"I Came up Short on the Academic Ladder": A Grounded Theory Study of Careerism in Academic Surgery

OBJECTIVE

This study aims to explore the definition of career success in academic surgery.

BACKGROUND

Career success in academic surgery is frequently defined as the achievement of a specific title, from full professor to department chair. This type of definition is convenient and established but potentially incomplete. The business literature has a more nuanced view of the relationship between titles and success, but this relationship has not been studied in medicine.

METHODS

Semi-structured interviews were conducted from May to November 2020. Data were analyzed in an iterative fashion using grounded theory methodology to develop a conceptual model.

RESULTS

We conducted 26 semi-structured interviews with practicing surgeons differing in years of experience; 12 (46%) participants were female, mean age of 48. Participants included 5 chairs of surgery, 6 division chiefs, and 7 past or current presidents of national societies. Four themes emerged on the importance of titles: Some study participants reported that (1) titles are a barometer of success; others argued that (2) titles are not a sufficient metric to define success; (3) titles are a means to an end; and (4) there is a desire to achieve the title of a respected mentor.

CONCLUSIONS

As the definition of career success in academic surgery changes to encompass a broader range of interests and ambitions, the traditional markers of success must come into review. Academic surgeons see the value of titles as a marker of success and as a means to achieving other goals, but overwhelmingly our interviewees felt that titles were a double-edged sword and that a more inclusive definition of academic success was needed.

What Is the Best Operation for Proximal Gastric Cancer and Distal Esophageal Cancer?

Cancer of the gastroesophageal junction (GEJ) is increasing in incidence, likely as a result of rising obesity and gastroesophageal reflux disease rates. The tumors that arise here share features of esophageal and gastric cancer, and are classified based on their location in relationship to the GEJ. The definition of the GEJ itself, as well as optimal resection strategy, extent of lymph node dissection, resection margin length, and reconstruction methods are still very much a subject of debate. This article summarizes the available evidence on this topic, and highlights specific areas for further research.

Evaluating Surgical Coaching: A Mixed Methods Approach Reveals More Than Surveys Alone

OBJECTIVE

Traditionally, surgical educators have relied upon participant survey data for the evaluation of educational interventions. However, the ability of such subjective data to completely evaluate an intervention is limited. Our objective was to compare resident and attending surgeons' self-assessments of coaching sessions from surveys with independent observations from analysis of intraoperative and postoperative coaching transcripts.

DESIGN

Senior residents were video-recorded operating. Each was then coached by the operative attending in a 1:1 video review session. Teaching points made in the operating room (OR) and in post-OR coaching sessions were coded by independent observers using dialogue analysis then compared using t-tests. Participants were surveyed regarding the degree of teaching dedicated to specific topics and perceived changes in teaching level, resident comfort, educational assessments, and feedback provision between the OR and the post-OR coaching sessions.

SETTING

A single, large, urban, tertiary-care academic institution.

PARTICIPANTS

Ten PGY4 to 5 general surgery residents and 10 attending surgeons.

RESULTS

Although the reported experiences of teaching and coaching sessions by residents and faculty were similar (Pearson correlation coefficient = 0.88), these differed significantly from independent observations. Observers found that residents initiated a greater proportion of teaching points and had more educational needs assessments during coaching, compared to the OR. However, neither residents nor attendings reported a change between the 2 environments with regard to needs assessments nor comfort with asking questions or making suggestions. The only metric on which residents, attendings, and observers agreed was the provision of feedback.

CONCLUSIONS

Participants' perspectives, although considered highly reliable by traditional metrics, rarely aligned with analysis of the associated transcripts from independent observers. Independent observation showed a distinct benefit of coaching in terms of frequency and type of learning points. These findings highlight the importance of seeking different perspectives, data sources, and methodologies when evaluating clinical education interventions. Surgical education can benefit from increased use of dialogue analyses performed by independent observers, which may represent a viewpoint distinct from that obtained by survey methodology.

Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees

IMPORTANCE

Mistreatment of medical students is pervasive and has negative effects on performance, well-being, and patient care.

OBJECTIVE

To document the published programmatic and curricular attempts to decrease the incidence of mistreatment.

DATA SOURCES

PubMed, Scopus, ERIC, the Cochrane Library, PsycINFO, and MedEdPORTAL were searched. Comprehensive searches were run on "mistreatment" and "abuse of medical trainees" on all peer-reviewed publications until November 1, 2017.

STUDY SELECTION

Citations were reviewed for descriptions of programs to decrease the incidence of mistreatment in a medical school or hospital with program evaluation data. A mistreatment program was defined as an educational effort to reduce the abuse, mistreatment, harassment, or discrimination of trainees. Studies of the incidence of mistreatment without description of a program, references to a mistreatment program without outcome data, or a program that has never been implemented were excluded.

DATA EXTRACTION AND SYNTHESIS

Authors independently reviewed all retrieved citations. Articles that any author found to meet inclusion criteria were included in a full-text review. The data extraction form was developed based on the guidelines for Best Evidence in Medical Education. An assessment of the study quality was conducted using a conceptual framework of 6 elements essential to the reporting of experimental studies in medical education.

MAIN OUTCOMES AND MEASURES

A descriptive review of the interventions and outcomes is presented along with an analysis of the methodological quality of the studies. A separate review of the MedEdPORTAL mistreatment curricula was conducted.

RESULTS

Of 3347 citations identified, 10 studies met inclusion criteria. Of the programs included in the 10 studies, all were implemented in academic medical centers. Seven programs were in the United States, 1 in Canada, 1 in the United Kingdom, and 1 in Australia. The most common format was a combination of lectures, workshops, and seminars over a variable time period. Overall, quality of included studies was low and only 1 study included a conceptual framework. Outcomes were most often limited to participant survey data. The program outcome evaluations consisted primarily of surveys and reports of mistreatment. All of the included studies evaluated participant satisfaction, which was mostly qualitative. Seven studies also included the frequency of mistreatment reports; either surveys to assess perception of the frequency of mistreatment or the frequency of reports via official reporting channels. Five mistreatment program curricula from MedEdPORTAL were also identified; of these, only 2 presented outcome data.

CONCLUSIONS AND RELEVANCE

There are very few published programs attempting to address mistreatment of medical trainees. This review identifies a gap in the literature and provides advice for reporting on mistreatment programs.

A Mixed-Methods Analysis of a Novel Mistreatment Program for the Surgery Core Clerkship

PURPOSE

To review mistreatment reports from before and after implementation of a mistreatment program, and student ratings of and qualitative responses to the program to evaluate the short-term impact on students.

METHOD

In January 2014, a video- and discussion-based mistreatment program was implemented for the surgery clerkship at the Stanford University School of Medicine. The program aims to help students establish expectations for the learning environment; create a shared and personal definition of mistreatment; and promote advocacy and empower ment to address mistreatment. Counts and types of mistreatment were compared from a year before (January-December 2013) and two years after (January 2014-December 2015) implementation. Students' end-of-clerkship ratings and responses to open-ended questions were analyzed.

RESULTS

From March 2014-December 2015, 141/164 (86%) students completed ratings, and all 47 (100%) students enrolled from January-August 2014 provided qualitative program evaluations. Most students rated the initial (108/141 [77%]) and final (120/141 [85%]) sessions as excellent or outstanding. In the qualitative analysis, students valued that the program helped establish expectations; allowed for sharing experiences; provided formal resources; and provided a supportive environment. Students felt the learning environment and culture were improved and reported increased interest in surgery. There were 14 mistreatment reports the year before the program, 9 in the program's first year, and 4 in the second year.

CONCLUSIONS

The authors found a rotation-specific mistreatment program, focused on creating shared understanding about mistreatment, was well received among surgery clerkship students, and the number of mistreatment reports decreased each year following implementation.

Quality of Life After Bariatric Surgery

PURPOSE OF REVIEW

The purpose of this review is to provide an introduction to quality of life (QOL) outcomes after bariatric surgery and a summary of the current evidence.

RECENT FINDINGS

QOL has been emphasized in bariatric surgery since the NIH Consensus Conference statement in 1991. Initial studies were limited to 1- and 2-year follow-up. More recent findings have expanded the follow-up period up to 12 years, providing a better description of the impact on long-term QOL. Overall, there is little to no consensus regarding the definition of QOL or the ideal survey. Bariatric surgery has the greatest impact on physical QOL, and the impact on mental health remains unclear. There are some specific and less frequently reported threats to quality of life after bariatric surgery that are also discussed. Obesity has a definite impact on quality of life, even without other comorbidities, and surgery for obesity results in significant and lasting improvements in patient-reported quality of life outcomes. This conclusion is limited by a wide variety of survey instruments and absence of consensus on the definition of QOL after bariatric surgery.

Complementing Operating Room Teaching With Video-Based Coaching

Importance

Surgical expertise demands technical and nontechnical skills. Traditionally, surgical trainees acquired these skills in the operating room; however, operative time for residents has decreased with duty hour restrictions. As in other professions, video analysis may help maximize the learning experience.

Objective

To develop and evaluate a postoperative video-based coaching intervention for residents.

Design, Setting, and Participants

In this mixed methods analysis, 10 senior (postgraduate year 4 and 5) residents were videorecorded operating with an attending surgeon at an academic tertiary care hospital. Each video formed the basis of a 1-hour one-on-one coaching session conducted by the operative attending; although a coaching framework was provided, participants determined the specific content collaboratively. Teaching points were identified in the operating room and the video-based coaching sessions; iterative inductive coding, followed by thematic analysis, was performed.

Main Outcomes and Measures

Teaching points made in the operating room were compared with those in the video-based coaching sessions with respect to initiator, content, and teaching technique, adjusting for time.

Results

Among 10 cases, surgeons made more teaching points per unit time (63.0 vs 102.7 per hour) while coaching. Teaching in the video-based coaching sessions was more resident centered; attendings were more inquisitive about residents' learning needs (3.30 vs 0.28, P = .04), and residents took more initiative to direct their education (27% [198 of 729 teaching points] vs 17% [331 of 1977 teaching points], P < .001). Surgeons also more frequently validated residents' experiences (8.40 vs 1.81, P < .01), and they tended to ask more questions to promote critical thinking (9.30 vs 3.32, P = .07) and set more learning goals (2.90 vs 0.28, P = .11). More complex topics, including intraoperative decision making (mean, 9.70 vs 2.77 instances per hour, P = .03) and failure to progress (mean, 1.20 vs 0.13 instances per hour, P = .04) were addressed, and they were more thoroughly developed and explored. Excerpts of dialogue are presented to illustrate these findings.

Conclusions and Relevance

Video-based coaching is a novel and feasible modality for supplementing intraoperative learning. Objective evaluation demonstrates that video-based coaching may be particularly useful for teaching higher-level concepts, such as decision making, and for individualizing instruction and feedback to each resident.

A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

BACKGROUND

Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction.

OBJECTIVE

To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers.

DESIGN

Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons.

PARTICIPANTS

Twenty-two internal medicine residents in their second or third postgraduate year.

INTERVENTION

An educational dinner describing the format and potential benefits of using the CPI.

MAIN MEASURES

Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians.

KEY RESULTS

All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups.

CONCLUSIONS

Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

Predictors of negative intraoperative findings at emergent laparotomy in patients with cirrhosis

BACKGROUND

Emergent surgery in the setting of decompensated cirrhosis is highly morbid. We sought to determine the clinical factors associated with negative intraoperative findings at emergent laparotomy.

METHODS

We performed a retrospective cohort study of consecutive inpatients with a diagnosis of cirrhosis (ICD-9 571) admitted to the Beth Israel Deaconess Medical Center (Boston, MA) who underwent emergent, nonhepatic, abdominal surgery between May 6, 2005 and September 3, 2012.

RESULTS

Eighty-six patients with cirrhosis were included with a mean model for end-stage liver disease score of 21.3 ± 7.95 and a 90-day mortality rate of 39.5%. Twelve (16.2%) patients had negative laparotomies. Negative intraoperative findings were independently associated with (1) paracentesis prior to a preoperative diagnosis of perforated viscus (P = 0.006), (2) development of an indication for emergent surgery after 24 h into hospital admission for another reason (P = 0.020), and (3) a preoperative diagnosis of bowel ischemia (P = 0.005), with odds ratios of 10.1 (CI 1.92-66.83), 5.80 (CI 1.32-33.39), and 11.1 (CI 2.08-77.4), respectively. Free air on computed tomography (CT) imaging was found in 64.3% (9/14) of patients who had a paracentesis within the preceding 48 h compared to 10.1% (7/72) among patients who did not undergo a paracentesis (P < 0.001). Only 45% of patients with free air following a paracentesis had positive findings at laparotomy compared to 100% in those without a preceding paracentesis (P = 0.038). Negative laparotomy was independently predictive of in-hospital mortality (OR 4.7; P = 0.034).

CONCLUSION

The possibility of a negative laparotomy is suggested by preoperative clinical factors. In particular, free air following a paracentesis does not necessarily indicate that operative intervention is required. Consideration of close observation before laparotomy in these patients is reasonable.

Tumor characteristics and survival analysis of incidental versus suspected gallbladder carcinoma

INTRODUCTION

Over half of all gallbladder carcinoma (GBC) is discovered incidentally after cholecystectomy for benign disease. There are scant data comparing presentation and outcome for patients with incidental versus suspected GBC. The goal of this study is to determine the clinical differences between these two entities.

STUDY DESIGN

Patients with GBC were identified retrospectively from records at academic healthcare institutions in Temuco, Chile; Atlanta, GA; and Rochester, MN between 1984 and 2008. Overall survival was compared for patients with and without preoperative suspicion using Kaplan-Meier curves and a multivariate Cox proportional hazards model.

RESULTS

Of 571 patients, 128 (22.4%) had preoperative suspicion of malignancy, and 443 (77.6 %) were discovered incidentally. Incidental tumors were of lower stage, better differentiated, and with lower rates of metastases. Median survival for incidentally discovered GBC was 32.3 versus 5.8 months for suspected GBC (p<0.0001). In a Cox proportional hazards model controlling for operation extent, T stage, differentiation, and other factors, preoperative suspicion remains a strong risk factor (odds ratio, 2.0; confidence interval, 1.5-2.9; p<0.0001).

CONCLUSIONS

Tumor characteristics differed significantly between patients with incidentally discovered versus preoperatively suspected GBC. Incidental GBC has a significantly better median survival.

Single versus multi-specialty operative teams: association with perioperative mortality after endovascular abdominal aortic aneurysm repair

Endovascular abdominal aortic aneurysm repair (EVAR) requires both endovascular and open surgical skills. Although usually performed by a single operating specialist, EVAR may alternatively involve multiple teams from different specialties performing separate procedural components. We examined the relative frequencies of single versus multi-specialty EVAR in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and explored the influence of multi-specialty EVAR on 30-day mortality. EVARs were identified and classified as single or multiple-specialty procedures based on Current Procedural Terminology codes. Baseline and procedural characteristics were compared using χ(2) or Fisher's exact test for categorical variables and t test for continuous variables. The association between multi-specialty EVAR and 30-day mortality was examined using a multivariate logistic regression model. Of 7269 EVAR patients identified, 7086 were single and 183 were multi-specialty. Multi-specialty patients had higher frequency of brachial or iliac artery exposure and longer operative times, but were otherwise similar in baseline and procedural characteristics. In the multivariate model, multi-specialty EVAR was associated with increased risk of 30-day mortality (odds ratio 2.35; 95% confidence interval 1.08-5.11; P value 0.031). Multi-specialty participation in EVAR procedures is associated with significantly higher 30-day mortality. Further research is warranted to determine whether multi-specialty participation reflects provider experience, institutional protocols, procedural complexity, non-surgical or other factors.

Single versus Multi-Specialty Operative Teams: Association with Perioperative Mortality after Endovascular Abdominal Aortic Aneurysm Repair

Endovascular abdominal aortic aneurysm repair (EVAR) requires both endovascular and open surgical skills. Although usually performed by a single operating specialist, EVAR may alternatively involve multiple teams from different specialties performing separate procedural components. We examined the relative frequencies of single versus multi-specialty EVAR in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and explored the influence of multi-specialty EVAR on 30-day mortality. EVARs were identified and classified as single or multiple-specialty procedures based on Current Procedural Terminology codes. Baseline and procedural characteristics were compared using χ2 or Fisher's exact test for categorical variables and t test for continuous variables. The association between multi-specialty EVAR and 30-day mortality was examined using a multivariate logistic regression model. Of 7269 EVAR patients identified, 7086 were single and 183 were multi-specialty. Multi-specialty patients had higher frequency of brachial or iliac artery exposure and longer operative times, but were otherwise similar in baseline and procedural characteristics. In the multivariate model, multi-specialty EVAR was associated with increased risk of 30-day mortality (odds ratio 2.35; 95% confidence interval 1.08–5.11; P value 0.031). Multi-specialty participation in EVAR procedures is associated with significantly higher 30-day mortality. Further research is warranted to determine whether multi-specialty participation reflects provider experience, institutional protocols, procedural complexity, non-surgical or other factors.

Docosahexaenoic acid status in females of reproductive age with maple syrup urine disease

Individuals with maple syrup urine disease (MSUD) have impaired metabolism of branched-chain amino acids (BCAA) valine, isoleucine, and leucine. Life-long dietary therapy is recommended to restrict BCAA intake and thus prevent poor neurological outcomes and death. To maintain adequate nutritional status, the majority of protein and nutrients are derived from synthetic BCAA-free medical foods with variable fatty acid content. Given the restrictive diet and the importance of omega-3 fatty acids, particularly docosahexaenoic acid (DHA), in neurological development, this study evaluated the dietary and fatty acid status of females of reproductive age with MSUD attending a metabolic camp. Healthy controls of similar age and sex were selected from existing normal laboratory data. Total lipid fatty acid concentration in plasma and erythrocytes was analyzed using gas chromatography-mass spectroscopy. Participants with MSUD had normal to increased concentrations of plasma and erythrocyte alpha linolenic acid (ALA) but significantly lower concentrations of plasma and erythrocyte docosahexaenoic acid (DHA) as percent of total lipid fatty acids compared with controls (plasma DHA: MSUD 1.03 +/- 0.35, controls 2.87 +/- 1.08; P = 0.001; erythrocyte DHA: MSUD 2.58 +/- 0.58, controls 3.66 +/- 0.80; P = 0.011). Dietary records reflected negligible or no DHA intake over the 3-day period prior to the blood draw (range 0-2 mg). These results suggest females of reproductive age with MSUD have lower blood DHA concentrations than age-matched controls. In addition, the presence of ALA in medical foods and the background diet may not counter the lack of preformed DHA in the diet. The implications of these results warrant further investigation.