Introducing Surgical Equity into Contemporary Medical Education: Results From Operation Equity, a Pilot Curriculum.

OBJECTIVE: To date, education about health equity for early-stage healthcare trainees is largely situated outside of surgical disciplines. This study aims to evaluate the effectiveness of a surgical equity curriculum offered to a voluntary group of medical and graduate students. DESIGN: Mixed-methods cohort study from January to June 2021. Pre- and post-course surveys measured domains of attitudes, self-reported confidence, and knowledge via 5-point Likert scale and multiple-choice questions. Paired t tests were used to analyze quantitative responses. Qualitative responses were studied via iterative thematic analysis. SETTING: At the University of Pennsylvania in Philadelphia, PA which provides tertiary level, institutional care, 10, interdisciplinary 1.5-hour sessions were held over 1 semester, teaching surgical equity topics that spanned the peri-operative continuum. PARTICIPANTS: Twenty-four medical and graduate students from across the University of Pennsylvania enrolled. Twenty completed both surveys. RESULTS: From pre- to post-course, students improved across all domains. Students improved in their self-rated ability to identify strategies to talk about sensitive health topics with patients (pre: 20%, post: 90%) and identify strategies to address healthcare disparities in surgery (pre: 10%, post: 90%). Qualitatively, from pre- to post-course, more students could articulate the role of bias and identify opportunities for surgeons to engage in surgical equity. The course strengthened any pre-existing interest in surgical equity, and for 1 student, created interest in a surgical career where it had not previously existed. Many also expressed greater resolve to provide patient-centric care. CONCLUSIONS: Formal curricula can improve students' ability to advocate for surgical equity. A similar framework may fill a need for medical students interested in health equity and surgical careers at other institutions.

Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans.

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

ICU Care in a Pandemic.

This letter to the editor responds to commentaries in the September-October 2021issue of the Hastings Center Report by Douglas B. White and Bernard Lo, by Govind Persad, and by Virginia A. Brown, which were themselves responding, in part, to the article "Life-Years and Rationing in the Covid-19 Pandemic: A Critical Analysis," by MaryKatherine Gaurke, Bernard Prusak, Kyeong Yun Jeong, Emily Scire, and Daniel P. Sulmasy.

The Center for Surgical Health: A Compassion-Driven Urban Surgical Mission.

We are the Center for Surgical Health (CSH), an academic community partnership that supports, educates, and advocates for vulnerable Philadelphians with surgical diseases, founded in 2016 by Dr. Jon B. Morris, a leader in surgical education and a general surgeon at the University of Pennsylvania, and Dr. Alan Herbst, a current third-year Penn general surgery resident. At the time, Dr. Morris, raised in a Reform Jewish household, had been participating in an RCIA Program to convert to Catholicism. The mission of providing surgery to uninsured patients, primarily undocumented individuals, by helping them obtain insurance and see Penn providers was seen by Dr. Morris as a form of Catholic charity, which he has continued to remain dedicated to as his faith in Jesus Christ has deepened. Dr. Herbst, now Associate Director of Clinics for the CSH, recalls working with Dr. Morris as a sub-intern during his conversion, beginning with passion and a neon poster board inviting people to "See the Surgeon." Since that time, the CSH has grown from an organization with 10 volunteers, called "personal patient navigators," who provide insurance support and advocacy at every step of the perioperative continuum, to one with over 50, who have now seen 156 patients and assisted in providing 49 needed procedures. Much of this growth has been brought about through the dedication and vision of Dr. Matthew Goldshore, the Deputy Director of the CSH and a fifth-year Penn general surgery resident, as well as Dr. Carrie Z. Morales, Associate Deputy Director of the CSH and a recent Perelman School of Medicine graduate. Through their leadership, and the talent and commitment of other members of the CSH board, overseen by Director Dr. Morris, the CSH now has policy and research divisions, a surgical equity curriculum, and continues to develop new ways of providing better care.

Life-Years & Rationing in the Covid-19 Pandemic: A Critical Analysis.

Prominent bioethicists have promoted the preservation of life-years as a rationing strategy in response to the Covid-19 pandemic. Yet the philosophical justification for maximizing life-years is underdeveloped and has a complex history that is not reflected in recent literature. In this article, we offer a critical investigation of the use of life-years, arguing that evidence of public support for the life-years approach is thin and that organ transplantation protocols (heavily cited in pandemic-response protocols) do not provide a precedent for seeking to save the most life-years. We point out that many state emergency-response plans ultimately rejected or severely attenuated the meaning of saving the most life-years, and we argue that philosophical arguments in support of rationing by life-years are remarkably wanting. We conclude by offering a fair alternative that adheres to the standard duties of beneficence, respect for persons, and justice.

Augmentation of response to nab-paclitaxel by inhibition of insulin-like growth factor (IGF) signaling in preclinical pancreatic cancer models.

Nab-paclitaxel has recently shown greater efficacy in pancreatic ductal adenocarcinoma (PDAC). Insulin like growth factor (IGF) signaling proteins are frequently overexpressed in PDAC and correlate with aggressive tumor phenotype and poor prognosis. We evaluated the improvement in nab-paclitaxel response by addition of BMS-754807, a small molecule inhibitor of IGF-1R/IR signaling, in preclinical PDAC models. In subcutaneous xenografts using AsPC-1 cells, average net tumor growth in different therapy groups was 248.3 mm3 in controls, 42.4 mm3 after nab-paclitaxel (p = 0.002), 93.3 mm3 after BMS-754807 (p = 0.01) and 1.9 mm3 after nab-paclitaxel plus BMS-754807 (p = 0.0002). In subcutaneous xenografts using Panc-1 cells, average net tumor growth in different therapy groups was: 294.3 mm3 in controls, 23.1 mm3 after nab-paclitaxel (p = 0.002), 118.2 mm3 after BMS-754807 (p = 0.02) and -87.4 mm3 (tumor regression) after nab-paclitaxel plus BMS-754807 (p = 0.0001). In peritoneal dissemination model using AsPC-1 cells, median animal survival was increased compared to controls (21 days) after therapy with nab-paclitaxel (40 days, a 90% increase, p = 0.002), BMS-754807 (27 days, a 29% increase, p = 0.01) and nab-paclitaxel plus BMS-754807 (47 days, a 124% increase, p = 0.005), respectively. Decrease in proliferation and increase in apoptosis by nab-paclitaxel and BMS-754807 therapy correlated with their in vivo antitumor activity. In vitro analysis revealed that the addition of IC25 dose of BMS-754807 decreased the nab-paclitaxel IC50 of PDAC cell lines. BMS-754807 therapy decreased phospho-IGF-1R/IR and phospho-AKT expression, and increased cleavage of caspase-3 and PARP-1. These results support the potential of BMS-754807 in combination with nab-paclitaxel as an effective targeting option for pancreatic cancer therapy.