Publications by authors named "Sophia K McKinley"

44 Publications

Challenges of virtual interviewing for surgical fellowships: a qualitative analysis of applicant experiences.

Surg Endosc 2021 Aug 27. Epub 2021 Aug 27.

Department of Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.

Background: The COVID-19 pandemic forced surgical fellowship programs to transition from in-person to remote applicant interviews; the virtual interviewing format presented new and unique challenges. We sought to understand applicants' perceived challenges to virtual interviewing for a surgical fellowship program.

Method: A grounded theory-based qualitative study was performed utilizing semi-structured interviews with fellowship applicants from the 2020 fellowship match. All Fellowship Council-registered applicants were eligible. We purposefully sampled participants to balance across gender, specialty-choice, and academic versus community-program affiliation. Interviews were inductively analyzed by two researchers for prominent themes.

Results: Fifteen interviews were conducted. Participants were 60% male (n = 9), with 33% (n = 5) from non-academic institutions. They applied for the following fellowships: Advanced Gastrointestinal/Minimal Invasive (55%), Bariatric (30%), Hepatopancreatobiliary (10%) and Surgical Oncology (5%). Four main themes emerged to describe virtual interview process challenges: (1) perceived data deficiency, (2) superficial personal connections, (3) magnification of non-professionalism, and (4) logistical frustrations. Applicants recommend program directors provide more information about the fellowship prior to interview day and offer informal independent interactions with current and previous fellows.

Conclusions: According to fellowship applicants, virtual interviews resulted in a lack of information for rank-list decision making ultimately requiring them to rely on other information avenues to base their decisions. These applicants have offered advice to fellowship program directors and future applicants to better optimize this process.
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http://dx.doi.org/10.1007/s00464-021-08691-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8393782PMC
August 2021

Evaluating and Comparing Emotional Intelligence and Improvement Mindset of Plastic Surgery Residents.

J Surg Res 2021 Aug 13. Epub 2021 Aug 13.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 506, Boston, Massachusetts 02114.

Background: Emotional Intelligence (EI) has been linked to burnout, job satisfaction, and work performance among resident physicians. Individuals with a growth mindset believe intelligence and ability are traits that can be increased or improved upon through learning. EI and mindset have yet to be studied among plastic surgeons in the United States.

Materials And Methods: An online survey was distributed to plastic surgery residents and general surgery residents at a single institution containing a validated EI survey tool (TEIQue-SF). Second, a survey was sent to all plastic surgery residents in the United States containing the TEIQue-SF and a validated survey tool to assess mindset (ITIS).

Results: The response rate for the local study was 82% (plastic surgery) and 75% (general surgery). Only 7.8% of plastic surgery residents had any prior formal EI training or education. Mean global EI scores of local plastic surgery residents were higher than the normative population sample (P <0.0001). Plastic surgery and general surgery residents had similar EI scores. Integrated residents and junior plastic surgery residents had higher Well-Being scores compared to independent (P = 0.04) and senior residents (P = 0.04). Sixty-four plastic surgery residents completed the national survey. No correlation was found between EI and ITIS scores among the national plastic surgery resident cohort.

Conclusion: Despite different work profiles, general surgery and plastic surgery residents may have similar EI profiles. Mindset does not appear to correlate to EI domains. Future studies will focus on how EI and mindset may develop over the course of residency training and their relationship to overall resident wellness.
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http://dx.doi.org/10.1016/j.jss.2021.06.061DOI Listing
August 2021

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Surg Endosc 2021 09 19;35(9):4903-4917. Epub 2021 Jul 19.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08625-5DOI Listing
September 2021

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education.

J Surg Educ 2021 Jun 3. Epub 2021 Jun 3.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Objective: A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence.

Design: Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks.

Setting: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program.

Participants: Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation.

Results: 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05).

Conclusion: Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.
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http://dx.doi.org/10.1016/j.jsurg.2021.04.003DOI Listing
June 2021

Disease Spectrum of Breast Cancer Susceptibility Genes.

Front Oncol 2021 20;11:663419. Epub 2021 Apr 20.

Division of Surgical Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.

Background: Pathogenic variants in cancer susceptibility genes can increase the risk of a spectrum of diseases, which clinicians must manage for their patients. We evaluated the disease spectrum of breast cancer susceptibility genes (BCSGs) with the aim of developing a comprehensive resource of gene-disease associations for clinicians.

Methods: Twelve genes (, and ), all of which have been conclusively established as BCSGs by the Clinical Genome Resource (ClinGen) and/or the NCCN guidelines, were investigated. The potential gene-disease associations for these 12 genes were verified and evaluated based on six genetic resources (ClinGen, NCCN, OMIM, Genetics Home Reference, GeneCards, and Gene-NCBI) and an additional literature review using a semiautomated natural language processing (NLP) abstract classification procedure.

Results: Forty-two diseases were found to be associated with one or more of the 12 BCSGs for a total of 86 gene-disease associations, of which 90% (78/86) were verified by ClinGen and/or NCCN. Four gene-disease associations could not be verified by either ClinGen or NCCN but were verified by at least three of the other four genetic resources. Four gene-disease associations were verified by the NLP procedure alone.

Conclusion: This study is unique in that it systematically investigates the reported disease spectrum of BCSGs by surveying multiple genetic resources and the literature with the aim of developing a single consolidated, comprehensive resource for clinicians. This innovative approach provides a general guide for evaluating gene-disease associations for BCSGs, potentially improving the clinical management of at-risk individuals.
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http://dx.doi.org/10.3389/fonc.2021.663419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093501PMC
April 2021

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials.

J Surg Res 2021 08 13;264:510-533. Epub 2021 Apr 13.

Harvard Medical School, General and Endocrine Surgery, Massachusetts General Hospital, Boston, MA.

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.
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http://dx.doi.org/10.1016/j.jss.2021.02.024DOI Listing
August 2021

Disease spectrum of gastric cancer susceptibility genes.

Med Oncol 2021 Mar 24;38(5):46. Epub 2021 Mar 24.

Division of Surgical Oncology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Yawkey 7, Boston, MA, 02114, USA.

Pathogenic variants in germline cancer susceptibility genes can increase the risk of a large number of diseases. Our study aims to assess the disease spectrum of gastric cancer susceptibility genes and to develop a comprehensive resource of gene-disease associations for clinicians. Twenty-seven potential germline gastric cancer susceptibility genes were identified from three review articles and from six commonly used genetic information resources. The diseases associated with each gene were evaluated via a semi-structured review of six genetic resources and an additional literature review using a natural language processing (NLP)-based procedure. Out of 27 candidate genes, 13 were identified as gastric cancer susceptibility genes (APC, ATM, BMPR1A, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH-Biallelic, PALB2, SMAD4, and STK11). A total of 145 gene-disease associations (with 45 unique diseases) were found to be associated with these 13 genes. Other gastrointestinal cancers were prominent among identified associations, with 11 of 13 gastric cancer susceptibility genes also associated with colorectal cancer, eight genes associated with pancreatic cancer, and seven genes associated with small intestine cancer. Gastric cancer susceptibility genes are frequently associated with other diseases as well as gastric cancer, with potential implications for how carriers of these genes are screened and managed. Unfortunately, commonly used genetic resources provide heterogeneous information with regard to these genes and their associated diseases, highlighting the importance of developing guides for clinicians that integrate data across available resources and the medical literature.
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http://dx.doi.org/10.1007/s12032-021-01495-wDOI Listing
March 2021

Non-medullary Thyroid Cancer Susceptibility Genes: Evidence and Disease Spectrum.

Ann Surg Oncol 2021 Oct 3;28(11):6590-6600. Epub 2021 Mar 3.

Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.

Background: The prevalence of non-medullary thyroid cancer (NMTC) is increasing worldwide. Although most NMTCs grow slowly, conventional therapies are less effective in advanced tumors. Approximately 5-15% of NMTCs have a significant germline genetic component. Awareness of the NMTC susceptibility genes may lead to earlier diagnosis and better cancer prevention.

Objective: The aim of this study was to provide the current panorama of susceptibility genes associated with NMTC and the spectrum of diseases associated with these genes.

Methods: Twenty-five candidate genes were identified by searching for relevant studies in PubMed. Each candidate gene was carefully checked using six authoritative genetic resources: ClinGen, National Comprehensive Cancer Network guidelines, Online Mendelian Inheritance in Man, Genetics Home Reference, GeneCards, and Gene-NCBI, and a validated natural language processing (NLP)-based literature review protocol was used to further assess gene-disease associations where there was ambiguity.

Results: Among 25 candidate genes, 10 (APC, DICER1, FOXE1, HABP2, NKX2-1, PRKAR1A, PTEN, SDHB, SDHD, and SRGAP1) were verified among the six genetic resources. Two additional genes, CHEK2 and SEC23B, were verified using the NLP protocol. Seventy-nine diseases were found to be associated with these 12 NMTC susceptibility genes. The following diseases were associated with more than one NMTC susceptibility gene: colorectal cancer, breast cancer, gastric cancer, kidney cancer, gastrointestinal stromal tumor, paraganglioma, pheochromocytoma, and benign skin conditions.

Conclusion: Twelve genes predisposing to NMTC and their associated disease spectra were identified and verified. Clinicians should be aware that patients with certain pathogenic variants may require more aggressive surveillance beyond their thyroid cancer risk.
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http://dx.doi.org/10.1245/s10434-021-09745-xDOI Listing
October 2021

A Needs Assessment of Video-based Education Resources Among General Surgery Residents.

J Surg Res 2021 07 27;263:116-123. Epub 2021 Feb 27.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Background: Video-based education (VBE) is an effective tool for knowledge and skill acquisition for medical students, but its utility is less clear for resident physicians. We sought to determine how to incorporate VBE into a general surgery resident operative curriculum.

Methods: We conducted a single-institution, survey-based needs assessment of general surgery residents to determine desired content and format of an operative VBE module.

Results: The response rate was 84% (53/63), with 66% senior (postgraduate year ≥3) resident respondents. VBE was the most commonly cited resource that residents used to prepare for an operation (93%) compared with surgical textbooks (89%) and text-based website content (57%). Junior residents were more likely to utilize text-based website content than senior residents (P < 0.01). The three most important operative video components were accuracy, length, and cost. Senior residents significantly preferred videos that were peer-reviewed (P < 0.05) and featured attending surgeons whom they knew (P = 0.03). A majority of residents (59%) believed 5-10 min is the ideal length of an operative video. Across all postgraduate year levels, residents indicated that detailed instruction of each operative step was the most important content of a VBE module. Senior residents believed that the overall indications and details of each step of the operation were the most important contents of VBE for a junior resident.

Conclusions: At this institution, general surgery residents preferentially use VBE resources for operative preparation. A centralized, standardized operative resource would likely improve resident studying efficiency, but would require personalized learning options to work for both junior and senior surgery residents.
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http://dx.doi.org/10.1016/j.jss.2021.01.035DOI Listing
July 2021

Surgical treatment of GERD: systematic review and meta-analysis.

Surg Endosc 2021 08 2;35(8):4095-4123. Epub 2021 Mar 2.

Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.

Background: Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

Methods: PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

Results: From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

Conclusions: The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08358-5DOI Listing
August 2021

Pearls and Pitfalls of the Virtual Interview: Perspectives From Both Sides of the Camera.

J Surg Res 2021 06 4;262:240-243. Epub 2021 Feb 4.

Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

As the SARS-COV-2 pandemic created the need for social distancing and the implementation of nonessential travel bans, residency and fellowship programs have moved toward a web-based virtual process for applicant interviews. As part of the Society of Asian Academic Surgeons 5th Annual Meeting, an expert panel was convened to provide guidance for prospective applicants who are new to the process. This article provides perspectives from applicants who have successfully navigated the surgical subspecialty fellowship process, as well as program leadership who have held virtual interviews.
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http://dx.doi.org/10.1016/j.jss.2020.12.052DOI Listing
June 2021

Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory.

Am J Surg 2021 Sep 19;222(3):541-548. Epub 2021 Jan 19.

Department of Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA. Electronic address:

Background: The American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills.

Methods: Surgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis.

Results: Three-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks.

Conclusions: Variability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.
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http://dx.doi.org/10.1016/j.amjsurg.2021.01.018DOI Listing
September 2021

"Fighting an uphill battle": A mixed methods exploration of surgeon involvement in medical schools' preclinical curricula.

Am J Surg 2021 02 28;221(2):315-322. Epub 2020 Oct 28.

Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA. Electronic address:

Background: Limited exposure to surgeons early on in medical school may adversely impact students' clerkship experiences and professional development. This explanatory sequential mixed methods study investigates a perceived discrepancy between surgical and nonsurgical instructors in our institution's preclinical curriculum.

Methods: The demographics of preclinical faculty were assessed before and after a curricular reform. Semi-structured interviews with 13 surgical faculty explored barriers and facilitators to surgeon involvement. Responses were inductively coded and thematically analyzed.

Results: Surgeons' contributions to preclinical instruction fell from 10% to 5% across the curriculum reform. Barriers both leading to and reinforced by surgeons' limited involvement relate to surgeon, medical school, and student factors. Participants proposed three solutions to barriers in each domain.

Conclusions: Surgeons provide a minority of our preclinical instruction and may be disproportionately impacted by reform efforts. Deliberate efforts are necessary to increase opportunities for surgeons to engage with preclinical medical students.
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http://dx.doi.org/10.1016/j.amjsurg.2020.10.034DOI Listing
February 2021

Surgical autonomy: A resident perspective and the balance of teacher development with operative independence.

Am J Surg 2021 02 22;221(2):336-344. Epub 2020 Oct 22.

Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.

Background: This study aims to understand the perspectives of operative autonomy of surgical residents at various postgraduate levels.

Methods: Categorical general surgery residents at a single academic residency were invited to participate in focus groups to discuss their opinions and definitions of operative autonomy. Employing constructivist thematic analysis, focus groups were audio recorded, transcribed, and inductively analyzed using a constant comparative technique.

Results: Twenty clinical surgical residents participated in 6 focus groups. Overarching themes identified include autonomy as a dynamic, progressive path to operative independence and the complex interaction of resident-as-teacher development and operative autonomy. Four within operative case themes were intrinsic factors, extrinsic factors, autonomy promoting or inhibiting behaviors, and the relationship between residents and attendings.

Conclusion: Residents define operative autonomy as a progressive and dynamic pathway to operative independence. Teacher development is viewed as both an extension beyond operative independence and potentially in conflict with their colleagues' development.
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http://dx.doi.org/10.1016/j.amjsurg.2020.10.024DOI Listing
February 2021

A multi-institutional study of patient-derived gender-based discrimination experienced by resident physicians.

Am J Surg 2021 02 15;221(2):309-314. Epub 2020 Oct 15.

Department of General Surgery, Massachusetts General Hospital, Boston, MA, USA.

Background: This study characterizes prevalence, frequency, and forms of patient-derived gender-based discrimination (GBD) experienced by resident physicians, as well as their experiences witnessing and reporting patient-derived GBD.

Methods: A web-based survey was sent to residents from 12 programs at three academic institutions.

Results: Response rate was 47.9% (309/645) with 55.0% of respondents identifying as women. Women were more likely than men to experience patient-derived GBD during residency (100% vs 68.8%, p < 0.001), including inappropriate physical contact, receiving less trust from patients, and being mistaken for a nurse (p < 0.001). While 85.9% of residents personally experienced and 95.0% of residents witnessed patient-derived GBD, only 3.4% of residents formally reported patient-derived GBD. Women were more likely to report negative personal and professional consequences of patient-derived GBD.

Conclusions: Patient-derived GBD is pervasive and disproportionately affects women residents. Current reporting mechanisms are not adequately capturing nor addressing patient-derived GBD.
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http://dx.doi.org/10.1016/j.amjsurg.2020.10.015DOI Listing
February 2021

A qualitative study of the perceived value of participation in a new Department of Surgery Research Residents as teachers program.

Am J Surg 2020 11 1;220(5):1194-1200. Epub 2020 Jul 1.

Department of Surgery, Massachusetts General Hospital, 55 Fruit Street GRB 425, Boston, MA, 02114, USA. Electronic address:

Objective: This study aims to understand the perspectives of surgical residents who completed a Research Residents as Teachers Program (RRATP).

Methods: Our RRATP included a 6 h workshop followed by formal teaching opportunities across one academic year. Resident teachers participated in semi-structured interviews, which were inductively analyzed for prominent themes.

Results: Eight surgical research residents completed the RRATP workshop and taught 330 h (median = 26 h, range: 8-105). Interview participation rate was 100%; kappa was 0.81. Residents reported four themes: 1) increased knowledge of teaching principles with subsequent teaching changes, specific factors that contributed to their development as a teacher, numerous personal benefits to participation, and broad positive consequences for the surgical department including improved culture and patient care.

Conclusion: A RRATP can generate a significant number of formal teaching hours by surgical research residents, who perceive a high value of formal education training to themselves and their surgical residency program.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.056DOI Listing
November 2020

What Is the Role of Neoadjuvant Radiation Therapy for Retroperitoneal Sarcoma?

Adv Surg 2020 09 20;54:273-284. Epub 2020 Jun 20.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, YAW-7-7926, Boston, MA 02114, USA. Electronic address:

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http://dx.doi.org/10.1016/j.yasu.2020.05.003DOI Listing
September 2020

The Surgical Knowledge "Growth Curve": Predicting ABSITE Scores and Identifying "At-Risk" Residents.

J Surg Educ 2021 Jan-Feb;78(1):50-59. Epub 2020 Jul 18.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Objective: Resident performance on the American Board of Surgery In-Training Examination (ABSITE) is used for evaluation of surgical knowledge and guides resident selection for institutional remediation programs. Remediation thresholds have historically been based on ABSITE percentile scores; however, this does not account for predictors that can impact a resident's exam performance. We sought to identify predictors of yearly ABSITE performance to help identify residents "at-risk" for performing below their expected growth trajectory.

Design: The knowledge of the residents, as measured by standardized ABSITE scores, was modeled as a function of the corresponding postgraduate year via a linear mixed effects regression model. Additional model covariates included written USMLE-1-3 examination scores, gender, number of practice questions completed, and percentage correct of practice questions. For each resident, the predicted ABSITE standard score along with a 95% bootstrap prediction interval was obtained. Both resident-specific and population-level predictions for ABSITE standard scores were also estimated.

Setting: The study was conducted at a single, large academic medical center (Massachusetts General Hospital, Boston, MA).

Participants: Six years of general surgery resident score reports at a single institution between 2014 and 2019 were deidentified and analyzed.

Results: A total of 376 score reports from 130 residents were analyzed. Covariates that had a significant effect on the model included USMLE-1 score (PGY1: p = 0.013; PGY2: p = 0.007; PGY3: p = 0.011), USMLE-2 score (PGY1: p < 0.001; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p < 0.001; PGY5: p = 0.032), male gender (PGY1: p = 0.003; PGY2: p < 0.001; PGY3: p < 0.001; PGY4: p = 0.008), and number of practice questions completed (p=0.003). Five residents were identified as having "fallen off" their predicted knowledge curve, including a single resident on 2 occasions. Population prediction curves were obtained at 7 different covariate percentile levels (5%, 10%, 25%, 50%, 75%, 90%, and 95%) that could be used to plot predicted resident knowledge progress.

Conclusion: Performance on USMLE-1 and -2 examinations, male gender, and number of practice questions completed were positive predictors of ABSITE performance. Creating residency-wide knowledge growth curves as well as individualized predictive ABSITE performance models allows for more efficient identification of residents potentially at risk for poor ABSITE performance and structured monitoring of surgical knowledge progression.
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http://dx.doi.org/10.1016/j.jsurg.2020.06.038DOI Listing
June 2021

Identification of Specific Educational Targets to Improve the Student Surgical Clerkship Experience.

J Surg Res 2020 10 11;254:49-57. Epub 2020 May 11.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Background: This study describes the relationship between medical student perception of surgery, frequency of positive surgery clerkship activities, and overall surgical clerkship experience.

Methods: Medical students at four academic hospitals completed pre- and post-clerkship surveys assessing 1) surgery clerkship activities/experiences and 2) perceptions of surgery during the 2017-2018 academic year.

Results: Ninety-one percent of students completed both a pre- and post-clerkship survey (n = 162 of 179). Student perception of surgery significantly improved across the clerkship overall (P < 0.0001) and for 7 of 21 specific items. Eighty-six percent of students agreed that the clerkship was a meaningful experience. Sixty-six percent agreed that the operating room was a positive learning environment. Multivariable logistic regression identified one-on-one mentoring from a resident (OR [95% CI] = 2.12 [1.11-4.04], P = 0.02) and establishing a meaningful relationship with a surgical patient (OR = 2.21 [1.12-4.37], P = 0.02) as activities predictive of student agreement that the surgical clerkship was meaningful. Making an incision (OR = 2.92 [1.54-5.56], P = 0.001) and assisting in dissection (OR = 1.67 [1.03-2.69], P = 0.035) were predictive of student agreement that the operating room was a positive learning environment. Positive student perception of surgery before the clerkship was associated with increased frequency of positive clerkship activities including operative involvement (r = 0.26, P = 0.001) and relationships with surgical attendings (r = 0.20, P = 0.01), residents (r = 0.41, P < 0.0001), and patients (r = 0.24, P = 0.003).

Conclusions: Interventions to improve surgery clerkship quality should target enhancing student relationships with residents and surgical patients as well as providing opportunity for student operative involvement beyond just suturing. In addition, fostering positive perceptions of surgery in the preclinical period may increase meaningfulness and experience with the later surgery clerkship.
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http://dx.doi.org/10.1016/j.jss.2020.03.066DOI Listing
October 2020

Enhancing the Formal Preclinical Curriculum to Improve Medical Student Perception of Surgery.

J Surg Educ 2020 Jul - Aug;77(4):788-798. Epub 2020 Mar 17.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: This study aims to determine the effect of formal, preclinical curricular interventions on medical students' perceptions of surgeons, surgical learning objectives, and concerns regarding the surgical clerkship.

Methods: Thirty-eight medical students underwent a newly required, formal introduction to surgery during the preclinical curriculum. Two months later, these students were given surveys regarding their perception of surgery before and after a bootcamp-style transitions to the wards workshop that immediately preceded their core clinical rotations. Student responses were compared to historical peers.

Results: Thirty-seven students participated in the study (97.4%). Relative to historical peers, students demonstrated improved overall perception of surgery (71.2 vs 66.6, p = 0.046). A smaller proportion of students indicated that they were worried about evaluation (18.9% in 2018 vs 55.3% in 2017, p = 0.001) and interactions with surgical educators (18.9% vs 50%, p = 0.005). Students' overall perception of surgery significantly improved after participation in the transition to the wards workshop (71.2 to 77.8, p ≤ 0.0001), as did student agreement with 9 of 21 specific items. Improvement in surgical perception across the bootcamp-style workshop was similar to that of a prior workshop (8.6 in 2018 vs 6.4 in 2017, p = 0.21).

Conclusions: A preclinical introduction to surgery can have a positive impact on medical student perception of surgery prior to entry to the wards and may mitigate student fears regarding their surgical rotation.
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http://dx.doi.org/10.1016/j.jsurg.2020.02.009DOI Listing
June 2021

Addressing Sexual Harassment in Surgical Training.

Ann Surg 2020 04;271(4):614-615

Department of Surgery, Massachusetts General Hospital, Boston, MA.

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http://dx.doi.org/10.1097/SLA.0000000000003711DOI Listing
April 2020

Inoperable Biliary Tract and Primary Liver Tumors: Palliative Treatment Options.

Surg Oncol Clin N Am 2019 10;28(4):745-762

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WAC 4-460, Boston, MA 02114, USA. Electronic address:

Primary liver tumors are most commonly hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Although surgical resection offers a chance for cure, these tumors generally present at a late, inoperable stage, necessitating an understanding of noncurative and palliative treatment options. These options include ablative therapies, including radiofrequency ablation; intra-arterial therapies, including transcatheter chemoembolization; biliary decompression; radiotherapy; systemic therapies, including traditional chemotherapeutic agents; and molecular therapies, such as sorafenib. Selection of nonoperative treatment depends on patient and tumor factors as well as institutional resources and expertise.
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http://dx.doi.org/10.1016/j.soc.2019.06.009DOI Listing
October 2019

"Yes, I'm the Doctor": One Department's Approach to Assessing and Addressing Gender-Based Discrimination in the Modern Medical Training Era.

Acad Med 2019 11;94(11):1691-1698

S.K. McKinley is resident physician, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. L.J. Wang is resident physician, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. R.M. Gartland is resident physician, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. M.L. Westfal is resident physician, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. C.L. Costantino is resident physician, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. D. Schwartz is resident physician, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. A.L. Merrill is a fellow, Department of Surgery, Ohio State University, Columbus, Ohio. E. Petrusa is associate professor, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. K. Lillemoe is professor and chair, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. R. Phitayakorn is associate professor, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

While gender-based bias and discrimination (GBD) is known to exist in medical training, there is limited guidance for training programs on how to understand and combat this issue locally. The Massachusetts General Hospital Department of Surgery established the Gender Equity Task Force (GETF) to address GBD in the local training environment. In 2017, members of the GETF surveyed residents in surgery, anesthesia, and internal medicine at 2 academic hospitals to better understand perceived sources, frequency, forms, and effects of GBD. Overall, 371 residents completed the survey (60% response rate, 197 women). Women trainees were more likely to endorse personal experience of GBD and sexual harassment than men (P < .0001), with no effect of specialty on rates of GBD or sexual harassment. Patients and nursing staff were the most frequently identified groups as sources of GBD. While an overwhelming majority of both men (86%) and women (96%) respondents either experienced or observed GBD in the training environment, less than 5% of respondents formally reported such experiences, most frequently citing a belief that nothing would happen. Survey results served as the basis for a variety of interventions addressing nursing staff and patients as sources of GBD, low confidence in formal reporting mechanisms, and the pervasiveness of GBD, including sexual harassment, across specialties. These results reproduce other studies' findings that GBD and sexual harassment disproportionately affect women trainees while demonstrating how individual training programs can incorporate local GBD data when planning interventions to address GBD.
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http://dx.doi.org/10.1097/ACM.0000000000002845DOI Listing
November 2019

The Patient Speaks: Importance of Patient Perspectives in Clinical Decision-Making.

Ann Surg Oncol 2019 Sep 27;26(9):2665-2666. Epub 2019 Jun 27.

Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, USA.

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http://dx.doi.org/10.1245/s10434-019-07575-6DOI Listing
September 2019

Gender-based discrimination is prevalent in the integrated vascular trainee experience and serves as a predictor of burnout.

J Vasc Surg 2020 01 18;71(1):220-227. Epub 2019 Jun 18.

Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.

Objective: Trainee burnout is on the rise and negative training environments may contribute. In addition, as the proportion of women entering vascular surgery increases, identifying factors that challenge recruitment and retention is vital as we grow our workforce to meet demand. This study sought to characterize the learning environment of vascular residents and to determine how gender-based discrimination and bias (GBDB) affect the clinical experience.

Methods: A survey was developed to evaluate the trainee experience; demographics and a two-item burnout index were also included. The instrument was sent electronically to all integrated (0 + 5) vascular surgery residents in the United States. Univariate analyses were performed and predictors of burnout identified.

Results: A total of 284 integrated vascular residents were invited to participate and 212 (75%) completed the survey. Participants were predominantly male (64%) and white (56%), with a median age of 30 years (interquartile range, 28-32 years). Seventy-nine percent of respondents endorsed some form of negative workplace experience and 30% met high-risk criteria for burnout. More than a third (38%) of residents endorsed personally experiencing GBDB, with a significant difference between men and women (14% vs 80%; P < .001). Women were more likely than men to report witnessing GBDB (76% vs 56%; P = .003). Patients and nurses were the most frequently cited sources of GBDB (80% and 64%, respectively), with vascular surgery attendings cited by 41% of trainees. One in four female resident respondents indicated being sexually harassed during the course of training; this was significantly higher than for male residents (25% vs 1%; P < .001). Nearly half (46%) of trainees who witnessed or experienced GBDB thought that quality of patient care, job satisfaction, personal well-being, and personal risk of burnout were directly affected as a result of GBDB. GBDB was predictive of burnout (odds ratio, 1.9; 95% confidence interval, 1.1-3.5; P = .04), as were longer work hours (>80 h/wk; odds ratio, 2.8; 95% confidence interval, 1.1-7.1; P = .03).

Conclusions: GBDB was experienced by 38% of integrated trainees, with women significantly more affected than men. GBDB is predictive of burnout, and this has significant implications for our specialty in the recruitment and retention of female physicians. Resources addressing these issues are needed to maintain a diverse workforce and to promote physician well-being.
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http://dx.doi.org/10.1016/j.jvs.2019.02.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908058PMC
January 2020

A comparison of patient satisfaction when office-based procedures are performed by general surgery residents versus an attending surgeon.

Surgery 2019 07 2;166(1):116-122. Epub 2019 Apr 2.

Department of Surgery, Massachusetts General Hospital, Boston, MA. Electronic address:

Background: Patient satisfaction is an increasingly important quality metric nationwide. The impact that surgical trainees have on patient-reported satisfaction when they perform operations independently, however, has not been studied.

Methods: We conducted a prospective study at a single academic institution from October 2016 to June 2017. An office-based, postprocedure survey was developed by adapting questions from the validated Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey. Top-box scoring was used to determine satisfaction for categorical questions and a comparison of the means was used for overall quality ratings (scale 0-10). Patients indicated whether their operation was completed by an attending surgeon or a postgraduate year 3 general surgery resident. The primary outcome measured was patient satisfaction with overall quality of care. Individual questions were grouped by phase of care and composite scores were measured as a secondary outcome.

Results: The survey response rate was 87.4% (n = 195). There were no differences in patient demographics or the types of procedures performed by residents or an attending surgeon. Excision of a soft tissue mass (ie, lipoma) accounted for 89.2% of all procedures performed (n = 174). There were no differences between preprocedure (resident = 92.5% vs attending = 94.2%) or postprocedure (resident = 95.3% vs attending = 97.7%) composite scores. There was, however, a significant difference in periprocedure satisfaction (resident = 78.7% vs attending = 90.7%, P = .02). There was no difference in overall ratings of quality of care given by patients who had their procedure performed by residents (9.8 ± 0.5) versus an attending surgeon (9.9 ± 0.3, P = .15). Finally, on adjusted analysis, resident care did not independently impact the likelihood of a "best possible care" rating for overall quality of care (odds ratio 0.84 ± 0.27, confidence interval 0.45-1.57, P = .58).

Conclusion: Patient satisfaction was very high when residents independently performed minor surgery operations in an office-based setting. Of note, there was no difference in satisfaction with overall quality of care compared with an attending surgeon. This study demonstrates that high resident operative autonomy and patient satisfaction are not mutually exclusive goals when postgraduate year 3 residents perform office-based outpatient procedures.
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http://dx.doi.org/10.1016/j.surg.2019.02.009DOI Listing
July 2019

Feasibility and Perceived Usefulness of Using Head-Mounted Cameras for Resident Video Portfolios.

J Surg Res 2019 07 8;239:233-241. Epub 2019 Mar 8.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Background: There is limited guidance on how to longitudinally administer simulation materials or to incorporate video recordings into assessment portfolios of simulated surgical skills.

Materials And Methods: We launched a longitudinal weekly simulation curriculum for PGY1-PGY3 surgical residents based on the ACS/APDS Curriculum. Residents underwent monthly objective structured assessment of technical skills (OSATS) while wearing head-mounted cameras. Videos of OSATS performance accrued into individual online video portfolios. Residents were surveyed about their attitudes toward video recording.

Results: Twenty-seven general surgical residents participated, completing 161 OSATS encompassing 11 distinct skills and generating 258 videos of simulated skills performance. The overall survey response rate was 88%. Residents viewed the curriculum favorably overall, and 36.4% of residents accessed their videos. Of those who did not watch their videos, 78.6% cited not having enough time, whereas 28.6% did not think the videos would be useful. Over 95% of surveyed residents expressed interest in having a video library of attending-performed procedures, 59.1% were interested in having their own operations recorded, and 45.5% were interested in video-based coaching.

Conclusions: Residents viewed longitudinal administration of the ACS/APDS Curriculum positively. Although video recording in simulation is feasible, resident interest may be higher for intraoperative recordings than for simulated skills.
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http://dx.doi.org/10.1016/j.jss.2019.01.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232965PMC
July 2019

Moving Beyond Representation as a Marker of Gender Equity.

Dis Colon Rectum 2019 03;62(3):269-271

Massachusetts General Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1097/DCR.0000000000001275DOI Listing
March 2019

Medical students' perceptions and motivations prior to their surgery clerkship.

Am J Surg 2019 08 21;218(2):424-429. Epub 2019 Jan 21.

Department of Surgery, Massachusetts General Hospital, 55 Fruit Street GRB 425, Boston, MA, 02114, United States. Electronic address:

Background: This study aims to determine the effect of a pre-clerkship workshop on medical students' perceptions of surgery and surgeons and to describe their concerns and learning goals.

Methods: Thirty-nine medical students completed surveys before and after a workshop preceding their surgery clerkship. Quantitative data and free responses that were inductively coded were used to assess effectiveness.

Results: Perceptions from 38 students (response rate = 97.4%) significantly improved for 11 of 21 items. At pre-workshop, the most frequently cited learning goals were improving technical skills (58%), surgical knowledge (53%), and understanding surgical culture and work (53%). Students' top concerns were meeting clerkship demands (68%) and being evaluated (55%). After the workshop, student learning objectives and concerns remained largely unchanged.

Conclusions: A pre-clerkship workshop improved student perceptions of surgery and surgeons. Understanding students' intrinsic motivations may facilitate future clerkship curriculum improvement via better alignment of educator and student goals and objectives.
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http://dx.doi.org/10.1016/j.amjsurg.2019.01.010DOI Listing
August 2019
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