Operative Confidence Among U.S General Surgery Residents.

BACKGROUND: General surgery residents (GSRs) must develop operative autonomy skills to practice independently after graduation. We aim to investigate perceived confidence and operative autonomy of GSR physicians in order to identify and address influential factors. METHODS: A 28-question anonymous online survey was distributed to 23 United States general surgery residency programs. Multivariable logistic regression was used for calculating the adjusted odds ratio (aOR) for binary outcomes. Significance was defined as P-values ≤ .05 or 95% confidence intervals (CIs) >1 or <1. RESULTS: There were 120/558 (21.5%) GSR respondents. General surgery residents with >200 overall operative case volume reported significantly higher confidence with minor cases (P = .05) and major cases (P = .02). General surgery residents that performed both minor and major surgeries reported higher confidence with minor cases at 85.7% compared to GSRs that performed mostly minor surgeries (64.7%) and mostly major surgeries (62.5%). General surgery residents who performed >50 minor surgeries during their PGY 1 and 2 were less confident with major cases than GSRs who performed <50 minor surgeries (aOR: 19.98, 95% CI: 1.26, 318). General surgery residents from community teaching hospitals reported higher confidence with major and minor cases than GSRs from university teaching hospitals and combined programs. CONCLUSION: Increased case volume, predominant case type, early surgical experience during PGY 1 and 2 years, and training at community teaching hospitals were identified as the most important factors that positively influence perception of operative confidence and autonomy among GSRs. These may have important implications in the development of future surgeons.

The Effects of COVID-19 Pandemic on Trauma Registry and Performance Improvement Operations and Workforce Nationwide: A Survey of Trauma Center Association of America Members.

BACKGROUND: Trauma Centers integrate Trauma Registrars and Performance Improvement Nurses to drive quality care. Delays in their duties could have negative impacts on outcomes and performance. We aim to investigate the impact of COVID-19 pandemic on Trauma Center operations by assessing performance of trauma registry and performance improvement processes across the United States. METHODS: A cross-sectional study was performed utilizing data from two anonymous questionnaires distributed to Trauma Center Association of America members. Descriptive statistics, Fisher's Exact Test, and multivariable logistic regression were performed with statistical significance defined as P < 0.05. RESULTS: Of 90.2% (83) of Trauma Registrars and 85.9% (67) of Performance Improvement personnel reported that their Trauma Centers have treated COVID-19 patients. Among trauma registrars, respondents did not significantly differ in the current status of completing registry cases (P> 0.05), during COVID-19 compared to prior (P> 0.05), or adjusted odds of COVID-19 delaying completion of entries (P> 0.05). Having >2 Performance Improvement Nurses was significantly associated with improved performance during the COVID-19 pandemic (P= 0.03) whereas working at a Trauma Center which treats adults-only or mixed patient population (adult and pediatric) was associated with being 1-3 months behind in closing of performance improvement cases (P= 0.02). CONCLUSIONS: The negative impact of COVID-19 on Trauma Registrars and Performance Improvement Nurses has been minimal. Adequate staffing/experience seem to mitigate delays and decreased performance. Implementation of expanded staffing, improved training, and evidenced-based revision of Trauma Center logistics may help mitigate future disruptions relating to COVID-19 and allow Trauma Centers to recover and improve their operations.

Emergency Resuscitative Thoracotomy for Civilian Thoracic Trauma in the Field and Emergency Department Settings: A Systematic Review and Meta-Analysis.

BACKGROUND: Emergency department resuscitative thoracotomy (ED-RT) or prehospital resuscitative thoracotomy (PH-RT) is performed for trauma patients with impending or full cardiovascular collapse. This systematic review and meta-analysis analyze outcomes in patients with thoracic trauma receiving PH-RT and ED-RT. METHODS: PubMed, JAMA Network, and CINAHL electronic databases were searched to identify studies published on ED-RT or PH-RT between 2000-2020. Patients were grouped by location of procedure and type of thoracic injury (blunt versus penetrating). RESULTS: A total of 49 studies met the criteria for qualitative analysis, and 43 for quantitative analysis. 43 studies evaluated ED-RT and 5 evaluated PH-RT. Time from arrival on scene to PH-RT >5 min was associated with increased neurological complications and time from the initial encounter to PH-RT or ED-RT >10 min was associated with increased mortality. ISS ≥ 25 and absent signs of life were also associated with increased mortality. There was higher mortality in all PH-RT (93.5%) versus all ED-RT (81.8%) (P = 0.02). Among ED-RTs, a significant difference was found in mortality rate between patients with blunt (92.8%) versus penetrating (78.7%) injuries (P < 0.001). When considering only blunt or penetrating injury types, no significant difference in RT mortality rate was found between ED-RT and PH-RT (P = 0.65 and P = 0.95, respectively). CONCLUSIONS: ED-RT and PH-RT are potentially life-saving procedures for patients with penetrating thoracic injuries in extremis and with signs of life. The efficacy of this procedure is time sensitive. Moreover, there appears to be a greater mortality risk for patients with thoracic trauma receiving RT in the PH setting compared to the ED setting. More studies are needed to determine the significance of PH-RT mortality.

Extracorporeal Membrane Oxygenation Utilization in Blunt and Penetrating Traumatic Injuries: A Systematic Review.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become an increasingly used treatment modality for severe respiratory insufficiency in trauma patients. Examining ECMO use specifically in blunt and penetrating traumas can aid in directing future protocols. We aim to evaluate the outcomes of ECMO use in both blunt and penetrating trauma patients through a systematic review of current literature. METHODS: An online search of 2 databases (PubMed and Google Scholar) was performed to analyze studies, which evaluated the use of ECMO in blunt and penetrating traumas. Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Grading of Recommendations Assessment, Development and Evaluation guidelines were followed. Data extracted included mechanism of injury, injury severity scores (ISSs), complications, and mortality rates. RESULTS: The search demonstrated 9 studies that met our review inclusion criteria. A total of 207 patients were included, of which 64 (30.9%) were non-survivors and 143 (69.1%) were survivors. There was a total of 201 blunt traumas with 61 (30.3%) deaths, whereas penetrating traumas had 2 deaths (33.3%) out of 6 total patients. Complications reported included acute renal failure, hemorrhage at the cannula site, and transient neurological deficits. Most studies found better survival rates and less complications in younger patients and those with lower ISS. CONCLUSION: Expanding the use of ECMO to include blunt and penetrating trauma patients provides the trauma surgeons with another crucial potentially lifesaving tool with an overall survival rate of 70%. Anticipating increased future use of ECMO in blunt and penetrating trauma patients, distinct protocols ought to be instilled to better address the care needed for these critically ill trauma patients.

Trauma outcomes for blunt and penetrating injuries by mode of transportation and day/night shift.

BACKGROUND: Effective management of trauma patients is dependent on pre-hospital triage systems and proper in-hospital treatment regardless of time of admission. We aim to investigate any differences in adjusted all-cause mortality between day vs. night arrival for adult trauma patients who were transported to the hospital via ground emergency medical services (GEMS) and helicopter emergency medical services (HEMS) and to determine if care/outcomes are inferior when admitted during the night shift as compared to the day shift. METHODS: Retrospective cohort analysis of adult blunt and penetrating injury patients requiring full team trauma activation at an American College of Surgeons Committee on Trauma (ACSCOT)-verified Level 1 trauma center from 2011 to 2019. Descriptive statistical analyses, chi-square analyses, independent-sample t-tests, and Fisher's exact tests were performed. Primary measurement outcome was adjusted observed/expected (O/E) mortality ratios utilizing TRISS methodology. RESULTS: 8370 patients with blunt injuries and 1216 patients with penetrating injuries were analyzed. There were no significant differences in day vs. night O/Es overall (blunt 0.65 vs. 0.59; p = 0.46) (penetrating 0.88 vs. 0.87; p = 0.97). There also were no significant differences when stratified by GEMS (blunt 0.64 vs. 0.55; p = 0.08) (penetrating 0.88 vs. 1.10; p = 0.09) and HEMS admissions (blunt 0.76 vs. 0.75; p = 0.91) (penetrating 0.88 vs. 0.91; p = 0.85). CONCLUSIONS: At an ACSCOT-verified Level 1 Trauma Center, care/outcomes of patients admitted during the night shift were not inferior to those admitted during the day shift. Trauma Center verification by the ACSCOT and multidisciplinary collaboration may allow for consistent care despite injury type and time of day.

Gender Distribution of Current Surgical Critical Care Fellows, Faculty, and Program Directors.

As women surgeons continue to represent a minority within the surgical field while also holding lower ranked positions, gaining a sub-specialized set of clinical skills through surgical fellowships, like surgical critical care (SCC), is one approach to advance within the surgical field. A cross-sectional analysis was performed investigating the websites of all 106 US-based SCC fellowships. A total of 116 SCC fellows were included in this analysis, comprising 67 (59.3%) men and 46 (40.7%) women. There were 977 SCC fellowship faculty were evaluated, comprising 619 (67.9%) men and 292 (32.1%) women. Additionally, 103 SCC fellowship program directors were analyzed, consisting of 77 (74.8%) men and 26 (25.2%) women. There is a significantly lower proportion of women fellows and faculty members (P < .001) compared to men. SCC programs with female program directors on average have higher proportions of female fellows and faculty compared to programs with male program directors (52% and 36% vs 31% and 29%, respectively). There is a stable yet unbalanced gender distribution throughout all positions in SCC fellowship programs. Actively supporting women surgeons pursuing SCC fellowship and removing barriers to their advancement through effective interventions can disrupt the persistently low prevalence of women SCC fellows, faculty, and program directors.

Gender distribution among surgical journals' editorial boards: Empowering women surgeon scientists.

BACKGROUND: Gender disparities still exist in the field of academic surgery. Women face additional obstacles obtaining high-ranking, surgical academia positions compared to men, and this may extend to the appointment of editorial board members. We aim to evaluate the gender distribution of editorial board members, associate editors, and editors-in-chief of top US surgical journals and to recommend interventions, which can promote equitable gender representation among editorial boards. METHODS: The study is a cross-sectional analysis using publicly available data regarding the number and proportion of female editorial board members, associate editors, and editors-in-chief from 42 US surgical journals. Descriptive statistics and linear regression were performed with significance defined as P < .05. RESULTS: Of 2,836 editorial board members from 42 US surgical journals, 420 (14.8%) were women. Of 881 associate editors, 118 (13.3%) were women. Only 2/42 (4.8%) of editors-in-chief were women. The mean proportions of female editorial board members and associate editors were 14.5% and 19.5%, respectively. No significant associations were found between the 2019 Scimago Journal & Country Rank indicator nor the 2019 impact factor and the proportion of female editorial board members and female associate editors after adjusting for author H-index. CONCLUSION: Gender disparities are evident in academic surgery, and women comprise a minority of US surgical editorial board members, associate editors, and editors-in-chief. The implementation of women mentorship from senior faculty on behalf of senior residents and junior faculty, as well as journal-facilitated pipeline programs, can diversify editorial board members by increasing women representation and reduce disparities in surgical journal editorial boards.

The Future of the surgeon-scientist: A Journey Funneled through inspiration, Roadblocks and Resilience.

•Declining financial opportunities along with clinical hour requirements to generate revenue produces role strains for surgeon-scientists.•Adjusting the current workload model to include protected research time and devising financial support through partnerships can improve strain on surgeon-scientists.•Early integration of research into medical education along with networking and mentorship can inspire future surgeon-scientists, potentially leading to positive career trajectories.

Implications of the United States Medical Licensing Examination Step 1 Examination Transition to Pass/Fail on Medical Students Education and Future Career Opportunities.

BACKGROUND: United States Medical Licensing Examination (USMLE) Step 1 will transition to pass/fail score by 2022. We aim to investigate US medical students' perspectives on the potential implications this transition would have on their education and career opportunities. METHODS: A cross-sectional study investigating US medical students' perspectives on the implications of transition of the USMLE Step 1 exam to pass/fail. Students were asked their preferences regarding various aspects of the USMLE Step 1 examination, including activities, educational opportunities, expenses regarding preparation for the examination, and future career opportunities. RESULTS: 215 medical students responded to the survey, 59.1% were women, 80.9% were allopathic vs. 19.1% osteopathic students. 34.0% preferred the USMLE Step 1 to be graded on a pass/fail score, whereas 53.5% preferred a numeric scale. Osteopathic vs. allopathic students were more likely to report that the pass/fail transition will negatively impact their residency match (aOR = 1.454, 95% CI: 0.515, 4.106) and specialty of choice (aOR = 3.187, 95% CI: 0.980, 10.359). 57.7% of respondents reported that the transition to a pass/fail grading system will change their study habits. CONCLUSIONS: The transition of the USMLE Step 1 to a pass/fail system has massive implications on medical students and residency programs alike. Though the majority of medical students did not prefer the USMLE Step 1 to have a pass/fail score, they must adapt their strategies to remain competitive for residency applications. Residency programs should create a composite score based off all aspects of medical students' applications in order to create a holistic and fair evaluation and ranking system.