Development of an Assessment Tool for Surgeons in Their First Year of Independent Practice: The Junior Surgeon Performance Assessment Tool.

OBJECTIVE: The purpose of this study was to create an assessment tool to evaluate newly practicing surgeons. DESIGN: In this prospective mixed methods study, a needs assessment was performed by conducting focus groups with practicing general surgeons, asking questions regarding essential surgeon qualities, behaviors observed in inexperienced surgeons, current assessment methods, and desired assessment tool elements and attributes. A qualitative analysis was performed using a grounded theory methodology. The Junior Surgeon Performance Assessment Tool (JSPAT) was created using a 4-point scale for each category developed, with themes identified in the qualitative analysis used to create behavioral anchors. The JSPAT was evaluated by focus group participants and by members of the American College of Surgeons Advisory Council for Rural Surgery using an online survey. SETTING: Rural and nonuniversity-based hospitals throughout the state of Oregon. PARTICIPANTS: Practicing general surgeons. RESULTS: Focus groups consisted of 31 surgeons (mean age 49, mean experience 17 years) from 11 different hospitals. Qualitative analysis revealed 91 different themes, which were grouped into 5 domains (technical skills, interaction with patients, interaction with surgeon colleagues, interactions with the greater medical community, and self-care) to create the assessment tool. Twenty online survey responses providing feedback on the assessment tool were obtained, with 75% rating the JSPAT useful or very useful and 69% satisfied or very satisfied with the time to complete the tool. CONCLUSIONS: A mixed-methods model was used to create an assessment tool for surgeons in their first year of independent practice. Survey data demonstrated that practicing surgeons find value in the JSPAT.

When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area.

BACKGROUND: Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons. METHODS: We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed. RESULTS: We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures. CONCLUSIONS: Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training.

Who Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Appendiceal Cancer? An Analysis of the National Cancer Database.

BACKGROUND: We sought to identify patterns of care for patients with appendiceal cancer and identify clinical factors associated with patient selection for multimodality treatment, including cytoreductive surgery and perioperative intraperitoneal chemotherapy (CRS/PIC). MATERIALS AND METHODS: National Cancer Database (NCDB) data from 2004 to 2014 of all diagnoses of appendiceal cancers were examined. We examined treatment modalities, as well as demographic, tumor-specific, and survival data. A multivariate logistic regression analysis was performed to determine the patient cohort most likely to receive CRS/PIC. Kaplan-Meier was used to estimate survival for all treatment groups. Significance was evaluated at P ≤ 0.05. RESULTS: We analyzed data on 18,055 patients. Nine thousand nine hundred ninety-two (55.3%) were treated with surgery only, 5848 (32.4%) received surgery and systemic chemotherapy, 1393 (7.71%) received CRS/PIC, 520 (2.88%) received chemotherapy alone, and 302 (1.67%) received neither surgery nor chemotherapy. Significant predictors of receiving CRS/PIC included male sex (OR 1.33, 95% CI: 1.11-1.59), white race (OR 2.00, 95% CI 1.40-2.86), non-Hispanic ethnicity (OR 1.92, 95% CI 1.21-3.05), private insurance (OR 1.52, 95% CI 1.26-1.84), and well-differentiated tumors (OR 4.25, CI: 3.39-5.32) (P < 0.05). Treatment with CRS/PIC was associated with a higher 5-year survival for mucinous malignancies, when compared to surgery alone (65.6% versus 62.4%, P < 0.01). Treatment with CRS/PIC was also associated with higher 5-year survival for well-differentiated malignancies, when compared to all other treatment modalities (74.9% versus 65.4%, P < 0.01). CONCLUSIONS: Patients were more likely to undergo CRS/PIC if they were male, white, privately insured, and with well-differentiated tumors. CRS/PIC was associated with improved survival in patients with mucinous and low-grade tumors.

Does Sex Influence Publication Productivity Among Colorectal Surgeons Participating in Fellowship Training Programs?

BACKGROUND: Underrepresentation of highly ranked women in academic surgery is recognized. OBJECTIVE: Our objective was to examine whether sex differences exist in faculty representation, academic rank, and publication productivity among colorectal faculty in fellowship programs. DESIGN: American Society of Colon and Rectal Surgeons fellowship program faculty were identified. Bibliometric data were obtained for each faculty member, including Hirsch index, the Hirsch index divided by research career duration, and number of publications. Linear mixed-effect regression models were constructed to determine the association between the Hirsch index and the Hirsch index divided by research career duration and sex, when controlling for institutional measures. A subset analysis of academic faculty examined the association between academic rank, sex, and Hirsch index and the Hirsch index divided by research career duration. SETTINGS: Colorectal fellowship programs, defined as academic, satellite-academic, and nonacademic, were evaluated. RESULTS: Three hundred fifty-eight faculty members were examined across 55 training programs; 22% (n = 77) were women and 78% (n = 281) were men. Sixty-one percent (n = 220) practiced in an academic setting, 23% (n = 84) in a satellite-academic setting, and 15% (n = 54) in a nonacademic setting. There was no difference in median number of publications between sexes (15 vs 10, p = 0.33); men, however, had longer careers (18 vs 11 years, p < 0.001). When controlling for confounders, there was no difference in the Hirsch index (p = 0.42) or the Hirsch index divided by research career duration (p = 0.73) between sexes. Academic rank was significantly associated with Hirsch index and the Hirsch index divided by research career duration (p < 0.001) after controlling for sex. LIMITATIONS: Our assessment of association between publication productivity and academic rank was only possible in the subset of academic faculty. In addition, this study is limited by its retrospective nature. CONCLUSIONS: We found no difference in median number of publications between men and women. When controlling for possible confounders, sex was not a significant predictor of a faculty member's publication productivity, as measured by the Hirsch index or the Hirsch index divided by research career duration; academic rank, however, was.

A Disease-Specific Hybrid Rotation Increases Opportunities for Deliberate Practice.

IMPORTANCE: Incorporating deliberate practice (DP) into residency curricula may optimize education. DP includes educationally protected time, continuous expert feedback, and a focus on a limited number of technical skills. It is strongly associated with mastery level learning. OBJECTIVE: Determine if a multidisciplinary breast rotation (MDB) increases DP opportunities. DESIGN: Beginning in 2010, interns completed the 4-week MDB. Three days a week were spent in surgery and surgical clinic. Half-days were in breast radiology, pathology, medical oncology, and didactics. The MDB was retrospectively compared with a traditional community rotation (TCR) and a university surgical oncology service (USOS) using rotation feedback and resident operative volume. Data are presented as mean ± standard deviation. SETTING: Oregon Health and Science University in Portland, Oregon; an academic tertiary care general surgery residency program. PARTICIPANTS: General surgery residents at Oregon Health and Science University participating in either the MDB, TCR or USOS. RESULTS: A total of 31 interns rated the opportunity to perform procedures significantly higher for MDB than TCR or USOS (4.6 ± 0.6 vs 4.2 ± 0.9 and 4.1 ± 1.0, p < 0.05). MDB was rated higher than TCR on quality of faculty teaching and educational materials (4.5 ± 0.7 vs 4.1 ± 0.9 and 4.0 ± 1.2 vs 3.5 ± 1.0, p < 0.05). Interns operated more on the MDB than on the USOS and were more focused on breast resections, lymph node dissections, and port placements than on the traditional surgical rotation or USOS. CONCLUSIONS: The MDB incorporates multidisciplinary care into a unique, disease-specific, and educationally focused rotation. It is highly rated and affords a greater opportunity for DP than either the USOS or TCR. DP is strongly associated with mastery learning and this novel rotation structure could maximize intern education in the era of limited work hours.

Trends in the Surgical Management of Crohn's Disease.

INTRODUCTION: Although medical management of Crohn's disease has changed in recent years, it is unclear whether surgical management has altered. We examined rate changes of surgical interventions, stoma constructions, and subset of ileostomy and colostomy constructions. MATERIALS AND METHODS: We reviewed the Nationwide Inpatient Sample database from 1988 to 2011. We examined the number of Crohn's-related operations and stoma constructions, including ileostomies and colostomies; a multivariable logistic regression model was developed. RESULTS: A total of 355,239 Crohn's-related operations were analyzed. Operations increased from 13,955 in 1988 to 17,577 in 2011, p < 0.001. Stoma construction increased from 2493 to 4283, p < 0.001. The subset of ileostomies increased from 1201 to 3169, p < 0.001 while colostomies decreased from 1351 to 1201, p = 0.05. Operation percentages resulting in stoma construction increased from 18 to 24 %, p < 0.001. Weight loss (OR 2.25, 95 % CI 1.88, 2.69) and presence of perianal fistulizing disease (OR 2.91, 95 % CI 2.31, 3.67) were most predictive for requiring stoma construction. CONCLUSIONS: Crohn's-related surgical interventions and stoma constructions have increased. The largest predictors for stoma construction are weight loss and perianal fistulizing disease. As a result, nutrition should be optimized and the early involvement of a multidisciplinary team should be considered.

A flexible postoperative debriefing process can effectively provide formative resident feedback.

BACKGROUND: Providing residents with formative operative feedback is one of the ongoing challenges in modern surgical education. This is highlighted by the recent American Board of Surgery requirement for formal operative assessments. A flexible and adaptable procedure feedback process may allow attending surgeons to provide qualitative and quantitative feedback to residents while encouraging surgeons-in-training to critically reflect on their own performance. STUDY DESIGN: We designed and implemented a flexible feedback process in which residents initiated a postoperative feedback discussion and completed a Procedure Feedback Form (PFF) with their supervising attending surgeon. Comparisons were made between the quantitative and qualitative assessments of attending and resident surgeons. Free text statements describing strengths and weaknesses were analyzed using grounded theory with constant comparison. RESULTS: We identified 346 assessments of 48 surgery residents performing 38 different cases. There was good inter-rater reliability between resident and attending surgeons' quantitative assessment, Goodman and Kruskal gamma > 0.65. Key themes identified on qualitative analysis included flow, technique, synthesis/decision, outcomes, knowledge, and communication/attitudes. Subthematic analysis demonstrated that our novel debriefing procedure was easily adaptable to a wide variety of clinical settings and grew more individualized for senior learners. CONCLUSIONS: This procedure feedback process is easily adaptable to a wide variety of cases and supports resident self-reflection. The process grows in nuance and complexity with the learner and may serve as a guide for a flexible and widely applicable postoperative feedback process.

Initial surgical management of ulcerative colitis in the biologic era.

BACKGROUND: The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically. OBJECTIVE: We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras. DESIGN: We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database. SETTINGS: This study was conducted at a single university. PATIENTS: A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study. MAIN OUTCOME MEASURES: We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization. RESULTS: Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis. LIMITATIONS: The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it. CONCLUSIONS: Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.

Increasing the number of lymph nodes examined after colectomy does not improve colon cancer staging.

BACKGROUND: Current quality initiatives call for examination of at least 12 lymph nodes in curative colon cancer resections. The aim of this study was to determine if the number of nodes harvested has increased, and if the increased number nodes correlates with improved staging or overall survival. STUDY DESIGN: A review of the Surveillance, Epidemiology, and End Results program database from 2004-2010 was performed. All patients who underwent colon cancer resection during this date range were analyzed. Number of nodes retrieved, patient stage, overall survival, and overall survival by stage were examined. Multivariable analysis controlled for stage, cancer site, age, year of diagnosis, and number of nodes retrieved. Improved staging was defined as increased detection of stage III patients. RESULTS: A total of 147,076 patients met inclusion criteria. Median number of nodes analyzed increased sequentially with each year examined, from 12 in 2004 to 17 in 2010. Despite greater number of total nodes obtained and analyzed, there was no increase in the percentage of patients with positive nodes (stage III disease). On multivariable analysis, after controlling for stage, site of disease, age, and year of diagnosis, there was a slight overall survival benefit with increasing nodal retrieval (hazard ratio = 0.987 for each additional node removed; 95% CI, 0.986-0.988; p < 0.001). CONCLUSIONS: Since quality initiatives have been put in place, there has been an increase in the number of nodes examined in colon cancer resections, but no improvement in staging. The improved survival seen with higher node counts was independent of stage, site of disease, patient age, and year of diagnosis.

Characteristics of highly ranked applicants to general surgery residency programs.

IMPORTANCE: With duty hour debates, specialization, and sex distribution changes in the applicant pool, the relative competitiveness for general surgery residency (GSR) is undefined. OBJECTIVE: To determine the modern attributes of top-ranked applicants to GSR. DESIGN Validation cohort, survey. SETTING: National sample of university and community-based GSR programs. PARTICIPANTS: Data were abstracted from Electronic Residency Application Service files of the top 20-ranked applicants to 22 GSR programs. We ranked program competitiveness and blinded review of personal statements. MAIN OUTCOMES AND MEASURES: Characteristics associated with applicant ranking by the GSR program (top 5 vs 6-20) and ranking by highly competitive programs were identified using t and χ2 tests and modified Poisson regression. RESULTS: There were 333 unique applicants among the 440 Electronic Residency Application Service files. Most applicants had research experience (93.0%) and publications (76.8%), and 28.4% had Alpha Omega Alpha membership. Nearly half were women (45.2%), with wide variation by program (20.0%-75.0%) and a trend toward fewer women at programs in the South and West (38.0% and 37.5%, respectively). Men had higher United States Medical Licensing Examination Step 1 scores (238.0 vs 230.1; P < .001) but similar Step 2 scores (245.3 vs 244.5; P = .54). Using bivariate analysis, highly competitive programs were more likely to rank applicants with publications, research experience, Alpha Omega Alpha membership, higher Step 1 scores, and excellent personal statements and those who were male or Asian. However, the only significant predictors were Step 1 scores (relative risk [RR], 1.36 for every 10-U increase), publications (RR, 2.20), personal statements (RR, 1.62), and Asian race (RR, 1.70 vs white). Alpha Omega Alpha membership (RR, 1.62) and Step 1 scores (RR, 1.01) were the only variables predictive of ranking in the top 5. CONCLUSIONS AND RELEVANCE: This national sample shows GSR is a highly competitive, sex-neutral discipline in which academic performance is the most important factor for ranking, especially in the most competitive programs. This study will inform applicants and program directors about applicants to the GSR program.

Utilization of laparoscopic colectomy in the United States before and after the clinical outcomes of surgical therapy study group trial.

OBJECTIVE: To evaluate the utilization of laparoscopic colectomy (LC) in the United States before and after prospective data supported its use for the treatment of colon cancer. METHODS: The Nationwide Inpatient Sample 2001-2003 [before Clinical Outcomes of Surgical Therapy (COST)] and 2005-2007 (after COST) was queried for elective colectomies for both benign and malignant disease. The COST trial was published in 2004; therefore, 2004 data were excluded. Univariate analyses including patient-specific, hospital-specific, and outcome variables were performed. Multivariate logistic regression models and subset analyses were used to evaluate these variables and operative approach by time frame. RESULTS: The query yielded 741,817 elective colectomies (684,969 open and 56,848 laparoscopic). The percentage of elective colectomies performed laparoscopically has increased over time. Laparoscopic colectomy for benign disease increased from 6.2% in 2001-2003 to 11.8% in 2005-2007, while those for colon cancer have increased by a larger percentage, 2.3% to 8.9%. In a multivariate model of patients with colon cancer, the odds ratio (OR) for having a laparoscopic approach after COST was 4.55 (confidence interval 3.81-5.44) compared with before COST. In contrast, for benign disease, the OR was 2.10 (confidence interval 1.79-2.46). Factors predictive of having a laparoscopic approach for cancer have changed very little over time: Patients are more likely to be male, insured, live in areas with the highest incomes, and undergo resection at urban teaching hospitals. CONCLUSIONS: Within 3 years after publication of the COST trial, the use of laparoscopic resection for colon cancer approached that of benign disease. However, almost 90% of cases are still performed open and utilization remains influenced by socioeconomic factors.

Dramatic decreases in mortality from laparoscopic colon resections based on data from the Nationwide Inpatient Sample.

OBJECTIVE: To determine the mortality rate and associated factors for laparoscopic and open colectomy as derived from the Nationwide Inpatient Sample database. DESIGN: Retrospective cohort. SETTING: Nationwide Inpatient Sample database. PATIENTS: Between 2002 and 2007, the Nationwide Inpatient Sample estimated 1,314,696 patients underwent colectomy in the United States. Most (n = 1,231,184) were open, but 83,512 were laparoscopic. Patients who underwent a laparoscopic procedure that was converted to open were analyzed within the laparoscopic group on an intention-to-treat basis. MAIN OUTCOME MEASURE: Mortality rate. Using a logistic regression model, patient and institutional characteristics were analyzed and evaluated for significant associations with in-hospital mortality. RESULTS: In a multivariate analysis, significant predictors of increased mortality included older age, male sex, lower socioeconomic status, comorbidities, and emergency or transfer admission. Additionally, a laparoscopic approach was an independent predictor of decreased mortality when compared with open colectomy (relative risk, 0.51; P < .001). CONCLUSION: Even when controlling for comorbidities, socioeconomic status, practice setting, and admission type, laparoscopy is an independent predictor of decreased mortality for colon resection.

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach.

BACKGROUND: This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting. METHODS: A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival. RESULTS: Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival. CONCLUSIONS: In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.

Treatment strategies and outcomes for rectal villous adenoma from a single-center experience.

OBJECTIVES: To analyze a 13-year, single-surgeon experience with villous adenoma of the rectum with respect to procedure, complications, recurrence, and cancer incidence. DESIGN: Retrospective review of patient and tumor characteristics, procedure, recurrence, and complications. SETTING: University hospital. PATIENTS: Patients who underwent excision of rectal villous adenoma. MAIN OUTCOME MEASURES: Complication, recurrence, and malignancy rates. RESULTS: Thirty-six patients underwent 30 transanal and 10 transabdominal excisions. Mean age was 66 years (range, 41-86 years) and mean follow-up was 25 months (range, 0.5-132 months). Mean tumor size was 3.0 cm (range, 0.5-11 cm) and the mean distance of the tumor from the anal verge was 4.9 cm (range, 0-10 cm). Preoperatively, 18 (45%) lesions harbored low-grade dysplasia while 17 (43%) had high-grade dysplasia. Postoperative pathology was discordant in 50% of patients, including 5 of 40 lesions (13%) that were recategorized as invasive cancer. Tumor size did not correlate with malignancy. The complication rate was significantly lower in transanal compared with transabdominal excisions (3.6% vs 50%, P = .005). There were 4 (12.5%) benign recurrences, all after transanal excisions. CONCLUSIONS: Complete excision is warranted for rectal villous adenomas, as biopsies were accurate only 50% of the time, and 1 in 8 patients had unsuspected cancer found after excision. Transanal excision with negative margins is associated with low recurrence and complication rates and is the preferred approach, even with large lesions.

Predictors of pouchitis after ileal pouch-anal anastomosis: a retrospective review.

PURPOSE: The primary end point of this study was to determine the risk factors that predict chronic pouchitis in those patients having ileal pouch-anal anastomosis. METHODS: A total of 237 patients with ulcerative colitis and undergoing ileal pouch-anal anastomosis by one surgeon at Oregon Health & Science University from 1993 to 2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire administered by telephone in 2004. Patients were excluded if there was less than one-year follow-up documented in the chart or they could not be contacted by telephone (n = 62), postoperative diagnosis of Crohn's disease (n = 3), failed ileoanal procedure (n = 1), and one-stage ileal pouch-anal anastomosis (n = 3), leaving 167 patients for evaluation. Patients were defined as having chronic pouchitis (> 3 episodes of pouchitis) or no pouchitis (< or = 3 episodes of pouchitis). Potential risk factors included number of operations used to perform ileal pouch-anal anastomosis, fulminant ulcerative colitis with two-stage operation, duration of diverting ileostomy after pouch formation, primary sclerosing cholangitis, other extraintestinal manifestations of ulcerative colitis, preoperative liver function tests, duration of ulcerative colitis, and the occurrence of postoperative complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate risk factors with P values < 0.2. RESULTS: The prevalence of chronic pouchitis in our population was 46 percent. The following variables were identified during univariate analysis and entered into a multivariate model: preoperative serum albumin (P = 0.07), PSC (P = 0.126), duration of diverting ileostomy (P = 0.111), fulminant ulcerative colitis with two-stage operation, (P = 0.051), the presence of postoperative complications (P = 0.031), and the type of postoperative complications (anastomotic complications, P = 0.013). Patients who did not undergo diverting ileostomy at the time of their ileal pouch-anal anastomosis trended toward a lower likelihood of developing chronic pouchitis (P = 0.06). Multivariate analysis showed that patients with postoperative complications (53 percent, P = 0.042), specifically anastomotic complications, were more likely to develop chronic pouchitis (P = 0.005). Eight percent of patients had primary sclerosing cholangitis and 11 percent of patients had at least one extraintestinal manifestation of ulcerative colitis. Patients with primary sclerosing cholangitis were not more likely to develop chronic pouchitis (P = 0.168). Patients with extraintestinal manifestations also were not more likely to develop chronic pouchitis (P = 0.273). CONCLUSIONS: Chronic pouchitis is a frequent complication after ileal pouch-anal anastomosis. In this study patients with primary sclerosing cholangitis or other extraintestinal manifestations of ulcerative colitis were not more likely to develop chronic pouchitis. Patients with postoperative complications, specifically anastomotic complications after ileal pouch-anal anastomosis, were more likely to develop chronic pouchitis and may benefit from early strategies to prevent pouchitis.