Faculty Bibliography

BACKGROUND:Effective surgical education is key to resident professional and personal development. There is little literature defining or assessing effective surgical educators and no common definition of effectiveness in use. The opinion of surgical residents has never been qualitatively studied. Our aim was to determine what general surgery residents perceive as qualities of effective surgical educators. METHODS:A qualitative and quantitative study of general surgery senior residents (postgraduate year [PGY]-4 and -5) at a single tertiary academic institution was performed. In-depth semistructured interviews were conducted with all senior residents to determine the overall opinion of effective educators. Thematic analysis was performed using grounded theory. Participants completed a Likert-based survey to determine which qualities of an effective educator were (1) most critical and (2) had been most commonly encountered during training. Institutional review board approval was obtained. RESULTS:Data saturation occurred after 13 interviews (7 PGY-4, 6 PGY-5). Interviewees described attitudes, behaviors, and cognitions essential for effective surgical educators. They described important attributes of the trainee-trainer relationship and learning environment. On quantitative analysis, excellent communication, promoting a positive learning climate, timely constructive feedback, and technical expertise were ranked as most critical. Residents most often encountered educators with excellent communication, who fostered a positive learning climate, with clinical and technical expertise, and who provided leadership or mentorship. CONCLUSION:General surgery residents believe effective educators recognize the importance of communication and a positive learning environment, are able to adapt to the learner or environment, have clinical and technical expertise, and form a bond with their learner. This framework can inform faculty development programs to improve surgical education.

BACKGROUND:Surgical educator effectiveness is valued but lacks an operational definition. Clearly defining attributes consistent with effective surgical educators allows for the development of professional activities directed to nurture these qualities. Our aim was to identify the literature defining qualities of an effective surgical educator, and tools to measure effectiveness. METHODS:We searched PubMed, Medline, Scopus and Academic Search Complete for English language articles from 1 July 2009-1 July 2019. Two reviewers screened all abstracts for relevance and read full text of selected articles to identify included studies. Inclusion criteria were description/definition of an effective surgical educator or description of assessment/measurement of effectiveness in surgical educators. Data extracted included: study design, participants, definition/description of qualities of an effective surgical educator, qualitative or quantitative methods to assess surgical educators. RESULTS:Initial search identified 8086 articles. Of these, 2357 articles were excluded as duplicates and 5729 abstracts screened with 5638 excluded due to irrelevance. Full text review was performed for 91 articles to assess eligibility, 23 met inclusion criteria. The majority (74%) did not clearly define an effective surgical educator. Themes from six studies that determined important qualities include: communication, leadership skills, professionalism, respect, positive learning climate, and brief-intraoperative teaching-debrief model. One validated assessment tool was identified. CONCLUSIONS:There is little published work defining or assessing effective surgical educators. Establishment of a positive learning climate and excellent communication skills continue to be important qualities that define surgical educator effectiveness.

This study assesses the prevalence of bullying and barriers to its eradication among US surgeons.

BACKGROUND:The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures. MATERIALS AND METHODS:We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference. RESULTS:A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39). CONCLUSIONS:MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.

BACKGROUND:Both pre-operative anemia and perioperative (intra- and/or post-operative) blood transfusion have been reported to increase post-operative complications in patients with colon cancer undergoing colectomy. However, their joint effect has not been investigated. The purpose of this study was to evaluate the joint effect of pre-operative anemia and perioperative blood transfusion on the post-operative outcome of colon-cancer patients after colectomy. METHODS:We identified patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2006-2016 who underwent colectomy for colon cancer. Multivariate logistic regression analysis was employed to assess the independent and joint effects of anemia and blood transfusion on patient outcomes. RESULTS:0.001) than patients without anemia who did not receive a transfusion. CONCLUSIONS:Pre-operative anemia and perioperative transfusion are associated with an increased risk of post-operative complications and increased death rate in colon-cancer patients undergoing colectomy.

INTRODUCTION:Surgical cost is astronomical in the US and instrument standardization is one potential mechanism for cost savings. This study describes a core competency based, multidisciplinary curriculum and evaluates resident attitudes towards operating room equipment standardization. MATERIALS AND METHODS:As part of a quality improvement initiative, surgery residents participated in an hour-long mixed curriculum consisting of brief didactics and small group exercises. Participants developed an equipment standardization plan for laparoscopic appendectomy and cholecystectomy. Participants also completed surveys to assess their attitudes towards 11 potential barriers to implementation as "improves, no change, or worsens". RESULTS:Fifteen general surgery residents participated. In general, participants felt that standardization improves or does not change metrics including surgeon autonomy, resident training experience, and patient safety. CONCLUSION:Our pilot curriculum addresses a gap in resident education about surgical cost. Residents generally regard equipment standardization as either improving or not changing hospital metrics.

This cohort study evaluates the variables used to estimate the risk of mortality in patients at high risk to undergo surgery.

BACKGROUND:Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS:The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS:412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS:ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.

BACKGROUND:Bowel preparation before colectomy is considered an effective strategy to decrease postoperative complications. However, data regarding the effect of bowel preparation in patients undergoing minimally invasive colectomy are limited. The aim of this study was to investigate the role of different bowel preparation strategies in patients undergoing open, minimally invasive, and converted-to-open elective colectomies. METHODS:We identified 39,355 patients who underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database (2012-2016). Multivariate logistic regression models were used to assess the impact of different bowel preparation strategies on postoperative complications and mortality in three subapproach groups: open (n = 12,141), minimally invasive (n = 23,057), and converted to open (n = 4157). RESULTS:Overall, a total of 10,066 (25.6%) patients received no preparation (NP), 11,646 (29.5%) mechanical bowel preparation (MBP) alone, 1664 (4.2%) antibiotic bowel preparation (ABP) alone, and 15,979 (40.6%) MBP + ABP. Compared with NP, MBP + ABP showed the strongest protective effects. MBP + ABP was associated with reduced risk of major complications (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.55-0.66), infectious complications (OR = 0.50, 95% CI: 0.46-0.54), any complications (OR = 0.55, 95% CI: 0.51-0.60), 30-d mortality (OR = 0.68, 95% CI: 0.48-0.96), anastomotic leak (OR = 0.50, 95% CI: 0.43-0.58), and length of stay ≥ 4 d (OR = 0.64, 95% CI: 0.61-0.67) in overall population. These protective effects, except for 30-d mortality, were observed in open, minimally invasive, and converted-to-open groups. When the analysis was limited to robotic surgery only, MBP + ABP was only associated with reduced risk of major complications (OR = 0.61, 95% CI: 0.38-0.97) compared with NP. The protective effects remained similar over the study time period. CONCLUSIONS:MBP + ABP is a preferred preoperative strategy in open, minimally invasive, and converted-to-open colectomy.

BACKGROUND:Surgical futility is poorly defined. However, there are patients with extremely high preoperative risk who still undergo surgery and ultimately die, suggesting futile care. To further explore surgical futility, we examined the incidence and factors associated with extreme-risk patients undergoing major emergency general surgery with early death. METHODS:The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all adults undergoing colectomy, small bowel resection, control of bleeding ulcer, lysis of adhesion, and exploratory laparotomy between 2007 and 2015. Extreme-risk was defined as having an estimated mortality risk ≥75% using the National Surgical Quality Improvement Program mortality-risk calculator. Futile care was defined as extreme-risk patients who died within 48 hours of an operation. The incidence of, and clinical factors associated with, futile surgery were identified. RESULTS:Of 94,350 emergency general surgery patients, 1.9% were extreme-risk. Among extreme-risk patients, 30-day mortality was 71.2%; 31.6% of extreme-risk patients died within 48 hours, representing futile care. Only 5.5% of extreme-risk patients were discharged home. Patients who were >80 years (odds ratio [OR] 6.25 vs 40-64; 95% confidence interval [CI], 4.51-8.66), septic (OR 4.63; 95% CI, 3.38-6.34), or had a dependent functional status (OR 2.50 vs independent; 95% CI, 1.83-3.43]) had higher odds of having a futile operation. CONCLUSION:A significant number of emergency general surgery operations were on extreme-risk patients who suffered early death, which may indicate futile care. Surgeons face numerous conflicting pressures when asked to perform potentially futile surgery. Additional research in the decision-making process in these cases is needed to understand why surgeons operate in such dire circumstances and whether they should.