Great Debate: Chemoradiation Should be Added to Chemotherapy as a Neoadjuvant Treatment Strategy for Resectable Gastric Adenocarcinoma.

BACKGROUND: Most patients with resectable gastric cancer present with locally advanced disease and warrant neoadjuvant chemotherapy based on level 1 evidence. However, the incremental benefit of adding radiation to chemotherapy as a neoadjuvant treatment strategy for these patients is less clear. METHODS: While awaiting the results of two ongoing randomized clinical trials attempting to specifically address this question (TOPGEAR and CRITICS-II), this article presents the debate between two gastric cancer surgery experts supporting each side of the argument on the use or omission of neoadjuvant radiation in this setting. RESULTS: On the one hand, neoadjuvant radiation may be better tolerated compared with modern triplet chemotherapy and may be associated with higher rates of major pathologic response. Additionally, there is evidence to suggest that radiation may offer a survival benefit when the tumor is located at the gastroesophageal junction or there is concern for a margin-positive resection. However, in the setting of adequate surgery, no survival benefit has been demonstrated by adding radiation to modern chemotherapy, likely reflecting the fact that death from gastric cancer is a result of distant recurrence, which is not addressed by local treatment such as radiotherapy. CONCLUSION: While awaiting the results of the TOPGEAR and CRITICS-II trials, this discussion of current evidence can facilitate the refinement of an optimal neoadjuvant therapy strategy in patients with resectable gastric cancer.

Preclinical Immersion Experiences Improve Medical Student Perceptions of Surgery.

INTRODUCTION: Medical students historically receive little to no preclinical exposure to surgery and surgical subspecialties. As a result, by the time they reach their clinical clerkship time, students often have already found interest in other specialties. The goal of this study is to utilize the knowledge to action (KTA) implementation framework to design and refine a clinical immersion experience during the second year of medical school. METHODS: A total of 94 second-year Harvard Medical School students underwent the surgical immersion experience between 2019 and 2022 (the program was postponed in 2020 due to COVID). The development and refinement of the curriculum were nicely modeled by the KTA implementation framework. We identified a gap in medical student preclinical education, adapted a curriculum for preclinical medical students at Massachusetts General Hospital , selected the curriculum components to provide a high-level overview of surgery, monitored the student experience, and evaluated outcomes using the student surveys. Based on the survey results, inductive thematic analysis was utilized to identify prominent positive and negative themes. The feedback was then used to tailor subsequent iterations of the immersion experience. RESULTS: Eighty-eight medical students completed the survey (RR = 93.6%), and 85% rated the immersion experience as "excellent", 11% "very good", 4% "good", and 0% "fair" or "poor". There was no significant difference in ratings between sessions. Several key themes were identified, including changed perceptions, diversity of surgical fields, teamwork, surgery clerkship preparedness, and the need for more preclinical exposure. CONCLUSIONS: Preclinical medical students gave overwhelmingly positive reviews of the surgical immersion experience. A half-day intervention is sufficient to begin changing students' views toward surgery, disproving stereotypes, and even inspiring some to consider a surgical field themselves. In addition, the KTA implementation framework is a useful model for the development and refinement of medical education curricula.

Timing of Adjuvant Immunotherapy in Stage III Melanoma, Does it Matter?

BACKGROUND: The optimal time to initiate adjuvant immune checkpoint inhibitors (ICI) following resection remains undefined. Herein, we investigated the impact of time to adjuvant ICI on survival in patients with stage III melanoma. METHODS: Patients with resected stage III melanoma receiving adjuvant immune therapy were identified within a multi-institutional retrospective cohort. Patients were stratified by time to adjuvant ICI: within 6 weeks, 6-12 weeks, and greater than 12 weeks from surgery. Recurrence-free survival (RFS) was compared among time strata with Kaplan-Meier and Cox proportional hazards methods in the multi-institutional cohort. RESULTS: Altogether, 626 patients were identified within the multi-institutional cohort: 39% of patients initiated adjuvant ICI within 6 weeks, 42.2% within 6-12 weeks, and 18.8% greater than 12 weeks from surgery. In a multivariate Cox model, adjusting for histology, nodal tumor burden, and pathologic stage, we found that increased time to adjuvant ICI was associated with improved RFS. Patients who initiated adjuvant ICI within 6 weeks of surgery had worse RFS. These findings were preserved in a conditional landmark analysis and separate subgroups of patients with (1) new melanoma diagnoses, (2) occult stage III disease, and (3) those receiving anti-PD-1 monotherapy. CONCLUSIONS: Outcomes for patients with stage III melanoma are not compromised when adjuvant ICI is initiated beyond 6 weeks from resection. Additional work is needed to better understand the underlying mechanisms and implications of timing of adjuvant ICI on long-term outcomes.

Successful virtual interviews for surgery residents.

The SARS-CoV-2 pandemic resulted in surgical residency and fellowship interviews shifting to a virtual, web-based format. Although virtual interviews have important benefits, this change also brought about new challenges for applicants, including a new interview etiquette and potential difficulty in evaluating and discriminating between programs. The aim of this article is to provide applicants with guidance for every step of their interview process so that they can confidently put forth their strongest performance. Preparing for effective virtual interviewing begins long before the interview day and involves critical self-reflection, practice with mock interviews, optimizing the interview environment, and conducting a technology trial run. During the interview day, standard interview advice for face-to-face interviews remains true for virtual interviews. However, there are a few additional considerations, including minimizing distractions, muting oneself in a group setting, and turning off the camera when stepping away from the screen. After the interview, there are several ways for applicants to elicit more information about the "fit" of different programs of interest. We recommend leveraging personal relationships to ask additional questions and consider visiting select programs in person, if possible. Although our recommendations are not exhaustive, we hope that by following these virtual interview best practices, applicants will be more prepared to present themselves strongly and successfully navigate the virtual interview process.

Do Resident Coaching Programs Benefit their Coaches? Impact of a Professional Development Coaching Program on The Coaches.

BACKGROUND: Coaching has been shown to decrease physician burnout; however, coachee outcomes have been the focus. We report the impact of coaching on women-identifying surgeons who participated as coaches in a 9-month virtual program. METHODS: A coaching program was implemented in the Association of Women Surgeons (AWS) to determine the effects of coaching on well-being and burnout from 2018 to 2020. AWS members volunteered and completed training in professional development coaching. Pre- and post-study measures were assessed, and bivariate analysis performed based on burnout and professional fulfillment score. RESULTS: Seventy-five coaches participated; 57 completed both pre- and post-study surveys. There were no significant changes in burnout or professional fulfillment including the Positive Emotion, Engagement, Relationship, Meaning, and Accomplishment scale, hardiness, self-valuation, coping, gratitude, or intolerance of uncertainty scores from baseline to post-survey. On bivariate analysis, hardiness was associated with lower burnout throughout the duration of the program. Coaches with lower burnout at the end of the program met with their coachee more frequently than coaches with higher burnout [mean (SD) 3.95(2.16) versus 2.35(2.13) p = 0.0099]. DISCUSSION: Burnout and professional fulfillment demonstrated no change in women surgeons who participated as professional development coaches. Those with lower burnout and higher professional fulfillment at the end of the program were found to have higher hardiness, which may be worth future investigation. CONCLUSIONS: Acquisition of coaching skills did not directly improve well-being in faculty who participated in a resident coaching program. Future studies would benefit from control groups and exploration of qualitative benefits of coaching.

Neurosurgeons' Perspectives on Vascular Entrustable Professional Activities.

This article discusses subspecialty Canadian neurosurgeons' perceptions of entrustable professional activities (EPAs) assessments and variabilities prior to the implementation of the Competence by Design (CBD) system in Canada. Vascular neurosurgeons were asked to reflect on how they would evaluate and give feedback to neurosurgery residents concerning the EPA "Performing surgery for patients with an intracranial aneurysm." Interviews were transcribed and analyzed using a deductive approach. Themes were derived from these interviews and reflected on the subjectivity and biases present in the EPA assessment forms. Indeed, faculty may require more training in the transitioning to a CBD evaluation system.

Impact of a Virtual Professional Development Coaching Program on the Professional Fulfillment and Well-Being of Women Surgery Residents: A Randomized Controlled Trial.

OBJECTIVE: Evaluate the effect of a virtual coaching program offered to women surgery residents in a surgical society. BACKGROUND: Randomized controlled experiments evaluating the effect of coaching on trainee well-being and burnout is lacking. METHODS: Women surgery residents in the Association of Women Surgeons were recruited to participate in a randomized controlled trial of the effects of a virtual coaching program on trainee well-being. Attending surgeons served as coaches after completing in-person training. Residents (n=237) were randomized to intervention (three 1:1 coaching sessions over 9 mo) or control (e-mailed wellness resources). Participants were surveyed at baseline and postintervention using validated measures of well-being, burnout, and resilience. Changes in outcome measures between presurvey and postsurvey were compared between study arms. RESULTS: Survey response rates were 56.9% (n=66) in the control group and 69.4% (n=84) in the intervention group ( P =0.05). The intervention group showed significant improvement in professional fulfillment ( P =0.021), burnout (0.026), work exhaustion (0.017), self-valuation (0.003), and well-being ( P =0.002); whereas the control group showed significant improvement in self-valuation ( P =0.015) and significant decline in resilience ( P =0.025). The intervention group had a significant improvement in well-being ( P =0.015) and intolerance of uncertainty ( P =0.015) compared to controls. CONCLUSIONS: Women surgery residents who participated in a remote coaching program offered by a surgical society demonstrated improvement in aspects of well-being relative to peers who did not receive coaching. Therefore, remote coaching offered by a professional society may be a useful component of initiatives directed at trainee well-being.

Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery.

OBJECTIVE: To investigate inpatient satisfaction with surgical resident care. BACKGROUND: Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed. METHODS: English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method. RESULTS: Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons. CONCLUSIONS: Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.

The Big Sibling program: Impact of a medical student-resident mentorship program during the surgery clerkship.

BACKGROUND: We created a Big Sibling mentorship program for medical students and studied the program effects. METHODS: Between July 2019 to December 2020, students completing their surgery clerkship were paired with a Big Sibling surgical research resident. Participation in and perceptions of the program were assessed by survey. RESULTS: 81 medical students and 25 residents participated with a 79% and 95% survey response rate, respectively. The most valuable topics discussed included ward skills, personal development and career advising. Students who interacted >2 times with their Big Sibling were more likely to perceive the operating room as a positive learning environment, view attendings as role models, and receive mentoring and feedback from residents and attendings (p = 0.03, 0.02, 0.01 respectively). 78% of residents thought the program was a positive experience and no residents found it burdensome. CONCLUSION: The Big Siblings program enhances the surgery clerkship learning environment. Students who engaged with their Big Sibling had a more positive view of the clerkship and the mentorship provided by residents and attendings.

Neoadjuvant therapy for melanoma: A critical appraisal.

The treatment of advanced melanoma has significantly changed since the development of targeted and immune therapy. To date, these agents have primarily been used in the adjuvant or metastatic setting. Given several theoretical advantages, there is increased interest in the use of these new therapeutics in the neoadjuvant setting. In this review, we detail the potential benefits and pitfalls of neoadjuvant therapy for melanoma, review the currently available data, and describe ongoing neoadjuvant trials.

Impact of Rater Training on Residents Technical Skill Assessments: A Randomized Trial.

OBJECTIVE: The ACS/APDS Resident Skills Curriculum's Objective Structured Assessment of Technical Skills (OSATS) consists of task-specific checklists and a global rating scale (GRS) completed by raters. Prior work demonstrated a need for rater training. This study evaluates the impact of a rater-training curriculum on scoring discrimination, consistency, and validity for handsewn bowel anastomosis (HBA) and vascular anastomosis (VA). DESIGN/ METHODS: A rater training video model was developed, which included a GRS orientation and anchoring performances representing the range of potential scores. Faculty raters were randomized to rater training or no rater training and were asked to score videos of resident HBA/VA. Consensus scores were assigned to each video using a modified Delphi process (Gold Score). Trained and untrained scores were analyzed for discrimination and score spread and compared to the Gold Score for relative agreement. RESULTS: Eight general and eight vascular surgery faculty were randomized to score 24 HBA/VA videos. Rater training increased rater discrimination and decreased rating scale shrinkage for both VA (mean trained score: 2.83, variance 1.88; mean untrained score: 3.1, variance 1.14, p = 0.007) and HBA (mean trained score: 3.52, variance 1.44; mean untrained score: 3.42, variance 0.96, p = 0.033). On validity analyses, a comparison between each rater group vs Gold Score revealed a moderate training impact for VA, trained κ=0.65 vs untrained κ=0.57 and no impact for HBA, R1 κ = 0.71 vs R2 κ = 0.73. CONCLUSION: A rater-training curriculum improved raters' ability to differentiate performance levels and use a wider range of the scoring scale. However, despite rater training, there was persistent disagreement between faculty GRS scores with no groups reaching the agreement threshold for formative assessment. If technical skill exams are incorporated into high stakes assessments, consensus ratings via a standard setting process are likely a more valid option than individual faculty ratings.

Implementation of a Coaching Program by a National Surgical Association.

OBJECTIVE: Using the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework for implementation science, we describe the implementation and impact of a virtual coaching program designed and conducted through a national surgical organization. DESIGN: The Association of Women Surgeons recruited and trained surgical faculty as coaches with no prior training in positive psychology to coach surgical residents. Coaching pairs completed three coaching sessions center on strength recognition, personal and professional fulfillment, and work life integration. SETTING: The initial coaching training was in person at a national conference, while subsequent training sessions and all coaching sessions were held remotely. PARTICIPANTS: A total of 75 coaches were trained and 121 surgical residents participated in the program. RESULTS: Coachees noted improvement in goal setting, self-confidence, and working relationships. Coaches noted improvement in communication skills both during and outside of the coaching experience. Eighty-six percent of coaches recommended implementing a coaching program at their home institution. This program has served as model for additional programs through other associations and institutions. CONCLUSIONS: The Coaching Project demonstrates the feasibility implementing a coaching project for coaching surgical residents, teaching new communication skills to coaches, while providing wellness benefits to coachees.

Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training.

BACKGROUND: Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum. METHODS: Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA. RESULTS: Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion. CONCLUSION: A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.

Finding my people: Effects of student identity and vulnerability to Stereotype Threat on sense of belonging in surgery.

BACKGROUND: Diversity in surgery lags behind the medical student population. We documented first-year medical students' vulnerability to stereotype threat (VST) and its impact on a sense of belonging in surgery. METHODS: All first-year medical students at a single academic institution were surveyed. Demographics, VST, anticipated clerkship experience, and sense of belonging were assessed. RESULTS: 44% of students were vulnerable to ST in upcoming clerkships, with the majority worried about surgical clerkships. More student from races/ethnicities underrepresented in medicine (URM; 74%) and sexual minorities (62%) were vulnerable than white (30%) and heterosexual (38%) students respectively (p = 0.001 and p = 0.017). Knowing a surgeon with a shared identity would enhance belonging for most students (84%). VST was higher for those who do not anticipate working with (p < 0.001) or do not know a surgeon (p = 0.0001) who shares their identity. CONCLUSION: VST significantly influences a student's sense of belonging in surgery. More research is needed to promote inclusivity in surgery.

A multisite study of medical student perspectives on the core surgical clerkship.

BACKGROUND: The surgical clerkship is the primary surgical learning experience for medical students. This study aims to understand student perspectives on the surgery clerkship both before and after the core surgical rotation. METHODS: Medical students at 4 academic hospitals completed pre and postclerkship surveys that included open-ended questions regarding (1) student learning goals and concerns and (2) how surgical clerkship learning could be enhanced. Thematic analysis was performed, and interrater reliability was calculated. RESULTS: Ninety-one percent of students completed both a pre and postclerkship survey (n =162 of 179), generating 320 preclerkship and 270 postclerkship responses. Mean kappa coefficients were 0.83 and 0.82 for pre and postclerkship primary themes, respectively. Thematic analysis identified 5 broad themes: (1) core learning expectations, (2) understanding surgical careers, culture, and work, (3) inhabiting the role of a surgeon, (4) inclusion in the surgical team, and (5) the unique role of the medical student on clinical clerkships. Based on these themes, we propose a learner-centered model of a successful surgical clerkship that satisfies discrete student learning and goals and career objectives while ameliorating the challenges of high-stakes clinical surgical environments such as the operating room. CONCLUSION: Understanding student perspectives on the surgery clerkship, including preclerkship motivations and concerns and postclerkship reflections on surgical learning, revealed potential targets of intervention to improve the surgery clerkship. Future investigation may elucidate whether the proposed model of the elements of a successful surgery clerkship learning facilitates improvement of the surgical learning environment and enhanced surgical learning.

Designing the "match of the future": challenges and proposed solutions in the interview and match phase of the UME-GME transition.

This review focuses on the interview and match process with the purpose of broadly reviewing challenges in the current surgical residency selection process, detailing potential solutions, and identifying future avenues of investigation.

Becoming Artemis's Mother.

MINI-ABSTRACT: This perspective piece describes the author's evolving relationship to motherhood during surgical residency training, and how motherhood became a source of professional ambition despite persistent gender inequity that exists in academic surgery.