Axillary Surgery for Chemoresidual (ypN-Positive) Nodal Disease.

This cohort study using pooled data from 2 randomized clinical trials examines whether removing more lymph nodes with axillary lymph node dissection improved outcomes over sentinel lymph node biopsy when most patients received adjuvant radiation therapy or regional nodal irradiation.

Quality and Outcome Assessment for Surgery.

ABSTRACT: This forum summarizes the proceedings of the joint European Surgical Association (ESA)/American Surgical Association (ASA) symposium on Quality and Outcome Assessment for Surgery that took place in Bordeaux, France, as part of the celebrations of the 30th anniversary of the ESA. Three presentations focused on a) the main messages from the Outcome4Medicine Consensus Conference, which took place in Zurich, Switzerland, in June 2022, b) the patient perspective, and c) benchmarking were hold by ESA members and discussed by ASA members in a symposium attended by members of both associations.

The Role of Implicit Bias in Surgical Resident Evaluations.

BACKGROUND: Implicit bias is a key factor preventing the advancement and retention of women and underrepresented minorities in academic surgery. PURPOSE: We examined the role of implicit bias in the technical component of the residency performance evaluation. The Fundamentals of Laparoscopic Surgery (FLS) score, an objective measure of technical performance, was compared to the subjective technical skills (TS) score given by attending surgeons. PROCEDURES: FLS scores and the average TS scores from chief resident evaluations at a university program were analyzed from 2015 to 2019 (n = 29 residents; female 22%, underrepresented minorities 27%).  The average TS score for each resident was calculated, scores dichotomized above and below the mean for the program and analyzed across gender and racial identity. MAIN FINDINGS: There were no significant differences in FLS or TS scores between male and female trainees or racial identity. The Kappa correlation coefficient between the 2 dichotomized scores was significantly lower for female (-0.50) versus male (0.23) trainees (p < 0.01); it was not significantly different between racial groups (p = 0.34). PRINCIPAL CONCLUSIONS: There was statistically significant difference in agreement between the FLS and TS scores of individual female and male trainees, suggesting the presence of implicit bias in our pilot study. Further research with a larger sample size is warranted. OBJECTIVE: To investigate the presence of implicit bias against women and underrepresented minorities in the technical component of the residency performance evaluation. We hypothesized that women and underrepresented racial minorities would have lower subjective technical skills (TS) scores as compared to their objective FLS scores, relative to the mean for the training program. DESIGN: FLS scores and the average TS scores from chief resident performance evaluations were analyzed from 2015-2019. Both FLS and the average TS scores were dichotomized above and below the mean for the program and analyzed across gender and racial identity.  Research was approved by institutional IRB. SETTING: This study was conducted at the University of Arizona General Surgery Residency Program at Banner University Medical Center in Tucson, Arizona. This is a tertiary care university training program. PARTICIPANTS: Educational records of graduated general surgery chief residents from 2015 to 2019 were accessed for the study. We analyzed 37 TS scores from attending performance evaluations and 29 FLS scores reported to the program during the study period (22% female, 27% underrepresented racial minorities). RESULTS: There were no significant differences in FLS or TS scores between male and female trainees or racial identity. The Kappa correlation coefficient between the 2 dichotomized scores was significantly lower for female (-0.50) versus male (0.23) trainees (p < 0.01); it was not significantly different between racial groups (p = 0.34). CONCLUSIONS: There was a statistically significant difference in agreement between the FLS and TS score of individual female and male trainees, suggesting the presence of implicit bias in this pilot study. Further research with a larger sample size is warranted.

Career Advancement for Surgeon-Educators:Findings from a Modified Delphi Process.

OBJECTIVES: Reward and recognition of surgical education as an academic activity remains a highly variable process between institutions. The goal of this study is to provide expert consensus definition of an academic surgical educator, with focus on criteria for academic promotion. STUDY DESIGN AND SETTING: Following IRB approval, a Web-based modified Delphi process was used to generate prioritized academic promotion criteria for surgical educators. PARTICIPANTS AND SETTING: Participants were recruited nationally from a pool of senior academic surgeons who are members of the Society of University Surgeons and the Society of Surgical Chairs. RESULTS: Following a three-round modified Delphi process, the top domains of educational activity for promotion to associate professor and professor were scholarship, teaching, and administration; mentorship was also a priority category for promotion to professor. The top three activities described for promotion to Associate Professor were active participation in conferences/ departmental educational activities for medical students and residents; educational portfolio demonstrating commitment to activities as an educator; and clinical teaching excellence at their home institution. The three activities most highly scored items for promotion to Professor were mentorship of junior surgical educators; active participation in conferences/ departmental educational activities for medical students and residents; and a record of teaching excellence at the medical student and resident levels. CONCLUSIONS: These findings demonstrate a progression from teacher to scholar to leader across a surgical educator's career, with each level incorporating and building upon the prior activities. Identification of categories and criteria may meaningfully inform best practices to be incorporated into the career development and promotion processes for surgeons on an educator academic pathway.

Bisphenols and Risk of Breast Cancer: A Narrative Review of the Impact of Diet and Bioactive Food Components.

Data from preclinical studies suggest a link between increased risk of breast cancer and exposure to bisphenols at doses below what the United States Food and Drug Administration (FDA) considers as safe for consumption. Bisphenols exert estrogenic effects and are found in canned and plastic wrapped foods, food packaging, and plasticware. Mechanistically, bisphenols bind to the estrogen receptor (ER) and activate the expression of genes associated with cell proliferation and breast cancer. In this paper, we present a narrative literature review addressing bisphenol A and chemical analogs including bisphenol AF, bisphenol F, and bisphenol S selected as prototype xenoestrogens; then, we discuss biological mechanisms of action of these bisphenols in breast cells and potential impact of exposure at different stages of development (i.e., perinatal, peripubertal, and adult). Finally, we summarize studies detailing interactions, both preventative and promoting, of bisphenols with food components on breast cancer risk. We conclude the review with a discussion of current controversies in interpretation of the above research and future areas for investigation, including the impact of bisphenols and food components on breast tumor risk.

Do Olive and Fish Oils of the Mediterranean Diet Have a Role in Triple Negative Breast Cancer Prevention and Therapy? An Exploration of Evidence in Cells and Animal Models.

Breast cancer is the most common malignancy and cause of cancer-related mortality among women worldwide. Triple negative breast cancers (TNBC) are the most aggressive and lethal of the breast cancer molecular subtypes, due in part to a poor understanding of TNBC etiology and lack of targeted therapeutics. Despite advances in the clinical management of TNBC, optimal treatment regimens remain elusive. Thus, identifying interventional approaches that suppress the initiation and progression of TNBC, while minimizing side effects, would be of great interest. Studies have documented an inverse relationship between the incidence of hormone receptor negative breast cancer and adherence to a Mediterranean Diet, particularly higher consumption of fish and olive oil. Here, we performed a review of studies over the last 5 years investigating the effects of fish oil, olive oil and their components in model systems of TNBC. We included studies that focused on the fish oil ω-3 essential fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) in addition to olive oil polyphenolic compounds and oleic acid. Both beneficial and deleterious effects on TNBC model systems are reviewed and we highlight how multiple components of these Mediterranean Diet oils target signaling pathways known to be aberrant in TNBC including PI3K/Akt/mTOR, NF-κB/COX2 and Wnt/ß-catenin.

The Hidden Burden of Mental Health Outcomes Following Firearm-related Injures.

OBJECTIVES: Examine the effect of different types of firearms on readmission due to acute stress disorder (ASD) and/or post-traumatic stress disorder (PTSD) in firearm-injury victims. BACKGROUND: Survivors of firearm-related injuries suffer long-term sequelae such as disability, work loss, and deterioration in the quality of life. There is a paucity of data describing the long-term mental health outcomes in these patients. METHODS: We performed a 5-year (2011-2015) analysis of the Nationwide Readmission Database. All adult patients with firearm injuries were stratified into 3 groups by firearm type: handgun, shotgun, and semiautomatic rifle. Outcome measures were the incidence and predictors of ASD/PTSD. RESULTS: A total of 100,704 victims of firearm-related injuries were identified, of which 13.3% (n = 13,393) were readmitted within 6 months of index hospitalization, 6.7% (n = 8970) of these due to ASD/PTSD. Mean age was 34 ±â€Š14 years, 88% were men. Of those readmitted due to ASD/PTSD, 24% (n = 2153) sustained a handgun-related injury on index hospitalization, 12% (n = 1076) shotgun, and 64% (n = 5741) semiautomatic gun (P = 0.039). On regression analysis, semiautomatic gun and shotgun victims had higher odds of developing ASD/PTSD upon readmission [odds ratio (OR): 2.05 (1.10-4.12) and OR: 1.41 (1.08-2.11)] compared to handgun. Female sex [OR: 1.79 (1.05-3.05)] and younger age representing those younger than 25 years [OR: 4.66 (1.12-6.74)] were also independently associated with higher odds of ASD/PTSD. CONCLUSIONS: Apart from the lives lost, survivors of semiautomatic rifle- and shotgun-related injuries suffer long-term mental health sequalae. These secondary and debilitating mental health outcomes are important considerations for capturing the overall burden of the disease.

Barriers to careers identified by women in academic surgery: A grounded theory model.

BACKGROUND: Faculty attrition has been widely acknowledged and poorly understood throughout academic medicine. To date, barriers to career advancement in academic surgery have been identified and described in a limited fashion using only survey data. The authors sought to characterize career barriers for women academic surgeons using grounded theory methodology. METHODS: Authors conducted semi-structured interviews with 15 mid-career and senior female academic surgeons in the United States. Data were drawn together using grounded theory analysis of interview transcripts to develop a conceptual model. RESULTS: Interviewees identified barriers constituting two intersecting categories: (1) obstacles within the system of academic surgery and (2) impediments based in broader culture and its power structures. Interviewees' robust description of the challenges of integrating clinical and non-clinical professional responsibilities is novel. CONCLUSIONS: Career barriers identified by women in academic surgery are complex and include cultural factors from within and outside of the profession. Identifying and dismantling barriers, particularly those that negatively impact perceptions of belonging, is imperative to creating a culture of sustained excellence in academic surgery. SUMMARY: The authors used grounded theory method to develop a conceptual model of barriers to careers in academic surgery as described by successful female academic surgeons. The authors identified intersecting cultural barriers specific to academic surgery and derived from cultural power differentials.

Characteristics of Effective Mentorship for Academic Surgeons: A Grounded Theory Model.

OBJECTIVE: The authors sought to describe characteristics of effective mentoring relationships in academic surgery based upon lived experiences of mid-career and senior female academic surgeons. BACKGROUND: Prior qualitative work describes characteristics of successful mentoring relationships. However, no model exists of effective mentorship that is specific to academic surgery. METHODS: The authors conducted in-depth interviews with mid-career and senior female US academic surgeons about the impact of mentoring on professional development during 2014 and 2015. Purposive selection aimed to maximize institutional, specialty, years in career, and racial diversity. Grounded theory method was used to generate a conceptual model of effective mentoring relationships. Data saturation occurred following 15 interviews. RESULTS: Interviewees described the need for multiple mentors over time with each mentor addressing a unique domain. Interviewees suggested that mentees should seek mentors who will serve as strategic advisors, who will be unselfish, and who engage with diverse mentees. CONCLUSIONS: This study identified a need for multiple mentors across time and disciplines, and identified 3 key characteristics of effective mentoring relationships in academic surgery. Future work in this area should generate an operational definition of mentorship that supports quantitative evaluation of mentor and mentoring panel performance.

X-Ray of Excised Cancerous Breast Tissue Does Not Affect Clinical Biomarker Expression.

CONTEXT: College of American Pathologists (CAP) and the American Society of Clinical Oncology have emphasized the need to reduce preanalytic variables for evaluating predictive biomarker expression in breast cancer. Postoperative x-ray of excised breast tissue is commonplace, yet is a variable that has not been investigated previously. We asked whether such radiation affects expression of relevant biomarkers. DESIGN: A previous study found that human breast cancers grown in mice demonstrate the same immunohistochemical and molecular profiles as the original tumors. Thirteen patient-derived xenografts were harvested fresh and divided for specimen radiography and a matched nonirradiated control, while following CAP/ASCO guidelines for cold ischemia time and fixation. Samples were processed in a tissue microarray for immunohistochemistry. Estrogen receptor (ER), progesterone receptor (PR), p53, and Ki67 staining was evaluated using an optimized scoring algorithm performed on digitally scanned slides. Samples were also scored manually by a blinded pathologist using the H-score method, and HER2 by the CAP/ASCO 2013 protocol. Histologic scores were compared by analysis of variance. RESULTS: There was no significant difference in quantity or intensity of staining between irradiated and nonirradiated samples for estrogen receptor (P=0.28), p53 (P=0.96), and Ki67 (P=0.94). A small but statistically significant difference was observed for PR (P=0.0058). HER2 staining was similarly unchanged in the 1 tumor exhibiting 3+ staining. CONCLUSIONS: Our study demonstrates that x-ray of breast carcinomas does not significantly affect the expression of predictive biomarkers, with the exception of PR for unclear reasons. It also highlights the utility of the patient-derived xenograft model for biomarker studies.

The role of same-sex mentorship and organizational support in encouraging women to pursue surgery.

INTRODUCTION: While women represent approximately half of all medical students, only 38% of general surgery residents are women. The objective of this study is to explore how access to mentors and organizational support affects career choices. METHODS: In June of 2016, a survey was sent to medical students at a single institution (n = 472). Questions utilized a 5-point Likert scale. A two-sample t-test was used to evaluate data. RESULTS: A total of 160 students participated in the survey. Among MS1/MS2 students, women were more likely to rank same-sex role models as a positive influence (mean 3.1 vs. 2.4; p < 0.05). Similar results were seen among MS3/MS4 students (mean 3.6 vs. 2.5; p < 0.05). More women ranked the presence of organizations that support women in surgery as being important (mean 4.6 vs. 4.1; p < 0.05). CONCLUSION: Exposure to same-sex mentors was highly rated among female participants. These findings encourage the creation of national mentorship programs. Early involvement in organizations can positively influence career choice. Addressing gaps in mentorship opportunities and widening accessibility to national organizations are important in reducing barriers.

Fall risk and function in older women after gynecologic surgery.

PURPOSE OF STUDY: To examine change in balance-related fall risk and daily functional abilities in the first 2 post-operative weeks and up to 6 weeks after gynecologic surgery. MATERIALS AND METHODS: Prospective cohort study in gynecologic surgery patients age 65 and older. Balance confidence (Activities-specific Balance Confidence Scale) and functional status (basic and instrumental activities of daily living) were recorded pre- and post-operatively daily for 1 week and twice the second week. Physical performance balance and functional mobility were measured pre- and 1 week post-operatively using the Tinetti Fall Risk Scale, Timed Up and Go, and 6-Minute Walk test. Measures were repeated 6 weeks after surgery. Non-parametric tests for paired data were used comparing scores baseline to post-operative (POD) 7 and to POD 42. RESULTS: Median age was 72 years (range 65-88). Fall risk was elevated during the first 2 post-operative weeks, greatest on the median discharge day, POD 2 (p<0.01). Balance performance and functional mobility at 1 week were significantly lower than baseline (p<0.01). Functional abilities declined, including new dependence in medication management at home in 22% of these independent and cognitively intact women. CONCLUSIONS: After gynecologic surgery, older women's fall risk is highest on POD 2 and remains elevated from baseline for 2 weeks. Functional limitations in the early home recovery period include the anticipated (bathing, cooking, etc.) and some unanticipated (medication management) ones. This information may help with post-operative discharge planning.

The Role of Genetic Testing in Patients With Breast Cancer: A Review.

Importance: In the United States from 2009 to 2013, the incidence of breast cancer was the highest of any cancer and the death rate was second to that of lung cancer. Approximately 5% to 10% of breast cancers are inheritable. Observations: BRCA1 and BRCA2 germline mutations account for up to 30% of inheritable breast cancers and are the most commonly assessed mutations in patients presenting with early-onset breast cancer, triple-negative breast cancer, bilateral breast cancer, and a family history of breast cancer. Less common non-BRCA mutations have also been identified and contribute to hereditary breast cancer syndromes. Although established in BRCA mutations, indications and interpretations of genetic testing in non-BRCA mutations are not well defined. Furthermore, costs associated with genetic testing are highly variable and dependent on laboratory pricing, insurance coverage, and individual risk factors. Conclusions and Relevance: Genetic testing is a powerful tool that allows for the detection of BRCA and non-BRCA germline mutations in individuals with high risks of breast cancer, which in turn aids in the individualization of treatment. Given the magnitude of this disease, it is of great benefit for physicians, including general surgeons, to understand the indications, interpretations, and costs associated with genetic testing in patients with breast cancer. Cost is an especially important part of the genetic testing process and point of discussion with patients.

The BREASTrial Stage II: ADM Breast Reconstruction Outcomes from Definitive Reconstruction to 3 Months Postoperative.

BACKGROUND: The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a prospective randomized trial comparing outcomes of tissue expander breast reconstruction using either AlloDerm or DermaMatrix. The trial was divided into 3 outcome stages; this study reports stage II outcomes, which are those from the time of definitive reconstruction to 3 months postoperative. METHODS: A randomized trial was conducted to compare complication rates between AlloDerm and DermaMatrix groups. The impact of matrix type, age, obesity, radiation therapy, chemotherapy, and reconstruction type on complications was analyzed with regression models. RESULTS: Of the 128 patients (199 breasts) who were randomly assigned into the trial, 111 patients (173 breasts) were available for analysis in stage II. There was no difference in overall rates of complications (15.4% vs 18.3%, P = 0.8) or implant loss (2.2% vs 3.7%, P = 0.5) between the AlloDerm and DermaMatrix groups, respectively. Obesity was the only significant predictor of complications on regression analysis (odds ratio, 4.31, P = 0.007). Matrix type, age, radiation therapy, chemotherapy, or reconstruction type had no impact on the incidence/severity of complications. CONCLUSIONS: Acellular dermal matrix (ADM) will likely continue to have a role in breast reconstructive surgery; however, caution should be taken when using ADM because of relatively high complication rates, especially in obese patients. The particular ADM product should be selected based on individual surgeon preference, experience, and success rates. These data and forthcoming long-term outcomes from the Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial will enable surgeons to carefully weigh the risks and benefits of ADM use in breast reconstruction.

Integrative analyses reveal signaling pathways underlying familial breast cancer susceptibility.

The signaling events that drive familial breast cancer (FBC) risk remain poorly understood. While the majority of genomic studies have focused on genetic risk variants, known risk variants account for at most 30% of FBC cases. Considering that multiple genes may influence FBC risk, we hypothesized that a pathway-based strategy examining different data types from multiple tissues could elucidate the biological basis for FBC. In this study, we performed integrated analyses of gene expression and exome-sequencing data from peripheral blood mononuclear cells and showed that cell adhesion pathways are significantly and consistently dysregulated in women who develop FBC. The dysregulation of cell adhesion pathways in high-risk women was also identified by pathway-based profiling applied to normal breast tissue data from two independent cohorts. The results of our genomic analyses were validated in normal primary mammary epithelial cells from high-risk and control women, using cell-based functional assays, drug-response assays, fluorescence microscopy, and Western blotting assays. Both genomic and cell-based experiments indicate that cell-cell and cell-extracellular matrix adhesion processes seem to be disrupted in non-malignant cells of women at high risk for FBC and suggest a potential role for these processes in FBC development.

Phase aberration simulation study of MRgFUS breast treatments.

PURPOSE: This simulation study evaluates the effects of phase aberration in breast MR-guided focused ultrasound (MRgFUS) ablation treatments performed with a phased-array transducer positioned laterally to the breast. A quantification of these effects in terms of thermal dose delivery and the potential benefits of phase correction is demonstrated in four heterogeneous breast numerical models. METHODS: To evaluate the effects of varying breast tissue properties on the quality of the focus, four female volunteers with confirmed benign fibroadenomas were imaged using 3T MRI. These images were segmented into numerical models with six tissue types, with each tissue type assigned standard acoustic properties from the literature. Simulations for a single-plane 16-point raster-scan treatment trajectory centered in a fibroadenoma in each modeled breast were performed for a breast-specific MRgFUS system. At each of the 16 points, pressure patterns both with and without applying a phase correction technique were determined with the hybrid-angular spectrum method. Corrected phase patterns were obtained using a simulation-based phase aberration correction technique to adjust each element's transmit phase to obtain maximized constructive interference at the desired focus. Thermal simulations were performed for both the corrected and uncorrected pressure patterns using a finite-difference implementation of the Pennes bioheat equation. The effect of phase correction was evaluated through comparison of thermal dose accumulation both within and outside a defined treatment volume. Treatment results using corrected and uncorrected phase aberration simulations were compared by evaluating the power required to achieve a 20 °C temperature rise at the first treatment location. The extent of the volumes that received a minimum thermal dose of 240 CEM at 43 °C inside the intended treatment volume as well as the volume in the remaining breast tissues was also evaluated in the form of a dose volume ratio (DVR), a DVR percent change between corrected and uncorrected phases, and an additional metric that measured phase spread. RESULTS: With phase aberration correction applied, there was an improvement in the focus for all breast anatomies as quantified by a reduction in power required (13%-102%) to reach 20 °C when compared to uncorrected simulations. Also, the DVR percent change increased by 5%-77% in seven out of eight cases, indicating an improvement to the treatment as measured by a reduction in thermal dose deposited to the nontreatment tissues. Breast compositions with a higher degree of heterogeneity along the ultrasound beam path showed greater reductions in thermal dose delivered outside of the treatment volume with correction applied than beam trajectories that propagated through more homogeneous breast compositions. An increasing linear trend was observed between the DVR percent change and the phase-spread metric (R(2) = 0.68). CONCLUSIONS: These results indicate that performing phase aberration correction for breast MRgFUS treatments is beneficial for the small-aperture transducer (14.4 × 9.8 cm) evaluated in this work. While all breast anatomies could benefit from phase aberration correction, greater benefits are observed in more heterogeneous anatomies.

The Effect of Radiation on Complication Rates and Patient Satisfaction in Breast Reconstruction using Temporary Tissue Expanders and Permanent Implants.

The optimal method of reconstruction following mastectomy for breast cancer patients receiving radiation therapy (RT) is controversial. This study evaluated patient satisfaction and complication rates among patients who received implant-based breast reconstruction. The specific treatment algorithm analyzed included patients receiving mastectomy and immediate temporary tissue expander (TE), followed by placement of a permanent breast implant (PI). If indicated, RT was delivered to the fully expanded TE. Records of 218 consecutive patients with 222 invasive (85%) or in situ (15%) breast lesions from the Salt Lake City region treated between 1998 and 2009 were retrospectively reviewed, 28% of whom received RT. Median RT dose was 50.4 Gy, and 41% received a scar boost at a median dose of 10 Gy. Kaplan-Meier analyses were performed to evaluate the cumulative incidence of surgical complications, including permanent PI removal. Risk factors associated with surgical events were analyzed. To evaluate cosmetic results and patient satisfaction, an anonymous survey was administered. Mean follow-up was 44 months (range 6-144). Actuarial 5-year PI removal rates for non-RT and RT patients were 4% and 22%, respectively. On multivariate analysis (MVA), the only factor associated with PI removal was RT (p = 0.009). Surveys were returned describing the outcomes of 149 breasts. For the non-RT and RT groups, those who rated their breast appearance as good or better were 63% versus 62%, respectively. Under 1/3 of each group was dissatisfied with their reconstruction. RT did not significantly affect patient satisfaction scores, but on MVA RT was the only factor associated with increased PI removal. This reconstruction technique may be considered an acceptable option even if RT is needed, but the increased complication risk with RT must be recognized.

Acceptability of the decision support for safer surgery tool.

BACKGROUND: We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events. METHODS: The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests. RESULTS: During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably. CONCLUSION: The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.