Publications by authors named "Douglas S Smink"

103 Publications

Perspectives of US General Surgery Program Directors on Cultural and Fiscal Barriers to Maternity Leave and Postpartum Support During Surgical Training.

JAMA Surg 2021 May 19. Epub 2021 May 19.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Although pregnancy during surgical residency is increasingly common, studies of surgical residents have identified challenges associated with pregnancy and motherhood. These include perceptions of different maternity leave policies among institutions, lack of mentorship, stigma, and desire for greater lactation support.

Objective: To describe the perspective and experience of US surgical program directors regarding maternity leave and postpartum support for surgical residents.

Design, Setting, And Participants: This qualitative study included surgical program directors of US general surgery residency programs who were selected using purposive-stratified, criterion-based sampling. Transcripts were collected from semi-structured interviews, which were audio-recorded and transcribed verbatim, from October 21, 2018, to June 1, 2019.

Exposures: Maternity leave and postpartum support.

Main Outcomes And Measures: Perspectives of program directors regarding maternity leave and postpartum support were categorized into common themes identified using content analysis.

Results: A total of 40 US general surgical programs directors (28 [70.0%] male; mean [SD] age, 49.7 [6.8] years) were interviewed, of whom 36 (90.0%) were from university-based programs. All reported having maternity leave policies allowing a duration of leave of 6 weeks or longer. Analysis of program director interviews identified 5 themes: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of certain residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) resentment from coresidents who are asked to provide maternity leave coverage varies based on the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Complex interpersonal issues affected residents differently, including stigma, reluctance to change established surgical training patterns, and challenges with work-life balance.

Conclusions And Relevance: This qualitative study found that sociopolitical issues within surgical training culture and fiscal constraints created obstacles against program directors supporting pregnant residents. These findings suggest that a multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and efforts by leadership to enforce family priorities is needed to promote a surgical culture that normalizes pregnancy and motherhood during training.
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http://dx.doi.org/10.1001/jamasurg.2021.1807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135061PMC
May 2021

Burnout Phenotypes Among U.S. General Surgery Residents.

J Surg Educ 2021 Apr 29. Epub 2021 Apr 29.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Electronic address:

Objective: Although well-established metrics exist to measure workplace burnout, researchers disagree about how to categorize individuals based on assessed symptoms. Using a person-centered approach, this study identifies classes of burnout symptomatology in a large sample of general surgery residents in the United States.

Design, Setting, Participants: A survey was administered following the 2018 American Board of Surgery In-Training Examination (ABSITE) to study wellness among U.S. general surgery residents. Latent class models identified distinct classes of residents based on their responses to the emotional exhaustion and depersonalization questions of the modified abbreviated Maslach Burnout Inventory (aMBI). Classes were assigned representative names, and the characteristics of their members and residency programs were compared.

Results: The survey was completed by 7415 surgery residents from 263 residency programs nationwide (99.3% response rate). Five burnout classes were found: Burned Out (unfavorable score on all six items, 9.8% of total), Fully Engaged (favorable score on all six items, 23.1%), Fatigued (favorable on all items except frequent fatigue, 32.2%), Overextended (frequent fatigue and burnout from work, 16.7%), and Disengaged (weekly symptoms of fatigue and callousness, 18.1%). Within the more symptomatic classes (Burned Out, Overextended, and Disengaged), men manifested more depersonalization symptoms, whereas women reported more emotional exhaustion symptoms. Burned Out residents were characterized by reports of mistreatment (abuse, sexual harassment, and gender-, racial-, or pregnancy and/or childcare-based discrimination), duty hour violations, dissatisfaction with duty hour regulations or time for rest, and low ABSITE scores.

Conclusions: Burnout is multifaceted, with complex and variable presentations. Latent class modeling categorizes general surgery residents based on their burnout symptomatology. Organizations should tailor their efforts to address the unique manifestations of each class as well as shared drivers.
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http://dx.doi.org/10.1016/j.jsurg.2021.03.019DOI Listing
April 2021

Non-technical skill assessments across levels of US surgical training.

Surgery 2021 Apr 1. Epub 2021 Apr 1.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland. Electronic address:

Background: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool.

Methods: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression.

Results: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories.

Conclusion: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills.
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http://dx.doi.org/10.1016/j.surg.2021.02.058DOI Listing
April 2021

Surgeons, Go Find a Coach.

Ann Surg 2021 Jun;273(6):1040-1041

Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.1097/SLA.0000000000004856DOI Listing
June 2021

Nontechnical skills training in cardiothoracic surgery: A pilot study.

J Thorac Cardiovasc Surg 2021 Feb 4. Epub 2021 Feb 4.

Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, Calif. Electronic address:

Objective: The importance of nontechnical skills in surgery is widely recognized. We demonstrate the feasibility of administering and assessing the results of a formal Non-Technical Skills in Surgery (NOTSS) curriculum to cardiothoracic surgery residents.

Methods: Eight cardiothoracic surgery residents participated in the NOTSS curriculum. They were assessed on their cognitive (situation awareness, decision-making) and social (communication and teamwork, leadership) skills based on simulated vignettes. The residents underwent pretraining NOTSS assessments followed by self-administered confidence ratings regarding the 4 skills. Subsequently, a formal NOTSS lecture was delivered and additional readings from the NOTSS textbook was assigned. A month later, the residents returned for post-training NOTSS assessments and self-administered confidence ratings. Changes across days (or within-day before vs after curriculum) were assessed using Wilcoxon signed rank test.

Results: There was a significant improvement in the overall NOTSS assessment score (P = .01) as well as in the individual categories (situation awareness, P = .02; decision-making, P = .02; communication and teamwork, P = .01; leadership, P = .02). There was also an increase in resident self-perception of improvement on the post-training day (P = .01).

Conclusions: We have developed a simulation-based NOTSS curriculum in cardiothoracic surgery that can be formally integrated into the current residency education. This pilot study indicates the feasibility of reproducible assessments by course educators and self-assessments by participating residents in nontechnical skills competencies.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.108DOI Listing
February 2021

Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout.

Ann Surg 2021 Jul;274(1):6-11

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Objectives: To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents.

Background Summary Data: Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood.

Methods: Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression.

Results: Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment.

Conclusions: Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.
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http://dx.doi.org/10.1097/SLA.0000000000004796DOI Listing
July 2021

A multi-institutional study assessing general surgery faculty teaching evaluations.

Am J Surg 2020 Dec 25. Epub 2020 Dec 25.

Department of Surgery, University of Washington Medical Center, Seattle, WA, USA. Electronic address:

Background: Resident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists.

Study Design: Twenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful.

Results: Number of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest.

Conclusion: There was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.030DOI Listing
December 2020

Mentoring experience of new surgeons during their transition to independent practice: A nationwide survey.

Surgery 2021 Jun 28;169(6):1354-1360. Epub 2020 Dec 28.

Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address:

Background: New surgeons are faced with inadequate mentoring when first entering practice. Our study examined challenges faced by young surgeons during their transition in practice and their mentoring experience when entering practice.

Methods: An article-based survey was mailed in August 2019 to general, colorectal, vascular, and cardiothoracic surgeons that became members of the American College of Surgeons within the past 5 years.

Results: A total of 853 of 2,915 surveys were completed (29.3% response rate). Both female (38%) and male (62%) surgeons participated. The 3 most common challenges during the transition to practice were confidence building (26.0%), adjusting to a new institutional culture (16.9%), and business and administrative aspects of practice (16.3%). First job attrition rate 44.2%, with the mean duration of the first job being 3.28 ± 0.17 years. Nearly one-third (28.3%) of respondents were not mentored when they first entered practice. The proportion of nonmentored young surgeons leaving their first job (64.3%) was almost twice as that of surgeons who received mentoring (36.3%). Furthermore, the mean duration of the first job was significantly shorter in nonmentored versus mentored surgeons (3.16 ± 0.26 vs 3.76 ± 0.25 years; P < .05). A significant number (43.3%) of respondents reported a desire to be mentored by retired surgeons.

Conclusion: Our survey highlights the importance of mentoring for young surgeons during their transition into practice. With many young surgeons being enthusiastic about mentoring by retired surgeons, specific programs are necessary to better use their expertise.
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http://dx.doi.org/10.1016/j.surg.2020.11.044DOI Listing
June 2021

When not winning means losing: Underrepresentation of women surgeons in recognition awards at a single institution.

Am J Surg 2021 Jul 5;222(1):45-46. Epub 2020 Dec 5.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, 02115, USA.

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http://dx.doi.org/10.1016/j.amjsurg.2020.12.002DOI Listing
July 2021

Episodes of strain experienced in the operating room: impact of the type of surgery, the profession and the phase of the operation.

BMC Surg 2020 Dec 7;20(1):318. Epub 2020 Dec 7.

Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, USA.

Background: Strain episodes, defined as phases of higher workload, stress or negative emotions, occur everyday in the operating room (OR). Accurate knowledge of when strain is most intense for the different OR team members is imperative for developing appropriate interventions. The primary goal of the study was to investigate temporal patterns of strain across surgical phases for different professionals working in the OR, for different types of operations.

Methods: We developed a guided recall method to assess the experience of strain from the perspective of operating room (OR) team members. The guided recall was completed by surgeons, residents, anesthesiologists, circulating nurses and scrub technicians immediately after 113 operations, performed in 5 departments of one hospital in North America. We also conducted interviews with 16 surgeons on strain moments during their specific operation types. Strain experiences were related to surgical phases and compared across different operation types separately for each profession in the OR.

Results: We analyzed 693 guided recalls. General linear modeling (GLM) showed that strain varied across the phases of the operations (defined as before incision, first third, middle third and last third) [quadratic (F = 47.85, p < 0.001) and cubic (F = 8.94, p = 0.003) effects]. Phases of operations varied across professional groups [linear (F = 4.14, p = 0.001) and quadratic (F = 14.28, p < 0.001) effects] and surgery types [only cubic effects (F = 4.92, p = 0.001)]. Overall strain was similar across surgery types (F = 1.27, p = 0.28). Surgeons reported generally more strain episodes during the first and second third of the operations; except in vascular operations, where no phase was associated with significantly higher strain levels, and emergency/trauma surgery, where strain episodes occurred primarily during the first third of the operation. Other professional groups showed different strain time patterns.

Conclusions: Members of the OR teams experience strain differently across the phases of an operation. Thus, phases with high concentration requirements may highly vary across OR team members and no single phase of an operation can be defined as a "sterile cockpit" phase for all team members.
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http://dx.doi.org/10.1186/s12893-020-00937-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720529PMC
December 2020

Editorial.

J Surg Educ 2020 Nov - Dec;77(6):1325-1326. Epub 2020 Oct 22.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

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http://dx.doi.org/10.1016/j.jsurg.2020.08.032DOI Listing
October 2020

Optimizing the Implementation of Surgical Coaching Through Feedback From Practicing Surgeons.

JAMA Surg 2021 Jan;156(1):42-49

Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

Importance: Surgical coaching is maturing as a tangible strategy for surgeons' continuing professional development. Resources to spread this innovation are not yet widely available.

Objective: To identify surgeon-derived implementation recommendations for surgical coaching programs from participants' exit interviews and ratings of their coaching interactions.

Design, Setting, And Participants: This qualitative analysis of the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, a quality improvement intervention, was conducted at 4 US academic medical centers. Participants included 46 practicing surgeons. The SCOPE program ran from December 7, 2018, to October 31, 2019. Data were analyzed from November 1, 2019, to January 31, 2020.

Interventions: Surgeons were assigned as either a coach or a coachee, and each coach was paired with 1 coachee by a local champion who knew the surgeons professionally. Coaching pairs underwent training and were instructed to complete 3 coaching sessions-consisting of preoperative goal setting, intraoperative observation, and postoperative debriefing-focused on intraoperative performance.

Main Outcomes And Measures: Themes from the participants' exit interviews covering 3 major domains: (1) describing the experience, (2) coach-coachee relationship, and (3) facilitators and barriers to implementing surgical coaching. Surgeons' responses were stratified by the net promoter score (NPS), a scale ranging from 0 to 10 points, indicating how likely they were to recommend their coaching session to others, with 9 to 10 indicating promoters; 7 to 8, passives; and 0 to 6, detractors.

Results: Among the 46 participants (36 men [78.3%]), 23 were interviewed (50.0%); thematic saturation was reached with 5 coach-coachee pairs (10 interviews). Overall, coaches and coachees agreed on key implementation recommendations for surgical coaching, including how to optimize coach-coachee relationships and facilitate productive coaching sessions. The NPS categories were associated with how participants experienced their own coaching sessions. Specifically, participants who reported excellent first sessions, had a coaching partner in the same clinical specialty, and were transparent about each other's intentions in the program tended to be promoters. Participants who described suboptimal first sessions, less clinical overlap, and unclear goals with their partner were more likely detractors.

Conclusions And Relevance: These exit interviews with practicing surgeons offer critical insights for addressing cultural barriers and practical challenges for successful implementation of peer coaching programs focused on surgical performance improvement. With empirical evidence on optimizing coach-coachee relationships and facilitating participants' experience, organizations can establish effective coaching programs that enable meaningful continuous professional development for surgeons and ultimately enhance patient care.
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http://dx.doi.org/10.1001/jamasurg.2020.4581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557712PMC
January 2021

A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum.

J Surg Educ 2021 May-Jun;78(3):896-904. Epub 2020 Oct 9.

Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Objective: Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum.

Design, Setting, And Participants: Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method.

Results: Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors.

Conclusions: Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.
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http://dx.doi.org/10.1016/j.jsurg.2020.09.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026762PMC
October 2020

Gathering Validity Evidence to Adapt the Non-technical Skills for Surgeons (NOTSS) Assessment Tool to the United States Context.

J Surg Educ 2021 May-Jun;78(3):955-966. Epub 2020 Oct 9.

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Center for Surgery & Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context.

Study Design: A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion.

Results: A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected.

Conclusions: A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S.
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http://dx.doi.org/10.1016/j.jsurg.2020.09.010DOI Listing
October 2020

Gender Disparity in Awards in General Surgery Residency Programs.

JAMA Surg 2020 Sep 2. Epub 2020 Sep 2.

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Women are disproportionately underrecognized as award winners within medical societies. The presence of this disparity has not been investigated in training programs.

Objective: To determine the presence of a gender disparity in award winners in general surgery residency programs.

Design, Setting, And Participants: In this retrospective survey study, 32 geographically diverse academic and independent general surgery residency programs were solicited for participation. The 24 participating programs (75.0%) submitted deidentified data regarding the gender distribution of residents and trainee award recipients for the period from July 1, 1996, to June 30, 2017. Data were analyzed from September 11, 2017, to December 21, 2018.

Exposures: Time and the proportion of female trainees.

Main Outcomes And Measures: The primary outcome was the percentage of female award winners. A multilevel logistic regression model accounting for the percentage of female residents in each program compared the odds of a female resident winning an award relative to a male resident. This analysis was repeated for the first and second decades of the study. Award winners were further analyzed by type of award (clinical excellence, nonclinical excellence, teaching, or research) and selection group (medical students, residents, or faculty members).

Results: A total of 5030 of 13 760 resident person-years (36.6%) and 455 of 1447 award winners (31.4%) were female. Overall, female residents were significantly less likely to receive an award compared with male residents (odds ratio [OR], 0.44; 95% CI, 0.37-0.54; P < .001). During the first decade of the study, female residents were 70.8% less likely to receive an award compared with male residents (OR, 0.29; 95% CI, 0.19-0.45; P < .001); this improved to 49.9% less likely in the second decade (OR, 0.50; 95% CI, 0.42-0.61; P < .001). Female residents were less likely to receive an award for teaching (OR, 0.33; 95% CI, 0.26-0.42; P < .001), clinical excellence (OR, 0.44; 95% CI, 0.31-0.61; P < .001), or nonclinical excellence (OR, 0.69; 95% CI, 0.48-0.98; P = .04). No statistical difference was observed for research award winners (OR, 0.76; 95% CI, 0.42-1.12; P = .17). The largest discrepancies were observed when award recipients were chosen by residents (OR, 0.23; 95% CI, 0.14-0.39; P < .001) and students (OR, 0.32; 95% CI, 0.25-0.42; P < .001) compared with faculty members (OR, 0.52; 95% CI, 0.42-0.66; P < .001).

Conclusions And Relevance: This study found that female residents were significantly underrepresented as award recipients. These findings suggest the presence of ongoing implicit bias in surgery departments and training programs.
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http://dx.doi.org/10.1001/jamasurg.2020.3518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489428PMC
September 2020

Surgeons' Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program.

Ann Surg 2020 Jul 24. Epub 2020 Jul 24.

Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Objective: To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program.

Background: Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain.

Methods: Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills.

Results: For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent."

Conclusions: Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture.
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http://dx.doi.org/10.1097/SLA.0000000000004323DOI Listing
July 2020

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills.

J Surg Educ 2020 Nov - Dec;77(6):e138-e145. Epub 2020 Jul 30.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.

Purpose: Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills.

Methods: Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16.

Results: A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05).

Conclusions: At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.
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http://dx.doi.org/10.1016/j.jsurg.2020.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704898PMC
July 2020

Investigating Association Between Sex and Faculty Teaching Evaluation in General Surgery Residency Programs: A Multi-Institutional Study.

J Am Coll Surg 2020 09 10;231(3):309-315.e1. Epub 2020 Jul 10.

Department of Surgery, University of Washington Medical Center, Seattle, WA.

Background: In specialties with gender imbalance, such as general surgery, women faculty frequently receive lower teaching evaluation scores compared with men, which can affect academic advancement.

Study Design: We collected 1 year of anonymous resident-derived faculty teaching evaluations from 21 general surgery programs, along with resident, faculty, and department leadership gender complement. A composite evaluation score was calculated for each faculty. After accounting for within-program correlations, we compared male and female scores using the cluster-adjusted t-test to describe the respective mean differences with a 95% CI. Programs were divided into quartiles based on percent female faculty, female residents, and combined total females to detect associations between female representation and faculty teaching evaluation scores.

Results: The 21 programs yielded 20,187 teaching evaluations of 1,177 faculty. Women comprised 28% of the faculty, 47% of residents, 43% of program directors, and 19% of department chairs. Overall, women faculty had significantly higher evaluation scores than men (90.6% vs 89.5%, p < 0.05). Female gender was associated with higher teaching evaluation scores compared with male faculty in the lowest quartiles for all combinations of women representation.

Conclusions: This multi-institutional analysis of general surgical resident evaluations of faculty identified that female gender was associated with higher evaluation scores than men (although the difference was small). This unanticipated finding might reflect the slowly changing gender balance within general surgery and attitudes towards female faculty in a traditionally male-dominated field. Contrary to our hypothesis, female gender was associated with higher faculty evaluation scores at programs with fewer women faculty and fewer women residents.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.05.026DOI Listing
September 2020

Ad astra per aspera (Through Hardships to the Stars): Lessons Learned from the First National Virtual APDS Meeting, 2020.

J Surg Educ 2020 Nov - Dec;77(6):1465-1472. Epub 2020 Jul 6.

Department of Surgery, Warren Alport School of Medicine, Brown University, Providence, Rhode Island.

Objective: After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting.

Design: APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking.

Setting: The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming.

Participants: There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally.

Results: There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance.

Conclusions: A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.
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http://dx.doi.org/10.1016/j.jsurg.2020.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336917PMC
December 2020

Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons' practice.

Surg Endosc 2021 Jul 8;35(7):3829-3839. Epub 2020 Jul 8.

Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, 401 Park Drive, 3rd Floor West, Boston, MA, 02215, USA.

Background: Evidence for surgical coaching has yet to demonstrate an impact on surgeons' practice. We evaluated a surgical coaching program by analyzing quantitative and qualitative data on surgeons' intraoperative performance.

Methods: In the 2018-2019 Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 practicing surgeons in multiple specialties at four academic medical centers were recruited to complete three peer coaching sessions, each comprising preoperative goal-setting, intraoperative observation, and postoperative debriefing. Coach and coachee rated the coachee's performance using modified Objective Structured Assessment of Technical Skills (OSATS, range 1-5) and Non-Technical Skills for Surgeons (NOTSS, range 4-16). We used generalized estimating equations to evaluate trends in skill ratings over time, adjusting for case difficulty, clinical experience, and coaching role. Upon program completion, we analyzed semi-structured interviews with individual participants regarding the perceived impact of coaching on their practice.

Results: Eleven of 23 coachees (48%) completed three coaching sessions, three (13%) completed two sessions, and six (26%) completed one session. Adjusted mean OSATS ratings did not vary over three coaching sessions (4.39 vs 4.52 vs 4.44, respectively; P = 0.655). Adjusted mean total NOTSS ratings also did not vary over three coaching sessions (15.05 vs 15.50 vs 15.08, respectively; P = 0.529). Regarding patient care, participants self-reported improved teamwork skills, communication skills, and awareness in and outside the operating room. Participants acknowledged the potential for coaching to improve burnout due to reduced intraoperative stress and enhanced peer support but also the potential to worsen burnout by adding to chronic work overload.

Conclusions: Surgeons reported high perceived impact of peer coaching on patient care and surgeon well-being, although changes in coachees' technical and non-technical skills were not detected over three coaching sessions. While quantitative skill measurement warrants further study, longitudinal peer surgical coaching should be considered a meaningful strategy for surgeons' professional development.
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http://dx.doi.org/10.1007/s00464-020-07776-1DOI Listing
July 2021

Nontechnical Skill Countermeasures for Pandemic Response.

Ann Surg 2020 09;272(3):e213-e215

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1097/SLA.0000000000004107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467039PMC
September 2020

Concordance Between Expert and Nonexpert Ratings of Condensed Video-Based Trainee Operative Performance Assessment.

J Surg Educ 2020 May - Jun;77(3):627-634. Epub 2020 Mar 20.

Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Objective: We examined the impact of video editing and rater expertise in surgical resident evaluation on operative performance ratings of surgical trainees.

Design: Randomized independent review of intraoperative video.

Setting: Operative video was captured at a single, tertiary hospital in Boston, MA.

Participants: Six common general surgery procedures were video recorded of 6 attending-trainee dyads. Full-length and condensed versions (n = 12 videos) were then reviewed by 13 independent surgeon raters (5 evaluation experts, 8 nonexperts) using a crossed design. Trainee performance was rated using the Operative Performance Rating Scale, System for Improving and Measuring Procedural Learning (SIMPL) Performance scale, the Zwisch scale, and ten Cate scale. These ratings were then standardized before being compared using Bayesian mixed models with raters and videos treated as random effects.

Results: Editing had no effect on the Operative Performance Rating Scale Overall Performance (-0.10, p = 0.30), SIMPL Performance (0.13, p = 0.71), Zwisch (-0.12, p = 0.27), and ten Cate scale (-0.13, p = 0.29). Additionally, rater expertise (evaluation expert vs. nonexpert) had no effect on the same scales (-0.16 (p = 0.32), 0.18 (p = 0.74), 0.25 (p = 0.81), and 0.25 (p = 0.17).

Conclusions: There is little difference in operative performance assessment scores when raters use condensed videos or when raters who are not experts in surgical resident evaluation are used. Future validation studies of operative performance assessment scales may be facilitated by using nonexpert surgeon raters viewing videos condensed using a standardized protocol.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.016DOI Listing
March 2020

Underrepresented Minorities in General Surgery Residency: Analysis of Interviewed Applicants, Residents, and Core Teaching Faculty.

J Am Coll Surg 2020 07 7;231(1):54-58. Epub 2020 Mar 7.

Department of Surgery, Maine Medical Center, Portland, ME.

Background: The Accreditation Council for Graduate Medical Education (ACGME) requires diversity in residency. The self-identified race/ethnicities of general surgery applicants, residents, and core teaching faculty were assessed to evaluate underrepresented minority (URM) representation in surgery residency programs and to determine the impact of URM faculty and residents on URM applicants' selection for interview or match.

Study Design: Data from the 2018 application cycle were collated for 10 general surgery programs. Applicants without a self-identified race/ethnicity were excluded. URMs were defined as those identifying as black/African American, Hispanic/Latino/of Spanish origin, and American Indian/Alaskan Native/Native Hawaiian/Pacific Islander-Samoan. Statistical analyses included chi-square tests and a multivariate model.

Results: Ten surgery residency programs received 9,143 applications from 3,067 unique applicants. Applications from white, Asian, Hispanic/Latino, black/African American, and American Indian applicants constituted 66%, 19%, 8%, 7% and 1%, respectively, of those applications selected to interview and 66%, 13%, 11%, 8%, and 2%, respectively, of applications resulting in a match. Among programs' 272 core faculty and 318 current residents, 10% and 21%, respectively, were identified as URMs. As faculty diversity increased, there was no difference in selection to interview for URM (odds ratio [OR] 0.83; 95% CI 0.54 to 1.28, per 10% increase in faculty diversity) or non-URM applicants (OR 0.68; 95% CI 0.57 to 0.81). Similarly, greater URM representation among current residents did not affect the likelihood of being selected for an interview for URM (OR 1.20; 95%CI 0.90 to 1.61) vs non-URM applicants (OR 1.28; 95% CI 1.13 to 1.45). Current resident and faculty URM representation was correlated (r = 0.8; p = 0.005).

Conclusions: Programs with a greater proportion of URM core faculty or residents did not select a greater proportion of URM applicants for interview. However, core faculty and resident racial diversity were correlated. Recruitment of racially/ethnically diverse trainees and faculty will require ongoing analysis to develop effective recruitment strategies.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.02.042DOI Listing
July 2020

Performance Coaching for Practicing Surgeons Enhancing Clinical Performance, Well-Being, and Trainee Experience.

J Surg Educ 2020 May - Jun;77(3):495-498. Epub 2020 Feb 25.

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. School of Public Health, Boston, Massachusetts.

Performance coaching can help surgeons, hospitals, and healthcare systems to continually improve patient care delivery by enhancing surgeons' professional development. Equally important, coaching also has great potential to combat burnout, promote physician well-being, and subsequently improve trainee education and experience. In this article, we discuss the rationale for, early evidence for, and ways to address implementation barriers for performance coaching among practicing surgeons and surgical trainees.
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http://dx.doi.org/10.1016/j.jsurg.2020.01.014DOI Listing
February 2020

Allowing failure so trainees can thrive: the importance of guided autonomy in medical education.

BMJ Qual Saf 2020 09 21;29(9):704-705. Epub 2020 Feb 21.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA

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http://dx.doi.org/10.1136/bmjqs-2019-010673DOI Listing
September 2020

The eNOTSS Platform for Surgeons' Nontechnical Skills Performance Improvement.

JAMA Surg 2020 05;155(5):438-439

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2019.5880DOI Listing
May 2020

Implementing and Evaluating a Multihospital Standardized Opioid Curriculum for Surgical Providers.

J Surg Educ 2020 May - Jun;77(3):621-626. Epub 2020 Jan 14.

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts.

Objective: (1) To identify gaps in providers knowledge on opioid medication and dosing, patient-specific characteristics that require alterations in dosing, and patient monitoring and treatment adjustments. (2) To evaluate an educational intervention aimed at minimizing these deficits.

Design: Observational prospective study. Providers took an anonymous paired pre-and posteducation knowledge assessment before and after participating in a 75-minute educational session. Results before and after the educational session were compared.

Setting: Surgical providers included nurse practitioners, physician assistants, preinterns, and general surgery residents across 4 quaternary care hospitals in Boston. Participants There were 194 participants and 174 completed both pre- and posteducation knowledge assessments.

Results: Average scores on the educational assessment increased from 59% before the course to 68% after the session. Posteducation, providers reported increased comfort in prescribing and 95% stated that the curriculum would impact their practice.

Conclusions: Surgical providers at multiple hospitals have significant gaps in knowledge for optimal prescribing and management of opioid prescriptions. A 75-minute opioid education session increased prescriber knowledge as well as comfort in prescribing. This multicenter study demonstrates how an educational initiative can be implemented broadly and result in decreased knowledge gaps.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.012DOI Listing
January 2020

Medical Event Management for Future Deep Space Exploration Missions to Mars.

J Surg Res 2020 02 12;246:305-314. Epub 2019 Nov 12.

STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Harvard Medical School/Brigham and Women's Hospital, Boston, Massachusetts. Electronic address:

Background: Long-duration exploration missions (LDEMs), such as voyages to Mars, will present unique medical challenges for astronaut crews, including communication delays and the inability to return to Earth early. Medical events threaten crewmember lives and increase the risk of mission failure. Managing a range of potential medical events will require excellent technical and nontechnical skills (NTSs). We sought to identify medical events with potential for rescue, range them according to the potential impact on crew health and mission success during LDEMs, and develop a list of NTSs to train for management of in-flight medical events.

Materials And Methods: Twenty-eight subject matter experts with specializations in surgery, medicine, trauma, spaceflight operations, NTS training, simulation, human factors, and organizational psychology completed online surveys followed by a 2-d in-person workshop. They identified and rated medical events for survivability, mission impact, and impact of crewmember NTSs on outcomes in space.

Results: Sudden cardiac arrest, smoke inhalation, toxic exposure, seizure, and penetrating eye injury emerged as events with the highest potential mission impact, greatest potential for survival, and that required excellent NTS for successful management. Key NTS identified to target in training included information exchange, supporting behavior, communication delivery, and team leadership/followership.

Conclusions: With a planned Mars mission on the horizon, training countermeasures need to be developed in the next 3-5 y. These results may inform policy, selection, medical system design, and training scenarios for astronauts to manage in-flight medical events on LDEMs. Findings may extend to surgical and medical care in any rural and remote location.
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http://dx.doi.org/10.1016/j.jss.2019.09.065DOI Listing
February 2020

Identifying Naturalistic Coaching Behavior Among Practicing Surgeons in the Operating Room.

Ann Surg 2021 01;273(1):181-186

Department of Surgery, Brigham and Women's Hospital, Boston, MA.

Objective: The aim of this study was to identify examples of naturalistic coaching behavior among practicing surgeons operating together by analyzing their intraoperative discussion.

Background: Opportunities to improve surgical performance are limited for practicing surgeons; surgical coaching is one strategy to address this need. To develop peer coaching programs that integrate with surgical culture, a better understanding is needed of how surgeons routinely discuss operative performance.

Methods: As part of a "co-surgery" quality improvement program, 20 faculty surgeons were randomized into 10 dyads who performed an operation together. Discourse analysis was conducted on transcribed intraoperative discussions. Themes were coded using an existing framework of surgical coaching principles (self-identified goals, collaborative analysis, constructive feedback, peer learning support) and surgical coaching content (technical skills, nontechnical skills). Coaching principles were cross-referenced with coaching content; c-coefficient measured the strength of association between pairs of themes.

Results: Overall, 44 unique coaching examples were identified in 10 operations. Of the 4 principles of surgical coaching, only self-identified goals and collaborative analysis were identified consistently. Self-identified goals were most associated with discussions regarding technical skills of "tissue exposure," "flow of operation," and "instrument handling" and the nontechnical skill "situation awareness." Collaborative analysis was most associated with discussions regarding technical skills of "respect for tissue" and "flow of operation" and nontechnical skills of "communication and teamwork."

Conclusions: In naturalistic discussions between practicing surgeons in the operating room, numerous examples of unprompted coaching behavior were identified that target intraoperative performance. Prominent coaching gaps-constructive feedback and peer learning support-were also observed. Surgical coach trainings should address these gaps.
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http://dx.doi.org/10.1097/SLA.0000000000003368DOI Listing
January 2021

The effect of gender on operative autonomy in general surgery residents.

Surgery 2019 11 17;166(5):738-743. Epub 2019 Jul 17.

Department of Surgery, University of Michigan, Ann Arbor.

Background: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees.

Methods: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

Results: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training.

Conclusion: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.
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http://dx.doi.org/10.1016/j.surg.2019.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382913PMC
November 2019