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In this randomized trial comparing ACGME duty-hour policies with more flexible policies for surgical residents, the flexible policies resulted in noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. In response to concerns about patient safety and resident well-being, the Accreditation Council for Graduate Medical Education (ACGME) introduced national regulations in 2003 that limited resident duty periods to 80 hours per week, capped overnight shift lengths, and mandated minimum time off between shifts. 1 , 2 Concerns persisted, 3 and in 2011, the ACGME implemented further restrictions to shorten maximum shift lengths for interns and increase time off after overnight on-call duty for residents. 1 , 4 , 5 Although most observers agree that some duty-hour regulation was necessary, critics cite a weak evidence base for the 2003 and 2011 reforms. 3 , 6 , 7 Several retrospective . . .

[...]began a collaboration that led to three rounds of multicenter studies with an entourage of colleagues we were able to assemble nationally. [...]collaborations outside of our immediate sphere of expertise broaden our research horizon, and in so doing make both the questions we ask and the conclusions we draw more robust, more aware, and more compelling. [...]I recognize that collaboration brings gratitude in its wake, for it renders us aware that the waves our lives create end up being carried along more by the contributions of others than the amplitude of our own ripples.

Surgery residents have experienced significant changes in lifestyle, including an up to 20 hour decrease in the average reported weekly work hours subsequent to these restrictions.1 A systematic review of the effect of duty hour restrictions on surgical residents showed an increase in hours of sleep and levels of alertness, with little to no effect on operative volumes.2 Despite these changes, concerns regarding resident fatigue and wellness remain, and have fostered ongoing discussions around flexible educational strategies that promote healthy sleep patterns and related effective personal and clinical function. [...]it is not clear that a 90-min mid-shift nap and 30-min recovery period represents a feasible and scalable construct for addressing resident fatigue issues in a fashion comparable to what might prove practical and effective for a transportation worker. Experience thus far with duty hour reform has suggested that seniorization of work, inaccurate reporting of hours, and infrequent efforts to go home early or hand off care due to cultural commitments to continuity and patient ownership are more common than not.5 There is a prevalent and persistent viewpoint within surgical training programs that the “old school” method of teaching is superior, and duty hour restrictions inhibit appropriate surgical training and preparation for autonomous practice.

Developing an operating room conflict management educational program for surgeons requires a formal needs assessment and information about behaviors that represent effective conflict management. Focus groups of circulating room nurses and surgeons were conducted at 5 participating centers. Participants responded to queries about conflict management training, conflict consequences, and effective conflict management behaviors. Transcripts of these sessions served as the data for this study. Educational preparation for conflict management was inadequate consisting of trial and error with observed behaviors. Conflict and conflict mismanagement had negative consequences for team members and team performance. Four behaviors emerge as representing effective ways for surgeons to manage conflict. There is a clear educational need for conflict management education. Target behaviors have now been identified that can provide the basis for a theoretically grounded and contextually adapted instruction and assessment of surgeon conflict management.

BackgroundReadmission status is an important clinical component of healthcare outcomes. 90-day readmission following complex open ventral hernia repair has not been well studied with national level data. This study aims to compare readmission rates for patients undergoing standard vs. complex (myocutaneous flap-based) ventral hernia repair. We hypothesize that complexity of reconstruction will be an independent predictor of readmission after ventral hernia repair.MethodsA retrospective cohort study was performed with 1:1 matching of hernia repair type using the National Readmissions Database. Patients were selected using ICD-9 codes corresponding to ventral hernia repair with or without myocutaneous flap. 90-day readmissions were determined on patients within the first through third quarters of each year. After matching, a multivariable logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, type of repair, urgency of repair, sociodemographic status, and payer. Likelihood of 90-day readmission was calculated from odds ratios.ResultsReadmission rates were 19.1% (38,313 out of 200,266) and 22.5% (692 out of 3075) at 90-day for standard ventral hernia repair and complex ventral hernia repair, respectively. 3116 standard ventral hernia repair patients were matched with 3074 complex ventral hernia repair patients. After matching there was a significantly increased readmission rate for repairs involving myocutaneous flaps, with odds ratio (OR) 1.30 (95% CI 1.22–1.60). Payer status (OR 1.82; 95% CI 1.21–2.74), teaching hospital status (OR 1.42; 95% CI 1.23–1.64) and income quartile (OR 1.35; CI 1.10–1.65) were independent predictors of readmission.ConclusionsPatients undergoing myocutaneous flap-based reconstruction have higher readmission rates than those undergoing less complex ventral hernia repair. Socioeconomic disparity as reflected in payer status is a particularly strong predictor of readmission. The data support the concept that focused efforts are needed to optimize patient outcomes for patients requiring more complex repair, including socioeconomically disadvantaged patient populations.Graphic abstract

IntroductionThe growth of surgeon burnout is of significant concern. As we work to reimagine the practice of surgery, an accurate understanding of the extent of surgeon burnout is essential. Our goal was to define the current prevalence of burnout and quality of life (QOL) among SAGES surgeons.MethodologyAn electronic survey was administered to SAGES members to establish a current baseline for QOL, burnout, depression, and career satisfaction. To assess outcomes, we utilized the validated Maslach Burnout Inventory for Medical Personnel, the Medical Outcomes Study Short Form, and the Primary Care Evaluation of Mental Disorders. All scoring followed validated norm-based methods.ResultsOf 4194 active members, 604 responded (14.40%). 69% met burnout threshold, with high levels of emotional exhaustion and depersonalization, and low personal accomplishment. 81% reported “being at the end of their rope”, 74% felt emotionally drained, and 65% felt used up daily. Nearly all maintained caring about what happened to their patients (96%), easily understanding how their patients feel (84.3%) and being capable of dealing effectively with their patient’s problems (87.6%). However, respondents never, rarely, or occasionally felt energetic (77.5%) or experienced a sense of professional accomplishment (57.8%). The overall QOL score was 69/100, with lower Mental than Physical scores (62.69 (SD 10.20) vs.77.27 (SD 22.24)). More than half of respondents met depression criteria. While 77% supported they would become a physician again, less than half would choose surgery again or recommend surgery to their children. Furthermore, less than a third felt work allowed sufficient time for their personal lives.ConclusionsParticipating SAGES surgeons reported alarmingly high rates of burnout and depression. Despite experiencing emotional exhaustion and depersonalization, they maintained a strong commitment to patient care. These findings likely reflect the broader state of surgeons, underscoring the urgent need for action to address this critical issue.

BackgroundSocioeconomic disparities have been associated with outcomes in many medical conditions. The association of socioeconomic status (SES) with readmissions after ventral and inguinal hernia repair has not been well studied on a national level. This study aims to evaluate the association of SES with readmission as a significant outcome in patients undergoing ventral and inguinal hernia repair.MethodsA retrospective cohort study was performed evaluating patients undergoing ventral hernia and inguinal hernia repair with 1:1 propensity score matching using the Nationwide Readmissions Database (2016–2017). Both 30- and 90-day readmissions were examined. After matching, a multivariate logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, urgency of repair, sociodemographic status, and payer. Likelihood of readmission was reported in odds ratio form.ResultsReadmission rates were 11.56% (24,323 out of 210,381) and 17.94% (30,893 out of 172,210) for 30- and 90-day readmissions, respectively. Patients with Medicaid and in the lower income quartile were more likely to present in an emergent fashion for hernia repair. After matching, a multivariate logistic regression analysis showed socioeconomic status (OR 1.250 and 1.229) was a statistically significant independent predictor of readmission at 30 and 90 days, respectively. Inversely, factors associated with the least likely chance of readmission were a laparoscopic approach (OR 0.646 and 0.641), elective admission (OR 0.824 and 0.779), and care in a teaching hospital (OR 0.784 and 0.798).ConclusionSES is an independent predictor of readmission at 30 and 90 days following open and laparoscopic ventral and inguinal hernia repair. Patients with a lower socioeconomic status were more likely to undergo hernia repair in the emergent setting. Efforts toward mitigating SES disparities by potentially promoting MIS techniques, enhancing access to elective cases, and systematic approaches to perioperative care for this disadvantaged population can potentially enhance overall hernia outcomes.

BackgroundBurnout among physicians is an increasing concern, and surgeons are not immune to this threat. The ongoing COVID-19 pandemic has caused dramatic changes to surgeon workflow, often leading to redeployment to other clinical areas, slowdown and shutdown of elective surgery practices, and an uncertain future of surgical practice in the post-pandemic setting. Paradoxically, for many surgeons who had to prepare for but not immediately care for a major surge, the crisis did allow for reflective opportunities and a resetting of priorities that could serve to mitigate chronic patterns contributory to Burnout.MethodsSAGES Reimagining the Practice of Surgery task force convened a webinar to discuss lessons learned from the COVID pandemic that may address burnout.ResultsBurnout is multifactorial and may vary in cause among different generation/experience groups. Those that report burnout symptoms often complain of lacking purpose or meaning in their work. Although many mechanisms to address Burnout are from a defensive standpoint—including coping mechanisms, problem solving, and identification of a physician having wellness difficulties—offensive mechanisms such as pursuing purpose and meaning and finding joy in one's work can serve as reset points that promote thriving and fulfillment. Understanding what motivates physicians will help physician leaders to develop and sustain effective teams. Reinvigorating the surgical workforce around themes of meaning and joy in the service rendered via our surgical skills may diminish Burnout through generative and aspirational strategies, as opposed to merely reactive ones. Fostering an educational environment free of discriminatory or demeaning behavior may produce a new workforce conducive to enhanced and resilient wellbeing at the start of careers.ConclusionSurgeon wellness and self-care must be considered an important factor in the future of all healthcare delivery systems, a need reaffirmed by the COVID-19 pandemic.

Prior research has shown that surgeons who effectively manage operating room conflict engage in a problem-solving stage devoted to modifying systems that contribute to team conflict. The purpose of this study was to clarify how systems contributed to operating room team conflict and clarify what surgeons do to modify them. Focus groups of circulating nurses and surgeons were conducted at 5 academic medical centers. Narratives describing the contributions of systems to operating room conflict and behaviors used by surgeons to address those systems were analyzed using the constant comparative approach associated with a constructivist grounded theory approach. Operating room team conflict was affected by 4 systems-related factors: team features, procedural-specific staff training, equipment management systems, and the administrative leadership itself. Effective systems problem solving included advocating for change based on patient safety concerns. The results of this study provide clarity about how systems contribute to operating room conflict and what surgeons can do to effectively modify these systems. This information is foundational material for a conflict management educational program for surgeons.

Introduction Butyrate is a bacterial fermentation product that produces its beneficial effects on colon through GPR109A, a butyrate receptor, and SLC5A8, a butyrate transporter. In this study, we compared the expression of GPR109A and SLC5A8 between conventional mice and germ-free mice to test the hypothesis that the expression of these two proteins will be decreased in germ-free mice compared to conventional mice because of the absence of bacterial fermentation products and that colonization of germ-free mouse colon with conventional bacteria will reverse these changes. Methods RNA was prepared from the ileum and colon of conventional mice and germ-free mice and used for RT-PCR to determine mRNA levels. Tissue sections were used for immunohistochemical analysis to monitor the expression of GPR109A and SLC5A8 at the protein level. cDNA microarray was used to determine the differential expression of the genes in the colon between conventional mice and germ-free mice. Results In conventional mice with normal bacterial colonization of the intestinal tract, GPR109A and SLC5A8 are expressed on the apical membrane of epithelial cells lining the ileum and colon. In germ-free mice, the expression of GPR109A and SLC5A8 is reduced markedly in the ileum and colon. The expression returns to normal levels when the intestinal tract of germ-free mice is colonized with bacteria. The expression of the Na + -coupled glucose transporter, SGLT1, follows a similar pattern. Microarray analysis identifies ∼700 genes whose expression is altered more than twofold in germ-free mice compared to conventional mice. Among these genes are the chloride/bicarbonate exchanger SLC26A3 and the water channel aquaporin 4. The expression of SLC26A3 and AQP4 in ileum and colon is reduced in germ-free mice, but the levels return to normal upon bacterial colonization. Conclusion Gut bacteria play an active role in the control of gene expression in the host intestinal tract, promoting the expression of the genes that are obligatory for the biological actions of the bacterial fermentation product butyrate and also the genes that are related to electrolyte and water absorption.