Publications by authors named "Ryan J Ellis"

49 Publications

National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being.

JAMA Netw Open 2021 Sep 1;4(9):e2123412. Epub 2021 Sep 1.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois.

Importance: Labor unions are purported to improve working conditions; however, little evidence exists regarding the effect of resident physician unions.

Objective: To evaluate the association of resident unions with well-being, educational environment, salary, and benefits among surgical residents in the US.

Design, Setting, And Participants: This national cross-sectional survey study was based on a survey administered in January 2019 after the American Board of Surgery In-Training Examination (ABSITE). Clinically active residents at all nonmilitary US general surgery residency programs accredited by the American Council of Graduate Medical Education who completed the 2019 ABSITE were eligible for participation. Data were analyzed from December 5, 2020, to March 16, 2021.

Exposures: Presence of a general surgery resident labor union. Rates of labor union coverage among non-health care employees within a region were used as an instrumental variable (IV) for the presence of a labor union at a residency program.

Main Outcomes And Measures: The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory and was defined as experiencing any symptom of depersonalization or emotional exhaustion at least weekly. Secondary outcomes included suicidality, measures of job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits.

Results: A total of 5701 residents at 285 programs completed the pertinent survey questions (response rate, 85.6%), of whom 3219 (56.5%) were male, 3779 (66.3%) were White individuals, 449 (7.9%) were of Hispanic ethnicity, 4239 (74.4%) were married or in a relationship, and 1304 (22.9%) had or were expecting children. Among respondents, 690 residents were from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized vs nonunionized programs (297 [43.0%] vs 2175 [43.4%]; odds ratio [OR], 0.92 [95% CI, 0.75-1.13]; IV difference in probability, 0.15 [95% CI, -0.11 to 0.42]). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits except that unionized programs more frequently offered 4 weeks instead of 2 to 3 weeks of vacation (27 [93.1%] vs 52 [30.6%]; OR, 19.18 [95% CI, 3.92-93.81]; IV difference in probability, 0.77 [95% CI, 0.09-1.45]) and more frequently offered housing stipends (10 [38.5%] vs 9 [16.1%]; OR, 2.15 [95% CI, 0.58-7.95]; IV difference in probability, 0.62 [95% CI 0.04-1.20]).

Conclusions And Relevance: In this evaluation of surgical residency programs in the US, unionized programs offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.23412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411294PMC
September 2021

Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US.

JAMA Surg 2021 Jul 28. Epub 2021 Jul 28.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Importance: Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents' experiences with gender discrimination and sexual harassment may inform solutions.

Objective: To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US.

Design, Setting, And Participants: This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible.

Exposures: Specific types, sources, and factors associated with gender-based discrimination and sexual harassment.

Main Outcomes And Measures: Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models.

Results: The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents).

Conclusions And Relevance: In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.
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http://dx.doi.org/10.1001/jamasurg.2021.3195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319819PMC
July 2021

National Evaluation of Surgical Resident Grit and the Association With Wellness Outcomes.

JAMA Surg 2021 Sep;156(9):856-863

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Importance: Grit, defined as perseverance and passion for long-term goals, is predictive of success and performance even among high-achieving individuals. Previous studies examining the effect of grit on attrition and wellness during surgical residency are limited by low response rates or single-institution analyses.

Objectives: To characterize grit among US general surgery residents and examine the association between resident grit and wellness outcomes.

Design, Setting, And Participants: A cross-sectional national survey study of 7464 clinically active general surgery residents in the US was administered in conjunction with the 2018 American Board of Surgery In-Training Examination and assessed grit, burnout, thoughts of attrition, and suicidal thoughts during the previous year. Multivariable logistic regression models were constructed to assess the association of grit with resident burnout, thoughts of attrition, and suicidal thoughts. Statistical analyses were performed from June 1 to August 15, 2019.

Exposures: Grit was measured using the 8-item Short Grit Scale (scores range from 1 [not at all gritty] to 5 [extremely gritty]).

Main Outcomes And Measures: The primary outcome was burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year.

Results: Among 7464 residents (7413 [99.3%] responded; 4469 men [60.2%]) from 262 general surgery residency programs, individual grit scores ranged from 1.13 to 5.00 points (mean [SD], 3.69 [0.58] points). Mean (SD) grit scores were significantly higher in women (3.72 [0.56] points), in residents in postgraduate training year 4 or 5 (3.72 [0.58] points), and in residents who were married (3.72 [0.57] points; all P ≤ .001), although the absolute magnitude of the differences was small. In adjusted analyses, residents with higher grit scores were significantly less likely to report duty hour violations (odds ratio [OR], 0.85; 95% CI, 0.77-0.93), dissatisfaction with becoming a surgeon (OR, 0.53; 95% CI, 0.48-0.59), burnout (OR, 0.53; 95% CI, 0.49-0.58), thoughts of attrition (OR, 0.61; 95% CI, 0.55-0.67), and suicidal thoughts (OR, 0.58; 95% CI, 0.47-0.71). Grit scores were not associated with American Board of Surgery In-Training Examination performance. For individual residency programs, mean program-level grit scores ranged from 3.18 to 4.09 points (mean [SD], 3.69 [0.13] points).

Conclusions And Relevance: In this national survey evaluation, higher grit scores were associated with a lower likelihood of burnout, thoughts of attrition, and suicidal thoughts among general surgery residents. Given that surgical resident grit scores are generally high and much remains unknown about how to employ grit measurement, grit is likely not an effective screening instrument to select residents; instead, institutions should ensure an organizational culture that promotes and supports trainees across this elevated range of grit scores.
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http://dx.doi.org/10.1001/jamasurg.2021.2378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246335PMC
September 2021

An evaluation of the nomina for death adders (Acanthophis Daudin, 1803) proposed by Wells amp; Wellington (1985), and confirmation of A. cryptamydros Maddock et al., 2015 as the valid name for the Kimberley death adder.

Zootaxa 2021 Jun 29;4995(1):161-172. Epub 2021 Jun 29.

Molecular Biology and Evolution at Bangor, School of Natural Sciences, Bangor University, Bangor, LL57 2UW, United Kingdom.

We assess the availability of four names proposed by Wells Wellington (1985) for Australian death adders (Acanthophis). In agreement with previous literature, A. hawkei is an available name, whereas A. armstrongi, A. lancasteri, and A. schistos are not described in conformity with the requirements of Articles 13.1.1 or 13.1.2 of the International Code of Zoological Nomenclature and are therefore considered nomina nuda. Consequently, A. cryptamydros Maddock et al., 2015, is confirmed as the valid name for the Kimberley death adder of Western Australia. We comment on the need for greater clarity in the Code, and emphasise that the responsibility for establishing the availability of new nomina rests with their authors, not subsequent researchers.
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http://dx.doi.org/10.11646/zootaxa.4995.1.9DOI Listing
June 2021

Underground Down Under: Skull anatomy of the southern blind snake Anilios australis Gray, 1845 (Typhlopidae: Serpentes: Squamata).

Anat Rec (Hoboken) 2021 Oct 24;304(10):2215-2242. Epub 2021 Jun 24.

Department of Biology and Center for Biodiversity and Ecosystem Stewardship, Villanova University, Villanova, Pennsylvania, USA.

The cranial anatomy of blindsnakes has been markedly understudied, with the small size and relative rarity of encountering these subterranean reptiles being significant limiting factors. In this article, we re-visit the skull anatomy of the Australian southern blind snake Anilios australis Gray, 1845 using microCT data, and produce the first complete atlas for the cranial anatomy of a representative of this speciose typhlopid genus. The skull is formed by 18 paired and four unpaired elements. We here produce a bone-by-bone description of each element as well as an inner ear endocast for each of two specimens differing in skull size. This approach has revealed the presence of a highly perforated dorsal plate on the septomaxilla-a structure convergent with the cribriform plate of the mammalian ethmoid bone-and a feature previously unknown for typhlopid snakes. This detailed anatomical study will facilitate ongoing taxonomic and systematic studies in the genus Anilios as well as provide comparative data for future studies on blindsnake anatomy more broadly.
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http://dx.doi.org/10.1002/ar.24696DOI Listing
October 2021

A return-on-investment approach for prioritization of rigorous taxonomic research needed to inform responses to the biodiversity crisis.

PLoS Biol 2021 06 1;19(6):e3001210. Epub 2021 Jun 1.

School of Biological Sciences, Monash University, Clayton, Australia.

Global biodiversity loss is a profound consequence of human activity. Disturbingly, biodiversity loss is greater than realized because of the unknown number of undocumented species. Conservation fundamentally relies on taxonomic recognition of species, but only a fraction of biodiversity is described. Here, we provide a new quantitative approach for prioritizing rigorous taxonomic research for conservation. We implement this approach in a highly diverse vertebrate group-Australian lizards and snakes. Of 870 species assessed, we identified 282 (32.4%) with taxonomic uncertainty, of which 17.6% likely comprise undescribed species of conservation concern. We identify 24 species in need of immediate taxonomic attention to facilitate conservation. Using a broadly applicable return-on-investment framework, we demonstrate the importance of prioritizing the fundamental work of identifying species before they are lost.
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http://dx.doi.org/10.1371/journal.pbio.3001210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168848PMC
June 2021

Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative.

J Trauma Acute Care Surg 2021 06;90(6):1048-1053

From the Department of Surgery (A.L.H., K.C.O., H.K.W., R.J.E., E.S.H., M.B.S., A.D.Y.), Feinberg School of Medicine, and Surgical Outcomes and Quality Improvement Center (R.J.E., A.D.Y.), Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Background: Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS.

Methods: Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests.

Results: Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009).

Conclusion: Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals.

Level Of Evidence: Care management, Level IV.
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http://dx.doi.org/10.1097/TA.0000000000003152DOI Listing
June 2021

A NSQIP-based randomized clinical trial evaluating choice of prophylactic antibiotics for pancreaticoduodenectomy.

J Surg Oncol 2021 May;123(6):1387-1394

Division of Hepatopancreatobiliary Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.

Surgical site infection after pancreaticoduodenectomy is often caused by pathogens resistant to standard prophylactic antibiotics, suggesting that broad-spectrum antibiotics may be more effective prophylactic agents. This article describes the rationale and methodology underlying a multicenter randomized trial evaluating piperacillin-tazobactam compared with cefoxitin for surgical site infection prevention following pancreaticoduodenectomy. As the first US randomized surgical trial to utilize a clinical registry for data collection, this study serves as proof of concept for registry-based clinical trials.
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http://dx.doi.org/10.1002/jso.26402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041048PMC
May 2021

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

Ann Surg 2021 07;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

Development and validation of a risk calculator for post-discharge venous thromboembolism following hepatectomy for malignancy.

HPB (Oxford) 2021 May 26;23(5):723-732. Epub 2020 Sep 26.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA.

Background: Post-discharge venous thromboembolism (VTE) chemoprophylaxis decreases VTEs following cancer surgery, however identifying high-risk patients remains difficult. Our objectives were to (1) identify factors available at hospital discharge associated with post-discharge VTE following hepatectomy for malignancy and (2) develop and validate a post-discharge VTE risk calculator to evaluate patient-specific risk.

Methods: Patients who underwent hepatectomy for malignancy from 2014 to 2017 were identified from the ACS NSQIP hepatectomy procedure targeted module. Multivariable logistic regression identified factors associated with post-discharge VTE. A post-discharge VTE risk calculator was constructed, and predicted probabilities of post-discharge VTE were calculated.

Results: Among 11 172 patients, 95 (0.9%) developed post-discharge VTE. Post-discharge VTE was associated with obese BMI (OR 2.29 vs. normal BMI [95%CI 1.31-3.99]), right hepatectomy/trisegmentectomy (OR 1.63 vs. partial/wedge [95%CI 1.04-2.57]), and several inpatient postoperative complications: renal insufficiency (OR 5.29 [95%CI 1.99-14.07]), transfusion (OR 1.77 [95%CI 1.12-2.80]), non-operative procedural intervention (OR 2.97 [95%CI 1.81-4.86]), and post-hepatectomy liver failure (OR 2.22 [95%CI 1.21-4.08]). Post-discharge VTE risk ranged from 0.3% to 30.2%. Twenty iterations of 10-fold cross validation identified internal validity.

Conclusions: Risk factors from all phases of care, including inpatient complications, are associated with post-discharge VTE following hepatectomy. Identifying high-risk patients may allow for personalized risk-based post-discharge chemoprophylaxis prescribing.
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http://dx.doi.org/10.1016/j.hpb.2020.09.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990740PMC
May 2021

Evaluating the Association of Multiple Burnout Definitions and Thresholds With Prevalence and Outcomes.

JAMA Surg 2020 11;155(11):1043-1049

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

Importance: Physician burnout is a serious issue, given its associations with physician attrition, mental and physical health, and self-reported medical errors. Burnout is typically measured in health care by assessing the frequency of symptoms in 2 domains, emotional exhaustion and depersonalization. However, the lack of a clinically diagnostic threshold to define burnout has led to considerable variability in reported burnout rates.

Objective: To estimate the prevalence of burnout using a range of definitions (ie, requiring symptoms in both domains or just 1) and thresholds (ie, requiring symptoms to occur weekly vs a few times per year) and examine the strength of the association of various definitions of burnout with suicidal thoughts and thoughts of attrition among general surgery residents.

Design, Setting, And Participants: A cross-sectional national survey of clinically active US general surgery residents administered in conjunction with the 2019 American Board of Surgery In-Training Examination assessed burnout symptoms, thoughts of attrition, and suicidal thoughts during the past year. Multivariable logistic regression models were used to assess the association of burnout symptoms with thoughts of attrition and suicidal thoughts. Values of R2 and C statistic were used to evaluate multivariable model performance.

Exposures: Burnout was evaluated with a 6-item, modified, abbreviated Maslach Burnout Inventory for 2 burnout domains: emotional exhaustion and depersonalization.

Main Outcomes And Measures: The primary outcome was prevalence of burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year.

Results: Among 6956 residents (a 85.6% response rate; including 3968 men [57.0%] and 4041 non-Hispanic White individuals [58.1%]) from 301 surgical residency programs, 2329 (38.6%) reported at least weekly symptoms of emotional exhaustion, and 1389 (23.1%) reported at least weekly depersonalization symptoms. Using the most common definition, 2607 general surgery residents (43.2%) reported weekly burnout symptoms on either subscale. Subtle changes in the definition of burnout selected resulted in prevalence estimates varying widely from 3.2% (159 residents; most stringent: daily symptoms on both subscales) to 91.4% (5521 residents; least stringent: symptoms a few times per year on either subscale). In multivariable models, all measures of higher burnout symptoms were associated with increased thoughts of attrition (depersonalization: R2, 0.097; C statistic, 0.717; emotional exhaustion: R2, 0.137; C statistic, 0.758; both: R2, 0.138; C statistic, 0.761) and suicidal thoughts (depersonalization: R2, 0.077; C statistic, 0.718; emotional exhaustion: R2, 0.102; C statistic, 0.750; both: R2, 0.106; C statistic, 0.751) among general surgery residents (all P < .001).

Conclusions And Relevance: In a national evaluation of general surgery residents, prevalence estimates of burnout varied considerably, depending on the burnout definition selected. Frequent burnout symptoms were strongly associated with both thoughts of attrition and suicide, regardless of the threshold selected. Future research on burnout should explicitly include a clear description and rationale for the burnout definition used.
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http://dx.doi.org/10.1001/jamasurg.2020.3351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489413PMC
November 2020

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout.

JAMA Surg 2020 09;155(9):851-859

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Importance: Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout.

Objectives: To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness.

Design, Setting, And Participants: This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education-approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018.

Main Outcomes And Measures: Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency.

Results: Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition.

Conclusions And Relevance: In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.
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http://dx.doi.org/10.1001/jamasurg.2020.2420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424543PMC
September 2020

Short-Term Risk of Performing Concurrent Procedures with Hepatic Artery Infusion Pump Placement.

Ann Surg Oncol 2020 Dec 1;27(13):5098-5106. Epub 2020 Aug 1.

Department of Surgery, Feinberg School of Medicine, Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL, USA.

Background: Hepatic artery infusion pump (HAIP) chemotherapy is an advanced cancer therapy for primary and secondary hepatic malignancies. The risk of concurrent hepatic and/or colorectal operations with HAIP placement is unknown. Our objective was to characterize the short-term outcomes of concurrent surgery with HAIP placement.

Methods: The 2005-2017 ACS NSQIP dataset was queried for patients undergoing hepatic and colorectal operations with or without HAIP placement. Outcomes were compared for HAIP placement with different combined procedures. Patients who underwent procedures without HAIP placement were propensity score matched with those with HAIP placement. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included infectious complications, wound complications, length of stay (LOS), and operative time.

Results: Of 467 patients who underwent HAIP placement, 83.9% had concurrent surgery. The rate of DSM was 10.7% for HAIP placement alone, 19.2% with concurrent minor hepatic procedures, 22.1% with concurrent colorectal resection, 23.2% with concurrent minor hepatic plus colorectal procedures, 28.4% with concurrent major hepatic resection, and 41.7% with concurrent major hepatic plus colorectal resection. On matched analyses, there was no difference in DSM, infectious, or wound complications for procedures with HAIP placement compared with the additional procedure alone, but operative time (294.7 vs 239.8 min, difference 54.9, 95% CI 42.8-67.0) and LOS (6 vs 5, IRR 1.20, 95% CI 1.08-1.33) were increased.

Conclusions: HAIP placement is not associated with additional morbidity when performed with hepatic and/or colorectal surgery. Decisions regarding HAIP placement should consider the risks of concurrent operations, and patient- and disease-specific factors.
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http://dx.doi.org/10.1245/s10434-020-08938-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746211PMC
December 2020

National Evaluation of Patient Preferences in Selecting Hospitals and Health Care Providers.

Med Care 2020 10;58(10):867-873

Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University.

Background: Patient utilization of public reporting has been suboptimal despite attempts to encourage use. Lack of utilization may be due to discordance between reported metrics and what patients want to know when making health care choices.

Objective: The objective of this study was to identify measures of quality that individuals want to be presented in public reporting and explore factors associated with researching health care.

Research Design: Patient interviews and focus groups were conducted to develop a survey exploring the relative importance of various health care measures.

Subjects: Interviews and focus groups conducted at local outpatient clinics. A survey administered nationally on an anonymous digital platform.

Measures: Likert scale responses were compared using tests of central tendency. Rank-order responses were compared using analysis of variance testing. Associations with binary outcomes were analyzed using multivariable logistic regression.

Results: Overall, 4672 responses were received (42.0% response rate). Census balancing yielded 2004 surveys for analysis. Measures identified as most important were hospital reputation (considered important by 61.9%), physician experience (51.5%), and primary care recommendations (43.2%). Unimportant factors included guideline adherence (17.6%) and hospital academic affiliation (13.3%, P<0.001 for all compared with most important factors). Morbidity and mortality outcome measures were not among the most important factors. Patients were unlikely to rank outcome measures as the most important factors in choosing health care providers, irrespective of age, sex, educational status, or income.

Conclusions: Patients valued hospital reputation, physician experience, and primary care recommendations while publicly reported metrics like patient outcomes were less important. Public quality reports contain information that patients perceive to be of relatively low value, which may contribute to low utilization.
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http://dx.doi.org/10.1097/MLR.0000000000001374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492361PMC
October 2020

A National Survey of Motor Vehicle Crashes Among General Surgery Residents.

Ann Surg 2020 Jun 4. Epub 2020 Jun 4.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Objectives: Evaluate the frequency of self-reported, post-call hazardous driving events in a national cohort of general surgery residents and determine the associations between duty hour policy violations, psychiatric well-being, and hazardous driving events.

Summary Of Background Data: MVCs are a leading cause of resident mortality. Extended work shifts and poor psychiatric well-being are risk factors for MVCs, placing general surgery residents at risk.

Methods: General surgery residents from US programs were surveyed after the 2017 American Board of Surgery In-Training Examination. Outcomes included self-reported nodding off while driving, near-miss MVCs, and MVCs. Group-adjusted cluster Chi-square and hierarchical regression models with program-level intercepts measured associations between resident- and program-level factors and outcomes.

Results: Among 7391 general surgery residents from 260 programs (response rate 99.3%), 34.7% reported nodding off while driving, 26.6% a near-miss MVC, and 5.0% an MVC over the preceding 6 months. More frequent 80-hour rule violations were associated with all hazardous driving events: nodding off while driving {59.8% with ≥5 months with violations vs 27.2% with 0, adjusted odds ratio (AOR) 2.86 [95% confidence interval (CI) 2.21-3.69]}, near-miss MVCs, [53.6% vs 19.2%, AOR 3.28 (95% CI 2.53-4.24)], and MVCs [14.0% vs 3.5%, AOR 2.46 (95% CI 1.65-3.67)]. Similarly, poor psychiatric well-being was associated with all 3 outcomes [eg, 8.0% with poor psychiatric well-being reported MVCs vs 2.6% without, odds ratio 2.55 (95% CI 2.00-3.24)].

Conclusions: Hazardous driving events are prevalent among general surgery residents and associated with frequent duty hour violations and poor psychiatric well-being. Greater adherence to duty hour standards and efforts to improve well-being may improve driving safety.
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http://dx.doi.org/10.1097/SLA.0000000000003729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747059PMC
June 2020

Association of Surgical Resident Wellness With Medical Errors and Patient Outcomes.

Ann Surg 2021 08;274(2):396-402

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

Objectives: The aims of this study were to: (1) measure the prevalence of self-reported medical error among general surgery trainees, (2) assess the association between general surgery resident wellness (ie, burnout and poor psychiatric well-being) and self-reported medical error, and (3) examine the association between program-level wellness and objectively measured patient outcomes.

Summary Of Background Data: Poor wellness is prevalent among surgical trainees but the impact on medical error and objective patient outcomes (eg, morbidity or mortality) is unclear as existing studies are limited to physician and patient self-report of events and errors, small cohorts, or examine few outcomes.

Methods: A cross-sectional survey was administered immediately following the January 2017 American Board of Surgery In-training Examination to clinically active general surgery residents to assess resident wellness and self-reported error. Postoperative patient outcomes were ascertained using a validated national clinical data registry. Associations were examined using multivariable logistic regression models.

Results: Over a 6-month period, 22.5% of residents reported committing a near miss medical error, and 6.9% reported committing a harmful medical error. Residents were more likely to report a harmful medical error if they reported frequent burnout symptoms [odds ratio 2.71 (95% confidence interval 2.16-3.41)] or poor psychiatric well-being [odds ratio 2.36 (95% confidence interval 1.92-2.90)]. However, there were no significant associations between program-level resident wellness and any of the independently, objectively measured postoperative American College of Surgeons National Surgical Quality improvement Program outcomes examined.

Conclusions: Although surgical residents with poor wellness were more likely to self-report a harmful medical error, there was not a higher rate of objectively reported outcomes for surgical patients treated at hospitals with higher rates of burnout or poor psychiatric well-being.
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http://dx.doi.org/10.1097/SLA.0000000000003909DOI Listing
August 2021

Hospital variation in use of prophylactic drains following hepatectomy.

HPB (Oxford) 2020 10 12;22(10):1471-1479. Epub 2020 Mar 12.

American College of Surgeons, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. Electronic address:

Background: Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use.

Methods: Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed.

Results: Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level.

Conclusion: Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.
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http://dx.doi.org/10.1016/j.hpb.2020.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8385641PMC
October 2020

Post Hepatectomy Liver Failure Risk Calculator for Preoperative and Early Postoperative Period Following Major Hepatectomy.

Ann Surg Oncol 2020 Aug 26;27(8):2868-2876. Epub 2020 Feb 26.

Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.

Background: Post hepatectomy liver failure (PHLF) is associated with significant perioperative morbidity and mortality. A tool to identify patients at risk for PHLF may allow for earlier intervention to mitigate its severity and help clinicians when counseling patients. Our objective was to develop a PHLF risk calculator.

Study Design: Patients who underwent hepatectomy for any indication from 2014 to 2017 were identified from ACS NSQIP. A multivariable logistic regression model was developed that included preoperative and intraoperative variables. Model fit was assessed for discrimination using the C-statistic, and calibration using Hosmer and Lemeshow (HL) Chi square. Validation of the calculator was performed utilizing tenfold cross validation.

Results: Among 15,636 hepatectomy patients analyzed, the overall incidence of clinically significant PHLF was 2.8%. Preoperative patient factors associated with increased PHLF were male gender, preoperative ascites within 30 days of surgery, higher ASA class, preoperative total bilirubin greater than 1.2 mg/dl, and AST greater than 40 units/l. Disease related factors associated with PHLF included histology, and use of neoadjuvant therapy. Intraoperative factors associated with PHLF were extent of resection, open surgical approach, abnormal liver texture, and biliary reconstruction. The calculator's C-statistic was 0.83 and the HL Chi square was 10.9 (p = 0.21) demonstrating excellent discrimination and calibration. On tenfold cross validation, the mean test group C-statistic was 0.82 and the HL p value was 0.26.

Conclusion: We present a multi-institutional preoperative and early postoperative PHLF risk calculator, which demonstrated excellent discrimination and calibration. This tool can be used to help identify high-risk patients to facilitate earlier interventions.
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http://dx.doi.org/10.1245/s10434-020-08239-6DOI Listing
August 2020

Crypsis and convergence: integrative taxonomic revision of the group (Squamata: Gekkonidae) from northern Australia.

PeerJ 2020 27;8:e7971. Epub 2020 Jan 27.

Division of Ecology and Evolution, Research School of Biology, and Centre for Biodiversity Analysis, Australian National University, Acton, ACT, Australia.

For over two decades, assessments of geographic variation in mtDNA and small numbers of nuclear loci have revealed morphologically similar, but genetically divergent, intraspecific lineages in lizards from around the world. Subsequent morphological analyses often find subtle corresponding diagnostic characters to support the distinctiveness of lineages, but occasionally do not. In recent years it has become increasingly possible to survey geographic variation by sequencing thousands of loci, enabling more rigorous assessment of species boundaries across morphologically similar lineages. Here we take this approach, adding new, geographically extensive SNP data to existing mtDNA and exon capture datasets for the and species complexes of gecko from northern Australia. The combination of exon-based phylogenetics with dense spatial sampling of mitochondrial DNA sequencing, SNP-based tests for introgression at lineage boundaries and newly-collected morphological evidence supports the recognition of nine species, six of which are newly described here. Detection of discrete genetic clusters using new SNP data was especially convincing where candidate taxa were continuously sampled across their distributions up to and across geographic boundaries with analyses revealing no admixture. Some species defined herein appear to be truly cryptic, showing little, if any, diagnostic morphological variation. As these SNP-based approaches are progressively applied, and with all due conservatism, we can expect to see a substantial improvement in our ability to delineate and name cryptic species, especially in taxa for which previous approaches have struggled to resolve taxonomic boundaries.
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http://dx.doi.org/10.7717/peerj.7971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991128PMC
January 2020

Mistreatment and Burnout in Surgical Residency Training. Reply.

N Engl J Med 2020 02;382(6):582-583

Northwestern University, Chicago, IL

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http://dx.doi.org/10.1056/NEJMc1915992DOI Listing
February 2020

Association between surgical approach and survival following resection of abdominopelvic malignancies.

J Surg Oncol 2020 Mar 22;121(4):620-629. Epub 2020 Jan 22.

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

Background And Objectives: Recent studies demonstrating decreased survival following minimally invasive surgery (MIS) for cervical cancer have generated concern regarding oncologic efficacy of MIS. Our objective was to evaluate the association between surgical approach and 5-year survival following resection of abdominopelvic malignancies.

Methods: Patients with stage I or II adenocarcinoma of the prostate, colon, rectum, and stage IA2 or IB1 cervical cancer from 2010-2015 were identified from the National Cancer Data Base. The association between surgical approach and 5-year survival was assessed using propensity-score-matched cohorts. Distributions were compared using logistic regression. Hazard ratio for death was estimated using Cox proportional-hazard models.

Results: The rate of deaths at 5 years was 3.4% following radical prostatectomy, 22.9% following colectomy, 18.6% following proctectomy, and 6.8% following radical hysterectomy. Open surgery was associated with worse survival following radical prostatectomy (HR, 1.18; 95% CI, 1.05-1.33; P = .005), colectomy (HR, 1.45; 95% CI, 1.39-1.51; P < .001), and proctectomy (HR, 1.28; 95% CI, 1.10-1.50; P = .002); however, open surgery was associated with improved survival following radical hysterectomy (HR, 0.61; 95% CI, 0.44-0.82; P = .003).

Conclusions: These results suggest that MIS is an acceptable approach in selected patients with prostate, colon, and rectal cancers, while concerns regarding MIS resection of cervical cancer appear warranted.
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http://dx.doi.org/10.1002/jso.25841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755029PMC
March 2020

Variation in Hospital Utilization of Minimally Invasive Distal Pancreatectomy for Localized Pancreatic Neoplasms.

J Gastrointest Surg 2020 12 25;24(12):2780-2788. Epub 2019 Nov 25.

Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA.

Background: Minimally invasive distal pancreatectomy (MIDP) for localized neoplasms has been demonstrated to be feasible and safe. However, national adoption of the technique is poorly understood. Objectives of this study were to identify factors associated with use of minimally invasive distal pancreatectomy for localized neoplasms and assess hospital variation in MIDP utilization.

Methods: Retrospective cohort study of patients with pancreatic cysts, stage I pancreatic ductal adenocarcinoma, and stage I pancreatic neuroendocrine tumors undergoing distal pancreatectomy from the ACS NSQIP Pancreas Targeted Dataset. Factors associated with use of MIDP were identified using multivariable logistic regression and hospital-level variation was assessed.

Results: Analysis included 3,059 patients at 139 hospitals. Overall, 64.5% of patients underwent minimally invasive distal pancreatectomy. Patients were more likely to undergo MIDP if they had lower ASA classification (P = 0.004) or BMI ≥ 30 (P < 0.001) and less likely if they had pancreatic adenocarcinoma (P < 0.001). There was notable hospital variability in utilization (range 0 to 100% of cases). Hospital-level utilization of minimally invasive distal pancreatectomy did not appear to be driven by patient selection, as hierarchical analysis demonstrated that only 1.8% of observed hospital variation was attributable to measured patient selection factors.

Conclusion: Utilization of MIDP for localized pancreatic neoplasms is highly variable. While some patient-level factors are associated with MIDP use, hospital adoption of MIDP appears to be the primary driver of utilization. Monitoring hospital-level use of MIDP may be a useful quality measure to monitor uptake of emerging techniques in pancreatic surgery.
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http://dx.doi.org/10.1007/s11605-019-04414-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747057PMC
December 2020

National Use of Chemotherapy in Initial Management of Stage I Pancreatic Cancer and Failure to Perform Subsequent Resection.

Ann Surg Oncol 2020 Mar 5;27(3):909-918. Epub 2019 Nov 5.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Introduction: Chemotherapy is increasingly administered prior to resection in patients with early-stage pancreatic adenocarcinoma, but the national prevalence of this practice is poorly understood. Our objectives were to (1) describe the utilization of upfront chemotherapy management of stage I pancreatic cancer; (2) define factors associated with the use of upfront chemotherapy and subsequent resection; and (3) assess hospital-level variability in upfront chemotherapy and subsequent resection.

Methods: The National Cancer Database was used to identify patients treated for clinical stage I pancreatic adenocarcinoma. Outcomes were receipt of upfront chemotherapy and surgical resection after upfront chemotherapy. Associations between patient/hospital factors and both initial management and subsequent resection were assessed by multivariable logistic regression.

Results: A total of 17,495 patients were included, with 26.6% receiving upfront chemotherapy. Upfront chemotherapy was more likely in patients who were ≥ 80 years of age (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.39-1.93), had T2 tumors (OR 2.56, 95% CI 2.36-2.78), or were treated at a low-volume center (OR 2.10, 95% CI 1.63-2.71). Among patients receiving upfront chemotherapy, only 33.5% underwent subsequent resection. Resection was more likely in patients with T1 tumors (OR 1.22, 95% CI 1.04-1.43) and in those treated at high-volume centers (OR 4.03, 95% CI 2.90-5.60). Only 20.4% of hospitals performed resection in > 50% of patients after upfront chemotherapy.

Conclusion: Rates of surgical resection after upfront chemotherapy are relatively low, and the proportion of patients who eventually undergo resection varies considerably between hospitals. The use of surgery after upfront chemotherapy in resectable pancreatic cancer should be considered as an internal quality-of-cancer-care measure.
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http://dx.doi.org/10.1245/s10434-019-08023-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004866PMC
March 2020

A comprehensive national survey on thoughts of leaving residency, alternative career paths, and reasons for staying in general surgery training.

Am J Surg 2020 02 25;219(2):227-232. Epub 2019 Oct 25.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. Electronic address:

Background: General surgery residencies continue to experience high levels of attrition.

Methods: Survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination. Outcomes were consideration of leaving residency, potential alternative career paths, and reasons for staying in residency.

Results: Among 7,409 residents, 930 (12.6%) reported considering leaving residency over the last year. Residents were more likely to consider other general surgery programs (46.2%) if PGY 2/3 (OR: 1.93, 95%CI 1.34-2.77) or reporting frequent duty hour violations (OR: 1.58, 95%CI 1.12-2.24). Consideration of other specialties (47.0%) was more likely if dissatisfied with being a surgeon (OR 2.86, 95%CI 1.92-4.26). Residents were more likely to consider leaving medicine (49.7%) if female (OR: 1.54, 95%CI 1.16-2.06) or dissatisfied with a surgical career (OR: 2.81, 95%CI 1.85-4.27). Common reasons for remaining in residency included a sense of too much invested to leave (65.3%) and career satisfaction (55.5%).

Conclusion: Profiles of trainees considering leaving residency exist based on factors associated with alternative careers. This may be a target for future interventions to reduce attrition.
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http://dx.doi.org/10.1016/j.amjsurg.2019.10.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7024040PMC
February 2020

Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training.

N Engl J Med 2019 10 28;381(18):1741-1752. Epub 2019 Oct 28.

From the Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern Medicine (Y.-Y.H., R.J.E., D.B. Hewitt, A.D.Y., K.Y.B.), the Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital (Y.-Y.H.), the American College of Surgeons (R.J.E., D.B. Hoyt, K.Y.B.), the Department of Medical Social Sciences, Northwestern University (E.O.C., J.T.M.), and the Accreditation Council for Graduate Medical Education (J.R.P., T.J.N.) - all in Chicago; and the Department of Surgery, Thomas Jefferson University Hospital (D.B. Hewitt), and the American Board of Surgery (J.B.) - both in Philadelphia.

Background: Physicians, particularly trainees and those in surgical subspecialties, are at risk for burnout. Mistreatment (i.e., discrimination, verbal or physical abuse, and sexual harassment) may contribute to burnout and suicidal thoughts.

Methods: A cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout (evaluated with the use of the modified Maslach Burnout Inventory), and suicidal thoughts during the past year. We used multivariable logistic-regression models to assess the association of mistreatment with burnout and suicidal thoughts. The survey asked residents to report their gender.

Results: Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, 31.9% reported discrimination based on their self-identified gender, 16.6% reported racial discrimination, 30.3% reported verbal or physical abuse (or both), and 10.3% reported sexual harassment. Rates of all mistreatment measures were higher among women; 65.1% of the women reported gender discrimination and 19.9% reported sexual harassment. Patients and patients' families were the most frequent sources of gender discrimination (as reported by 43.6% of residents) and racial discrimination (47.4%), whereas attending surgeons were the most frequent sources of sexual harassment (27.2%) and abuse (51.9%). Proportion of residents reporting mistreatment varied considerably among residency programs (e.g., ranging from 0 to 66.7% for verbal abuse). Weekly burnout symptoms were reported by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment at least a few times per month were more likely than residents with no reported mistreatment exposures to have symptoms of burnout (odds ratio, 2.94; 95% confidence interval [CI], 2.58 to 3.36) and suicidal thoughts (odds ratio, 3.07; 95% CI, 2.25 to 4.19). Although models that were not adjusted for mistreatment showed that women were more likely than men to report burnout symptoms (42.4% vs. 35.9%; odds ratio, 1.33; 95% CI, 1.20 to 1.48), the difference was no longer evident after the models were adjusted for mistreatment (odds ratio, 0.90; 95% CI, 0.80 to 1.00).

Conclusions: Mistreatment occurs frequently among general surgery residents, especially women, and is associated with burnout and suicidal thoughts.
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http://dx.doi.org/10.1056/NEJMsa1903759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907686PMC
October 2019

An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture.

Ann Surg 2019 10;270(4):585-592

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

Objectives: To empirically describe surgical residency program culture and assess program characteristics associated with program culture.

Summary Background Data: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture.

Methods: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed.

Results: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics.

Conclusions: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.
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http://dx.doi.org/10.1097/SLA.0000000000003545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896212PMC
October 2019

Post-operative complications and readmissions following outpatient elective Nissen fundoplication.

Surg Endosc 2020 05 6;34(5):2143-2148. Epub 2019 Aug 6.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA.

Introduction: Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests.

Results: Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325).

Conclusions: Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.
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http://dx.doi.org/10.1007/s00464-019-07020-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382912PMC
May 2020

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?

BMJ Qual Saf 2020 02 31;29(2):103-112. Epub 2019 Jul 31.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA

Background: Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy.

Methods: Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression.

Results: A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers.

Conclusions And Relevance: Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.
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http://dx.doi.org/10.1136/bmjqs-2019-009742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382916PMC
February 2020
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