Emergency Restructuring of a General Surgery Residency Program During the Coronavirus Disease 2019 Pandemic: The University of Washington Experience.

Seattle, Washington, is an epicenter of the coronavirus disease 2019 epidemic in the United States. In response, the Division of General Surgery at the University of Washington Department of Surgery in Seattle has designed and implemented an emergency restructuring of the facility's general surgery resident care teams in an attempt to optimize workforce well-being, comply with physical distancing requirements, and continue excellent patient care. This article introduces a unique approach to general surgery resident allocation by dividing patient care into separate inpatient care, operating care, and clinic care teams. Separate teams made up of all resident levels will work in each setting for a 1-week period. By creating this emergency structure, we have limited the number of surgery residents with direct patient contact and have created teams working in isolation from one another to optimize physical distancing while still performing required work. This also provides a resident reserve without exposure to the virus, theoretically flattening the curve among our general surgery resident cohort. Surgical resident team restructuring is critical during a pandemic to optimize patient care and ensure the well-being and vitality of the resident workforce while ensuring the entire workforce is not compromised.

Surgeons' Disclosures of Clinical Adverse Events.

Importance: Surgeons are frequently faced with clinical adverse events owing to the nature of their specialty, yet not all surgeons disclose these events to patients. To sustain open disclosure programs, it is essential to understand how surgeons are disclosing adverse events, factors that are associated with reporting such events, and the effect of disclosure on surgeons. Objective: To quantitatively assess surgeons' reports of disclosure of adverse events and aspects of their experiences with the disclosure process. Design, Setting, and Participants: An observational study was conducted from January 1, 2011, to December 31, 2013, involving a 21-item baseline questionnaire administered to 67 of 75 surgeons (89%) representing 12 specialties at 3 Veterans Affairs medical centers. Sixty-two surveys of their communication about adverse events and experiences with disclosing such events were completed by 35 of these 67 surgeons (52%). Data were analyzed using mixed linear random-effects and logistic regression models. Main Outcomes and Measures: Self-reports of disclosure assessed by 8 items from guidelines and pilot research, surgeons' perceptions of the adverse event, reported personal effects from disclosure, and baseline attitudes toward disclosure. Results: Most of the surgeons completing the web-based surveys (41 responses from men and 21 responses from women) used 5 of the 8 recommended disclosure items: explained why the event happened (55 of 60 surveys [92%]), expressed regret for what happened (52 of 60 [87%]), expressed concern for the patient's welfare (57 of 60 [95%]), disclosed the adverse event within 24 hours (58 of 60 [97%]), and discussed steps taken to treat any subsequent problems (59 of 60 [98%]). Fewer surgeons apologized to patients (33 of 60 [55%]), discussed whether the event was preventable (33 of 60 [55%]), or how recurrences could be prevented (19 of 59 [32%]). Surgeons who were less likely to have discussed prevention (33 of 60 [55%]), those who stated the event was very or extremely serious (40 of 61 surveys [66%]), or reported very or somewhat difficult experiences discussing the event (16 of 61 [26%]) were more likely to have been negatively affected by the event. Surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients' surgical outcomes or events following disclosure (odds ratio, 1.54; 95% CI, 1.16-2.06). Conclusions and Relevance: Surgeons who reported they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences, were more negatively affected by disclosure than others. Quality improvement efforts focused on recognizing the association between disclosure and surgeons' well-being may help sustain open disclosure policies.

Getting the science right on the surgeon workforce issue.

In this article we summarize the perspectives given by a range of health policy researchers as presented at the fifth annual meeting of the Surgical Outcomes Club at the annual meeting of the American College of Surgeons in Chicago, Illinois, on October 11, 2009. During that session, the participants reviewed 3 main areas that are summarized here: history of physician/surgeon workforce policy, current beliefs, recent policy activity, and issues related to forecasting/planning the future surgical workforce.

Workforce issues in rural surgery.

Almost one quarter of America's population and one third of its landmass are defined as rural and served by approximately 20% of the nation's general surgeons. General surgeons are the backbone of the rural health workforce. There is significant maldistribution of general surgeons across regions and different types of rural areas. Rural areas have markedly fewer surgeons per population than the national average. The demography of the rural general surgery workforce differs substantially from the urban general surgery workforce, raising concerns about the extent to which general surgical services can be maintained in rural areas of the United States.

A longitudinal analysis of the general surgery workforce in the United States, 1981-2005.

HYPOTHESIS: The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas. DESIGN: Retrospective longitudinal analysis. SETTING: Clinically active general surgeons in the United States. PARTICIPANTS: The American Medical Association's Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States. MAIN OUTCOME MEASURES: Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons. RESULTS: General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (-27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (-21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas. CONCLUSIONS: The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

Clinical utility and cost-effectiveness of routine preoperative computed tomography scanning in patients with colon cancer.

BACKGROUND: The aims of this study were to assess the clinical utility of the practice of routine preoperative CT scanning and to determine its cost-effectiveness in colon cancer patients. METHODS: A 6-year database of colon cancer patients treated at a veterans affairs medical was reviewed to determine the influence of preoperative CT scanning on clinical management. Cost analysis involved comparison of the institutional cost of CT scanning with the cost savings provided by avoiding nontherapeutic operations. RESULTS: CT scans were obtained in 130 consecutive patients. CT scans provided information that was used in treatment planning in 43 (33%) patients and definitively altered the mode of treatment in 21 (16%) patients. The practice saved the institution $24,018 over 6 years. CONCLUSION: Routine preoperative CT scanning definitively alters treatment in a small number of cases and is cost-effective.

Characterizing the general surgery workforce in rural America.

BACKGROUND: General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas. HYPOTHESIS: We hypothesize that the rural areas of the United States are relatively undersupplied with general surgeons. DESIGN AND SETTING: The American Medical Association's Physician Masterfile was used to identify all clinically active general surgeons as well as their locations and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas. Surgeons were classified as practicing in urban areas, large rural areas, or small/isolated rural areas. RESULTS: There are currently 17 243 general surgeons practicing in the United States. Nationally, the number of general surgeons per population of 100 000 varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation's general surgeons are female. Wide variations in numbers of general surgeons were found between and within individual states. General surgeons in the smallest rural areas are more likely than those in urban areas to be male (92.7% vs 88.3%, P<.001), 50 years of age or older (51.6% vs 42.1%, P<.001), or international medical graduates (25.2% vs 20.1%, P<.001). CONCLUSIONS: The overall size of the rural general surgical workforce has remained static over the last decade, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. Steps to reverse this trend are needed to preserve the viability of health care in many parts of rural America.

The utility of routine preoperative computed tomography scanning in the management of veterans with colon cancer.

BACKGROUND: The aim of this study is to assess the clinical utility of routine preoperative computed tomography (CT) scanning in patients with cancer of the intraperitoneal colon. METHODS: From November 1997 to June 2001, all patients at VA Puget Sound Healthcare System with a diagnosis of colon cancer were referred for a preoperative CT scan. Medical records and operative notes were reviewed to determine the influence of preoperative CT on clinical management. RESULTS: Seventy patients received a CT per protocol. Preoperative CT provided information that was used in treatment planning and management in 26 (37%) cases. However, if preoperative scans had not been performed, the clinical management would have been definitively altered in only 13 (19%) patients. CONCLUSIONS: Although these data suggest potential benefit for routine preoperative CT scanning, we believe additional study, including cost analysis, should precede the adoption of CT scanning as a routine preoperative study in patients with colon cancer.