Resident Perspectives on Effective Surgical Training: Incivility, Confidence, and Mindset

OBJECTIVE

Ample evidence exists that one's internal state (e.g., mindset, emotion) impacts one's performance. Both the military and sports organizations have focused on optimizing internal states of their service members and athletes, respectively, to improve performance and wellbeing. The internal states of surgical residents and the factors that influence their internal states have not yet been examined. Our goal is to better understand whether certain internal states are beneficial for resident operative performance, and how to optimize these during surgical training.

DESIGN

A 17-question survey, containing both open-ended and multiple-choice questions, was distributed to all (n = 134) surgical residents at the University of Wisconsin. In open-ended questions, recurring themes were identified utilizing content analysis. Recurring themes stated by 25% or more of the respondents are reported.

SETTING

Department of Surgery at the University of Wisconsin-Madison.

PARTICIPANTS

Surgical residents at the University of Wisconsin.

RESULTS

The survey response rate varied between n = 47 (35%) and n = 32 (24%), as not all respondents answered all questions. (1) Effective surgical educators were identified to demonstrate humanism and focus on teaching. (2) Nearly all residents affirmed that certain mindsets help them excel in the OR, including positive and confident mindsets. (3) Nearly all residents affirmed that faculty and senior residents influence their mindsets. (4) Constructive resident mindsets were promoted by positive faculty behaviors and personal preparation, while negative faculty behaviors were identified to stifle constructive mindsets. (5) Factors contributing to favorable OR performance included personal preparation and positive OR environments. (6) Factors contributing to poor OR performance included inadequate preparation and negative interactions with faculty.

CONCLUSIONS

Residents near unanimously believe that certain mindsets help them excel, and that faculty impact their mindsets. As teachers, we must strive to better understand how to foster constructive mindsets in residents to optimize learning, performance, and wellbeing.

Adjuvant therapy following resection of gastroenteropancreatic neuroendocrine tumors provides no recurrence or survival benefit

BACKGROUND AND OBJECTIVES

Lack of high-level evidence supporting adjuvant therapy for patients with resected gastroenteropancreatic neuroendocrine tumors (GEP NETs) warrants an evaluation of its non-standard of care use.

METHODS

Patients with primary GEP NETs who underwent curative-intent resection at eight institutions between 2000 and 2016 were identified; 91 patients received adjuvant therapy. Recurrence-free survival (RFS) and overall survival (OS) were compared between adjuvant cytotoxic chemotherapy and somatostatin analog cohorts.

RESULTS

In resected patients, 33 received cytotoxic chemotherapy, and 58 received somatostatin analogs. Five-year RFS/OS was 49% and 83%, respectively. Cytotoxic chemotherapy RFS/OS was 36% and 61%, respectively, lower than the no therapy cohort (P < .01). RFS with somatostatin analog therapy (compared to none) was lower (P < .01), as was OS (P = .01). On multivariable analysis, adjuvant cytotoxic therapy was negatively associated with RFS but not OS controlling for patient/tumor-specific characteristics (RFS P < .01).

CONCLUSIONS

Our data, reflecting the largest reported experience to date, demonstrate that adjuvant therapy for resected GEP NETs is negatively associated with RFS and confers no OS benefit. Selection bias enriching our treatment cohort for individuals with unmeasured high-risk characteristics likely explains some of these results; future studies should focus on patient subsets who may benefit from adjuvant therapy.

Medawar's Paradox and Immune Mechanisms of Fetomaternal Tolerance

Brazilian-born British biologist Dr. Peter Medawar played an integral role in developing the concepts of immunologic rejection and tolerance, which led to him receiving the Nobel Prize "for the discovery of acquired immunologic tolerance" and eventually made organ transplantation a reality. However, at the time of his early work in tolerance, a paradox to his theories was brought to his attention; how was pregnancy possible? Pregnancy resembles organ transplantation in that the fetus, possessing paternal antigens, is a semi-allogeneic graft that can survive without immunosuppression for 9 months. To answer this question, Medawar proposed three hypotheses of how a mother supports her fetus in utero, now known as "Medawar's Paradox." The mechanisms that govern fetomaternal tolerance are still incompletely understood but may provide critical insight into how to achieve immune tolerance in organ transplantation. Here, we review current understanding of the immune factors responsible for fetomaternal tolerance during pregnancy and discuss the potential implications for advances in transplantation science.

Interaction of race and pathology for neuroendocrine tumors: Epidemiology, natural history, or racial disparity?

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Background: The prognostic value of pathologic variables is not consistent for gastroenteropancreatic neuroendocrine tumors (GEP-NETs). We previously demonstrated a limited prognostic role of lymph node (LN) positivity in small bowel NETs (SBNET) compared to pancreatic NETs (panNET). Although minority race is often associated with worse cancer outcomes, the interaction of race with pathologic and oncologic outcomes of pts with GEP-NETS is not known. Methods: Pts with GEP-NETs who underwent curative intent resection at eight institutions of the US NET Study Group from 2000-16 were included. Given few pts of other races, only Black and White race pts were analyzed. Results: Of 2,182 pts, 1,143 met inclusion criteria. Median age was 58 yrs, median follow up was 3 yrs, 48% were male, 14% (n = 157) were Black, and 86% (n = 986) were White. Black pts were more likely uninsured (7 vs 2%, p = 0.005), had symptomatic bleeding (13 vs 7%, p = 0.006), required emergency surgery (7 vs 3%, p = 0.003), and had LN positive disease (47 vs 36%, p = 0.016). Despite this, Black pts had improved 5 yr recurrence free survival (RFS) compared to White pts (90 vs 80%, p = 0.008). The quality of care received was comparable between both groups, demonstrated by similar LN yield at surgery, neg margin resection rate, post-op complications, and need for reoperation or readmission (all p > 0.05). Black pts were more likely to have SBNET (22 vs 13%) and less likely to have panNET (43 vs 68%) compared to White pts (p < 0.001). Consistent with prior data, pts with LN pos panNET had decreased 5yr RFS (67 vs 83%, p = 0.001); however, for SBNET, LN involvement was not prognostic (77 vs 96%, p = 0.08). The prognostic value of LN pos disease was similar between Black and White pts in both SBNET (p = 0.34) and panNET (p = 0.95). Conclusions: Black pts with GEP-NET present with more advanced disease, including higher LN positivity. Despite this, Black pts have improved RFS compared to White pts. Although there may be delays in seeking or reaching care, Black pts received similar quality of care compared to White pts. The improved RFS seen in Black pts may be attributed to the epidemiologic differences in the site of presentation of GEP-NETs and variable prognostic value of LN pos disease.

Expanding the Scope of Evidence-Based Cancer Care

This article explores how oncology research can be expanded to ensure that research spending results in maximum benefit. The focus has shifted to the value and quality of care, which view cancer care with the perspective of the patient at the center and cover the spectrum of care. Because there is no agreed-upon definition for value in cancer care, we overview various contributions to defining value and quality in oncology. We outline how cancer care costs are measured in the United States and explore outcome measures that have been proposed and implemented to enable us to assess value in oncology.

Impact of insurance status on survival in neuroendocrine tumors: A multi-institutional Study from the U.S. Neuroendocrine Study Group

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Background: Insurance status predicts access to medical care in the United States. Previous studies show uninsured and government insured patients have worse outcomes than those with private insurance. However, the impact of insurance status on survival in patients with Gastrointestinal Neuroendocrine Tumors (GI-NETs) is unclear. We evaluate the association between insurance status and survival in patients with GI-NETs. Methods: Our analysis includes 2022 patients who had surgical resection of GI-NETs at 8 institutions in the U.S. Neuroendocrine Study Group. Patients were categorized based on insurance as private (PI), government (GovI) or uninsured (UI). Factors associated with insurance status were assessed by uni- and multi-variate analysis. Primary endpoint was overall survival. Results: Patient demographics between the insurance categories were similar in ECOG performance status and tumor size at presentation. GovI patients had a higher median age than PI or UI (66 vs. 54 vs. 56 years respectively; p<0.01). Uninsured patients were more likely African American (21.5%) or Latino (5%) compared to PI (11.5%, 2%) or GovI (15%, 2%) (p<0.01). The UI group had a higher proportion of patients who underwent no surveillance imaging post-operatively (39%) compared to PI (26%) and GovI patients (26%) but this was not statistically significant (p=0.15). There was no difference in operative intent (curative vs. palliative) between groups (p=0.2). Five-year overall survival was 86% for PI, 82% for GovI, and 73% for UI patients (p<0.01). On multivariate regression analysis, being uninsured was independently associated with reduced survival when controlling for ASA Class, ECOG, race, tumor location, neoadjuvant and adjuvant chemotherapy, Somatostatin analog, or radiation therapy (HR 1.39, p = 0.012). Conclusions: This is the first systematic analysis of insurance status’s association with overall survival in GI-NET patients. Our analysis shows uninsured or government insured patients have shortened survival compared to the privately insured. The disparity is likely underrepresented in this study, as we examined only patients who underwent surgical resection.