83.10 Characterizing #PhysicianBurnout through Social Media Posts, Responses, Traffic, and Influencers

Posted on January 31, 2019

C. Hwang1,2, T. Bellomo1,2, M. Byrnes2, M. A. Corriere1,2  1University Of Michigan,Vascular Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Health Outcomes And Policy,Ann Arbor, MI, USA

Introduction:
Physician burnout is highly prevalent among surgeons. Negative impacts include depression, divorce, substance abuse, and attrition.  Survey and focus group methods have been used to study burnout, but potential non-response bias among affected doctors is a major potential limitation of these approaches.  Social media is a potentially rich source of information related to provider burnout because users can post while experiencing stress. We analyzed posts with hashtags related to burnout to characterize themes and influential users.

Methods:
A healthcare social media analytic platform was used to identify burnout-related hashtags. Posts specifically identifying physician burnout over a 90-day period (May26 -August 24, 2018) were analyzed. User influence was assessed using an impact factor algorithm accounting for healthcare relevance, conversation partners, and stakeholder roles identified through metadata.  Users, content volume, trends, and themes were evaluated using mixed methods. 

Results:
23 hashtags linked to burnout were identified. Hashtag names referenced burnout directly (#Physicianburnout), sarcastically (#joyofmedicine), through narratives (#ShareASToryInOneTweet), through impacts on patients and coworkers (#Thosewecarry), and countermeasures (#ProviderWellness).  #Physicianburnout was associated with over 5300 unique tweets, 3200 retweets, >20 million impressions, 3300 shared links, and 1800 visual file shares over 90 days.  Individual doctors accounted for the largest share of activity, followed by healthcare organizations, non-physician individuals in healthcare, and non-health individuals. Individual doctors represented 24/35 (68.5%) of top influencers, including the four highest ranking influencers. Trending terms included "Maslow's hierarchy," "broken work systems," and "Telling doctors to be more resilient…".  Prevalent themes included depression, stigma, depersonalization, negative impacts on patient care, activities that protect against burnout, and the need for collective action from physicians and medical schools. Trends indicated increases in social media volume ranging from 25%-39% from the preceding period.

Conclusion:
Social media provides rich and dynamic information about physician burnout. The majority of burnout-related content is posted by individual doctors who are potentially inaccessible through survey or focus group studies. Physician advocacy and support groups (including surgical societies) presently account for a limited portion of social media content related to burnout.  In addition to understanding burnout, social media represents a potential means of communicating initiatives and strategies to combat this problem.  Stakeholders invested in addressing physician burnout should leverage social media as a tool and consider partnering with influential posters.
 

83.09 Defining a Leader – Characteristics That Distinguish a Chair of Surgery

Posted on January 31, 2019

A. Tanious1, H. McMullin2, C. Jokisch2, M. K. Tanious3, L. T. Boitano1, M. F. Conrad1, M. L. Shames2  1Massachusetts General Hospital,Vascular Surgery,Boston, MA, USA 2University Of South Florida College Of Medicine,Vascular Surgery,Tampa, FL, USA 3Brigham And Women’s Hospital,Anesthesia And Pain Medicine,Boston, MA, USA

Introduction:
            Chair of the Department of Surgery, sometimes referred to as the Chief of the Department of Surgery, is a title with significant historical connotations.  As medicine has progressed, these individuals have become beacons of leadership to advance all aspects of surgery within our hospitals.  Our group sought to understand what qualifications unify them as group.

Methods:
            We defined our cohort by first looking at all teaching hospitals with regard to general surgical training as defined by the ACGME.  Then, utilizing publically available data for all US teaching hospitals, demographic information was accumulated for the named chair/chiefs of surgery as of the end of the calendar year of 2016.  Information collected included geographic location of their program, individual medical/surgical training history, surgical specialty training, previous chair/chief titles held (for both individual and entire departments), and academic productivity.  Specific to academic productivity, PubMed searches were done for all peer-reviewed manuscripts and library searches were conducted to account for all book and book chapter publications.

Results:

           Of the 259 academic surgical programs listed by the ACGME, data was available on 245 individuals.  These leaders were trained in 19 different specialties, with 177 (72.2%) of these practitioners having had fellowship training.  The top three specialties of these practitioners are general surgery (40, 16.3%), surgical oncology (38, 15.5%), and vascular surgery (33, 13.5%).  There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree.

The general surgery training program that has produced the greatest number of these individuals is Johns Hopkins University (n = 11), followed by the Massachusetts General Hospital (n = 8), and Beth Israel Deaconess Medical Center (n = 7).

Forty percent (n = 99) have held previous positions of leadership of surgical subdivisions as division chiefs.  Sixteen percent (n = 40) were previous chairs of other departments prior to their current position as chair. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Other traits studied included Alpha Omega Alpha honors society membership (n = 37, 15%), and dual degree status (n = 37, 15%).

Chair’s at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P < .0001) as well as were more likely to be fellowship trained (P = .0113).

Conclusion:
            While there are no set guidelines that define the position of Chair of Department of Surgery, these individuals are well trained, well published, and familiar with leadership roles.  By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

83.08 Leadership Amongst Regional And National Surgical Organizations: The Tides Are Changing

Posted on January 31, 2019

S. M. Krise1, I. A. Etheart2, A. T. Perzynski3, K. J. Conrad-Schnetz4  1Ohio University,Heritage College Of Osteopathic Medicine,Cleveland, OH, USA 2West Virginia School of Osteopathic Medicine,Lewisberg, WV, USA 3MetroHealth Medical Center,Cleveland, OH, USA 4Cleveland Clinic,Cleveland, OH, USA

Introduction:  Leadership amongst regional and national organizations is a key opportunity to obtain scholarly activity which is essential for attaining academic advancement. Data has been reported showing gender disparity in scholarly activity, specifically in publication status and NIH grants, with women having decreased rates compared to male colleagues (Awad 2017, Svider 2014). Gender disparity in leadership of surgical organizations is important to examine given this relationship. Our objective was to examine the differences between male and female leadership within surgical organizations. 

Methods:  Credentials were obtained through an Internet search of organization websites. Variables included organization type, leadership role, gender, advanced degree, medical school graduation year, publications, and employment at an academic institution. A bivariate analysis was performed between genders. A p-value < 0.05 was considered statistically significant.

Results: 532 leaders were identified in 43 surgical organizations. There was a statistically significant difference in the number of male and female leaders (73.3% vs 26.7%, p=0.012). Women were most likely to hold the role of Other (35.5%) and least likely to be Vice-President (10.5%) and President-Elect (13.8%). In line with other research, women had a decreased publication rate than male colleagues (85.2% vs 93.1%, p=0.005). Women had a higher rate of advanced degrees than men (24.8% vs 16.7%, p=0.035). Women were found to be involved earlier in their careers than men (4.9 years, 95% CI 4.1-7.8 years, p<0.01). OB/GYN organizations were the only organization type to show gender parity with 55% of leader roles held by women. Vascular surgery (0%), ENT and General Surgery (13%), and Thoracic Surgery (15%) had the least female representation in leadership. 

Conclusion: Male and female leaders are nearly equal in their credentials with women having less publications, but more advanced degrees; yet women are under-represented in leadership of surgical organizations. Our data show women are involved earlier in their careers in conflict to the belief that women hold off on career pursuits due to family planning and work/life balance. Data have shown that it takes women longer to reach Full Professor than men (Abelson 2015). This knowledge could lead women to be more aggressive in their leadership endeavors, explaining their early involvement. Since a higher rate of women hold lower level leadership roles, they must continue to be mentored and encouraged into higher leadership positions. Surgical organization leadership should be re-examined in the future to identify if gender parity is reached with more women holding higher level leadership roles. 

 

83.06 Gender differences at national academic surgery conferences: examination of the "broken pipeline".

Posted on January 31, 2019

T. Lysaght2, M. Wooster1, N. Anton1, D. Stefanidis1  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA 2Ohiohealth Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OH, USA

Introduction: Women comprise 19% of all surgeons in the United States, 22% of full time faculty and only 1% of department chairs. Their participation in national meetings as presenters, while unknown, could indicate their engagement in academic surgery. Our objective was to determine the percentage of women presenting at national surgical meetings over time, and the relationship of that percentage with society president gender and meeting focus on gender disparity.

Methods: The annual meeting program of 10 surgical organizations (SO) including Academic Surgical Congress (ASC), American Association for the Surgery of Trauma (AAST), American College of Osteopathic Surgeons Academic Clinical Assembly (ACA), American College of Surgeons Clinical Congress (ACS), the Americas Hepato-Pancreato-Biliary Association (AHPBA), American Society of Clinical Oncology (ASCO), Surgical Education Week (SEW), Eastern Association for the Surgery of Trauma (EAST), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and Western Trauma Association (WTA), was reviewed for years 2013, 2015, and 2017. The gender of scientific program presenters, panel chairs, session moderators, panelists, and keynote speakers was recorded and its association with the meeting’s president and president-elect gender. Topics pertaining to gender disparities, which addressed the current gender gap in the surgical field or adversities women face with advancing in their field identified by key words gender, female or women in the title, was assessed.

Results: 30.8% (4/13) to 53.8% (7/13) of meetings had women presidents and presidents elect. Women comprised 15.9-45.4% (mean 28.3%, SD+/-9.26%) of presenters across the 10 meetings. The highest rate was observed at the 2017 SEW meeting and the lowest at the 2015 ACA meeting. A statistically significant increase in the number of female participants was found over time in the ACA and ASCO meetings (p=0.0175, p=0.0131). Meetings that incorporated discussions of gender disparities had a higher proportion of women presidents and president elects ranging from 4-10 to those without 1-2, respectively (30.1%-33.2%  vs 20.5%-25.4%, respectively). A strong correlation existed between gender of president and president elect and percentage of women presenters (r=0.9108), whereas, a weak correlation was found with discussion of gender disparity (r=0.1714). (Table 1).

Conclusion: While significant variability exists in the academic engagement of women among surgical societies, overall participation is on par or better than their representation among the surgical workforce. Societies with women leaders may be associated with increased women participation at national meetings. 

83.05 Ethical Concerns During the Medical Student Surgical Clerkship

Posted on January 31, 2019

K. A. Marsden1, L. C. Kaldjian3, E. M. Carlisle2  1University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA 2University Of Iowa,Division Of Pediatric Surgery/Department Of Surgery,Iowa City, IA, USA 3University Of Iowa,Carver College Of Medicine/Program In Bioethics And Humanities,Iowa City, IA, USA

Introduction: There is an ever increasing focus on the development of medical school ethics curricula. While much effort has focused on the preclinical years, several groups have worked to identify ethical issues medical students face during their clinical rotations. This work has largely focused on internal medicine, pediatrics, and OBGYN clerkships. Little data is available regarding ethical issues students encounter on the surgery clerkship. Identification of such issues will allow preclinical and clinical course directors to refine ethics curricula to insure students are prepared to address the ethical issues they are most likely to encounter on the surgical rotation. To this end, we performed a content analysis of ethical issues encountered by medical students on a surgical clerkship.

Methods: All medical students on the surgical clerkship at a university hospital between April 2017 and June 2018 submitted a written reflection regarding an ethical issue encountered during the clerkship.  Two independent investigators performed content analysis of each reflection. References to core ethical principles (beneficence, non-maleficence, justice, autonomy) were tabulated, and ethical issues were classified into 10 main categories and 58 subcategories based on a modified version of a published rubric.

Results: 140 reflections were reviewed. 6 were removed due to lack of focus on an ethical issue. 134 reflections underwent content analysis. Non-maleficence was the predominant core ethical principle mentioned, however this was closely followed by justice.  Regarding ethical issues, students wrote about challenges with decision making (28%), communication among healthcare team members (14%), justice (12%), communication between providers, patients and families (10%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student specific issues (5%), documentation issues (1%), and miscellaneous/other (7%).

Conclusion: Our analysis identified ethical issues that are of concern to students on the surgical clerkship.  Consistent with prior analysis of students on other rotations, our work demonstrates that students express most concern with issues related to decision making. Unlike their peers on other clerkships, surgical students express increased concern with ethical issues surrounding informed consent, communication between treatment teams, and justice. Interestingly, fewer surgical students expressed concern about disrespectful treatment of patients by providers than did students on other clerkships. However, more surgical students expressed concern related to ambiguity about their role/responsibility on the surgical team, as well as the challenge of balancing delivery of efficient yet high-quality care. Integration of these specific ethical concerns into preclinical and clinical ethics curricula may help prepare medical students for the ethical issues that they will encounter on the surgical clerkship. 

 

83.04 Does Gender Define General Surgery Resident Well-Being?

Posted on January 31, 2019

J. Felton1, S. Kidd-Romero1, N. Kubicki1, S. M. Kavic1  1University Of Maryland,Surgery,Baltimore, MD, USA

Introduction:  Burnout, depression, and poor psychological well-being are pervasive among general surgery residents, and there is recent evidence to suggest that there are differences between male and female residents.  We sought to describe and evaluate the gender differences in burnout, depression, and wellness among general surgery residents at a single institution.

Methods:  We created a novel 50-question anonymous survey with Likert scales to assess burnout, depression, and wellness.  This was distributed to the general surgery residents at two separate time points during the academic year, before and after the introduction of a wellness initiative, to evaluate for any differences.  Bivariate analysis was performed to determine the association between gender and specific variables.

Results: Forty-two of 55 residents participated in the first survey.  We found that women felt more satisfied by their work than men (p <0.01) and tended to exercise more often than men (p = 0.04).  We also found that women tend to feel sad (p = 0.04) and feel anxious (p <0.01) more often than men.  Furthermore, women tend to stress eat (p = 0.01) more often than men and have more alcoholic drinks per sitting (p = 0.02) than men.  Finally, we found that women tend to think about death or suicide more often than their male counterparts (p = 0.04).  Thirty-five residents participated in the second survey.  In terms of self-view, more men had more positive days than negative days (p <0.01) compared to women.  Women took more time to think, reflect, and meditate (p = 0.03).  Again, we found that women tend to feel sad (p = 0.01) and feel anxious (p = 0.01) more often than men.  In addition, we found that women tend to feel fatigued (p = 0.02) and experience stress headaches (p = 0.04) more often than men.  Finally, we found that women make time to see people outside of the hospital more often than men (p = 0.06). 

Conclusion: We found that there exist several significant differences between male and female general surgery residents at one academic institution.  The reasons underlying these differences are not fully understood or elucidated.  In the future, more investigation must be done, and general surgery residencies may need to create gender-based programs to address these differences.

 

83.03 Underrepresentation of Women in Surgical Societies: Analysis of Awards and Invited Speakers

Posted on January 31, 2019

L. Kuo1, P. Lu1,2, R. Atkinson1, N. L. Cho1, N. Melnitchouk1,2  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2Center for Surgery and Public Health,Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Gender disparities within academic medicine are well described. Specialty societies provide opportunities for leadership and career advancement, but little is known about the role specialty societies play in propagating or eliminating gender disparities. Previous studies have demonstrated that society awards are less likely to be given to women than men. Here, we examined surgical society award distribution and podium speakership by gender to investigate disparities in recognition and inclusion.

Methods:
National general surgery and associated subspecialty (bariatric, colorectal, endocrine, hepatobiliary, oncologic, pediatric, plastic, thoracic, transplant, and trauma surgery) societies with publicly available information on awards and invited lecturers at annual meetings between 2008-2018 were identified. Awards targeted specifically towards women, military personnel, medical students or non-physicians were excluded. A subset of awards for trainees (fellows or residents) was also identified. The gender of each award winner or invited speaker was determined based on name and internet query. The percentage of female award winners and invited speakers for each society was calculated and compared to the percentage of female practicing and trainee surgeons in 2015 and 2017, respectively, as reported by the Association of American Medical Colleges.

Results:
21 surgical societies were identified. From 2008-2018, 1294 awards were given, of which 372 were awarded to women (28.7%). A total of 1026 awards were given to non-trainees. Of these, 239 were given to women (23.3%), which is greater than the 19.2% of practicing surgeons who were female in 2015. Across the 21 societies examined, the percentage of female award recipients by society ranged from 0% to 54%. When examining the 288 awards given to trainees, 49.6% were awarded to women, which is greater than the 38.4% of female residents nationwide in 2017. Rates of female trainee award winners amongst individual societies ranged from 13.3% to 69.2%. Over this same time period, 445 invited speakers were featured at annual meetings. 75 (16.9%) were women, with individual societies featuring female speakers at rates varying from 0% to 25.8%.

Conclusion:
Women are well represented as award winners in surgical societies, both as trainees and as practicing surgeons. However, some individual societies have low rates of female award winners. Women are also underrepresented as invited speakers. Specialty societies should consider interventions to recognize the achievements of female members and to promote parity across genders.
 

83.02 Sexual Harassment during Residency Training: A Cross-Sectional Analysis

Posted on January 31, 2019

L. F. Arnold1, S. R. Zargham1, C. E. Gordon1, W. I. William I. McKinley1, E. H. Bruenderman1, J. L. Weaver1, M. E. Egger1, M. V. Benns1, A. T. Motameni1  1University Of Louisville,Surgery,Louisville, KY, USA

Introduction:  

The reality of sexual harassment is unmasking in many fields. Residents make up a vulnerable group and are at risk of being sexually harassed. In this study we focus on prevalence of sexual harassment among residents in general surgery, pediatrics and internal medicine with a focus on identifying underlying reasons for lack of victim reporting.

Methods:  

Survey on sexual harassment was emailed to 261 general surgery, 132 pediatric, and 271 internal medicine programs. The survey focused on specific examples of sexual harassment, reporting and resident knowledge and awareness of institutional support programs for victims of sexual harassment.

Results: 

379 residents responded to the survey. Females were more likely to be subject of harassment compared to males (83% vs 46%, p<.0001). Offensive and/or suggestive jokes and comments were the most common type of harassment experienced by both genders. Most residents were unlikely to report the offender (87% females vs. 93% males). There was no significant difference in the number of residents who reported experiencing some sort of harassment based on resident specialty (69% general surgery, 64% internal medicine, 69% pediatrics). 73% of residents believed they would be supported by their program if they reported a sexual harassment events, only 38% of females and 40% of males were aware of institutional support in place for victims of sexual harassment at their program.

Conclusion: 

Sexual harassment continues to be a problem in the medical field. Residents continue to train in environments where reaching their full potential can be restrained. Radical steps must be taken to address the problem of sexual harassment and to create the optimal setting for training residents.

83.01 Disordered Eating and Well-being Among Surgical Residents

Posted on January 31, 2019

A. Salles1, E. E. Fitzimmons-Craft2, G. Nicol2, D. Wilfley2, J. Yu1, C. Herleth5, T. M. Ciesielski4, R. P. McAlister3  5McCallum Place,St. Louis, MO, USA 1Washington University in St. Louis,Surgery,St. Louis, MO, USA 2Washington University,Psychiatry,St. Louis, MO, USA 3Washington University,Obstetrics And Gynecology,St. Louis, MO, USA 4Washington University,Department Of Medicine,St. Louis, MO, USA

Introduction:  There is increasing attention on the ongoing physician well-being crisis. Numerous studies have documented the high rates of burnout among physicians and, in particular, surgeons. One consequence of being a surgeon is having little time for eating and drinking. This may, in turn, be associated with disordered eating, which can include episodes of eating in which people feel they cannot control what or how much they eat. In this study, we assessed surgical trainees across multiple specialties at one institution for evidence of disordered eating. We also assessed whether stress and burnout are associated with disordered eating.

Methods:  We invited all surgical residents at Washington University School of Medicine in St. Louis to participate in a voluntary online survey regarding eating behaviors and well-being in spring 2018. Measures included the Dutch Eating Behaviour Questionnaire (DEBQ), Cohen’s perceived stress scale (PSS), and representative items from the emotional exhaustion and depersonalization subscales of the Maslach Burnout Inventory (MBI).

Results: A total of 146 trainees participated in the survey (response rate 67%; 54% women). The scores on the key measures are shown in the table. The perceived stress scale (r=0.24, p=0.007) and both subscales of the MBI (emotional exhaustion r=0.29, p<0.001; depersonalization r=0.33, p<0.001) were significantly associated with disordered eating as measured by the DEBQ. In regression analyses controlling for gender and post-graduate year, these relationships remained statistically significant (B=1.74, p=0.04 for perceived stress, B=3.71, p=0.004 for emotional exhaustion, B=4.20, p=0.03 for depersonalization) such that more stress and more burnout were associated with more disordered eating.

Conclusion: This is the first study we are aware of that examines disordered eating among surgical residents. Our results suggest that surgical trainees are affected by disordered eating which was associated with stress and burnout. These data are cross-sectional in nature, so no causation can be inferred. Future studies should examine the effects of interventions targeting healthy eating behaviors and well-being outcomes including burnout. Something as simple as providing easy access to food and drink may counteract the tendency toward disordered eating, which may be in part fueled by limited time for eating and drinking during working hours. Any intervention aimed at improving eating behaviors will be most likely to be successful as part of a comprehensive well-being program.

 

82.10 A Fetal 3D Surgical Simulator of Minimally Invasive In Utero Gastroschisis Repair

Posted on January 31, 2019

E. H. Steen1, J. Fisher1,3, O. Olutoye1,3, J. Zaneveld4, N. Salas1, T. Lee1,3, S. Keswani1,3  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 4Lazarus 3D,Houston, TX, USA

Introduction: We have reported the clinical benefits of fetal minimally invasive surgery (MIS) in attenuating preterm labor, uterine morbidity, and subsequent C-sections – complications associated with open fetal surgery. Other non-lethal diseases may also benefit from fetal MIS, such as gastroschisis. 3D printing allows the creation of lifelike human models. The aim of this study is developing and validating a 3D fetal MIS model to test an in utero procedure for gastroschisis repair.

Methods: A 3D reconstruction of a uterus and fetus with gastroschisis (based on a mid-gestation fetal MRI) was optimized (3D Slicer) and rapidly prototyped using a next-gen Lazarus 3D printer. A four-step MIS procedure (evaluation of fetus, evaluation of bowel, reduction of bowel, coverage of defect) was designed and time-tested in three cohorts repeated in triplicate (fetal/neonatal surgeons, residents, and students, n=6/group). A ten question post-trial validation survey was administered to the participants. Data is presented as mean +/-SD, analysis by ANOVA, post-hoc Tukey HSD, p<0.05.

Results: All procedures were completed successfully (n=54). Operative time was significantly related to surgical training level (fetal/neonatal surgeons 125s+/-29s, residents 141s+/-30s, students 376s+/-107s; p<0.05) with sequential attempts yielding significant rates of improvement in all cohorts. All surgeons reported that the model 1) is an accurate tactile and visually representative model, 2) adequately assessed technical skills required for the procedure, and 3) would be a valuable training tool. The cost for this model was $68.69/trial and can be refurbished/reused for $200.

Conclusion:Our data supports construct, content, and face validity of a novel 3D fetal surgical simulator. This model is more cost effective than animal models in developing fetal techniques and seems to be more representative of the human disease. With the attenuation of maternal-fetal risk observed in fetal MIS, in utero therapies for gastroschisis may be considered.

 

82.09 Traditional versus Realistic Bleeding Control Training Models

Posted on January 31, 2019

M. Araujo1, F. Cai1, R. Lei1, E. E. Fox1, C. E. Wade1, S. D. Adams1  1McGovern Medical School at UTHealth,McGovern Medical School,Houston, TX, USA

Introduction: Uncontrolled bleeding is the main cause of preventable traumatic death and the arrival of first responders may be delayed due to safety concerns. The educational “Stop the Bleed” program was created to train non-medical bystanders with skills to control hemorrhagic wounds until first responders arrive, potentially saving lives. Prior studies found that 1-hour hands-on instruction an effective method to teach these techniques. We hypothesized that a realistic bleeding simulator would improve the quality and impact of this training.

Methods: Third year medical students (MS3) and non-medical summer students (NMS) underwent “Stop the Bleed” training. Each student was given an anonymous identifier to track results and was randomized into standard “DRY” model or realistic “WET“ bleeding simulator groups. After a didactic lecture by a certified instructor they each had hands-on training to pack wounds and place tourniquets.  Students completed pre and post surveys to evaluate baseline knowledge, teaching effectiveness, and willingness and preparedness to intervene to help a bleeding stranger.  They were observed placing a tourniquet and packing a wound, timed and evaluated on technique.  Statistical significance, set at p? 0.05, was analyzed using T-test and the Likert scale by Wilcoxon-signed ranked test.

Results: Students (n=360) were trained in bleeding control techniques (241 MS3, 119 NMS) and stratified between WET (n=171) and DRY models (n=189).  Results were excluded if unpaired or incomplete. While both groups demonstrated improved average correct of 5 knowledge questions after training (MS3 3.9 to 4.8, NMS 3.3 to 4.2) there was a significant difference in the NMS compared to the MS both before and after. Both groups had a similar and significant increase in willingness and preparedness to help a bleeding stranger after training, irrespective of the method. Compared to the DRY teaching model, students on the WET model needed more correction on technique and significantly more time for tourniquet placement (DRY: 50 sec, WET: 62 sec). For wound packing, however, students on the WET model were faster (DRY: 72 sec, WET: 62 sec), but this could be attributed to different packing spaces between the models.

Conclusions: Students receiving training in bleeding control techniques are confident and empowered to aid a bleeding victim irrespective of method. Students on the WET tourniquet model voiced anxiety due to the active “bleeding”, and were visibly fumbling, which may account for the longer time to placement.  This may be a better representation of the real world experience, and may help them overcome those anxieties to intervene while still in a training situation.

 

82.08 Deceased Organ Donors a Valuable Source of Surgical Experience for Residents and Medical Students

Posted on January 31, 2019

T. J. Hathaway1, R. S. Mangus1  1Indiana University School Of Medicine,Surgery / Transplant,Indianapolis, IN, USA

Introduction:
An increasing number of rules and regulations govern interactions between learners and patients in the clinical setting. This strict oversight limits the amount of hands-on training available to medical students and residents alike. This paradigm has resulted in increased use of procedural labs with “virtual” experience. A potential source of human subjects available for clinical practice are the thousands of organ donors each year who consent to use of their body for  education and research purposes. This study evaluates the potential surgical learning available from deceased organ donors with an intact cardiopulmonary system.

Methods:
The records of all deceased organ donors processed locally by the Indiana Donor Network over the last 18 months (Feb 2017-Aug 2018) were reviewed. Patient consent for research and education was documented. A list of proposed procedures was developed to predict the potential benefit of organ donors as a learning platform for medical students and residents. Limitations to this approach were identified.

Results:
During the study period, 242 of 255 (95%) donors consented for their bodies to be used for education purposes. A list of 27 potential procedures was developed. Simple procedures include endotracheal intubation, central venous catheter insertion, tube thoracostomy, and insertion other peripheral venous and arterial catheters. Complex procedures include more invasive and time consuming procedures such as splenectomy, prostatectomy, hysterectomy, bowel resection and anastomosis. Primary barriers to general adoption of this model for surgical education included extending time in the operating room, risks of contamination to transplant organs, additional cost of extra equipment, potential risks of travel to the donor hospital, and disfigurement of the donor body. After analysis of these factors, it was determined that a single learner could easily participate in 3-5 procedures per donor with implementation of a robust system and support from the attending surgeon. In the last 18 months at this center, 242 donors consented for use of their body for education purposes, suggesting 40-70 missed procedural opportunities per month. Approximately 90% of the available donations occurred in hospitals within a 30-minute drive of a medical education site in our state.

Conclusion:
Routine use of organ donors in the procedural education of medical students and residents could serve as a valuable resource throughout the world. The use of these opportunities will likely become more important as further limitations are placed on the clinical learning environment. In instituting this model, care must be taken to protect the donor and to be responsive to concerns from the donor’s family.
 

82.07 An Analysis of Verbal Response Modes, Team Role, and Teamwork in Simulated Trauma Resuscitations

Posted on January 31, 2019

B. Statz2, I. H. Osman2, A. A. Rosser2, S. Sullivan2, R. Thompson1, H. Jung2  1University Of Wisconsin,Department Of Emergency Medicine,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: We sought to understand if role or gender affected the way team members spoke during trauma resuscitations and if those differences impacted trauma team performance.

Methods: Communication in 27 interdisciplinary trauma simulations was transcribed. Three physicians (trauma chief resident, trauma junior resident, emergency medicine resident) and two nurses (emergency medicine) participated in each simulation. Team performance was assessed using the Team Emergency Assessment Measure (TEAM) scale.
Speech was coded with Verbal Response Modes (VRM). VRM is a taxonomy that describes the relationship dynamics present in conversation by how the speech acts relate to the speaker or the person whom the speech targets. VRM codes can be classified into three dimensions: Attentive vs. Informative, Presumptuous vs. Unassuming, and Directive vs. Acquiescent. All utterances concerning another’s experience are considered Attentive, whereas utterances concerning the speaker’s experience are considered Informative. When an utterance presumes knowledge about the other person, it is considered Presumptuous. If no such presumption is made, the utterance is Unassuming. Finally, Directive utterances use the speaker’s frame of reference in order to guide conversation, while Acquiescent utterances allow the other’s viewpoint to determine the course of the conversation.
Ratios of speech acts in the three VRM dimensions for each team member were examined. We aggregated these proportions to compute mean VRM dimension ratios for each role and gender within the trauma team. Multiple regression and cluster analysis were performed to investigate relationships between VRM, team role (all physicians, trauma chief, nurses), gender, and TEAM score.

Results: T-tests of VRM dimension ratios demonstrated significant differences between physicians and nurses in how they spoke within simulated trauma resuscitations. Nurse speech was more attentive and unassuming than that of physicians. However, both physicians and nurses used equally directive speech. Trauma teams whose leaders used unassuming speech acts more than presumptuous speech acts had higher TEAM scores (p=0.039). Team member gender did not correlate with differences in speech acts or team performance.

Conclusion: Physicians and nurses speak differently within trauma resuscitations. Teams with leaders who communicate in an unassuming manner perform better. Based on VRM, the relationships between team members and the ways they spoke to one another did not correlate with gender.

 

82.06 Impact of Trauma Responders Unify to Empower (TRUE) Communities Course in Chicago High Schools

Posted on January 31, 2019

L. C. Tatebe1, D. Ferrer1, D. Kang2, M. Saeed3, M. Swaroop1  2Rush University Medical Center,Chicago, IL, USA 3State University of New York Health Science Center at Brooklyn,Brooklyn, NY, USA 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:  Chicago’s ballooning violence disproportionately affects socioeconomically disadvantaged neighborhoods exposing young people to trauma. Bystanders are present at 60-97% of traumas and more likely to assist if given prior training. The Trauma Responders Unify to Empower (TRUE) Communities Course was designed and implemented across the city to create Immediate Responders to traumatic events. We evaluated the impact of bringing these skills to high schools in at-risk neighborhoods, in an attempt to improve self-efficacy and ultimately outcomes for victims of trauma.

Methods:  A three-hour trauma immediate responder course was designed using community based focus groups and qualitative analysis of the bystander effect. The course addressed basic first aid, trauma wound care, principles of bystander care, and the psychological impact of trauma. The course was taught in community centers, churches, and schools, to both minor and adult participants. Pre- and post-course questionnaires were offered. Seven evidence-based empowerment questions were assessed on a scale of 1 to 10. Ten knowledge-based questions were presented as single best of four multiple choice answers. The change in empowerment measures and knowledge scores were analyzed using chi-squared and t-test methods with p<0.05 considered significant. Subset analysis was performed comparing results from current high school students were compared to the rest of participants.

Results: Of the182 high school students and 286 individuals post-high school who participated, approximately half of each cohorts had seen someone shot with a gun (45.3% vs 55.6%, respectively, p=0.04). However, far fewer high school students received prior first-aid training (33.9% vs 60.4%, p<0.001). For the high school students, the mean increase in empowerment was 2.9 out of 10 (p<0.001) while the remaining cohort increased scores by 2.7 (p<0.001). The increase was not different between the groups (p=0.45). The students were outperformed by the remaining cohort in both the pre- and post-course knowledge evaluation (5.2 vs 6.7 and 6.8 vs 7.5, both p<0.001); although, the high school students showed a significantly larger increase in their scores (1.5 vs 0.7, p<0.001). 

Conclusion: Violence remains a pervasive public health issue in Chicago. Within at-risk communities, high schoolers are not spared exposure to this violence but have not yet received Immediate Responder training on how to approach a victim of trauma. Our evidence-based community course successfully improved self-efficacy and knowledge of trauma first-aid among Chicago’s high school students. Such training should be considered for high school students nationwide. 

 

82.04 Resident Endoscopy Experience Correlates Poorly with Colonoscopy Performance on a VR Simulator

Posted on January 31, 2019

K. S. Oberoi1, M. T. Scott2, J. Schwartzman1, N. Maloney Patel2, M. M. Alvarez-Downing1, A. M. Merchant1, A. Kunac1  1Rutgers New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 2Rutgers Robert Wood Johnson Medical School,Department Of Surgery,New Brunswick, NJ, USA

Introduction: Fundamentals of Endoscopic Surgery (FES) certification is now required for American Board of Surgery exam eligibility. Previous studies have shown that there is a correlation between clinical endoscopy experience and FES exam scores, which are based on a summation of one’s performance of 5 individual tasks on a virtual-reality simulator (VRS). These tasks are meant to test specific endoscopy skills in isolation of one another. When one performs a complete diagnostic colonoscopy, however, one must utilize all of these skills concurrently, rather than in isolation. As such, we aimed to evaluate the association between clinical endoscopy experience and performance of a complete diagnostic colonoscopy on a VRS at two large, academic surgical residency programs.

Methods: PGY2 through PGY5 residents in two large, academic general surgery programs completed an assessment on the Symbionix GI Bronch-Mentor™ VRS. This included 2 brief practice modules followed by “easy” and “difficult” diagnostic colonoscopies. The difficult colon was prone to loop formation. The simulator recorded several performance parameters. Endoscopy numbers for each resident were obtained from ACGME case logs. Correlations between endoscopy experience and performance parameters were assessed using Spearman’s correlation. Bivariate logistic regression was used to assess for an association between experience and both the ability to retroflex as well as complete the colonoscopy. A p-value of <0.05 was considered significant.

Results: The assessment was completed by 55 out of 66 total PGY2 through PGY5 residents across both institutions.

Easy colonoscopy: There was a positive correlation between upper endoscopy experience and percentage of mucosa examined (ρ=0.30; p=0.03). This correlation was not seen with lower or total endoscopy experience. There was no correlation between endoscopy experience and time to cecum, percentage of time the virtual patient was in pain, or ability to retroflex.

Difficult colonoscopy: There was a correlation between upper (ρ=0.37; p=0.02), lower (ρ=0.29; p=0.02), and total (ρ=0.38; p=0.004) endoscopy experience and time to cecum. There was no correlation between endoscopy experience and percentage of mucosa examined, withdrawal time greater than 6 minutes, ability to complete the colonoscopy, and percentage of time the virtual patient was in pain.

Conclusions: Clinical endoscopy experience may correlate with time to cecum in a colon prone to loop formation, suggesting that residents with more experience may be more facile at loop reduction. However, there is no correlation between clinical endoscopy experience and any of the other meaningful performance parameters recorded during a VRS colonoscopy and the VRS may not be a useful surrogate for testing endoscopic skills.

82.03 Surgical Boot Camp for Senior Medical Students: Impact on Objective Skills and Subjective Confidence

Posted on January 31, 2019

J. Simon1, L. A. Bevilacqua1, D. Rutigliano1, S. Docimo1, J. Sorrento1, R. Verma1, A. Wackett2, L. Chandran3, M. Talamini1  1Stony Brook University Medical Center,Surgery,Stony Brook, NY, USA 2Stony Brook University Medical Center,Emergency Medicine,Stony Brook, NY, USA 3Stony Brook University Medical Center,Office Of The Dean,Stony Brook, NY, USA

Introduction: In recent years, boot camp courses for senior medical students have risen in popularity with the goal of improving preparation for residency. While studies have demonstrated increased student confidence after such boot camps, data is lacking on the impact of these courses on objective clinical skills. The American College of Surgeons (ACS) has developed a curriculum for use in such courses. This study aims to test the impact of a Surgical Boot Camp course using the ACS-based curriculum and objective, observer-based rating tools, on both subjective confidence and objective skills of fourth-year medical students.            

Methods: Fourth-year medical students who had matched into surgical subspecialties were invited to participate in a two-week Surgical Boot Camp. Informed consent was obtained on the first day of the course. Prior to any teaching, students performed five tasks (patient handoff, suturing, knot tying, central line placement, and chest tube placement) which were scored using objective rating tools provided by the ACS. Students also completed two subjective confidence measures, the New General Self-Efficacy scale (NSGE) and a Task-Specific Confidence Scale (i.e., "How confident are you placing a central line"). Both measures used a 5-point likert scale. After two weeks of dedicated lectures, simulation, and cadaver-based anatomy review, students were scored on the same five tasks and repeated the confidence measures. To help avoid potential bias, each scorer graded a different skill at pre- and post-course testing, so that they were unaware of scores given by the previous assessor.

Results: Twelve students participated in the Boot Camp. Average age was 26.7 years; 25% of subjects were female. Subspecialties represented included general surgery (N=5) orthopedics (N=3), integrated plastics (N=2), urology (N=1), and neurosurgery (N=1). Scores on objective skills improved significantly in all five tasks at post-course testing (Table 1). Mean NSGE scores did not improve over the study period (4.49 vs. 4.46; p=0.866), however mean scores on task-specific confidence improved significantly (2.77 vs. 3.64; p<0.0010). 

Conclusion: Implementation of a two-week, multimodal Surgical Boot Camp improved student performance on objectively-rated surgical skills and increased student confidence. Research is still lacking on whether, and for how long, these improvements persist into surgical residency. Future studies utilizing larger samples of students with matched controls are needed to confirm these findings and support the use of such boot camps in undergraduate medical education nationwide.

82.02 Implicit Biases in the Operating Room: A Simulation Based Study

Posted on January 31, 2019

S. Jones1, P. P. Parikh1, T. N. Crawford4, P. Hershberger3, A. Cochran2, L. Peterson1, G. Falls1  1Wright State University,Department Of Surgery,Dayton, OH, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA 3Wright State University,Department Of Family Medicine,Dayton, OH, USA 4Wright State University,Division Of Epidemiology And Biostatistics, Department Of Population And Public Health Sciences,Dayton, OH, USA

Introduction: Implicit biases are increasingly recognized as a wide-spread phenomenon in medicine, including surgery.  In surgery, physicians and other providers of different specialties and expertise work together in an operating room (OR) that impacts lives. Any implicit biases in such dynamic environments could lead to poor satisfaction and performance of providers, which in turn may result in poor patient outcomes. The primary objective of this study was to assess perception of the lead surgeon in OR.

Methods:
The simulated scenarios used 8 different actors as lead surgeon with the combination of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). An IRB approved anonymous video-based survey was distributed nationwide to surgeons, residents, OR nurses and ancillary OR staff. It included demographic questions, 3 short videos and questions regarding the perception of the situation and surgeon. The perception towards the lead surgeon was divided into favorable, unfavorable, and neutral categories. Favorable perception included the surgeon’s behavior that was thought to be commendable, acceptable, or the surgeon should have received an apology. The unfavorable perception included responses such as “inform managers of surgeon’s behavior,” “surgeon should apologize to the OR staff,” or the “surgeon should receive probation.” The participants also rated overall performance of the surgeon using a 5-star rating system.

Results:
There were 419 respondents, 53.7% were females. A higher proportion of the respondents (53.5%) were attending surgeons. Our results suggest that both gender and age are significantly associated with the perception of a lead surgeon. Older surgeons were perceived more favorably than their younger counterparts; 50.5% versus 35.6%, respectively. Similarly, male surgeons were perceived more favorably than female surgeons; 47.2 vs. 37.7 (Figure 1). The overall rating of a surgeon suggests that older surgeons were rated higher than younger (3.27 vs 3.05). While assessing the group of older surgeons in details for race, our data showed that older white males were ranked significantly higher (3.53/5) than all other group of surgeons. 

Conclusion:
Widespread perception of gender bias in surgery may not be the only bias that exists in the OR. Our data shows that older surgeons, especially older white males, are perceived more favorably than any other lead surgeon. These results shed light on some of the challenges faced by young surgeons, particularly females, taking on a leadership role in OR.  These results can provide insight in developing inter-professional education curriculum or training for residents, attendings and OR staff to address implicit biases and to foster cohesiveness of the surgical team in order to provide optimal patient care.
 

82.01 Can VR be used to track skills decay during the research years?

Posted on January 31, 2019

H. Mohamadipanah1, K. H. Perrone1, B. Wise1, C. Parthiban2, M. Zinn2, A. Witt1, C. Pugh1  1Stanford University,Palo Alto, CA, USA 2University Of Wisconsin,Madison, WI, USA

Introduction:
In surgery, time away from practice can lead to skills decay. Laboratory residents are thought to be prone to skills decay given their lack of experience and limited exposure to clinical activities. This study takes a cross-sectional approach to assessing differences in residents’ skills at the start and end of their laboratory years using Virtual Reality (VR). We hypothesize that laboratory residents will have measurable decay in psychomotor skills when evaluated using VR.

Methods:
Surgical residents (N=28) were divided into two groups based on where they were in their research time. The first group was just beginning their research time (N=19) and the second group (N=9) had just finished at least 2 years of research. All participants were asked to perform a target-tracking task using a haptic device in a VR environment (Figure 1). In this task participants used a stylus to follow a moving target on a screen. To challenge residents to demonstrate their psychomotor abilities, random distracting forces were applied to the stylus throughout the task with varying levels of force. Psychomotor skills demonstrated during this task include hand-eye coordination, motor-control, reaction time and error management. The metric investigated in this study was “Tracking Error”, defined as the average distance of the stylus to the center of the moving target. Analysis was conducted using a two-sample t-test.

Results:
The second group, who just finished their research time, showed a higher level of “Tracking Error”, when compared to the first group, who just started their research time, (mean 16.9±4.3mm vs 14.1±2.0mm; t(26)=2.39, p=0.0245).

Conclusion:
The increased “Tracking Error” among residents at the end of their research time suggests psychomotor skills decay in residents who spend time away from clinical duties in a laboratory. This decay demonstrates the need for research residents to regularly participate in clinical activities, simulation or assessment to minimize and monitor skills decay while away from clinical practice. Additional longitudinal studies may help to better map learning and decay curves for residents who spend time in the laboratory.
 

81.10 Renal Function Changes Following Fenestrated Endovascular Abdominal Aortic Aneurysm Repair (fEVAR)

Posted on January 31, 2019

M. M. Oberdoerster1, M. M. Wynn1, P. D. DiMusto1  1University Of Wisconsin,Madison, WI, USA

Introduction:  Fenestrated endovascular abdominal aortic aneurysm repair (fEVAR) has been approved for clinical use since 2012.  One possible complication of this repair is impairment in renal function. We sought to assess the clinical outcomes related to renal function over time in patients undergoing fEVAR at our tertiary referral center.

Methods:  A retrospective review was conducted of prospectively collected data on all patients undergoing fEVAR at our institution between 2012 and 2017.  Patient characteristics, procedural variables, laboratory values, and imaging characteristics were collected. Serum creatinine was measured preoperatively, and at 1 month, 6 months, 1 year and yearly thereafter. Estimated glomerular filtration rate was calculated using the Cockcroft Gault equation.

Results: A total of 58 patients were included: 42 men and 16 women with an average age of 75 years. The average follow up time was 469 days; 6 patients were lost to follow up.  A total of 111 out of 116 main renal arteries were successfully revascularized. Only one main renal artery that was planned for revascularization was not due to the inability to place a stent intraoperatively. The other four were above the graft and did not require revascularization.  There were 11 accessory renal arteries that were covered with the aortic graft. 

Eighteen patients (31%) had advanced chronic kidney disease (CKD) prior to the repair; 17 stage III, 1 stage IV.  Nine patients (15.5%), including 3 of the 18 who had CKD prior to the repair, had an increase of at least 30% from baseline creatinine over two or more follow up visits.  All nine had evidence of post-operative renal insult including infarct, renal artery stenosis, or occlusion. Four patients (7%) with no prior history of CKD progressed to stage II, 13 (22%) patients progressed from stage II to III, and 3 patients (5%) progressed from stage III to stage IV over the follow up period. Only the patient with stage IV CKD at the time of the repair went on to require dialysis 8 months after his procedure. 

Eight patients (13.7%) developed stenosis in one of the renal artery stents.  Five of these patients had worsening of their renal function with progression by one CKD stage.  Two patients had an intervention due to the stenosis, but only one was successful.  Four additional patients developed a renal artery occlusion, three of which had a progression of CKD by one stage.  None of these patients went on to dialysis. A total of 24 patients (41%) developed renal infarction on imaging over the follow up period. Nine of these patients had progression of their CKD stage, however none went on to dialysis.  

Conclusion: Our review demonstrates that while kidney dysfunction can occur over the long term following fEVAR, rates of worsening renal function are relatively low.  Additionally, in patients with pre-operative CKD, fEVAR remains safe and effective with low rates of progression to dialysis.  
 

81.09 Assessment of the “Weekend Effect” in Lower Extremity Vascular Trauma

Posted on January 31, 2019

A. K. Jundoria1, B. Grant1, O. A. Olufajo1, E. De La Cruz1, D. Metcalfe2, M. Williams1, E. E. Cornwell1, K. Hughes1  1Howard University College Of Medicine,Washington, DC, USA 2University of Oxford,Nuffield Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences (NDORMS),Oxford, OX3 9BU, United Kingdom

Introduction:  Numerous studies have suggested that compared to the weekday, weekend admissions may be associated with worse patient outcomes across a range of patient diagnoses. Lower extremity vascular trauma is increasingly common and requires immediate/urgent surgical intervention. Although this weekend effect has been reported for several domains, it has not been elucidated in vascular trauma. The objective of this study was to determine if there is a weekend effect in patient outcomes of lower extremity vascular trauma (LEVT).

Methods:  Retrospective data was retrieved from the National Inpatient Sample database, a 20% stratified sample of the United States inpatient population, from 2005 – 2014. Patients ages 18 and above with International Classification of Diseases, 9th Edition codes indicating trauma to the lower extremity vessels were included. Patients and hospital characteristics were extracted including age, sex, race, insurance type, median household income, Injury Severity Score, Charlson comorbidity score, Abbreviated Injury Scale (AIS) for extremity body region, and location/teaching status of hospital. Outcomes (mortality, amputation, hospital length of stay, and discharge disposition) among patients admitted on weekdays versus patients admitted on weekends were measured. Independent factors associated with outcomes were identified using multivariable regression models. Supplementary analyses were performed using patients with only isolated LEVT, which was defined by AIS of zero in every body region except extremity.

Results: There were 9282 patient records with LEVT (2866 admitted on the weekend vs. 6416 admitted on the weekday). Compared to patients admitted on the weekday, patients admitted on the weekends were more likely to be younger than 45 years old (67.6% vs. 55.4%), males (80.5% vs. 74.6%), and uninsured (22.1% vs. 17.2%) [all p < 0.001]. Comparison of outcomes for patients on weekend vs. weekday showed mortality of 3.80% vs. 3.29% [p = 0.209], amputation rates of 7.85% vs. 7.19% [p = 0.258], hospital length of stay (LOS) of 15.5 days vs. 13.8 days [p = 0.009], and discharge home rates of 57.3% vs. 56.1% [p = 0.271]. The multivariable regressions showed the following outcomes for weekend vs. weekday admissions: mortality (Odds Ratio, OR [95% Confidence Interval, CI]); 1.06 [0.79-1.40], amputation (OR [95% CI]); 1.09 [0.89-1.30], discharge home (OR [95% CI]); 0.95 [0.85-1.06] and hospital LOS (predicted mean LOS [95% CI]); 0.33 [-0.34-1.00].

Conclusion: This study demonstrated there was no weekend effect identified in patients admitted with LEVT in the United States. This suggests that there is likely no difference in the level of care given to lower extremity vascular trauma patients, regardless of whether they present on a weekend or on a weekday.

 

Next Page »