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IMPORTANCE: Childbearing has been a particular barrier to successful recruitment and retention of women in surgery. Pregnant surgeons are more likely to have major pregnancy complications, such as preterm delivery, intrauterine growth restriction, infertility, and miscarriage, compared with nonsurgeons. The average obstetric complication rate for surgeons ranges between 25% and 82% in the literature and is considerably higher than that in the general US population at 5% to 15%. OBSERVATIONS: The risks that pregnant surgeons experience were individually analyzed. These risks included missed prenatal care; musculoskeletal hazards, such as prolonged standing, lifting, and bending; long work hours; overnight calls; exposure to teratogenic agents, such as ionizing radiation, anesthetic gases, chemotherapy agents, and methyl methacrylate; and psychological stress and discrimination from the long-standing stigma associated with balancing motherhood and professional life. CONCLUSIONS AND RELEVANCE: A clear, translatable, and enforceable policy addressing perinatal care of surgeons was proposed, citing evidence of the risks reviewed from the literature. A framework of protection for pregnant individuals is essential for attracting talented students into surgery, retaining talented surgical trainees and faculty, and protecting pregnant surgeons and their fetuses.

IMPORTANCE: A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs’ clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known. OBJECTIVE: To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used deidentified data from the EPA Pilot Study, with participating sites at 28 general surgery residency programs, prospectively collected from July 1, 2018, to June 30, 2020. Data were analyzed from September 27, 2022, to February 15, 2023. EXPOSURE: Microassessments of resident entrustment for pilot EPAs (gallbladder disease, inguinal hernia, right lower quadrant pain, trauma, and consultation) collected within the course of routine clinical care across four 6-month study cycles. Summative entrustment ratings were then determined by program CCCs for each study cycle. MAIN OUTCOMES AND MEASURES: The primary outcome was CCC decision-making confidence rating (high, moderate, slight, or no confidence) for summative entrustment decisions, with a secondary outcome of number of EPA microassessments received per summative entrustment decision. Bivariate tests and mixed-effects regression modeling were used to evaluate factors associated with CCC confidence. RESULTS: Among 565 residents receiving at least 1 EPA microassessment, 1765 summative entrustment decisions were reported. Overall, 72.5% (1279 of 1765) of summative entrustment decisions were made with moderate or high confidence. Confidence ratings increased with increasing mean number of EPA microassessments, with 1.7 (95% CI, 1.4-2.0) at no confidence, 1.9 (95% CI, 1.7-2.1) at slight confidence, 2.9 (95% CI, 2.6-3.2) at moderate confidence, and 4.1 (95% CI, 3.8-4.4) at high confidence. Increasing number of EPA microassessments was associated with increased likelihood of higher CCC confidence for all except 1 EPA phase after controlling for program effects (odds ratio range: 1.21 [95% CI, 1.07-1.37] for intraoperative EPA-4 to 2.93 [95% CI, 1.64-5.85] for postoperative EPA-2); for preoperative EPA-3, there was no association. CONCLUSIONS AND RELEVANCE: In this cohort study, the CCC confidence in EPA summative entrustment decisions increased as the number of EPA microassessments increased, and CCCs endorsed moderate to high confidence in most entrustment decisions. These findings provide early validity evidence for this novel assessment framework and may inform program practices as EPAs are implemented nationally.

IMPORTANCE: As the surgical education paradigm transitions to entrustable professional activities, a better understanding of the factors associated with resident entrustability are needed. Previous work has demonstrated intraoperative faculty entrustment to be associated with resident entrustability. However, larger studies are needed to understand if this association is present across various surgical training programs. OBJECTIVE: To assess intraoperative faculty-resident behaviors and determine if faculty entrustment is associated with resident entrustability across 4 university-based surgical training programs. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted at 4 university-based surgical training programs from October 2018 to May 2022. OpTrust, a validated tool designed to assess both intraoperative faculty entrustment and resident entrustability behaviors independently, was used to assess faculty-resident interactions. A total of 94 faculty and 129 residents were observed. Purposeful sampling was used to create variation in type of operation performed, case difficulty, faculty-resident pairings, faculty experience, and resident training level. MAIN OUTCOMES AND MEASURES: Observed resident entrustability scores (scale 1-4, with 4 indicating full entrustability) were compared with reported measures (faculty level, case difficulty, resident postgraduate year [PGY], resident gender, observation month) and observed faculty entrustment scores (scale 1-4, with 4 indicating full entrustment). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients. RESULTS: A total of 338 cases were observed. Cases observed were evenly distributed by faculty experience (1-5 years’ experience: 67 [20.9%]; 6-14 years’ experience: 186 [58%]; ≥15 years’ experience: 67 [20.9%]), resident PGY (PGY 1: 28 [8%]; PGY 2: 74 [22%]; PGY 3: 64 [19%]; PGY 4: 40 [12%]; PGY 5: 97 [29%]; ≥PGY 6: 36 [11%]), and resident gender (female: 183 [54%]; male: 154 [46%]). At the univariate level, PGY (mean [SD] resident entrustability score range, 1.44 [0.46] for PGY 1 to 3.24 [0.65] for PGY 6; F = 38.92; P < .001) and faculty entrustment (2.55 [0.86]; R2 = 0.94; P < .001) were significantly associated with resident entrustablity. Path analysis demonstrated that faculty entrustment was associated with resident entrustability and that the association of PGY with resident entrustability was mediated by faculty entrustment at all 4 institutions. CONCLUSIONS AND RELEVANCE: Faculty entrustment remained associated with resident entrustability across various surgical training programs. These findings suggest that efforts to develop faculty entrustment behaviors may enhance intraoperative teaching and resident progression by promoting resident entrustability.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2005.10.018 Byline: Derek T. Woodrum (a), Pamela B. Andreatta (b), Rajani K. Yellamanchilli (b), Lauren Feryus (a), Paul G. Gauger (a)(b), Rebecca M. Minter (a)(b) Keywords: LapSim TM; Laparoscopy; Surgical education; Virtual reality; Laparoscopic simulator; simulation; Construct validity Abstract: Computer-aided simulators may increase the safety and efficiency of training in laparoscopic surgery. Before implementation of the Immersion LapSim (Gaithersburg, MD) simulator in our training curriculum, we wished to determine its construct validity (ie, whether the simulator could differentiate laparoscopic novices from trainees with greater experience). Author Affiliation: (a) Department of Surgery, University of Michigan, 1500 E. Medical Center Drive, 2920 Taubman Center, Ann Arbor, MI 48109-0331, USA (b) Department of Medical Education, University of Michigan, Ann Arbor, MI, USA Article History: Received 7 April 2005; Revised 9 October 2005 Article Note: (footnote) Supported in part by a research grant from United States Surgical (Norwalk, CT) and by the Association for Surgical Education Foundation's Center for Excellence in Surgical Education and Research (Springfield, IL).

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Objective: The Fellowship Council (FC) is transitioning to a competency-based medical education (CBME) model, including the introduction of Entrustable Professional Activities (EPAs) for training and assessment of Fellows. This study describes the implementation process employed by the FC during a ten-month pilot project and presents data regarding feasibility and perceived value. Methods: The FC coordinated the development of EPAs in collaboration with the sponsoring societies for Advanced GI/MIS, Bariatrics, Foregut, Endoscopy and Hepatopancreaticobiliary (HPB) fellowships encompassing the preoperative, intraoperative, and postoperative phases of care for key competencies. Fifteen accredited fellowship programs participated in this project. The assessments were collected through a unique platform on the FC website. Programs were asked to convene a Clinical Competency Committee (CCC) on a quarterly basis. The pilot group met monthly to support and improve the process. An exit survey evaluated the perceived value of EPAs. Results: The 15 participating programs included 18 fellows and 106 faculty. A total of 655 assessments were initiated with 429 (65%) completed. The average (SD) number of EPAs completed for each fellow was 24(18); range 0–72. Intraoperative EPAs were preferentially completed (71%). The average(SD) time for both the fellow and faculty to complete an EPA was 27(78) hours. Engagement increased from 39% of fellows completing at least one EPA in September to 72% in December and declining to 50% in May. Entrustment level increased from 6% of EPAs evaluated as “Practice Ready” in September to 75% in June. The exit survey was returned by 63% of faculty and 72% of fellows. Overall, 46% of fellows and 74% of program directors recommended full-scale implementation of the EPA framework. Conclusion: A competency-based assessment framework was developed by the FC and piloted in several programs. Participation was variable and required ongoing strategies to address barriers. The pilot project has prepared the FC to introduce CBME across all FC training programs.

Entrustable professional activities (EPAs) have been increasingly used as an assessment framework to formally capture the myriad ad hoc entrustment decisions that occur on a daily basis in clinical settings with learners present. Following the definition of Core EPAs for Entering Residency by the Association of American Medical Colleges in 2014, the American Board of Surgery (ABS) began to explore the utility of EPAs as a framework to support competency-based resident education within general surgery in 2016. As the complement of EPAs drafted for a specialty serve to define the core tasks of a professional within that discipline, initial efforts to define the entire scope of general surgery were fraught with difficulty as no commonly accepted definition of a general surgeon currently exists. Opting to prioritize a pilot of the EPA conceptual framework within surgical training rather than defining the entirety of the specialty, ABS leaders identified 5 EPAs that represent a core of general surgery with which to begin. This article details the process of choosing the initial set of EPAs and provides a roadmap for other disciplines interested in testing the feasibility of this assessment framework while garnering buy-in among the community of educators. Future steps, including implementation of the existing 5 EPAs beyond the initial pilot sites and drafting and implementation of the additional complement of EPAs, are also described.

Effective self-assessment is a cornerstone of lifelong professional development; however, evidence suggests physicians have a limited ability to self-assess. Novel strategies to improve the accuracy of learner self-assessment are needed. Our institution's surgical entrustable professional activity (EPA) implementation strategy incorporates resident self-assessment to address this issue. This study evaluates the accuracy of resident self-assessment versus faculty assessment across 5 EPAs in general surgery.

Concerns over resident ability to practice effectively after graduation have led to the competency-based medical education movement. Entrustable professional activities (EPAs) may facilitate competency-based medical education in surgery, but implementation is challenging. This manuscript describes 1 strategy used to implement EPAs into an academic general surgery residency.

The current health care environment is complex. Systems often cross US state boundaries to provide care to patients with a wide variety of medical needs. The coronavirus disease 2019 pandemic is challenging health care systems across the globe. Systems face varying levels of complexity as they adapt to the new reality. This pandemic continues to escalate in hot spots nationally and internationally, and the worst strain on health care systems may be yet to come. The purpose of this article is to provide a road map developed from lessons learned from the experience in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health and University of Wisconsin Health, based on past experience with incident command structures in military combat operations and Federal Emergency Management Agency responses. We will discuss administrative restructuring leveraging a team-of-teams approach, provide a framework for deploying the workforce needed to deliver all necessary urgent health care and critical care to patients in the system, and consider implications for the future.

To obtain a legal understanding of the “key” or “critical” portions of an operation, pertaining to attending supervision, resident autonomy, and patient safety.

Background: Data-driven patient selection guidelines are not available to optimize outcomes in minimally invasive pancreaticoduodenectomy (MIPD). We aimed to define risk factors associated with conversion from MIPD to open PD and to determine the impact of conversion on post-operative outcomes. Methods: We conducted a retrospective review of MIPD using NSQIP from 2014 to 2015. Propensity score was used to match patients who underwent completed MIPD to converted MIPD. Results: 467 patients were included: 375 (80.3%) MIPD and 92 (19.7%) converted. Converted patients were more often male (64% vs. 52%, p= 0.030), had higher rates of dyspnea (10% vs. 3%, p= 0.009), underwent more vascular (44% vs. 14%, p< 0.001) or multivisceral resection (19% vs. 6%, p= 0.0005), and were more likely attempted laparoscopically compared to robotically (76% vs. 51%, p< 0.001). Robotic approach was independently associated with reduced risk of conversion (OR 0.40, 95% CI 0.23–0.69), while male gender (OR 1.70, 95% CI 1.02–2.84), history of dyspnea (OR 3.85, 95% CI 1.49–9.96), vascular resection (OR 4.32, 95% CI 2.53–7.37), and multivisceral resection (OR 2.18, 95% CI 1.05–4.52) were associated with increased risk. Major complications were more common in converted patients (68% vs. 37%, p< 0.001). Converted patients had increased odds of non-home discharge (OR 3.25, 95% CI 1.06–9.97) and an associated increased length of stay of 3 days (95% CI 0.1–6.7). Conclusion: Patients with a history of dyspnea or tumors requiring vascular or multivisceral resection were at increased risk of conversion, and the robotic platform was associated with a lower rate of conversion. Conversion was independently associated with increased overall complications, increased length of stay, and non-home discharge.

This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.

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IMPORTANCE: A critical balance is sought between faculty supervision, appropriate resident autonomy, and patient safety in the operating room. Variability in the release of supervision during surgery represents a potential safety hazard to patients. A better understanding of intraoperative faculty-resident interactions is needed to determine what factors influence entrustment. OBJECTIVE: To assess faculty and resident intraoperative entrustment behaviors and to determine whether faculty behaviors drive resident entrustability in the operating room. DESIGN, SETTING, AND PARTICIPANTS: This observational study was conducted from September 1, 2015, to August 31, 2016, at Michigan Medicine, the University of Michigan’s health care system. Two surgical residents, 1 medical student, 2 behavioral research scientists, and 1 surgical faculty member observed surgical intraoperative interactions between faculty and residents in 117 cases involving 28 faculty and 35 residents and rated entrustment behaviors. Without intervening in the interaction, 1 or 2 researchers observed each case and noted behaviors, verbal and nonverbal communication, and interaction processes. Immediately after the case, observers completed an assessment using OpTrust, a validated tool designed to assess progressive entrustment in the operating room. Purposeful sampling was used to generate variation in type of operation, case difficulty, faculty-resident pairings, faculty experience, and resident training level. MAIN OUTCOMES AND MEASURES: Observer results in the form of entrustability scores (range, 1-4, with 4 indicating full entrustability) were compared with resident- and faculty-reported measures. Difficulty of operation was rated on a scale of 1 to 3 (higher scores indicate greater difficulty). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and observation duration, observation month, and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients. RESULTS: Twenty-eight faculty and 35 residents were observed across 117 surgical cases from 4 surgical specialties. Cases observed by postgraduate year (PGY) of residents were distributed as follows: PGY-1, 21 (18%); 2, 15 (13%); 3, 17 (15%); 4, 27 (23%); 5, 28 (24%); and 6, 9 (8%). Case difficulty was evenly distributed: 36 (33%) were rated easy/straightforward; 43 (40%), moderately difficult; and 29 (27%), very difficult by attending physicians. Path analysis showed that the association of PGY with resident entrustability was mediated by faculty entrustment (0.23 [.03]; P < .001). At the univariate level, case difficulty (mean [SD] resident entrustability score range, 1.97 [0.75] for easy/straightforward cases to 2.59 [0.82] for very difficult cases; F = 6.69; P = .01), PGY (range, 1.31 [0.28] for PGY-1 to 3.16 [0.54] for PGY-6; F = 22.85; P < .001), and faculty entrustment (2.27 [0.79]; R2 = 0.91; P < .001) were significantly associated with resident entrustability. Mean (SD) resident entrustability scores were highest for very difficult cases (2.59 [0.82]) and PGY-6 (3.16 [0.54]). CONCLUSIONS AND RELEVANCE: Faculty entrustment behaviors may be the primary drivers of resident entrustability. Faculty entrustment is a feature of faculty surgeons’ teaching style and could be amenable to faculty development efforts.

•Learning analytics provide meaningful feedback supporting formative and summative decisions.•Data dashboards support various stakeholders in progressive entrustment decisions for trainees.•Intuitive analytics platforms for EPA microassessment data support CCC decisions for promotion.

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors’ expectations and new residents’ performance.In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 core EPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment.The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors’ expectations and new residents’ performance, enhancing patient safety and increasing residents’, educators’, and patients’ confidence in the care these learners provide in the first months of their residency training.

This review outlines the current state of undergraduate medical education for the surgeon in training, and highlights ongoing efforts to improve the preparation of graduating students entering surgical residency. Possible models for improved integration of specialty specific training in medical school are explored, and future directions in undergraduate surgical education are considered in the context of ongoing curricular initiatives in medical schools within North America.

Significant risk factors for recurrence after surgical resection of nonfunctional pancreatic neuroendocrine tumors include tumor grade, stage, Ki-67 index, and CD68 score as a marker of macrophage infiltration. Use of the CD68 score may identify patients with low-grade tumors who are at increased risk for disease recurrence.

The reported influence of Accreditation Council for Graduate Medical Education resident duty hour limitations on operative case volume has been mixed. Additional restrictions instituted in July 2011 further limited the work hours of postgraduate year 1 (PGY-1) residents, threatening to reduce availability for educational and operative activities. In this study, we evaluate our novel intern call schedule, which we hypothesized would preserve operative experience despite these increased restrictions.

Lipopolysaccharide binding protein (LBP) plays an essential role in the pulmonary immune response to gram-negative bacterial infection. LBP knockout mice with gram-negative pneumonia have increased mortality compared with wild-type controls. This mortality difference can be abolished with systemic LBP gene therapy. We postulate that LBP knockout mice will develop derangements in lung physiology from gram-negative pneumonia and that these changes can be reversed with systemic LBP gene therapy.

The antiinflammatory cytokine interleukin IL10 has been detected in serum after visceral ischemiareperfusion injury and exogenous IL10 administration has been shown to attenuate the associated distant organ injury. This study was designed to examine the role that endogenous IL10 production plays on both local and distant organ injury after visceral ischemiareperfusion injury. Wildtype and IL10−−null C57BL6 mice were subjected to 20 min of supraceliac aortic occlusion or sham laparotomy. Serum and lung tissue cytokine levels tumor necrosis factor alpha, IL1, IL6, KCGRO, and IL10 were measured after reperfusion 1, 2, andor 4 h using either enzymelinked immunoassay or bioassay. Lung neutrophil infiltration and injury were quantified after reperfusion injury using myeloperoxidase concentration 2 h and mean capillary permeability 4 h, respectively, whereas the direct liver injury was quantified with serum aspartate aminotransferase levels 1, 2, and 4 h. A subset of IL10−−null animals was administered human recombinant IL10 before the visceral ischemia and lung MPO was measured after reperfusion 2 h. Visceral ischemiareperfusion in the wildtype and IL10−−null mice was associated with in an increase in both serum IL1, KCGRO, IL6 and lung tissue IL1, KCGRO cytokine levels and resulted in lung neutrophil infiltration myeloperoxidase, lung injury mean capillary permeability and liver injury aspartate aminotransferase. The magnitude of the lung tissue cytokine response IL1, KCGRO, neutrophil infiltration, and injury were greater in the IL10−−null mice. Exogenous IL10 resulted in a decrease in the lung neutrophil infiltration in the IL10−−null mice. The endogenous IL10 response to visceral ischemiareperfusion attenuates the associated lung neutrophil infiltration and injury but has no effect upon either the hepatic injury or the magnitude of the systemic inflammatory response. The beneficial effects of IL10 may be mediated by the inhibition of IL1 and KCGRO through an endocrine rather than paracrine signal.

Bioglass®is a bioactive, resorbable ceramic particle that was developed to assure binding to living tissues. Bioglass®is currently employed to fill osseus defects in oral surgery, and it possesses both unique anti-inflammatory and antimicrobial properties. In an effort to determine whether Bioglass®may be useful as an adjunct anti-inflammatory device in local inflammatory processes, we examined whether exposure of the peritoneal cavity to Bioglass®would induce a pro- or anti-inflammatory response, and then modulate a subsequent proinflammatory response to endotoxin. Three- to fifty-milligram doses of 5 m Bioglass®were administered intraperitoneally in C57BL/6 mice. Total leukocyte, myeloperoxidase, and cytokine levels in the peritoneal wash fluid were determined. In addition, the peritoneal cavity was pre-exposed to Bioglass®, and was then subjected to a subsequent endotoxin administration. All doses of Bioglass®were found to induce a significant peritoneal IL-6 response; however, Bioglass®did not induce a TNF-, IL-1, IL-10, or a white cell recruitment into the peritoneal lavage fluid. Pretreatment of the peritoneal cavity with Bioglass®produced a transient reduction in the proinflammatory response to endotoxin. We conclude that exposure to Bioglass®produces an IL-6 response without concurrent expression of TNF- or IL-1. Bioglass®appears to transiently suppress the inflammatory response to endotoxin, possibly through the early induction of IL-6. These findings suggest that Bioglass®may offer a unique approach in modifying the inflammatory response in local tissue compartments.

The application of gene therapy to acute inflammation has not received as much research attention as has the treatment of genetically-based diseases, cancer, and viral infections. However, gene therapy as a drug delivery system offers several theoretical and practical advantages over current protein delivery systems. These include the ability to target therapies to individual tissues or cell types, to locally produce proteins that can act intracellularly or in an autocrine, juxtacrine, or paracrine fashion, and to sustain new protein synthesis for periods up to several weeks after a single administration. Although retrovirus, herpes simplex, and adeno-associated virus have been proposed for gene therapy in cancer and in genetic diseases, nonviral and adenovirus approaches appear most applicable as drug delivery systems due to their rapid onset and short duration of transgene expression. The relative modest transduction efficiencies obtained at present with nonviral approaches, and the inherent inflammatory properties of first-generation adenovirus constructs, however, have limited their usefulness to date. The present review discusses the theoretical and practical benefits of specific gene therapy approaches for the treatment of acute inflammatory diseases, as well as our experiences with liposome:plasmid DNA and adenovirus-based approaches. Although a number of technical and theoretical hurdles remain before it can be evaluated in humans with acute inflammation, gene therapy offers a novel approach for the treatment of acute inflammation, and will likely enter the armamentarium of critical care physicians in the near future.

To meet the Accreditation Council for Graduate Medical Education core competency in Practice-Based Learning and Improvement, educational curricula need to address training in quality improvement (QI). We sought to establish a program to train residents in the principles of QI and to provide practical experiences in developing and implementing improvement projects.

Toolkits to assess progressive resident autonomy are integral to the movement toward competency-based surgical education. OpTrust is one such tool validated for intraoperative assessment of both faculty and resident entrustment behaviors. We developed a supplementary tool to OpTrust that would aid faculty and residents in making meaningful improvements in entrustment behavior by providing talking points and reflection items tailored to different motivational styles as defined by Regulatory Focus Theory (RFT).

•The public service loan forgiveness program is often utilized by trainees•Utilization of public service loan forgiveness has an impact on career choices•There is a poor understanding of the PSLF criteria among trainees