93.15 Rural Trauma Team Development Course Instills Confidence in Critical Access Hospitals

Posted on January 31, 2019

Z. M. Bauman1, A. Hodson1, A. Farrens1, V. Shostrom1, J. Summers1, L. Schlitzkus1  1University Of Nebraska College Of Medicine,Trauma And Acute Care Surgery,Omaha, NE, USA

Introduction:  The American College of Surgeons’ Rural Trauma Team Development Course (RTTDC) was designed to help rural hospitals optimize a team approach to trauma management and recognize the need for early transfer to the nearest trauma center.  It takes significant time, travel, and financial resources to host a course, but little literature exists on the overall success of RTTDC in achieving its objectives.  The purpose of this study was to determine the impact of RTTDC on rural trauma team members hypothesizing RTTDC increases healthcare provider confidence in managing trauma patients.

Methods:  RTTDC was hosted at 7 rural hospitals – 5 Level IV state designated trauma centers and 2 undesignated rural hospitals.  A pre-course 30-question survey tool consisting of Likert responses gauging confidence in managing trauma patients was administered to participants.  Four weeks following completion of RTTDC, the same participants were administered a post-course survey with corresponding Likert questions and 11 trauma knowledge questions to determine retention.  Chi-square, Fisher’s exact tests and general linear models for continuous data was utilized.  Statistical significance was set at p<0.05.

Results: 111 participants completed the pre-course survey and 53 completed the post-course survey (48% follow-up rate).  The majority of participants and those completing the post-course surveys were nurses followed by EMS.  Results are presented on a 5 point Likert scale with 1 = not at all comfortable to 5 = extremely comfortable.  There was no statistical significance in the perceived efficiency of the trauma resuscitation or team communication after RTTDC.  Given the course focuses on roles of team members and not interventions, it is not surprising that there was no statistical significance difference after RTTDC in airway management comfort level as well.  The table demonstrates areas in which there was significant improvements in confidence levels of the rural trauma team members after RTTDC. There was a 3.2% increase in participant decision to transfer trauma patients within the first 15 minutes of patient arrival.  Of the 11 knowledge-based questions, participants answered 82% of them correctly.  

Conclusion:  RTTDC instills confidence in healthcare providers at rural hospitals.  Furthermore, the information provided throughout the course is well retained, allowing for quality care and timely patient transfer to the nearest regional trauma center.   

 

93.11 Surgeon Education on Hemostatic Agents

Posted on January 31, 2019

C. Ochoa Chaar1, N. Gholitabar1, M. Devlin1, J. Luo1, Y. Zhang1, H. Hsia1, D. Silasi1, F. Lui1  1Yale University School Of Medicine,Vascular Surgery,New Haven, CT, USA

Introduction: Wide variation in use of Hemostatic agents (HA) by surgeons can significantly affect the cost of care. We postulate that surgeon’s education on HA impacts practice pattern and choice of products and can potentially be incorporated in a cost containment strategy.

Methods: A survey (17 questions) inquiring about the attitudes and preferences of surgeons regarding HA in a multi-hospital healthcare network was conducted electronically. Respondents were divided into 2 groups based on whether they had updated their knowledge and received education on HA (group A) or not (group B).   

Results: There were 148 respondents (25% response rate) in a variate of specialties. (Figure 1) Only 57 surgeons (38.5%) had received updated education on HA (group A). Group A surgeons were significantly more likely to select HA based on literature (33.3% vs 6.6%) while group B surgeons were more likely to rely on what they used in training (28.6% vs 14%) or what is available in the hospital (58.2% vs 47.4%) (P=0.0007). There was little influence by vendor marketing in the 2 groups (A=5.3% vs B=8.8%, P=0.5). Surgeons in group A were significantly more likely to be aware of the costs of HA (47.4% vs 28.6%, P=0.02) and correctly estimate the cost of Surgicel (26.3% vs 13.2%, P=0.05) compared to group B. In the operating room, most surgeons did not routinely open HA (A= 63.2% vs B= 71.4%, P =0.35). However, group A surgeons were more likely to be specific regarding the size and amount of HA requested (A=33.3% vs B=14.3%, P=0.0027). Group A surgeons were more receptive to changing the choice of HA compared to group B (63.2% vs 44%, P=0.03).

Conclusion: Surgeon education on HA is associated with increased awareness of cost and may affect practice pattern in the operating room. Surgeon education can potentially lead to cost-conscious behavior and improve engagement in cost containment strategies.

 

 

93.10 Global Health in Surgery- A Platform for Learner-Faculty Growth: The West African Experience.

Posted on January 31, 2019

E. O. Abara1,2, N. O. Abara2,3, S. Osaghae2, E. O. Abara1,2  1Northern Ontario School of Medicine,Clinical Sciences,Sudbury-Thunder Bay, ONTARIO, Canada 2Richmond Hill Urology and Prostate Institute,Global Health And Outreach Program,Richmond Hill, ONTARIO, Canada 3University of Texas Medical Branch, Internal Medicine, Geriatrics, Galveston, TX, USA

 

Introduction : Since 2012, a group of surgical health professionals have undertaken an outreach to marginalized populations in West Africa aimed at ‘building capacity while providing service’. By 2014, residents have been encouraged to attend to gain experience and develop professionalism. We report the 2017  Burkina Faso experience.

Methods:  For seven days, health professionals from 8 countries functioned as a team. We worked at the Ouahigouya District Hospital. The program included: Out-patient assessments and Surgeries-pediatric, oncology, general surgery, otolaryngology, orthopedics, gynecology, and urology. Transfer of skills and tricks of the trade among peers; Faculty Case-based Learning and an interactive workshop for peers and learners; Learner-Learner exchange of ideas from their institutions – all provided stimuli for professional growth. The host provided accommodation, meals and local transportation. Participants cared for their travel arrangements.

Results: There were 6 ‘diaspora ’ and 8 local surgeons, 2 anesthetists and several nurse anesthetists, OR nurses and support staff. Three residents (from the Cameroons and Texas, USA) were present. There were 200 cases in all. Short-term outcomes were satisfactory. Long-term results will be necessary to validate the efforts.  The educational content of the outreach was described by most as transformative as the professionals shared knowledge and skill while patients received excellent collaborative care.

Conclusion: Short-term surgical outreach like this can be questioned as ineffective and unsustainable. However, the building of interdisciplinary, collaborative partnerships that are respectful and culturally sensitive is an asset. Our learners become winners and partners in global health for all.

 

89.20 Scrotal Hematoma with Pseudoaneurysm after Trans-Femoral Catheterization

Posted on January 31, 2019

S. Hung Fong1, S. Jaafar1, S. Misra1,2, V. Narasimha1  1Brandon Regional Hospital,GME – Surgery,Brandon, FL, USA 2HCA,West Florida,Tampa, FL, USA

Introduction:  Trans-femoral catheterization is a relative safe, minimally invasive procedure to assess coronary arteries and limb ischemia and subsequently revascularization with the placement of a stent or balloon angioplasty. However, complications can still manifest as bleeding, infection, hematoma, pseudoaneurysm, arteriovenous (AV) fistula formation and femoral artery thrombosis. In spite of appropriate use of vascular closing devices (VCD) and its lower rate of vascular complications as compared to manual compression, there have also been reported rare cases of scrotal hematoma following post trans-femoral catheterization for coronary intervention. We report a similar case of scrotal and right groin hematoma post trans-femoral vascular access, but for evaluation of limb ischemia.

Methods: A case report was described of a 72-year-old male who underwent transfemoral catheterization for evaluation of limb ischemia complicated by groin and scrotal hematoma that was successfully treated conservatively. Four different reported  cases were found on Pubmed, Google scholar and Cohchrane on scrotal hematoma associated with transfemoral access approach. Several characteristic were compared from each reported cases including sign and symptoms of hemorrhagic shock, history of use of anticoagulation, use of vascular closing device, whether mechanical compression was done, the injured vessel involved, the level of drop in hemoglobin and the mode of management. Our case report also included all of these characteristic for comparison with the other four reported cases

Results: Three out of four cases present with hemorrhagic shock, and reported use of VCD; two cases reported use of anticoagulation; the most common vessel injured is the common femoral artery; an average of 2 g/dL of hemoglobin lead to symptoms of hemorrhagic shock; three cases required groin exploration and one case managed conservatively.

Conclusion: Scrotal hematoma can present with or without signs of hemorrhagic shock. Symptoms most commonly present are groin and scrotal pain associated with swelling and ecchymosis. Scrotal hematoma is a rare complication, but the increasing popularity of transfemoral access approach lead to increase risk of urologic complications, warranting a urologic consultation and groin/genital exploration. Identifying those may be at high risk for this complication may prevent significant morbidity and mortality in these patients.

84.04 Does Baseline Performance Modify How Video Games Recalibrate Physician Heuristics in Trauma Triage?

Posted on January 31, 2019

S. S. Kulkarni1, M. R. Rosengart1, B. Fischhoff4, A. E. Barnato5, D. C. Angus2, D. M. Yealy3, D. J. Wallace2, D. Mohan2  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2University of Pittsburgh,Department Of Critical Care Medicine,Pittsburgh, PA, USA 3University of Pittsburgh,Department Of Emergency Medicine,Pittsburgh, PA, USA 4Carnegie Mellon University,College Of Engineering And Public Policy,Pittsburgh, PA, USA 5Dartmouth Medical School,The Dartmouth Institute For Health Policy And Clinical Practice,Lebanon, NH, USA

Introduction:  Up to 70% of severely-injured patients fail to receive care at a trauma center according to best practice guidelines (under-triage),in part, because of physicians’ reliance on poorly-calibrated heuristics (intuitive judgments). In prior work, we developed two video game interventions to recalibrate these heuristics, and, in clinical trials, found that game-based training improved performance on a series of detailed clinical simulations that evaluated triage decision-making. In this post-hoc secondary analysis, we evaluated how baseline triage practices might modify the effect of the interventions using the novel approach of assessing trial participants’ practice patterns in Medicare claims data.

Methods:  We obtained Medicare claims records from 2010 to 2015 to measure baseline physician triage practices prior to their participation in one of the two clinical trials conducted in 2016 and 2017. We categorized physicians as having received game-based training or being assigned to the control arm and estimated the proportion of severely-injured patients under-triaged by the two groups. We compared group-level baseline triage performance using the Mann-Whitney test. We then used multivariable models to assess for heterogeneity of the effect of game-based training between high and low baseline performers on triage decision-making in clinical simulations.

Results: Of the 374 eligible physicians from our trials, we identified 319 (85.3%) who had filed a claim for a Medicare fee-for-service beneficiary between 2010-2015. Their median age was 41 years (SD 9.0), 211 (66.1%) were male, and 212 (66.5%) were white. Physicians in both groups managed a similar number of severely-injured patients (median 5 vs. 4, p=0.75) prior to enrollment and both groups under-triaged a similar proportion of patients (mean 0.78 vs. 0.75, p = 0.52) indicating successful randomization. After adjusting for baseline triage performance, physicians who completed game-based training under-triaged 14.2% fewer patients (p = 0.005) in the simulations compared to the control group. The interaction between baseline performance and intervention effect was not significant (p = 0.86).

Conclusions: We used claims data to test the heterogeneity of the treatment effect of behavioral interventions designed to recalibrate physician heuristics. Video game-based training significantly improved under-triage independent of physicians’ baseline triage patterns. We did not find a large heterogeneity of treatment effect between high and low baseline performers.

 

84.03 What Makes a Good Surgical Coach?

Posted on January 31, 2019

K. Vande Walle1, S. Pavuluri Quamme1, D. Wiegmann2, H. Ghousseini3, J. Dimick4, C. Greenberg1  1University Of Wisconsin,Surgery,Madison, WI, USA 2University Of Wisconsin,Industrial And Systems Engineering,Madison, WI, USA 3University Of Wisconsin,Curriculum And Instruction,Madison, WI, USA 4University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  Surgical coaching programs have shown promise as a method for facilitating continuous professional development. However, there is currently no objective way to identify surgeons who will make effective coaches. The purpose of this study was to determine if the Myers-Briggs Type Indicator (MBTI)® and the Life Styles Inventory (LSI)™ can identify characteristics of effective surgical coaches.

Methods:  Surgeon coaches in the Wisconsin Surgical Coaching Program (WSCP) and Michigan Bariatric Surgery Collaborative (MBSC) coaching program were administered the MBTI and LSI. Coaching sessions were audio recorded and transcribed. An overall coach effectiveness score (1-5) for each session was generated by a minimum of 2 blinded raters using a validated tool. The four dichotomies of the MBTI (extraversion/introversion, sensing/intuition, thinking/feeling, judging/perceiving) were rated on a continuous scale. The 12 thinking styles of the LSI were grouped into 3 clusters: constructive passive/defensive, and aggressive/defensive. Cluster scores were calculated by averaging the 4 LSI style scores included in each cluster. A Pearson correlation coefficient was calculated between each MBTI dichotomy and LSI style/cluster with the overall coach effectiveness score.

Results: 18 coaches were included in the MBTI and 15 were included in the LSI analysis. 9/18 (50.0%) coaches preferred extraversion, 13/18 (72.2%) preferred sensing, 12/18 (66.7%) preferred thinking, and 12/18 (66.7%) preferred judging. The Pearson correlation coefficients for each MBTI dichotomy and overall coach effectiveness were < 0.4 and not statistically significant. The mean score on the LSI (out of 100) was 61.5 for constructive, 58.1 for passive/defensive, and 44.8 for aggressive/defensive. A higher LSI constructive score correlated with a higher overall coach effectiveness (r=0.59, p=0.02) while passive/defensive scores and aggressive/defensive scores did not correlate with overall coach effectiveness (r=-0.04, p=0.88; r=-0.01, p=0.98). The mean overall coach effectiveness scores for the highest and lowest LSI constructive score tertiles were 3.7 and 2.9, respectively. Two of the four styles in the constructive cluster also correlated with overall coach effectiveness (self-actualizing r=0.60, p=0.02; humanistic-encouraging r=0.58, p=0.02).

Conclusion: This is the first study to propose a quantifiable assessment to identify effective surgical coaches. A higher LSI constructive score correlated with an increase in overall coach effectiveness. This suggests the LSI constructive score may be used to identify the most effective surgical coaches and training to increase an individual’s constructive behaviors may lead to more effective coaching.

84.02 Probability of Failing to Meet Minimum Case Volumes in Pediatric Surgery Fellowship

Posted on January 31, 2019

D. J. Lucas1,2, E. Y. Huang1,2, A. Gosain1,2  1University Of Tennessee Health Science Center,Division Of Pediatric Surgery, Department Of Surgery,Memphis, TN, USA 2Children’s Foundation Research Institute, Le Bonheur Children’s Hospital,Division Of Pediatric Surgery,Memphis, TN, USA

Introduction:  The number of pediatric surgery fellowship programs has markedly increased since the early 2000’s, with approximately 45 fellows graduating per year currently. There is concern that this change has diluted the training experience, especially for complex or rare index cases. The Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) established minimum case numbers in defined categories in 2015, but this has been a program rather than an individual requirement. The American Board of Surgery (ABS) is considering enacting an individual requirement for minimum case volumes as a condition for board eligibility. The objective of this study was to determine the historical likelihood of pediatric surgery fellows failing to meet minimum RRC case requirements.

Methods:  The ACGME National Data Report summary case logs were obtained for graduating fellows in pediatric surgery from 2008-17. Median case volumes were compared to minimum ACGME RRC case numbers. Using Poisson distributions, probabilities of individual fellows failing to meet minimum case numbers were calculated.

Results: The probability that a fellow in a median program would fail to meet minimum case numbers in at least one category ranged from 11.7-36.2% over the 10 years, with no temporal trend (0.46% per year, 95% CI: -1.87% to 2.79%, p=0.661). Using the 10-year average of case medians, the probability was 18.4%. Individual case categories with the highest probability of being below median were pull-through for Hirschsprung disease (8.9%), biliary atresia/choledochal cyst (3.4%), head and neck (1.9%), and tracheoesophageal fistula/esophageal atresia (1.8%) (Table).

Conclusion: The probability that a graduating fellow in a program that possesses national median case volumes would fail to meet minimum numbers in at least one category is 18.4%. This probability is increased for the programs that are below the median. If the ABS defines individual case minimum requirements using similar case mix and volume metrics as the RRC, it is possible that a significant number of graduating pediatric surgery fellows will be adversely impacted by this new individual requirement.

 

84.01 Case Distributions in General Surgery Residency: Sub-Specialization Happens before Fellowship

Posted on January 31, 2019

A. R. Marcadis1, T. Spencer1, D. Sleeman1, O. C. Velazquez1, J. I. Lew1  1University Of Miami,DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:
In the current era of surgical sub-specialization and duty hour restrictions, many General Surgery (GS) residents desire additional training in their area of future specialty. This study examines the relationship between distribution of cases performed by GS residents during their 5 years of clinical residency training and their area of chosen future fellowship. 

Methods:

A retrospective review of Accreditation Council for Graduate Medical Education (ACGME) case logs from 101 graduated GS residents at a single academic institution (2002-2018) was performed. Area of fellowship specialization as well as total number of major / minor cases performed overall and in specific ACGME-defined categories were recorded for each resident. Average number of cases performed in each defined category were compared between groups of residents with differing areas of future fellowship specialization, using multiple t-test comparison. Only fellowship areas pursued by 3 or more residents during the study period were included in the analysis, and residents in accelerated specialty track programs (plastic, cardiothoracic, vascular) were excluded.

Results:

On average, surgical residents performed 1416 major and minor cases during their GS residency. Residents pursuing fellowships in cardiothoracic or thoracic surgery (n=8), endocrine surgery (n=5), surgical oncology (n=3), transplant surgery (n=3), trauma /critical care (n=21), and vascular surgery (n=8) performed significantly more thoracic (61 vs. 41; p<.001), endocrine (63 vs. 32; p<.001), biliary (135 vs. 108; p<.05), transplant (23 vs. 13; p<.05), trauma (83 vs. 71; p<.05), and vascular surgery (225 vs. 162; p<.001) cases respectively when compared to the program average. Residents pursuing fellowships in breast or colorectal surgery performed higher than the average (though non-statistically significant) number of cases in breast (94 vs. 78; p>.05) and anorectal /large intestinal (38 vs. 35/132 vs. 125; p>.05) surgery respectively when compared to peers. Residents who chose a career in GS (no fellowship) performed significantly more endoscopy cases (131 vs. 105; p<.05) compared to peers. Residents who chose fellowships in minimally invasive surgery (n=11), pediatric surgery (n=10), and plastic surgery (n=15) did not perform significantly more cases in any particular discipline compared to peers. 

Conclusion:

GS residents pursuing fellowships in many surgical sub-specialty disciplines are performing more cases than their peers in their respective areas of future specialization.  This may be the result of GS residents seeking additional focused training and preparation for fellowship, while still meeting ACGME defined category minimums and work-hour restrictions.

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.

 

82.10 A Fetal 3D Surgical Simulator of Minimally Invasive In Utero Gastroschisis Repair

Posted on January 31, 2019

E. H. Steen1, J. Fisher1,3, O. Olutoye1,3, J. Zaneveld4, N. Salas1, T. Lee1,3, S. Keswani1,3  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 4Lazarus 3D,Houston, TX, USA

Introduction: We have reported the clinical benefits of fetal minimally invasive surgery (MIS) in attenuating preterm labor, uterine morbidity, and subsequent C-sections – complications associated with open fetal surgery. Other non-lethal diseases may also benefit from fetal MIS, such as gastroschisis. 3D printing allows the creation of lifelike human models. The aim of this study is developing and validating a 3D fetal MIS model to test an in utero procedure for gastroschisis repair.

Methods: A 3D reconstruction of a uterus and fetus with gastroschisis (based on a mid-gestation fetal MRI) was optimized (3D Slicer) and rapidly prototyped using a next-gen Lazarus 3D printer. A four-step MIS procedure (evaluation of fetus, evaluation of bowel, reduction of bowel, coverage of defect) was designed and time-tested in three cohorts repeated in triplicate (fetal/neonatal surgeons, residents, and students, n=6/group). A ten question post-trial validation survey was administered to the participants. Data is presented as mean +/-SD, analysis by ANOVA, post-hoc Tukey HSD, p<0.05.

Results: All procedures were completed successfully (n=54). Operative time was significantly related to surgical training level (fetal/neonatal surgeons 125s+/-29s, residents 141s+/-30s, students 376s+/-107s; p<0.05) with sequential attempts yielding significant rates of improvement in all cohorts. All surgeons reported that the model 1) is an accurate tactile and visually representative model, 2) adequately assessed technical skills required for the procedure, and 3) would be a valuable training tool. The cost for this model was $68.69/trial and can be refurbished/reused for $200.

Conclusion:Our data supports construct, content, and face validity of a novel 3D fetal surgical simulator. This model is more cost effective than animal models in developing fetal techniques and seems to be more representative of the human disease. With the attenuation of maternal-fetal risk observed in fetal MIS, in utero therapies for gastroschisis may be considered.

 

82.09 Traditional versus Realistic Bleeding Control Training Models

Posted on January 31, 2019

M. Araujo1, F. Cai1, R. Lei1, E. E. Fox1, C. E. Wade1, S. D. Adams1  1McGovern Medical School at UTHealth,McGovern Medical School,Houston, TX, USA

Introduction: Uncontrolled bleeding is the main cause of preventable traumatic death and the arrival of first responders may be delayed due to safety concerns. The educational “Stop the Bleed” program was created to train non-medical bystanders with skills to control hemorrhagic wounds until first responders arrive, potentially saving lives. Prior studies found that 1-hour hands-on instruction an effective method to teach these techniques. We hypothesized that a realistic bleeding simulator would improve the quality and impact of this training.

Methods: Third year medical students (MS3) and non-medical summer students (NMS) underwent “Stop the Bleed” training. Each student was given an anonymous identifier to track results and was randomized into standard “DRY” model or realistic “WET“ bleeding simulator groups. After a didactic lecture by a certified instructor they each had hands-on training to pack wounds and place tourniquets.  Students completed pre and post surveys to evaluate baseline knowledge, teaching effectiveness, and willingness and preparedness to intervene to help a bleeding stranger.  They were observed placing a tourniquet and packing a wound, timed and evaluated on technique.  Statistical significance, set at p? 0.05, was analyzed using T-test and the Likert scale by Wilcoxon-signed ranked test.

Results: Students (n=360) were trained in bleeding control techniques (241 MS3, 119 NMS) and stratified between WET (n=171) and DRY models (n=189).  Results were excluded if unpaired or incomplete. While both groups demonstrated improved average correct of 5 knowledge questions after training (MS3 3.9 to 4.8, NMS 3.3 to 4.2) there was a significant difference in the NMS compared to the MS both before and after. Both groups had a similar and significant increase in willingness and preparedness to help a bleeding stranger after training, irrespective of the method. Compared to the DRY teaching model, students on the WET model needed more correction on technique and significantly more time for tourniquet placement (DRY: 50 sec, WET: 62 sec). For wound packing, however, students on the WET model were faster (DRY: 72 sec, WET: 62 sec), but this could be attributed to different packing spaces between the models.

Conclusions: Students receiving training in bleeding control techniques are confident and empowered to aid a bleeding victim irrespective of method. Students on the WET tourniquet model voiced anxiety due to the active “bleeding”, and were visibly fumbling, which may account for the longer time to placement.  This may be a better representation of the real world experience, and may help them overcome those anxieties to intervene while still in a training situation.

 

82.08 Deceased Organ Donors a Valuable Source of Surgical Experience for Residents and Medical Students

Posted on January 31, 2019

T. J. Hathaway1, R. S. Mangus1  1Indiana University School Of Medicine,Surgery / Transplant,Indianapolis, IN, USA

Introduction:
An increasing number of rules and regulations govern interactions between learners and patients in the clinical setting. This strict oversight limits the amount of hands-on training available to medical students and residents alike. This paradigm has resulted in increased use of procedural labs with “virtual” experience. A potential source of human subjects available for clinical practice are the thousands of organ donors each year who consent to use of their body for  education and research purposes. This study evaluates the potential surgical learning available from deceased organ donors with an intact cardiopulmonary system.

Methods:
The records of all deceased organ donors processed locally by the Indiana Donor Network over the last 18 months (Feb 2017-Aug 2018) were reviewed. Patient consent for research and education was documented. A list of proposed procedures was developed to predict the potential benefit of organ donors as a learning platform for medical students and residents. Limitations to this approach were identified.

Results:
During the study period, 242 of 255 (95%) donors consented for their bodies to be used for education purposes. A list of 27 potential procedures was developed. Simple procedures include endotracheal intubation, central venous catheter insertion, tube thoracostomy, and insertion other peripheral venous and arterial catheters. Complex procedures include more invasive and time consuming procedures such as splenectomy, prostatectomy, hysterectomy, bowel resection and anastomosis. Primary barriers to general adoption of this model for surgical education included extending time in the operating room, risks of contamination to transplant organs, additional cost of extra equipment, potential risks of travel to the donor hospital, and disfigurement of the donor body. After analysis of these factors, it was determined that a single learner could easily participate in 3-5 procedures per donor with implementation of a robust system and support from the attending surgeon. In the last 18 months at this center, 242 donors consented for use of their body for education purposes, suggesting 40-70 missed procedural opportunities per month. Approximately 90% of the available donations occurred in hospitals within a 30-minute drive of a medical education site in our state.

Conclusion:
Routine use of organ donors in the procedural education of medical students and residents could serve as a valuable resource throughout the world. The use of these opportunities will likely become more important as further limitations are placed on the clinical learning environment. In instituting this model, care must be taken to protect the donor and to be responsive to concerns from the donor’s family.
 

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