Search

OBJECTIVE: Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume. METHODS: We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis. RESULTS: Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10-1.39) and Hispanic (OR: 1.19; 95% CI: 1.10-1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22-1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis. CONCLUSIONS: Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race. [ABSTRACT FROM AUTHOR]

A type II obturator hernia is a rare clinical entity that may be found on imaging and at surgery, as seen in this case of a 91-year-old woman who presented to our emergency department. Images are presented with treatment choices and a brief discussion on different types of obturator hernias. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate junior resident self-assessments and utilization of effective coaching principles by chief resident coaches in a resident peer surgical coaching program., Design: All residents underwent the Surgical Coaching for Operative Performance Enhancement (SCOPE) coaching curriculum. Junior residents ("coachees") were paired with chief resident coaches. A case was selected for coaching. The coaching structure was: 1) junior resident preoperative goal setting, 2) unscrubbed, intraoperative case observation by the coach, 3) postoperative coaching debrief. Debriefs were recorded to determine frequency of junior resident self-assessment and use of the effective coaching principles (goal setting, collaborative analysis, constructive feedback, action planning). Deductive thematic analysis was conducted., Setting: A general surgery residency at a single, large academic medical center., Participants: 16 junior resident (PGY1-3) coachees and 6 chief resident (PGY5) coaches., Results: There were 18 recorded coaching debrief sessions that lasted an average of 12.65 minutes (range 4-31 minutes). All debrief sessions included self-assessments by the junior resident coachees. There were numerous examples of the 4 effective coaching principles with all debriefs including use of at least 3. The most commonly used were collaborative analysis and constructive feedback. For technical skills, these highlighted body positioning, needle angles, and dissection techniques, including instrument choice, laparoscopic instrument technique, and use of electrocautery. Collaborative analysis of nontechnical skills emphasized communication with the attending surgeon, specifically operative decision-making and advocating for resident autonomy. Nontechnical constructive feedback addressed strategies the coaches themselves used for managing stress, interacting with attendings, and excelling in the operating room., Conclusions: Self-assessments and use of effective coaching principles were frequent throughout peer coaching debriefs. Collaborative analysis and constructive feedback were employed to promote operative technical and nontechnical skill development. Within a peer coaching program, residents are able to employ high level teaching and coaching techniques to encourage operative performance enhancement., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There is increasing availability of operative video for use in surgical training. Emerging technologies can now assess video footage and automatically generate metrics that could be harnessed to improve the assessment of operative performance. However, a comprehensive understanding of which technology features are most impactful in surgical training is lacking. The aim of this scoping review was to explore the current use of automated video analytics in surgical training., Methods: PubMed, Scopus, the Web of Science, and the Cochrane database were searched, to 29 September 2023, following PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Search terms included 'trainee', 'video analytics', and 'education'. Articles were screened independently by two reviewers to identify studies that applied automated video analytics to trainee-performed operations. Data on the methods of analysis, metrics generated, and application to training were extracted., Results: Of the 6736 articles screened, 13 studies were identified. Computer vision tracking was the common method of video analysis. Metrics were described for processes (for example movement of instruments), outcomes (for example intraoperative phase duration), and critical safety elements (for example critical view of safety in laparoscopic cholecystectomy). Automated metrics were able to differentiate between skill levels (for example consultant versus trainee) and correlated with traditional methods of assessment. There was a lack of longitudinal application to training and only one qualitative study reported the experience of trainees using automated video analytics., Conclusion: The performance metrics generated from automated video analysis are varied and encompass several domains. Validation of analysis techniques and the metrics generated are a priority for future research, after which evidence demonstrating the impact on training can be established., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Introduction: Surgical coaching is utilized to enhance technical, nontechnical, and teaching skills. This study aims to evaluate the feasibility and benefit of a resident peer coaching program., Methods: Chief residents (postgraduate year 5) acted as coaches for junior residents (postgraduate year 1-3, "coachees"). All participants completed the Harvard Surgical Coaching for Operative Performance Enhancement curriculum. The coaching structure included 1) preoperative goal setting, 2) unscrubbed intraoperative observation, and 3) postoperative debrief. Upon completion, residents were surveyed to assess their experience. Descriptive and thematic analyses were performed., Results: There were 22 participants (6 coaches, 16 coachees). Five (83.3%) coaches and 14 (87.5%) coachees reported the program was useful, citing dedicated reflection outside the operating room, in-depth feedback, and structured self-assessment with increased accountability. Thirteen (81.3%) coachees reported perceived improvement in technical skills and 12 (75%) within nontechnical skills. All coaches felt they benefited and improved their ability to provide feedback. When asked how coaching compared to usual methods of operative feedback, 14 (87.5%) coachees and 5 (83.3%) coaches reported it was better, with only 1 coachee reporting it was worse. Benefits over typical operating room teaching included more feedback provided, more specific feedback, and the benefit of peer relationships. Twelve (54.5%) residents cited difficulty with coordinating sessions, but 21 (95.5%) reported that they would participate again., Conclusions: Implementation of a resident peer surgical coaching program is feasible. Both coaches and coachees perceive significant benefit with improvement in technical, nontechnical, and feedback delivery skills. Given preference over other methods of operative feedback, expansion of peer coaching programs is warranted., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs., Background: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown., Methods: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences., Results: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199)., Conclusions: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Purpose: Continuing increases in application volume have driven a national dialogue to reform the residency recruitment process. Program signaling allows applicants to express interest in a program at the preinterview stage with the goal of helping programs identify applicants with more genuine interest in their programs. This study explored the relationship between program signals and program and applicant characteristics., Method: Participating dermatology, general surgery, and categorical internal medicine (IM) programs and applicants of the 2022 supplemental ERAS application (SuppApp) were included. Data from the SuppApp, the MyERAS Application for Residency Applicants (MyERAS), and the 2020 GME Track Survey were used. Cohen's h was used to determine effect size, and chi-squared was used to determine statistical significance., Results: There was an uneven distribution of signals to programs, with 25% of programs receiving about half of the signals across all 3 specialties. Programs with larger numbers of both residents and applicants received greater numbers of program signals relative to their program density, although this effect was small ( h < 0.50, P < .001). No meaningful differences were seen across genders for any specialty. Only Hispanic applicants in IM sent a higher proportion of signals to programs with more underrepresented in medicine residents than White only applicants (40% vs 26%, h = 0.30, P < .001). Across all specialties, there was a small-to-moderate effect for international medical graduate (IMG) applicants sending a larger proportion of signals to programs with more IMG residents ( h < 0.80, P < .001)., Conclusions: This first-year pilot study (i.e., SuppApp) provided initial evidence that supports the feasibility and fairness of program signals in residency selection. As program signals become more common across specialties, future research should continue to evaluate trends in where applicants send signals, and possible relationships between program and application characteristics., (Copyright © 2023 the Association of American Medical Colleges.)

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale., Study Design: In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated., Results: Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out., Conclusions: Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify which strain episodes are concurrently reported by several team members; to identify triggers of strain experienced by operating room (OR) team members during the intraoperative phase., Summary: OR teams are confronted with many sources of strain. However, most studies investigate strain on a general, rather than an event-based level, which does not allow to determine if strain episodes are experienced concurrently by different team members., Methods: We conducted an event-based, observational study, at an academic medical center in North America and included 113 operations performed in 5 surgical departments (general, vascular, pediatric, gynecology, and trauma/acute care). Strain episodes were assessed with a guided-recall method. Immediately after operations, participants mentally recalled the operation, described the strain episodes experienced and their content., Results: Based on 731 guided recalls, 461 strain episodes were reported; these refer to 312 unique strain episodes. Overall, 75% of strain episodes were experienced by a single team member only. Among different categories of unique strain episodes, those triggered by task complexity, issues with material, or others' behaviors were typically experienced by 1 team member only. However, acute patient issues (n = 167) and observations of others' strain (n = 12) (respectively, 58.5%; P  < 0.001 and 83.3%; P  < 0.001) were often experienced by 2 or more team members., Conclusions and Relevance: OR team members are likely to experience strain alone, unless patient safety is at stake. This may jeopardize the building of a shared understanding among OR team members., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Surgical coaching programmes are a means of improving surgeon performance. Embedded audiovisual technology has the potential to further enhance participant benefit and scalability of coaching. The objective of this systematic review was to evaluate how audiovisual technology has augmented coaching in the acute-care hospital setting and to characterize its impact on outcomes., Methods: A systematic review was conducted, searching PubMed, Ovid MEDLINE, Embase, PsycInfo, and CINAHL databases using PRISMA. Eligible studies described a coaching programme that utilized audiovisual technology, involved at least one coach-coachee interaction, and included healthcare professionals from the acute-care hospital environment. The risk of bias 2 tool and grading of recommendations, assessment, development, and evaluations (GRADE) framework were used to evaluate studies. Synthesis without meta-analysis was performed, creating harvest plots of three coaching outcomes: technical skills, self-assessment/feedback, and non-technical skills., Results: Of 10 458 abstracts screened, 135 full texts were reviewed, and 21 studies identified for inclusion. Seventeen studies were conducted within surgical specialties and six classes of audiovisual technology were utilized. An overall positive direction of effect was demonstrated for studies measuring improvement of either technical skills or non-technical skills. Direction of effect for self-assessment/feedback was weakly positive., Conclusion: Audiovisual technology has been used successfully in coaching programmes within acute-care hospital settings to facilitate or assess coaching, with a positive impact on outcome measures. Future studies may address the additive benefits of video over in-person observation and enhance the certainty of evidence that coaching impacts on surgeon performance, surgeon well-being, and patient outcomes., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Objective: Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control., Background: There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions., Method: We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups., Results: Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography., Conclusion: Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support., Application: Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

Background: In recent years, mounting challenges for applicants and programs in resident recruitment have catapulted this topic into a top priority in medical education. These challenges span all aspects of recruitment-from the time an applicant applies until the time of the Match-and have widespread implications on cost, applicant stress, compromise of value alignment, and holistic review, and equity. In 2021-2022, the Association of Program Directors in Surgery (APDS) set forth recommendations to guide processes for General Surgery residency recruitment., Objectives: This work summarizes the APDS 2021-2022 resident recruitment process recommendations, along with their justification and program end-of-cycle program feedback and compliance. This work also outlines the impact of these data on the subsequent 2022-2023 recommendations., Methods: After a comprehensive review of the available literature and data about resident recruitment, the APDS Task Force proposed recommendations to guide 2021-2022 General Surgery resident recruitment. Following cycle completion, programs participating in the categorical General Surgery Match were surveyed for feedback and compliance., Results: About 122 of the 342 programs (35.7%) participating in the 2022 categorical General Surgery Match responded. Based on available data in advance of the cycle, recommendations around firm application and interview numbers could not be made. About 62% of programs participated in the first round interview offer period with 86% of programs limiting offers to the number of slots available; 95% conducted virtual-only interviews. Programs responded they would consider or strongly consider the following components in future cycles: holistic review (90%), transparency around firm requirements (88%), de-emphasis of standardized test scores (54%), participation in the ERAS Supplemental application (58%), single first round interview release period (69%), interview offers limited to the number of available slots (93%), 48-hour minimum interview offer response time (98%), operationalization of applicant expectations (88%), and virtual interviews (80%). There was variability in terms of the feedback regarding the timing of the single first round offer period as well as support for a voluntary, live site visit for applicants following program rank list certification., Conclusions: The majority of programs would consider implementing similar recommendations in 2022-2023. The greatest variability around compliance revolved around single interview release and the format of interviews. Future innovation is contingent upon the ongoing collection of data as well as unification of data sources involved in the recruitment process., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Improvements to the medical student surgical learning environment are limited by lack of granular data and recall bias on end-of-clerkship evaluations. The purpose of this study was to identify specific areas for intervention using a novel real-time mobile application., Design: An application was designed to obtain real-time feedback from medical students regarding the learning environment on their surgical clerkship. Thematic analysis of student experiences was performed at the conclusion of 4 consecutive 12-week rotation blocks., Setting: Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts., Results: Fifty-four medical students at a single institution were asked to participate during their primary clerkship experience. Students submitted 365 responses over 48 weeks. Multiple themes emerged which were dichotomized into positive and negative emotions centered on specific student priorities. Approximately half of responses were associated with positive emotions (52.9%) and half with negative emotions (47.1%). Student priorities included the desire to feel included in the surgical team (resulting in feeling engaged/ignored), to have a positive relationship with members of the team (perceiving kind/rude interactions), to witness compassionate patient care (observing empathy/disrespect for patients), to have a well-planned surgical rotation (experiencing organization/disorganization within teams), and to feel that student well-being is prioritized (reporting opportunities/disregard for student wellness)., Conclusion: A novel, user-friendly mobile application identified several areas to improve the experience and engagement of students on their surgery clerkship. Allowing clerkship directors and other educational leaders to collect longitudinal data in real time may allow for more targeted, timely improvements to the medical student surgical learning environment., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Our research objectives were to (1) assess the correlation between PD perceptions and their residents' reported experiences and (2) identify PD and program characteristics associated with alignment between PD perceptions and their residents' reports., Design, Setting, Participants: A survey was administered to US general surgery residents following the 2019 American Board of Surgery In-Training Examination (ABSITE) to study wellness (burnout, thoughts of attrition, and suicidality) and mistreatment (gender discrimination, sexual harassment, racial/ethnic/religious discrimination, bullying). General surgery program directors (PDs) were surveyed about the degree to which they perceived mistreatment and wellness within their programs. Concordance between PDs' perceptions and their residents' reports was assessed using Spearman correlations. Multivariable logistic regression models examined factors associated with alignment between PDs and residents., Results: Of 6,126 residents training at SECOND Trial-enrolled programs, 5,240 (85.5%) responded to the ABSITE survey. All 212 PDs of programs enrolled in the SECOND Trial (100%) responded to the PD survey. Nationally, the proportion of PDs perceiving wellness issues was similar to the proportion of residents reporting them (e.g., 54.9% of PDs perceive that burnout is a problem vs. 40.1% of residents experience at least one burnout symptom weekly); however, the proportion of PDs perceiving mistreatment vastly underestimated the proportion of residents reporting it (e.g., 9.3% of all PDs perceive vs. 65.9% of all residents report bullying). Correlations between PDs' perceptions of problems within their program and their residents' reports were weak for racial/ethnic/religious discrimination (r = 0.176, p = 0.019), sexual harassment (r = 0.180, p = 0.019), burnout (r = 0.198, p = 0.007), and thoughts of attrition (r = 0.193, p = 0.007), and non-existent for gender discrimination, bullying, or suicidality. Multivariable regression models did not identify any program or PD characteristics that were consistently associated with improved resident-program director alignment., Conclusions: Resident and PD perceptions were generally disparate regarding mistreatment, burnout, thoughts of attrition, and suicidality. Reconciling this discrepancy is critical to enacting meaningful change to improve the learning environment and resident well-being., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Medical events can affect space crew health and compromise the success of deep space missions. To successfully manage such events, crew members must be sufficiently prepared to manage certain medical conditions for which they are not technically trained. Extended Reality (XR) can provide an immersive, realistic user experience that, when integrated with augmented clinical tools (ACT), can improve training outcomes and provide real-time guidance during non-routine tasks, diagnostic, and therapeutic procedures. The goal of this study was to develop a framework to guide XR platform development using astronaut medical training and guidance as the domain for illustration. We conducted a mixed-methods study-using video conference meetings (45 subject-matter experts), Delphi panel surveys, and a web-based card sorting application-to develop a standard taxonomy of essential XR capabilities. We augmented this by identifying additional models and taxonomies from related fields. Together, this "taxonomy of taxonomies," and the essential XR capabilities identified, serve as an initial framework to structure the development of XR-based medical training and guidance for use during deep space exploration missions. We provide a schematic approach, illustrated with a use case, for how this framework and materials generated through this study might be employed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To describe the first year of the Educational Quality Improvement Program (EQIP) DESIGN: The Educational Quality Improvement Program (EQIP) was formed by the Association of Program Directors in Surgery (APDS) in 2018 as a continuous educational quality improvement program. Over 18 months, thirteen discrete goals for the establishment of EQIP were refined and executed through a collaborative effort involving leaders in surgical education. Alpha and beta pilots were conducted to refine the data queries and collection processes. A highly-secure, doubly-deidentified database was created for the ingestion of resident and program data., Setting & Participants: 36 surgical training programs with 1264 trainees and 1500 faculty members were included in the dataset. 51,516 ERAS applications to programs were also included. Uni- and multi-variable analysis was then conducted., Results: EQIP was successfully deployed within the timeline described in 2020. Data from the ACGME, ABS, and ERAS were merged with manually entered data by programs and successfully ingested into the EQIP database. Interactive dashboards have been constructed for use by programs to compare to the national cohort. Risk-adjusted multivariable analysis suggests that increased time in a technical skills lab was associated with increased success on the ABS's Qualifying Examination, alone. Increased time in a technical skills lab and the presence of a formal teaching curriculum were associated with increased success on both the ABS's Qualifying and Certifying Examination. Program type may be of some consequence in predicting success on the Qualifying Examination., Conclusions: The APDS has proved the concept that a highly secure database for the purpose of continuous risk-adjusted quality improvement in surgical education can be successfully deployed. EQIP will continue to improve and hopes to include an increasing number of programs as the barriers to participation are overcome., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Gender disparities in resident operative experience have been described; however, their etiology is poorly understood, and racial/ethnic disparities have not been explored. This study investigated the relationship between gender, race/ethnicity, and surgery resident case volumes., Materials and Methods: A retrospective analysis of graduating general surgery resident case logs (2010-2020) at an academic medical center was performed. Self-reported gender and race/ethnicity data were collected from program records. Residents were categorized as underrepresented in medicine (URM) (Black, Hispanic, Native American) or non-URM (White, Asian). Associations between gender and URM status and major, chief, and teaching assistant (TA) mean case volumes were analyzed using t-tests., Results: The cohort included 80 residents: 39 female (48.8%) and 17 URM (21.3%). Compared to male residents, female residents performed fewer TA cases (33 versus 47, P < 0.001). Compared to non-URM residents, URM residents graduated with fewer major (948 versus 1043, P = 0.008) and TA cases (32 versus 42, P = 0.038). Male URM residents performed fewer TA cases than male non-URM residents (32 versus 50, P = 0.031). Subanalysis stratified by graduation year demonstrated that from 2010 to 2015, female residents performed fewer chief (218 versus 248, P = 0.039) and TA cases (29 versus 50, P = 0.001) than male residents. However, from 2016 to 2020, when gender parity was achieved, no significant associations were observed between gender and case volumes., Conclusions: Female and URM residents perform fewer TA and major cases than male non-URM residents, which may contribute to reduced operative autonomy, confidence, and entrustment. Prioritizing gender and URM parity may help decrease case volume gaps among underrepresented residents., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Recent literature on parental leave during residency has focused on the importance of supporting new mothers, but the needs and challenges faced by expectant nonchildbearing residents are less well described. Male residents are more likely than their female counterparts to have children during surgical training, and they experience similar stressors including childcare and conflicts between work and home priorities. As nonchildbearing parents of this generation become more involved in childrearing, the need to establish inclusive parental leave policies is essential. The aim of this study was to provide a deeper understanding of the perspectives of male residents about parental leave., Design: A semi-structured interview guide was developed using a literature search and an expert panel. Interviews were audio-recorded and transcribed verbatim and emergent themes were identified using content analysis., Setting: Four academic institutions., Participants: Four focus groups were held with of a total of 15 male resident-parents. These were selected using convenience sampling., Results: Multiple themes emerged: 1) male residents perceive greater stigma attached to taking leave compared to female colleagues; 2) paternity leave policies are vague and sometimes non-existent; 3) male residents experience a high burden of guilt related to burdening peers with clinical coverage while on leave; 4) male residents face internal conflict between surgical and parental responsibilities; 5) male residents have little mentorship on successful work-life integration and feel compelled to model the behavior of their attendings who often prioritize career before family; and 6) shifts in family values and priorities are common following childbirth and impact how male resident-parents view other new parents in training., Conclusions: Significant challenges exist for residents who become fathers during their surgical training. Key stressors include poorly defined leave policies, historic paradigms of prioritizing professional duties before personal duties, stigma against taking time off for parental bonding in the absence of medical need, and guilt related to extra work imposed on colleagues by time away. Establishment of formal parental leave policies for both genders, programmatic support to offset the increased workload on colleagues, and greater mentorship on balancing family and career are needed to foster a culture of work-life integration., Competing Interests: Declaration of Competing Interest The authors have no disclosures., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Our study evaluated general surgery resident indebtedness and perspectives on financial compensation., Methods: In May 2020, a survey was distributed nationwide by general surgery program directors in the Association of Program Directors in Surgery on a voluntary basis to their residents., Results: The survey was completed by 419 general surgery residents. Median salary was $60-65 K and median medical educational debt was $200-250 K. Approximately 61% of residents reported that their financial needs were not met by their income. Most residents (76%) believe that for a fair compensation, their salaries should be 30-50% higher. Proposed interventions for improvement in resident compensation included: overtime payment, redirection of GME funds to the residency programs, and compensating residents for billable services., Conclusions: Residents enter training with significant medical educational debt and feel unfairly compensated for their work. Therefore, comprehensive interventions with input from residents are needed to improve their financial well-being., (Published by Elsevier Inc.)

Background: Although the ACGME has called for outcomes-based evaluation of residency programs, few metrics or benchmarks exist connecting educational processes with resident educational outcomes. To address this deficiency, a national Education Quality Improvement Program (EQIP) for General Surgery training is proposed., Methods: We describe the initial efforts to create this platform. In addition, a national survey was administered to 330 Program Directors to assess their interest in and concerns about a continuous educational quality improvement project., Results: We demonstrate that through a collaborative process and the support of the Association of Program Directors in Surgery (APDS), we were able to develop the groundwork for a national surgical educational improvement project, now called EQIP. The survey response rate was 45.8% (152 of 332 programs) representing a mix of university (55.3%), university-affiliated (18.4%), independent (24.3%), and military (2.0%) programs. Most respondents (66.2%) had not previously heard of EQIP. Most respondents (69.7%) believe that educational outcomes can be measured. The majority of respondents indicated they believed EQIP could be successful (57%). Only 2.3% thought EQIP would not be successful. Almost all programs (98.7%) expressed a willingness to participate, although 19.1% did not believe that they had adequate resources to participate., Conclusion: The APDS EQIP platform holds promise as a useful and achievable method to obtain educational outcomes data. These data can be used as a basis for continuous surgical educational quality improvement. General Surgery Program Directors have expressed enthusiasm for EQIP and are willing to participate in the program examining outcomes of General Surgery training programs, with an ultimate goal of improving overall residency training., (Copyright © 2022. Published by Elsevier Inc.)

Objective: The importance of nontechnical skills in surgery is widely recognized. We demonstrate the feasibility of administering and assessing the results of a formal Non-Technical Skills in Surgery (NOTSS) curriculum to cardiothoracic surgery residents., Methods: Eight cardiothoracic surgery residents participated in the NOTSS curriculum. They were assessed on their cognitive (situation awareness, decision-making) and social (communication and teamwork, leadership) skills based on simulated vignettes. The residents underwent pretraining NOTSS assessments followed by self-administered confidence ratings regarding the 4 skills. Subsequently, a formal NOTSS lecture was delivered and additional readings from the NOTSS textbook was assigned. A month later, the residents returned for post-training NOTSS assessments and self-administered confidence ratings. Changes across days (or within-day before vs after curriculum) were assessed using Wilcoxon signed rank test., Results: There was a significant improvement in the overall NOTSS assessment score (P = .01) as well as in the individual categories (situation awareness, P = .02; decision-making, P = .02; communication and teamwork, P = .01; leadership, P = .02). There was also an increase in resident self-perception of improvement on the post-training day (P = .01)., Conclusions: We have developed a simulation-based NOTSS curriculum in cardiothoracic surgery that can be formally integrated into the current residency education. This pilot study indicates the feasibility of reproducible assessments by course educators and self-assessments by participating residents in nontechnical skills competencies., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Residents of color experience microaggressions in the work environment, are less likely to feel that they fit into their training programs, and feel less comfortable asking for help. Discrimination has been documented among surgical residents, but has not been extensively studied and largely remains unaddressed. We sought to determine the extent of perceived discrimination among general surgery residents., Materials and Methods: Residents who were enrolled in a randomized controlled trial investigating a cultural dexterity curriculum completed baseline assessments prior to randomization that included demographic information and the Everyday Discrimination Scale (EDS). Data from the baseline assessments were analyzed for associations of EDS scores with race, ethnicity, sex, socioeconomic level, language ability, and training level., Results: Of 266 residents across seven residency programs, 145 (55%) were men. Racial breakdown was 157 (59%) White, 45 (17%) Asian, 30 (11%) Black, and 12 (5%) Multiracial. The median EDS score was seven (range: 0-36); 58 (22%) fell into the High EDS score group. Resident race, fluency in a language other than English, and median household income were significantly associated with EDS scores. When controlling for other sociodemographic factors, Black residents were 4.2 (95% CI 1.62-11.01, P = 0.003) times as likely to have High EDS scores than their White counterparts., Conclusions: Black surgical residents experience high levels of perceived discrimination on a daily basis. Institutional leaders should be aware of these findings as they seek to cultivate a diverse surgical training environment., (Copyright © 2021. Published by Elsevier Inc.)

Background: Cultural competency training provides participants with knowledge and skills to improve cross-cultural communication and is required for all graduate medical education (GME) training programs., Objective: The authors sought to determine what cultural competency curricula exist specifically in GME., Methods: In April 2020, the authors performed a scoping review of the literature using a multidatabase (PubMed, Ovid, MedEdPORTAL) search strategy that included keywords relevant to GME and cultural competency. The authors extracted descriptive data about the structure, implementation, and analysis of cultural competency curricula and analyzed these data for trends., Results: Sixty-seven articles met criteria for inclusion, of which 61 (91%) were focused exclusively on residents. The most commonly included specialties were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). The shortest intervention was a 30-minute online module, while the longest contained didactics, electives, and mentoring programs that spanned the entirety of residency training (4 years). The sample sizes of included studies ranged from 6 to 833 participants. Eight (11.9%) studies utilized OSCEs as assessment tools, while 17 (25.4%) conducted semi-structured interviews or focus groups. Four common themes were unique interventions, retention of learning, trainee evaluation of curricula, and resources required for implementation., Conclusions: Wide variation exists in the design, implementation, and evaluation of cultural competency curricula for residents and fellows., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: Surgical patients with limited digital literacy may experience reduced telemedicine access. We investigated racial/ethnic and socioeconomic disparities in telemedicine compared with in-person surgical consultation during the coronavirus disease 2019 (COVID-19) pandemic., Study Design: Retrospective analysis of new visits within the Division of General & Gastrointestinal Surgery at an academic medical center occurring between March 24 through June 23, 2020 (Phase I, Massachusetts Public Health Emergency) and June 24 through December 31, 2020 (Phase II, relaxation of restrictions on healthcare operations) was performed. Visit modality (telemedicine/phone vs in-person) and demographic data were extracted. Bivariate analysis and multivariable logistic regression were performed to evaluate associations between patient characteristics and visit modality., Results: During Phase I, 347 in-person and 638 virtual visits were completed. Multivariable modeling demonstrated no significant differences in virtual compared with in-person visit use across racial/ethnic or insurance groups. Among patients using virtual visits, Latinx patients were less likely to have video compared with audio-only visits than White patients (OR, 0.46; 95% CI 0.22-0.96). Black race and insurance type were not significant predictors of video use. During Phase II, 2,922 in-person and 1,001 virtual visits were completed. Multivariable modeling demonstrated that Black patients (OR, 1.52; 95% CI 1.12-2.06) were more likely to have virtual visits than White patients. No significant differences were observed across insurance types. Among patients using virtual visits, race/ethnicity and insurance type were not significant predictors of video use., Conclusion: Black patients used telemedicine platforms more often than White patients during the second phase of the COVID-19 pandemic. Virtual consultation may help increase access to surgical care among traditionally under-resourced populations., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Although men are increasingly involved in childrearing, little is known about paternity leave in surgical residency. Conflict between professional and family duties contribute to burnout and decreased career satisfaction for surgeons of both sexes. With men more likely than women to have children during their clinical years of surgical training, understanding the issues surrounding paternity leave is imperative to ensuring the longevity of our workforce., Objective: To explore surgical program directors' perspectives on the challenges of providing paternity leave., Design, Setting, and Participants: This qualitative descriptive study of transcripts collected from semistructured interviews of US surgical program directors was performed from October 2018 to June 2019. Program directors were selected using purposive-stratified criterion-based sampling. Interviews were audio-recorded and transcribed verbatim, with emergent themes identified using content analysis., Exposure: Paternity leave., Main Outcomes and Measures: Program directors' perspectives on paternity leave were categorized into common themes., Results: A total of 40 US general surgery program directors were interviewed (28 male [70%]; mean [SD] age, 49.7 [6.8] years; 36 [90%] were university-based programs). Twenty (50%) reported providing paternity leave of 1-week duration. Five major themes were identified: (1) paternity leave policies are poorly defined by many programs and require self-initiation by residents; (2) residents often do not take the full amount of time offered for leave; (3) stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave; (4) paternity leave has little to no impact on colleagues' workload owing to the brevity of time taken; and (5) men desire longer leave than what they are currently offered and wish to receive equal time off compared with childbearing parents., Conclusions and Relevance: Surgical program directors report male residents take brief paternity leave despite a desire for more time off, which may be influenced by fear of stigma and surgical culture that avoids handing off work, even for short periods of time. A cultural shift toward supporting family planning as a normal part of young adult life, rather than a medical condition to be accommodated, is necessary to promote life balance and behaviors that will sustain a long career in surgery. Implementation of defined leave policies at individual programs for the nonchildbearing parent is critical to make parental leave socially acceptable among surgical residents.

Objective: To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program., Background: Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain., Methods: Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills., Results: For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent.", Conclusions: Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The COVID-19 pandemic exposed racism as a public health crisis embedded in structural processes. Editors of surgical research journals pledged their commitment to improve structure and process through increasing diversity in the peer review and editorial process; however, little benchmarking data are available., Methods: A survey of editorial board members from high impact surgical research journals captured self-identified demographics. Analysis of manuscript submissions from 2016 to 2020 compared acceptance for diversity, equity, and inclusion (DEI)-focused manuscripts to overall rates., Results: 25.6% of respondents were female, 2.9% Black, and 3.3% Hispanic. There was variation in the diversity among journals and in the proportion of DEI submissions they attract, but no clear correlation between DEI acceptance rates and board diversity., Conclusions: Diversity among board members reflects underrepresentation of minorities seen among surgeons nationally. Recruitment and retention of younger individuals, representing more diverse backgrounds, may be a strategy for change. DEI publication rates may benefit from calls for increasing DEI scholarship more so than changes to the peer review process., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Although well-established metrics exist to measure workplace burnout, researchers disagree about how to categorize individuals based on assessed symptoms. Using a person-centered approach, this study identifies classes of burnout symptomatology in a large sample of general surgery residents in the United States., Design, Setting, Participants: A survey was administered following the 2018 American Board of Surgery In-Training Examination (ABSITE) to study wellness among U.S. general surgery residents. Latent class models identified distinct classes of residents based on their responses to the emotional exhaustion and depersonalization questions of the modified abbreviated Maslach Burnout Inventory (aMBI). Classes were assigned representative names, and the characteristics of their members and residency programs were compared., Results: The survey was completed by 7415 surgery residents from 263 residency programs nationwide (99.3% response rate). Five burnout classes were found: Burned Out (unfavorable score on all six items, 9.8% of total), Fully Engaged (favorable score on all six items, 23.1%), Fatigued (favorable on all items except frequent fatigue, 32.2%), Overextended (frequent fatigue and burnout from work, 16.7%), and Disengaged (weekly symptoms of fatigue and callousness, 18.1%). Within the more symptomatic classes (Burned Out, Overextended, and Disengaged), men manifested more depersonalization symptoms, whereas women reported more emotional exhaustion symptoms. Burned Out residents were characterized by reports of mistreatment (abuse, sexual harassment, and gender-, racial-, or pregnancy and/or childcare-based discrimination), duty hour violations, dissatisfaction with duty hour regulations or time for rest, and low ABSITE scores., Conclusions: Burnout is multifaceted, with complex and variable presentations. Latent class modeling categorizes general surgery residents based on their burnout symptomatology. Organizations should tailor their efforts to address the unique manifestations of each class as well as shared drivers., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool., Methods: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression., Results: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories., Conclusion: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Resident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists., Study Design: Twenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful., Results: Number of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest., Conclusion: There was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development., Competing Interests: Declaration of competing interest The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Although pregnancy during surgical residency is increasingly common, studies of surgical residents have identified challenges associated with pregnancy and motherhood. These include perceptions of different maternity leave policies among institutions, lack of mentorship, stigma, and desire for greater lactation support., Objective: To describe the perspective and experience of US surgical program directors regarding maternity leave and postpartum support for surgical residents., Design, Setting, and Participants: This qualitative study included surgical program directors of US general surgery residency programs who were selected using purposive-stratified, criterion-based sampling. Transcripts were collected from semi-structured interviews, which were audio-recorded and transcribed verbatim, from October 21, 2018, to June 1, 2019., Exposures: Maternity leave and postpartum support., Main Outcomes and Measures: Perspectives of program directors regarding maternity leave and postpartum support were categorized into common themes identified using content analysis., Results: A total of 40 US general surgical programs directors (28 [70.0%] male; mean [SD] age, 49.7 [6.8] years) were interviewed, of whom 36 (90.0%) were from university-based programs. All reported having maternity leave policies allowing a duration of leave of 6 weeks or longer. Analysis of program director interviews identified 5 themes: (1) residents are reluctant to extend training despite being offered multiple leave options; (2) childbearing negatively impacts the quality of work of certain residents; (3) lack of formal lactation policies creates practical challenges in supporting residents who are nursing; (4) resentment from coresidents who are asked to provide maternity leave coverage varies based on the prepregnancy reputation of the resident on leave; and (5) lack of salary support limits the practicality of extended leave options. Complex interpersonal issues affected residents differently, including stigma, reluctance to change established surgical training patterns, and challenges with work-life balance., Conclusions and Relevance: This qualitative study found that sociopolitical issues within surgical training culture and fiscal constraints created obstacles against program directors supporting pregnant residents. These findings suggest that a multidimensional approach to supporting residents through written maternity and lactation policies, structured mentorship and coaching programs, and efforts by leadership to enforce family priorities is needed to promote a surgical culture that normalizes pregnancy and motherhood during training.

Objectives: To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents., Background Summary Data: Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood., Methods: Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression., Results: Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment., Conclusions: Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Evidence for surgical coaching has yet to demonstrate an impact on surgeons' practice. We evaluated a surgical coaching program by analyzing quantitative and qualitative data on surgeons' intraoperative performance., Methods: In the 2018-2019 Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 practicing surgeons in multiple specialties at four academic medical centers were recruited to complete three peer coaching sessions, each comprising preoperative goal-setting, intraoperative observation, and postoperative debriefing. Coach and coachee rated the coachee's performance using modified Objective Structured Assessment of Technical Skills (OSATS, range 1-5) and Non-Technical Skills for Surgeons (NOTSS, range 4-16). We used generalized estimating equations to evaluate trends in skill ratings over time, adjusting for case difficulty, clinical experience, and coaching role. Upon program completion, we analyzed semi-structured interviews with individual participants regarding the perceived impact of coaching on their practice., Results: Eleven of 23 coachees (48%) completed three coaching sessions, three (13%) completed two sessions, and six (26%) completed one session. Adjusted mean OSATS ratings did not vary over three coaching sessions (4.39 vs 4.52 vs 4.44, respectively; P = 0.655). Adjusted mean total NOTSS ratings also did not vary over three coaching sessions (15.05 vs 15.50 vs 15.08, respectively; P = 0.529). Regarding patient care, participants self-reported improved teamwork skills, communication skills, and awareness in and outside the operating room. Participants acknowledged the potential for coaching to improve burnout due to reduced intraoperative stress and enhanced peer support but also the potential to worsen burnout by adding to chronic work overload., Conclusions: Surgeons reported high perceived impact of peer coaching on patient care and surgeon well-being, although changes in coachees' technical and non-technical skills were not detected over three coaching sessions. While quantitative skill measurement warrants further study, longitudinal peer surgical coaching should be considered a meaningful strategy for surgeons' professional development.

Competing Interests: The authors declare no conflicts of interest.

Background: New surgeons are faced with inadequate mentoring when first entering practice. Our study examined challenges faced by young surgeons during their transition in practice and their mentoring experience when entering practice., Methods: An article-based survey was mailed in August 2019 to general, colorectal, vascular, and cardiothoracic surgeons that became members of the American College of Surgeons within the past 5 years., Results: A total of 853 of 2,915 surveys were completed (29.3% response rate). Both female (38%) and male (62%) surgeons participated. The 3 most common challenges during the transition to practice were confidence building (26.0%), adjusting to a new institutional culture (16.9%), and business and administrative aspects of practice (16.3%). First job attrition rate 44.2%, with the mean duration of the first job being 3.28 ± 0.17 years. Nearly one-third (28.3%) of respondents were not mentored when they first entered practice. The proportion of nonmentored young surgeons leaving their first job (64.3%) was almost twice as that of surgeons who received mentoring (36.3%). Furthermore, the mean duration of the first job was significantly shorter in nonmentored versus mentored surgeons (3.16 ± 0.26 vs 3.76 ± 0.25 years; P < .05). A significant number (43.3%) of respondents reported a desire to be mentored by retired surgeons., Conclusion: Our survey highlights the importance of mentoring for young surgeons during their transition into practice. With many young surgeons being enthusiastic about mentoring by retired surgeons, specific programs are necessary to better use their expertise., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Nontechnical skills are of increasing focus for safe and effective performance in the operating room. Assessment tools have been developed in Europe, Africa, and Asia but not adapted to the unique aspects of surgical delivery in the United States. Our objective was to use the Non-Technical Skills for Surgeons (NOTSS) assessment tool as a basis to establish consensus on essential nontechnical skills for surgical trainees and practicing surgeons in the U.S surgical context., Study Design: A mixed-methods research design was used in the form of a modified Delphi process to build consensus on essential NOTSS. A panel of surgical experts from hospitals across the U.S used this iterative process in 4 rounds to generate, rate, and classify behaviors. The primary outcome was consensus on behaviors as being essential for surgeons to achieve the best patient outcomes in the operating room, with a median rating of ≥6 on a 7-point scale for inclusion., Results: A total of 10 surgical experts participated. One hundred and thirty eight behaviors were generated in Round 1, and reduced to 100 behaviors in Rounds 2 and 3 based on application of inclusion criteria. The final skill list consisted of behaviors in Situation Awareness (n = 26), Decision Making (n = 18), Teamwork (n = 25), and Leadership (n = 31). No additional NOTSS categories or elements emerged from the analysis. In Round 4, all 100 behaviors were successfully grouped into 12 nontechnical skills elements. Labels and definitions were reworded to reflect the U.S. context, and an appropriate assessment scale was selected., Conclusions: A panel of surgical experts from across the U.S. reached consensus on the essential NOTSS to achieve the best patient outcomes in the operating room. These behaviors form an empirical basis for the first context-specific nontechnical skills assessment and training tool for practicing surgeons in the U.S., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum., Design, Setting, and Participants: Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method., Results: Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors., Conclusions: Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to identify examples of naturalistic coaching behavior among practicing surgeons operating together by analyzing their intraoperative discussion., Background: Opportunities to improve surgical performance are limited for practicing surgeons; surgical coaching is one strategy to address this need. To develop peer coaching programs that integrate with surgical culture, a better understanding is needed of how surgeons routinely discuss operative performance., Methods: As part of a "co-surgery" quality improvement program, 20 faculty surgeons were randomized into 10 dyads who performed an operation together. Discourse analysis was conducted on transcribed intraoperative discussions. Themes were coded using an existing framework of surgical coaching principles (self-identified goals, collaborative analysis, constructive feedback, peer learning support) and surgical coaching content (technical skills, nontechnical skills). Coaching principles were cross-referenced with coaching content; c-coefficient measured the strength of association between pairs of themes., Results: Overall, 44 unique coaching examples were identified in 10 operations. Of the 4 principles of surgical coaching, only self-identified goals and collaborative analysis were identified consistently. Self-identified goals were most associated with discussions regarding technical skills of "tissue exposure," "flow of operation," and "instrument handling" and the nontechnical skill "situation awareness." Collaborative analysis was most associated with discussions regarding technical skills of "respect for tissue" and "flow of operation" and nontechnical skills of "communication and teamwork.", Conclusions: In naturalistic discussions between practicing surgeons in the operating room, numerous examples of unprompted coaching behavior were identified that target intraoperative performance. Prominent coaching gaps-constructive feedback and peer learning support-were also observed. Surgical coach trainings should address these gaps., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Surgical coaching is maturing as a tangible strategy for surgeons' continuing professional development. Resources to spread this innovation are not yet widely available., Objective: To identify surgeon-derived implementation recommendations for surgical coaching programs from participants' exit interviews and ratings of their coaching interactions., Design, Setting, and Participants: This qualitative analysis of the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, a quality improvement intervention, was conducted at 4 US academic medical centers. Participants included 46 practicing surgeons. The SCOPE program ran from December 7, 2018, to October 31, 2019. Data were analyzed from November 1, 2019, to January 31, 2020., Interventions: Surgeons were assigned as either a coach or a coachee, and each coach was paired with 1 coachee by a local champion who knew the surgeons professionally. Coaching pairs underwent training and were instructed to complete 3 coaching sessions-consisting of preoperative goal setting, intraoperative observation, and postoperative debriefing-focused on intraoperative performance., Main Outcomes and Measures: Themes from the participants' exit interviews covering 3 major domains: (1) describing the experience, (2) coach-coachee relationship, and (3) facilitators and barriers to implementing surgical coaching. Surgeons' responses were stratified by the net promoter score (NPS), a scale ranging from 0 to 10 points, indicating how likely they were to recommend their coaching session to others, with 9 to 10 indicating promoters; 7 to 8, passives; and 0 to 6, detractors., Results: Among the 46 participants (36 men [78.3%]), 23 were interviewed (50.0%); thematic saturation was reached with 5 coach-coachee pairs (10 interviews). Overall, coaches and coachees agreed on key implementation recommendations for surgical coaching, including how to optimize coach-coachee relationships and facilitate productive coaching sessions. The NPS categories were associated with how participants experienced their own coaching sessions. Specifically, participants who reported excellent first sessions, had a coaching partner in the same clinical specialty, and were transparent about each other's intentions in the program tended to be promoters. Participants who described suboptimal first sessions, less clinical overlap, and unclear goals with their partner were more likely detractors., Conclusions and Relevance: These exit interviews with practicing surgeons offer critical insights for addressing cultural barriers and practical challenges for successful implementation of peer coaching programs focused on surgical performance improvement. With empirical evidence on optimizing coach-coachee relationships and facilitating participants' experience, organizations can establish effective coaching programs that enable meaningful continuous professional development for surgeons and ultimately enhance patient care.