How Did We Get Here and Where Are We Going? Career Trajectories of United States General Surgery Residency Program Directors

OBJECTIVE

To develop the future of United States (US) surgical education leadership, surgical trainees and early career faculty who aspire to become program directors (PDs) must understand the potential career pathways and requisite skills and experience to become a general surgery residency PD. The objective of this study was to understand the demographics, career experiences, and professional satisfaction of US PDs in general surgery.

DESIGN

An anonymous, cross-sectional survey utilizing a novel instrument.

SETTING

An electronic survey distributed to US general surgery PDs between June and November 2022 PARTICIPANTS: PDs of US general surgery residency programs. A list of the Accrediting Council for Graduate Medical Education (ACGME)-accredited general surgery PDs was created from the ACGME list from the 2022 to 23 academic year.

RESULTS

The survey achieved a response rate of 46.2% (159/344). Only 32.1% of PDs identified as female and 67.3% identified as male with 1 respondent preferring not to identify their gender. PDs were White or Caucasian (68.6%), Asian (13.8%), and Black (3.7%); 4.4% were Hispanic or Latino. Only 83.7% of PDs completed fellowship training. PDs have been in the role for an average of 5.5 ± 4.9 years. The PDs were compensated for an average of 54.7% (±14.9% SD, 0%-100% range) of their time towards clinical duties. They were compensated on average for 35.7% (±12.6%, 0%-100%) of effort for residency-related administrative duties. Only 5% of PDs had obtained or were enrolled in an education-related degree. Only 55.4% of PDs had received formal surgical education training in teaching and assessment. 54.1% of PDs were interested in obtaining a more senior leadership position in the future. Most PDs (38.4%) expect to serve as PD for 5 to 8 years in total. Overall, the majority of PDs were very satisfied (29.6%) or satisfied (51.6%) professionally; similarly 28.9% were very satisfied and 48.4% satisfied personally.

CONCLUSIONS

This study represents the most up-to-date characterization of the personal, academic, and career-related features of current surgical residency PDs across the US. PDs enjoy a high degree of professional and personal satisfaction and most aspire to increasing leadership within their organizations. Compared to prior data, PDs have become more diverse in terms of both gender and race over time. Opportunities exist for increased mentorship of aspiring and current PDs as well as increased training in teaching and assessment.

Socioeconomic disparity in the association between fine particulate matter exposure and papillary thyroid cancer

BACKGROUND

Limited data exists suggesting that cumulative exposure to air pollution in the form of fine particulate matter (aerodynamic diameter ≤ 2.5 μm [PM2.5]) may be associated with papillary thyroid carcinoma (PTC), although this relationship has not been widely established. This study aims to evaluate the association between PM2.5 and PTC and determine the subgroups of patients who are at the highest risk of PTC diagnosis.

METHODS

Under IRB approval, we conducted a case-control study of adult patients (age ≥ 18) newly diagnosed with PTC between 1/2013-12/2016 across a single health care system were identified using electronic medical records. These patients were compared to a control group of patients without any evidence of thyroid disease. Cumulative PM2.5 exposure was calculated for each patient using a deep learning neural networks model, which incorporated meteorological and satellite-based measurements at the patients' residential zip code. Adjusted multivariate logistic regression was used to quantify the association between cumulative PM2.5 exposure and PTC diagnosis. We tested whether this association differed by gender, race, BMI, smoking history, current alcohol use, and median household income.

RESULTS

A cohort of 1990 patients with PTC and a control group of 6919 patients without thyroid disease were identified. Compared to the control group, patients with PTC were more likely to be older (51.2 vs. 48.8 years), female (75.5% vs 46.8%), White (75.2% vs. 61.6%), and never smokers (71.1% vs. 58.4%) (p < 0.001). After adjusting for age, sex, race, BMI, current alcohol use, median household income, current smoking status, hypertension, diabetes, COPD, and asthma, 3-year cumulative PM2.5 exposure was associated with a 1.41-fold increased odds of PTC diagnosis (95%CI: 1.23-1.62). This association varied by median household income (p-interaction =0.03). Compared to those with a median annual household income <$50,000, patients with a median annual household income between $50,000 and < $100,000 had a 43% increased risk of PTC diagnosis (aOR = 1.43, 95%CI: 1.19-1.72), and patients with median household income ≥$100,000 had a 77% increased risk of PTC diagnosis (aOR = 1.77, 95%CI: 1.37-2.29).

CONCLUSIONS

Cumulative exposure to PM2.5 over 3 years was significantly associated with the diagnosis of PTC. This association was most pronounced in those with a high median household income, suggesting a difference in access to care among socioeconomic groups.

Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Are We Making an Impact? A Qualitative Program Assessment of the Resident Leadership, Well-being, and Resiliency Program for General Surgery Residents

OBJECTIVE

After implementing a formal resident well-being and resiliency program in our surgery residency, we performed in-depth qualitative interviews to understand residents' perceptions of: (1) the impact and benefits, (2) the essential elements for success, and (3) the desired changes to the well-being program.

DESIGN

The well-being program is structured to address mental, physical, and social aspects of resident well-being through monthly experiential sessions. All General Surgery residents participated in the program; content is delivered during residents' protected educational time. For this study, we conducted individual semistructured interviews: residents were asked for their feedback to understand the value, benefits, and drawbacks of program.

SETTING

Accreditation Council for Graduate Medical Education-accredited General Surgery residency program PARTICIPANTS: We used purposeful selection to maximize diversity in recruiting residents who had participated in program for at least 1 year. Recruitment continued until themes were saturated. Eleven residents were interviewed including 2 from each residency year.

RESULTS

Residents reported benefits in 3 thematic spheres: (1) Culture/Community, (2) Communication/Emotional Intelligence, and (3) Work-Life Integration Skills. Key structural elements of success for a well-being program included a committed leader, a receptive department culture, occurrence during protected time, and interactive sessions that taught applicable life skills. In discussing opportunities for improvement, residents desired more faculty-level involvement. Some residents were skeptical of the benefit of time spent learning nontechnical skills; some wanted more emphasis placed on accountability to patients and work.

CONCLUSIONS

Our qualitative assessment of a novel resident well-being program demonstrates reported benefits that reflect the intent of the program. Residents most benefited from sessions that were interactive, introduced readily applicable skills for their day-to-day lives, and included reinforcement of principles through experiential learning. Engagement of the department leadership is essential to the success of the program, as is ongoing feedback and modification to ensure that program is tailored to the needs of residents.

Diversity in the Last Decade of the Association of Program Directors in Surgery: A Descriptive Analysis of Leadership and Future Directions

OBJECTIVE

The Association of Program Directors in Surgery Diversity and Inclusion Taskforce (APDS-DIT) was created in 2017 after the Executive Committee recognized low diversity in its membership. The DIT was charged to address gaps in diversity and inclusion at various phases of training and development from medical student to surgical leader. The aim of this study was to examine APDS demographics and determine the status of inclusion of women, racial and ethnic minorities, and nonuniversity surgeons.

DESIGN

Eleven years (2008-2018) of APDS annual-meeting programs, web directory, 2018-membership lists, and 2017-AAMC data were analyzed. Leadership positions were examined by officer (program chair/vice chair, executive committee, and board of directors. Internet searches identified gender, race, and institutional affiliation. Representative members to other organizations, resident liaisons, and historian members were excluded. APDS "Member," "Associate," and "Resident" lists and AAMC data were divided by gender.

RESULTS

Fifty-one individuals fulfilled 223 leadership positions over 11 years; 13 (25%) were women and 5 (10%) were non-Caucasian. Since 2013, the percentage of nonuniversity surgeons in APDS leadership has declined while, over the last 2 years, the percentage of women and ethnic/racial minority has increased. In 2018, the percentage of women in leadership (38%) was higher than the percentage of women in membership (combined total of program directors and associate program directors [26%]) and nonuniversity-affiliated surgeons comprised 35% of the APDS membership but only 14% of leadership roles.

CONCLUSIONS

Over the last 11 years, representation of women, non-Caucasians, and nonuniversity surgeons has been at or less than 1/3 of their counterparts. As an organization that is tasked with creating future generations of the surgical workforce, it is imperative to recognize an under-representation of those members with diverse backgrounds that would add to the creative growth of the organization. The creation of the APDS-DIT emphasizes the organization's commitment to diversity and inclusion and an effort to create a pipeline of diverse leaders in the APDS and surgical training in general.