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Almost half of practicing surgeons in the United States are currently older than 55, but guidelines on how to prepare for retirement are limited. We sought to identify possible facilitators for, and obstacles to, surgeons' preparations for retirement.A qualitative study was conducted using semi-structured interviews with clinically inactive academic surgeons. Emergent themes were identified via a grounded theory approach.We interviewed 12 surgeons (83% male; median age 75 years). Major barriers to retirement from surgery included uncertainty about when to retire, limited identity outside of surgery, and perception of retirement as strictly individual/private. Facilitators of a successful retirement identified by the participants included early career financial planning, awareness of career trajectory, development of post-surgery goals, and utilization of collective knowledge.There are numerous barriers encountered by surgeons seeking to transition from clinical practice to retirement that could be overcome by dedicated departmental and institutional efforts.

Universal spinal immobilization has been the standard of prehospital trauma care since the 1960s. Selective immobilization has been shown to be safe and effective for emergency medical services use, but it is unclear whether such protocols reduce unnecessary and potentially harmful immobilization practices. This study evaluated the impact of a selective spinal immobilization protocol on practice patterns in a regional trauma system.All encounters for traumatic injury in the Tidewater Emergency Medical Services region from 2010 to 2016 were extracted from the Virginia Pre-Hospital Information Bridge. An interrupted time series analysis was used to assess practice change after system-wide protocol implementation in 2013. Intravenous access was used as a nonequivalent outcome measure in the absence of an appropriate control group.A total of 63,981 encounters were analyzed. At baseline, 16.7% of patients underwent full immobilization. The preprotocol slope was slightly positive (0.2% per month; 95% confidence interval, 0.1-0.2%). Slope and level changes after protocol implementation did not differ from those observed for intravenous access (-0.4% vs. -0.4% per month [ p = 0.4917] and -1.6% vs. -1.1% [ p = 0.1202], respectively). Cervical spinal immobilization became more common over the postimplementation period (0.1% per month; 95% confidence interval, 0.1-0.1%). Rates of immobilization for isolated penetrating trauma remained unchanged.Implementation of a selective spinal immobilization protocol did not reduce prehospital immobilization rates in a regional trauma system. Given the entrenched nature of immobilization practices, more intensive education and training strategies are needed. Efforts should prioritize eliminating immobilization for isolated penetrating trauma given its association with increased mortality.Therapeutic/Care Management; Level IV.

Objective To report the 30-day outcomes of patients with perioperative SARS-CoV-2 infection undergoing surgery in the USA. Summary background data Uncertainty regarding the postoperative risks of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exists. Methods As part of the COVIDSurg multicenter study, all patients aged ≥17 years undergoing surgery between January 1 and June 30, 2020 with perioperative SARS-CoV-2 infection in 70 hospitals across 27 states were included. The primary outcomes were 30-day mortality and pulmonary complications. Multivariable analyses (adjusting for demographics, comorbidities, and procedure characteristics) were performed to identify predictors of mortality. Results A total of 1,581 patients were included; more than half of them were males (n= 822, 52.0%) and older than 50 years (n=835, 52.8%). Most procedures (n=1,261, 79.8%) were emergent, and laparotomies (n= 538, 34.1%). The mortality and pulmonary complication rates were 11.0 and 39.5%, respectively. Independent predictors of mortality included age ≥70 years (OR 2.46, 95% CI [1.65-3.69]), male sex (2.26 [1.53-3.35]), ASA grades 3-5 (3.08 [1.60-5.95]), emergent surgery (2.44 [1.31-4.54]), malignancy (2.97 [1.58-5.57]), respiratory comorbidities (2.08 [1.30-3.32]), and higher Revised Cardiac Risk Index (1.20 [1.02-1.41]). While statewide elective cancelation orders were not associated with a lower mortality, a sub-analysis showed it to be associated with lower mortality in those who underwent elective surgery (0.14 [0.03-0.61]). Conclusions Patients with perioperative SARS-CoV-2 infection have a significantly high risk for postoperative complications, especially elderly males. Postponing elective surgery and adopting non-operative management, when reasonable, should be considered in the USA during the pandemic peaks.

Shifts in American healthcare delivery mechanisms pose significant hurdles to new physicians. Surgeons are particularly susceptible to these changes, but surgical residency educational efforts primarily focus on technical and clinical training to the exclusion of business and management practices. This study conducted a needs assessment of perceived gaps in practice management skills among early career surgeons to guide future training curricula.This study was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify early career (5 years following fellowship completion) surgeons across the United States. A semi-structured interview guide was created from interviews with surgical administrators and physician administrative curricula. Transcripts were de-identified and analyzed using a constructivist grounded theory approach.Ten surgeons from 6 specialties and 6 institutions were interviewed along with 3 surgeon administrators. Three major domains of need were identified: (1) fundamentals of procedural coding, clinical billing,compliance, (2) finding/building a practice, and (3) navigating organizational challenges. First, surgeons thought trainees would benefit from a better understanding of reimbursement schema and the basics of health policy. They also thought that more exposure to malpractice litigation, especially for handling case review or expert witness requests, would be helpful for discerning how to handle such issues early in their career. In addition, early career surgeons expressed a desire to have dedicated mentorship time, a primer on evaluating job offers with simulated contract negotiation, and guidance regarding administrative roles. Finally, surgeons requested training in change management techniques, care pathway construction, and the basics of staffing decisions.There are significant practice management gaps in surgical training which may be amenable to targeted educational efforts during a residency or fellowship program. Future research will test the generalizability of these findings as well as build curricula that adequately meet these needs.

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. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08691-9.

OBJECTIVES: This study aimed to determine the strategies used and critical considerations among an international sample of hospital leaders when mobilizing human resources in response to the clinical demands associated with the COVID-19 pandemic surge. METHODS: This was a cross-sectional, qualitative research study designed to investigate strategies used by health system leaders from around the world when mobilizing human resources in response to the global COVD-19 pandemic. Prospective interviewees were identified through nonprobability and purposive sampling methods from May to July 2020. The primary outcomes were the critical considerations, as perceived by health system leaders, when redeploying health care workers during the COVID-19 pandemic determined through thematic analysis of transcribed notes. Redeployment was defined as reassigning personnel to a different location or retraining personnel for a different task. RESULTS: Nine hospital leaders from 9 hospitals in 8 health systems located in 5 countries (United States, United Kingdom, New Zealand, Singapore, and South Korea) were interviewed. Six hospitals in 5 health systems experienced a surge of critically ill patients with COVID-19, and the remaining 3 hospitals anticipated, but did not experience, a similar surge. Seven of 8 hospitals redeployed their health care workforce, and 1 had a redeployment plan in place but did not need to use it. Thematic analysis of the interview notes identified 3 themes representing effective practices and lessons learned when preparing and executing workforce redeployment: process, leadership, and communication. Critical considerations within each theme were identified. Because of the various expertise of redeployed personnel, retraining had to be customized and a decentralized flexible strategy was implemented. There were 3 concerns regarding redeployed personnel. These included the fear of becoming infected, the concern over their skills and patient safety, and concerns regarding professional loss (such as loss of education opportunities in their chosen profession). Transparency via multiple different types of communications is important to prevent the development of doubt and rumors. CONCLUSIONS: Redeployment strategies should critically consider the process of redeploying and supporting the health care workforce, decentralized leadership that encourages and supports local implementation of system-wide plans, and communication that is transparent, regular, consistent, and informed by data.

OBJECTIVE: To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. SUMMARY BACKGROUND DATA: Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. METHODS: This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative (MBSC). Surgeons were categorized as coach, participant, or non-participant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. RESULTS: The coaching program was viewed favorably by most surgeons and many participants described numerous technical and non-technical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants and non-participants of 0.99 (0.62–1.37), 0.91 (0.64–1.17) and 1.15 (0.83–1.47), respectively. Operative times did improve for participants, but not coaches or non-participants, with risk differences of −14.0 (−22.3, −5.7), −1.0 (−4.5, 2.4), and −2.6 (−6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. CONCLUSIONS: This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (2.5kg) is associated with poor surgical outcomes.Patients who underwent enterostomy reversal from 2005 to 2013 at less than 6months old were identified in our institutional database. Only patients who underwent emergent enterostomy creation (i.e. for necrotizing enterocolitis or spontaneous perforation) were included. Demographics, disease process, comorbidities, stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of p0.05. The primary outcome examined was major morbidity, defined as the presence of anastomotic leak, obstruction, hernia, EC fistula, perforation, wound infection, sepsis, or death.Eighty-nine patients met inclusion criteria. Demographics (sex, ethnicity, surgical disease process, reversal indication, and ASA score) were similar. The lowest weight group had lower gestational age (p0.001) and birth weight (p=0.005), and contained a higher proportion of jejunostomies to ileostomies (p=0.013). On univariable analysis, only incisional hernia was significantly different as a complication between weight groups. On multivariable analysis controlling for gestational age and ASA, there was no significant difference in odds of major operative morbidity between groups.Enterostomy reversal at lower weight may not be associated with increased risk of perioperative complications. Early stoma reversal may be acceptable when required for progression of neonatal care.Level III, Treatment Study (Retrospective comparative study).

Summary A 39-year-old Negro woman had the mesenchymal type of generalized amyloidosis and myeloma of bone. Malnutrition and heart failure dominated the clinical course and led to her death. The autopsy study is summarized in the following diagnoses