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Objective: Resident-Applicant Buddy Programs (RABPs) are a new initiative designed to improve resident recruitment. This study aims to evaluate the impact and perceived value of RABPs and to identify areas for improvement for future recruitment cycles., Design: Anonymous online survey study of RABP participants with mixed-methods approach to evaluate participants' experience and perceived impact of the program. The survey queried demographics, Likert responses, and open-ended responses. Qualitative thematic analysis of open-ended responses was performed with inductive coding in an iterative fashion by 2 raters., Setting: This study was conducted at a general surgery residency program at a tertiary academic institution during 2022-2023 recruitment cycle., Participants: Of 125 RABP participants (n = 39 residents and n = 86 interviewed applicants), surveys from n = 45 participants (n = 19 residents, 66%; n = 26 applicants, 30%) were completed and analyzed., Results: Applicants were predominantly female (65%) and first-generation physicians (69%). Buddy pairings were 65% gender concordant and 48% race/ethnicity concordant. Many applicants (60%) participated in RABPs at other institutions. Buddies connected for a mean (SD) of 52 (28) minutes. Majority of applicants agreed the program decreased stress/apprehension about interviewing (70%, 4.0 [1.1]), helped understand resident life at the program (91%, 4.3 [1.0]), and increased desire to match in the program (65%, 4.0 [1.1]). Residents agreed they enjoyed participation (89%, 4.5 [0.7]), the program should be continued (100%, 4.8 [0.4]), and desired to participate again (100%, 4.8 [0.4]). Thematic analysis revealed applicants valued the program as an approachable source of information, illumination of program culture, aid in interview preparation, and connection between applicant and program. Applicants appreciated the intentionality of the program to create a RABP., Conclusions: RABP decreased applicants' stress, improved understanding of resident life, and for the majority, increased desire to match at the program. Resident engagement and desire for ongoing participation in the RABP was high. Overall, RABPs can increase applicant interest and program transparency., (Published by Elsevier Inc.)

Abstract: Two senior surgeons with active elective surgery practices call on their personal experiences to encourage acute care surgery programs to explore ways to incorporate elective surgery into their practice models. Although there are obstacles, these are not insurmountable problems, potential solutions exist, and this may help protect against burnout., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients., Methods: We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs., Results: We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001)., Conclusions: Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To Study the Outcomes of the First Virtual General Surgery Certifying Exam of the American Board of Surgery., Summary of Background Data: The ABS General Surgery CE is normally an in-person oral examination. Due to the COVID-19 outbreak, the ABS was required to reschedule these. After 2 small pilots, the CE's October administration represented the first large-scale remote virtual exam. The purpose of this report is to compare the outcomes of this virtual and the previous in-person CEs., Methods: CE candidates were asked to provide feedback on their experience via a survey. The passing rate was compared to the 1025 candidates who took the 2019-2020 in-person CEs., Results: Of the 308 candidates who registered for the virtual CE, 306 completed the exam (99.4%) and 188 completed the survey (61.4%). The majority had a very positive experience. They rated the virtual CE as very good/excellent in security (90%), ease of exam platform (77%), audio quality (71%), video quality (69%), and overall satisfaction (86%). Notably, when asked their preference, 78% preferred the virtual exam. There were no differences in the passing rates between the virtual or in-person exams., Conclusions: The first virtual CE by the ABS was completed using available internet technology. There was high satisfaction, with the majority preferring the virtual platform. Compared to past in-person CEs, there was no difference in outcomes as measured by passing rates. These data suggest that expansion of the virtual CE may be desirable., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, 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: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume., Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume., Design, Setting, and Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations., Main Outcome and Measures: Total major cases performed by each resident during the first 4 months of the pandemic., Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03)., Conclusions and Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.

Background: Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD)., Study Design: We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs., Results: Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001)., Conclusions: Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.

Background: Interest in acute care surgery (ACS) has increased over the past 10 years as demonstrated by the linear increase in fellowship applicants to the different fellowships leading to ACS careers. It is unclear why interest has increased, whether various fellowship pathways attract different applicants or whether fellowship choice correlates with practice patterns after graduation., Methods: An online survey was distributed to individuals previously registered with the Surgical critical care and Acute care surgery Fellowship Application Service. Fellowship program directors were also asked to forward the survey to current and former fellows to increase the response rate. Data collected included demographics, clinical interests and motivations, publications, and postfellowship practice patterns. Fisher's exact and Pearson's χ were used to determine significance., Results: Trauma surgery was the primary clinical interest for all fellowship types (n = 273). Fellowship type had no impact on academic productivity or practice patterns. Most fellows would repeat their own fellowship. The 2-year American Association for the Surgery of Trauma-approved fellowship was nearly uniformly reported as the preferred choice among those who would perform a different fellowship. Career motivations were similar across fellowships and over time though recent trainees were more likely to consider predictability of schedule a significant factor in career choice. Respondents reported graduated progression to full responsibility, further exposure to trauma care and additional operative technical training as benefits of a second fellowship year., Conclusion: American Association for the Surgery of Trauma-approved 2-year fellows appear to be the most satisfied with their fellowship choice. No differences were noted in academic productivity or practice between fellowships. Future research should focus on variability in trauma training and operative experience during residency and in practice to better inform how a second fellowship year would improve training for ACS careers., Level of Evidence: Descriptive, mixed methods, Level IV.

Background: Acute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics., Methods: We queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates., Results: Of the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients., Conclusion: Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs., Level of Evidence: Epidemiologic, level III.

Objective: To assess the consistent availability of basic surgical resources at selected facilities in seven countries., Methods: In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh ( n  = 14), the Plurinational State of Bolivia ( n  = 18), Ethiopia ( n  = 19), Guatemala ( n  = 20), the Lao People's Democratic Republic ( n  = 12), Liberia ( n  = 12) and Rwanda ( n  = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available., Findings: Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh., Conclusion: Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Background: Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure., Methods: A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool., Results: The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%)., Conclusions: The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

Background: Experimentation involving human subjects requires careful attention to the protection of their rights. Beginning with the Belmont Report in 1979, the United States has developed various sets of rules and regulations that identify the requirements for performing human subject research. In addition, these standards attempt to define the fundamental difference between what constitutes research versus clinical treatment versus innovation. We explore the intersection between two areas of independent bioethics, surgical innovation and emergency research; the point we refer to as emergency innovation., Methods: A systematic literature review in each of the fields of emergency research and surgical innovation was completed. The ethical principles involved in each field were identified. In addition, a recent case of surgical innovation within the context of emergency treatment is evaluated for the ethics invoked., Results: One of the great challenges in emergency innovation is that the main protection offered in innovation (heightened informed consent) is not possible in the emergency context where in fact informed consent is waived. Interestingly, the rest of the protections outlined for each field are not mutually exclusive. They can and should be utilized in any project that takes place at this intersection. However, as there are no strict regulations in place for the collision of these two fields, the possibility of having the majority of the involved ethical principles misinterpreted or ignored is very real., Conclusions: For emergency innovation, where it is unclear what ethical principles and regulatory powers apply, it is imperative to be unambiguous about the purpose of the investigation, to adhere to all applicable ethical principles, and to have utmost consideration for protection of the research subject. To determine intent, the goals of the study must be outlined precisely - and if those include the prospect of publication, institutional review board (IRB) approval should be involved early. If, however, the innovation is subtle and the goal geared toward improved patient care, a small feasibility trial would be an appropriate first step before transitioning to a formal larger study approved by an IRB. In either case, the degree of the change in practice must be carefully evaluated and the vulnerability of the research subjects respected. With careful attention paid to all applicable ethical principles at the emergency innovation intersection, medical progress can continue at minimized risk to the human subject participants.

Background: Our goal was to identify factors that can be targeted during medical education to encourage a career in surgery., Study Design: We conducted a cross-sectional survey of first and fourth year classes in a Liaison Committee on Medical Education-accredited medical school. Students scored 19 items about perceptions of surgery using a Likert-type scale. Students also indicated their gender and ranked their top three career choices., Results: There were 121 of 210 (58%) first year and 110 of 212 (52%) fourth year students who completed the survey. First year students expressed a positive correlation between surgery and career opportunities, intellectual challenge, performing technical procedures, and obtaining a residency position, although length of training, work hours, and lifestyle during and after training were negatively correlated with choosing surgery. Fourth year student responses correlated positively with career and academic opportunities, intellectual challenge, technical skills, role models, prestige, and financial rewards. Factors that correlated negatively were length of training, residency lifestyle, hours, call schedule, and female gender of the student respondent. Forty-four percent of first year male students expressed an interest in surgery versus 27% of fourth year male students (p < 0.04). Eighteen percent of first year female students expressed an interest in surgery versus 5% of fourth year female students (p < 0.006)., Conclusions: Lifestyle issues remain at the forefront of student concerns. Intellectual challenge, career opportunities, and technical skills are consistently recognized as strengths of surgery. Additionally, fourth year students identify role models, prestige, and financial rewards as positive attributes. Emphasizing positive aspects may facilitate attracting quality students to future careers in surgery.

IntroductionThere is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail.MethodsWe queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity.Results430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity.ConclusionsOur data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity.Short summaryWe applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.

BackgroundAcute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics.MethodsWe queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates.ResultsOf the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients.ConclusionAcute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs.Level of evidenceEpidemiologic, level III.