Attending and Resident Surgeon Perspectives and Prescribing Practices of Pain Medication During the Opioid Epidemic.

OBJECTIVE: Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes. DESIGN: Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play. SETTING: Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest. PARTICIPANTS: Attending and resident physicians within the Departments of Surgery participated anonymously. RESULTS: Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p < 0.05), discuss the potential of opioid abuse (31% vs. 6%; p < 0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p < 0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with >5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%). CONCLUSION AND RELEVANCE: Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.

Mid-Year Medical Knowledge Milestones and ABSITE Scores in First-Year Surgery Residents.

OBJECTIVE: Accreditation Council for Graduate Medical Education (ACGME) Surgery milestone ratings in the "Knowledge of Diseases and Conditions" (MK1) sub competency have been shown to correlate with American Board of Surgery In Training Examination (ABSITE) scores, and hypothesized to predict them. To better assess the predictive value of the MK1 milestone and avoid the potential bias caused by previous years' ABSITE scores, we designed a study including only first-year (PGY-1) residents and analyzed the correlation between their mid-year MK1 ratings and their scores in the ABSITE they took approximately a month later. METHODS: De-identified United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, mid-year MK1 milestone ratings and the subsequent ABSITE standard scores for the five academic years from 2014-2015 to 2018-2019 were collected and tabulated for 247 PGY-1 preliminary- and categorical-track residents from ten ACGME-accredited surgery residency programs. RESULTS: The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical residents' subset. Notably, controlling for all other independent predictors, each half-point increase in MK1 rating was associated with a 25-point increase in ABSITE score. Preliminary residents performed significantly worse on the ABSITE, and their scores did not correlate significantly with their MK1 ratings. CONCLUSIONS: The mid-year rating of PGY-1 residents' MK1 was predictive of their subsequent first ABSITE score for the entire cohort and for the categorical but not the preliminary residents. This finding suggests that evaluators correctly rated MK1 higher in the categorical residents who did perform better on the subsequent ABSITE.

Comparison of pulmonary lobectomies using robotic and video-assisted thoracoscopic approaches: results from 2010-2013 National Inpatient Sample.

BACKGROUND: Robotic lobectomies for pulmonary pathologies, such as lung cancer, have seen increased usage over the past 10 years. Previous studies have shown that robotic lung surgery is safe and can lead to improved outcomes for patients. The purpose of this study was to compare postoperative complications associated with robotic lobectomy and video-assisted thoracoscopic surgery (VATS) lobectomy using the National Inpatient Sample (NIS) database in the USA. The use of this large, nationwide database may help clarify differences in outcomes of these two operative approaches. METHODS: Patients who underwent VATS and robotic lobectomy from 2010-2013 were identified using the NIS database. A propensity score matched analysis was applied in a 1:1 ratio to minimize imbalance between preoperative comorbidities. RESULTS: Final analysis included a total of 2868 patients: 1434 were VATS and 1434 were robotic cases. Postoperatively, the rate of overall morbidity was not statistically different in the VATS versus the robotic group (39.9% vs. 43.0%, P=0.084). Specific complications that were higher in the robotic group included: rates of accidental puncture or laceration (1.8% vs. 0.8%, P=0.016), pneumonia (5.7% vs. 4.1%, P=0.048), and bleeding complications (2.4% vs. 1.1%, P=0.012). Total costs were lower for the VATS group than the robotic group ($77,940.54 vs. $102,057.07, P<0.001). CONCLUSIONS: Overall morbidity between the two groups was not statistically different. Patients that underwent robotic versus VATS lobectomy were significantly more likely to experience accidental puncture or laceration, pneumonia, and bleeding complications. Robotic surgery also incurred more cost.

Trends and Outcomes of Synchronous Resection of Colorectal Metastasis in the Modern Era-Analysis of Targeted Hepatic NSQIP Database.

BACKGROUND: Previous studies using the NSQIP database to study hepatectomies lacked hepatic specific variables and outcomes. We used the targeted NSQIP hepatectomy database to examine the nationwide trend and the safety profile of synchronous liver and colorectal resection compared with hepatectomy alone for colorectal liver metastasis. METHODS: The targeted NSQIP hepatectomy database from 2014 was used to study patients who underwent hepatectomy for diagnosis of adenocarcinoma of the colon and rectum. RESULTS: Of the 3064 hepatic resections in the database, 1138 cases were performed for colorectal metastasis. Of these, 1040 were liver-alone surgery and 98 were synchronous liver and colorectal resection. Most (58.7%) patients received neoadjuvant therapy. The rate of neoadjuvant therapy, intraoperative ablation, biliary reconstruction, and the use of minimally invasive technique were similar between the two groups. The overall 30-d mortality in this cohort was low (1.1%). While the mortality rate in the synchronous group was similar to liver-only group (3.1% versus 0.9%, P = 0.077). The rate of liver failure (3.3% versus 4.1%, P = 0.722) and biliary leak (5.3% versus 9.6%, P = 0.084) were similar between the two groups. However, the rate of major complications was higher on multivariable analyses (25.5% versus 12.1%, OR 2.5, 95% CI 1.5-4.1, P < 0.001) for the synchronous group. CONCLUSIONS: Hepatic resection for colorectal metastasis in the modern era has low short-term mortality. While synchronous resection was associated with a higher incidence of major complications, liver-specific complications did not increase with synchronous resection.

Racial disparities in breast cancer persist despite early detection: analysis of treatment of stage 1 breast cancer and effect of insurance status on disparities.

PURPOSE: Prior research demonstrates racial disparities in breast cancer treatment. Disparities are commonly attributed to more advanced stage at presentation or aggressive tumor biology. We seek to evaluate if racial disparities persist in the treatment of stage 1 breast cancer patients who by definition are not delayed in presentation. METHODS: We selected stage 1 breast cases in the National Cancer Data Base. Patients were divided into two cohorts based on race and included White and Black patients. We also performed a subgroup analysis of patients with private insurance for comparison to determine if private insurance diminished the racial disparities noted. We analyzed differences in time to treatments by race. RESULTS: Our analysis included 546,351 patients of which 494,784 (90.6%) were White non-Hispanic and 51,567 (9.4%) were Black non-Hispanic. Black women had significantly longer times to first treatment (35.5 days vs 28.1 days), surgery (36.6 days vs 28.8 days), chemotherapy (88.1 days vs 75.4 days), radiation (131.3 days vs 99.1 days), and endocrine therapy (152.1 days vs 126.5 days) than White women. When patients with private insurance were analyzed the difference in time to surgery decreased by 1.2 days but racial differences remained statistically significant. CONCLUSIONS: Despite selecting for early-stage breast cancer, racial disparities between White and Black women in time to all forms of breast cancer treatment persist. These disparities while likely not oncologically significant do suggest institutional barriers for obtaining care faced by women of color which may not be addressed with improving access to mammography alone.

Outcomes associated with resident involvement in ventral hernia repair: A population based study using the NSQIP database.

INTRODUCTION: This study evaluated the effect of resident involvement on patient outcomes following major ventral hernia repair (VHR). METHODS: National Surgical Quality Improvement Program database was queried to identify patients with major VHR between 2007 and 2010. Patient outcomes were compared based on presence or absence of resident in the operating room. RESULTS: Residents participated in 57% of the 27,773 identified cases. There was no significant difference in return to operating room or 30-day mortality. A higher incidence of superficial surgical site infection (SSI) (4.9% vs 3.9%, P = 0.013) and longer operative time (129.2 vs 99.1 min, P < 0.001) were observed with resident involvement in open inpatient cases. We found no evidence of a "July effect" on outcomes. CONCLUSION: Resident involvement in VHR has little impact on morbidity, and patients can be reassured that resident participation in their care is safe.

Work-Related Quality of Life of US General Surgery Residents: Is It Really so Bad?

PURPOSE: The quality of working life of US surgical residents has not been studied, and given the complexity of interaction between work and personal life there is a need to assess this interaction. We utilized a validated Work Related Quality of Life (WRQoL) questionnaire to evaluate the perceived work-related quality of life of general surgery residents, using a large, nationally representative sample in the United States. METHODS: Between January 2016 and March 2016, all US general surgery residents enrolled in an ACGME general surgery training program were invited to participate. The WRQoL scale measures perceived quality of life covering six domains: General Well-Being (GWB), Home-Work Interface (HWI), Job and Career Satisfaction (JCS), Control at Work (CAW), Working Conditions (WCS) and Stress at Work (SAW). RESULTS: After excluding for missing data, the final analysis included 738 residents. The average age was 30 (±3) years, of whom 287 (38.9%) were female, 272 (36.9%) were from a community hospital, and 477 (64.6%) were juniors (postgraduate year ≤ 3). Demographically, the respondents matched expected percentages. When male and female residents were compared, males had statistically better HWI (p<0.001), better GWB (p = 0.03), more CAW (p = 0.0003) and WCS (p = 0.001). Junior residents had a lower JCS (p = 0.002) and CAW (p = 0.04) compared to seniors. There were no differences between university and community residents in any of the domains of WRQoL. Although residents were more stressed than other professions but the overall WRQoL was comparable. CONCLUSIONS: The nature of surgical residency and a surgical career may in fact be more "stressful" than other professions, yet may not translate into a worsened Quality of Life. Our findings suggest further study is needed to elucidate why female residents have or experience a lower perceived WRQoL than their male colleagues.

Multi-institutional study of self-reported attitudes and behaviors of general surgery residents about ethical academic practices in test taking.

PURPOSE: Correlation exists between people who engage in academic dishonesty as students and unethical behavior once in practice. Previously, we assessed the attitudes of general surgery residents and ethical practices in test taking at a single institution. Most residents had not participated in activities they felt were unethical, yet what constituted unethical behavior was unclear. We sought to verify these results in a multi-institutional study. METHODS: A scenario-based survey describing potentially unethical activities related to the American Board of Surgery In-training Examination (ABSITE) was administered. Participants were asked about their knowledge of or participation in the activities and whether the activity was unethical. Program directors were surveyed about the use of ABSITE results for resident evaluation and promotion. RESULTS: Ten programs participated in the study. The resident response rate was 67% (186/277). Of the respondents, 43% felt that memorizing questions to study for future examinations was unethical and 50% felt that using questions another resident memorized was unethical. Most felt that buying (86%) or selling (79%) questions was unethical. Significantly more senior than junior residents have memorized (30% vs 16%; p = 0.04) or used questions others memorized (33% vs 12%; p = 0.002) to study for future ABSITE examinations and know of other residents who have done so (42% vs 20%; p = 0.004). Most programs used results of the ABSITE in promotion (80%) and set minimum score expectations and consequences (70%). CONCLUSION: Similar to our single-institution study, residents had not participated in activities they felt to be unethical; however the definition of what constitutes cheating remains unclear. Differences were identified between senior and junior residents with regard to memorizing questions for study. Cheating and unethical behavior is not always clear to the learner and represents an area for further education.

Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology?

BACKGROUND: The purpose of this study was to describe the incidence and clinical/pathologic characteristics of papillary thyroid microcarcinoma (PMC) in a community hospital setting and to evaluate the frequency and characteristics of these lesions when unsuspected preoperatively. METHODS: A total of 723 patients underwent a partial or total thyroidectomy. A retrospective review was performed. RESULTS: A total of 194 of the 723 patients had a final diagnosis of papillary carcinoma. Ninety-six (49%) of these tumors were PMCs defined as being 1.0 cm or less in diameter. One third (32 of 96) of these lesions were multifocal and 16.7% (16 of 96) were found to have regional lymph node metastases. The majority (58%) of PMCs were found on final pathology and were clinically unsuspected (occult). Multifocality was found in 32.1% (18 of 56) of patients with clinically unsuspected PMC, with nodal metastases in 3.6% (2 of 56). The other 40 patients with PMC had surgeries performed for a clinical reason related to that pathologic lesion. This clinically suspected group was comparably multifocal (35%), but more likely to have cervical lymph node metastasis (35%). Sixty-six percent (37 of 56) diagnosed with a clinically unsuspected PMC underwent a partial thyroidectomy at the initial surgery. CONCLUSIONS: The prevalence of clinically unsuspected PMC in our population undergoing thyroidectomy was 7.7% (56 of 723). In our institution, this is more than half of all PMCs. The incidence of cervical lymph node metastasis in clinically unsuspected PMC was only 3.6% compared with 35% in clinically suspected disease, suggesting that the biological behavior (and possibly treatment) may be different. Long-term follow-up evaluation is needed to better evaluate the significance of these differences.

Improving satisfaction ratings of surgical patients from referral to follow-up in the faculty medical center clinic.

OBJECTIVE: The objective of this study was to evaluate patient satisfaction in an outpatient community-based surgical clinic to seek opportunities for improvement. METHODS: A paper survey was distributed to patients at the Faculty Medical Center Clinic over a 12-week period. The survey allowed patients to rate their experience on a 5-point scale from "very dissatisfied" to "very satisfied." The survey addressed referral to the clinic, appointment scheduling, visit experience, wait times, laboratory testing, and satisfaction with surgery. Separate from the surveys, data were collected regarding wait time in clinic prior to being placed in an examining room, time spent waiting for the physician, time spent with the physician, overall time spent in clinic, and appointment time to surgery. RESULTS: During the 12-week time period, 87 surveys were returned from patients in the surgery clinic for a 69% response rate. Most patients were referred to the surgery clinic from the emergency department or their primary care physicians at 44% and 43%, respectively. Just over half of the patients responded that they were "very satisfied" with their overall experience. Of those surveyed, 40% of patients were "very satisfied" with their wait time for the first visit to the clinic, 52% with time in waiting room, 43% with time in examining room, and 47% with time spent with physician. Only 16.4% of patients were "very dissatisfied" or "mostly dissatisfied" with time waiting for appointment, 17.9% with time available for appointment, 14.3% with time in waiting room, 18.2% in time waiting in examination room for the physician, and 20.9% of time wait to schedule surgery. Data were also collected on 203 surgical clinic patients during this time. Of the 203 patients, 55% were new patients, 31% were postoperative patients, and 14% were in the clinic for another type of visit. CONCLUSIONS: Overall patient satisfaction was good for the clinic, yet there were areas to improve. Efficiency of scheduling patients, improving wait time for waiting room, examining room, and time prior to scheduling surgery are areas that need improvement. Modification of the current practice at the surgery clinic could result in improvement of patient satisfaction in future evaluation.

Operative decision-making for follicular thyroid lesions: a community hospital system experience.

Follicular neoplasms of the thyroid are a frequent indication for surgery of the thyroid gland. We evaluated the use of frozen sections on intraoperative decision-making, possible avoidance of reoperative surgery, and histologic findings in a retrospective cohort. A database was created of all thyroid operations from 2001 to 2007. Data collected included age, gender, preoperative cytology, indication for surgery, surgeon, intraoperative decision-making, and histologic findings. Of the 723 thyroidectomies, 203 were performed for follicular neoplasms diagnosed by fine needle aspiration. Of these, 135 had cytology reports available within our electronic medical record; 44 per cent (59 of 135) of these patients had an intraoperative frozen section. Only two of 59 (3.4%) were positive for carcinoma, both of which were papillary carcinomas. One was interpreted as "suspicious" for carcinoma by the pathologist. In these three cases, the surgeon proceeded with total thyroidectomy at the time of initial surgery. The results of frozen section altered the operation in only three of 59 cases (5.1%). Intraoperative frozen section rarely impacts the conduct of thyroidectomy for follicular neoplasms.

The influence of gender of the surgeon on surgical procedure preference for breast cancer.

There are few data in the literature with regard to the influence of surgeon gender and the treatment of breast cancer. In this retrospective review we propose to test the hypothesis that male surgeons are just as likely as female surgeons to provide breast-conservative treatment. From 1990 through 1997 2271 women with breast cancer in Cincinnati, Ohio were operated on by surgeons within the TriHealth Corporation. We compared the performance rate of breast conservation therapy (BCT) with the rate of mastectomy in early-stage breast cancer patients between male and female surgeons. Male surgeons were significantly more likely to provide their patients with breast-conserving treatment than their female colleagues for stages 0 and IIb (P < 0.05). Although male surgeons performed more BCT than female surgeons for stages I and IIa the difference was not statistically significant. For the three stages combined there was a 30 per cent greater chance of a patient receiving breast-conserving treatment if she went to a male surgeon (P < 0.05). We conclude that in our institution male surgeons are no more likely to select mastectomy than their female colleagues and there appears to be an increased use of BCT by male surgeons.