83.10 Characterizing #PhysicianBurnout through Social Media Posts, Responses, Traffic, and Influencers

Posted on January 31, 2019

C. Hwang1,2, T. Bellomo1,2, M. Byrnes2, M. A. Corriere1,2  1University Of Michigan,Vascular Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Health Outcomes And Policy,Ann Arbor, MI, USA

Introduction:
Physician burnout is highly prevalent among surgeons. Negative impacts include depression, divorce, substance abuse, and attrition.  Survey and focus group methods have been used to study burnout, but potential non-response bias among affected doctors is a major potential limitation of these approaches.  Social media is a potentially rich source of information related to provider burnout because users can post while experiencing stress. We analyzed posts with hashtags related to burnout to characterize themes and influential users.

Methods:
A healthcare social media analytic platform was used to identify burnout-related hashtags. Posts specifically identifying physician burnout over a 90-day period (May26 -August 24, 2018) were analyzed. User influence was assessed using an impact factor algorithm accounting for healthcare relevance, conversation partners, and stakeholder roles identified through metadata.  Users, content volume, trends, and themes were evaluated using mixed methods. 

Results:
23 hashtags linked to burnout were identified. Hashtag names referenced burnout directly (#Physicianburnout), sarcastically (#joyofmedicine), through narratives (#ShareASToryInOneTweet), through impacts on patients and coworkers (#Thosewecarry), and countermeasures (#ProviderWellness).  #Physicianburnout was associated with over 5300 unique tweets, 3200 retweets, >20 million impressions, 3300 shared links, and 1800 visual file shares over 90 days.  Individual doctors accounted for the largest share of activity, followed by healthcare organizations, non-physician individuals in healthcare, and non-health individuals. Individual doctors represented 24/35 (68.5%) of top influencers, including the four highest ranking influencers. Trending terms included "Maslow's hierarchy," "broken work systems," and "Telling doctors to be more resilient…".  Prevalent themes included depression, stigma, depersonalization, negative impacts on patient care, activities that protect against burnout, and the need for collective action from physicians and medical schools. Trends indicated increases in social media volume ranging from 25%-39% from the preceding period.

Conclusion:
Social media provides rich and dynamic information about physician burnout. The majority of burnout-related content is posted by individual doctors who are potentially inaccessible through survey or focus group studies. Physician advocacy and support groups (including surgical societies) presently account for a limited portion of social media content related to burnout.  In addition to understanding burnout, social media represents a potential means of communicating initiatives and strategies to combat this problem.  Stakeholders invested in addressing physician burnout should leverage social media as a tool and consider partnering with influential posters.
 

83.09 Defining a Leader – Characteristics That Distinguish a Chair of Surgery

Posted on January 31, 2019

A. Tanious1, H. McMullin2, C. Jokisch2, M. K. Tanious3, L. T. Boitano1, M. F. Conrad1, M. L. Shames2  1Massachusetts General Hospital,Vascular Surgery,Boston, MA, USA 2University Of South Florida College Of Medicine,Vascular Surgery,Tampa, FL, USA 3Brigham And Women’s Hospital,Anesthesia And Pain Medicine,Boston, MA, USA

Introduction:
            Chair of the Department of Surgery, sometimes referred to as the Chief of the Department of Surgery, is a title with significant historical connotations.  As medicine has progressed, these individuals have become beacons of leadership to advance all aspects of surgery within our hospitals.  Our group sought to understand what qualifications unify them as group.

Methods:
            We defined our cohort by first looking at all teaching hospitals with regard to general surgical training as defined by the ACGME.  Then, utilizing publically available data for all US teaching hospitals, demographic information was accumulated for the named chair/chiefs of surgery as of the end of the calendar year of 2016.  Information collected included geographic location of their program, individual medical/surgical training history, surgical specialty training, previous chair/chief titles held (for both individual and entire departments), and academic productivity.  Specific to academic productivity, PubMed searches were done for all peer-reviewed manuscripts and library searches were conducted to account for all book and book chapter publications.

Results:

           Of the 259 academic surgical programs listed by the ACGME, data was available on 245 individuals.  These leaders were trained in 19 different specialties, with 177 (72.2%) of these practitioners having had fellowship training.  The top three specialties of these practitioners are general surgery (40, 16.3%), surgical oncology (38, 15.5%), and vascular surgery (33, 13.5%).  There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree.

The general surgery training program that has produced the greatest number of these individuals is Johns Hopkins University (n = 11), followed by the Massachusetts General Hospital (n = 8), and Beth Israel Deaconess Medical Center (n = 7).

Forty percent (n = 99) have held previous positions of leadership of surgical subdivisions as division chiefs.  Sixteen percent (n = 40) were previous chairs of other departments prior to their current position as chair. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Other traits studied included Alpha Omega Alpha honors society membership (n = 37, 15%), and dual degree status (n = 37, 15%).

Chair’s at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < .0001) as well as were more likely to be fellowship trained (P = .0113).

Conclusion:
            While there are no set guidelines that define the position of Chair of Department of Surgery, these individuals are well trained, well published, and familiar with leadership roles.  By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

83.08 Leadership Amongst Regional And National Surgical Organizations: The Tides Are Changing

Posted on January 31, 2019

S. M. Krise1, I. A. Etheart2, A. T. Perzynski3, K. J. Conrad-Schnetz4  1Ohio University,Heritage College Of Osteopathic Medicine,Cleveland, OH, USA 2West Virginia School of Osteopathic Medicine,Lewisberg, WV, USA 3MetroHealth Medical Center,Cleveland, OH, USA 4Cleveland Clinic,Cleveland, OH, USA

Introduction:  Leadership amongst regional and national organizations is a key opportunity to obtain scholarly activity which is essential for attaining academic advancement. Data has been reported showing gender disparity in scholarly activity, specifically in publication status and NIH grants, with women having decreased rates compared to male colleagues (Awad 2017, Svider 2014). Gender disparity in leadership of surgical organizations is important to examine given this relationship. Our objective was to examine the differences between male and female leadership within surgical organizations. 

Methods:  Credentials were obtained through an Internet search of organization websites. Variables included organization type, leadership role, gender, advanced degree, medical school graduation year, publications, and employment at an academic institution. A bivariate analysis was performed between genders. A p-value < 0.05 was considered statistically significant.

Results: 532 leaders were identified in 43 surgical organizations. There was a statistically significant difference in the number of male and female leaders (73.3% vs 26.7%, p=0.012). Women were most likely to hold the role of Other (35.5%) and least likely to be Vice-President (10.5%) and President-Elect (13.8%). In line with other research, women had a decreased publication rate than male colleagues (85.2% vs 93.1%, p=0.005). Women had a higher rate of advanced degrees than men (24.8% vs 16.7%, p=0.035). Women were found to be involved earlier in their careers than men (4.9 years, 95% CI 4.1-7.8 years, p<0.01). OB/GYN organizations were the only organization type to show gender parity with 55% of leader roles held by women. Vascular surgery (0%), ENT and General Surgery (13%), and Thoracic Surgery (15%) had the least female representation in leadership. 

Conclusion: Male and female leaders are nearly equal in their credentials with women having less publications, but more advanced degrees; yet women are under-represented in leadership of surgical organizations. Our data show women are involved earlier in their careers in conflict to the belief that women hold off on career pursuits due to family planning and work/life balance. Data have shown that it takes women longer to reach Full Professor than men (Abelson 2015). This knowledge could lead women to be more aggressive in their leadership endeavors, explaining their early involvement. Since a higher rate of women hold lower level leadership roles, they must continue to be mentored and encouraged into higher leadership positions. Surgical organization leadership should be re-examined in the future to identify if gender parity is reached with more women holding higher level leadership roles. 

 

83.06 Gender differences at national academic surgery conferences: examination of the "broken pipeline".

Posted on January 31, 2019

T. Lysaght2, M. Wooster1, N. Anton1, D. Stefanidis1  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA 2Ohiohealth Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OH, USA

Introduction: Women comprise 19% of all surgeons in the United States, 22% of full time faculty and only 1% of department chairs. Their participation in national meetings as presenters, while unknown, could indicate their engagement in academic surgery. Our objective was to determine the percentage of women presenting at national surgical meetings over time, and the relationship of that percentage with society president gender and meeting focus on gender disparity.

Methods: The annual meeting program of 10 surgical organizations (SO) including Academic Surgical Congress (ASC), American Association for the Surgery of Trauma (AAST), American College of Osteopathic Surgeons Academic Clinical Assembly (ACA), American College of Surgeons Clinical Congress (ACS), the Americas Hepato-Pancreato-Biliary Association (AHPBA), American Society of Clinical Oncology (ASCO), Surgical Education Week (SEW), Eastern Association for the Surgery of Trauma (EAST), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and Western Trauma Association (WTA), was reviewed for years 2013, 2015, and 2017. The gender of scientific program presenters, panel chairs, session moderators, panelists, and keynote speakers was recorded and its association with the meeting’s president and president-elect gender. Topics pertaining to gender disparities, which addressed the current gender gap in the surgical field or adversities women face with advancing in their field identified by key words gender, female or women in the title, was assessed.

Results: 30.8% (4/13) to 53.8% (7/13) of meetings had women presidents and presidents elect. Women comprised 15.9-45.4% (mean 28.3%, SD+/-9.26%) of presenters across the 10 meetings. The highest rate was observed at the 2017 SEW meeting and the lowest at the 2015 ACA meeting. A statistically significant increase in the number of female participants was found over time in the ACA and ASCO meetings (p=0.0175, p=0.0131). Meetings that incorporated discussions of gender disparities had a higher proportion of women presidents and president elects ranging from 4-10 to those without 1-2, respectively (30.1%-33.2%  vs 20.5%-25.4%, respectively). A strong correlation existed between gender of president and president elect and percentage of women presenters (r=0.9108), whereas, a weak correlation was found with discussion of gender disparity (r=0.1714). (Table 1).

Conclusion: While significant variability exists in the academic engagement of women among surgical societies, overall participation is on par or better than their representation among the surgical workforce. Societies with women leaders may be associated with increased women participation at national meetings. 

83.05 Ethical Concerns During the Medical Student Surgical Clerkship

Posted on January 31, 2019

K. A. Marsden1, L. C. Kaldjian3, E. M. Carlisle2  1University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA 2University Of Iowa,Division Of Pediatric Surgery/Department Of Surgery,Iowa City, IA, USA 3University Of Iowa,Carver College Of Medicine/Program In Bioethics And Humanities,Iowa City, IA, USA

Introduction: There is an ever increasing focus on the development of medical school ethics curricula. While much effort has focused on the preclinical years, several groups have worked to identify ethical issues medical students face during their clinical rotations. This work has largely focused on internal medicine, pediatrics, and OBGYN clerkships. Little data is available regarding ethical issues students encounter on the surgery clerkship. Identification of such issues will allow preclinical and clinical course directors to refine ethics curricula to insure students are prepared to address the ethical issues they are most likely to encounter on the surgical rotation. To this end, we performed a content analysis of ethical issues encountered by medical students on a surgical clerkship.

Methods: All medical students on the surgical clerkship at a university hospital between April 2017 and June 2018 submitted a written reflection regarding an ethical issue encountered during the clerkship.  Two independent investigators performed content analysis of each reflection. References to core ethical principles (beneficence, non-maleficence, justice, autonomy) were tabulated, and ethical issues were classified into 10 main categories and 58 subcategories based on a modified version of a published rubric.

Results: 140 reflections were reviewed. 6 were removed due to lack of focus on an ethical issue. 134 reflections underwent content analysis. Non-maleficence was the predominant core ethical principle mentioned, however this was closely followed by justice.  Regarding ethical issues, students wrote about challenges with decision making (28%), communication among healthcare team members (14%), justice (12%), communication between providers, patients and families (10%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student specific issues (5%), documentation issues (1%), and miscellaneous/other (7%).

Conclusion: Our analysis identified ethical issues that are of concern to students on the surgical clerkship.  Consistent with prior analysis of students on other rotations, our work demonstrates that students express most concern with issues related to decision making. Unlike their peers on other clerkships, surgical students express increased concern with ethical issues surrounding informed consent, communication between treatment teams, and justice. Interestingly, fewer surgical students expressed concern about disrespectful treatment of patients by providers than did students on other clerkships. However, more surgical students expressed concern related to ambiguity about their role/responsibility on the surgical team, as well as the challenge of balancing delivery of efficient yet high-quality care. Integration of these specific ethical concerns into preclinical and clinical ethics curricula may help prepare medical students for the ethical issues that they will encounter on the surgical clerkship. 

 

83.04 Does Gender Define General Surgery Resident Well-Being?

Posted on January 31, 2019

J. Felton1, S. Kidd-Romero1, N. Kubicki1, S. M. Kavic1  1University Of Maryland,Surgery,Baltimore, MD, USA

Introduction:  Burnout, depression, and poor psychological well-being are pervasive among general surgery residents, and there is recent evidence to suggest that there are differences between male and female residents.  We sought to describe and evaluate the gender differences in burnout, depression, and wellness among general surgery residents at a single institution.

Methods:  We created a novel 50-question anonymous survey with Likert scales to assess burnout, depression, and wellness.  This was distributed to the general surgery residents at two separate time points during the academic year, before and after the introduction of a wellness initiative, to evaluate for any differences.  Bivariate analysis was performed to determine the association between gender and specific variables.

Results: Forty-two of 55 residents participated in the first survey.  We found that women felt more satisfied by their work than men (p <0.01) and tended to exercise more often than men (p = 0.04).  We also found that women tend to feel sad (p = 0.04) and feel anxious (p <0.01) more often than men.  Furthermore, women tend to stress eat (p = 0.01) more often than men and have more alcoholic drinks per sitting (p = 0.02) than men.  Finally, we found that women tend to think about death or suicide more often than their male counterparts (p = 0.04).  Thirty-five residents participated in the second survey.  In terms of self-view, more men had more positive days than negative days (p <0.01) compared to women.  Women took more time to think, reflect, and meditate (p = 0.03).  Again, we found that women tend to feel sad (p = 0.01) and feel anxious (p = 0.01) more often than men.  In addition, we found that women tend to feel fatigued (p = 0.02) and experience stress headaches (p = 0.04) more often than men.  Finally, we found that women make time to see people outside of the hospital more often than men (p = 0.06). 

Conclusion: We found that there exist several significant differences between male and female general surgery residents at one academic institution.  The reasons underlying these differences are not fully understood or elucidated.  In the future, more investigation must be done, and general surgery residencies may need to create gender-based programs to address these differences.

 

83.03 Underrepresentation of Women in Surgical Societies: Analysis of Awards and Invited Speakers

Posted on January 31, 2019

L. Kuo1, P. Lu1,2, R. Atkinson1, N. L. Cho1, N. Melnitchouk1,2  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2Center for Surgery and Public Health,Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Gender disparities within academic medicine are well described. Specialty societies provide opportunities for leadership and career advancement, but little is known about the role specialty societies play in propagating or eliminating gender disparities. Previous studies have demonstrated that society awards are less likely to be given to women than men. Here, we examined surgical society award distribution and podium speakership by gender to investigate disparities in recognition and inclusion.

Methods:
National general surgery and associated subspecialty (bariatric, colorectal, endocrine, hepatobiliary, oncologic, pediatric, plastic, thoracic, transplant, and trauma surgery) societies with publicly available information on awards and invited lecturers at annual meetings between 2008-2018 were identified. Awards targeted specifically towards women, military personnel, medical students or non-physicians were excluded. A subset of awards for trainees (fellows or residents) was also identified. The gender of each award winner or invited speaker was determined based on name and internet query. The percentage of female award winners and invited speakers for each society was calculated and compared to the percentage of female practicing and trainee surgeons in 2015 and 2017, respectively, as reported by the Association of American Medical Colleges.

Results:
21 surgical societies were identified. From 2008-2018, 1294 awards were given, of which 372 were awarded to women (28.7%). A total of 1026 awards were given to non-trainees. Of these, 239 were given to women (23.3%), which is greater than the 19.2% of practicing surgeons who were female in 2015. Across the 21 societies examined, the percentage of female award recipients by society ranged from 0% to 54%. When examining the 288 awards given to trainees, 49.6% were awarded to women, which is greater than the 38.4% of female residents nationwide in 2017. Rates of female trainee award winners amongst individual societies ranged from 13.3% to 69.2%. Over this same time period, 445 invited speakers were featured at annual meetings. 75 (16.9%) were women, with individual societies featuring female speakers at rates varying from 0% to 25.8%.

Conclusion:
Women are well represented as award winners in surgical societies, both as trainees and as practicing surgeons. However, some individual societies have low rates of female award winners. Women are also underrepresented as invited speakers. Specialty societies should consider interventions to recognize the achievements of female members and to promote parity across genders.
 

83.02 Sexual Harassment during Residency Training: A Cross-Sectional Analysis

Posted on January 31, 2019

L. F. Arnold1, S. R. Zargham1, C. E. Gordon1, W. I. William I. McKinley1, E. H. Bruenderman1, J. L. Weaver1, M. E. Egger1, M. V. Benns1, A. T. Motameni1  1University Of Louisville,Surgery,Louisville, KY, USA

Introduction:  

The reality of sexual harassment is unmasking in many fields. Residents make up a vulnerable group and are at risk of being sexually harassed. In this study we focus on prevalence of sexual harassment among residents in general surgery, pediatrics and internal medicine with a focus on identifying underlying reasons for lack of victim reporting.

Methods:  

Survey on sexual harassment was emailed to 261 general surgery, 132 pediatric, and 271 internal medicine programs. The survey focused on specific examples of sexual harassment, reporting and resident knowledge and awareness of institutional support programs for victims of sexual harassment.

Results: 

379 residents responded to the survey. Females were more likely to be subject of harassment compared to males (83% vs 46%, p<.0001). Offensive and/or suggestive jokes and comments were the most common type of harassment experienced by both genders. Most residents were unlikely to report the offender (87% females vs. 93% males). There was no significant difference in the number of residents who reported experiencing some sort of harassment based on resident specialty (69% general surgery, 64% internal medicine, 69% pediatrics). 73% of residents believed they would be supported by their program if they reported a sexual harassment events, only 38% of females and 40% of males were aware of institutional support in place for victims of sexual harassment at their program.

Conclusion: 

Sexual harassment continues to be a problem in the medical field. Residents continue to train in environments where reaching their full potential can be restrained. Radical steps must be taken to address the problem of sexual harassment and to create the optimal setting for training residents.

83.01 Disordered Eating and Well-being Among Surgical Residents

Posted on January 31, 2019

A. Salles1, E. E. Fitzimmons-Craft2, G. Nicol2, D. Wilfley2, J. Yu1, C. Herleth5, T. M. Ciesielski4, R. P. McAlister3  5McCallum Place,St. Louis, MO, USA 1Washington University in St. Louis,Surgery,St. Louis, MO, USA 2Washington University,Psychiatry,St. Louis, MO, USA 3Washington University,Obstetrics And Gynecology,St. Louis, MO, USA 4Washington University,Department Of Medicine,St. Louis, MO, USA

Introduction:  There is increasing attention on the ongoing physician well-being crisis. Numerous studies have documented the high rates of burnout among physicians and, in particular, surgeons. One consequence of being a surgeon is having little time for eating and drinking. This may, in turn, be associated with disordered eating, which can include episodes of eating in which people feel they cannot control what or how much they eat. In this study, we assessed surgical trainees across multiple specialties at one institution for evidence of disordered eating. We also assessed whether stress and burnout are associated with disordered eating.

Methods:  We invited all surgical residents at Washington University School of Medicine in St. Louis to participate in a voluntary online survey regarding eating behaviors and well-being in spring 2018. Measures included the Dutch Eating Behaviour Questionnaire (DEBQ), Cohen’s perceived stress scale (PSS), and representative items from the emotional exhaustion and depersonalization subscales of the Maslach Burnout Inventory (MBI).

Results: A total of 146 trainees participated in the survey (response rate 67%; 54% women). The scores on the key measures are shown in the table. The perceived stress scale (r=0.24, p=0.007) and both subscales of the MBI (emotional exhaustion r=0.29, p<0.001; depersonalization r=0.33, p<0.001) were significantly associated with disordered eating as measured by the DEBQ. In regression analyses controlling for gender and post-graduate year, these relationships remained statistically significant (B=1.74, p=0.04 for perceived stress, B=3.71, p=0.004 for emotional exhaustion, B=4.20, p=0.03 for depersonalization) such that more stress and more burnout were associated with more disordered eating.

Conclusion: This is the first study we are aware of that examines disordered eating among surgical residents. Our results suggest that surgical trainees are affected by disordered eating which was associated with stress and burnout. These data are cross-sectional in nature, so no causation can be inferred. Future studies should examine the effects of interventions targeting healthy eating behaviors and well-being outcomes including burnout. Something as simple as providing easy access to food and drink may counteract the tendency toward disordered eating, which may be in part fueled by limited time for eating and drinking during working hours. Any intervention aimed at improving eating behaviors will be most likely to be successful as part of a comprehensive well-being program.

 

63.21 Surgeons Are Leaders in Healthcare. Are They Prepared for the Role?

Posted on January 31, 2019

D. R. Heller1, V. Kurbatov1, M. R. Freedman-Weiss1, G. Chao1, R. A. Jean1, P. S. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:  Surgeons function as team leaders on the wards, in the operating room, and at all levels of training and practice. Yet leadership skills are not an ACGME core competency, nor is leadership training a standard curricular requirement for residents. We explored resident perceptions and experiences with leadership to assess for unmet educational needs.  

Methods:  An anonymous survey was electronically distributed to all General Surgery residents at a university-affiliated hospital (Qualtrics Survey Software). Questions centered on perceptions and experiences around physician leadership in healthcare and formal leadership training. Leadership experiences were defined as participation in healthcare-related administrative roles or committees. Leadership training was defined as participation in symposia or conferences teaching leadership theory and skill-building.  

Results: Of 70 residents, 56 (80.0%) responded to the survey. Males comprised 57.1% and each post-graduate year 1–5 had majority representation, ranging from 68.8% – 100%. Almost all respondents, 98.2%, ranked physician leadership in healthcare as somewhat or very important vs. neutral or unimportant. A large majority, 87.3%, ranked leadership training during residency as somewhat or very important. Far less reported exposure to leadership experiences (37.0%), and less still reported receiving leadership training during residency (24.1%). Senior residents had significantly more exposure to leadership experiences (p=0.01) and training (p=0.01), and married residents with higher incomes saw a trend toward association with leadership experiences. Among those who received formal education, roughly half were trained by the hospital/university or external healthcare organizations; only 14.3% reported training by the residency program. When polled about the leadership style most often employed by surgical residents, a majority reported “pacesetting” (31.2%) and “commanding” (22.2%); the “visionary” and “affiliative” styles were least-often employed (7.4% and 9.3%, respectively). 

Conclusion: At a large academic surgical residency, nearly all residents perceive physician leadership in healthcare systems and formal leadership training as important. Yet roughly a third are exposed to leadership roles and a quarter to leadership training at a given point in residency. Since leadership development is not an ACGME requirement, opportunities for experience and education during residency may be lacking, and trainees may preferentially acquire a narrow band of skills rather than the balanced spectrum requisite for effective leadership. Hospitals and training programs should mind this educational gap and aim to expand opportunities for residents during the critical years of professional development. 

63.20 Lessons from Developing a Mobile App for Postop Recovery following Weight-Loss Surgery

Posted on January 31, 2019

P. Dolan1, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction: Weight-loss surgery has been shown to be the most effective way to lose weight, but remains under-utilized. One reason is due to the initial cost of surgery, including the subsequent inpatient hospitalization as well as readmissions. Although the complication rate from weight-loss surgery is declining over time, currently about 11% of patients visit an emergency room within 30 days after surgery, leading to 4.4% of patients being readmitted. The most common complications leading to ER visits are dehydration and abdominal pain, both costly and potentially avoidable with appropriate early intervention and triaging. Length of stay after the initial procedure is also becoming shorter, however, most patients stay at least 1-2 days in the hospital after surgery. Mobile health apps have been tested in other patient populations and have been shown to decrease length of stay and improve outcomes. Our goal is to develop and test a mobile health application to assess patients’ recovery and triage common issues in the 30 days after weight-loss surgery, such as dehydration, nausea, and abdominal pain. Use of the app will hopefully decrease cost by shortening length of stay and reducing readmission rates.

Methods:  Mixed methods, single-center prospective pilot/feasibility study of all eligible English-speaking adults undergoing weight-loss surgery. We have been developing and refining the mobile app over the course of the last 12 months. The app has multiple components, one of which is a daily survey. Survey questions were developed to monitor post op recovery and symptoms.  These questions were developed through a review of the literature and by interviewing bariatric nutritionists, bariatric nurse specialists and attending bariatric surgeons in conjunction with an experienced survey developer. Patients also get push notifications with reminders designed to improve recovery. After the first few patients had completed the pilot, the app was revised based on patient feedback.  The app is currently being tested and refined on additional patients.

Results: After our first three 3 patients completed the 30-day trial period they were surveyed to find out preference and usability of the app. All patients expressed satisfaction with the app.  Patients reported that push notifications were helpful. However, patients were frustrated with the length of surveys after the first few days. Especially if they were doing well after surgery, they found the surveys to be redundant. Therefore, we tailored the app to patients’ feedback, to a simpler system with shorter follow-up surveys. We are now testing the app further, for feasibility and usability.

Conclusion: App development is feasible, but complex and must be tailored to the procedure and the patient. They require a significant amount of time to develop and refine to patient needs. Our next steps are to pilot the app a larger set of patients and assess utility and feasibility in practice.

 

63.19 Effect of Operating Room Personnel Generation On Perceptions and Responses to Surgeon Behavior

Posted on January 31, 2019

J. G. Luc1, E. M. Corsini2, K. G. Mitchell2, N. S. Turner2, A. A. Vaporciyan2, M. B. Antonoff2  1University Of British Columbia,Cardiovascular Surgery,Vancouver, British Columbia, Canada 2University Of Texas MD Anderson Cancer Center,Thoracic And Cardiovascular Surgery,Houston, TX, USA

Introduction: As surgeons, we rely on allied health professionals in our day-to-day work in the operating room and care of patients; as such, it is imperative for us to learn about and embrace generational and sex-specific differences in their perceptions and responses to our behavior. The present study aims to study the effect of allied health respondent sex as stratified by generation on their perceptions and responses to various surgeon behaviors through five realistic intraoperative scenarios.

Methods: A prospective, randomized study was conducted in which operating room personnel were asked to assess surgeon operating room behavior across a standardized set of five scenarios via an online survey. For each scenario, respondents were asked to identify the behavior as either acceptable, unacceptable but would ignore, unacceptable and would confront the surgeon or unacceptable and would report to management. Chi-squared analyses were used to compare respondent assessment of surgeon behavior with respondent generation and sex. 

Results: The response rate was 4.4% (3101/71143) of which 41% of respondents were baby boomers (n=1280; 249 male, 1031 female), 31% were Gen X (n=955; 197 male, 758 female) and 28% were Gen Y (n=866; 130 male, 736 female). Overall tolerance of surgeon behavior by scenario is shown in the Figure. Baby boomer males were more likely to find it inappropriate and would report the surgeon compared to baby boomer females in regards to surgeon impatience in the operating room (Male 8.8% vs. Female 1.9%, p<0.001) and surgeon lateness for a case (Male 10.4% vs. Female 6.0%, p=0.013). Whereas baby boomer females were more likely to find surgeon swearing to be inappropriate and would report the surgeon (Male 24.1% vs. Female 32.0%, p=0.015). In terms of a surgeon forgetting a timeout, baby boomer females (Male 44.6% vs. Female 59.3%, p<0.001) and Gen X females (Male 40.1% vs. Female 54.2%, p<0.001) were more likely to find it inappropriate and would talk to the surgeon directly than males. Baby boomer females were also more likely to find surgeon shouting in the operating room in a crisis to be inappropriate but would let it go when compared to baby boomer males (Male 9.6% vs. Female 17.1%, p=0.004). 

Conclusion: Results of our prospective randomized study demonstrate that operating room respondent generation and sex affects their perceptions and response to surgeon behavior. Awareness of generational and sex-specific differences in perceptions of surgeon behavior is key to improving the intraoperative environment for all. 

 

63.18 Beyond Donate Life: Utilization and Re-perfusion of Unused Organs for Simulation and Education

Posted on January 31, 2019

S. M. Wrenn1, S. R. Russell1, M. N. Barnett1, F. Hirashima1, C. E. Marroquin1  1University Of Vermont College Of Medicine / Fletcher Allen Health Care,The Robert Larner College Of Medicine,Burlington, VT, USA

Introduction: It is imperative that trainees obtain adequate surgical skills for independent practice. However, autonomy must be balanced with patient safety. Simulation has become a popular method of developing competency-based curriculums. Unfortunately, simulation often (whether cadaveric or synthetic) lacks the fidelity and realism of true operative tissue.

Methods: Solid abdominal and thoracic organs (heart, lung, kidney, pancreas, and liver) deemed unsuitable for transplantation were provided for simulation and research. Organs were kept fresh and then re-perfused using a roller pump-based perfusion circuit with pigmented blood substitute. Organs were sewn in-line to create a closed loop circuit. Residents and medical students participated in multiple workshops designed to improve surgical techniques, including transplant-based interventions. These educational sessions were led by attending surgeons from both cardiothoracic, abdominal organ transplant, and hepato-biliary services. Residents and medical students were queried on their perceptions of the workshop after completion via electronic survey.

Results:Multiple simulations were attended over a 12-month period. Skills performed included vena cava, portal vein and hepatic arterial anastomosis and dissection. Hepatic “re-animation” was followed by cholecystectomy, biliary dissection, and hepatic resection. Residents performed renal allograft anastomosis and vessel repair. Superior mesenteric and portal veins were sewn into a closed circuit and the “pancreatic tunnel” developed to allow division of the pancreatic neck. Finally, coronary artery bypass and aortic valve replacement was performed.

Of the 17 responding residents or students surveyed, 9 had participated in the workshops (22% medical students, 11% intern, 22% junior residents, and 44% senior residents). Participants rated the workshops as valuable and more realistic than traditional cadaveric or synthetic based simulation workshops. Respondents rated tissue fidelity and realism as 8 out of 10 (range, 6-9). 100% of participants reported that the simulations improved their operative skills, that they would attend further sessions, and that the sessions were a valuable use of the organs.

Conclusion: Use of fresh solid organs unfit for transplantation provides an opportunity for operative simulation of high fidelity and quality. There remains a large national opportunity to integrate these organs into surgical education. This proof of concept study demonstrates a novel means of creating realistic and reproducible surgical education for improvement in educational paradigms while allowing surgical educators to preserve the public trust by ensuring residents are ready to operate on living patients.
 

63.17 How Many Clicks Does It Take to Get to the Center of a Department-wide Wellness Initiative

Posted on January 31, 2019

M. E. Hadley1, A. Coughlan1, J. G. Chipman1, C. J. Tignanelli1,2,3  1University Of Minnesota,Department Of Surgery,Minneapolis, MN, USA 2University Of Minnesota,Institute For Health Informatics,Minneapolis, MN, USA 3North Memorial Health Hospital,Department Of Surgery,Minneapolis, MN, USA

Introduction:
Burnout is a public health crisis that affects over 50% of healthcare providers and results in adverse patient outcomes, poor physician job satisfaction, depersonalization, and increased rates of depression, substance abuse, and physician suicide. Our institution developed a unique Department of Surgery wellness program to combat this issue, reduce stress, and promote wellbeing. The aim of this study was to evaluate user interaction with our program vis-à-vis a monthly newsletter as a dissemination tool.

Methods:
Our wellness program is sponsored by the Department of Surgery Wellness Committee and includes the following regular activities: chair yoga, wellness walks, photography club, craft lunch, visiting seasonal farmers market and music on the plaza, sitcom break, and themed potlucks. Additionally, it includes wellness insights from faculty and opportunities to participate in University of Minnesota fundraisers such as the annual Turtle Derby or Chainbreaker events. A regular wellness newsletter was developed to disseminate this program which is sent to Department of Surgery housestaff, faculty, and staff, with approximately 350 subscribers. Mailchimp® (marketing automation platform, Atlanta, GA) was used to evaluate subscriber interaction with the newsletter from April, 2017 – July, 2018. Interactions were defined as the number of subscribers opening each newsletter and the number of subscribers who clicked on linked content within the newsletter. The Mailchimp® industry average for health and fitness newsletters was used a reference standard.

Results:
The average number of subscribers who opened the newsletter each month was 178, or 51% compared to the industry average of 16% (Table 1). There was an average of 18 subscribers clicking content per newsletter. Thus, of the people who received the newsletter, 5% of subscribers opened and then clicked for further content. This is higher than the industry average of 2%. All employee types equally opened the newsletter; however, staff were most likely to click individual content within each newsletter.  

Conclusion:
A wellness newsletter is an effective tool to disseminate a wellness program within a Department of Surgery and is interacted with more than the industry average. Future directions should focus on identifying ways to further improve interaction with and better integrate surgical wellness programs for faculty and housestaff. A wellness newsletter may be an important way to reach healthcare workers who are at risk for burnout.
 

63.16 Variation in the Quality of Thyroid Nodule Evaluations Prior to Surgical Referral

Posted on January 31, 2019

L. Jiang1, C. Lee1, D. Sloan1, R. Randle1  1University Of Kentucky,Department Of General Surgery,Lexington, KY, USA

Introduction:

While thyroid nodules are very common, they need an appropriate evaluation given the increasing incidence of thyroid cancer. We hypothesized that most patients do not receive high-quality, streamlined thyroid nodule evaluations. The objective of this study was to describe and characterize the quality of thyroid nodule evaluations prior to surgical referral.

Methods:
We reviewed all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We defined an efficient initial laboratory investigation as one that obtained a thyroid stimulating hormone (TSH) level without additional thyroid related labs. We defined a high-quality ultrasound as one that included commentary on nodule structure, echogenicity, 3-dimensional size, and lymph nodes since these features help stratify the risk of malignancy.

Results:
The study cohort included 64 patients, with a median age of 51.5 years. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). Patients saw a mean of 1.63 providers for their nodule prior to surgical referral. In total, 35.9% of evaluations did not include a TSH value, and 53.1% included additional, unnecessary thyroid labs. Only 14.1% met our definition of an efficient initial laboratory investigation with a TSH as the only thyroid related lab obtained. Almost all evaluations (95.3%) included a thyroid ultrasound, but these were of varying quality. The Figure shows the proportion of ultrasound reports that noted specific characteristics of the dominant nodule. Only12.3% of ultrasound reports commented on the 4 criteria indicative of a high-quality thyroid ultrasound. Of the 6 evaluations (9.4%) that included a thyroid uptake scan, only 2 (33.3%) were indicated, and 4 patients with a suppressed TSH did not receive a thyroid uptake scan as indicated. Overall, 93.1% of biopsy reports appropriately classified thyroid nodule cytology according to the Bethesda System.

Conclusion:
There are marked discrepancies in the quality of thyroid nodule evaluations prior to surgical referral. Even though a TSH is necessary in the work-up of all thyroid nodules, over a third of evaluations did not include one. Additionally, most ultrasound reports do not include sufficient commentary on the sonographic features necessary to stratify the risk of malignancy. Therefore, quality improvement initiatives targeting laboratory testing and ultrasound imaging might promote efficiency and quality in thyroid nodule evaluations. 
 

63.15 Trends in Medical Education Research: A Look at Abstracts from the Academic Surgical Congress

Posted on January 31, 2019

M. Mankarious1,2, E. Palmquist1, L. Chen1  1Tufts Medical Center,Department Of Surgery,Boston, MA, USA 2Tufts University School of Medicine,Boston, MA, USA

Introduction:

Medical education research is a quickly growing field of interest that has attracted many brilliant minds over the last decade that address this multifaceted landscape. With the surgical educational environment undergoing many significant changes, new topics emerged with increasing trends and interesting results. In this study, we utilize available abstracts from Academic Surgical Congress (ASC) over the past years to examine emerging topics and trends in medical education research.

Methods:

ASC abstracts over the past four years were obtained from the ASC website. University and state affiliation of the first author for each abstract was collected. Abstracts were categorized according to topic (Curriculum/Teaching, Innovations, Assessment, Program Evaluation, Wellbeing/Burnout, and Miscellaneous) and design (Descriptive, Test Assessment, Relational, and Qualitative) based on previously published categories. Miscellaneous topics were recategorized based on theme.

Results:

A total of 429 abstracts were obtained from previous four ASC meetings. 405 abstracts were from within the United States and 24 from other countries. 29.6% of abstracts within the USA came from Wisconsin, Illinois, California, and Texas.

Overall number of abstracts nearly doubled from 77 in 2015 to 140 in 2018. Descriptive studies were the most common research design (41%), followed by test assessment (20%), qualitative (18%), relationship (18%), and experimental (3%). Annual topic proportions were considerably stable with 21% curriculum and teaching, 26% technical and performance assessment, 6% wellbeing and burnout, and 5% program evaluations. 33% of the abstracts belonged to the miscellaneous category. Of the miscellaneous, most common topics addressed Global Health (19.15%) and Gender/Race (14.18%). Remainder of miscellaneous topics included personality traits of students, residents, and surgeons, experience and overall trends in practice, impact and utilization of social media, resident work-hour limits, and financial questions in surgical training.

Conclusion:
Research into medical education is a transforming and evolving field. Since 2000, there has been an increasing number of studies as well as new prominent topics that are more relevant to the current educational environment. Up to date knowledge of these current topic trends in medical education may inform future research. For instance, the increasing trend towards evaluating and restructuring global health programs points to the increasing prevalence of the topic to residency programs as it becomes an integrated aspect of many residency programs. Similarly, research regarding gender and racial inequalities in the surgical environment points to the changing landscape and the importance of creating a more inclusive environment. 

63.14 Educating Surgeons on Skills in Outpatient Communication

Posted on January 31, 2019

S. E. Raper1, J. Joseph1  1University Of Pennsylvania,Quality And Risk Management/Surgery/Medicine,Philadelphia, PA, USA

Introduction: Good communication remains a keystone of patient care, yet there is a dearth of literature on educating surgeons in this critical element. With the shift to progressively more care in the outpatient setting, skills specific to outpatient communication have assumed greater importance. We hypothesized that a short course in outpatient communication for academic surgical faculty could be presented with high levels of participation and satisfaction.

Methods: Four separate courses (general, cardiac, plastics, urology) were taught to maximize attendance and provide particularized data. The course first introduced topics important to the health system: evolution of the physician practice plan and patient satisfaction initiatives. The status of transparency initiatives with respect to Consumer Assessment of Healthcare Providers and Systems (CAHPS) satisfaction survey scores was amplified with the ranked data for each individual departmental surgeon. Also the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System (MIPS). Next, benefits of and barriers to good communication were discussed. This material was augmented by use of a short video clip simulating patient interactions serving to sharpen communication skills. Lastly, of the many options for improving physician communication skills, we focused on the critical role of listening.

Results:A voluntary, anonymous six question Likert-type survey assessed participant satisfaction: Q1) Goals were clearly communicated; Q2) Practice plan information was instructive; Q3) CAHPS & MIPS- information was instructive; Q4) Public reporting and transparency information was instructive; Q5) Benefits of good communication was instructive; Q6) Listening as a critical communication skill was valuable. 84/105 (80%) faculty participated and 54% returned the survey. Survey, questions 1, 4, 5, 6 all had responses ≥ 4.5. For Q2 & Q3, the average was <4.5. For Q2, the average was statistically significant by t-test (Table).

Conclusion:Turnout was robust, mediated in part by using regularly scheduled, conflict-free educational slots and provision of CME credit where possible. Satisfaction was high, with the benefits of good communication and material on listening given the highest and material on changes in the practice plan and CMS reimbursement given the lowest scores. The data suggest that focusing specifically on direct communication strategies may be better received. Our experience in course development for teaching outpatient communication highlights an important topic in contemporary surgery, and can be readily expanded to any surgical program with material that is relevant to all, yet particularized with institution and surgeon-specific data.

 

63.13 Objective Assessment of General Surgery Trainee Performance

Posted on January 31, 2019

Y. N. AlJamal1, D. R. Farley1  1Mayo Clinic,Rochester, MN, USA

Introduction:

While surgical educators have a variety of options to evaluate trainees’ surgical skills, program directors have historically used operative case volume as the gold standard of operative competence1. Given better objective assessments of skills competency, we reviewed the current literature on the use of objective tools to assess general surgery trainees’ skills competency.

Methods:

A literature review (2000-2017) in PubMed using keywords (objective assessment, surgery, and competence) was conducted. The methodologies of the assessment tools are examined.

Results:

A total of 420 publications were identified. Only 39 papers focused on the objective assessment of surgical trainee performance in general surgery. Of these 39, 26 assessed open surgical skills, 11 looked at laparoscopic skills and 2 assessed both skills. Most open (57%) and laparoscopic (81%) skill assessments used objective structured assessment tools. Assessment using simulation options did occur: open skills = 65%, laparoscopic = 27%. Publications focusing on actual competency (12%) were less common.

Conclusion:

Publications involving objective assessments of general surgery trainee skills competency is varied: open skills assessment predominates with most occurring in a simulated setting; laparoscopic assessment is more prevalent in the operating room. Defining actual competency is uncommon and suggests further efforts are needed to better evaluate general surgery trainee performance.

 

63.12 Acceptance of Xenotransplantation Among Nursing Students

Posted on January 31, 2019

W. Paris1, L. Padilla2, Z. Aburjania6, R. Bgainer3, K. Jang1, D. Cleveland6, Y. Lau4, S. Floyd6, D. Mauchley6, R. Dabal6, D. K. Cooper5  1Abilene Christian University,School Of Social Work,Abilene, TX, USA 2University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA 3Texas Tech University Health Sciences Center,School Of Nursing,Lubbock, TX, USA 4University of Alabama at Birmingham,Division Of Pediatric Cardiology,Birmingham, AL, USA 5University Of Alabama at Birmingham,Department Of Surgery, Xenotransplant Program,Birmingham, AL, USA 6University Of Alabama at Birmingham,Department Of Surgery, Division Of Cardiothoracic Surgery,Birmingham, AL, USA

Introduction: Organ donation rates have not kept pace with the global incidence of end-stage organ failure. Given recent experimental progress, xenotransplantation (XTP; i.e., pig to human) has the potential to provide an unlimited supply of donor organs, but will present with many challenging public health issues for consideration. The objective of the study was to identify and report the most recent information relevant to XTP clinical trials; and report initial acceptance about the procedure.

Methods: A cross-sectional study among 70 nursing students from a large mid-western public university was conducted (July, 2017). An email was forwarded with a 35 item survey developed by the research team using a weblink after online consent.

Results: Regression analysis found that their willingness to consider receiving a XTP was being an organ donor themselves (p<0.01).  Only 7% were aware that pig donors must be genetically modified (to prevent rejection) before they could be used as sources of organs for transplantation into humans.  Wilcoxon Rank-Sum procedures found that anticipation of poorer medical outcomes with XTP (when compared to than human organ donation) was significantly associated with greater concern about potential psychosocial sequlae (p<0.01). 

Conclusion: The most commonly related factors towards acceptance of XTP among healthcare professionals were being an organ donor, and the expectation of positive medical results.  Findings suggest that even among healthcare professional’s knowledge of the process and immunology is limited.  The findings highlight the need to increase knowledge and awareness of XTP among healthcare professionals as an incremental step in public education and preparation for clinical trials.  

 

63.11 Factors Predicting Unplanned 30-Day Readmissions in Surgical Patients

Posted on January 31, 2019

K. Y. Hu1, J. J. Blank1, Y. He2, T. J. Ridolfi1, K. A. Ludwig1, C. Y. Peterson1  1Medical College Of Wisconsin,Division Of Colorectal Surgery, Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Biostatistics,Milwaukee, WI, USA

Introduction:
Unplanned readmissions have negative consequences for hospitals and patients. Preoperative patient factors have been shown to be most predictive of readmission in surgical patients, with improved prediction after inclusion of postoperative variables such as laboratory values. In patients admitted to medicine services, vital sign instability on discharge has been associated with increased readmission and mortality. We hypothesized that certain abnormal laboratory values and vital signs at time of discharge may be predictive of readmission in surgical patients and attempted to identify patients at increased risk for readmission.

Methods:
This was a single-institution retrospective review of patients discharged from surgical inpatient units between 11/1/16 and 11/30/17 after admission for surgery. Patients were stratified into those with unplanned 30-day readmissions from their index admission, and those who were not readmitted. The last filled vital signs, most recent laboratory values (white blood cell count (WBC), hemoglobin, glucose, blood urea nitrogen (BUN), and albumin), number of bowel movements, ASA score, and insurance status were analyzed. Patients with planned readmissions were excluded. The primary outcome was 30-day readmission.

Results:
Of 2607 surgical admissions, 243 were readmitted within 30 days (9.1%). Readmitted patients were more likely to have an increased length of stay during their index admission (12.01 vs 6.55 days, p<0.01). In unadjusted univariate analysis, heart rate (HR) >99 (p=0.03, positive predictive value (PPV) 11.6%), BUN >23mg/dL (p<0.01, PPV 19.4%), albumin <3.8 g/dL (p<0.01, PPV 18.4%) and presence of any abnormal lab value (p<0.01, PPV 13.6%) were associated with readmission. In risk-adjusted multivariate logistic regression, variables associated with readmission were ASA of 4-5 (OR 3.31, 95% CI 1.87-5.84, p<0.01), abnormal HR (OR 1.46, 95% CI 1.07-1.98, p=0.02), and BUN >23mg/dL (OR 1.57, 95% CI 1.05-2.34, p=0.03).

Conclusion:
HR >99, BUN >23mg/dL, albumin <3.8g/dL, and presence of any abnormal lab were associated with readmission, but with poor sensitivity and weak predictive value, limiting their clinical utility. With risk-adjustment, high ASA (4-5), HR >99, and BUN >23mg/dL were associated with readmission; however, ASA and BUN may be reflective of unmodifiable patient factors and of minimal clinical significance. Although identifying key predictors at time of discharge could aid in patient counseling and optimization of high-risk discharges, our results show that readmission is challenging to predict in surgical patients based on discrete numeric data. Focus should be turned to identifying social factors that contribute to readmission.
 

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