safety and explore perceptions of a funded rideshare program.

DESIGN

An electronic survey was delivered and inquired in retrospective fashion about fatigue and sleepiness while driving, occurrences of AMVEs, and projected use of a funded rideshare program as a potential solution to unsafe driving. Chi-square testing determined categorical differences between response choices.

SETTING

Yale University School of Medicine, Department of Surgery, New Haven, CT-a general surgery program with 4 urban clinical sites positioned along a roughly twenty mile stretch of interstate highway in Southeastern Connecticut.

PARTICIPANTS

General Surgery residents at the Yale University School of Medicine.

RESULTS

Of 58 respondents (81% response rate), 97% reported that fatigue compromised their safety while driving to or from work. Eighty-three percent reported falling nearly or completely asleep, and 22% reported AMVEs during work-related driving. Junior residents were more likely than Seniors to drive fatigued on a daily-to-weekly basis (69% vs 47%, p = 0.02) and twice as likely to fall asleep on a weekly-to-monthly basis (67% vs 33%, p = 0.02). Despite this, only 7% of residents had ever hired a ride service when fatigued, though 88%, would use a free rideshare service if provided.

CONCLUSIONS

Work-related fatigue impairs the driving safety of nearly all residents, contributing to frequent AMVEs. Currently, few residents hire rideshare services. Eliminating the cost barrier by funding a rideshare and encouraging its routine use may protect surgical trainees and other drivers.

Surgical Education in the Time of COVID: Understanding the Early Response of Surgical Training Programs to the Novel Coronavirus Pandemic

OBJECTIVE

Describe the early impact of the COVID-19 pandemic on general surgery residency training nationwide.

DESIGN

A 31-question electronic survey was distributed to general surgery program directors. Qualitative data underwent iterative coding analysis. Quantitative data were evaluated with summary statistics and bivariate analyses.

PARTICIPANTS

Eighty-four residency programs (33.6% response rate) with representation across US geographic regions, program affiliations, and sizes.

RESULTS

Widespread changes were observed in the surgical training environment. One hundred percent of programs reduced the number of residents on rounds and 95.2% reduced the size of their in-hospital resident workforce; on average, daytime staffing decreased by nearly half. With telehealth clinics (90.5%) and remote inpatient consults (26.2%), both clinical care and resident didactics (86.9%) were increasingly virtual, with similar impact across all program demographics. Conversely, availability of some wellness initiatives was significantly higher among university programs than independent programs, including childcare (51.2% vs 6.7%), housing (41.9% vs 13.3%), and virtual mental health services (83.7% vs 53.3%).

CONCLUSIONS

Changes in clinical care delivery dramatically reduced in face-to-face learning opportunities for surgical trainees during the COVID-19 pandemic. While this effect had equal impact across all program types, sizes, and geographies, the same cannot be said for wellness initiatives. Though all programs initiated some strategies to protect resident health, the disparity between university programs and independent programs may be cause for action.

What's it Worth?: The Costs and Benefits of an Initiative to Decrease Post-Call Fatigued Driving Among Surgery Residents

BACKGROUND

In 2017 the ACGME enacted new regulations requiring sponsoring institutions to ensure "safe transportation options for residents who may be too fatigued to safely return home." We investigate here the impact of a pilot "Safe Ride" program designed to mitigate the risks of fatigued driving.

METHODS

During a 2-month pilot period at a single university-affiliated general surgery residency with four urban clinical sites, all residents (n = 72) were encouraged to hire a rideshare (e.g., Uber, Lyft) to and from 24-h clinical shifts if they felt too fatigued to drive safely. The cost of the rideshare was fully reimbursed to the resident. The impact of this intervention was evaluated using utilization data and a post-intervention resident survey.

RESULTS

A total of 16.6% of trainees utilized a rideshare at least one time. Sixty-three post-call rides were taken, predominantly by junior residents (92.4%) and for commutes greater than 15 miles (91%). The cost for the 60-day pilot was $3030. Comparing pre-intervention to post-intervention data, there was a significant improvement in the reported frequency of falling asleep or nearly asleep while driving (P < 0.001). Trainees nearly unanimously (98%) supported efforts to make the program permanent.

DISCUSSION

Driving while fatigued is common among surgical residents, with increased risk among junior residents, during longer commutes and following longer shifts. A reimbursed rideshare program effectively targets these risk factors and was associated with a significant decrease in rates of self-reported fatigued driving. Future efforts should focus on strategies to promote use of reimbursed rideshare programs while remaining cost efficient.

Creating an Opioid Recommendation Card for Trainees: Methods, Use, and Impact

BACKGROUND

In academic hospitals, surgical residents write most of the postoperative prescriptions; yet, few residents are trained on postoperative analgesia. This leads to wide variability in practices and often excess opioid prescribing. We sought to create an opioid guideline pocket card for surgical residents to access when prescribing opioids postoperatively and to evaluate the impact of this initiative.

METHODS

A comprehensive literature review was conducted to generate evidence-based procedure-specific opioid recommendations; additional recommendations were formulated via consensus opinion from surgical divisions at an academic institution. A pocket-sized guideline card was developed to include these procedure-specific recommendations as well as opioid guidelines for discharges after inpatient stays, non-opioid analgesic recommendations, access to opioid safety and disposal instructions for patients discharge, an equianalgesic dosing chart, and instructions for naloxone use. The card was distributed to all General Surgery house staff at a university-affiliated hospital in the spring of 2018. Following the distribution, trainees were surveyed on their use of the card. Descriptive statistics were used to analyze the survey.

RESULTS

Of 85 trainees, 62 (72.9%) responded to the survey in full; 58% use the card regularly. Of the 27 junior resident respondents, 70.4% use the card at least monthly including 48.1% who use the card daily-to-weekly. Overall, 81.6% of residents changed their opioid-prescribing practices because of this initiative and 89.8% believe the card should continue to be distributed and used.

DISCUSSION

An evidence-based guideline card for postoperative analgesia is highly valued and utilized by surgical trainees, especially those most junior in their training.

"Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent

OBJECTIVE

Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations.

DESIGN

This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature.

CONCLUSIONS

We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.

A Critical Appraisal of the July Effect: Evaluating Complications Following Pancreaticoduodenectomy

BACKGROUND

Reports of higher rates of medical errors in the month of July have generated concern regarding major surgery at academic institutions early in the yearly promotion cycle. This study was designed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) at different times of the year.

MATERIALS AND METHODS

Outcomes were retrospectively evaluated for patients treated in July versus the rest of the year and in the first quarter (July-September) versus the remaining quarters. The primary outcome was operative morbidity as measured by Clavien-Dindo grade, a classification system of surgical complications. Secondary outcomes included mortality, operative blood loss, pancreatic fistula formation, delayed gastric emptying, intraabdominal abscess, anastomotic leak, reoperation, and other variables of interest.

RESULTS

From January 2003 to September 2015, 472 patients underwent PD by a single academic surgeon. Overall, 77.1% of PDs were performed for malignancy. The number of patients did not significantly vary by month or by quarter. The incidence of major morbidity (Clavien-Dindo grade ≥ III) in patients who had a PD was 12.2% in July and 17.5% in all other months (P = 0.79). The rate of pancreatic fistula, intraabdominal abscess, reoperation, readmission, and mortality did not differ significantly by month or by quarter (P > 0.05 for all).

CONCLUSIONS

The current study does not find any correlation between time of year and operative morbidity or mortality, suggesting that PD can be safely performed irrespective of timing.

Earlier Is Better: Evaluating the Timing of Tracheostomy After Liver Transplantation

BACKGROUND

Respiratory failure after orthotopic liver transplantation is associated with increased mortality and prolonged hospitalization.

METHODS

A retrospective analysis was conducted through the query of the National In-patient Sample for subjects who underwent orthotopic liver transplantation and tracheostomy after transplantation from 2000 to 2011. Tracheostomies by post-transplantation day 14 were considered "early," whereas those after day 14 were "routine." A Cox proportional hazards model was used to evaluate the impact of early tracheostomy on post-tracheostomy length of stay.

RESULTS

There were 2,149 weighted discharges. Of these, 783 (36.4%) had early tracheostomy after transplantation. The subjects who received an early tracheostomy after transplantation were more likely to have a Charlson Comorbidity index²² score of ≥3 (early 71.1% vs late 60.0%; P = .038). Early tracheostomy after transplantation had lower in-hospital mortality (early 26.4% vs late 36.7%; P = .01). Unadjusted median post-tracheostomy length of stay was 31 d for early tracheostomy after transplantation versus 39 d for late tracheostomy after transplantation (P = .034). Early tracheostomy after transplantation was associated with 20% decreased odds of in-hospital mortality (hazard ratio 0.80; P = .01). Early tracheostomy had 41% higher daily rate of discharge alive (hazard ratio 1.41; P < .001).

CONCLUSIONS

Early tracheostomy after transplantation was associated with lower in-hospital mortality, shorter post-tracheostomy length of stay, and quicker discharge alive. These results supported our hypothesis that, among subjects with respiratory failure after orthotopic liver transplantation, early tracheostomy after transplantation may be associated with more favorable outcomes than a delayed approach.

Pandemic Recovery Using a COVID-Minimal Cancer Surgery Pathway

The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented disruption in health care delivery around the world. In an effort to prevent hospital-acquired COVID-19 infections, most hospitals have severely curtailed elective surgery, performing only surgeries if the patient's survival or permanent function would be compromised by a delay in surgery. As hospitals emerge from the pandemic, it will be necessary to progressively increase surgical activity at a time when hospitals continue to care for COVID-19 patients. In an attempt to mitigate the risk of nosocomial infection, we have created a patient care pathway designed to minimize risk of exposure of patients coming into the hospital for scheduled procedures. The COVID-minimal surgery pathway is a predetermined patient flow, which dictates the locations, personnel, and materials that come in contact with our cancer surgery population, designed to minimize risk for virus transmission. We outline the approach that allowed a large academic medical center to create a COVID-minimal cancer surgery pathway within 7 days of initiating discussions. Although the pathway represents a combination of recommended practices, there are no data to support its efficacy. We share the pathway concept and our experience so that others wishing to similarly align staff and resources toward the protection of patients may have an easier time navigating the process.

Application of Advanced Bioinformatics to Understand and Predict Burnout Among Surgical Trainees

OBJECTIVE

Physician burnout, including surgical trainees, is multidimensional. Input variables used to predict burnout include grit, exhaustion, and financial stress. Each instrument has intrinsic limitations of scope and strength. We hypothesize that bioinformatics methods borrowed from oncogenetics may allow meta-analysis of existing predictive tools to improve identification of subpopulations at highest risk of burnout.

DESIGN

A composite survey was created using widely accepted instruments: demographic factors, burnout using the Single-Item Maslach Burnout Inventory Emotional Exhaustion Measure, grit using the Duckworth Grit Scale, occupational fatigue using the Occupational Fatigue Exhaustion/Recovery Scale, financial well-being, perceptions of physician leadership, and attitudes towards robotic surgery. Surveys were analyzed using k-means analysis and supervised/unsupervised clustering.

SETTING

Yale General Surgery Residency.

PARTICIPANTS

Survey participants consisted of Yale General Surgery residents. Of 70 residents, 53 responded (75.7%). Males comprised 57.1% and each postgraduate year had majority representation, 68.8% to 100%.

RESULTS

Unsupervised hierarchical clustering showed heterogeneous resident answer patterns and suggested clusters of responders. To define groups of dissimilar responders, we performed k-means clustering, testing 15 iterations with 50 attempts. The analysis revealed 3 discrete clusters of responders with differential risk for burnout (p = 0.021). The highest risk group demonstrated the lowest grit score, low interest in innovation and leadership, higher financial stress, and concordantly, the highest rates of anxiety, dread, and self-reported burnout. (p = 0.0004; 0.0014; 0.1217; 0.0625; 0.021; 0.0011; 0.0224) CONCLUSIONS: The limited scope of common tools aiming to predict burnout constrains their utility. The machine-learning technique of cluster analysis organizes compound data to describe complex outcomes such as oncologic risks. We apply this analysis technique to create a composite predictor of burnout among surgical residents. Our method determines subgroups of residents sharing unique traits predictive of burnout. Residencies can use this tool to allocate resources to best support resident well-being.

First-in-Human Experience With Peritoneal Direct Sodium Removal Using a Zero-Sodium Solution: A New Candidate Therapy for Volume Overload

BACKGROUND

Loop diuretics have well-described toxicities, and loss of response to these agents is common. Alternative strategies are needed for the maintenance of euvolemia in heart failure (HF). Nonrenal removal of sodium directly across the peritoneal membrane (direct sodium removal [DSR]) with a sodium-free osmotic solution should result in extraction of large quantities of sodium with limited off-target solute removal.

METHODS

This article describes the preclinical development and first-in-human proof of concept for DSR. Sodium-free 10% dextrose was used as the DSR solution. Porcine experiments were conducted to investigate the optimal dwell time, safety, and scalability and to determine the effect of experimental heart failure. In the human study, participants with end-stage renal disease on peritoneal dialysis (PD) underwent randomization and crossover to either a 2-hour dwell with 1 L DSR solution or standard PD solution (Dianeal 4.25% dextrose, Baxter). The primary end point was completion of the 2-hour dwell without significant discomfort or adverse events, and the secondary end point was difference in sodium removal between DSR and standard PD solution.

RESULTS

Porcine experiments revealed that 1 L DSR solution removed 4.1±0.4 g sodium in 2 hours with negligible off-target solute removal and overall stable serum electrolytes. Increasing the volume of DSR solution cycled across the peritoneum increased sodium removal and substantially decreased plasma volume (P=0.005). In the setting of experimental heart failure with elevated right atrial pressure, sodium removal was ≈4 times greater than in healthy animals (P<0.001). In the human proof-of-concept study, DSR solution was well tolerated and not associated with significant discomfort or adverse events. Plasma electrolyte concentrations were stable, and off-target solute removal was negligible. Sodium removal was substantially higher with DSR (4.5±0.4 g) compared with standard PD solution (1.0±0.3 g; P<0.0001).

CONCLUSIONS

DSR was well tolerated in both animals and human subjects and produced substantially greater sodium removal than standard PD solution. Additional research evaluating the use of DSR as a method to prevent and treat hypervolemia in heart failure is warranted. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03801226.

Improving Satisfaction With Operating Room Feedback: An Effective, Low-Profile, No-Cost Intervention

OBJECTIVE

The objective of this study was to develop and implement an effective and minimally invasive tool to enhance formative and goal specific feedback for general surgery residents in the operating room.

DESIGN

Placards reminding surgical faculty and residents to engage in goal directed feedback were installed at scrub sinks outside of every operating room. The purpose was to encourage both residents and faculty to agree on a learning goal before the case, teach and learn that goal during the case, and discuss progress and next steps after the case. Preintervention and postintervention questionnaires were administered via Qualtrics Online Survey Software to all general surgery residents and core faculty members.

SETTING

Placards were installed at every scrub sink across all 4 hospitals associated with Yale School of Medicine General Surgery Residency over a 6-month time period.

PARTICIPANTS

Respondents included general surgery residents and core surgical faculty of the Yale School of Medicine General Surgery Residency.

RESULTS

Following the intervention, residents reported a statistically significant increase in preoperative discussion of learning goals, debriefing about specific learning goals postoperatively, and overall satisfaction with feedback (p < 0.01). Conversely, faculty perception of feedback did not change as a result of the intervention with faculty consistently reporting higher rates of preoperative learning goal discussions, providing goal specific feedback intraoperatively, and debriefing postoperatively when compared to residents (p < 0.01).

CONCLUSIONS

Formative feedback reminder placards placed near operating rooms serve as a low-profile, no-cost intervention to improve general surgery resident satisfaction with operative feedback and increase the perceived rate of goal specific feedback discussions both pre- and postoperatively.

Paying the Price: Understanding the Opportunity Cost of Dedicated Research Time during Surgical Training

The pursuit of dedicated research time during surgical residency prolongs training and delays entry into practice. Currently, there is a lack of research quantifying the financial implication of this delay and trainees’ understanding of its impact on career earnings. An opportunity cost analysis was performed regarding the impact of delay due to training within general surgery and selected subspecialties. An anonymous survey was distributed to general surgery categorical junior trainees in 2017 at a large academic hospital in the Northeast to determine understanding and beliefs regarding dedicated training on career earnings. For all specialties analyzed, dedicated research time was shown to negatively affect career earnings. The net cost was highest among those intending to pursue cardiothoracic surgery and lowest for those intending to pursue surgical oncology. A total of 26 of 35 (74%) present research residents and clinical residents intending to perform dedicated research time responded to an anonymous survey. On average, survey respondents underestimated the impact of dedicated research time on career earnings by $1.4 million. Dedicated research time during general surgery residency carries a substantial opportunity cost to overall career earnings. General surgery residents lack understanding of both the direction and the magnitude of this opportunity cost.

Paying the Price: Understanding the Opportunity Cost of Dedicated Research Time during Surgical Training

The pursuit of dedicated research time during surgical residency prolongs training and delays entry into practice. Currently, there is a lack of research quantifying the financial implication of this delay and trainees' understanding of its impact on career earnings. An opportunity cost analysis was performed regarding the impact of delay due to training within general surgery and selected subspecialties. An anonymous survey was distributed to general surgery categorical junior trainees in 2017 at a large academic hospital in the Northeast to determine understanding and beliefs regarding dedicated training on career earnings. For all specialties analyzed, dedicated research time was shown to negatively affect career earnings. The net cost was highest among those intending to pursue cardiothoracic surgery and lowest for those intending to pursue surgical oncology. A total of 26 of 35 (74%) present research residents and clinical residents intending to perform dedicated research time responded to an anonymous survey. On average, survey respondents underestimated the impact of dedicated research time on career earnings by $1.4 million. Dedicated research time during general surgery residency carries a substantial opportunity cost to overall career earnings. General surgery residents lack understanding of both the direction and the magnitude of this opportunity cost.

The impact of a curriculum on postoperative opioid prescribing for novice surgical trainees

BACKGROUND

Surgical residents are frequently responsible for prescribing postoperative analgesia, yet the vast majority are never formally educated on the subject.

METHODS

A resident-led educational presentation on postoperative analgesia prescribing was provided to incoming surgical interns at a tertiary academic center. Pre- and post-surveys assessed comfort in prescribing postoperative analgesia. Following the educational intervention, opioid prescriptions during the interns' first two months were compared to that of the prior year's interns.

RESULTS

Education was provided to 31 interns. Prior to the session, few interns felt comfortable prescribing opioids (20%) or non-opioid analgesia (32%). After the session, 96% felt more comfortable prescribing opioids and 91% more comfortable prescribing multi-modal analgesia. Interns who received education prescribed an average of 127.8 Morphine Milligram Equivalents (MME) per prescription, compared to 208.5 MME by the prior year's interns (p < 0.01).

CONCLUSION

Education on postoperative analgesia targeting interns can be effective in preparing trainees in effective and judicious analgesic prescribing.

Liver paired exchange: Can the liver emulate the kidney?

Kidney paired exchange (KPE) constitutes 12% of all living donor kidney transplantations (LDKTs) in the United States. The success of KPE programs has prompted many in the liver transplant community to consider the possibility of liver paired exchange (LPE). Though the idea seems promising, the application has been limited to a handful of centers in Asia. In this article, we consider the indications, logistical issues, and ethics for establishing a LPE program in the United States with reference to the principles and advances developed from experience with KPE. Liver Transplantation 24 677-686 2018 AASLD.

Beyond 250: A Comprehensive Strategy to Maximize the Operative Experience for Junior Residents

OBJECTIVES

Among surgical educators, duty-hour restrictions led to concern regarding the adequacy of operative experience during residency, especially for junior residents. The American Board of Surgery recently instituted guidelines mandating "a minimum of 250 operations by the end of the PGY-2 year". A series of programmatic and institutional changes were implemented at our institution to augment the junior resident operative experience and to exceed compliance with this mandate.

METHODS

Operative data from Accreditation Council for Graduate Medical Education case logs for categorical and nondesignated preliminary interns from our large academic surgical residency were identified for 5 consecutive academic years, 2011 until 2016. American Board of Surgery In-Training Examination (ABSITE) scores were collected anonymously. The program systematically instituted the following changes: night float minimization, identification of new surgical opportunities, augmenting use of midlevel care providers, identification of rotations with suboptimal operative experiences, maximizing rotations with involvement of junior residents in the operating room, and systematic review of junior case logs.

RESULTS

After implementation, average total cases for residents completing postgraduate year (PGY)-2 increased from 176 to 330 (p < 0.001). Specifically, there was an 18% increase for interns (p = 0.059) and a 118% increase for PGY-2 residents (p < 0.001). There were statistically significant increases in skin and soft tissue cases, vascular cases, endoscopy, and complex laparoscopic cases. Average case volumes for senior residents did not change. Night float time was significantly decreased (5.7 vs 3.4 wk; p = 0.04). ABSITE scores were not significantly changed during this time.

CONCLUSIONS

Before implementation of these interventions, our program would have had 0% compliance with the 250 junior resident case rule. Within 12 months of implementation, total case volumes for residents completing PGY-2 increased by 88%-exceeding minimum standards. Overall, 100% programmatic compliance was achieved. Our program's experience exemplifies how mandates from the American Board of Surgery can lead to programmatic changes that improve the experience of surgical house officers.

Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents

OBJECTIVE

Opioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience.

DESIGN

Anonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription.

SETTING

Accreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital.

PARTICIPANTS

Categorical and preliminary general surgery residents of all postgraduate years.

RESULTS

The percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription.

CONCLUSION AND RELEVANCE

Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.

Kidney Transplantation With and Without Native Nephrectomy for Polycystic Kidney Disease: Results of the National Inpatient Sample and the Rationale for a 2-Staged Procedure

BACKGROUND

Polycystic kidney disease (PKD) is one of the most common causes of end-stage renal disease requiring hemodialysis or transplantation. In patients requiring transplantation, there are several indications for native nephrectomy, including recurrent cyst infection, bleeding, or to provide room for the graft. There is disagreement about whether it is advisable to perform kidney transplantation alone (KT), or to perform KT with simultaneous native nephrectomy (KTN). We compared postoperative outcomes of KTN and KT in a large national cohort.

STUDY DESIGN

The Nationwide Inpatient Sample (NIS) between 2000 and 2014 was examined for a diagnosis of PKD with evidence for KT or KTN. Logistic regression, adjusting for age, sex, comorbidity, and hospital region, was used to compare groups for the need for blood transfusion, need for critical care interventions, and development of postoperative complications.

RESULTS

A total of 4,003 hospitalizations were identified, which was representative of 19,302 weighted discharges nationally. In adjusted logistic regression models, KTN demonstrated significantly higher risk for blood transfusion (odds ratio [OR] 2.06; 95% CI 1.44 to 2.96; p < 0.0001), postoperative complications (OR 1.44; 95% CI 1.05 to 1.96; p = 0.02), and critical care interventions (OR 1.44; 95% CI 1.07 to 1.95; p = 0.02). Other significant predictors for blood transfusion included female sex (OR 1.76; 95% CI 1.45 to 2.13; p < 0.0001), age older than 61 years (OR 1.60; 95% CI 1.21 to 2.10; p = 0.001), and Charlson comorbidity score ≥2 (OR 1.52; 95% CI 1.10 to 2.09; p = 0.01).

CONCLUSIONS

Among patients with PKD, in comparison with KTN, KT alone represents a decreased risk for negative postoperative outcomes. A 2-staged procedure should be considered, when feasible, to minimize adverse patient outcomes.

Patient and Graft Survival Among Sexagenarian and Septuagenarian Renal Transplant Recipients and Donors: The Context for Older Recipients

Due to the increasing number of patients with end-stage renal disease, there is a growing demand for transplants for recipients and donors aged 60 years and older. Using data from the Scientific Registry of Transplant Recipients, we performed survival analyses and multivariate logistic regression to help guide transplant professional decisions regarding the selection of graft type (living vs deceased) and donor age (60-69 vs 70+ years) for recipients aged 60 years and older.

Belatacept and Eculizumab for Treatment of Calcineurin Inhibitor-induced Thrombotic Microangiopathy After Kidney Transplantation: Case Report

Thrombotic microangiopathy (TMA) after kidney transplantation is an uncommon and challenging cause of graft dysfunction and is associated with early graft loss. An idiosyncratic endothelial reaction to calcineurin inhibitors (CNIs) has been implicated as a frequent cause of TMA. This reaction is marked by uncontrolled activation of complement and subsequent cellular destruction. Usual therapy consists of withdrawal of the inciting drug and plasmapheresis to minimize levels of circulating complement. Recently, eculizumab, a monoclonal antibody to complement component C5, has been used for the treatment of atypical hemolytic uremic syndrome. Belatacept, an inhibitor of T cell costimulatory protein CTLA-4 has been used in immunosuppression strategies aimed at minimization of CNI. Here we report the first case of treatment of CNI-associated TMA/hemolytic uremic syndrome with withdrawal of tacrolimus and initiation of both belatacept and eculizumab. The case describes a favorable clinical course for both graft and patient, and is accompanied by a review of the literature.

Perioperative outcomes of coronary artery bypass graft in renal transplant recipients in the United States: results from the Nationwide Inpatient Sample

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). In fact, death from cardiovascular disease is the number one cause of graft loss in kidney transplant (KTx) patients. Compared to patients on dialysis, CKD patients with KTx have increased quality and length of life. It is not known, however, whether outcomes of coronary artery bypass graft (CABG) surgery differ between CKD patients with KTx or on dialysis.

METHODS

This was a retrospective cohort study comparing CKD patients with KTx or on dialysis undergoing CABG surgery included in the Nationwide Inpatient Sample from 2002 to 2011. Logistic and linear regression models were used to estimate the adjusted associations of KTx on all-cause in-hospital mortality, length of stay, cost of hospitalization, and rate of complications in CABG surgery.

RESULTS

CKD patients with KTx had decreased all-cause in-hospital mortality (2.68% vs 5.86%, odds ratio (OR)=0.56, 95% confidence interval (CI)=0.32 to 0.99, P=.046), length of stay (β=-2.96, 95% CI=-3.67 to -2.46, P<.001), and total hospital charges (difference=-$38 884, 95% CI=-$48 173 to -29 596, P<.001). They also had decreased rate of a number of perioperative complications.

CONCLUSIONS

CKD patient with KTx have better perioperative outcomes in CABG surgery compared to patients on dialysis.

Senior Surgical Resident Confidence in Performing Flexible Endoscopy: What Can We Do Differently?

INTRODUCTION

The American Board of Surgery endoscopy requirements for general surgery training are evolving. In 2006, the Residency Review Committee in Surgery increased the total number of endoscopy cases required before completion of general surgery residency training. This requirement is set to change further, given the new Flexible Endoscopic Curriculum that would be a requirement for applicants graduating surgical training during or after the 2017 to 2018 academic year. Given these changes, our goal was to evaluate the confidence of senior surgical residents performing flexible endoscopy.

METHODS

A survey was developed and sent to general surgery residents nationally, querying them regarding demographics and program-specific characteristics; additionally they were asked to rate their confidence level in performing flexible upper endoscopy and colonoscopy on a Likert scale of 1 to 5. We then compared those residents who indicated confidence (Likert scale 4-5) to those who did not (Likert scale 1-3). For the purpose of this study, only senior (postgraduate year 4 and 5) general surgery residents were assessed.

RESULTS

We received 1176 responses from senior surgical residents: 56% of these were postgraduate year 5 residents, 65% male, 68% from University Programs, and 56% from programs associated with a Veteran's Affairs Hospital; 33% were from programs in the Northeast, 29% in the South, 24% in the Midwest, and 14% in the West; 75% were going on to additional fellowship training after the completion of residency; 42% indicated that they would go into academic practice and 32% into private practice; 66.7% reported confidence performing upper endoscopy and 52.7% reported confidence performing colonoscopy. Male gender, overall operative volume, and graduating from a medium-sized program or program in the South were associated with increased confidence performing flexible endoscopy.

CONCLUSIONS

A large percentage of senior residents do not report confidence in performing flexible endoscopy. Although increasing the number of cases required for graduation has likely helped improve the training of residents in endoscopy, additional improvements in training are required. The Flexible Endoscopic Curriculum helps standardize the curriculum and demonstrate that the graduating resident has the fundamental knowledge and skills required in the performance of endoscopy. Simulation training and dedicated endoscopic rotations during the course of residency training could help improve endoscopy training and proficiency for future graduating residents.

Non-alcoholic fatty liver disease following liver transplantation: a clinical review

Non-alcoholic steatohepatitis (NASH) is rapidly becoming the leading indication for liver transplantation (LT) in the United States. While post-transplantation outcomes are similar to other indications for transplant, recent evidence has suggested that reduction in risk factors for post-transplant metabolic syndrome may impose a significant survival benefit in this patient population. Cardiovascular mortality is the leading cause of death following transplantation for NASH. While pre-transplant pharmacologic and surgical approaches have been utilized to reduce cardiovascular risk factors following transplantation, the effectiveness of these treatment approaches in the post-transplant setting is poorly defined. Studies are urgently needed in the treatment of this rapidly growing population.