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Introduction: Efforts have been made to increase the number of women and physicians who are underrepresented in medicine (UIM). However, surgery has been slow to diversify, and there are limited data surrounding the impact of intersectionality., Objective: To assess the combined association of race and ethnicity and sex with rates of promotion and attrition among US academic medical department of surgery faculty., Design, Setting, and Participants: This was a retrospective cohort study using faculty roster data from the Association of American Medical Colleges. All full-time academic department of surgery faculty with an appointment any time from January 1, 2005, to December 31, 2020, were included. Study data were analyzed from September 2022 to February 2023., Exposures: Full-time academic faculty in a department of surgery with a documented self-reported race, ethnicity, and sex within the designated categories of the faculty roster of Association of American Medical Colleges., Main Outcomes and Measures: Trends in race and ethnicity and sex, rates of promotion, and rates attrition from 2010 to 2020 were assessed with Kaplan-Meier and Cox time-to-event analyses., Results: A total of 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 institutions were included. The mean (SD) program percentage of UIM male faculty increased from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty members increased from 2.3% (2.6%) to 3.3% (2.5%) over the 10-year period (P < .001). The mean program percentage of non-UIM females increased at every rank (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all P < .001). There was no change in the mean program percentage of UIM female instructors or full professors. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%) and 1.6% (3.2%) to 2.2% (3.4%), respectively (P =.002). There was no change in the mean program percentage of UIM male instructors, associate, or full professors. Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). Non-UIM males had the shortest median (IQR) time to promotion, whereas non-UIM females had the longest (6.9 [6.8-7.0] years vs 7.2 [7.0-7.6] years, respectively; P < .001). After 10 years, 79% of non-UIM males (13 202 of 16 299), 71% of non-UIM females (3784 of 5330), 68% of UIM males (1738 of 2538), and 63% of UIM females (625 of 999) remained on the faculty. UIM females had a higher risk of attrition compared with non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001) and UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .05). The mean (SE) time to attrition was shortest for UIM females and longest for non-UIM males (8.2 [0.14] years vs 9.0 [0.02] years, respectively; P < .001)., Conclusion and Relevance: Results of this cohort study suggest that intersectionality was associated with promotion and attrition, with UIM females least likely to be promoted and at highest risk for attrition. Further efforts to understand these vulnerabilities are essential.

Based on census data, over one-third of the US population identifies as a racial or ethnic minority. This group of racial and ethnic minorities is more likely to develop cancer and die from it when compared with the general population of the USA. These disparities are most pronounced in the African American community. Despite overall CRC rates decreasing nationally and within certain racial and ethnic minorities in the USA, there continue to be disparities in incidence and mortality when compared with non-Hispanic Whites. The disparities in CRC incidence and mortality are related to systematic racism and bias inherent in healthcare systems and society. Disparities in CRC management will continue to exist until specific interventions are implemented in the context of each racial and ethnic group. This review's primary aim is to highlight the disparities in CRC among African Americans in the USA. For surgeons, understanding these disparities is formative to creating change and improving the quality of care, centering equity for all patients., (© 2021. Society of Surgical Oncology.)

Background: Success in academic surgery is challenging and research cannot survive without funding. NIH K-awards are designed to mentor junior investigators to achieve independence. As a result we aimed to study K awardees in departments of surgery and learn from their experience., Material and Methods: Utilizing the NIH RePORTer database and filtering by department of surgery, clinically active surgeons receiving a K-award between 2008 and 2018 were asked to complete an online survey. Qualitative data from two open-ended questions were coded independently using standard qualitative methods by three researchers. Using grounded theory, major themes emerged from the codes., Results: Of the 144 academic surgeons identified, 89 (62%) completed the survey. The average age was 39 ± 3 when the K-award was granted. Most identified as white (69%). Men (70%) were more likely to be married (P = 0.02) and have children (P = 0.05). To identify intention to pursue R01 funding, surgeons having a K-award for 5 y or more were analyzed (n = 45). Most either intended to (11%) or had already applied (80%) of which 36% were successful. Men were more likely to apply (P = 0.05). Major themes to succeed include protected time, mentorship, and support from leadership. Common barriers to overcome include balancing time, pressures to be clinically productive, and funding., Conclusions: The demographics and career trajectory of NIH K-awarded surgeons is described. The lack of underrepresented minorities receiving grants is concerning. Most recipients required more than one application attempt and plan to or have applied for R01 funding. The major themes were very similar; a supportive environment and time available for research are the most crucial factors to succeed as an academic surgeon., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: As an increasing number of general surgery residents apply for fellowship positions, it is important to identify factors associated with successful matriculation. For applicants to colon and rectal surgery, there are currently no objective data available to distinguish which applicant attributes lead to successful matriculation., Objective: The purpose of this study was to identify objective factors that differentiate colon and rectal surgery fellowship applicants who successfully matriculate with those who apply but do not matriculate., Design: This was a retrospective analysis of colon and rectal surgery applicant characteristics., Settings: Deidentified applicant data provided by the Association of American Medical Colleges from 2015 to 2017 were included., Main Outcome Measures: Applicant demographics, medical school and residency factors, number of program applications, number of publications, and journal impact factors were analyzed to determine associations with successful matriculation., Results: Most applicants (n = 371) and subsequent matriculants (n = 248) were white (61%, 62%), male (65%, 63%), US citizens (80%, 88%) who graduated from US allopathic medical schools (66%, 75%). Statistically significant associations included graduation from US allopathic medical schools (p < 0.0001), US citizenship (p < 0.0001), and number of program applications (p = 0.0004). Other factors analyzed included American Osteopathic Association membership (p = 0.57), university-based residency (p = 0.51), and residency association with a colon and rectal surgery training program (p = 0.89). Number of publications and journal impact factors were not statistically different between cohorts (p = 0.067, p = 0.150)., Limitations: American Board of Surgery In-Training Examination scores, rank list, and subjective characteristics, such as strength of interview and letters of recommendation, were not available using our data source., Conclusions: Successful matriculation to a colon and rectal surgery fellowship program was found to be associated with US citizenship, graduation from a US allopathic medical school, and greater number of program applications. The remaining objective metrics analyzed were not associated with successful matriculation. Subjective and objective factors that were unable to be measured by this study are likely to play a determining role. See Video Abstract at http://links.lww.com/DCR/B415., Evaluacin De Factores Vinculados En La Inmatriculacin Exitosa Para Becas De Ciruga Colorrectal: ANTECEDENTES:A medida que un número cada vez mayor de residentes de Cirugía General solicitan una beca, es importante identificar los factores vinculados con una inmatriculación exitosa. Para los candidatos a una beca en Cirugía Colorrectal, hoy en día no existen datos objetivos disponibles para distinguir qué atributos del solicitante conducen a una inmatriculación exitosa.OBJETIVO:Identificar objetivamente los factores que diferencian un candidato a una beca en Cirugía Colorrectal que se inmatricula con éxito de aquel que aplica pero no llega a inmatricularse.DISEÑO:Análisis retrospectivo de las características de los solicitantes de beca para Cirugía Colorrecatl.AJUSTES:Datos de los solicitantes no identificados, proporcionados por la Asociación de Colegios Médicos Estadounidenses de 2015 a 2017.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los factores demográficos del solicitante, las facultades de medicina y los factores de la residencia, el número de solicitudes de programas, el número y el factor de impacto de las publicaciones realizadas para determinar la asociación con una inmatriculación exitosa.RESULTADOS:La mayoría de los solicitantes (n = 371) que posteriormente fueron inmatriculados exitosamente (n = 248) eran blancos (61%, 62%, respectivamente), hombres (65%, 63%), ciudadanos estadounidenses (80%, 88%) que se graduaron de Facultades de medicina alopática en los EE. UU. (66%, 75%). Las asociaciones estadísticamente significativas incluyeron la graduación de las escuelas de medicina alopática de los EE. UU. (P <0,0001), la ciudadanía de los EE. UU. (P <0,0001) y el número de solicitudes de programas (p = 0,0004). Otros factores analizados incluyeron: membresía AOA (p = 0,57), la residencia universitaria (p = 0,51) y asociación de la residencia con un programa de formación en Cirugía Colorrectal (p = 0,89). El número de publicaciones y los factores de impacto de las revistas no fueron estadísticamente diferentes entre las cohortes (p = 0,067, p = 0,15, respectivamente).LIMITACIONES:El Score ABSITE, la posición en lista de clasificación y las características subjetivas como el de una buena entrevista y las cartas de recomendación no se encontraban disponibles en la fuente de datos.CONCLUSIONES:Se encontró que la inmatriculación exitosa a un programa de becas de Cirugía Colorreectal estaba asociada con la ciudadanía estadounidense, la graduación en una Facultad de medicina alopática en los EE. UU, y al mayor número de solicitudes de programas. El analisis de las medidas objetivas restantes no se asociaron con una inmatriculación exitosa. Es probable que los factores subjetivos y objetivos que no pudieron ser medidos por este estudio jueguen un papel determinante. Consulte Video Resumen en http://links.lww.com/DCR/B415. (Traducción-Dr Xavier Delgadillo)., (Copyright © The ASCRS 2020.)

Background: Attrition from general surgery residency is high with a national rate of 20%. We evaluated potential associations between financial considerations and attrition., Methods: National prospective cohort study of categorical general surgery trainees., Results: Of the 1048 interns who started training in 2007, 681 (65%) had complete survey and follow-up data. In logistic regression, those with higher starting attending salary expectations (>$300K) were more likely to leave training (OR 2.9, 95% CI 1.2-6.9). Women with a partner who earned more (>$50K/year) were more likely to leave training (OR 4.1, 95% CI 1.6-10.5). In a subgroup of interns undecided about their future practice setting (academic, community, private practice, industry), those with less debt (≤$100K) were more likely to leave training (OR 2.4, 95% CI 1.1-5.2)., Conclusions: Several financial matters were associated with attrition. Addressing these financial concerns may help decrease attrition in surgical training and improve surgical training., Competing Interests: Declaration of competing interest Dr. Yeo’s spouse receives salary from Bioscrip, Inc. a home infusion company. Dr. Sosa is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by Novo Nordisk, GlaxoSmithKline, Astra Zeneca, and Eli Lilly. Drs. Dolan and Symer receive support from an NIH AHRQ T-32HS000066 grant. The authors have no other potential conflicts to disclose., (Copyright © 2020. Published by Elsevier Inc.)

Importance: American Board of Surgery board certification requires passing both a written qualifying examination and an oral certifying examination. No studies have been conducted assessing the effect of sociodemographic variables on board passage rates., Objective: To evaluate if trainee sociodemographic factors are associated with board passage rates., Design, Setting, and Participants: This national and multi-institutional prospective observational cohort study of 1048 categorical general surgery trainees starting in 2007-2008 were surveyed. Data collection began in June 2007, follow-up was completed on December 31, 2016, and analysis began September 2018., Main Outcomes and Measures: Survey responses were linked to American Board of Surgery board passage data., Results: Of 662 examinees who had complete survey and follow-up data, 443 (65%) were men and 459 (69%) were white, with an overall board passage rate of 87% (n = 578). In a multinomial regression model, trainees of Hispanic ethnicity were more likely to not attempt the examinations (vs passed both) than non-Hispanic trainees (odds ratio [OR], 4.7; 95% CI, 1.5-14). Compared with examinees who were married with children during internship, examinees who were married without children (OR, 0.3; 95% CI, 0.1-0.8) or were single (OR, 0.4; 95% CI, 0.2-0.9) were less likely to fail the examinations. Logistic regression showed white examinees compared with nonwhite examinees (black individuals, Asian individuals, and individuals of other races) (OR, 1.8; 95% CI, 1.03-3.0) and examinees who performed better on their first American Board of Surgery In-Training Examination (OR, 1.03; 95% CI, 1.02-1.05) were more likely to pass the qualifying examination on the first try. White examinees compared with nonwhite examinees (OR, 1.8; 95% CI, 1.1-2.8), non-Hispanic compared with Hispanic examinees (OR, 2.4; 95% CI, 1.2-4.7), and single women compared with women who were married with children during internship (OR, 10.3; 95% CI, 2.1-51) were more likely to pass the certifying examination on the first try., Conclusions and Relevance: Resident race, ethnicity, sex, and family status at internship were observed to be associated with board passage rates. There are multiple possible explanations for these worrisome observations that need to be explored. Tracking demographics of trainees to help understand passage rates based on demographics will be important. The American Board of Surgery already has begun addressing the potential for unconscious bias among board examiners by increasing diversity and adding implicit bias training.

Objective: To describe public willingness to participate in regionalized surgical care for cancer., Summary of Background Data: Improved outcomes at high-volume centers following complex surgery have driven a push to regionalize surgical care. Patient attitudes toward regionalization are not well described., Methods: As part of the Cornell National Social Survey, a cross-sectional telephone survey was performed. Participants were asked about their willingness to seek regionalized care in a hypothetical scenario requiring surgery. Their responses were compared with demographic characteristics. A geospatial analysis of hospital proximity was performed, as well as a qualitative analysis of barriers to regionalization., Results: Cooperation rate was 48.1% with 1000 total respondents. They were an average of 50 years old (range 18 to 100 years) and 48.9% female. About 49.6% were unwilling to travel 5 hours or more to seek regionalized care for improved survival. Age >70 years [odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.19-0.60] and perceived distance to a center >30 minutes (OR 0.60, 95% CI 0.41-0.86) were associated with decreased willingness to seek regionalized care, while high income (OR 2.09, 95% CI 1.39-3.16) was associated with increased willingness. Proximity to a major center was not associated with willingness to travel (OR 0.92, 95% CI 0.67-1.22). Major perceived barriers to regionalization were transportation, life disruption, social support, socioeconomic resources, poor health, and remoteness., Conclusion: Americans are divided on whether the potential for improved survival with regionalization is worth the additional travel effort. Older age and lower income are associated with reduced willingness to seek regionalized care. Multiple barriers to regionalization exist, including a lack of knowledge of the location major centers.

Background: Racial/ethnic diversity remains poor in academic surgery. However, no study has quantified differences in the rates of retention and promotion of underrepresented minority (URM) academic surgeons., Methods: The American Association of Medical Colleges Faculty Roster was used to track all first-time assistant and associate professors appointed between 1/1/2003 and 12/31/2006. Primary endpoints were percent promotion and retention at ten-year follow-up., Results: Initially, the majority of assistant and associate professors of surgery were White (62%; 75%). Black assistant professors had lower 10-year promotion rates across all specialties (p < 0.01). There were no race/ethnicity-based differences in promotion for associate professors. Retention rates were higher for White assistant professors than Asian or Black/Hispanic/Other minority faculty (61.3% vs 52.8% vs. 50.8% respectively; p < 0.01). There was no difference in 10-year retention rates among associate professors based on race/ethnicity., Conclusions: Underrepresented minority surgeons are less likely to remain in academia and Black assistant professors have the lowest rates of promotion. These findings highlight the need to develop institutional programs to better support and develop minority faculty members in academic medicine., (Copyright © 2018. Published by Elsevier Inc.)

Importance: Attrition from general surgery training is highest during internship. Whether the expectations and attitudes of new trainees affect their subsequent risk of attrition is unknown., Objective: To identify the expectations of general surgery residency associated with attrition from training., Design, Setting, and Participants: This prospective observational cohort study included categorical general surgery interns entering training in the 2007-2008 academic year. Residents were surveyed regarding their expectations of training and of life as an attending at the start of their intern year (June 1 to August 31, 2007). Expectations were grouped into factors by principal component analysis, and a multivariable model was created using these factors in addition to known demographic and program characteristics associated with attrition. Follow-up was completed on December 31, 2016., Main Outcomes and Measures: Attrition from training was determined by linkage to American Board of Surgery resident files through 2016, allowing 8 additional years of follow-up., Results: Of 1048 categorical surgery interns in the study period, 870 took the survey (83.0% response rate), and 828 had complete information available for analysis (524 men [63.3%], 303 women [36.6%], and 1 missing information [0.1%]). Most were white (569 [69.1%]) and at academic programs (500 [60.4%]). Six hundred sixty-six residents (80.4%) completed training. Principal component analysis generated 6 factors. On adjusted analysis, 2 factors were associated with attrition. Interns who choose their residency based on program reputation (factor 2) were more likely to drop out (odds ratio, 1.08; 95% CI, 1.01-1.15). Interns who expected as an attending to work more than 80 hours per week, to have a stressful life, and to be the subject of malpractice litigation (career life expectation [factor 6]) were less likely to drop out (odds ratio, 0.90; 95% CI, 0.82-0.98)., Conclusions and Relevance: Interns with realistic expectations of the demands of residency and life as an attending may be more likely to complete training. Medical students and residents entering training should be given clear guidance in what to expect as a surgery resident.

Importance: Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency., Objective: To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency., Design, Setting, and Participants: This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016., Main Outcomes and Measures: Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency., Results: Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (n = 164). Attrition was highest in the first postgraduate year (67.6% [n = 111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; P = .04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; P = .01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; P = .05); at year 5, at large compared with small programs (26.0% vs 18.4%; P = .04). Race and program location were not associated with attrition., Conclusions and Relevance: Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.

Background: There is limited understanding of the wide variation in attrition rates among general surgery residencies. We used the validated Behavior Inhibitory System/Behavior Approach System (BIS/BAS) instrument to compare motivational traits among residents who did and not complete surgical training., Study Design: All US general surgery categorical interns in the class of 2007-2008 were surveyed with a validated motivational trait assessment tool. American Board of Surgery records from 2008-2016 were used to determine who completed training. Motivation, an aspect of personality, was assessed with the BIS/BAS, which correlates with an individual's tendency to approach pleasant stimuli (BAS) or avoid negative stimuli (BIS). Subscale mean scores were compared with regard to the primary end point, attrition., Results: Eight hundred and one (76.5%) interns completed the survey and had matching records. Six hundred and forty-five (80.5%) completed training. Men had lower scores than women in the BAS Drive subscale (12.0 vs 12.5; p < 0.002), BAS Reward Response subscale (17.2 vs 17.7; p < 0.01), and BIS scale (19.3 vs 20.9; p < 0.01). The BAS Reward Response scores differed based on program type (academic 17.3 vs community 17.6 vs military 16.6; p < 0.0027). There were no differences based on program size (BIS average, small program 19.9 vs large program 19.7; p = 0.43). There were also no differences in BIS/BAS subscale scores based on residency completion status (BIS mean: completed 19.9 vs dropped out 20.1; p = 0.51)., Conclusions: Surgery residents are characterized by a strong drive and persistence toward their goals. However, residents who drop out do not differ from those who complete training in their motivational personality traits., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study provides an updated description of diversity along the academic surgical pipeline to determine what progress has been made., Methods: Data was extracted from a variety of publically available data sources to determine proportions of minorities in medical school, general surgery training, and academic surgery leadership., Results: In 2014-2015, Blacks represented 12.4% of the U.S. population, but only 5.7% graduating medical students, 6.2% general surgery trainees, 3.8% assistant professors, 2.5% associate professors and 2.0% full professors. From 2005-2015, representation among Black associate professors has gotten worse (-0.07%/year, p < 0.01). Similarly, in 2014-2015, Hispanics represented 17.4% of the U.S. population but only 4.5% graduating medical students, 8.5% general surgery trainees, 5.0% assistant professors, 5.0% associate professors and 4.0% full professors. There has been modest improvement in Hispanic representation among general surgery trainees (0.2%/year, p < 0.01), associate (0.12%/year, p < 0.01) and full professors (0.13%/year, p < 0.01)., Conclusion: Despite efforts to promote diversity in surgery, Blacks and Hispanics remain underrepresented. A multi-level national focus is imperative to elucidate effective mechanisms to make academic surgery more reflective of the US population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are unknown. In addition, the current rates and outcomes of robotic surgery are unknown., Objective: The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time., Design: This was a retrospective study., Settings: This study was conducted in a tertiary referral hospital., Patients: Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status., Main Outcome Measures: In-hospital mortality and postoperative complications of surgery were measured., Results: A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic)., Limitations: This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting., Conclusions: Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.

Background: National adoption of sphincter-preserving surgery (SPS) and minimally invasive surgery (MIS) has not been well documented. We examined national trends in use of SPS and MIS., Materials and Methods: The National Inpatient Sample was used to evaluate open, laparoscopic, and robotic low anterior resection (LAR) or abdominoperineal resection (APR) for patients undergoing rectal cancer surgery from 2009 to 2011. Trends in SPS and MIS were stratified by hospital volume. Propensity score matching was used., Results: A total of 24,999 (62.0%) patients underwent LAR, and 15,288 (38.0%) underwent APR from 2009 to 2011. A total of 22,310 (89.2%) LARs were open and 2689 (10.8%) MIS. A total of 11,600 (75.9%) APRs were open and 3688 (24.1%) MIS. Most procedures were at high-volume centers. In propensity-matched analysis, length of stay for LAR was longer in open surgery (6 versus 5 d; P = 0.01); in APR, MIS patients were less likely to have wound, infectious, urinary, and gastrointestinal complications, and length of stay was shorter (6 versus 8 d; P < 0.01)., Conclusions: SPS and MIS rates have increased nationally, especially in high-volume centers. In addition, the perioperative benefits seen in randomized clinical trials are maintained in a national database. Further studies should focus on understanding differences in survival and oncologic outcomes with MIS techniques., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine how race influences US general surgery residents' experiences during residency training., Background: Minorities are underrepresented in medicine, particularly surgery, with no large-scale studies investigating their training experiences., Methods: Cross-sectional national survey administered after the 2008 American Board of Surgery In-Training Examination to all categorical general surgery residents. Demographic characteristics and survey responses with respect to race were evaluated using the χ test and hierarchical logistic regression modeling., Results: A total of 4339 residents were included: 61.9% whites, 18.5% Asians, 8.5% Hispanics, 5.3% Blacks, and 5.8% Others. Minorities differed from whites in sex proportion, marital status, number of children, geographic location, type of residency program, and 24 survey items (all Ps < 0.05). Compared with white residents, Black, Asian, and Other residents were less likely to feel they fit in at their programs (86.2% vs 73.9%, 83.3%, and 81.2%, respectively; P < 0.001). Black and Asian residents were more likely to report that attendings would think worse of them if they asked for help (13.5% vs 20.4% and 18.4%, respectively; P = 0.002), and Black residents were less likely to feel they could count on their peers for help (85.2% vs 77.2%; P = 0.017). On hierarchical logistic regression modeling, Blacks were least likely to fit in at their programs (odds ratio = 0.6; P = 0.004), and all minorities were more likely to feel that there was a need for additional specialty training (odds ratio = 1.4 Blacks and Hispanics, 1.9 Asians, and 2.1 Others; all Ps ≤ 0.05)., Conclusions: Minority residents report less positively on program fit and relationships with faculty and peers. Future studies should focus on examining residency interventions to improve support and integration of minority residents.

Background: Postdoctoral fellows from the Robert Wood Johnson Clinical Scholars Program are among a growing number of physician-researchers training in community-based participatory research (CBPR). These fellows are uniquely positioned to observe and evaluate CBPR training needs and the experience of collaboratively conducting a CBPR project., Purpose: To describe, from the perspective of physician-researchers, experiences in intragroup and intergroup collaborations while conducting CBPR., Methods: During a 2-year fellowship, a group of seven fellows received 6 months of didactic training and then spent 18 months conducting a mentored CBPR project. The CBPR project was complemented by a 2-year facilitated leadership seminar, which allowed for reflection on intragroup (among fellows) and intergroup (fellows/community members) relationships throughout the CBPR process., Results: Seven core principles of CBPR were found to apply to not only intergroup but also intragroup relationships: (1) building trust, (2) finding a shared interest, (3) power-sharing, (4) fostering co-learning and capacity building among partners, (5) building on existing strengths, (6) employing an iterative process, and (7) finding a balance between research and action for the mutual benefit of all partners., Conclusions: Establishing and maintaining relationships is at the core of CBPR. The development of intragroup relationships paralleled the development of intergroup relationships with community members. Applying the core principles of CBPR to the development of intragroup relationships provided experience that may have enhanced relationships with community partners. An a priori acknowledgement of the importance of relationships and the time needed to develop and manage those relationships may add to the CBPR training experience and assist in successfully executing collaborative projects.

Context: Thyroid disease is common, and thyroidectomy is a mainstay of treatment for many benign and malignant thyroid conditions. Overall, thyroidectomy is associated with favorable outcomes, particularly if experienced surgeons perform it., Objective: To examine racial differences in clinical and economic outcomes of patients undergoing thyroidectomy in the United States., Design, Setting, Patients: The nationwide inpatient sample was used to identify thyroidectomy admissions from 1999 to 2004, using ICD-9 procedure codes. Race and other clinical and demographic characteristics of patients were collected along with surgeon volume and hospital characteristics to predict outcomes., Main Outcome Measures: Inpatient mortality, complication rates, length of stay (LOS), discharge status, and mean total costs by racial group., Results: In 2003-2004, 16,878 patients underwent thyroid procedures; 71% were white, 14% black, 9% Hispanic, and 6% other. Mean LOS was longer for blacks (2.5 days) than for whites (1.8 days, P < 0.001); Hispanics had an intermediate LOS (2.2 days). Although rare, in-hospital mortality was higher for blacks (0.4%) compared with that for other races (0.1%, P < 0.001). Blacks trended toward higher overall complication rates (4.9%) compared with whites (3.8%) and Hispanics (3.6%, P = 0.056). Mean total costs were significantly lower for whites ($5447/patient) compared with those for blacks ($6587) and Hispanics ($6294). The majority of Hispanics (55%) and blacks (52%) had surgery by the lowest-volume surgeons (1-9 cases per year), compared with only 44% of whites. Highest-volume surgeons (>100 cases per year) performed 5% of thyroidectomies, but 90% of their patients were white (P < 0.001). Racial disparities in outcomes persist after adjustment for surgeon volume group., Conclusions: These findings suggest that, although thyroidectomy is considered safe, significant racial disparities exist in clinical and economic outcomes. In part, inequalities result from racial differences in access to experienced surgeons; more data are needed with regard to racial differences in thyroid biology and surveillance to explain the balance of observed disparities.