Faculty Bibliography

OBJECTIVE/UNASSIGNED:To investigate the number of safety net hospitals (SNHs) that have American College of Surgeons (ACS) accreditation for surgical programs. BACKGROUND/UNASSIGNED:SNHs provide healthcare to a substantial proportion of uninsured and underserved patient populations and rely heavily on public funding to sustain their operations. ACS accreditation emphasizes evidence-based care and standardization to improve patient outcomes. However, SNHs face financial and administrative barriers to ACS accreditation. METHODS/UNASSIGNED:We investigated the number of SNHs with ACS accreditation for specific programs by utilizing the publicly available listing of ACS-accredited programs and the listing of SNHs from the America's Essential Hospitals membership. We then performed a descriptive analysis of the number and geographic distribution of SNHs within the United States and the number of SNHs with ACS-accredited programs. RESULTS/UNASSIGNED:SNHs vary by regional disparities and demographic characteristics of respective states. Almost 20% of states are without access to SNHs. Most SNHs do not pursue ACS accreditation. Of 322 SNHs, 36% were accredited for cancer care (Commission on Cancer), 31% for trauma (Trauma Quality Improvement Program), 21% for bariatrics (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program), 13% for breast care (National Accreditation Program for Breast Centers), and 5% for rectal cancer (National Accreditation Program for Rectal Cancer). CONCLUSIONS/UNASSIGNED:ACS accreditation can benefit SNHs in improving guideline-concordant care for medically underserved patients and SNHs should be encouraged to attain ACS accreditation to improve access to and quality of care for vulnerable patient populations.

BACKGROUND:Existing research exploring predictors of success on American Board of Surgery (ABS) exams focused on either resident or residency program characteristics, but limited studies focus on both. This study examines relationships between both resident and program characteristics and ABS Qualifying (QE) and Certifying Exam (CE) outcomes. STUDY DESIGN/METHODS:Multilevel logistic regression was used to analyze the relationship between resident and program characteristics and ABS QE and CE 1st attempt pass and eventual certification. Resident characteristics were gender, IMG status, and prior performance, measured by 1st attempt USMLE Step 2 CK and Step 3 scaled scores. Program characteristics were size, %female, %International Medical Graduate (IMG), and program type. The sample included surgeons with QE and CE data from 2007-2019 and matched USMLE scores. RESULTS:Controlling for other variables, prior medical performance positively related to all ABS exam outcomes. The relationships between USMLE scores and success on ABS exams varied but were generally strong. Other resident characteristics that predicted ABS exam outcomes were gender and IMG (QE 1st attempt pass). The only program characteristic that significantly predicted ABS outcomes was %IMG (QE and CE 1st attempt pass). Despite statistical significance, gender, IMG, and %IMG translated to small differences in predicted probabilities of ABS exam success. CONCLUSION/CONCLUSIONS:This study highlights resident and program characteristics that predict success on ABS exams. USMLE scores consistently and strongly related to ABS exam success, providing evidence that USMLE scores relate to future high-stakes consequences like board certification. After controlling for prior performance, gender, IMG, and program %IMG significantly related to ABS exam success, but effects were small.

OBJECTIVE:As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes. SUMMARY BACKGROUND DATA/BACKGROUND:Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics and cardiovascular) and now entrustable professional activities (EPAs) as part of competency based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available. METHODS:Convened subcommittee discussions to determine needed focus for recommendations. RESULTS:Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students and residents in training. CONCLUSIONS:Changes in surgical training related to CBME offer opportunity for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training.

BACKGROUND:The need for evidence to inform interventions to prevent mass shootings (MS) in the USA has never been greater. METHODS:Data were abstracted from the Gun Violence Archive, an independent online database of US gun violence incidents. Descriptive analyses consisted of individual-level epidemiology of victims, suspected shooters and weapons involved, trends and county-level choropleths of population-level incident and fatality rates. Counties with and without state-level assault weapons bans (AWB) were compared, and we conducted a multivariable negative binomial model controlling for county-level social fragmentation, median age and number of gun-related homicides for the association of state-level AWB with aggregate county MS fatalities. RESULTS:73.3% (95% CI 72.1 to 74.5) of victims and 97.2% (95% CI 96.3 to 98.3) of shooters were males. When compared with incidents involving weapons labelled 'handguns', those involving a weapon labelled AR-15 or AK-47 were six times more likely to be associated with case-fatality rates greater than the median (OR=6.1, 95% CI 2.3 to 15.8, p<0.00001). MS incidents were significantly more likely to occur on weekends and during summer months. US counties in states without AWB had consistently higher MS rates throughout the study period (p<0.0001), and the slope for increase over time was significantly lower in counties with AWB (beta=-0.11, p=0.01). In a multivariable negative binomial model, counties in states with AWB were associated with a 41% lower incidence of MS fatalities (OR=0.58, 95% CI 0.37 to 0.97, p=0.02). CONCLUSIONS:Counties located in states with AWB were associated with fewer MS fatalities between 2014 and 2022.

Addressing disparities is crucial for enhancing population health, ensuring health security, and fostering resilient health systems. Disparities in acute care surgery (trauma, emergency general surgery, and surgical critical care) have been well documented and the magnitude of inequities demand an intentional, organized, and effective response. As part of its commitment to achieve high-quality, equitable care in all aspects of acute care surgery, the American Association for the Surgery of Trauma convened an expert panel at its eigty-second annual meeting in September 2023 to discuss how to take action to work towards health equity in acute care surgery practice. The panel discussion framed contemporary disparities in the context of historic and political injustices, then identified targets for interventions and potential action items in health system structure, health policy, the surgical workforce, institutional operations and quality efforts. We offer a four-pronged approach to address health inequities: identify, reduce, eliminate, and heal disparities, with the goal of building a healthcare system that achieves equity and justice for all.

OBJECTIVE:This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS:A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS:Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION:Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level III.

BACKGROUND:With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time. STUDY DESIGN:The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American. RESULTS:From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001). CONCLUSIONS:Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway.