Faculty Bibliography

BACKGROUND:The American Board of Surgery In-Training Exam is administered annually to general surgery residents and could provide a way to predict attrition, potentially offering a point of intervention. METHODS:In 2007, a national survey of categorical general surgery interns was performed. Resident characteristics were linked to an American Board of Surgery database of American Board of Surgery In-Training Exam scores. Attrition was determined based on completion of training during eight years of follow-up. To identify residents at risk of attrition, American Board of Surgery In-Training Exam scores were analyzed based on average rank and change in American Board of Surgery In-Training Exam score. RESULTS:Of 1,048 residents, 739 (70.5%) participated and 108 (14.6%) did not complete training. Average American Board of Surgery In-Training Exam rank was higher for participants who completed training than those who did not (51.8 vs. 42.7 percentile respectively, P < .001). Ranking below the 25th percentile was less common among those who dropped out (41.7% ranked below 25th percentile and dropped out versus 51.5% ranked below 25th percentile and completed, P = .06), but those whose rank dropped >16.5 percentile points were more likely to leave training (attrition rate 13.0% with a drop versus 6.0% without a drop, P = .003). In adjusted analysis, a one percentile increase in American Board of Surgery In-Training Exam rank was associated with decreased odds of attrition (OR 0.98, P < .01). CONCLUSION:Lower American Board of Surgery In-Training Exam scores are associated with attrition, but this difference is small, and some residents complete training with very low scores. A large drop in American Board of Surgery In-Training Exam scores from one year to the next appears to be associated with attrition. Program directors should focus their efforts on these at-risk residents.

Importance:Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency. Objective:To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency. Design, Setting, and Participants:This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016. Main Outcomes and Measures:Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency. Results:Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (n = 164). Attrition was highest in the first postgraduate year (67.6% [n = 111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; P = .04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; P = .01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; P = .05); at year 5, at large compared with small programs (26.0% vs 18.4%; P = .04). Race and program location were not associated with attrition. Conclusions and Relevance:Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.

INTRODUCTION:Hormone replacement therapy has been shown to reduce colorectal cancer incidence, but its effect on colorectal cancer mortality is controversial. The objective of this study was to determine the effect of hormone replacement therapy on survival from colorectal cancer. PATIENTS AND METHODS:We performed a secondary analysis of data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, a large multicenter randomized trial run from 1993 to 2001, with follow-up data recently becoming mature. Participants were women aged 55 to 74 years, without recent colonoscopy. Data from the trial were analyzed to evaluate colorectal cancer incidence, disease-specific mortality, and all-cause mortality based on subjects' use of hormone replacement therapy at the time of randomization: never, current, or former users. RESULTS:A total of 75,587 women with 912 (1.21%) incident colorectal cancers and 239 associated deaths were analyzed, with median follow-up of 11.9 years. Overall, 88.6% were non-Hispanic white, and < 10% had not completed high school. The never-user group was slightly older than the current or former user groups (average, 63.8 vs. 61.4 vs. 63.3 years; P < .001). Almost one-half (47.1%) of the current users had undergone hysterectomy, compared with 21.6% of never-users and 34.0% of former users (P < .001). Adjusted colorectal cancer incidence in current users compared to never-users was lower (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.69-0.94; P = .005), as was death from colorectal cancer (HR, 0.63; 95% CI, 0.47-0.85; P = .002) and all-cause mortality (HR, 0.76; 95% CI, 0.72-0.80; P < .001). CONCLUSIONS:Hormone replacement therapy is associated with a reduced risk of colorectal cancer incidence and improved colorectal cancer-specific survival, as well as all-cause mortality.

BACKGROUND:There is limited understanding of the wide variation in attrition rates among general surgery residencies. We used the validated Behavior Inhibitory System/Behavior Approach System (BIS/BAS) instrument to compare motivational traits among residents who did and not complete surgical training. STUDY DESIGN:All US general surgery categorical interns in the class of 2007-2008 were surveyed with a validated motivational trait assessment tool. American Board of Surgery records from 2008-2016 were used to determine who completed training. Motivation, an aspect of personality, was assessed with the BIS/BAS, which correlates with an individual's tendency to approach pleasant stimuli (BAS) or avoid negative stimuli (BIS). Subscale mean scores were compared with regard to the primary end point, attrition. RESULTS:Eight hundred and one (76.5%) interns completed the survey and had matching records. Six hundred and forty-five (80.5%) completed training. Men had lower scores than women in the BAS Drive subscale (12.0 vs 12.5; p < 0.002), BAS Reward Response subscale (17.2 vs 17.7; p < 0.01), and BIS scale (19.3 vs 20.9; p < 0.01). The BAS Reward Response scores differed based on program type (academic 17.3 vs community 17.6 vs military 16.6; p < 0.0027). There were no differences based on program size (BIS average, small program 19.9 vs large program 19.7; p = 0.43). There were also no differences in BIS/BAS subscale scores based on residency completion status (BIS mean: completed 19.9 vs dropped out 20.1; p = 0.51). CONCLUSIONS:Surgery residents are characterized by a strong drive and persistence toward their goals. However, residents who drop out do not differ from those who complete training in their motivational personality traits.

BACKGROUND:This study provides an updated description of diversity along the academic surgical pipeline to determine what progress has been made. METHODS:Data was extracted from a variety of publically available data sources to determine proportions of minorities in medical school, general surgery training, and academic surgery leadership. RESULTS:In 2014-2015, Blacks represented 12.4% of the U.S. population, but only 5.7% graduating medical students, 6.2% general surgery trainees, 3.8% assistant professors, 2.5% associate professors and 2.0% full professors. From 2005-2015, representation among Black associate professors has gotten worse (-0.07%/year, p < 0.01). Similarly, in 2014-2015, Hispanics represented 17.4% of the U.S. population but only 4.5% graduating medical students, 8.5% general surgery trainees, 5.0% assistant professors, 5.0% associate professors and 4.0% full professors. There has been modest improvement in Hispanic representation among general surgery trainees (0.2%/year, p < 0.01), associate (0.12%/year, p < 0.01) and full professors (0.13%/year, p < 0.01). CONCLUSION/CONCLUSIONS:Despite efforts to promote diversity in surgery, Blacks and Hispanics remain underrepresented. A multi-level national focus is imperative to elucidate effective mechanisms to make academic surgery more reflective of the US population.

Anal cancer is a rare condition, although its incidence has been increasing over the past several decades, particularly in women. The majority of anal cancers are squamous cell cancers and are linked with human papilloma virus (HPV) infection. Recent work in HPV basic science has delineated the mechanism by which the virus leads to the development of anal cancer. With widespread availability of an HPV vaccine since 2006, vaccination has become an important strategy for anal cancer prevention. However, in the US, there remain no guidelines for anal cancer screening. Treatment of anal cancer is dictated largely by accurate staging, which is generally accomplished with a combination of physical exam, magnetic resonance imaging, computed tomography, and positron emission tomography. Chemoradiation remains the mainstay of treatment for most patients, with surgery reserved for salvage therapy. Recent trials have identified the optimal use of available chemotherapeutics. Exciting developments in immune therapies targeting HPV oncoproteins as well as therapeutic vaccines may soon dramatically change the way patients with anal cancer are managed.

BACKGROUND:Mobile health technologies (mHealth) may improve post-operative care but it is unknown if patients are willing to use this technology. METHODS:We surveyed 800 NY State residents to determine their willingness to engage in mHealth after surgery and compared socioeconomic factors that may affect willingness to engage. RESULTS:A majority of respondents reported willingness to wear a tracker on their wrist (80.6%), fill out a survey (74.3%), send pictures of their wound to their surgeon (66.3%), and share updates with friends/family (59.1%). Older age was associated with lower likelihood of having a smartphone, but not associated with willingness to engage with other features. Hispanic ethnicity was associated with lower likelihood of wearing a tracker while Black race was associated with lower willingness to send pictures. CONCLUSIONS:Overall, potential users of mHealth are interested and willing to use mHealth. Older respondents are as willing as younger respondents to engage with mHealth. Individuals with Hispanic ethnicity and Black race may be less willing to engage and therefore may require education regarding benefits of this technology.

INTRODUCTION/BACKGROUND:Many surgical readmissions are preventable. Mobile health technology can identify nascent complications and potentially prevent readmission. METHODS:We performed a pilot study of a new mobile health application in adults undergoing major abdominal surgery. Patients reported their pain, answered surveys, photographed their wound, were reminded to stay hydrated, and used a Fitbit™ device. Abnormal responses triggered alerts for further evaluation. Patients were followed postoperatively for 30 days and compliance with app use was tracked. RESULTS:Thirty-one patients participated. Most were female (58%) and white (61%). Six (19%) had an ostomy as part of their surgery. 83.9% of patients completed an app-related task at least 70% of the time and 89% said using the app was easy to use. Patients generated an average of 1.1 alerts. One patient was readmitted and generated seven alerts prior to readmission. Patients participated most in collecting Fitbit data (84.8% of days) and completing a single-item photoaffective meter, but had more difficulty uploading photographs (51.4% completed). Eighty-nine percent of patients found the application easy to use. CONCLUSIONS:A novel mobile health app can track patient recovery from major abdominal surgery, is easy to use, and has potential to improve outcomes. Further studies using the app are planned.

BACKGROUND:Recently, mobile health technology has emerged as a promising avenue for improving physician-patient communication and patient outcomes. The objective of our study was to determine the public's perception of barriers and benefits to using mobile health technology technologies to enhance recovery after operation. METHODS:We used the Empire State Poll to ask 2 open-ended questions to 800 participants assessing their perceptions of benefits and barriers to use mobile health technology after operation. All responses were coded independently, and any discrepancies were resolved by consensus. We used grounded theory to allow themes to arise from the codes. Interrater reliability was calculated using Cohen's Kappa. RESULTS:Participants identified a range of possible barriers to using mobile health technology apps after operation including: protecting personal health information, technology effectiveness and failure, preference for face-to-face interaction with their surgeon, level of effort required, and ability of the older adults to navigate mobile health technology. Participants identified multiple possible benefits including: better monitoring, improved communication with their surgeon, minimizing follow-up visits, improved convenience, and increased patient knowledge. In the study, 15% of all respondents stated there were no barriers whereas 6% stated there were no benefits. CONCLUSION:Participants were receptive to the many potential benefits of this technology to enhance not only their relationships with providers and the convenience of access, but also their health outcomes. We must address participants concerns about data security and their fears of losing a personal relationship with their doctor.

Adherent cells are typically cultured on rigid substrates that are orders of magnitude stiffer than their tissue of origin. Here, we describe a method to rapidly fabricate 96 and 384 well platforms for routine screening of cells in tissue-relevant stiffness contexts. Briefly, polyacrylamide (PA) hydrogels are cast in glass-bottom plates, functionalized with collagen, and sterilized for cell culture. The Young's modulus of each substrate can be specified from 0.3 to 55 kPa, with collagen surface density held constant over the stiffness range. Using automated fluorescence microscopy, we captured the morphological variations of 7 cell types cultured across a physiological range of stiffness within a 384 well plate. We performed assays of cell number, proliferation, and apoptosis in 96 wells and resolved distinct profiles of cell growth as a function of stiffness among primary and immortalized cell lines. We found that the stiffness-dependent growth of normal human lung fibroblasts is largely invariant with collagen density, and that differences in their accumulation are amplified by increasing serum concentration. Further, we performed a screen of 18 bioactive small molecules and identified compounds with enhanced or reduced effects on soft versus rigid substrates, including blebbistatin, which abolished the suppression of lung fibroblast growth at 1 kPa. The ability to deploy PA gels in multiwell plates for high throughput analysis of cells in tissue-relevant environments opens new opportunities for the discovery of cellular responses that operate in specific stiffness regimes.