The Effect of Intersectionality on Attrition among US General Surgery Trainees.

OBJECTIVE: To examine the association between intersectionality of race, ethnicity, and sex on retention of U.S. general surgery residents. SUMMARY BACKGROUND DATA: There are limited data on the role that intersectionality plays on the US general surgery resident experience. METHODS: Analysis was performed using Association of American Medical Colleges (AAMC) data for general surgery residents who started their training between 2005-2015 (followed through completion). Regression analyses were used to assess demographic associations with time to attrition or successful completion of residency training. Associations between faculty and resident demographics were assessed. RESULTS: 25,029 residents were included. Over the decade-long study period, the number of underrepresented in medicine (UIM) residents as a percentage of all residents remained similar from 17% to 19% (P=0.24). The percent of UIM males starting training in 2005 was 11% and 12% in 2015 (P-value=0.38). UIM females comprised 5.5% of trainees in 2005 and increased to 6.9% (P-value=0.003) in 2015; and female non-UIM residents increased from 23 to 28% (P-value<0.001). The overall rate of resident attrition was 15%. UIM females had the highest yearly attrition rate at 21% compared to non-UIM males at 13% (HR 1.7, P<0.001). UIM females were more likely to leave residency compared to UIM males (HR: 1.5; P<0.001). The percent of UIM faculty was positively correlated with percent of UIM residents (r=0.64, P<0.001). CONCLUSIONS: Increasing intersectionality is positively associated with attrition during surgery residency. The diversity of faculty appears to be associated with resident diversity.

Surgeon Intersectionality and Academic Promotion and Retention in the US.

Introduction: Efforts have been made to increase the number of women and physicians who are underrepresented in medicine (UIM). However, surgery has been slow to diversify, and there are limited data surrounding the impact of intersectionality. Objective: To assess the combined association of race and ethnicity and sex with rates of promotion and attrition among US academic medical department of surgery faculty. Design, Setting, and Participants: This was a retrospective cohort study using faculty roster data from the Association of American Medical Colleges. All full-time academic department of surgery faculty with an appointment any time from January 1, 2005, to December 31, 2020, were included. Study data were analyzed from September 2022 to February 2023. Exposures: Full-time academic faculty in a department of surgery with a documented self-reported race, ethnicity, and sex within the designated categories of the faculty roster of Association of American Medical Colleges. Main Outcomes and Measures: Trends in race and ethnicity and sex, rates of promotion, and rates attrition from 2010 to 2020 were assessed with Kaplan-Meier and Cox time-to-event analyses. Results: A total of 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 institutions were included. The mean (SD) program percentage of UIM male faculty increased from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty members increased from 2.3% (2.6%) to 3.3% (2.5%) over the 10-year period (P < .001). The mean program percentage of non-UIM females increased at every rank (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all P < .001). There was no change in the mean program percentage of UIM female instructors or full professors. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%) and 1.6% (3.2%) to 2.2% (3.4%), respectively (P =.002). There was no change in the mean program percentage of UIM male instructors, associate, or full professors. Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). Non-UIM males had the shortest median (IQR) time to promotion, whereas non-UIM females had the longest (6.9 [6.8-7.0] years vs 7.2 [7.0-7.6] years, respectively; P < .001). After 10 years, 79% of non-UIM males (13 202 of 16 299), 71% of non-UIM females (3784 of 5330), 68% of UIM males (1738 of 2538), and 63% of UIM females (625 of 999) remained on the faculty. UIM females had a higher risk of attrition compared with non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001) and UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .05). The mean (SE) time to attrition was shortest for UIM females and longest for non-UIM males (8.2 [0.14] years vs 9.0 [0.02] years, respectively; P < .001). Conclusion and Relevance: Results of this cohort study suggest that intersectionality was associated with promotion and attrition, with UIM females least likely to be promoted and at highest risk for attrition. Further efforts to understand these vulnerabilities are essential.

Perceived Implications of Compensation Structure for Academic Surgical Practice: A Qualitative Study.

This qualitative study examines how incentive-based and salary-only compensation models affect academic surgeons.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons.

Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons. Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender. Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience. Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons. Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals. Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Neoadjuvant botensilimab plus balstilimab response pattern in locally advanced mismatch repair proficient colorectal cancer.

In patients with locally advanced cancer without distant metastases, the neoadjuvant setting presents a platform to evaluate new drugs. For mismatch repair proficient/microsatellite stable (pMMR/MSS) colon and rectal cancer, immunotherapy has shown limited efficacy. Herein, we report exceptional responses observed with neoadjuvant botensilimab (BOT), an Fc-enhanced next-generation anti-CTLA-4 antibody, alongside balstilimab (BAL; an anti-PD-1 antibody) in two patients with pMMR/MSS colon and rectal cancer. The histological pattern of rapid immune response observed ("inside-out" (serosa-to-mucosa) tumor regression) has not been described previously in this setting. Spatial biology analyses (RareCyte Inc.) reveal mechanisms of actions of BOT, a novel innate-adaptive immune activator. These observations have downstream implications for clinical trial designs using neoadjuvant immunotherapy and potentially sparing patients chemotherapy.

Social Media: The Good, The Bad, and The Ugly.

The use of social media platforms in a professional capacity has grown and presents unique opportunities for women surgeons. Women surgeons face unique obstacles and challenges compared with their male counterparts. Social media has helped women surgeons create an online community and has provided opportunities for mentorship and professional advancement. In addition, it has helped break down traditional constructs of what it means to be a surgeon and allowed the medical community and public to view images of a modern surgeon. Social media has played an important role in continually increasing efforts to diversify the field of surgery and break down traditional stereotypes associated with surgeons. However, there are some downsides of social media that women surgeons need to be aware of, particularly, the risk of harassment, criticism, and potentially harmful online reviews.

The accuracy of race & ethnicity data in US based healthcare databases: A systematic review.

BACKGROUND: The availability and accuracy of data on a patient's race/ethnicity varies across databases. Discrepancies in data quality can negatively impact attempts to study health disparities. METHODS: We conducted a systematic review to organize information on the accuracy of race/ethnicity data stratified by database type and by specific race/ethnicity categories. RESULTS: The review included 43 studies. Disease registries showed consistently high levels of data completeness and accuracy. EHRs frequently showed incomplete and/or inaccurate data on the race/ethnicity of patients. Databases had high levels of accurate data for White and Black patients but relatively high levels of misclassification and incomplete data for Hispanic/Latinx patients. Asians, Pacific Islanders, and AI/ANs are the most misclassified. Systems-based interventions to increase self-reported data showed improvement in data quality. CONCLUSION: Data on race/ethnicity that is collected with the purpose of research and quality improvement appears most reliable. Data accuracy can vary by race/ethnicity status and better collection standards are needed.

Establishing the Essential Role of Household Extenders for Surgeon Wellbeing.

OBJECTIVE: The aim of this study was to investigate the association between a change in household support during the Covid-19 pandemic and surgeon stress. BACKGROUND: The hours and unpredictability of surgical practice often necessitate the employment of household extenders (eg, child caregivers) to maintain a safe home environment for surgeons and their families. The Covid-19 pandemic destabilized these relationships and provided an opportunity to reflect on the role that household extenders play in a surgical household. METHODS: A multi-institutional telephone survey of surgeons practicing at five geographically diverse academic institutions was conducted (May 15, 2020-June 5, 2020). Surgeons were classified by change in household extenders (HE) during the pandemic (decrease, increase, no change, or none). The primary outcome was self-reported surgeon stress level. Multivariable linear regression was used to examine the relationship between change in HE and surgeon stress, adjusting for training and relationship status, the presence of pets and children in the household, and study site. RESULTS: The majority (182, 54.3%) of surgeons employed HE before the pandemic; 121 (36.1%) reported a decrease in HE during the pandemic, 9 (2.7%) reported an increase, and 52 (15.5%) reported no change. Stress scores varied significantly by change in HE group ( P = 0.016). After controlling for potential confounders, having an increase in HE was associated with a higher stress score (+1.55 points) than having no decrease in HE (P = 0.033), and having a decrease in HE was associated with a higher stress score (+0.96 points) than having no decrease ( P = 0.004). CONCLUSIONS: Household extenders play a vital and complex role in enabling the healthcare workforce to care of the population. Surgeons who experienced a change in household extenders reported the highest stress levels. We suggest that health systems should proactively support surgeons by supporting the household extender workforce.

Longitudinal evaluation of the surgical workforce experience during the Covid-19 pandemic.

BACKGROUND: An updated examination of the surgeon experience during the Covid-19 pandemic is lacking. This study sought to describe how surgeon stress levels and sources of stress evolved over the pandemic. METHODS: An electronic survey was administered to surgeons at four academic hospitals at 6-months and 12-months following an initial telephone survey. The primary outcome was stress level and secondary outcomes were the individual stressors. Thematic analysis was applied to free text responses. RESULTS: A total of 103 and 53 responses were received at 6-months and 12-months, respectively. The mean overall stress level was 5.35 (SD 1.89) at 6-months and 4.83 (SD 2.19) at 12-months. Mean number of stressors declined from 3.77 (SD 2.39) to 2.06 (SD 1.60, P < 0.001), though the "finances" stressor increased frequency (27.2% to 34.0%). Similar qualitative themes were identified, however codes for financial and capacity challenges were more prominent at 12-months. CONCLUSIONS: The surgical workforce continues to report elevated levels of stress, though the sources of this stress have changed. Targeted interventions are imperative to protect surgeons from long-term psychological and financial harm.

Public perception on opioids & pain management after major surgery.

BACKGROUND: In the US, opioids are overprescribed after surgery contributing to the opioid epidemic. Patients' expectations regarding postoperative opioids remains unclear. METHODS: A representative survey using random-digit dial telephone sampling of English-speaking adults in US was conducted from August 28 to December 11, 2019. RESULTS: Of the 1533 eligible persons contacted, 1000 completed the interviews yielding a cooperation rate of 65%. The mean age was 47 (±18) years, half were men, and most were non-Hispanic white (73%). Forty-eight percent expected an opioid prescription after major surgery, 50% worry about addiction, and 61% believe they contribute to the opioid epidemic. Interestingly, 31% assume that opioid-dependent users were first exposed to opioids following surgery. CONCLUSION: Many Americans surveyed expect to receive an opioid containing pain medication after major surgery, but fear the risk of addiction and believe that they are contributing to the opioid epidemic. They do not think that opioid-dependent users were first exposed to opioids after surgery. This discordance may represent an area of policy action and education.

Bias Issues in Colorectal Cancer Management: A Review.

Based on census data, over one-third of the US population identifies as a racial or ethnic minority. This group of racial and ethnic minorities is more likely to develop cancer and die from it when compared with the general population of the USA. These disparities are most pronounced in the African American community. Despite overall CRC rates decreasing nationally and within certain racial and ethnic minorities in the USA, there continue to be disparities in incidence and mortality when compared with non-Hispanic Whites. The disparities in CRC incidence and mortality are related to systematic racism and bias inherent in healthcare systems and society. Disparities in CRC management will continue to exist until specific interventions are implemented in the context of each racial and ethnic group. This review's primary aim is to highlight the disparities in CRC among African Americans in the USA. For surgeons, understanding these disparities is formative to creating change and improving the quality of care, centering equity for all patients.

Ischemic Colitis From Idiopathic Myointimal Hyperplasia of the Mesenteric Veins in a Post-Liver Transplant Patient.

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of nonthrombotic, noninflammatory ischemic colitis. IMHMV classically presents in men with abdominal pain and bloody diarrhea and is frequently misdiagnosed as inflammatory bowel disease. However, IMHMV causes a more protracted, relapsing course of abdominal pain that does not respond to medical therapy. The diagnosis can be secured by colonoscopic biopsy. Surgical resection is curative and should be considered even in high-risk patients. Here, we describe a case of IMHMV diagnosed preoperatively in a post-liver transplant patient with residual portal hypertension who ultimately underwent successful surgical resection.

Disparities in Surgical Oncology: Management of Advanced Cancer.

Significant variations in the patterns of care, incidence, and mortality rates of several common cancers have been noted. These disparities have been attributed to a complex interplay of factors, including genetic, environmental, and healthcare-related components. Within this review, primarily focusing on commonly occurring cancers (breast, lung, colorectal), we initially summarize the burden of these disparities with regard to incidence and screening patterns. We then explore the interaction between several proven genetic, epigenetic, and environmental influences that are known to contribute to these disparities.