Impact of a Surgical Subspecialty Roundtable on Career Perception for Preclerkship Medical Students.

BACKGROUND: Limited exposure to surgical subspecialties during medical school may be responsible for decreasing medical student interest in surgery. Although most medical schools have surgery interest groups to increase exposure, our aim was to evaluate the impact of a focused surgical subspecialty roundtable on preclerkship students' perceptions of surgical careers. METHODS: Faculty members from each surgical subspecialty shared their experiences and led roundtable discussions with five to seven first- and second-year medical students at a time (total n = 59). Pre-event and post-event surveys were administered to assess students' interest in surgery, knowledge of training paths, values related to specialty selection, and perception of surgeons. RESULTS: Forty students completed pre-event and post-event surveys. The number of students who were extremely or very interested in surgery increased after this event (65% versus 72.5%, P < 0.001). The greatest number of students indicated an interest in orthopedic surgery, and the fewest indicated an interest in neurosurgery. After the event, thirteen (32.5%) students changed their preferences for the subspecialty in which they were most interested. Students demonstrated improved knowledge of training length and integrated residencies (83.8% versus 96.3%, P = 0.003). The perceived importance of intellectual challenge, research opportunities, and training length decreased, whereas the importance of compensation, work/life balance, long-term patient follow-up, and the job market increased. Students' perceptions of surgeons' work/life balance (10% versus 25%, P < 0.001) and ability to be team players (82.5% versus 85%, P = 0.01) improved significantly after the roundtable. CONCLUSIONS: The surgical specialty roundtable increased students' interest in surgery, improved knowledge of training paths, and altered perceptions related to career decision-making.

Learning to teach: A novel method for assessing surgical trainees' teaching and operative knowledge.

BACKGROUND: The purpose of this study was to investigate the feasibility of a simulated teaching activity as an assessment of surgical knowledge and teaching competencies. METHODS: In this prospective observational study, 15 residents and 1 fellow in the Department of Surgery watched three video clips of laparoscopic cholecystectomies and provided feedback to a participant learner. Qualitative and statistical analysis identified differences in surgical knowledge and teaching strategies. RESULTS: As compared to senior trainees, junior trainees were more likely to speculate on the learner's actions (p = 0.033), identify which actions looked correct (p = 0.028), and speculate more on the learner's thoughts (p = 0.02). Senior trainees noted case difficulty more frequently (p = 0.028), identified more actions that looked incorrect (p = 0.004), and speculated more about the learner's emotions (p = 0.033). CONCLUSIONS: A simulated teaching scenario successfully assessed operative and teaching competencies, suggesting a novel assessment method.

Perceptions Regarding Mentorship Among General Surgery Trainees With Academic Career Intentions.

OBJECTIVE: Effective mentorship may be an opportunity to mitigate career de-prioritization, improve stress management, and bolster professional growth. Relatively few studies address specific challenges that occur for general surgery trainees. We conducted a focus group-based investigation to determine facilitators/barriers to effective mentorship among general surgery residents, who are intending to pursue an academic career. DESIGN: A semistructured focus group study was conducted to explore residents' attitudes and experiences regarding (1) needs for mentorship, (2) barriers to identifying mentors, and (3) characteristics of successful mentor-mentee interactions. Subjects self-identified and were characterized as either "Mentored" or "Nonmentored." Transcriptions were independently reviewed by 3 coders. Inter-rater reliability between the coders was evaluated by calculating Cohen's kappa for each coded item. SETTING: General surgery residents from 2 academic tertiary hospitals, University of Pittsburgh Medical Center, and University of Washington, participated. PARTICIPANTS: Thirty-four general surgery trainees were divided into 8 focus groups. RESULTS: There were no gender-based differences in mentoring needs among residents. Barriers to establishing a relationship with a mentor, such as lack of exposure to faculty, and time and determination on the part of both mentor and mentee, were exacerbated by aspects of surgical culture including gender dynamics, criticism, and hierarchy. Successful relationships between mentee and mentor were perceived to require personal/professional compatibility and a feeling that the mentor is invested in the mentee, while conflicts of interest and neglect detracted from a successful relationship. CONCLUSIONS: Our investigations demonstrate the importance of surgical hierarchy and culture in facilitating interpersonal interactions with potential mentors. Further studies will be necessary to determine how best to address these barriers.

A qualitative study of gender differences in the experiences of general surgery trainees.

BACKGROUND: Women surgeons continue to face unique challenges to professional advancement. Higher attrition rates and lower confidence among female surgical residents suggest that experiences during residency differ by gender. Few studies have investigated gender-specific experiences during training. This study identifies gender-based differences in the experiences of general surgery residents that could affect professional development. MATERIALS AND METHODS: Male and female general surgery residents at the University of Pittsburgh Medical Center participated in a semi-structured interview study exploring the significance of gender in training. Recurring themes were identified from transcribed interviews using inductive methods. Two individuals independently coded interviews. Themes were compared for male and female residents. Certain themes arose with greater frequency in reference to one gender over the other. RESULTS: Twenty-four male and eighteen female residents participated (87.5%) in the study. Fewer female residents self-identified as a "surgeon" (11.1% versus 37.5%, P < 0.001). Residents felt that patients and physicians more frequently disregarded female residents' professional role (P < 0.001). Female residents also more often mentioned perceiving aggressive behaviors from attendings and support staff (9% versus 1% and 10% versus 3%, respectively). Relative to men, women more often mentioned lack of mentorship (0% versus 8%), discomfort (4% versus 8%), feeling pressured to participate in unprofessional behaviors (2% versus 5%), and having difficulty completing tasks (5% versus 10%, P < 0.001). CONCLUSIONS: Women experience gender-based challenges during surgical training. Further investigation is needed to determine how these experiences affect professional development.

Changes in inflammatory endometrial cancer risk biomarkers in individuals undergoing surgical weight loss.

OBJECTIVE: Obesity has been strongly linked to endometrial cancer (EC) risk. A number of potential EC risk biomarkers have been proposed, including heightened pro-inflammatory cytokines and adipokines. To evaluate if bariatric surgery can serve as a means for altering levels of such EC risk biomarkers, we investigated changes in these biomarkers after weight loss. METHODS: Blood samples were collected pre-operatively and 6months post-operatively in 107 female bariatric surgery patients aged 18-72years. Wilcoxon signed-rank tests were used to compare biomarker levels (measured using xMAP immunoassays) pre- and post-surgery. Normative comparisons were implemented to contrast 6-month post-surgery biomarker levels to levels in a sample of 74 age-matched non-obese women. Linear regression was used to evaluate the relationship between biomarker expression at baseline and 6months post-surgery and the relationship between race and biomarker levels. RESULTS: On average, participants lost 30.15kg (SD: 12.26) after the bariatric intervention. Levels of C-peptide, insulin, CRP, leptin, IL-1Rα, and IL-6 significantly decreased, while levels of SHBG, IGFBP1, and adiponectin significantly increased with weight loss. Normative comparisons showed the levels of SHBG, C-peptide, insulin, IGFBP1, adiponectin, CRP, and TNFα after bariatric intervention approached the level of markers in comparison group. Multiple regression analyses revealed significant relationships between changes in BMI and changes in biomarker levels. The changes in IL-1Rα were significantly associated with race. CONCLUSIONS: Our findings demonstrate that normalization of EC risk biomarkers can be achieved with bariatric surgery. Improved understanding of biological mechanisms associated with weight loss may inform preventive strategies for EC.

How can surgeons facilitate resident intraoperative decision-making?

BACKGROUND: Cognitive skills such as decision-making are critical to developing operative autonomy. We explored resident decision-making using a recollection of specific examples, from the attending surgeon and resident, after laparoscopic cholecystectomy. METHODS: In a separate semi-structured interview, the attending and resident both answered five questions, regarding the resident's operative roles and decisions, ways the attending helped, times when the attending operated, and the effect of the relationship between attending and resident. Themes were extracted using inductive methods. RESULTS: Thirty interviews were completed after 15 cases. Facilitators of decision-making included dialogue, safe struggle, and appreciation for retraction. Aberrant case characteristics, anatomic uncertainties, and time pressures provided barriers. Attending-resident mismatches included descriptions of transitioning control to the attending. CONCLUSIONS: Reciprocal dialogue, including concept-driven feedback, is helpful during intraoperative teaching. Unanticipated findings impede resident decision-making, and we describe differences in understanding transfers of operative control. Given these factors, we suggest that pre-operative discussions may be beneficial.

Endometrial cancer associated biomarkers in bariatric surgery candidates: exploration of racial differences.

BACKGROUND: Obesity is the main risk factor for endometrial cancer (EC), the most common gynecologic malignancy in the United States. A number of potential risk biomarkers have been associated with EC development, including altered proinflammatory cytokines, chemokines, and adipokines. OBJECTIVES: The overarching aim of this research is to investigate racial differences in the expression of EC-associated biomarkers among bariatric surgery candidates. SETTING: Tertiary academic medical center METHODS: Blood samples were collected from 175 women aged 18 to 72 (mean age: 42.93; standard deviation 11.66), before bariatric surgery. Levels of biomarkers associated with obesity and EC risk were measured using xMAP immunoassays. Wilcoxon rank sum and Fisher's exact tests were utilized to compare biomarker and demographic variables between African American and European American women. Linear regression models, adjusted for menopause status and diabetes, were utilized to identify factors associated with biomarker levels. RESULTS: When the biomarker levels were compared by race, insulin-like growth factor-binding protein 1 and adiponectin were significantly lower in African American women (P<.05), whereas estradiol was significantly higher in African American women (P<.05). Linear regression models found that race significantly predicted insulin-like growth factor binding protein 1, adiponectin, resistin, and interleukin-1 receptor alpha expression levels, menopause status and diabetes status were significantly associated with adiponectin and leptin levels, whereas body mass index was significantly associated with leptin, adiponectin, interleukin-1 receptor alpha, and interleukin-6 levels. CONCLUSION: As one of the first efforts to explore racial differences in EC-associated biomarkers in a cohort of women with severe obesity, this study found several significant differences that should be further explored in large-scale studies.

Prophylactic mesh placement for prevention of incisional hernia after open bariatric surgery: a systematic review and meta-analysis.

BACKGROUND: Prophylactic mesh during laparotomy has been shown to be effective in preventing postoperative incisional hernia (IH) in high-risk patients. Since obesity is a risk factor for IH, we wished to determine whether mesh prevents IH in open and laparoscopic bariatric surgery patients. METHODS: We conducted a systematic review of the literature with meta-analysis. Seven studies met inclusion criteria. We abstracted data regarding postoperative IH development, surgical site infection, and seroma or wound leakage and performed meta-analysis. RESULTS: The prophylactic mesh group had significantly decreased odds of developing IH than the standard closure group (odds ratio, .30, 95% CI, .13 to .68, P = .004). No included studies evaluated outcomes after prophylactic mesh during laparoscopic bariatric surgery. CONCLUSIONS: Prophylactic mesh during open bariatric surgery appears to be beneficial in reducing postoperative IH without significant increasing the odds of surgical site infection or seroma or wound leakage. Higher quality studies, including those in laparoscopic patients, and cost-utility analysis, are needed to support routine use of this intervention.

The effect of video review of resident laparoscopic surgical skills measured by self- and external assessment.

BACKGROUND: Video review of surgical skills is an educational modality that allows trainees to reflect on self-performance. The purpose of this study was to determine whether resident and attending assessments of a resident's laparoscopic performance differ and whether video review changes assessments. METHODS: Third-year surgery residents were invited to participate. Elective laparoscopic procedures were video recorded. The Global Operative Assessment of Laparoscopic Skills evaluation was completed immediately after the procedure and again 7 to 10 days later by both resident and attending. Scores were compared using t tests. RESULTS: Nine residents participated and 76 video reviews were completed. Residents scored themselves significantly lower than the faculty scores both before and after video review. Resident scores did not change significantly after video review. CONCLUSIONS: Attending and resident self-assessment of laparoscopic skills differs and subsequent video review does not significantly affect Global Operative Assessment of Laparoscopic Skills scores. Further studies should evaluate the impact of video review combined with verbal feedback on skill acquisition and assessment.

Endometrial histology in severely obese bariatric surgery candidates: an exploratory analysis.

BACKGROUND: Endometrial pathology risk has been linked to obesity; however, little is known of its prevalence in severely obese women not seeking care for endometrial pathology associated symptoms. This pilot study was designed to explore the frequency and risk factors associated with endometrial pathology in cancer-free, severely obese, bariatric surgery candidates using the Pipelle endometrial sampling technique (SureFlex Preferred Curette, Bioteque America, Inc, New Taipei City, Taiwan). METHODS: Twenty-nine severely obese bariatric surgery candidates with intact uteruses and no history of endometrial cancer or endometrial ablation were included in this subanalysis from a larger cohort of 47. Endometrial samples were obtained using a Pipelle endometrial suction curette at a single time point before surgery. Logistic regression was used to assess the relationship between body mass index and endometrial pathology when adjusting for age and race. RESULTS: Of the 29 successful biopsies, 8 (27.6%) were classified as abnormal endometrium: 1 was classified as complex atypical hyperplasia, 1 was classified as hyperplasia without atypia, 4 samples were identified with endometrial polyps, and 2 samples were identified with metaplasia. None presented with cancer. Increasing body mass index was significantly associated with higher risk of abnormal endometrium (OR = 1.19, 95% CI [1.03-1.36], P = .01). CONCLUSIONS: The findings in this sample suggest that obesity may be associated with increased risk of having undiagnosed endometrial pathology. More thorough examination of relationships between levels of obesity and endometrial pathology are needed to better characterize high cancer risk groups who may benefit from introducing new screening measures.

S/he who can, does and teaches. S/he who cannot, doesn't.

BACKGROUND: The saying, "[h]e who can, does. He who cannot, teaches." suggests that those who have the skills to perform do so, whereas those who do not have those skills become teachers. We hypothesize that this saying as it relates to general surgery residents is not true. METHODS: This was a retrospective study of general surgery chief residents from 2009 to 2013. Technical ability was assessed with the Fundamentals of Laparoscopic Surgery examination performance. Teaching ability was assessed with medical student evaluations on a 9-point Likert scale as well as with receipt of teaching awards: The Arnold P. Gold Teaching Award, the surgical teaching award given by each graduating class of the medical school, and resident induction into Alpha Omega Alpha. Mann-Whitney U tests were performed between resident groups based on teaching award status and Fundamentals of Laparoscopic Surgery examination outcomes, using an α = 0.05. RESULTS: For 32 chief residents (7 female), the median score on the Manual Skills Section was 531 (interquartile range [IQR] [478-563]). On the Cognitive Section, the cohort of residents who won each award outperformed the residents who did not win that specific award (all p < 0.05). On the Manual Skills Section, residents who received any teaching award/the Arnold P. Gold Teaching Award (n = 7) performed similar to residents who did not receive this award (n = 25) (584 [IQR {491-620}] vs. 527 [IQR {482-537}]) (p = 0.09). Residents who received the surgical teaching award from the medical school (n = 3) performed similar to residents who did not receive this award (n = 29) (608 [IQR {474-637}] vs. 527 [IQR {482-555}]) (p = 0.23). Eligible residents who were inducted into Alpha Omega Alpha (n = 4) outperformed residents who were not inducted (n = 18) (596 [IQR {564-637}] vs. 527 [IQR {446-551}]) (p = 0.01). CONCLUSIONS: There is some evidence that superior resident teachers have greater content knowledge and a higher degree of laparoscopic skills.

Validity and interrater reliability of a regional mock oral board examination.

BACKGROUND: There have been decreasing pass rates recently on the American Board of Surgery Certifying Examination (ABSCE). General surgery residents from the University of Pittsburgh Medical Center, the West Penn Allegheny Health System, the Conemaugh Health System, and Mercy Hospital participate in a mock oral board examination, which is similar to the ABSCE. The aims of the study are to compare examinee performance on the mock oral boards with the ABSCE and to evaluate the interrater reliability of examiner pairs. METHODS: In this retrospective study from 2003 to 2010, outcomes on the mock oral boards and the first attempt of the ABSCE for chief residents were compared for the 4 regional residency programs. Interrater reliability for examiner pairs was evaluated with agreement and kappa statistics. Nonparametric statistics were performed, with α = 0.05. RESULTS: A total of 32 of 38 (84.2%) chief residents passed the mock oral boards. The median score for each of the 3 rooms was 6 (clear pass). A total of 37 of 38 (97.4%) residents passed the ABSCE. The sensitivity of the mock oral boards was 83.8%, with a positive predictive value of 96.9%, and an accuracy of 81.6%. A total of 25 of 47 (53.2%) examiner pairs were from the same residency institution, whereas 22 of 47 (46.8%) were from different institutions. The median agreement was 100% (interquartile range (IQR) [100% - 100%]). The median kappa statistic was 1.00 (IQR [0.38-1.00]). The Mann-Whitney U tests showed no difference in agreement or kappa for examiner pairs from the same or from different institutions (p> 0.05). CONCLUSIONS: The mock oral boards have substantial sensitivity and positive predictive value in relation to the ABSCE. There are also very high levels of interrater agreement and interrater reliability. This regional mock oral board examination is valuable for ABSCE preparation.

The traveling salesman problem in surgery: economy of motion for the FLS Peg Transfer task.

BACKGROUND: In the Peg Transfer task in the Fundamentals of Laparoscopic Surgery (FLS) curriculum, six peg objects are sequentially transferred in a bimanual fashion using laparoscopic instruments across a pegboard and back. There are over 268 trillion ways of completing this task. In the setting of many possibilities, the traveling salesman problem is one where the objective is to solve for the shortest distance traveled through a fixed number of points. The goal of this study is to apply the traveling salesman problem to find the shortest two-dimensional path length for this task. METHODS: A database platform was used with permutation application output to generate all of the single-direction solutions of the FLS Peg Transfer task. A brute-force search was performed using nested Boolean operators and database equations to calculate the overall two-dimensional distances for the efficient and inefficient solutions. The solutions were found by evaluating peg object transfer distances and distances between transfers for the nondominant and dominant hands. RESULTS: For the 518,400 unique single-direction permutations, the mean total two-dimensional peg object travel distance was 33.3 ± 1.4 cm. The range in distances was from 30.3 to 36.5 cm. There were 1,440 (0.28 %) of 518,400 efficient solutions with the minimized peg object travel distance of 30.3 cm. There were 8 (0.0015 %) of 518,400 solutions in the final solution set that minimized the distance of peg object transfer and minimized the distance traveled between peg transfers. Peg objects moved 12.7 cm (17.4 %) less in the efficient solutions compared to the inefficient solutions. CONCLUSIONS: The traveling salesman problem can be applied to find efficient solutions for surgical tasks. The eight solutions to the FLS Peg Transfer task are important for any examinee taking the FLS curriculum and for certification by the American Board of Surgery.

Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) core competency of practice-based learning and improvement can be assessed with surgical Morbidity and Mortality Conference (MMC). We aim to describe the MMC reporting patterns of general surgery residents, describe the adverse event rate for patients and compare that with existing published rates, and describe the nature of our institutional adverse events. We hypothesize that reporting patterns and incidence rates will remain constant over time. METHODS: In this retrospective cohort study, archived MMC case lists were evaluated from January 1, 2009 to December 31, 2010. The reporting patterns of the residents, the adverse event ratios, and the specific categories of adverse events were described over the academic years. χ(2) and Fisher's exact tests were used to compare across academic years, using an α = 0.05. RESULTS: There were 85 surgical MMC case lists evaluated. Services achieved a reporting rate above 80% (p < 0.001). The most consistent reporting was done by postgraduate year (PGY) 5 level chief residents for all services (p > 0.05). Out of 11,368 patients evaluated from complete MMC submissions, 289 patients had an adverse event reported (2.5%). This was lower than published reporting rates for patient adverse event rates (p < 0.001). Adverse event rates were consistent for residents at the postgraduate year 2, 4, and 5 levels for all services (p > 0.05). Over 2 years, 522 adverse events were reported for 461 patients. A majority of adverse events were from death (24.1%), hematologic and/or vascular events (16.7%), and gastrointestinal system events (16.1%). CONCLUSIONS: Surgery resident MMC reporting patterns and adverse event rates are generally stable over time. This study shows which adverse event cases are important for chief residents to report.

The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors.

OBJECTIVE: Morbidly obese patients frequently present with mood and anxiety disorders, which are often treated with serotonin reuptake inhibitors (SRIs). Having observed that patients treated with SRIs frequently relapse after Roux-en-Y gastric bypass surgery, the authors sought to assess whether SRI bioavailability is reduced postoperatively. METHOD: Twelve gastric bypass candidates treated with an SRI for primary mood or anxiety disorders were studied prospectively. Timed blood samples for SRI plasma levels were drawn for pharmacokinetic studies before surgery and 1, 6, and 12 months afterward. Maximum concentration, time to maximum concentration, and area under the concentration/time curve (AUC) were determined. RESULTS: In eight of the 12 patients, AUC values 1 month after surgery dropped to an average of 54% (SD=18) of preoperative levels (range=36%-80%); in six of these patients, AUC values returned to baseline levels (or greater) by 6 months. Four patients had an exacerbation of depressive symptoms, which resolved by 12 months in three of them. Three of the four patients had a reduced AUC level at 1 month and either gained weight or failed to lose weight between 6 and 12 months. Normalization of the AUC was associated with improvement in symptom scores. CONCLUSIONS: Patients taking SRIs in this study were at risk for reduced drug bioavailability 1 month after Roux-en-Y gastric bypass. The authors recommend close psychiatric monitoring after surgery.

The American Board of Surgery Certifying Examination: a retrospective study of the decreasing pass rates and performance for first-time examinees.

BACKGROUND: There has been a noticeable decrease in the pass rate for the American Board of Surgery Certifying Examination during the last 5 years. We hypothesize that this decline is statistically significant, and we wish to determine whether the pass rates had any geographic patterns of distribution. METHODS: In this retrospective cohort trial, publically available electronic data sets of pass rates on the American Board of Surgery Certifying Examination were evaluated from the American Board of Surgery website. χ(2) tests were used to determine whether there was any association between the pass rates and the academic year. A descriptive geographic evaluation of program-specific pass rates for first-time examinees was also performed. RESULTS: From 2006 to 2010, there has been a 7% decrease in the pass rate for the American Board of Surgery Certifying Examination. A χ(2) test shows that there is a statistically significant association with the pass percentage on the American Board of Surgery Certifying Examination and the year (p < 0.0001). Subgroup analysis demonstrated a difference in pass rate between 2006 and 2007 (p = 0.02). Geographic analysis showed the pass rates for first-time examinees were the highest in Rhode Island (100%) and the lowest in Puerto Rico (63%) from 2005 to 2010. Three of the 5 highest-performing states are on the Pacific Coast, and 4 of the 9 lowest-performing states are in the southern United States. There are differences between these 2 groups of states (p < 0.001). CONCLUSIONS: There was a significant decrease in the pass rate for the American Board of Surgery Certifying Examination from 2006 to 2010. There also were some geographic patterns relating to first-time examinee performance from 2005 to 2010.