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Objective: To compare long-term quality of life (QOL) outcomes in breast cancer survivors who received breast-conserving surgery with radiotherapy (BCS+RT) with those who received a mastectomy and reconstructive surgery (Mast+Recon) without radiotherapy and identify other important factors. Background: The long-term differences in patient-reported QOL outcomes following BCS+RT and Mast+Recon are not well understood. Methods:We identified patients from the Texas Cancer Registry with stage 0--II breast cancer diagnosed in 2009--2014 after BCS+RT orMast+Recon without radiotherapy. Sampling was stratified by age and race and ethnicity. A paper survey was sent to 4800 patients which included validated BREAST-Q and PROMIS modules. Multivariable linear regression models were implemented for each outcome.Minimal clinically important difference for BREAST-Q and PROMIS modules, respectively, was 4 points and 2 points. Results: Of 1215 respondents (25.3% response rate), 631 received BCS +RT and 584 received Mast+Recon. The median interval from diagnosis to survey completion was 9 years. In adjusted analysis, Mast+Recon was associated with worse BREAST-Q psychosocial well-being (effect size: 3.80, P=0.04) and sexual well-being (effect size: 5.41, P=0.02), but better PROMIS physical function (effect size: 0.54, P=0.03) and similar BREAST-Q satisfaction with breasts, physical well-being, and PROMIS upper extremity function (P>0.05) compared with BCS+RT. Only the difference in sexual well-being reached clinical significance. Older (≥65) patients receiving BCS+RT and younger (< 50) patients receiving autologous Mast+Recon typically reported higher QOL scores. Receipt of chemotherapy was associated with detriments to multiple QOL domains. Conclusions: Patients who underwent Mast+Recon reported worse longterm sexual well-being compared with BCS+RT. Older patients derived a greater benefit from BCS+RT, while younger patients derived a greater benefit from Mast+Recon. These data inform preference-sensitive decision- making for women with early-stage breast cancer. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the prevalence of incivility among trainees and faculty in cardiothoracic surgery, general surgery, plastic surgery, and vascular surgery in the U.S, and to determine the association of incivility on job and work withdrawal and organizational commitment. Background: Workplace incivility has not been described in surgery and can negatively impact the well-being of individuals, teams, and organizations at-large. Methods: Using a cross-sectional, web-based survey study of trainees and faculty across 16 academic institutions in the U.S., we evaluated the prevalence of incivility and its association with work withdrawal and organizational commitment. Results: There were 486 (18.3%) partial responses, and 367 (13.8%) complete responses from surgeons [including 183 (56.1%) faculty and 143 (43.9%) residents or fellows]. Of all respondents, 92.2% reported experiencing at least 1 form of incivility over the past year. Females reported significantly more incivility than males (2.4 ± 0.91 versus 2.05 ± 0.91, P < 0.001). Asian Americans reported more incivility than individuals of other races and ethnicities (2.43 ± 0.93, P = 0.003). After controlling for sex, position, race, and specialty, incivility was strongly associated with work withdrawal (β = 0.504, 95% CI: 0.341–0.666). There was a significant interaction between incivility and organizational commitment, such that highly committed individuals had an even greater impact of incivility on the outcome of job and work withdrawal (β = 0.178, 95% CI: 0.153–0.203). Conclusions: Incivility is widespread in academic surgery and is strongly associated with work withdrawal. Leaders must invest in strategies to eliminate incivility to ensure the well-being of all individuals, teams, and organizations at-large. [ABSTRACT FROM AUTHOR]

Objective: We sought to gain a comprehensive understanding of the current methods for conflict resolution and the ways in which women surgeons would prefer workplace conflicts to be adjudicated. Summary of Background Data: Interprofessional workplace conflicts are poorly studied, particularly for women in surgery. These conflicts may negatively impact surgical team dynamic and be detrimental to patient safety. Moreover, workplace conflicts and their management are a proposed driver of decreased professional satisfaction and achievement. How women surgeons experience workplace conflicts and how these are managed remains unexplored. Methods: We conducted 30 semi-structured interviews with women surgeons across the United States who had experienced workplace conflict that resulted in action by a nonphysician. Surgeons were diverse with respect to demographics, specialty, and institutional settings. Through thematic analysis using NVivo, we analyzed and reported patterns within the data. Results: Although the majority of women asserted resilience in how they engage with these situations, many also cited ways in which these events could better be adjudicated. Recommendations included (1) more direct conflict resolution, (2) more transparency in reporting processes, (3) greater opportunity to address complaints, (4) explicit policies for events that repeatedly result in workplace conflict, and (5) divorcing interpersonal complaints from patient safety reporting mechanisms. Conclusion: This study motivates and informs best practices around adjudication of workplace conflict to help protect women surgeons and nonclinicians. Going forward, best practices should include more objective criteria for how conflicts are adjudicated. Continued efforts at an institutional level are needed to help mitigate inequities against women surgeons. [ABSTRACT FROM AUTHOR]

Gender inequality exists in advanced faculty and leadership positions at academic medical centers; however, despite growing awareness, how to best approach and rectify the issue is unknown. To energize the conversation on gender inequality at one academic medical center, chairs and women faculty were surveyed to identify barriers faced by women navigating their careers. A symposium with short talks to increase awareness, a panel with University leaders to discuss issues and successful strategies to overcome gaps, and focus groups to delve further into key areas that underlie inequity through an active café style format were planned and implemented. This multifaceted approach resulted in a wealth of knowledge. The symposium and panel highlighted important relevant issues and offered personal strategies for successful career advancement, while the focus group discussions further identified barriers and inspired ongoing efforts across departments and novel approaches to overcome three key issues (work-life integration, deliberate promotion of mentor/sponsor relationships, and overcoming unconscious bias) identified through the initial surveys. Compiled data were then disseminated to participants and University leaders to enhance awareness of available programs and prompt action in critical areas lacking support. Overall, the approach indicated that securing support from leaders and the academic community alike are pertinent to emphasize actions needed to overcome issues affecting women in academic medicine. Moreover, bringing leaders and faculty together for an informational session and brainstorming appears to energize the conversation. Such efforts can ultimately instill change and establish an inclusive environment where all members of the academic medicine community can thrive. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to determine specialist physicians’ attitudes and practices regarding disclosure of pre-referral errors. Summary Background Data: Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. Methods: We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. Results: Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient–physician relationships. Conclusions: Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development. [ABSTRACT FROM AUTHOR]

Objective: To evaluate complications after postmastectomy breast reconstruction, particularly in the setting of adjuvant radiotherapy. Background: Most studies of complications after breast reconstruction have been conducted at centers of excellence; relatively little is known about complication rates in irradiated patients treated in the broader community. This information is relevant for decision making in patients with breast cancer. Methods: Using the claims-based MarketScan database, we described complications in 14,894 women undergoing mastectomy for breast cancer from 1998 to 2007 and who underwent immediate autologous reconstruction (n = 2637), immediate implant-based reconstruction (n = 3007), or no reconstruction within the first 2 postoperative years (n = 9250). We used a generalized estimating equation to evaluate associations between complications and radiotherapy over time. Results: Wound complications were diagnosed within the first 2 postoperative years in 2.3% of patients without reconstruction, 4.4% patients with implants, and 9.5% patients with autologous reconstruction (P < 0.001). Infection was diagnosed within the first 2 postoperative years in 12.7% of patients without reconstruction, 20.5% with implants, and 20.7% with autologous reconstruction (P < 0.001). A total of 5219 (35%) women received radiation. Radiation was not associated with infection in any surgical group within the first 6 months but was associated with an increased risk of infection in months 7 to 24 in all 3 groups (each P < 0.001). In months 7 to 24, radiation was associated with higher odds of implant removal in patients with implant reconstruction (odds ratio = 1.48; P < 0.001) and fat necrosis in those with autologous reconstruction (odds ratio = 1.55; P = 0.01). Conclusions: Complication risks after immediate breast reconstruction differ by approach. Radiation therapy seems to modestly increase certain risks, including infection and implant removal. [ABSTRACT FROM AUTHOR]