Beyond burnout: Nurturing wellness and resilience

Beyond burnout: Nurturing wellness and resilience

A U G U S T 2 0 1 9 | V O L U M E 1 0 4 N U M B E R 8 | A M E R I C A N C O L L E G E O F S U R G E O N S

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Contents

FEATURES

COVER STORIES: ACS Resident and Associate Society: Beyond burnout: Nurturing wellness and resilience

Nurturing wellness and fostering resilience during a surgical career: An introduction 12Rebecca L. Hoffman, MD, MSCE

The transformation of surgical education and its influence on resident wellness 15Brett M. Tracy, MD; Kathryn M. Stadeli, MD, MPH; Julia R. Coleman, MD, MPH; Vamsi Aribindi, MD; Randi Ryan, MD; and K. Benjamin Lee, MD

Silence is deadly: The importance of communication in addressing wellness and burnout in surgical residency 22Meghana V. Kashyap, MD, DIM&PH; Melissa Red Hoffman, MD, ND; Erica K. Ludi, MD; and Crystal N. Johnson-Mann, MD

A sense of belonging and community can mitigate physician burnout 30Yewande Alimi, MD, MHS; Maria S. Altieri, MD, MS; Jeremy D. Kauffman, MD; Pridvi Kandagatla, MD; Patricia Martinez Quinones, MD, PhD; Madeline B. Torres, MD; and Rebecca L. Williams-Karnesky, MD, PhD

Training resilient surgeons: Where do we go from here? 36 Rebecca L. Williams-Karnesky, MD, PhD; Rachel Hanke, MD; Erica K. Ludi, MD; Christopher L. Kalmar, MD, MBA; Meghana V. Kashyap, MD, DIM&PH; Ravi Viradia, MD; Franki Boulos, MSc, MD; and Kaitlin A. Ritter, MD

Shift work surgery: Loss of continuity or sensible balance of responsibility? 45Julia R. Coleman, MD, MPH; Brett M. Tracy, MD; Christopher L. Kalmar, MD, MBA; Christopher F. McNicoll, MD; and Randi Ryan, MD

AUG 2019 BULLETIN American College of Surgeons

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COLUMNSLooking forward 9

David B. Hoyt, MD, FACS

From residency to retirement: Medical Student Program at Clinical Congress has lasting impact 52

Sarah J. Armenia

ACS Clinical Research Program: Gastric cancer: Recent updates in surgical and multimodality therapy 55

Rebecca A. Snyder, MD, MPH; Naruhiko Ikoma, MD, MS; Judy C. Boughey, MD, FACS; and Christina L. Roland, MD, MS, FACS

A look at The Joint Commission: 2018 Eisenberg Award winners include Society of Thoracic Surgeons 60Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

NTDB data points: Under the influence: Alcohol-related trauma 62

Richard J. Fantus, MD, FACS

NEWSDr. Henry Buchwald receives the 2019 ACS Jacobson Innovation Award 64

In memoriam: Donald D. Trunkey, MD, FACS, a giant in trauma surgery 66

Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon)

Your ACS Benefits: Operation Giving Back provides array of volunteer opportunities 71

Sadie Bazur-Leidy, MPH

The Brandeis EMBA for Physicians offers scholarship for ACS Fellows 74

Get involved with JACS 74

Coming next month in JACS and online now 74

RAS-ACS announces inaugural Outstanding Mentor of the Year Award 75

Residents: Prepare to take your ACS membership to the next level 76

Chapter news 78

Luke Moreau and Brian Frankel

SCHOLARSHIPSTraveling Fellow to Japan reports on experience 84

Liliana Bordeianou, MD, MPH, FACS

MEETINGS CALENDARCalendar of events 88

V104 No 8 BULLETIN American College of Surgeons

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Contents continued

Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5.

The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Suite 2400, Chicago, IL 60611-3295; tel. 312-202-5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Suite 1000, Washington, DC. 20001-6701; tel. 202-337-2701.

Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons.

©2019 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher.

Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

EDITOR-IN-CHIEFDiane Schneidman

SENIOR GRAPHIC DESIGNER/PRODUCTION MANAGER

Tina Woelke

SENIOR EDITORTony Peregrin

NEWS EDITORMatthew Fox

EDITORIAL AND PRODUCTION ASSISTANT

Kira Plotts

EDITORIAL ADVISORSDanielle A. Katz, MD, FACSDhiresh Rohan Jeyarajah, MD, FACSCrystal N. Johnson-Mann, MDMark W. Puls, MD, FACSBryan K. Richmond, MD, FACSMarshall Z. Schwartz, MD, FACSAnton N. Sidawy, MD, FACSGary L. Timmerman, MD, FACSDouglas E. Wood, MD, FACS

FRONT COVER DESIGNTina Woelke

The American College of Surgeons is dedicated

to improving the care of the surgical patient

and to safeguarding standards of care in an

optimal and ethical practice environment.

CLINICAL CONGRESS 2019The Best Surgical Education. All in One Place.

October 27–31 Moscone Convention Center | San Francisco, CA

Register by August 26!facs.org/clincon2019

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Letters to the Editor should be sent

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Editor-in-Chief, Bulletin, American

College of Surgeons, 633 N. Saint Clair St.,

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Officers and Staff of the American College of Surgeons

OfficersRonald V. Maier, MD, FACSSeattle, WAPRESIDENT

Barbara L. Bass, MD, FACSHouston, TXIMMEDIATE PAST-PRESIDENT

Mark C. Weissler, MD, FACSChapel Hill, NCFIRST VICE-PRESIDENT

Philip R. Caropreso, MD, FACSIowa City, IASECOND VICE-PRESIDENT

Edward E. Cornwell III, MD, FACS, FCCMWashington, DCSECRETARY

William G. Cioffi, Jr., MD, FACSProvidence, RITREASURER

David B. Hoyt, MD, FACS Chicago, ILEXECUTIVE DIRECTOR

Gay L. Vincent, CPAChicago, ILCHIEF FINANCIAL OFFICER

Officers-Elect (take office October 2019)Valerie W. Rusch, MD, FACSNew York, NYPRESIDENT-ELECT

John A. Weigelt, MD, FACSSioux Falls, SDFIRST VICE-PRESIDENT-ELECT

F. Dean Griffen, MD, FACSShreveport, LASECOND VICE-PRESIDENT-ELECT

Board of RegentsGerald M. Fried, MD, FACS, FRCSCMontreal, QCCHAIR

James K. Elsey, MD, FACSAtlanta, GAVICE-CHAIR

Anthony Atala, MD, FACSWinston-Salem, NCJohn L. D. Atkinson, MD, FACSRochester, MNJames C. Denneny III, MD, FACSAlexandria, VAMargaret M. Dunn, MD, FACSFairborn, OHTimothy J. Eberlein, MD, FACSSaint Louis, MO

Henri R. Ford, MD, FACSMiami, FLJames W. Gigantelli, MD, FACSOmaha, NEB.J. Hancock, MD, FACS, FRCSCWinnipeg, MBEnrique Hernandez, MD, FACSPhiladelphia, PALenworth M. Jacobs, Jr., MD, FACSHartford, CTL. Scott Levin, MD, FACSPhiladelphia, PAFabrizio Michelassi, MD, FACSNew York, NYLena M. Napolitano, MD, FACSAnn Arbor, MILinda G. Phillips, MD, FACSGalveston, TXKenneth W. Sharp, MD, FACSNashville, TNAnton N. Sidawy, MD, FACSWashington, DCBeth H. Sutton, MD, FACSWichita Falls, TXGary L. Timmerman, MD, FACSSioux Falls, SDSteven D. Wexner, MD, FACSWeston, FLDouglas E. Wood, MD, FACSSeattle, WAMichael J. Zinner, MD, FACSMiami, FL

Board of Governors/Executive CommitteeSteven C. Stain, MD, FACSAlbany, NYCHAIR

Daniel L. Dent, MD, FACSSan Antonio, TX VICE-CHAIR

Ronald J. Weigel, MD, PhD, FACSIowa City, IASECRETARY

Terry L. Buchmiller, MD, FACSBoston, MAAndre R. Campbell, MD, FACS San Francisco, CATaylor Sohn Riall, MD, PhD, FACSTucson, AZMika N. Sinanan, MD, PhD, FACSSeattle, WADavid J. Welsh, MD, FACSBatesville, IN

Advisory Council to the Board of Regents(Past-Presidents)Kathryn D. Anderson, MD, FACSEastvale, CAW. Gerald Austen, MD, FACSBoston, MAL. D. Britt, MD, MPH, FACS, FCCMNorfolk, VAJohn L. Cameron, MD, FACSBaltimore, MDEdward M. Copeland III, MD, FACSGainesville, FLA. Brent Eastman, MD, FACSRancho Santa Fe, CAGerald B. Healy, MD, FACSWellesley, MAR. Scott Jones, MD, FACSCharlottesville, VAEdward R. Laws, MD, FACSBoston, MALaSalle D. Leffall, Jr., MD, FACSWashington, DCLaMar S. McGinnis, Jr., MD, FACSAtlanta, GADavid G. Murray, MD, FACSSyracuse, NYPatricia J. Numann, MD, FACSSyracuse, NYCarlos A. Pellegrini, MD, FACS Seattle, WAJ. David Richardson, MD, FACSLouisville, KYRichard R. Sabo, MD, FACSBozeman, MTSeymour I. Schwartz, MD, FACSRochester, NYCourtney M. Townsend, Jr., MD, FACSGalveston, TXAndrew L. Warshaw, MD, FACSBoston, MA

Executive StaffEXECUTIVE DIRECTOR

David B. Hoyt, MD, FACSDIVISION OF ADVOCACY AND HEALTH POLICY

Frank G. Opelka, MD, FACSMedical Director, Quality and Health Policy

Patrick V. Bailey, MD, MLS, FACS Medical Director, AdvocacyChristian ShalgianDirector

AMERICAN COLLEGE OF SURGEONS FOUNDATION

Shane HollettExecutive Director

ALLIANCE/AMERICAN COLLEGE OF SURGEONS CLINICAL RESEARCH PROGRAM

Kelly K. Hunt, MD, FACSChair

CONVENTION AND MEETINGSRobert HopeDirector

DIVISION OF EDUCATIONAjit K. Sachdeva, MD, FACS, FRCSCDirector

EXECUTIVE SERVICESLynese KelleyDirector, Leadership Operations

FINANCE AND FACILITIESGay L. Vincent, CPADirector

HUMAN RESOURCES AND OPERATIONS

Michelle McGovernDirector

INFORMATION TECHNOLOGYBrian HarperDirector

DIVISION OF INTEGRATED COMMUNICATIONS

Interim DirectorJOURNAL OF THE AMERICAN COLLEGE OF SURGEONS

Timothy J. Eberlein, MD, FACSEditor-in-Chief

DIVISION OF MEMBER SERVICESPatricia L. Turner, MD, FACSDirectorM. Margaret Knudson, MD, FACSMedical Director, Military Health Systems Strategic PartnershipGirma Tefera, MD, FACSDirector, Operation Giving Back

PERFORMANCE IMPROVEMENTWill Chapleau, RN, EMT-P Director

DIVISION OF RESEARCH AND OPTIMAL PATIENT CARE

Clifford Y. Ko, MD, MS, MSHS, FACSDirectorHeidi Nelson, MD, FACSMedical Director, CancerRonald M. Stewart, MD, FACSMedical Director, Trauma


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DR. BOUGHEY (g) is the W.H. Odell Professor in Individualized Medicine, professor of surgery, and vice-chair, research, department of surgery, Mayo Clinic, Rochester, MN. She is Chair, ACS Clinical Research Program (CRP) Education Committee.

DR. BOULOS (h) is a PGY-3 general surgery resident, University of Oklahoma Health Sciences Center, Oklahoma City.

DR. COLEMAN (i) is a PGY-5 general surgery resident, University of Colorado-Denver, Aurora. She is Vice-Chair, ACS-Resident and Associate Society (RAS)Advocacy and Issues Committee, and RAS-ACS Liaison, Committee on Trauma.

continued on next page

b

Author bios*

*Titles and locations current at the time articles were submitted for publication.

DR. ALIMI (a) is a postgraduate year (PGY)-5 general surgery resident, MedStar Georgetown University Hospital, Washington, DC.

DR. ALTIERI (b) is a minimally invasive surgery fellow, Washington University, St. Louis, MO.

DR. ARIBINDI (c) is a PGY-4 general surgery resident, Baylor College of Medicine, Houston, TX.

e

g

a

f

MS. ARMENIA (d) is a fourth-year medical student, Rutgers New Jersey Medical School, Newark. She is a medical student member, American College of Surgeons (ACS) Committee on Medical Student Education.

MS. BAZUR-LEIDY (e) is Program Administrator, Operation Giving Back, ACS Division of Member Services, Chicago, IL.

DR. BORDEIANOU (f ) is associate professor of surgery, Harvard Medical School; chair, Massachusetts General Hospital Colorectal and Pelvic Floor Disorders Centers; and co-director, Partners HealthCare Colorectal Surgery Collaborative, Boston.

d

h i

DR. FANTUS (j) is interim chairman, department of surgery; medical director, trauma services; and chief, section of surgical critical care, Advocate Illinois Masonic Medical Center, Chicago. He is clinical professor of surgery, University of Illinois College of Medicine, Chicago, and Past-Chair, ad hoc Trauma Registry Advisory Committee, Committee on Trauma.

MR. FRANKEL (k) is Manager, International Chapter Services and Special Initiatives, ACS Division of Member Services.

DR. HANKE (l) is a pediatric surgery research fellow, Cincinnati Children’s Hospital, OH, and a PGY-3 general surgery resident, Penn State Health Milton S. Hershey Medical Center, Hershey, PA.

DR. MELISSA RED HOFFMAN (m) is a fellow, hospice and palliative medicine, Mountain Area Health Education Center, and staff surgeon, Mission Hospital, Asheville, NC. She is Vice-Chair, RAS-ACS Communications Committee.

DR. REBECCA HOFFMAN (n) is a Fellow, colon and rectal surgery, Washington University, St. Louis, and Chair, RAS-ACS.

DR. IKOMA (o) is assistant professor of surgical oncology, University of Texas MD Anderson Cancer Center, Houston, TX.

DR. JOHNSON-MANN (p) is assistant professor, department of surgery, division of gastrointestinal surgery, University of Florida College of Medicine, Gainesville. She is Chair, RAS-ACS Communications Committee.

DR. KALMAR (q) is a PGY-4 clinical research fellow, division of plastic and reconstructive surgery, Children’s Hospital of Philadelphia, PA.

DR. KANDAGATLA (r) is a PGY-4 general surgery resident, Henry Ford Health System/Wayne State University, Detroit, MI.


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Author bios continued

j

m

q

k


n

p

o

r

l

x

DR. KASHYAP (s) is a PGY-4 general surgery resident, department of surgery, University of Nebraska Medical Center, Omaha, and a fetal research fellow, Children’s Hospital of Philadelphia.

DR. KAUFFMAN (t) is a pediatric surgery critical care fellow, University of Michigan, Ann Arbor, and PGY-4 general surgery resident, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA. He is Secretary, RAS-ACS Membership Committee, and RAS-ACS Liaison to the ACS International Relations Committee.

DR. LEE (u) is a PGY-4 general surgery resident, George Washington University, Washington, DC.

DR. LUDI (v) is a second-year global surgery research fellow in Santa Cruz, Bolivia, and a PGY-2 general surgery resident, department of surgery, Emory University, Atlanta, GA.

DR. MAIER (w) is surgeon-in-chief, Harborview Medical Center; and professor and vice-chair of surgery and Jane and Donald D. Trunkey professor of trauma surgery, University of Washington, Seattle. He is President of the ACS.

DR. MARTINEZ QUINONES (x) is a PGY-3 general surgery resident, Medical College of Georgia at Augusta University.

DR. McNICOLL (y) is a PGY-5 general surgery resident, University of Nevada, Las Vegas, School of Medicine. He is Chair, RAS-ACS Advocacy and Issues Committee.

MR. MOREAU (z) is Manager, Domestic Chapter Services, ACS Division of Member Services.

DR. PELLEGRINI (aa) is professor and chair emeritus, department of surgery, University of Washington, Seattle. He is a Past-President of the ACS and a member of the Board of The Joint Commission.


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t u

z

s


y

v w

aa


DR. RITTER (bb) is a PGY-5 general surgery resident, Cleveland Clinic Foundation, OH.

DR. ROLAND (cc) is assistant professor, surgical oncology, and section chief, sarcoma surgery, University of Texas MD Anderson Cancer Center.

DR. RYAN (dd) is a PGY-4 general surgery resident, University of Kansas Medical Center, Kansas City, and Secretary, RAS-ACS Advocacy and Issues Committee.

DR. SNYDER (ee) is assistant professor of surgery and public health, East Carolina University Brody School of Medicine, Greenville, NC.

DR. STADELI (ff) is a PGY-5 general surgery resident, University of Washington, Seattle.

DR. TORRES (gg) is a PGY-3 general surgery resident, Penn State Milton S. Hershey Medical Center, Hershey.

DR. TRACY (hh) is a PGY-6 trauma and surgical critical care fellow, Emory University. He is RAS-ACS Liaison to the Health Policy Advisory Council and the General Surgery Coding & Reimbursement Committee.

DR. VIRADIA (ii) is an orthopaedic hand surgery fellow, University of Connecticut School of Medicine, Farmington, and a former general surgery resident, West Virginia University, Charleston Division.

DR. WILLIAMS-KARNESKY (jj) is a surgery education research fellow and a PGY-3 general surgery resident, University of New Mexico, Albuquerque. She is RAS-ACS Liaison, Committee on Medical Student Education.


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Earlier this year, I described the many advantag-es of having San Francisco, CA, serve as the host city for Clinical Congress 2019. In this column,

I showcase the outstanding educational programming and networking opportunities we have planned for this year’s conference.

The American College of Surgeons (ACS) Clinical Congress remains the premier annual meeting for surgeons, surgical residents, and other health care professionals who provide care to surgical patients. The hallmarks of the Clinical Congress are a range of hands-on and didactic educational programs and timely discussion of relevant surgical practices and research, along with unparalleled access to peers, mentors, and lifelong friends.

The theme of this year’s meeting, selected by ACS President Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon), is For Our Patients. The Program Committee, chaired by Henri R. Ford, MD, MHA, FACS, FAAP, FRCSEng(Hon), and the ACS Division of Education, led by Ajit K. Sachdeva, MD, FACS, FRCSC, FSACME, have developed a cutting-edge Scientific Program that addresses critical educa-tion and training needs in the ever-changing health care environment.

Can’t miss ceremoniesTwo highlights of the annual Clinical Congress are Convocation and the Opening Ceremony. The Con-vocation, 6:00−8:00 pm Sunday, October 27, at the Moscone Center, includes conferral of Fellowship upon surgeons who have successfully met the Col-lege’s full membership standards. The ceremony also includes recognition of the Honorary Fellows, presen-tation of the Distinguished Service Award, installa-tion of the ACS Officers, and the Presidential Address.

The Opening Ceremony, 8:00−9:00 am Monday, October 28, will feature a short video highlighting the new President’s theme for the year, introduction of the Honorary Fellows, the recipient of the Distin-guished Philanthropist Award, Past-Presidents, Col-lege Officers and Regents, Special Invited Guests from national and international health care organizations,


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by David B. Hoyt, MD, FACS

Looking forward

EXECUTIVE DIRECTOR’S REPORT

the Resident Research Scholars, and the International Guest Scholars.

Named LecturesImmediately after the Opening Ceremony, Nina Toten-berg, a correspondent for National Public Radio, will deliver the Martin Memorial Lecture: The Health of the Supreme Court. Ms. Totenberg has agreed to stay after the lecture for a meet and greet, 9:30−10:30 am at the Moscone Center.

Among the 10 other Named Lectures that should be of interest to all ACS Members are the following:

• ACS President Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon), will deliver the I.S. Ravdin Lecture in the Basic and Surgical Sciences: Response to Injury: The Genomic Storm and Precision Medicine, 4:15−5:00 pm Monday, October 28.

• M. Margaret Knudson, MD, FACS, Medical Director, Military Health Systems Strategic Partnership, ACS Division of Member Services, will give the Scudder Oration on Trauma: A Perfect Storm, 12:45−1:30 pm Tuesday, October 29.

• ACS Past-President Andrew L. Warshaw, MD, FACS, FRCSEd(Hon), will deliver the Commission on Cancer Oncology Lecture: Progress and Prospects, 12:45−1:45 pm Wednesday, October 30.

All Named Lectures will take place at the Moscone Center.

Scientific ProgramThe Clinical Congress is the perfect venue to learn about leading-edge technology and best practices in surgery. This year’s conference comprises 14 Surgical Skills Courses, including the following:

• Advanced Skills Training for Rural Surgeons: Laparoscopic Common Bile Duct Exploration

and Image-Guided Interventions of the Chest and Abdomen

• Advanced Robotic Surgery for Complex Abdominal Cancer Cancers

• Minimally Invasive Approach to Rectal Cancer: Transanal Total Mesorectal Excision

• Transoral Thyroidectomy

• Ultrasound-Guided Resuscitation for Trauma and Critically Ill Patients

• Two courses on oncoplastic breast surgery—one on the fundamentals and one that shows participants how to use this approach in their practices

Didactic Courses, 19 of which are offered this year, that may be of interest to many Clinical Congress at-tendees include the following:

• Global Health Competencies for Surgeons: Cognitive and System Skills

• Ethical Issues in Geriatric Surgical Care

• Beyond Cutting for Cure: Tools for Enhanced Pain and Symptom Management, Communication, and Delivery of High-Quality, Patient-Centered Care

• Successful Management of Your Private Practice

• Put PEP in Your Step: Empowerment Practices in Leadership Development

More than 110 Panel Sessions on timely topics will be offered, and the Scientific Forum will include many exciting research presentations and e-Posters. All e-Posters will be available for viewing for the dura-tion of the Clinical Congress. Video-Based Education Sessions will showcase surgical procedures. Meet-the-Expert and Town Hall Meetings will provide more casual and spontaneous learning environments.

The Clinical Congress is the perfect venue to learn about leading-edge technology and best practices in surgery.


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If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at [email protected].

Meet your requirementsAttendees may earn up to 50 AMA PRA Category 1 Cred-its, 38 of which are available for nonticketed sessions. On-site claiming of Continuing Medical Education (CME) will be available at the MyCME booth and ki-osks located throughout Moscone Center. Claims for CME Credit will be accepted through December 1.

In addition, attendees will have opportunities to earn Self-Assessment Credit as necessary and cred-its to meet state licensing board mandates, as well as credit to address ACS Accreditation/Verification requirements. The ACS requires that staff at College-accredited institutions earn these credits to meet compliance and site survey standards in metabolic and bariatric, breast, cancer, geriatric, pediatric, and trauma surgery.

Get to know your colleaguesAs in years past, the Clinical Congress will provide a number of Special Interest Sessions where you can interact with other attendees who share your clinical and nonclinical interests. Want to learn more about ACS chapters and building lasting connections? Come to the Chapter Speed Networking session to meet with members of the Board of Governors Chapter Activities Workgroups. Are you a medical student interested in a program specially designed for those of you consid-ering a career in surgery? Register for the three-day Medical Student Program and explore lifestyle issues, community outreach, and navigating the residency application process. These sessions also address issues that are specific to rural surgeons, Resident Members, Associate Fellows, and Young Fellows, and feature posters, research awards, and more.

The ACS will be offering a variety of wellness activi-ties during the week, including running and walking tours that will offer the opportunity to explore San Francisco and early morning yoga to start your day.

ACS Taste of the City, the last night of the Clinical Congress, is an opportunity to experience a sampling of San Francisco’s unique and diverse dining and cul-tural scene while networking with your colleagues.

Bring your appetite and guests to enjoy live music, fun activities, and camaraderie with ACS leaders, staff, and friends.

The annual ACS Career Fair is a unique recruiting event that brings together hospitals, private practices, and health care organizations from around the country looking to meet top-level candidates from a variety of surgical specialties. We encourage all levels of interest-ed ACS members, from residents through late-career surgeons, to visit the ACS Career Fair.

As always, I urge you stop by ACS Central and meet some of the ACS leaders and staff. In ACS Central, you can update your member profile, order the latest edu-cational products, and learn about our programs and services. This year, you will even have the chance to visit a video booth and talk about your experiences with the organization. ACS Central also houses the ACS Theatre, which will feature daily discussions of College innovations and other efforts to improve the experience of our members.

See you thereI anticipate that this year’s Clinical Congress will pro-vide you with professional and personal experiences that you will remember for years to come. And for those of you who still have doubts about traveling to San Francisco, I suggest you check out the website that Albert I. Alexander, MD, FACS, developed after a scout-ing trip to the city: aialex4.simplesite.com. He has also posted in the ACS Member Communities about his experience. I look forward to seeing you in San Fran-cisco. ♦

We encourage all levels of interested ACS members, from residents through late-career surgeons, to visit the ACS Career Fair.


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Nurturing wellness and fostering resilience during a surgical career:An introductionby Rebecca L. Hoffman, MD, MSCE


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SURGEON WELLNESS AND RESILIENCE

It’s no secret that a surgical career is challenging, gru-eling, demanding, and emotionally and physically exhausting. We know that surgeons experience

burnout at a significantly higher rate (37 percent to 53 percent) than both the general population and phy-sicians of all specialties.1 Burnout occurs for a variety of reasons, including challenges maintaining a work-life balance, the ever-changing health care landscape and associated bureaucracy, and prolonged train-ing and delayed gratification. Furthermore, surgical trainees and young, new-to-practice surgeons are at particularly high risk for burnout.2

Nonetheless, every year, surgical residency positions are overloaded with medical school graduates drawn to the discipline. It sometimes can be hard to describe to a nonsurgeon the allure of the operating room envi-ronment, the technical beauty of a procedure, or the gratification of providing quality patient care—all of which make this vocation so rewarding at such a high, personal cost. In this issue of the Bulletin, the Resident and Associate Society of the American College of Sur-geons (RAS-ACS) expands the focus beyond surgeon burnout to topics related to cultivating and nurturing surgeon wellness and resilience.

What is wellness?It is tempting to define wellness as the antithesis of burnout; however, we should challenge ourselves to think more critically about what being well really means. What are we seeking, both personally and professionally, that would provide us optimal levels of emotional and intellectual fulfillment? Does it mean perfect work-life integration with equal time spent at work and time with family or friends? Does well-ness mean daily workouts and a healthy diet? Does it mean always feeling like your work is meaningful and purpose-driven? A state of wellness undoubt-edly has a different meaning to each surgeon, and so to provide a definition is a challenging endeavor. Physicians at the family medicine residency program

at Oakland University William Beaumont School of Medicine, Rochester, MI, developed this shared definition of wellness when embarking on a culture change at their institution: “Wellness is defined as a dynamic and ongoing process involving self-aware-ness and healthy choices resulting in a successful, balanced lifestyle.”3

Promoting wellness among surgeons must be a conscious effort in the workplace, as well as a person-ally driven effort. Bohman and colleagues define three major reciprocal domains of well-being: efficiency of practice, culture of wellness, and personal resilience, noting that the first two are primarily organizational responsibilities, and the latter the responsibility of the individual surgeon.4 Each domain inevitably has an effect on the other, and expecting physicians to improve their self-care or build resilience without accompanying cultural improvements in the work-place environment, or vice versa, is illogical.

In recognition of the increasing evidence for a mul-tipronged approach to wellness, the Accreditation Council for Graduate Medical Education issued revised standards in 2017 that, for the first time, include well-ness as a training priority.5 These standards essentially identify self-care, meaning/purpose, mentorship, and education as pillars of well-being that should be culti-vated as part of a physician’s professional development.

As of May 2019, Shapiro and colleagues have fur-ther clarified meaningful practical interventions for physician wellness. The result is the Health Profes-sional Wellness Hierarchy. Modeled after Maslow’s hierarchy of needs, it defines key levels and factors at those levels that can be addressed in the workplace using a systematic approach to support wellness.6 Importantly, the structure of this hierarchy places physician autonomy, patient connection, contribu-tions to the field, and the delivery of optimal care at the highest level, and suggests that the best patient care occurs when physician wellness, in terms of basic human needs, safety, respect, and appreciation, is pro-moted and nurtured.


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The role of the ACSAs a result of the efforts of the ACS Board of Governors Physician Competency and Health Workgroup, the Col-lege has played an active role in promoting wellness among its members by providing an interactive, anon-ymous Physician Well-Being Index, available at facs.org/wellbeing. This index allows you to benchmark yourself against other physicians nationally, as well as yourself over time. In addition, it provides local and national resources to help address your specific needs. Further-more, the ACS maintains a repository of resources, which can be found on the Surgeon Well-Being Resource page under facs.org/wellbeing.

The RAS-ACS, in many respects, represents the group of surgeons who are both most likely to suffer from burn-out and also most likely to incorporate and perpetuate a wellness cultural change within surgery for generations to come. As such, we chose to dedicate this year’s August issue of the Bulletin to wellness and resilience in surgery. We approach this topic from diverse perspectives to pro-vide readers with a well-rounded understanding of the subject matter, and we anticipate that readers will find these articles thought-provoking and insightful.

The articles emanate from each RAS-ACS standing committee and address themes such as perceptions of wellness across the history of surgery, the role of posi-tive self-talk in nurturing wellness, membership and community as mediators of wellness, and the influence other industries have on promoting wellness and resil-ience in surgery. These articles are written primarily with trainees in mind, but we anticipate that the infor-mation presented will be useful to clinicians at all stages of their career. ♦

REFERENCES1. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout:

A systematic review. J Am Coll Surg. 2016;222(6):1230-1239.

2. Pulcrano M, Evans SR, Sosin M. Quality of life and burnout rates across surgical specialties: A systematic review. JAMA Surg. 2016;151(10):970-978.

3. Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the conversation from burnout to wellness: Physician well-being in residency training programs. J Grad Med Educ. 2009;1(2):25-230.

4. Bohman B, Dyrbye L, Sinsky CA, et al. Physician well-being: The reciprocity of practice efficiency, culture of wellness, and personal resilience. NEJM Catalyst. August 2, 2017. Available at: https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/. Accessed May 30, 2019.

5. Accreditation Council for Graduate Medical Education. Summary of changes to ACGME common program requirements section VI:VI.C: Well-being. 2017. Available at: www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements/Summary-of-Proposed-Changes-to-ACGME-Common-Program-Requirements-Section-VI. Accessed May 28, 2019.

6. Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond burnout: A physician wellness hierarchy designed to prioritize interventions at the systems level. Am J Med. 2019;132(5):556-563.

It is tempting to define wellness as the antithesis of burnout; however, we should challenge ourselves to think more critically about what being well really means.


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Resident wellness and its opposing state—burnout—are common themes in today’s graduate medical education discourse. There

is growing recognition that burnout contributes not only to poor patient care,1,2 but also to personal and professional dissatisfaction, as well as attri-tion, depression, suicidal ideation, and suicide.2-4 Though burnout occurs in many occupations, it is much higher among medical professionals, with rates in U.S. physicians increasing from 45 percent in 2011 to 54 percent in 2014.3

Psychologist Herbert Freudenberger, PhD, origi-nally defined burnout in 1974 as “the consequences of severe or prolonged stress and anxiety experienced by people working in the healing professions.”5 In 1981, Maslach and Jackson coined burnout’s three defining features: emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment.5

Surgical trainees particularly are at risk for burnout and difficulty maintaining well-being as the result of sustained levels of excessive stress, high acuity of

patient diseases, extensive work hours, inadequate time for personal life, prolonged training with little autonomy, and a culture of professional shaming.2,6-9

Interestingly, all of these factors are inherent to the environment of surgical training rather than charac-teristics of individual trainees. Some personal factors (such as personality traits, emotional intelligence, and grit/resolve)6,10,11 may influence the risk of burnout, but by its very definition, burnout reflects a disorder tied to the workplace rather than a personal disorder or dysfunction.

Some surgeons may argue that the training envi-ronment has improved over the last 50 years, especially with the advent of duty-hour restrictions. Given these enhancements, the increasing pervasiveness of burn-out may seem unusual. In an effort to evaluate this paradox, this article examines the defining features of historical and modern surgical training and then explores changes in the surgical training model over time and the potential impact of each adjustment on resident wellness.

The good old days: A historical perspectiveResidents often hear disheartening statements, such as, “In my days of training, things were so much harder,” from more seasoned surgeons regarding burnout man-agement. Perhaps a more appropriate response would be, “Things were so different.”

The term “resident” originates from the era of William S. Halsted, MD, FACS, when physicians-in-training inhabited the hospital, toiling and sleeping in the workplace.12 Training under this pyramidal model, which was designed to fashion an elite group

The transformation of surgical education and its influence on resident wellness

by Brett M. Tracy, MD; Kathryn M. Stadeli, MD, MPH; Julia R. Coleman, MD, MPH; Vamsi Aribindi, MD;

Randi Ryan, MD; and K. Benjamin Lee, MD

HIGHLIGHTS• Describes surgical training from

a historical perspective

• Summarizes the transition to a contemporary training model

• Identifies changes in the surgical training model and their potential effect on resident wellness

• Examines the benefits and challenges of maintaining work-life balance


| 15


of surgical leaders, had no set time frame for comple-tion.13 Surgical trainees worked all day, every day, and received minimal financial compensation.14 The Halstedian model lauded dedication to work and patient care over resident well-being. Weakness, complaints, or personal problems were not discussed openly.15 Marriage was discouraged,14 and we now know that single status during surgical residency is associated with psychological risk and depression.16 This archaic, intimidating, and hierarchical design of surgical training fostered certain behaviors that should have made surgeons in training susceptible to burnout.17 For example, repeated exposure to indi-vidually targeted shame and blame as a method of resident training is shown to result in high levels of depersonalization.9

This Halstedian model has evolved for myriad reasons, although it did have its advantages. For the resident, the continuous interaction between hospital staff and trainees increased camaraderie and rapport, thereby boosting communication.18 Importantly, this training model also fostered an all-in venture in men-torship. Mentorship influences the mentee’s work ethic, academic pursuits, social network, and reactions to adversity.19 Mentors who are dedicated to and invested in their mentees engender confidence and productivity, generating a legacy of formidable surgeons.

Another advantage of Halsted’s system was its posi-tive effect on patient care. In-house residents benefitted patients because they were able to lead every step in perioperative management. The accessibility of the resident boosted patient confidence in a trainee’s abil-ity to operate,13 and if the patient had concerns or an acute decompensation, the resident (usually the same individual who performed the operation) was imme-diately available. Furthermore, miscommunication was less common because residents practically never left the hospital, which eliminated potential errors during handoffs.20

This model also maximized learning. There were no missed opportunities for clinical pearls or develop-ing mature decision-making abilities because residents worked around the clock and rarely took vacations.

Furthermore, maximizing all operative opportuni-ties accelerated surgical dexterity. Alfred Blalock, MD, FACS, former American College of Surgeons (ACS) President, understood the balance between paternalism and autonomy and granted his residents independence on the wards and in the operating room (OR).19 Con-sequently, there was little perceived need for surgeons to pursue a fellowship or other additional training.21,22 Although these working conditions were severe, the extent and volume of training during this time ulti-mately afforded a well-rounded surgeon capable of independently handling a multitude of operations.

Modern training: Transitioning to today’s modelIn 1937, the American Board of Surgery (ABS) was formed to standardize the training and education of aspiring surgeons. After its creation, the ABS asserted that “technical training under supervision in an institution must replace unsupervised experi-ence obtained in private practice at the expense of an unsuspecting public.”23 However, multiple fac-tors, including the litigious and profit-driven nature of health care, the advent of the electronic health record (EHR), and pressures from hospital adminis-tration, can hinder the modern-day resident’s quest to become a board-certified general surgeon. Further-more, in comparison with less than a century ago, a significantly larger proportion of the U.S. popula-tion lives with multiple chronic conditions, including obesity, hypertension, and diabetes, making surgical care more complex and time-consuming.24,25

In part, the increasing prevalence of these con-ditions, as well as the drive to remain competitive and satisfactorily reimbursed, has driven surgeons to specialization. Consequently, more surgical spe-cialists than generalists now train general surgery residents.26 Some surgeon educators may argue that subspecialists are less invested in trainees because of the mentality that any relevant training deficien-cies can be corrected during fellowship.26 Why teach a surgical resident how to do a peroral endoscopic

Residents often hear disheartening statements, such as, “In my days of training, things were so much harder,” from more seasoned surgeons regarding burnout management. Perhaps a more appropriate response would be, “Things were so different.”


16 |


myotomy for achalasia, or robotic portal lymph node dissection for gallbladder carcinoma when the indi-vidual will rarely, if ever, perform the procedure as a breast surgeon? Nevertheless, the decreasing prepared-ness and dwindling confidence of graduating chiefs has been cited as one reason more residents are pursuing fellowships and new apprenticeship models.27 How-ever, with longer training and growing debt, trainees may become financially hampered and jaded.28

In addition to these modifications in surgical edu-cation and training, new technology has changed how operations and procedures are performed (that is, open, laparoscopic, robotic, and endoscopic). To standardize the product of general surgery residency with these innovations, the Accreditation Council for Graduate Medical Education and the ABS have instituted requirements to apply for the qualifying and certifying exam in general surgery. Chief resi-dents must complete and maintain certification in Advanced Cardiovascular Life Support and Advanced Trauma Life Support®, pass the Fundamentals of Laparoscopic Surgery and Fundamentals of Endo-scopic Surgery courses, take the ABS In-Training Examination, meet the appropriate threshold for the subjectively graded surgical milestones, participate in at least six operative performance assessments and six clinical assessment and management exams (out-patient), all while meeting the quota for operative cases in each defined category.29

Although today’s residents perform in total an equal number of operations as their counterparts in the Halsted era, chief residents perform fewer oper-ations with less autonomy in part because of the supervision requirements from governing bodies.30

The only increases in volume that residents experi-ence are in the clerical responsibilities that remove them from clinical training. As use of the EHR becomes more widespread, more resident hours are spent outside of the hospital, performing nonschol-arly activities. A recent study shows that 30 percent of resident hours in the hospital are used for docu-mentation, and one-third of total EHR usage time is done outside of inhospital work hours.31

Many surgical training programs and organi-zations have pushed for more simulations to avert surgical training deficiencies, but the technology and infrastructure surrounding this movement are still in their infancy. These changes are designed to prepare residents for practice, but they also serve as significant burdens that did not always exist.

Historical training and wellnessConsidering the lack of work/life balance in the Hal-sted era, burnout should have been a bigger issue for physicians then; however, no evidence is available to support that perspective. Perhaps surgical trainees at that point in time were more resistant to stress, more dispassionate, and better able to tolerate the severe training environment.16,32 More plausible, however, is that stress related to medical bureaucracy seen in the modern age of surgical training simply was not a factor during the Halsted era.33 For example, paper charts containing the patient’s bare essentials were acceptable during this period.34 Surgeons were not expected to document a visit diagnosis or update the problem list. Furthermore, no accrediting body had been established in the early 1900s to evaluate the knowledge and abilities of a chief surgical resident. National standards for competency and safety were nonexistent and requirements for Fellowship in the ACS were rudimentary:23

• A year’s internship, usually rotating

• Two years as an assistant under a preceptor

• Visits to surgical clinics

• Submission of a list of 50 consecutive operations

Graduation from an approved medical school became a requirement for Fellowship in the ACS as late as 1920.23

Reis and colleagues offer a different explanation regarding why trainees during the Halstedian era


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avoided burnout. The authors state that well-being is sus-tained by three elements: autonomy, competence, and relatedness.35 Successful achievement of a particular sur-gical skill (competence) on one’s own terms or direction (autonomy) promotes well-being, and modern research has shown burnout decreases when people can point to personal accomplishments and competencies.6 Halsted’s model was stringent, but it centered on autonomy and independent action, perhaps mitigating burnout.6

Furthermore, previous-era trainees had renowned men-tors. Mentoring relationships promoted job satisfaction, self-confidence, motivation, companionship, and elevated personal aspirations.36 Edward Delos Churchill, MD, FACS, believed that these time-honored academic pairings were dangerous because residents would idolize only one sur-geon who might be anti-intellectual and anti-scientific.23 There was little room for deviation from the mentoring surgeon’s dogma in these “quasi-parental, self-aggrandizing, and authoritarian tutelages,” which potentially wasted the creativity and passion of vibrant, young trainees.23 More recently, however, Zhang and colleagues have shown that effective formal mentorship programs in surgical residency may alleviate stress and burnout, and facilitate personal sat-isfaction and a better quality of life.37

Training and burnoutThe attrition rate for general surgery residency is approxi-mately 20 percent, placing it higher than other specialties.10 Several studies have suggested that an increased workload, including longer hours, more days on call, and more patients, is the reason.32,28 Combining this excessive workload with other educational and societal pressures, resident work hours were restricted to 80 hours per week. However, according to Lindeman and colleagues, the new duty-hour regulations have had a limited impact on the quality of life for residents.11 So, if not long hours or fatigue, why do 69 percent of U.S. general surgery trainees meet the criteria for burnout, while 44 percent have contemplated dropping out?11,38

Family physician, chief executive of f icer of TheHappyMD.com, and Burnout Proof mobile phone appli-cation developer Dike Drummond, MD, offers the following five common causes of burnout:39

REFERENCES1. Wallace JE, Lemaire JB, Ghali WA. Physician

wellness: A missing quality indicator. Lancet. 2009;374(9702):1714-1721.

2. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.

3. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general U.S. working population between 2011 and 2017. Mayo Clin Proc. February 2019 [Epub ahead of print].

4. Dodson TF, Webb ALB. Why do residents leave general surgery? The hidden problem in today’s programs. Curr Surg. 2005;62(1):128-131.

5. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2(2):99-113.

6. Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW, Epel ES. Burnout and stress among U.S. surgery residents: Psychological distress and resilience. J Am Coll Surg. 2018;226(1):80-90.

7. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-455.

8. Meyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. Resident autonomy in the operating room: Expectations versus reality. Ann Thorac Surg. 2017;104(3):1062-1068.

9. Shapiro MC, Rao SR, Dean J, Salama AR. What a shame: Increased rates of OMS resident burnout may be related to the frequency of shamed events during training. J Oral Maxillofac Surg. 2017;75(3):449-457.

10. Salles A, Lin D, Liebert C, et al. Grit as a predictor of risk of attrition in surgical residency. Am J Surg. 2017;213(2):288-291.

11. Lindeman B, Petrusa E, McKinley S, et al. Association of burnout with emotional intelligence and personality in surgical residents: Can we predict who is most at risk? J Surg Educ. 2017;74(6):e22-e30.

12. Are C. Workforce needs and demands in surgery. Surg Clin North Am. 2016;96(1):95-113.

Zhang and colleagues have shown that effective formal mentorship programs in surgical residency may alleviate stress and burnout, and facilitate personal satisfaction and a better quality of life.



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• The practice of clinical medicine (great responsibility with little control)

• The specific job (call schedules, salaries, politics)

• Having a life (family and social pressures)

• The conditioning of medical education (to never show weakness)

• The leadership abilities of supervisors

The first three reasons are intuitive, but the latter two merit exploration. The personal characteristics that once led to success in medical education also may predispose residents to burnout. Whether one is the workaholic, the superhero, the perfectionist, or the lone ranger, the stress of caring so aggressively for patients eventually will end in fatigue, chronic defensiveness, or guilt.39

The quality of a supervisor and mentor also has a direct effect on burnout. Van Vendeloo and colleagues support this claim and cite supervisory support, accessibility of supervi-sors, and mutually supportive relationships with supervisors as key factors to prevent burnout.40 Schönrock-Adema and colleagues have shown that the ability to identify positive role models and the ability to receive direct feedback corre-late with resident burnout.41 Unfortunately, because of the increased clinical and academic demands affecting the surgi-cal trainee experience,42 mentorship has, in many respects, devolved, and these formative relationships are in short supply.36

Increased administrative duties are another major source of stress for surgical trainees. Electronic charting consumes much of the time of a surgical resident, which often thwarts physicians from directly caring for patients.43 In a previous era, the physician-patient relationship provided satisfac-tion for both physicians and patients, but research shows that contemporary physicians spend more time working on EHRs than with their patients.44 Furthermore, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 imposed financial penalties for provid-ers who do not use the EHR. Since the Centers for Medicare & Medicaid Services began implementation of this legislation,

13. Barr J. The education of American surgeons and the rise of surgical residencies, 1930–1960. J Hist Med Allied Sci. 2018;73(3):274-302.

14. Organ CH. Resident work hours. Arch Surg. 2001;136(12):1426-1432.

15. Lin DT, Liebert CA, Tran J, Lau JN, Salles A. Emotional intelligence as a predictor of resident well-being. J Am Coll Surg. 2016;223(2):352-358.

16. Lin DT, Liebert CA, Esquivel MM, et al. Prevalence and predictors of depression among general surgery residents. Am J Surg. 2017;213(2):313-317.

17. Marmon LM, Heiss K. Improving surgeon wellness: The second victim syndrome and quality of care. Semin Pediatr Surg. 2015;24(6):315-318.

18. Koch BE. Surgeon-nurse anesthetist collaboration advanced surgery between 1889 and 1950. Anesth Analg. 2015;120(3):653-662.

19. Kensinger CD, Merrill WH, Geevarghese SK. Surgical mentorship from mentee to mentor. JAMA Surg. 2015;150(2):98-99.

20. Sharit J, McCane L, Thevenin DM, Barach P. Examining links between sign-out reporting during shift changeovers and patient management risks. Risk Anal. 2008;28(4):969-981.

21. George BC, Bohnen JD, Williams RG, et al. Readiness of U.S. general surgery residents for independent practice. Ann Surg. 2017;266(4):582-594.

22. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery. Ann Surg. 2014;259(6):1041-1053.

23. Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.

24. Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. RAND Corporation; 2017. Available at: www.rand.org/pubs/tools/TL221.html. Accessed June 24, 2019.

25. Hurt RT, Kulisek C, Buchanan LA, McClave SA. The obesity epidemic: Challenges, health initiatives, and implications for gastroenterologists. Gastroenterol Hepatol (NY). 2010;6(12):780-792.

26. Longo WE, Sumpio B, Duffy A, Seashore J, Udelsman R. Early specialization in surgery: The new frontier. Yale J Biol Med. 2008;81(4):187-191.

REFERENCES, CONTINUED



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clinical documentation has nearly doubled among U.S. physi-cians, and U.S. clinical notes are now four times longer than the rest of the developed world using EHRs.34 This increased computer time equates to patient encounters in which less than 25 percent of the visit is spent communicating with a patient.34 Chung and Ahmed, in a study on resident effi-ciency, found that junior residents spend excessive time on rounds and the remainder of their day completing aimless, less educational tasks that provide no sense of accomplish-ment.45 The anxiety and disparaging chores become toxic, resources are depleted, and burnout becomes inevitable.

In his 2009 book, Drive: The Surprising Truth About What Motivates Us, Daniel H. Pink argues that staying motivated and avoiding burnout centers on autonomy, mastery, and purpose.46 Surgical trainees are self-directed and want to be able to control a task, time, technique, and team in order to be productive. However, because of increasing managerial constraints, government cost regulations, and patient safety demands, residents have less autonomy than ever.1 Mastery involves a healthy work environment with clearly defined goals and the infrastructure necessary to achieve a task.46

However, administrative obligations erode clinical mastery. In fact, residents diagnosed with work-related post-traumatic stress disorder (PTSD) cite these tasks as one of the top sources of their condition.47 A 2015 study by Thomp-son and colleagues revealed that 17 percent of 144 surgical trainees had pathological symptoms consistent with PTSD, attributed not only to the burden of overregulation but also to the negative media portrayal of surgeons and the shame physicians experience when medical errors occur.48

Mr. Pink describes purpose as the fuel for autonomy and mastery. From a trainee standpoint, purpose is the sense that the work one does is meaningful, important, and consequen-tial. Direct patient care, rather than administrative work or research, is often cited as the most meaningful aspect of a physician’s occupation. Shanafelt and colleagues demon-strated that physicians who spend less than 20 percent of their time on the activity that is most meaningful to them had significantly higher rates of burnout.49 Exploitation of residents as scribes, secretaries, and laparoscope navigators is making the concept of purpose increasingly elusive for these trainees. While burnout transpires when at least one of the elements of Mr. Pink’s trinity (autonomy, mastery,

27. Richardson JD. ACS transition to practice program offers residents additional opportunities to hone skills. Bull Am Coll Surg. 2013;98(9):23-27.

28. Tevis SE, Rogers AP, Carchman EH, Foley EF, Harms BA. Clinically competent and fiscally at risk: Impact of debt and financial parameters on the surgical resident. J Am Coll Surg. 2018;227(2):163-171.

29. American Board of Surgery. Booklet of information—surgery. 2018. Available at: www.absurgery.org/xfer/BookletofInfo-Surgery.pdf. Accessed May 2, 2019.

30. Sandhu G, Teman NR, Minter RM. Training autonomous surgeons. Ann Surg. 2015;261(5):843-845.

31. Cox ML, Farjat AE, Risoli T, et al. Documenting or operating: Where is time spent in general surgery residency? J Surg Educ. 2018;75(6):e97-e106.

32. Oskrochi Y, Maruthappu M, Henriksson M, Davies AH, Shalhoub J. Beyond the body: A systematic review of the nonphysical effects of a surgical career. Surgery. 2016;159(2):650-664.

33. Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: Are we treating the symptoms instead of the disease? Ann Thorac Surg. 2017;104(4):1117-1122.

34. Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: Are we ignoring the real cause? Ann Intern Med. 2018;169(1):50-51.

35. Reis HT, Sheldon KM, Gable SL, Roscoe J, Ryan RM. Daily well-being: The role of autonomy, competence, and relatedness. Personal Soc Psychol Bull. 2000;26(4):419-435.

36. Memon B, Memon MA. Mentoring and surgical training: A time for reflection! Adv Heal Sci Educ. 2010;15(5):749-754.

37. Zhang H, Isaac A, Wright ED, Alrajhi Y, Seikaly H. Formal mentorship in a surgical residency training program: A prospective interventional study. J Otolaryngol–Head Neck Surg. 2017;46(13):1-6.

38. Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National survey of burnout among U.S. general surgery residents. J Am Coll Surg. 2016;223(3):440-451.


Direct patient care, rather than administrative work or research, is often cited as the most meaningful part of a physician’s occupation.



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39. Drummond D. Physician burnout: Its origin, symptoms, and five main causes. Fam Pract Manag. 2015;22(5):42-47.

40. Van Vendeloo SN, Prins DJ, Verheyen CCPM, et al. The learning environment and resident burnout: A national study. Perspect Med Educ. 2018;7(2):120-125.

41. Schönrock-Adema J, Visscher M, Raat AN, Brand PL. Development and validation of the Scan of Postgraduate Educational Environment Domains (SPEED): A brief instrument to assess the educational environment in postgraduate medical education. PLoS One. 2015;10(9):e0137872,1-12.

42. Patel VM, Warren O, Ahmed K, et al. How can we build mentorship in surgeons of the future? ANZ J Surg. 2011;81(6):418-424.

43. Patti MG, Schlottmann F, Sarr MG. The problem of burnout among surgeons. JAMA Surg. 2018;153(5):403-404.

44. Alexander AG, Ballou KA. Work-life balance, burnout, and the electronic health record. Am J Med. 2018;131(8):857-858.

45. Bukur M, Singer MB, Chung R, et al. Influence of resident involvement on trauma care outcomes. Arch Surg. 2012;147(9):856-862.

46. Pink DH. Drive: The Surprising Truth about What Motivates Us. New York, NY: Penguin Group (USA) Inc.; 2009.

47. Jackson T, Provencio A, Bentley-Kumar K, et al. PTSD and surgical residents: Everybody hurts…sometimes. Am J Surg. 2017;214(6):1118-1124.

48. Thompson CV, Naumann DN, Fellows JL, Bowley DM, Suggett N. Post-traumatic stress disorder amongst surgical trainees: An unrecognised risk? Surg. 2017;15(3):123-130.

49. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990-995.

50. Sacks GD, Shannon EM, Dawes AJ, et al. Teamwork, communication and safety climate: A systematic review of interventions to improve surgical culture. BMJ Qual Saf. 2015;24(7):458-467.

and purpose) is disrupted, in the contemporary training system, all three often are jeopardized.

Rekindling the fire without burning outSeveral factors have been implicated in trainee burnout, including the length of training, extensive working hours, imbalance between career and family, and poor mentorship. Despite these factors, general surgery resident education has continued to evolve in many notable ways. Residents are able to live outside the hospital, and the system is now geared toward having all residents, rather than just an elite few, successfully finish a training program. Furthermore, the culture has shifted toward more reasonable treatment of trainees and the health care team as a whole. Surgeons are expected to treat individuals with respect, and the culture of safety encourages all team members, regardless of their perceived position in the hierarchy, to be patient advocates.50 Nonetheless, it is important to continue to examine the state of surgical education.

Because residents must meet more regulatory require-ments but experience less time in the hospital, we must find solutions to maximize clinical and educational opportunities to achieve adequate training. As with any complex problem, many separate routes can be taken to improve the system. For example, resident autonomy previously stemmed from residents operating without the attending’s presence in the OR. Perhaps resident autonomy could be improved with implementation of a formal system of graded independence in the OR.8 More flexibility in the work-hour restrictions may facilitate more comprehensive perioperative manage-ment, while still maintaining reasonable expectations as to the time commitment of residents. Modifying the EHR to improve workflow and decreasing the administrative burden on physicians is an opportunity to develop wellness and reduce the risk of burnout in both resident and attend-ing physicians.

Because resident wellness is negatively affected by an increased administrative burden and decreased autonomy, burnout could be mitigated by prioritizing the educational tactics that support self-actualization among surgical train-ees. Above all, altering surgical education can only occur in a manner that maintains the patient at the center of care. ♦



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Walk in the shoes of a junior surgery resident for a day. Wake up at 4:30 am to another dark morning and drive to work. Do a chart

check and note the pertinent data on the list for the team. The chief resident, exhausted after being called in overnight, is irritated that information is missing from the list and chides you to be more thor-ough. Pre-round with the team. The nursing staff is annoyed that their 6:00 am pages and orders have yet to be addressed. Rush to the preoperative holding area to receive consent from a patient who is vexed that he hasn’t spoken to the attending and wants assurance that the attending, not a resident, will per-form the operation. Scurry to write notes and place orders from pre-rounding as the patient is rolled into the operating room (OR).

As you finish up and respond to pages, the attend-ing walks in and is peeved that the patient isn’t positioned and prepped yet. During the procedure, your attending allows you to perform some portions

of the operation but takes over at the critical portion without explaining why or offering suggestions on how you could improve your technique. Your pager goes off multiple times, and the sighs emanating from the circulating nurse make it clear that he is irritated about answering your pages. Scrub out and rush to finish the brief postop note and orders while return-ing several more pages. The anesthesia team is now irritated that you are sitting at the computer instead of helping to transfer the patient to the postoperative acute care unit (PACU) bed. You leave the paperwork incomplete and go to PACU with your patient.

Next, you run off to a consult and check on a few floor patients, complete the preoperative consult on the next patient, and return to the OR in time to prep and position the patient to avoid upsetting the attending again. Notify your chief resident of the consult and plan, but you don’t hear back until you’re scrubbed in; scrub out. Your chief is annoyed that you didn’t meet her to see the consult. Your attend-ing wants to round, so you tell the chief and finalize the consult plan together after rounds. The night float intern sends you a text at 7:00 pm, expressing concern that he is getting paged about patients whom you have yet to discharge. Respond to the pages and finish your notes and orders. At 9:00 pm, you finally sign out. Head home in the dark with reading to do for the next day. Never mind food, exercise, or any other method of self-care. Never mind that you need to vent, haven’t spoken to your friends and family in a week, and have neither the time nor energy to make those phone calls. Instead, you finish your reading,

by Meghana V. Kashyap, MD, DIM&PH; Melissa Red Hoffman, MD, ND; Erica K. Ludi, MD; and Crystal N. Johnson-Mann, MD

HIGHLIGHTS• Describes the effect of positive

communication on resident wellness

• Summarizes evidence-based solutions to encourage transparency in the workplace

• Highlights potential barriers for physicians seeking help, including the stigma associated with mental illness

Silence is deadly:The importance of communication in addressing wellness and burnout in surgical residency


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and get four hours of sleep until the alarm wakes you at 4:30 am. Rinse and repeat.

These daily slights, whether nonverbal (sighs or eye rolls) or verbal, are noticeable. How we communicate within our teams, among our fellow residents, with our attendings, the OR staff, and our patients, directly affects every aspect of our professional lives. Brief, negative interactions add up. As medical students, many of us were taught that the patient’s needs should take priority over our own. This mantra is reinforced throughout surgical training. Expressing our needs—whether physical, emotional, or spiritual—can result in backlash from our colleagues within the surgical community.

In her 2018 Academic Surgical Congress presiden-tial address, Taylor S. Riall, MD, PhD, FACS, discussed the fallacy of how we romantically or heroically view our surgical culture of “strength and invincibility,” commenting that “it is even more flawed in its asser-tion that a surgeon who allows himself or herself to be vulnerable is unworthy of being a trusted and respected colleague.”¹

This article reviews the effect of communica-tion on resident wellness and offers evidence-based solutions to encourage transparency and disrupt the culture of silence in a positive manner.

The power of positive self-talkOne of the foundations of cognitive behavioral therapy is self-instructional training—the process of identify-ing negative self-talk and reframing these statements into positive thoughts.² This method of cognitive behavioral modification has been used to treat many mental health conditions, including anxiety, atten-tion deficit disorder, and depression. Neuroimaging studies have shown that forms of self-talk, such as third-person self-talk, can help an individual regulate emotional responses to stressful situations.³ In sports psychology, positive self-talk has been associated with improved performance. In a 1995 study, Van Raalte

and colleagues instructed participants to say, “You can do it,” “You cannot do it,” or nothing at all before throwing darts. Study subjects who said “You can do it” displayed a statistically significant more accurate performance than individuals who said “You cannot do it” or those who said nothing.4 Recently, the idea of positive self-talk has been further classified into two distinct categories: motivational self-talk, such as “I’ve got this,” and instructional self-talk like “watch the finish line.”

A meta-analysis of the effect of self-talk on sports and task performance identified three points that translate well to surgical residency. First, instruc-tional self-talk has a greater impact on fine motor skills than on gross motor tasks. Second, although it leads to improvement in both well-learned and novel tasks, self-talk has a higher impact on novel task performance. Finally, training subjects in posi-tive self-talk results in more immediate results and a larger effect (see Table 1, this page).5 Because oper-ating requires fine motor skills, the ability to adapt to unexpected findings, and an expectation of lead-ership during stressful situations both in and out of the OR, surgical residents may benefit from training in positive self-talk.

Interpersonal communicationDespite the 80-hour per week duty-hour limits, sur-gical residents still spend most of their time at work. We often spend more time with our colleagues than with our families and friends. As most practicing sur-geons can attest, this way of life extends well beyond residency. Therefore, our daily interactions at work certainly can affect our well-being both in and out of the hospital.

One of the more frequent interactions residents have is with nursing staff and other nonphysician team members. Several studies explore interpro-fessional communication between physicians and other health care professionals, including physical

TABLE 1. IMPACT OF POSITIVE SELF-TALK• Improved fine motor skills

• Improved novel task performance

• More immediate results with a larger effect


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therapists, occupational therapists, and social work-ers. In one case study comparing hospitalists and consultant internists at community hospitals, three themes were identified as playing a significant role in positive communication dynamics. First, in-house hospitalists were more available, leading to improved, more efficient communication. In contrast, consul-tants were less likely to have developed long-term relationships with the other health care team mem-bers, leading to more formality and even reduced communication. Finally, team members felt that con-sultant units were physician-centered and did not foster a collaborative environment.6

In a similar study of two urban teaching hospitals, interprofessional communication was found to be poor between physicians, nursing, and allied health staff. Intraprofessional rounds were prioritized over interprofessional rounds, and during these rounds the most frequent communication was between phy-sicians and other team members, without mutual discussion of patients. Unscheduled interactions that occurred outside of rounds were infrequent and tended toward abrupt question-answer formats between physicians and nurses rather than the more extensive exchange of ideas between nurses and allied health care professionals.7

Multiple studies have examined the communica-tion patterns between surgical residents and nurses. In a 2016 study of 31 nurses and 18 surgical trainees at two Canadian academic medical centers, researchers reported multiple themes that impaired interpro-fessional communication. The surgical residents experienced nurses as territorial and disrespectful of their clinical knowledge, whereas nurses felt resi-dents were inattentive to their clinical concerns and had a poor understanding of the nurses’ role on the team.8 However, another 2016 study of 38 surgical interns and 11 nursing students found that partic-ipation in an eight-hour interprofessional training session improved attitudes toward collaboration in both groups. Postsession interviews revealed that

both groups gained clarity regarding the roles of both interns and nurses on the team.9 These studies shed light on several ways that we, as residents, can improve communication and engage in more posi-tive and effective interactions with our colleagues, including the following:

• Be available and attentive

• Develop positive relationships

• Foster a collaborative team environment

• Respect others’ training and expertise

Several studies have explored communication pat-terns between surgeons and other physicians, with general surgeons tending to exhibit more aggressive verbal communication.10,11 As a result, there has been a push for culture change.12 A 2015 qualitative study of communication between surgeons and intensivists defined “good” and “bad” communication.12

Good communication occurred when both teams felt they were heard and were working toward a mutual goal for the patient. This communication was possible despite multiple barriers that can exist between surgical and intensive care unit (ICU) teams, including cultural differences and the presence of closed ICUs, wherein decisional authority is limited to the intensivist.

Poor communication occurred when team members felt their knowledge and experience were undervalued and seemed to stem, in part, from dis-crepancies between how clinicians rated their own experience versus how other health care profession-als viewed their experience. In an outpatient setting, a survey of primary care physicians (PCPs) and spe-cialists demonstrated disparate perceptions as well.13 Specialists believed they effectively communicated results back to PCPs but did not receive adequate information in the referral, whereas PCPs believed

The highest-scoring surgeon engaged all team members in the room upon entering the OR, discussed the plan for the case with the anesthesiologist, allowed the surgical resident to offer input on the case, and maintained enthusiasm throughout the operation.


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they effectively communicated information regard-ing the consultation but did not receive follow-up information from the referrals. Through continued research and identification of discordant perceptions that surgeons and physician colleagues have of each other, we can begin addressing the problem through team-building simulation and training.

One of the most significant examples of surgeon-team communication occurs in the OR, where surgeons are viewed as leaders. Using a validated scoring system, a 2017 retrospective review of sur-geon behavior during complex operations shed light on how a task-focused leadership style is less effec-tive than a team-oriented approach.14 Different types of behavior affected scoring of surgeon leadership, including exhibiting specific voice behavior, allowing a safe space for team members to vocalize concerns, encouraging cooperative behavior, fostering a col-laborative environment, and sharing knowledge. The highest-scoring surgeon engaged all team members in the room upon entering the OR, discussed the plan for the case with the anesthesiologist, allowed the surgical resident to offer input on the case, and maintained enthusiasm throughout the operation.

In a conceptual model of disruptive surgeon behav-ior in the OR, participants (nurses, scrub technicians, medical students, residents, and anesthesiologists) identified four coping strategies:15

• Speaking with others for support

• Externalizing the behavior so that it is taken less personally

• Avoiding the surgeon

• Warning others as an altruistic effort to prevent simi-lar episodes of disruptive behavior

Similar to the study of interprofessional training for surgical interns and nursing students mentioned

previously,9 Awad and colleagues instituted medical team training using multiple instructional modal-ities and followed implementation of the learned skills on preoperative brief ings.16 Surgery and anesthesia personnel rated improved perception of communication between team members after four months of enacting these preoperative briefings. Numerous other publications have highlighted inter-ventions to improve the atmosphere in the OR and team dynamics. The key to all of these enhance-ments is communication.

Ultimately, communication has the most mean-ingful impact on the patient. By far the most important interaction that surgical residents have on a daily basis is the time spent with patients and fam-ilies. However, as all residents know, patients and their families commonly assume that “the doctor” has not rounded on them until the attending shows up, despite how often a resident has rounded on the patient throughout the day. How residents commu-nicate with patients can affect the treatment they receive from patients, nurses, attendings, and other members of the health care team. Multiple simu-lated models assess and intervene on resident-patient interactions. Senior residents tend to score higher on these evaluations, suggesting that communication skills improve over time.17-20 Objective, structured clinical exams with standardized patients are com-monly administered in medical school and during the Step 2 Clinical Skills portion of the U.S. Medical Licensing Exam; however, these assessments are no longer performed when surgical residency begins. Published simulation models and validated patient-centered assessment tools clearly demonstrate the importance of early education and continued assess-ment of resident-patient communication skills.

Surgical residents often are reluctant to speak up and may fall prey to the culture of silence because of the hierarchical nature of our field.21 In an attempt to address this code of silence and encourage resi-dents to voice their concerns, one group studied the


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“two-challenge rule” as a method for residents to communicate concerns in a nonthreatening manner during a debriefing session.22

Anesthesia residents were subjects in two simu-lated cases in which a faculty anesthesiologist, an attending surgeon, and a circulating nurse intro-duced communication challenges. After the first case, a debriefing session allowed residents to reflect on their responses or lack thereof. They were then taught the two-challenge rule, which calls for using advocacy-inquiry language, such as, “I see that you want to administer succinylcholine to this patient. She has a 40 percent total body surface area (TBSA) burn. Can you clarify the choice of medication?” If the first challenge is ignored or insufficiently answered, the resident is encouraged to repeat with their critical thinking. “I see that you want to administer succi-nylcholine to this patient with a 40 percent TBSA burn. I have learned that this medication is contra-indicated and may cause fatal hyperkalemia. Should we use vecuronium as an alternative?” The analy-sis was notable for increased verbalization on the behalf of the resident using “crisp advocacy-inquiry language” to relay concerns to the attending surgeon and faculty anesthesiologist following the debriefing session between Case A and Case B, with no signifi-cant change in communication patterns between the resident and nurse. This finding highlights the ben-efits of the two-challenge rule as an effective means of improving communication between trainee and faculty by overcoming potential hierarchy-related barriers to improve teamwork when patient safety is the concern.

As stated previously, how we communicate throughout the day affects every aspect of our lives. The positive interactions we have with others can lead to a sense of personal fulfillment and commu-nity; conversely, negative interactions lead to a sense of frustration, anger, loneliness, or despair. Training residents in evidence-based communication and lead-ership skills, with amplification of the resident voice,

can improve morale, provide a sense of belonging, and remind residents that they are valued members of the patient care team.

When communication failsWhen team communication breaks down, patients are the first to be affected, and residents often are next. When plans are made during morning rounds, the most junior resident typically is tasked with com-pleting the orders, writing the notes, and seeing the consults, despite the fact that he or she may have the least knowledge regarding the drugs ordered or the procedures performed. Often, even if there is a question about the utility of a certain drug or the reason for the treatment plan, no time is allot-ted to critically think and discuss the situation with the senior resident. Similarly, senior residents are too busy managing rounds and rushing to the OR to engage in a discourse with the attendings. This lack of communication can lead not only to a failed learning opportunity, but also to patient harm or provider self-harm.

Rates of major depressive disorder (MDD) and death by suicide are higher among physicians than in the general population. It is estimated that 300 to 400 physicians die each year from suicide, double the rate of the general population.23 Risk factors for MDD and suicide include work demands, sleep deprivation, poor nutrition and fitness, desensitization to illness and death in the workplace, increased administra-tive oversight, access to medication, and burnout.24 A survey of members of the American College of Sur-geons demonstrated that suicidal ideation is associated with burnout, symptoms of depression, and perceived medical error in the last three months. Unfortunately, of the 7 percent of survey respondents who expressed suicidal ideation in the previous 12 months, only 26 percent sought help.25

Barriers to physicians seeking help include the stigma of mental illness, concern for negative

When team communication breaks down, patients are the first to be affected, and residents often are next.


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consequences on medical licensing and insurance cov-erage, and the perception that others will find them less competent.24,26,27 Consequently, many physicians, including surgeons, suffer in silence, missing out on the opportunity to connect with colleagues who are having similar experiences, as well as the opportunity to engage with people who may be able to connect them with available resources. Studies have shown that 40–50 percent of patients who die by suicide have seen a primary care physician within one month of their death, and 17 percent within one week; how-ever, they did not discuss their symptoms, suicidal ideation, or plans.28

Communication is paramount for identifying and addressing burnout, depressive symptoms, and suicide risk. Prompting conversation, commiserating, and sharing experiences is the first step toward identify-ing distress and reducing stigma within the medical community. Once the doors of communication are opened, referrals to the appropriate resources can follow.

When communication is valued Wellness among trainees and faculty has become a major discussion point in surgery, and more studies are needed to determine root causes and appropriate interventions. Several surgical residency programs are paving the way and leading by example.

After a beloved surgical colleague committed suicide just months after completing residency, the Stanford University, CA, surgical residency program director and multiple residents collaborated to develop the Balance in Life program in 2011 to address key factors affecting resident physician well-being.29 In this program, residents are provided with the fol-lowing resources: 24-hour access to healthy snacks and drinks, an after-hours guide to the city, sched-uled group counseling, a senior-to-junior resident mentorship program, elected class representatives who express concerns to the program director at

REFERENCES1. Riall TS. Enjoy the journey. Surg. 2018;164(6):1382-1387.2. Meichenbaum D. Self-instructional strategy training: A

cognitive prosthesis for the aged. Human Development. 1974;17(4):273-280.

3. Moser JS, Dougherty A, Mattson WI, et al. Third-person self-talk facilitates emotion regulation without engaging cognitive control: Converging evidence from ERP and fMRI. Sci Rep. 2017;7(1):4519.

4. Van Raalte JL, Brewer BW, Lewis BP, et al. The effects of positive and negative self-talk on dart throwing performance. J Sport Behav. 1995;18(1):50-57.

5. Hatzigeorgiadis A, Zourbanos N, Galanis E, Theodorakis Y. Self-talk and sports performance: A meta-analysis. Perspect Psychol Sci. 2011;6(4):348-356.

6. Gotlib-Conn L, Reeves S, Dainty K, Kenaszchuk C, Zwarenstein M. Interprofessional communication with hospitalist and consultant physicians in general internal medicine: A qualitative study. BMC Health Serv Res. November 30, 2012. Available at: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-12-437. Accessed June 25, 2019.

7. Zwarenstein M, Rice K, Gotlib-Conn L, Kenaszchuk C, Reeves S. Disengaged: A qualitative study of communication and collaboration between physicians and other professions on general internal medicine wards. BMC Health Serv Res. November 25, 2013. Available at: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-494. Accessed June 25, 2019.

8. Fernando O, Coborn NG, Nathens AB, et al. Interpersonal communication between surgery trainees and nurses in the inpatient wards: Why time and space matter. J Interprof Care. 2016;30(5):567-573.

9. Raparla N, Davis D, Shumaker D, et al. A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study. Am J Surg. 2017;213(2):292-298.

10. Lazaraus JL, Hosseini M, Kamangar F, et al. Verbal aggressiveness among physicians and trainees. J Surg Ed. 2016;73(4):756-760.

11. Sacks GD, Shannon EM, Dawes AJ, et al. Teamwork, communication and safety climate: A systematic review of interventions to improve surgical culture. BMJ Qual Saf. 2015;24(7):458-467.



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regularly scheduled meetings, and sponsored group social events. Objective measures, such as burnout and general psychological well-being, were not sig-nificantly different after introducing this program, but the surveyed residents expressed generally positive responses to all six of the program’s resource areas. Furthermore, most of the residents attended the psy-chological counseling sessions and felt that debriefing with colleagues who shared similar experiences was of value. Although a stigma is still attached to counsel-ing, with many residents hesitant to express personal emotions in a group setting, what we glean from Stan-ford’s intervention is that training programs should create the physical space and time for commiserating and sharing to occur.

Similarly, the University of Arizona, Tucson, general surgery program implemented the Energy Leadership Well-Being and Resiliency Program devel-oped by a professional coach along with the residents and program leadership.30 In this program, residents attend monthly interactive sessions during protected educational time, and topics such as leadership, team building, and communication are addressed. Although objective measures did not show statistically signif-icant decreases in burnout (similar to the findings of the Stanford University program), components of burnout, such as emotional exhaustion, profes-sional efficacy, and perceived stress, did improve. Positive trends also were demonstrated in areas such as self-rated satisfaction with communication skills, leadership ability, and work relationships. Ultimately, program satisfaction in the annual Accreditation Council for Graduate Medical Education survey increased to 96 percent from 80 percent.

More local and national programs are being devel-oped out of the concern for, and personal experiences with, physician burnout and depression. After suffering from both conditions, Michael Weinstein, MD, FACS, an acute care surgeon in Philadelphia, PA, started the LiveWell Physicians program.31 This weekly physi-cian peer support group provides a safe forum for the

12. Hass B, Gotlib-Conn L, Rubenfeld GD, et al. “It’s parallel universes”: An analysis of communication between surgeons and intensivists. Crit Care Med. 2015;43(10):2147-2154.

13. O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians. Arch Intern Med. 2011;171(1):56-65.

14. Hu YY, Parker SH, Lipsitz SR, et al. Surgeons’ leadership styles and team behavior in the operating room. J Am Coll Surg. 2016;222(1):41-51.

15. Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. Am J Surg. 2015;209(1):65-70.

16. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-774.

17. Branson CF, Chipman JG. Improving surgical residents’ communication in disclosing complications: A qualitative analysis of simulated physician and patient surrogate conversations. Am J Surg. 2018;215(2):331-335.

18. Trickey AW, Newcomb AB, Porrey M, et al. Two-year experience implementing a curriculum to improve residents’ patient-centered communication skills. J Surg Educ. 2017;74(6):e124-e132.

19. Schmitz CC, Chipman JG, Luxenberg MG, Beilman GJ. Professionalism and communication in the intensive care unit: Reliability and validity of a simulated family conference. Simul Healthc. 2008;3(4):224-238.

20. Stausmire JM, Cashen CP, Myerholtz L, Buderer N. Measuring general surgery residents’ communication skills from the patient’s perspective using the communication assessment tool (CAT). J Surg Educ. 2015;72(1):108-116.

21. Pei KY, Cochran A. Workplace bullying among surgeons—the perfect crime. Ann Surg. 2019;269(1):43-44.

22. Pian-Smith MC, Simon R, Minehart RD, et al. Teaching residents the two-challenge rule: A simulation-based approach to improve education and patient safety. Simul Healthc. 2009;4(2):84-91.

23. Andrew LB, Brenner BE. Physician suicide. Medscape. August 1, 2018. Available at: https://emedicine.medscape.com/article/806779-overview. Accessed March 22, 2019.

Prompting conversation, commiserating, and sharing experiences is the first step toward identifying distress and reducing stigma within the medical community.




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confidential expression of stress and negative emo-tions, while also providing the skills to recognize and address symptoms of burnout and depression. The program seeks to destigmatize seeking counseling from mental health professionals.

ConclusionCommunication is the common thread that is intri-cately woven into every aspect of our daily lives as physicians. From evaluating the impact of positive self-talk to examining the methods in which we posi-tively (or negatively) communicate among ourselves and with other health care professionals, it is clear that the effects on our well-being cannot be ignored. Failure to effectively communicate on one level can compound on multiple additional levels, with signifi-cant and long-lasting consequences. Understanding and appreciating the value of effective communi-cation is, without question, an important factor in physician wellness and, ultimately, in maintaining career satisfaction and minimizing burnout. Ensur-ing the ready availability of training resources for teaching effective communication skills and imple-menting wellness-focused initiatives are paramount to moving the needle forward in this increasingly important area in order to preemptively address small issues before they manifest into larger and potentially fatal outcomes. ♦

24. Texas Medical Association. Break the silence: Physician suicide. Course for continuing medical education. January 2015. Available at: http://services.inreachce.com/materials/texmed/product/e1666668-b1b0-43a3-a7cb-b3fa710b48cc/Course_Break%20the%20Silence_Physician%20Suicide.pdf. Accessed March 14, 2019.

25. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: Suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.

26. Gold KJ, Andrew LB, Goldman EB, Schwenk TL. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. Gen Hosp Psychiatry. 2016;43(6):51-57.

27. Schwenk TL, Gorenflo DW, Leja LM. A survey on the impact of being depressed on the professional status and mental health care of physicians. J Clin Psychiatry. 2008;69(4):617-620.

28. Pearson A, Saini P, Da Cruz D, et al. Primary care contact prior to suicide in individuals with mental illness. Br J Gen Pract. 2009;59(568):825-832.

29. Salles A, Liebert CA, Esquivel ME, Greco M, Henry R, Mueller C. Perceived value of a program to promote surgical resident well-being. J Surg Ed. 2017;74(6):921-927.

30. Riall TS, Teiman J, Chang M, et al. Maintaining the fire but avoiding burnout: Implementation and evaluation of a resident well-being program. J Am Coll Surg. 2018;226(4):369-379.

31. Weinstein MS. Out of the straitjacket. N Engl J Med. 2018;378(9):793-795.



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A sense of belonging and community can mitigate physician burnout

by Yewande Alimi, MD, MHS; Maria S. Altieri, MD, MS; Jeremy D. Kauffman, MD; Pridvi Kandagatla, MD;

Patricia Martinez Quinones, MD, PhD; Madeline B. Torres, MD; and Rebecca L. Williams-Karnesky, MD, PhD

A s residents and surgeons in training, the topic of wellness and resiliency resonates in our minds. The startling statistics of physician

burnout are ever-present as we press on to finish sur-gical training and pursue our professional careers.1 Resident engagement in physician groups, national societies, and local organizations may serve as a way for trainees to remain connected to the practice of medicine, both practically and emotionally. Work-ing alongside fellow trainees and colleagues on projects that we feel passionate about may lead to timeless bonds and help alleviate the burdens asso-ciated with busy clinical practice. Furthermore, having mentors and peers with whom to commis-

erate and to whom we can offer a helping hand or listening ear may keep our motivation strong and spirits high. Maintaining a focus on wellness and resiliency during training through membership in professional societies and community involvement can serve as a good foundation and preventative measure against burnout, and it may prove key to developing enduring resiliency.

Physician burnout: Causes and effects Burnout is characterized by a state of emotional, mental, or physical exhaustion in response to stress. Changes in our health care system have led to increased demands on clinical productivity, decreased funding opportunities, limited resources, more exten-sive workloads, and longer hours spent completing administrative tasks, all of which make surgeons and surgical trainees prone to burnout. In fact, the rate of burnout among physicians is rising at an alarming rate and has been reported to be as high as 69 per-cent among surgical residents and up to 60 percent among practicing physicians.1,2-4 Burnout negatively affects people both personally and professionally.

HIGHLIGHTS• Summarizes the causes and effects of burnout

• Underscores the importance of professional society membership in fostering wellness

• Describes the role of social media in building resilience


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Professionally, burnout can lead to decreased qual-ity of patient care, as it is associated with poor career satisfaction, decreased effectiveness, substandard prescribing patterns, increased medical errors, and medical liability lawsuits.5-8 Personally, burnout is associated with depression, substance abuse, attri-tion, and suicide.9-11

Several studies have examined risk factors for burnout among surgeons. A survey completed in June 2009 of the American College of Surgeons (ACS) membership included responses from 7,905 surgeons who identified the following independent predictors of burnout: younger age, female gender, parenthood, area of specialization, number of nights on call per week, hours worked per week, and compensation based entirely on billing.3,12-14

As public awareness of surgeon burnout has increased, new methods of prevention and interven-tion have emerged. Identifying those colleagues at risk and facilitating solutions are essential to averting the ramifications of burnout. Many residency programs are developing wellness programs to provide train-ees with the necessary skills to effectively respond to stress and prevent burnout. These programs are designed to foster resilience and improve emotional intelligence.15,16 Some studies also suggest that men-toring relationships can aid in recognizing burnout and developing strategies to alleviate stressors.2 In addition, a good support system can be invaluable to maintaining emotional and physical wellness. The development of educational/wellness programs that promote skills and behaviors that strengthen compas-sionate interactions may be key to managing stress and avoiding burnout.17

Community and group support Haslam and colleagues have noted, “Groups that pro-vide us with a sense of place, purpose, and belonging tend to be good for us psychologically. They give us a sense of grounding and imbue our lives with

meaning. They make us feel distinctive and special, efficacious and successful. They enhance our self-esteem and sense of worth.”18

Many surgeons have been fed a steady diet of rugged individual determinism—of pulling oneself up by one’s bootstraps, forging one’s own destiny, and being the captain of one’s own ship. Perhaps more than any other specialty, the surgical profes-sion naturally self-selects individuals who embody these ideals.19 We tend to believe that we are self-sufficient and essentially invincible.20 When we are honest with ourselves, however, we must admit that every step of the journey to becoming compe-tent, independent surgeons has been facilitated by other people. The instruction we receive in medical school and the mentoring provided in the operating room would not be possible without someone else’s involvement. One way or another, surgeons have a fundamental need for community and comradery, as these factors have been part of their development over the years.21 Family, civic or religious organiza-tions, interaction with colleagues in the workplace, involvement in professional societies, or some com-bination thereof offer the human connection we all need to thrive—to build resilience and grow.

In their study of resilience among U.S. Navy SEALs (sea, air, and land teams) and World War II veterans, Everly and colleagues include “interper-sonal connectedness” among the seven qualities that characterize resilient people.22 Peer support can be an effective antidote to potentially crippling adversi-ties that surgeons routinely face, including the stress of long work hours, the risk of litigation, and coping with bad outcomes.23 Organizations that build such support into their programming structure can have a significant effect on the wellness of their physicians. This support can include changes in schedules and reductions in intensity of workload, increased super-vision to decrease work demand, and enhanced job control, all of which have been demonstrated to significantly affect the wellness of physicians. In


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Many surgeons have been fed a steady diet of rugged individual determinism.... We tend to believe that we are self-sufficient and essentially invincible.

their meta-analysis of 19 randomized control trials examining the impact of interventions to reduce burnout among physicians, Panagioti and colleagues found that interventions initiated at the organiza-tional level had a greater effect than interventions that physicians initiate themselves, suggesting that a systems-level approach to physician wellness is both feasible and effective.24

In another meta-analysis of randomized trial and cohort studies to prevent physician burnout, West and colleagues reviewed 2,617 articles studying 3,630 physicians, and likewise found that organizational strategies were effective in achieving a clinically meaningful reduction in burnout among physicians.15 A combined approach that targets both the individual and the system is likely to achieve the most promis-ing results.25

Wellness and resilience are valuable not only to the individual physician but also to patients and colleagues. Individuals and organizations that take self-care and organizational care seriously initiate a domino effect that has far-reaching benefits beyond the immediately perceptible effects. Surgical societies like the ACS—which exist to preserve the highest standards of the profession through research, education, and advo-cacy—are important not only for the services they provide, but for the impact they have on the broader community. By engaging with these societies, surgeons expand their opportunities to advance personally and professionally and inspire the next generation of sur-geons. There is evidence to suggest that membership in surgical societies contributes to greater academic pro-ductivity.26-28 Of equal importance, academic societies provide a platform for the exchange of ideas, innova-tions, and expertise.

Recently, professional societies have played a more active role in improving physician well-being. The College, for example, provides numerous resources focused on physician wellness, such as the Physician Well-Being Index, which is a tool to help physicians track their well-being over time and compare their

results with colleagues.29 Similarly, the American Medi-cal Association offers a collection of modules called STEPS Forward, to help understand and improve physician wellness.30 Medical students and residents can access similar resources through the Association of American Medical Colleges, which offers articles, conferences, programs, and courses pertaining to well-being.31

Perhaps one of the largest efforts to address physi-cian well-being is the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, which comprises more than 150 orga-nizations that are working to improve physician well-being.32 The three goals of this collaborative are improving understanding of challenges to clinician well-being, raising the visibility of stress and burnout, and elevating evidence-based solutions. Most of the programs described in this article are in their infancy; thus, identification, design, and improvement of tar-geted support that mitigates burnout need to be a high priority.

There is good evidence to suggest that membership and engagement in professional societies such as the ACS is an important step toward overcoming physician burnout. Beyond the benefits of educational resources, mentoring, and networking, group membership has been shown to boost psychological well-being and self-esteem.18,33,34 Why is group membership so important and beneficial? Psychologically speaking, groups pro-vide us with a sense of belonging and meaning and are a source of grounding and support. In other words, they help us understand ourselves and our role in the world, and they help us feel better about both. Group membership provides us with a common perspective, a lens that shapes our view of the world and moves us from isolation toward connection—from “me” to “we.” Active membership in groups, such as the Resident and Associate Society (RAS) committees, provides mem-bers with intellectual stimulation, opportunities for collaborative learning, social companionship, and emotional bonding.18


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Group membership repeatedly has been shown to provide significant health benefits.35-37 The evidence suggests that belonging to social groups can protect against depression, alleviate symptoms of depression, and reduce the risk of depression relapse. An evaluation of more than 9,000 participants demonstrated this effect even when individuals joined one group alone.35

Life transitions make one particularly sus-ceptible to burnout. For instance, the transition from medical school to residency and from residency or fellowship into practice can pose particular challenges to personal well-being.38 Fortunately, research has shown that group membership can help buffer individuals from the negative consequences of change by pro-viding a strong source of personal identity.38 The even better news is that the effect is addi-tive; membership in more groups appears to enhance the benefits of belonging.33,38

Social media and venues to build resilience Social media connects surgeons around the world and provides a large community with which to network, mentor, and collaborate. The use of social media among physicians, and par-ticularly among surgeons, has increased rapidly over the years. More than 90 percent of physi-cians are involved in social media for personal or professional use.39 At its inception, Twit-ter and blogs were the preferred platforms,40 but as the use of social media became widely accepted, additional platforms blossomed, including video- and photo-sharing sites and professional online networking sites targeted to physicians.40 Today, widely used platforms include Twitter, YouTube channels, Facebook, SnapChat, and Instagram, among others. The use of social media in health care can enhance

REFERENCES1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout

and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613.


3. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.



6. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358-367.

7. Melville A. Job satisfaction in general practice: Implications for prescribing. Soc Sci Med Med Psychol Med Sociol. 1980;14A(6):495-499.

8. Jones J, Barge B, Steffy B, Fay L, Kunz L, Wuebker L. Stress and medical malpractice: Organizational risk assessment and intervention. J Appl Psychol. 1988;73(4):727-735.

9. Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship between work-home conflicts and burnout among American surgeons: A comparison by sex. Arch Surg. 2011;146(2):211-217.

10. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174.

11. Shanafelt T, Balch, Charles M., Dyrbye L, et al. Special report: Suicidal ideation among American surgeons. JAMA Surg. 2011;146(1):54-62.

12. Campbell DA, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery. 2001;130(4):696-705.

13. Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout among surgical oncologists: Report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol. 2007;14(11):3043-3053.



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Group membership repeatedly has been shown to provide significant health benefits.

professional networking, improve marketing for individual physicians and organizations, disseminate patient education, and serve as a tool for professional and patient advocacy. However, social media engagement also poses certain risks because of the potential sharing of misinformation, violation of patient privacy, or breach of institutional social media guidelines.41

For surgery residents, one potential benefit of social media engagement is the opportunity to strengthen a sense of community through interaction with trainees who share similar professional and personal experiences. It is well established in the literature that social and organizational inf luences contribute to a decrease in burnout. The ability to engage with others via social media allows for the sharing of expertise and the capacity to devise solu-tions to ease stress and enhance wellness. The widespread distribution of literature shared on social media platforms like Twitter allows users to learn from the challenges and successes of physician wellness programs that have already been implemented. Social media provides a pos-sible antidote to burnout insofar as it provides a virtual community where communication, support, and collaboration can develop.

ConclusionWhile joining an ACS chapter or the RAS may not be the ultimate solution to burnout, mem-bership in societies has been well documented as a deterrent to burnout and a contributor to physician resiliency. Membership in these groups provides an opportunity to access resources on physician wellness and burnout and to collabo-rate with peers and mentors who have similar experiences and interests. Ongoing engagement in societies and groups not only provides support for the individual, but also drives the individual’s

14. Ramirez A, Richards M, Cull A, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. 1995;71(6):1263-1269.

15. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.

16. McCue JD, Sachs CL. A stress management workshop improves residents’ coping skills. Arch Intern Med. 1991;151(11):2273-2277.

17. Lown BA. A social neuroscience-informed model for teaching and practising compassion in health care. Med Educ. 2016;50(3):332-342.

18. Haslam SA, Jetten J, Postmes T, Haslam C. Social identity, health and well‐being: An emerging agenda for applied psychology. Appl Psychol. 2009;58(1):1-23.

19. Drosdeck JM, Osayi SN, Peterson LA, Yu L, Ellison EC, Muscarella P. Surgeon and nonsurgeon personalities at different career points. J Surg Res. 2015;196(1):60-66.

20. Cope A, Bezemer J, Mavroveli S, Kneebone R. What attitudes and values are incorporated into self as part of professional identity construction when becoming a surgeon? Acad Med. 2017;92(4):544-549.

21. Money SR. Surgical personalities, surgical burnout, and surgical happiness. J Vasc Surg. 2017;66(3):683-686.

22. Everly GSJ, McCormack DK, Strouse DA. Seven characteristics of highly resilient people: Insights from Navy SEALs to the “greatest generation.” Int J Emerg Ment Health. 2012;14(2):87-93.

23. Shapiro J, Galowitz P. Peer support for clinicians: A programmatic approach. Acad Med. 2016;91(9):1200-1204.

24. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.

25. Ruzycki SM, Lemaire JB. Physician burnout. CMAJ. 2018;190(2):E53.

26. Milgrom DP, Koniaris LG, Valsangkar NP, et al. An assessment of the academic impact of Shock Society members. Shock Augusta Ga. 2018;49(5):508-513.

27. Valsangkar NP, Milgrom DP, Martin PJ, et al. The positive association of Association for Academic Surgery membership with academic productivity. J Surg Res. 2016;205(1):163-168.

28. Valsangkar NP, Kays JK, Feliciano DV, et al. The impact of members of the Society of University Surgeons on the scholarship of American surgery. Surgery. 2016;160(1):47-53.



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29. American College of Surgeons. Surgeon well-being resources. Available at: facs.org/member-services/surgeon-wellbeing/resources. Accessed June 1, 2019.

30. American Medical Association. Professional well-being. Available at: https://edhub.ama-assn.org/steps-forward/pages/professional-well-being. Accessed June 1, 2019.

31. Association of American Medical Colleges. Well-being in academic medicine. www.aamc.org/initiatives/462280/well-being-academic-medicine.htm. Accessed June 1, 2019.

32. National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience. Available at: https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed June 1, 2019.

33. Jetten J, Branscombe NR, Haslam SA, et al. Having a lot of a good thing: Multiple important group memberships as a source of self-esteem. PLoS One. 2015;10(5):e0124609.

34. McNeill KG, Kerr A, Mavor KI. Identity and norms: The role of group membership in medical student wellbeing. Perspect Med Educ. 2014;3(2):101-112.

35. Cruwys T, Dingle GA, Haslam C, Haslam SA, Jetten J, Morton TA. Social group memberships protect against future depression, alleviate depression symptoms and prevent depression relapse. Soc Sci Med. 2013;98(23):179-186.

36. Saylor J, Lee S, Ness M, et al. Positive health benefits of peer support and connections for college students with type 1 diabetes mellitus. Diabetes Educ. 2018;44(4):340-347.

37. Zaitsu M, Kawachi I, Ashida T, Kondo K, Kondo N. Participation in community group activities among older adults: Is diversity of group membership associated with better self-rated health? J Epidemiol. 2018;28(11):452-457.

38. Iyer A, Jetten J, Tsivrikos D, Postmes T, Haslam SA. The more (and the more compatible) the merrier: Multiple group memberships and identity compatibility as predictors of adjustment after life transitions. Br J Soc Psychol. 2009;48(4):707-733.

39. Ventola CL. Social media and health care professionals: Benefits, risks, and best practices. PT. 2014;39(7):491-499.

40. Logghe HJ, McFadden CL, Tully NJ, Jones C. History of social media in surgery. Clin Colon Rectal Surg. 2017;30(04):233-239.

41. Fehring KA, De Martino I, McLawhorn AS, Sculco PK. Social media: Physicians-to-physicians education and communication. Curr Rev Musculoskelet Med. 2017;10(2):275-277.

engagement in the organization, resulting in ongoing contributions because of the fostered sense of community.

Engaging physicians in group participation during times of transition—from resident or fellowship to practice or from student to resi-dency, for example—is critical because of their vulnerability and susceptibility to burnout. This sense of community is well fostered in the age of social media, which provides a forum in which members may be engaged from a distance, con-temporaneously, or in a delayed fashion. ♦


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The goal of medical training is to equip future physicians and surgeons with the skills and knowledge they need to support the health and well-being of their patients.

Paradoxically, the demands associated with the U.S. medical education system can have well-documented negative effects on the health and well-being of trainees.1-3 Despite the fact that college graduates who are matriculating into medical school have significantly lower levels of depression and burn-out than their age- and education-matched peers who are entering other fields, by the time they graduate from train-ing, levels of depression and burnout in medical students are nearly twice that of nonphysician professionals.1,3

Levels of burnout continue to rise as trainees enter resi-dency.4-6 This trend is especially apparent in general surgery residents, with approximately 70 percent of these individu-als meeting the criteria for burnout.5,6 Additionally, nearly one in five general surgery residents leave residency before

Training resilient surgeons:Where do we go from here?

by Rebecca L. Williams-Karnesky, MD, PhD; Rachel Hanke, MD; Erica K. Ludi, MD; Christopher L. Kalmar, MD, MBA; Meghana V. Kashyap, MD, DIM&PH;

Ravi Viradia, MD; Franki Boulos, MSc, MD; and Kaitlin A. Ritter, MD

HIGHLIGHTS• Describes strategies for alleviating

burnout in surgical training, including duty-hour restrictions and department wellness programs

• Examines the aviation and education domains to assess successful approaches to building resilience

• Summarizes action items for developing a health care culture that fosters physician wellness


36 |


completing their training.7 Reasons cited for attri-tion include a lack of work-life balance and the high personal cost of residency training.8,9 In addition to the tremendous personal cost of residency attri-tion, these losses in the surgical workforce further tax an already under-resourced health care system and erode its ability to provide appropriate care to patients.10

Perhaps most concerning is the fact that as trainees advance from residency into professional practice, they generally continue to display signs of burnout. It is reasonable to say that burnout among U.S. physicians has reached epidemic levels.11,12 The effect on patient care is substantial. In a study of 7,905 practicing surgeons in the U.S., approximately 10 percent reported that they had made a major medical error within the preceding three months.13 These errors were significantly associated with the presence of burnout. Furthermore, symptoms of both burnout and depression were revealed to be independent predictors of reporting major medical errors.13,14

The gravity of this issue is further compounded by the effect of burnout on the mental and emo-tional health of physicians. One survey of 25,073 U.S. surgeons found that approximately 14 percent of men and 26 percent of women met criteria for alcohol abuse or dependence and that the presence of symptoms of burnout or depression were significant risk factors.15 A similar study of 7,905 U.S. surgeons showed that surgeons who met the criteria for burn-out were nearly twice as likely to exhibit suicidal ideation in the last 12 months as surgeons who did not meet the criteria for burnout after controlling for personal and professional characteristics.16 These stark findings demonstrate that addressing surgeon burnout is imperative for our professional and soci-etal well-being. A call to action has been issued, and surgical organizations are searching for solutions to this troubling trend across all levels of training and experience.

Addressing burnout in surgical trainingInitial efforts to address physician burnout largely focused on improving resilience by providing sup-port for individual wellness and stress management through activities such as meditation and yoga.17 Yoga and meditation are shown to reduce stress hormones, as well as improve relaxation response and parasym-pathetic functions, which can help instill a feeling of greater control over situations.18 These strategies pro-vide benefits for practitioners, with multiple studies offering moderate-quality evidence to support the role of yoga in mitigating depression, anxiety, and fatigue.19

Mindfulness-based therapies also have been shown to alleviate a variety of mental and physical conditions associated with chronic stress.20 One study involv-ing primary care physicians used mindfulness-based techniques such as meditation and self-awareness exercises to train health care professionals to deal more effectively with unpleasant thoughts and feel-ings, to better manage conflict, to more effectively set boundaries, and to prioritize self-care. This inter-vention resulted in both short-term and sustained improvements in well-being.20 Although these results have been promising, a meta-analysis of interventions to reduce burnout showed that though individual-level interventions successfully reduce burnout, the benefits are modest.17 This finding illustrates that additional institutional-level interventions are needed to sufficiently address burnout.

Duty-hour restrictionsSome of the first attempts to tackle burnout in health care at a systemic level were instituted in 2003 with the implementation of the 80-hour resident workweek. Although this intervention did result in a measur-able reduction in burnout, it did not eliminate the issue and had almost no effect on attrition rates.21,22 In 2011, the Accreditation Council for Graduate Med-ical Education (ACGME) attempted to improve on these advances with the initiation of duty-hour limits aimed at reducing burnout and its complications. In


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a two-year evaluation of these new policies involving 213 surgical interns, 82 percent of residents reported a neutral or good overall quality of life, but approx-imately one-third of the respondents continued to report symptoms of burnout.23

Duty-hour restrictions are not linked to notable improvements in patient outcomes, patient safety, or resident satisfaction in terms of well-being.24 In fact, it is possible that the increased frequency of hand-offs associated with duty-hour restrictions leads to additional opportunities for mistakes, decreases edu-cational opportunities, and interferes with continuity in patient care, thereby creating an additional burden for residents who are forced to choose between profes-sional values of patient care continuity and regulatory compliance.25 Duty-hour restrictions, while well-intentioned, ultimately demonstrate that burnout, wellness, and patient care are predicated on more than the number of hours worked.

Departmental wellness programsTo further promote an institutional culture of wellness, many residency programs have begun to implement curricular interventions into their program infra-structure. Researchers at Stanford University, CA, designed a multifaceted Balance in Life program that addresses six components of resident well-being, including a resident mentoring program, counseling sessions, healthy food options, and resource guides.26 Although this intervention yielded little statistical improvement in psychological well-being or burn-out, implementation did correlate with increased “grit” scores, increased resident-reported sleep, and increased rates of resident-reported exercise and phys-ical activity.26

Other programs have responded to low resident morale by organizing monthly social events, such as family-friendly activities, and support groups to encourage sharing of common experiences to foster a sense of relatedness and belonging.27 Other resi-dency programs have taken these interventions a step

further by attempting to apply additional objective measures to their wellness programs. The depart-ment of neurosurgery at the Medical University of South Carolina, Mount Pleasant, employed activity monitors and psychological and physical testing to track health measures, including resident weight, blood pressure, and sleep habits.28 This information was shared with residents, and trainees were provided with wellness lectures, group exercise sessions, and an increased availability of healthy food options. To date, this intervention has shown modest improve-ments in weight loss and an increase in self-reported team comradery.28

Multipronged approaches to addressing wellness often use a combination of training in mindfulness, teambuilding, stress-reduction techniques, and emo-tional intelligence. Other novel strategies that have been implemented to enhance resident well-being include dry cleaning service for surgical residents, mandatory quarterly or monthly half-days to attend to personal needs, and even meal delivery for res-idents returning to clinical duties after parental leave. Many residency programs host annual resident retreats during which residents are free of clinical duties for the entire day to participate in team-building activities.

Despite these innovative approaches and the prog-ress that has been made, we are far from achieving optimal wellness in the field of surgery and surgical education. What will the next chapter of wellness interventions look like, and how can we as learners and educators influence this work?

Learning from other high-stress fieldsResearch examining the major domains that contrib-ute to physician well-being have identified efficiency of practice, an institutional culture of wellness, and personal resilience as key factors for avoiding burn-out and professional fulfillment (see Figure 1, page 39).29 This work demonstrates that both individuals


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Research examining the major domains that contribute to physician well-being have identified efficiency of practice, an institutional culture of wellness, and personal resilience as key drivers for avoiding burnout and professional fulfillment.

FIGURE 1.INSTITUTIONAL AND INDIVIDUAL FACTORS BOTH CONTRIBUTE TO SURGEON WELLNESS

and health care institutions must be equal partners in addressing surgeon burnout in order to create a culture of wellness. To highlight novel strategies for moving to the next phase of burnout prevention, we examined comparable professions—specifically high-stress fields that require near-perfect levels of performance—to see what interventions and tech-niques have been used to maintain a culture of wellness and resilience.

Lessons from the field of aviationMany parallels have been made between aviation and the health care fields, which have led to advances in promoting passenger and patient safety, including checklists, simulation training, team-based work, performance analysis, and incident reporting.30 Similar associations can be made when considering the management of pilot and health care profes-sional well-being and fatigue. In both aviation and health care, fatigue and burnout can lead to errors, reduced reaction time, poor communication, and an overall increased risk to individuals who count

on professionals to deliver safe outcomes.30,31 For instance, long days with multiple short flights and quick ground turnaround times are comparable to performing multiple short operations with fast turnover times, leaving little time for nutrition and hydration. Night flights and night duties contrib-ute to disrupted circadian rhythms and rest periods during normal awake hours. Analogous to what has been seen in surgical residency, duty hours in the aviation industry have limitations that often para-doxically aggravate or compound fatigue.32 Ideal minimum break periods between shifts—defined as nine hours in aviation and eight hours in surgery—do not account for factors such as travel time to home, meal preparation, and family responsibilities, which cut into the amount of time remaining for sleep and recuperation.

To combat pilot fatigue and the associated nega-tive consequences, the airline industry has introduced the fatigue risk management system (FRMS) as an alternative to prescriptive duty limitations. An FRMS is a data-driven, flexible process of monitoring and

Institutional factors

Individual factors

Culture of wellness

Support for self-care, sense of community, appreciation

and recognition

Personal resilience

Healthy coping strategies, techniques

for stress reduction and emotional regulation (such as mindfulness),

self-compassion

Efficiency of practice

Electronic health record efficiency, fatigue

mitigation, streamlined clinical workflow, adequate

support staff, reduction of administrative burden


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managing fatigue risk to maximize operational effi-ciency.31,32 The minimum components of an FRMS include a managing policy published by the govern-ing or regulating body, education and awareness training, nonpunitive identification and reporting systems for fatigue-related incidents, and enforce-ment at all levels within the organization.32 The four main objectives of an FRMS are used to establish policies for plan enforcement, manage pilot workload through predictive scheduling models, require safety data collection through air safety and flight reports, and provide sleep and fatigue assessments using in-flight observations and self-generated feedback. The FRMS also ensures that pilots receive regular train-ing on the physiologic consequences of fatigue and learn strategies for recovery, planning, and optimized break time.31 As more research has been conducted to assess reduced break times before shifts in the aviation industry, researchers have found that the longest duty times do not always correlate with the highest number of adverse events, suggesting that team cooperation and automation are more heavily relied upon during the longer shifts to compensate for individual fatigue.

The aviation industry’s FRMS initiative has sig-nificant implications for surgical residencies and duty hours. Shifting from a prescriptive, time-based approach to a more strategic fatigue management

system might better mitigate the effects of acute and cumulative fatigue. Moreover, the promotion of restorative break times that incorporate a good balance of family time, meals, and rest would allow for greater alertness and better mood during duty time. When longer duty hours are required, as in the instance of overnight call coverage, incorporating automation, such as cell phone reminders and elec-tronic health record notifications, as well as increased emphasis on teamwork, may reduce the number of safety incidents secondary to fatigue and diminished well-being. Most importantly, an FRMS intervention emphasizes the importance of creating a culture of wellness at the institutional level and enhances ease of practice—two essential components in a holistic model of surgeon wellness.

Lessons from the field of educationAnother decidedly influential and demanding field in the U.S. is teaching. High daily stress frequently leads to educator burnout, with 40–50 percent of teachers leaving the profession within the first five years.33 Edu-cators regularly face increasing job demands, including increased number and frequency of standardized exams, student behavioral issues, and parental con-cerns. This trend directly parallels the all-too-familiar struggle of surgical residents and new-to-practice sur-geons, who are expected to develop an exponentially

FIGURE 2.SIMPLIFIED JOB DEMANDS-RESOURCES MODEL APPLIED TO SURGEON BURNOUT AND WELLNESS


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Job resources Job demands

Wellness Burnout

Culture of wellness

Institutional support

Physical workload

Emotional strain

increasing medical knowledge base, engage more patients with compassion, and tackle ever-increas-ing documentation requirements. Physicians, who regularly assume the role of teacher to colleagues, residents, and patients, face similar stressors and may benefit from interventions that are being used in education.

Interventions to improve the wellness of our nation’s teachers and educational system as a whole have been divided into three levels: indi-vidual, organizational-individual interface, and organizational.34 Individual-level interventions, such as cognitive behavioral techniques, have been shown to enhance awareness development, provide a coping mechanism for managing dif-ficulties, and increase emotional well-being by reducing anxiety and depression.34 In random-ized controlled trials of educators, contemplative practices like yoga and meditation were found to decrease burnout, lessen the impact of nega-tive emotions, decrease the physical symptoms of stress, increase mindfulness, improve emo-tional well-being, increase positive emotions, and improve teaching efficacy.34,37 Interestingly, these interventions also resulted in improved overall quality of teaching.34

Organization-individual interface inter-ventions, which focus on building workplace relationships and support, have been found to result in significant improvements in teacher well-being.34 Longitudinal mentoring programs for novice teachers have proven particularly effective in increasing educator satisfaction and retention and bolstering student achievement. Workplace wellness programs, focused on nutrition or exer-cise, have been found to reduce health risk, health care costs, and absenteeism. Although many orga-nizational initiatives are directed at the culture of wellness in education, little data is available to indicate the impact these interventions have had on educator wellness and performance.

REFERENCES1. Brazeau CMLR, Shanafelt T, Durning SJ, et al. Distress

among matriculating medical students relative to the general population. Acad Med J Assoc Am Med Coll. 2014;89(11):1520-1525.

2. Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: A multicentre study. Med Educ. 2009;43(3):274-282.

3. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451.

4. Coste C. Resident impairment: The risky business of becoming a doctor. New Physician. 1978;27(4):28-31.



7. Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and causes of attrition among surgical residents: A systematic review and meta-analysis. JAMA Surg. 2017;152(3):265-272.

8. Sullivan MC, Yeo H, Roman SA, et al. Surgical residency and attrition: Defining the individual and programmatic factors predictive of trainee losses. J Am Coll Surg. 2013;216(3):461-471.

9. Bongiovanni T, Yeo H, Sosa JA, et al. Attrition from surgical residency training: Perspectives from those who left. Am J Surg. 2015;210(4):648-654.

10. Williams TE, Satiani B, Thomas A, Ellison EC. The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg. 2009;250(4):590-597.

11. Pulcrano M, Evans SRT, Sosin M. Quality of life and burnout rates across surgical specialties: A systematic review. JAMA Surg. 2016;151(10):970-978.

12. Raimo J, LaVine S, Spielmann K, et al. The correlation of stress in residency with future stress and burnout: A 10-year prospective cohort study. J Grad Med Educ. 2018;10(5):524-531.


14. Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93(11):1571-1580.



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REFERENCES, CONTINUED Four key factors have been identified as major contributors to teacher stress: school organiza-tion, job demands, work resources, and social and emotional competence.34 These findings echo the conceptual framework outlined in job demands-resource theory,35,36 a model for understanding burnout that is used in occupa-tional psychology and has direct implications for understanding burnout in surgery (see Figure 2, page 40). From a systems perspective, a collegial, supportive environment is paramount to high performance, as well-being requires both a sense of belonging as well as the ability to contribute as an individual. The creation of a supportive environment involves strong leadership with a clear sense of direction, trustworthy colleagues, and suitable working conditions. Institutional support in the form of ease of practice and a cul-ture of wellness plays a key role in maintaining and enhancing teacher well-being.

Analogous to findings from the medical field, educator wellness is heavily inf luenced by the work environment, which encompasses fac-tors such as institutional culture, resources, and support. Though much of the early research in educator well-being focused on interven-tions at the individual level that are aimed at enhancing personal resilience, current studies are now moving toward an increased focus on the importance of policy and program changes in improving educator wellness.

Recommendations for moving forwardFrequently the focus is on individual-level interventions to promote surgeon well-being; however, both the aviation and education pro-fessions demonstrate that concurrent systemic changes are necessary to foster a surgical culture that encourages and actively enhances physician wellness. Fortunately, leaders in surgery and

15. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174.

16. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: Suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.

17. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.

18. Rao RM, Amritanshu R, Vinutha HT, et al. Role of yoga in cancer patients: Expectations, benefits, and risks: A review. Indian J Palliat Care. 2017;23(3):225-230.

19. Cramer H, Lauche R, Klose P, Lange S, Langhorst J, Dobos GJ. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017;3(1):CD010802.

20. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.

21. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-871.

22. Leibrandt TJ, Pezzi CM, Fassler SA, Reilly EF, Morris JB. Has the 80-hour work week had an impact on voluntary attrition in general surgery residency programs? J Am Coll Surg. 2006;202(2):340-344.

23. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-455.

24. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374(8):713-727.

25. Byrne JM, Loo LK, Giang DW. Duty hour reporting: Conflicting values in professionalism. J Grad Med Educ. 2015;7(3):395-400.

26. Salles A, Liebert CA, Esquivel M, Greco RS, Henry R, Mueller C. Perceived value of a program to promote surgical resident well-being. J Surg Educ. 2017;74(6):921-927.



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Surgeons can expand our understanding of the factors that drive burnout by studying applications of occupational psychology.

REFERENCES, CONTINUEDeducation are making great strides in this regard. The American College of Surgeons now offers access to a Physician Well-Being Index38 that allows members to complete an online self-assess-ment and track various measures of well-being over time, with free resources tailored to respond to the risks identified in the self-assessment. The ACGME also has taken steps to address wellness through more explicit wording in the common program requirements39 and through the use of resident feedback in the Clinical Learning Environment Review program. The Ameri-can Medical Association offers an innovative STEPS Forward program, designed to educate physicians about evidence-based individual- and organizational-level interventions to improve physician wellness.40 These and other initiatives empower surgeons at all levels to alleviate burn-out through increased engagement in shaping the culture of medicine and creating interven-tions to enhance ease of practice at both the local and the national level.

Recent research has suggested adapting Maslow’s hierarchy of needs as a framework for addressing physician wellness.41,42 This hierar-chy provides a guideline for thinking about a progressive approach to addressing wellness. It suggests that as needs are met at each level, individuals are motivated to progress upward toward higher-order needs and achievement. This model is exceedingly practical; it assumes that ultimately surgeons will be most fulfilled when their higher-order needs—such as finding joy in practice—are met. It acknowledges, how-ever, that to reach this state, surgeons must first have their basic physiologic needs met, such as hydration, sustenance, and sleep.

Moving forward, strategies to promote wellness and mitigate burnout should focus on approaches that address both institutional issues, such as a culture of wellness and efficiency of

27. Van Orden KE, Talutis SD, Ng-Glazier JH, et al. Implementation of a novel structured social and wellness committee in a surgical residency program: A case study. Front Surg. March 13, 2017. Available at: www.frontiersin.org/articles/10.3389/fsurg.2017.00014/full. Accessed July 1, 2019.

28. Fargen KM, Spiotta AM, Turner RD, Patel S. Operation La Sierra: A novel wellness initiative for neurological surgery residents. J Grad Med Educ. 2016;8(3):457-458.

29. Bohman B, Dyrbye L, Sinsky C, et al. Physician well-being: Efficiency, resilience, wellness. NEJM Catalyst. August 7, 2017. Available at: https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/. Accessed January 6, 2019.

30. Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. Aviation and healthcare: A comparative review with implications for patient safety. JRSM Open. December 2, 2015. Available at: http://eprints.lse.ac.uk/68780/1/Parand_Aviation%20in%20healthcare_author.pdf. Accessed July 1, 2019.

31. Cabon P, Deharvengt S, Grau JY, Maille N, Berechet I, Mollard R. Research and guidelines for implementing fatigue risk management systems for the French regional airlines. Accid Anal Prev. 2012;Suppl 45:41-44.

32. Air Line Pilots Association International. ALPA White Paper: Fatigue risk management systems: Addressing fatigue within a just safety culture. June 2008. Available at: www.alpa.org/-/media/ALPA/Files/pdfs/news-events/white-papers/white-paper-fatigue-risk-management-systems.pdf?la=en. Accessed March 22, 2019.

33. Gallup. State of America’s schools. Available at: www.gallup.com/services/178709/state-america-schools-report.aspx. Accessed March 26, 2019.

34. Robert Wood Johnson Foundation. Teacher stress and health. September 1, 2016. Available at: www.rwjf.org/en/library/research/2016/07/teacher-stress-and-health.html. Accessed March 26, 2019.

35. Bakker AB, Demerouti E. Job demands—resources theory: Taking stock and looking forward. J Occup Health Psychol. 2017;22(3):273-285.

36. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499-512.



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practice, as well as personal resiliency.29 As demonstrated in other high-stress fields such as aviation and education, these strategies need to be responsive and creative—not prescriptive. Surgeons can expand our understanding of the factors that drive burnout by studying applica-tions of occupational psychology. This approach explores how ideas such as job-crafting—the process of actively engaging workers in defin-ing their scope of work and providing them with structural job resources while minimizing nega-tive job demands—may move us even further toward achieving a true reduction in resident and surgeon burnout.43

Involvement of all stakeholders, including policymakers, individual institutions, faculty, and residents, is imperative to making real, sus-tainable change. The national and international dialogue about how to address the epidemic of burnout in the field of surgery should continue, and trainees and health care professionals at all levels should be empowered to be change agents in shaping the process of moving from burnout to wellness. ♦

37. Harris AR, Jennings PA, Katz DA, Abenavoli RM, Greenberg MT. Promoting stress management and wellbeing in educators: Feasibility and efficacy of a school-based yoga and mindfulness intervention. Mindfulness. 2016;7(1):143-154.

38. American College of Surgeons. Surgeon well-being. Available at: facs.org/member-services/surgeon-wellbeing. Accessed March 20, 2019.

39. Accreditation Council for Graduate Medical Education. Tools and resources. Available at: www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources. Accessed March 20, 2019.

40. American Medical Association. Physician wellness program. Available at: www.ama-assn.org/ama-member-benefits/practice-member-benefits/physician-wellness-program. Accessed March 20, 2019.

41. Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond burnout: A physician wellness hierarchy designed to prioritize interventions at the systems level. Am J Med. 2019;132(5):556-563.

42. Hale AJ, Ricotta DN, Freed J, Smith CC, Huang GC. Adapting Maslow’s hierarchy of needs as a framework for resident wellness. Teach Learn Med. 2019;31(1):109-118.

43. Dominguez LC, Dolmans D, de Grave W, Sanabria A, Stassen LP. Job crafting to persist in surgical training: A qualitative study from the resident’s perspective. J Surg Res. 2019;239(7):180-190.



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Shift work surgery:Loss of continuity or sensible balance of responsibility?


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RAS-ACS SYMPOSIUM: SHIFT WORK SURGERY

by Julia R. Coleman, MD, MPH; Brett M. Tracy, MD;

Christopher L. Kalmar, MD, MBA; Christopher F. McNicoll, MD;

and Randi Ryan, MD

The Advocacy and Issues Committee of the Res-ident and Associate Society of the American College of Surgeons (RAS-ACS) hosts the annual

RAS Symposium at the Clinical Congress. During this session, a panel discusses an issue affecting sur-geons and surgical residents. The 2019 symposium will explore the topic of shift work surgery and whether this trend erodes continuity of patient care or allows residents to achieve a sensible balance of responsibility. The RAS Symposium will take place Sunday, October 27, at the Moscone Center, San Fran-cisco, CA.

IntroductionSurgical residency training programs have imple-mented dynamic scheduling and curricula changes in recent decades. Perhaps the most remarkable of those changes was the move by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 to standardize the 80-hour workweek.1 These duty-hour restrictions were implemented in response to concerns about physician fatigue, medical errors, communication-related errors, and physician burnout.2 After implementation of these standards, researchers involved in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial suggested that trac-table work hours better promoted patient continuity of care and resident education without associated negative patient outcomes.3 Even so, the FIRST trial highlighted concerns regarding work-life integration. Ultimately, this trial has energized a debate over how duty-hour restrictions have changed not only resident physician scheduling and patient outcomes but also surgical culture.

The historical model for surgical training included unrestricted hours. Residents stayed at the hospital to finish cases and start new ones, attended to patients throughout the entire perioperative period, and worked home-call shifts for nights and weekends without designated time off. However, duty-hour restrictions spawned structural changes toward a shift work model,

with 12-hour schedules, designated days off, and limi-tations on hours within call shifts. This arrangement has been incorporated into several surgical specialties, including trauma and acute care surgery. Other surgical specialties have initiated shift work arrangements too, with dedicated coverage to prevent 24/7 call responsi-bilities for an individual surgeon.

This shift work model has been so widely adopted, initially because of the ACGME mandate, that it has caused a cultural shift, with movement toward height-ened awareness of physician wellness and burnout; efforts to improve communication, particularly during handoffs; and the establishment of reasonable limita-tions to arduous schedules. These trends have had a positive effect on the surgical culture but have also ignited concern that this shift work approach has ushered in a change in surgeon mentality—namely, that surgeons undervalue continuity of care and patient ownership—as well as hands-on educational opportunities.

This concern has led to debate within the profes-sion regarding the optimal way to implement surgical shifts or whether surgery should avoid moving toward shift work entirely. The 2019 RAS Symposium partici-pants will debate whether shift work surgery should be encouraged to foster a sensible balance of responsibil-ity and promote surgeon wellness or whether it should be discouraged, as it reduces continuity of patient care and exposure to educational opportunities.

This article outlines the history of shift work sur-gery, explores the possibility that this model acts as a detriment to patient care and resident education, and examines whether it functions as an appropri-ate response to work-hour restrictions with improved resident wellness and a sensible balance of patient responsibility.

The transition to shift work Scheduled shifts were first introduced in the 1980s in the form of night float teams in obstetrics/gynecology residencies, as a result of the Council on Resident

HIGHLIGHTS• Summarizes the early adoption and ongoing

evolution of the shift work surgery model

• Describes the challenges associated with shift work scheduling, including diminished continuity of care

• Highlights the benefits of shift work, including improved job satisfaction and enhanced resident education opportunities


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Education in Obstetrics and Gynecology’s focus on reducing hours spent in the hospital.4 A transition to shift work scheduling came in the wake of the work-hour restriction laws instituted in the state of New York after the March 1984 death of Libby Zion, an 18-year-old college student who tragically died in the emergency room while in the care of overworked residents.5 In logical fashion, the ACGME imposed similar work-hour restrictions on accredited residen-cies nationwide.6 The night float system subsequently became widespread across residency programs to accommodate these new regulations.

The demands for work-hour restrictions led to debate concerning the effect of shift work on resi-dent education. Initial reports examining resident education in the night float system suggested residents on night float interact less with faculty, receive less feedback, are absent from daytime didactic sessions, and have less operative experience.7,8 Despite these potential drawbacks, the night float system persisted and programs have made adjustments to ensure that educational quality is maintained.9 The benefits to patients and residents with a night float system have been reported.10 In a 2019 study of more than 7,000 surgical patients comparing night float with overnight on-call residents, Yu and colleagues found decreased postoperative bleeding and shorter response time to emergent consultations in the night float system.11

Goldstein and colleagues reported results of a resident survey after implementation of a night float system at a New York general surgery program. Resi-dents reported decreased fatigue, better resident-nurse communication, more time for sleep at home, and increased time spent on independent study.12 Despite these benefits, faculty in this same study reported decreased continuity of care as a result of the night float system. This concern has been echoed in other studies, highlighting concern about the shift work model and its link to a decreased sense of patient ownership.13,14

The debate around continuity of care, communi-cation errors in sign-out, decreased physician fatigue, and improved physician wellness in the context of the

night float system has regained momentum in the shift work era. Shift work surgery is virtually synony-mous with acute care surgery, the specialty that has most widely adopted this structure.15 This construct allows a dedicated attending to be available for 12- or 24-hour shifts, free of clinic and elective caseloads.16 This structure was created to improve health care outcomes, maximize surgical resources, and increase cost savings for hospitals, but it also has attracted more physicians to surgery as a result of the lifestyle benefits derived from a more controlled schedule and night-time responsibilities.16-19 The shift work structure has been compared with previous call models and the lit-erature reports decreased time to the operating room (OR), decreased complication rates, and decreased length of stay for common acute care pathologies (such as appendicitis and cholecystitis) because an acute care surgeon is in-house on shifts.16,18 However, recent lit-erature has highlighted the concern within this model about physician fatigue and chronic sleep deprivation, which may result from demanding shifts and duties that often extend beyond designated hours.20,21 Fur-thermore, some surgeons have voiced concern about continuity of care and communication within this fragmented model of shift work, as many acute care surgery models still lack formal sign-out procedures.19 Other specialties have adopted shift work and have thereby expanded the discourse regarding the pros and cons of this structure.

Shift work surgery: Loss of continuityShift work mentality can be seen as a threat to the pro-fessional tenets that define the core values of a surgeon. These values are grounded in the concept of patient care ownership, which translates into the primary sur-geon being available and responsible for all events and decisions in the perioperative care of the patient at all times. Patient care ownership has been described as “a central tenet of surgical professionalism dating back decades and is fundamental when facing critical patient care decisions.”22


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The ACGME, which established the standards for duty-hour compliance, has also recognized the impor-tance of continuity of care, stating that “continuity of care must take precedence—without regard to the time of day, day of the week, number of hours already worked, or on-call schedules.”23 The ability to provide continuity of care can be beneficial to both the patient and the surgical trainees.24-26 Many surgeons agree that signing out a patient to a different provider is a poor substitute for knowing the important details of that patient’s clinical course and can lead to communication errors.27 Patient management by the same individual ensures a thorough understanding of all nuances of their perioperative course. The resident providing this continuous care also benefits from opportunities to see how a patient’s disease evolves, which can be an invaluable educational experience.

Teman and colleagues surveyed 239 attending sur-geons and found that 14 percent of the respondents cited shift work mentality, decreased patient owner-ship, and sense of responsibility as factors preventing residents from achieving graduated autonomy in the OR.28 Despite duty-hour restrictions, evidence has shown that surgical residents often continue to work after their designated shift as a result of beliefs about patient ownership and professionalism,29 indicating a reluctance to succumb to a shift work mentality.

In parallel to work-hour restrictions affecting the structure of surgical residency, changes at the level of surgical staffing have occurred as well. The acute care surgery model has been structured as shift work since its inception, but shift work may be ill-suited for training in other surgical specialties. Most acute care surgery cases involve new patients who are receiving care for a new urgent or emergent surgical condition. Surgeons who provide elective operations historically have been responsible for continuous management of their patients. This practice ensures that the surgeon who evaluated the patient in the clinic and performed the initial procedure also is the one who makes deci-sions regarding postoperative care. An important, established relationship forms between the surgeon and the patient, especially in surgical oncology—one

that can span months to years. To many surgeons, this relationship justifies the expectation that a patient’s surgeon continues to be responsible for any surgical issues that arise.

Although structured shifts exist across resident training programs, and different variations of night and weekend coverage are increasingly common out-side the realm of the acute care surgery model, there is evidence that many residents and attendings alike often modify or work outside of the hours of their scheduled shifts.30 Unfortunately, any shift work arrangement opens the door for adoption of a shift work mentality, especially as the culture of previous surgical genera-tions begins to fade. If a shift work mentality becomes more widely adopted with these changes, it could lead to decreased quality of patient care, professionalism, and resident education.

Shift work surgery: Sensible balance of responsibilityWhile concerns about shift work mentality have emerged in recent years, that discussion detracts focus from the motivating factor for adoption of shift work surgery. Surgical trainees are at an ethical impasse where they must choose between discontinuity in patient care and personal exhaustion. Neither option is innocuous, so many residents attempt to resolve this dilemma by fabricating their duty hours or find-ing loopholes in documentation.31 Despite surpassing the 80-hour limit, some residents will continue to work even after leaving the hospital or on designated days off by charting and tracking patients via the electronic health record.30 Many modern trainees are so stalwart in their commitment to patient care at the sacrifice of their well-being that they unfalteringly attend work when physically ill.32

Shift work has emerged in part as a result of surgeon concerns about work-life integration, including time for sleep and recovery.33,34 Rest is crucial for humans, particularly those individuals charged with caring for the lives of others. For example, the Federal Avia-tion Administration limits the time for a single pilot

Shift work mentality can be seen as a threat to the professional tenets that define the core values of a surgeon.


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voyage to eight hours.35 Likewise, the Federal Motor Carrier Safety Administration regulates driving time to no more than 11 hours per day and 60 hours per week.36 The American Academy of Sleep Medicine has gone as far as to support drowsy-driving legislation, which states that a person who has been awake for more than 22 of the previous 24 hours is functionally impaired by sleep deprivation.37 Working while exhausted is hazardous, so why are surgeons expected to perform without time to recuperate?

With respect to surgical trainees, sleep defi-cit negatively affects monotonous tasks and can jeopardize safety when residents drive home after shifts.38 Residents have been shown to make more technical errors and take longer to com-plete simulated laparoscopic tasks after a night on call.36 Literature demonstrating the need for rest among attending surgeons has been pub-lished. Rothschild and colleagues demonstrated a 1.7-fold increased rate of complications in post-nighttime cases among attendings who had six or less hours of sleep opportunity compared with attendings whose sleep opportunity exceeded six hours.39 Patient safety is of paramount impor-tance, such that the Sleep Research Society has drafted legislation requiring that surgeons who have been awake for 22 of the previous 24 hours inform their patients of the safety impact of sleep deprivation before performing any operation.37

Shift work may have a negative undertone to many seasoned surgeons, but as Coleman and colleagues have reported, lifestyle is an impor-tant factor in the modern-day trainee’s choice of specialty.34 Similarly, Santry and colleagues reported that among 18 prominent acute care surgery leaders, key reported benefits of this spe-cialty were improved job satisfaction, increased operative volume, and a better lifestyle.19 The acute care surgery shift work model offers pager-free periods yet still entails responsibilities on certain nights and weekends. This practice pat-tern facilitates rest and family time, and promotes

REFERENCES1. Nasca TJ, Day SH, Amis ES, Jr. The new recommendations

on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.

2. Devitt KS, Kim MJ, Gotlib Conn L, et al. Understanding the multidimensional effects of resident duty hours restrictions: A thematic analysis of published viewpoints in surgery. Acad Med. 2018;93(2):324-333.

3. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374(8):713-727.

4. Seltzer V, Foster HW Jr., Gordon M. Resident scheduling: Night float programs. Obstet Gynecol. 1991;77(6):940-943.

5. Patel N. Learning lessons: The Libby Zion case revisited. J Am Coll Cardiol. 2014;64(25):2802-2804.

6. Nasca TJ, Day SH, Amis ES, Jr., Force ADHT. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.

7. Roses RE, Foley PJ, Paulson EC, et al. Revisiting the rotating call schedule in less than 80 hours per week. J Surg Educa. 2009;66(6):357-360.

8. Lefrak S, Miller S, Schirmer B, Sanfey H. The night float system: Ensuring educational benefit. Am J Surg. 2005;189(6):639-642.

9. Rentea RM, Forrester JA, Kugler NW, Dua A, Webb TP. Twelve tips for improving the general surgery resident night float experience. WMJ. 2015;114(3):110-115.

10. Mann SM, Borschneck DP, Harrison MM. Implementation of a novel night float call system: Resident satisfaction and quality of life. Can J Surg. 2014;57(1):15-20.

11. Yu HW, Choi JY, Park YS, et al. Implementation of a resident night float system in a surgery department in Korea for 6 months: Electronic medical record-based big data analysis and medical staff survey. Ann Surg Treat Res. 2019;96(5):209-215.

12. Goldstein MJ, Kim E, Widmann WD, Hardy MA. A 360 degrees evaluation of a night-float system for general surgery: A response to mandated work-hours reduction. Curr Surg. 2004;61(5):445-451.

13. Sun NZ, Gan R, Snell L, Dolmans D. Use of a night float system to comply with resident duty hours restrictions: Perceptions of workplace changes and their effects on professionalism. Acad Med. 2016;91(3):401-408.

14. Vaughn DM, Stout CL, McCampbell BL, et al. Three-year results of mandated work hour restrictions: Attending and resident perspectives and effects in a community hospital. Am Surg. 2008;74(6):542-546.

15. Garland AM, Riskin DJ, Brundage SI, et al. A county hospital surgical practice: A model for acute care surgery. Am J Surg. 2007;194(6):758-763.



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continued enthusiasm for the profession.34 This model also facilitates career advancement, allowing unhindered time for research, quality improvement endeavors, and teaching.

Acute care surgeons are not the only health care professionals benefitting from the shift work approach. Surgical hospitalists, often referred to as surgicalists, have attempted to assuage the lack of surgical coverage that afflicts 75 percent of U.S. emergency departments.40,41 Maa and colleagues studied the impact of a surgical hos-pitalist service at the University of California San Francisco Medical Center, which employed three full-time board-certified general surgeons who staffed the service on a rotating weekly basis.40 The surgeons had a minimal number of elective procedures or clinic hours during their service week and were responsible for round-ing daily, supervising residents, and seeing all emergency department and inpatient consults. By having more time as a result of not being con-tinuously met with elective cases, administrative duties, and clinic patients, these surgeons could appropriately bill for services rendered during a patient’s hospitalization. By maximizing docu-mentation and coding, the hospital’s revenue generation from surgical services increased 415 percent. Furthermore, from the time an emergency room physician placed a consult, the patient was seen by a surgicalist within 20 minutes rather than several hours, which was common prior to shift work implementation.40

Similar shift work delivery systems have led to greater satisfaction among referring physicians and hospitals,19,34 increased resident supervision,40 and decreased hospital costs and lengths of stay.42 Many training programs see the benefit of shift work and have implemented night float systems, and as Kohlbrenner and col-leagues have demonstrated, this approach leads to better compliance with duty-hour restrictions, improved resident education, and higher quality of life.43 Shift work surgery will always have its

16. Cubas RF, Gomez NR, Rodriguez S, Wanis M, Sivanandam A, Garberoglio CA. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: Impact on timing and cost. J Am Coll Surg. 2012;215(5):715-721.

17. Lau B, Difronzo LA. An acute care surgery model improves timeliness of care and reduces hospital stay for patients with acute cholecystitis. Am Surg. 2011;77(10):1318-1321.

18. Earley AS, Pryor JP, Kim PK, et al. An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg. 2006;244(4):498-504.

19. Santry HP, Pringle PL, Collins CE, Kiefe CI. A qualitative analysis of acute care surgery in the United States: It’s more than just “a competent surgeon with a sharp knife and a willing attitude.” Surgery. 2014;155(5):809-825.

20. Coleman JJ, Robinson CK, Zarzaur BL, Timsina L, Rozycki GS, Feliciano DV. To sleep, perchance to dream: Acute and chronic sleep deprivation in acute care surgeons. J Am Coll Surg. April 6, 2019. Available at: www.journalacs.org/article/S1072-7515(19)30240-6/pdf. Accessed July 1, 2019.

21. Ball CG, Hameed SM, Brenneman FD. Acute care surgery: A new strategy for the general surgery patients left behind. Can J Surg. 2010;53(2):84-85.

22. Van Eaton EG, Horvath KD, Pellegrini CA. Professionalism and the shift mentality: How to reconcile patient ownership with limited work hours. Arch Surg. 2005;140(3):230-235.

23. Wallack MK, Chao L. Resident work hours: The evolution of a revolution. Arch Surg. 2001;136(12):1426-1431.

24. Tsai TC, Orav EJ, Jha AK. Care fragmentation in the postdischarge period: Surgical readmissions, distance of travel, and postoperative mortality. JAMA Surg. 2015;150(1):59-64.

25. Main DS, Cavender TA, Nowels CT, Henderson WG, Fink AS, Khuri SF. Relationship of processes and structures of care in general surgery to postoperative outcomes: A qualitative analysis. J Am Coll Surg. 2007;204(6):1147-1156.

26. Saadat LV, Dahlke AR, Rajaram R, et al. Program director perceptions of surgical resident training and patient care under flexible duty hour requirements. J Am Coll Surg. 2016;222(6):1098-1105.

27. Date DF, Sanfey H, Mellinger J, Dunnington G. Handoffs in general surgery residency, an observation of intern and senior residents. Am J Surg. 2013;206(5):693-697.

28. Teman NR, Gauger PG, Mullan PB, Tarpley JL, Minter RM. Entrustment of general surgery residents in the operating room: Factors contributing to provision of resident autonomy. J Am Coll Surg. 2014;219(4):778-787.

The shift work model provides an alternative pathway whereby surgeons are relieved by colleagues to allow a revitalized workforce.




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critics, but as sleep medicine physician Michael Farquhar, MD, stated, “There is no shame in being ordinary, in acknowledging we have the same human needs as our patients for comfort, for rest, and for sleep. Without them, we cannot function. The shame is in allowing systems to depend on us routinely being extraordinary because ultimately, we—and they—will fail.”44

ConclusionIn the era following work-hour restrictions, shift work surgery has become increasingly adopted within the acute care surgery model and other surgical specialties. The resulting debate centers on patient outcomes, resident physician well-ness and education, and the surgical culture at large. Commitment, accountability, and con-sistent quality remain cornerstones of optimal patient care; however, the ability of any human being to deliver on these qualities at all hours has raised concerns regarding dilution of these traits due to physician fatigue and decreased quality of personal life. The shift work model provides an alternative pathway whereby surgeons are relieved by colleagues to allow a revitalized workforce. At the same time, increased transi-tions between health care professionals prompt concern about decreased continuity of care predisposing to increased medical errors and decreased perception of ownership.

The RAS Symposium at the ACS Clinical Congress will explore the topic of shift work surgery with a debate on whether this model represents a loss of continuity in patient care or offers a sensible balance of responsibility. Join other residents, Associate Fellows, and leaders in the field at the symposium to discuss the optimal approach to providing continuous, uncompro-mised patient care and resident education. ♦

29. Coverdill JE, Alseidi A, Borgstrom DC, et al. Professionalism in the twilight zone: A multicenter, mixed-methods study of shift transition dynamics in surgical residencies. Acad Med. 2016;91(11):S31-S36.

30. Cox ML, Farjat AE, Risoli TJ, et al. Documenting or operating: Where is time spent in general surgery residency? J Surg Edu. 2018;75(6):e97-e106.

31. Fargen KM, Drolet BC, Philibert I. Unprofessional behaviors among tomorrow’s physicians: Review of the literature with a focus on risk factors, temporal trends, and future directions. Acad Med. 2016;91(6):858-864.

32. Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours: Time for a shift change? JAMA. 2012;308(21):2195-2196.

33. Businger AP, Kaderli RM. Different views about work-hour limitations in medicine: A qualitative content analysis of surgeons’, lawyers’, and pilots’ positive and negative arguments. PloS One. November 24, 2014. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0113578. Accessed July 1, 2019.

34. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Acute care surgery: Now that we have built it, will they come? J Trauma Acute Care Surg. 2013;74(2):463-468.

35. Ballard SB. The U.S. commercial air tour industry: A review of aviation safety concerns. Aviat Space Environ Med. 2014;85(2):160-166.

36. Mohtashami F, Thiele A, Karreman E, Thiel J. Comparing technical dexterity of sleep-deprived versus intoxicated surgeons. JSLS. 2014;18(4):e2014.00142.

37. Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med. 2010;363(27):2577-2579.

38. Zinner MJ, Fresichlag JA. Surgeons, sleep, and patient safety. JAMA. 2013;310(17):1807-1808.

39. Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565-1572.

40. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: A new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.

41. Owens LJ. A new model for acute-care surgery. Physician Leadersh J. 2017;4(3):28-30.

42. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

43. Kohlbrenner A, Dirks R, Davis J, Wolfe M, Maser C. Of duty hour violations and shift work: Changing the educational paradigm. Am J Surg. 2016;211(6):1164-1168.

44. Stain SC, Farquhar M. Should doctors work 24 hour shifts? BMJ. 2017;358:j3522.



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by Sarah J. Armenia

FROM RESIDENCY TO RETIREMENT


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Editor’s note: Each year, the American College of Surgeons (ACS) Division of Education offers students from all four years of medical school the opportunity to participate in a special three-day Medical Student Program at the ACS Clinical Congress. Programming varies from day to day, and students may attend all or selected portions of this three-day program. The program is provided at no charge to ACS Medical Student members who register in advance, and is augmented with financial support from the ACS Foundation. In the following column, a fourth-year medical school student describes her experience as a regular participant in the Medical Student Program and the impact it has had on her career trajectory.

It can be very intimidating to arrive at Clinical Congress as a medical student. The

conference center is packed with people who have made it—people who have worked hard and are now thriving in the profession we so desperately want to join. As you walk through the convention center, you pick up on bits and pieces of conversations around you—discussions of challenging cases and lighthearted jokes about hospital protocols. It would truly

be a challenging environment to face if the ACS did not support a program specifically for medical students. Not only does the Medical Student Program provide a haven for students interested in surgery who may not have otherwise attended the conference, but it provides an exceptionally curated experience to cultivate that interest.

Surgeon faculty put you at easeI began attending the Medical Student Program as a first-year medical student in 2015, and I have attended every year since. I was admittedly a bit apprehensive as I walked into the first session because medical students interested in surgery can certainly be intense, and I did not know any other attendees. However, as the session began and the faculty from the ACS Committee on Medical Student Education (CMSE) began introducing themselves, I instantly felt at ease. Amid the daunting formality of some aspects of Clinical Congress, the faculty injected refreshing levity and approachability into these initial introductions and subsequent sessions. It was apparent that

the faculty members were very experienced in working with medical students and had a keen understanding of our needs and concerns.

As someone who began attending the Medical Student Program early in medical school, the elephant in the room for me had persistently been: What if I don’t make it? What if I came to this amazing program every year and don’t even make it into surgery? However, every year at the program, panelists and speakers have shown a sense of vulnerability in discussing their personal failures, never once pretending to uphold the impossible image of perfection we often assign to the profession.

The first year I attended the program, I was particularly struck by a session that Diana L. Farmer, MD, FACS, FRCSC—an internationally renowned fetal and neonatal surgeon; chair, department of surgery, University of California Davis Health; and immediate Past-Chair, ACS Board of Governors—gave early on the first day. As she came to the podium, I anticipated a cautionary speech about how competitive and rigorous the

Medical Student Program at Clinical Congress has lasting impact

A LOOK AT THE JOINT COMMISSION

PUTTING TOGETHER THE PROGRAM

In 2018, the Medical Student Program attracted more than 475 medical students and more than 200 surgeon volunteers over the course of the three days, not including the 13 members of the CMSE, who met monthly with Division of Education staff to plan and present the program.

Members of the Committee on Medical School Education

Susan Steinemann, MD, FACS, Chair

Stephen C. Yang, MD, FACS, Vice-Chair

Adnan A. Alseidi, MD, EdM, FACS

Sarah J. Armenia, medical student member

Celeste M. Hollands, MD, FACS

Joseph A. Iocono, MD, MBA, FACS

Brenessa M. Lindeman, MD, MEHP

Jeremy M. Lipman, MD, FACS

Sarkis H. Meterissian, MD, FACS

Barbara J. Pettitt, MD, FACS

Jacob A. Quick, MD, FACS

Paul J. Schenarts, MD, FACS

Rebecca L. Williams, MD, PhD

ACS Division of Education staff responsible for developing the Medical Student Program

Ajit K. Sachdeva, MD, FACS, FRCSC, FSACME, Division Director

Patrice Gabler Blair, MPH, Associate Division Director

Kim Echert, Senior Manager

Katrina McKenzie, Administrator


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upcoming process would be, but I was immediately engaged in the focus of her discussion. She cast aside the image we perpetuate of the person who knows exactly who she wants to be from a young age and who simply executes that vision without obstacles. Instead of leading with a discussion of her renowned work in fetal and neonatal surgery, Dr. Farmer spoke humbly about how she began following her interests in marine biology without any thought of ultimately winding up in medicine. She spoke candidly about her experience navigating residency and shared a unique vulnerability with us that was particularly powerful, given our understanding of her groundbreaking career.

Networking opportunitiesThe casual conversations medical students can have with faculty members from all across the country are one of the most beneficial components of the Medical Student Program. For example, one of the program sessions is a presentation of awards to the winners of the Medical Student Poster Session. One year at the awards presentation, Robert Cowles, MD, FACS, associate professor of surgery, Yale School

Not only does the Medical Student Program provide a haven for students interested in surgery who may not have otherwise attended the conference, but it provides an exceptionally curated experience to cultivate that interest.

My greatest takeaway from the program overall is that surgeons are simply people who have their frailties just like the rest of us.

SUPPORTING THE MEDICAL STUDENT PROGRAM

Help a student like Sarah participate in the Medical Student Program at Clinical Congress by donating to the ACS Foundation—the philanthropic arm of the College.

Your tax-deductible gift of $250 will ensure the participation of one medical student in this career-enhancing program, which helps aspiring surgeons build their knowledge of surgical career options and enhances their engagement with the College.

To support this program, donate online to the ACS Foundation at facs.org/donate, text MEDSTUDENT to 41444, or call 312-202-5338.

of Medicine, New Haven, CT, was sitting next to me. Dr. Cowles is a pediatric surgeon and he was there to support a medical student from his lab. We struck up a conversation about the Medical Student Program while we waited for the program to begin, as he was curious about the program’s structure. This seamlessly led into a more in-depth discussion of my goals for medical school, and we touched upon his lab’s specific research interests.

After returning home from the conference, I e-mailed Dr. Cowles, referencing our conversation at the Medical Student Program, and expressed interest in working in his lab, despite being at a different institution. From this single conversation at the program, I ultimately spent a summer, and subsequently a full year, working in his lab, and Dr. Cowles remains one of my most inf luential mentors to this day. The Medical Student Program truly offers an opportunity to network with faculty members in a way unlike any other setting.

My greatest takeaway from the program overall is that surgeons are simply people who have their frailties just like the rest of us. These senior surgeons are open to sharing their

stories, triumphs, and failures candidly and offer realistic advice about how to navigate similar situations. There are no outdated PowerPoints, and no antiquated advice is given during these exchanges. The panelists speak from their personal experience and openly encourage questions. They work with students in a hands-on manner—particularly during surgical skills sessions and mock interviews—and truly want you to succeed in this process. The faculty member who worked with me at my first suturing session at the program is now someone who I will see in the hospital this summer at an away rotation.

In the end, my best advice to my fellow medical students is to set aside your apprehension and push yourself to attend Clinical Congress, because the Medical Student Program will instill in you a renewed sense of inspiration as you continue along the journey to becoming a surgeon.

For more information For more information about the Clinical Congress 2019 Medical Student Program, see the sidebars on page 53 and this page, or visit facs.org/clincon2019/events/special/medical-student. ♦


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Although the incidence of gastric cancer in the U.S. is slowly declining, it still

is a deadly diagnosis for many patients. In 2018, an estimated 26,240 people in the U.S. were diagnosed with gastric cancer, and 10,800 died of the disease. The five-year overall survival (OS) is 68.1 percent for patients with localized disease but is much lower for patients with regional lymph node (LN) involvement (30.6 percent) or distant disease (5.2 percent).1

Two classic randomized control trials in gastric cancer, the Intergroup (INT-0116) trial and the Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial, have formed the basis of multimodality therapy for gastric cancer for nearly two decades. INT-0116, published in 2001, demonstrated an improvement in OS among patients with resected stage IB-IV(M0) gastric cancer treated with adjuvant f luorouracil (5-FU)-based chemoradiation versus surgery alone (36 versus 27 months).2 Five years later, the British MAGIC

trial found an improved five-year OS in stage II–IV(M0) in patients randomized to receive perioperative chemotherapy with three cycles of epirubicin, cisplatin, and 5-FU (ECF) preoperatively and three cycles postoperatively, compared with patients treated with surgery and observation (36.3 percent versus 23 percent).3

However, both of these studies had major limitations, which has led to controversy regarding the optimal management of resectable gastric adenocarcinoma. In contrast to current operative practice, most of the patients in INT-0116 (54 percent) underwent a D0 dissection, which is a less than complete resection of N1 nodes, and only 10 percent of the study cohort underwent a D2 LN dissection (that is, lymphadenectomy of the perigastric, celiac, splenic, hepatic artery, and cardiac LNs). Many critics have suggested that the survival benefit of chemoradiation was only observed due to inadequate surgical therapy. In contrast, a major criticism of

the MAGIC trial was the poor compliance with chemotherapy. A high proportion of patients (58.4 percent) assigned to the perioperative chemotherapy arm were unable to complete all six cycles because of progression of disease or cancer-related death (15.6 percent), postoperative complications (4 percent), or treatment toxicity (6 percent), leading to concerns about the generalizability of this treatment regimen to clinical practice.

Recent evidenceDespite the benefit of both adjuvant chemoradiation and perioperative chemotherapy based on the best available evidence, the optimal treatment for gastric cancer has remained controversial in the absence of a direct comparative trial. The recently published CRITICS (Chemotherapy Versus Chemoradiotherapy After Surgery and Preoperative Chemotherapy for Resectable Gastric Cancer) trial from the Netherlands (2007–2015) sought to address this issue


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ACS CLINICAL RESEARCH PROGRAM

by Rebecca A. Snyder, MD, MPH; Naruhiko Ikoma, MD, MS; Judy C. Boughey, MD, FACS; and Christina L. Roland, MD, MS, FACS

Gastric cancer:Recent updates in surgical and multimodality therapy

by randomizing nearly 800 patients with resectable gastric cancer to either perioperative (pre- and postoperative) chemotherapy (epirubicin, cisplatin or oxaliplatin, and capecitabine) or perioperative chemotherapy combined with postoperative chemoradiation (45 Gray [Gy] in 25 fractions with capecitabine and cisplatin).4 Median survival was 43 months in the chemotherapy arm and 37 months in the chemotherapy plus postoperative chemoradiation arm (p = 0.90), failing to demonstrate an added survival benefit of postoperative chemoradiation following perioperative chemotherapy and resection. Notably, only 59 percent of patients in the perioperative chemotherapy-only arm and 62 percent of patients in the chemotherapy plus chemoradiation arm initiated the protocol-specified adjuvant therapy after gastrectomy. The persistently observed poor compliance with postoperative therapy has encouraged the development of studies that focus on the optimization of preoperative treatment strategies.

Perhaps one of the most notable studies in gastric cancer is the recently presented Perioperative Chemotherapy with Docetaxel, Oxaliplatin, and Fluorouracil/Leucovorin

(FLOT) Versus Epirubicin, Cisplatin, and Fluorouracil or Capecitabine (ECF/ECX) for Resectable Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma (FLOT4-AIO) trial, which was a multicenter, randomized phase III trial from Germany.5 Given the high toxicity of the MAGIC regimen (ECF), this study compared an alternative perioperative chemotherapy regimen, involving 716 patients with at least a T2 tumor and/or clinically node positive disease. Only 37 percent of patients in the ECF/ECX study arm completed therapy, versus 50 percent in the FLOT arm. In addition to the reduced toxicity, FLOT improved both progression-free and OS, with a median survival of 50 months in the FLOT arm compared with 35 months in the ECF/ECX arm. Based on these findings, docetaxel, oxaliplatin, and FLOT has become the preferred perioperative (pre- and postoperative) chemotherapy regimen at most high-volume centers in the U.S.

Updates in surgical approachIn addition to the emerging evidence focused on systemic therapy in gastric cancer, new evidence regarding surgical management of this disease is

emerging. Based on the results of the randomized Dutch D1D2 Trial (Dutch Gastric Cancer Group Trial) showing a survival benefit of D2 LN dissection after 15-year follow-up,6 National Comprehensive Cancer Network guidelines recommend D2 LN dissection for gastric cancer.7 According to Japanese guidelines, the extent of D1 and D2 LN dissection may vary depending on tumor location.8 If distal gastrectomy is performed, neither D1 nor D2 include station #10 (splenic hilar LNs); therefore, splenectomy should not be performed. In the setting of a total gastrectomy, D2 LN dissection, including station #10, is recommended; however, the role of routine splenectomy for proximal gastric cancer remains controversial.

The Japanese Clinical Oncology Group conducted a multicenter randomized control trial investigating the survival impact of prophylactic splenectomy in patients with proximal cT2–4, nonlinitis gastric cancer without greater curvature involvement.9 From 2002 to 2009, the study enrolled 505 patients who underwent total gastrectomy with D2 lymphadenectomy, either with or without splenectomy, at one of 36 specialized institutions, defined as gastric cancer surgical units with perioperative

Despite the benefit of both adjuvant chemoradiation and perioperative chemotherapy based on the best available evidence, the optimal treatment for gastric cancer has remained controversial in the absence of a direct comparative trial.


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TABLE 1. RECENTLY COMPLETED AND ONGOING TRIALS IN RESECTABLE GASTRIC CANCER

Trial/study

Country, year

Study size

Study population Standard arm Study arm(s) Results

Key findings and criticisms

CRITICS4 Netherlands, 2018

788 Stage IB-IVA resectable gastric or gastroesophageal junction (GEJ) cancer

Perioperative chemotherapy with epirubicin, cisplatin or oxaliplatin, and capecitabine

Perioperative chemotherapy + postoperative chemoradiation

Median overall survival (OS) of 43 months in chemotherapy arm versus 37 months in chemotherapy + chemoradiation arm (p = 0.90).

No survival benefit of adding chemoradiation to perioperative chemotherapy.Poor overall compliance with postoperative therapy, suggesting increasing role of preoperative therapy.

FLOT4-AIO5 Germany, 2017

716 ≥ clinical T2 and/or N+ gastric or GEJ cancer

Perioperative chemotherapy with epirubicin, cisplatin, and fluorouracil (5-FU) (ECF)

Perioperative chemotherapy with docetaxel, oxaliplatin, leucovorin, 5-FU (FLOT)

Median OS 35 months (ECF) versus 50 months (FLOT). Similar perioperative complication rates (50% versus 51%).

Perioperative FLOT improved OS compared with traditional ECF regimen.

JCOG 01109 Japan, 2017 505 cT2-4, any N, non-linitis proximal gastric cancer not involving greater curve

Total gastrectomy + D2 lymphadenectomy including splenectomy

Total gastrectomy + D2 lymphadenectomy (spleen preservation)

Postoperative complication rate increased in splenectomy arm (16% versus 30%).No difference in five-year OS (76.4% versus 75.1%).

Prophylactic splenectomy should not be performed in the setting of a total gastrectomy and D2 lymphadenectomy because of an increase in morbidity without improved survival.

TOPGEAR11 International, 2017

120 (interim analysis)

Stage IB-IIIC gastric or GEJ cancer

Perioperative chemotherapy with ECF

Perioperative chemotherapy and preoperative chemoradiation

Proportion of patients proceeding to surgery is similar (90% versus 85%). Completion rates of postoperative chemotherapy (65% and 53%).

On interim analysis, preoperative chemotherapy and chemoradiation showed high-compliance rates with preoperative therapy, but low compliance with postoperative therapy. Results highly anticipated.

CRITICS II12 Netherlands, 2017

Actively enrolling

Stage IB-IIIC gastric cancer

4 cycles docetaxel, oxaliplatin, and capecitabine (DOC)

A) 2 cycles DOC + chemoradiation

B) chemoradiation alone

Primary endpoint: event-free survival.

Secondary endpoints: R0 resection rates, recurrence, OS.

Goal to identify optimal preoperative treatment regimen that can be compared with standard therapy in a future phase III trial.

mortality of less than 2 percent. An R0 resection was achieved in nearly all patients (only four R1 resections). Among patients who underwent splenectomy, the postoperative complication rate doubled (30 percent versus 16 percent; p <0.001) because of an increased incidence of

pancreatic fistula (13 percent versus 2 percent) and abdominal abscess (8 percent versus 4 percent). Postoperative mortality was similar (0.4 percent versus 0.8 percent; p = 0.62). At a median follow-up of 72 months, no difference in five-year OS was detected

(75.1 percent in splenectomy and 76.4 percent in spleen-preserving arm). Based on these data, the authors concluded that prophylactic splenectomy should be avoided in total gastrectomy for proximal gastric cancer that does not invade the greater curvature.


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Ongoing trials in resectable gastric cancerAlthough the use of preoperative chemotherapy has sharply increased over the past 10 years in the U.S.,10 the role of preoperative radiation remains unknown. The ongoing TOPGEAR (A Randomized, Phase III Trial of Perioperative ECF Chemotherapy with or Without Preoperative Chemoradiation for Resectable Gastric Cancer) phase III international trial is investigating the benefit of preoperative chemoradiation in addition to perioperative chemotherapy.11 In this trial, the chemotherapy-only group receives pre- and postoperative ECF (three cycles for each), and the chemoradiation group receives chemoradiation (45Gy in 25 fractions with concurrent 5-FU) in place of the third cycle of ECF. A planned interim safety analysis of 120 patients (planned accrual 752) reported high compliance rates with preoperative therapy (>90 percent) and expected low compliance rates with postoperative therapy (53 percent in chemoradiation group and 65 percent in chemotherapy-only group), as well as an equivalent toxicity profile. The final results from this ongoing trial are highly anticipated.

Similarly, the Dutch CRITICS-II (A Multicenter Randomized Phase II Trial Of Neo-Adjuvant Chemotherapy Followed by Surgery Versus Neo-Adjuvant Chemotherapy and Subsequent Chemoradiotherapy Followed by Surgery Versus Neo-Adjuvant Chemoradiotherapy Followed by Surgery in Resectable Gastric Cancer) phase II trial is investigating the optimal preoperative treatment regimen by comparing preoperative chemotherapy (docetaxel, oxaliplatin, and capecitabine), preoperative chemotherapy followed by preoperative chemoradiation (45Gy with paclitaxel and carboplatin), and preoperative chemoradiation alone. The primary endpoint of this trial is event-free survival, with the intention that these results will inform a follow-up phase III trial comparing the identified optimal regimen with standard therapy.12 See Table 1, page 57, for a summary of the trials.

Conclusions and future directions Treatment of localized gastric cancer remains a significant problem; however, recent advances in the optimization of perioperative chemotherapy and surgical safety have led to

Treatment of localized gastric cancer remains a significant problem; however, recent advances in the optimization of perioperative chemotherapy and surgical safety have led to significant improvements in short- and long-term outcomes, with low perioperative mortality and median survival of 50 months in Western patients.

Based on these findings, docetaxel, oxaliplatin, and FLOT has become the preferred perioperative (pre- and postoperative) chemotherapy regimen at most high-volume centers in the U.S.


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significant improvements in short- and long-term outcomes, with low perioperative mortality and median survival of 50 months in Western patients. Current best practice is for perioperative chemotherapy with docetaxel, oxaliplatin, and FLOT with gastrectomy and D2 lymphadenectomy without splenectomy. Further improvements in perioperative multimodality completion, perhaps with total neoadjuvant approaches, and treatment of patients with microscopic peritoneal involvement are needed, including better defining the role of heated intraperitoneal chemotherapy.

Furthermore, the role of targeted therapy (for example, anti-HER2) and immunotherapy in the multimodality treatment of patients with nonmetastatic gastric cancer remain undefined. Novel clinical trial designs, such as presurgical or window trials, are needed to address these important questions. ♦

REFERENCES1. National Cancert Institute. Surveillance, Epidemiology, and End Results

Program. SEER Cancer Statistics Review, 1975–2015. April 2018. Available at: https://seer.cancer.gov/csr/1975_2015/. Accessed April 29, 2019.

2. Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. New Engl J Med. 2001;345(10):725-730.

3. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. New Engl J Med. 2006;355(1):11-20.

4. Cats A, Jansen EPM, van Grieken NCT, et al. Chemotherapy versus chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): An international, open-label, randomised phase 3 trial. Lancet Oncol. 2018;19(5):616-628.

5. Al-Batran S-E, Homann N, Schmalenberg H, et al. Perioperative chemotherapy with docetaxel, oxaliplatin, and fluorouracil/leucovorin (FLOT) versus epirubicin, cisplatin, and fluorouracil or capecitabine (ECF/ECX) for resectable gastric or gastroesophageal junction (GEJ) adenocarcinoma (FLOT4-AIO): A multicenter, randomized phase 3 trial. J Clin Onc. 2017;35(15_Suppl):4004.

6. Songun I, Putter H, Kranenbarg EM, Sasako M, van de Velde CJ. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol. 2010;11(5):439-449.

7. Ajani JA, D’Amico TA, Almhanna K, et al. Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016;14(10):1286-1312.

8. Japanese Gastric Cancer A. Japanese gastric cancer treatment guidelines 2014 (ver. 4). Gastric Cancer. 2017;20(1):1-19.

9. Sano T, Sasako M, Mizusawa J, et al. Randomized Controlled Trial to Evaluate Splenectomy in Total Gastrectomy for Proximal Gastric Carcinoma. Ann Surg. 2017;265(2):277-283.

10. Ikoma N, Cormier JN, Feig B, et al. Racial disparities in preoperative chemotherapy use in gastric cancer patients in the United States: Analysis of the National Cancer Data Base, 2006–2014. Cancer. 2018;124(5):998-1007.

11. Leong T, Smithers BM, Haustermans K, et al. TOPGEAR: A Randomized, Phase III Trial of Perioperative ECF Chemotherapy with or Without Preoperative Chemoradiation for Resectable Gastric Cancer: Interim Results from an International, Intergroup Trial of the AGITG, TROG, EORTC and CCTG. Ann Surg Oncol. 2017;24(8):2252-2258.

12. Slagter AE, Jansen EPM, van Laarhoven HWM, et al. CRITICS-II: A multicentre randomised phase II trial of neo-adjuvant chemotherapy followed by surgery versus neo-adjuvant chemotherapy and subsequent chemoradiotherapy followed by surgery versus neo-adjuvant chemoradiotherapy followed by surgery in resectable gastric cancer. BMC Cancer. 2018;18(1):877.

Although the use of preoperative chemotherapy has sharply increased over the past 10 years in the U.S., the role of preoperative radiation remains unknown.


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The Joint Commission and the National Quality Forum (NQF) presented

the 2018 John M. Eisenberg Patient Safety and Quality Awards, which recognize the achievement of health care professionals and organizations that have made significant and long-lasting contributions to improve patient safety and quality of care, earlier this spring.

STSThe Society of Thoracic Surgeons (STS), Chicago, IL, received the Eisenberg Award for Innovation in Patient Safety and Quality at the National Level for its extraordinary efforts as a trailblazer and industry leader in sophisticated performance measurement and consumer-friendly public reporting.

The centerpiece of the STS quality program is the STS National Database, which was developed in 1989 and is considered to be one of the premier clinical data registries in health care. Essential features include the following:*

• Subspecialty registries for adult and pediatric cardiac surgery, mechanical circulatory support, and general thoracic surgery

• Clinician-designed, explicitly defined, standardized data elements

• Broad national penetration among providers

• Exceptional data accuracy, verified by an external audit

Using these data, STS developed risk models and NQF-endorsed composite performance measures for all of its subspecialties and major procedures, results of which providers use to guide their improvement initiatives.

Furthermore, in an effort to facilitate consumer choice, STS introduced an outcomes-centric, voluntary public reporting program in 2010 that has achieved high participation rates.

The value of the STS quality program is demonstrated by longitudinal tracking, which documents sustained reductions in adverse outcomes and near-universal adoption of desirable care processes. The STS quality program has introduced numerous interventions that have significantly advanced

*The Society of Thoracic Surgeons. STS National Database. Available at: www.sts.org/registries-research-center/sts-national-database. Accessed June 26, 2019.

The value of the STS quality program is demonstrated by longitudinal tracking, which documents sustained reductions in adverse outcomes and near-universal adoption of desirable care processes.


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2018 Eisenberg Award winners include Society of Thoracic Surgeons

by Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)


quality and safety in cardiothoracic surgery.

Other award recipientsThe two other winners were as follows:

• Brent C. James, MD, MStat, received the Individual Achievement Award for his passion as a global leader in bringing quality improvement science and methods to clinical care for more than three decades.

• BJC HealthCare, St. Louis, MO, received the Innovation in Patient Safety and Quality at the Local Level Award for a system-wide approach to improving patient safety through reductions in preventable harm. In 2008, the 15-hospital health system launched a five-year, system-wide initiative to reduce preventable harm in a variety of

categories, including falls with serious injury, pressure ulcers, adverse drug events, health care-associated infections, and venous thromboembolism. By implementing practical interventions for categories of harm, the health system had sustained success in improving outcomes, with a 75 percent reduction in preventable harm over 10 years.

Created in 2002 by The Joint Commission and the NQF, the annual awards program is named for John M. Eisenberg, MD, MBA. An advocate for health care quality improvement, Dr. Eisenberg was a founding member of NQF’s board of directors and the former Agency for Healthcare Research and Quality administrator (1997–2002). He dedicated his life to ensuring care was based on a strong foundation of research

while considering the patient’s needs and perspectives.

An awards ceremony recognizing the winners took place March 25 at NQF’s 2019 Annual Conference in Washington, DC. For more information about the awards, past winners, and Dr. Eisenberg, visit www.jointcommission.org/topics/eisenberg.aspx.

The winners also will be featured in an upcoming issue of The Joint Commission Journal on Quality and Patient Safety, which can be found at www.jointcommissionjournal.com. ♦

DisclaimerThe thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

2018 Eisenberg Award presentation: David M. Shahian, MD (center), chairman, STS Council on Quality, Research, and Patient Safety, with Shantanu Agrawal, MD, MPhil (left),

NQF president and chief executive officer, and David Baker, MD, MPH, FACP, executive vice-president, Division of Health Care Quality Evaluation, The Joint Commission

(Photo courtesy of The Joint Commission and the NQF)


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According to the legal definition, “under the influence” is a term that

describes a state of intoxication that is criminal when engaging in certain activities; for instance, public intoxication or driving under the influence.* It is unlawful in all 50 states and the District of Columbia to drive a vehicle when one’s blood alcohol concentration (BAC) is greater than 0.08 percent. On the Centers for Disease Control and Prevention motor vehicle safety web page, under the “BAC Effects” tab, is a table that outlines how much alcohol needs to be consumed to reach certain BAC levels, typical effects, and predictable effects on driving.†

Know your limitThe table uses a standard drink size in the U.S. of 14.0 grams (0.6 ounces) of pure alcohol. This equates to a 12-ounce beer (5 percent alcohol content), eight ounces of malt liquor (7 percent

alcohol content), five ounces of wine (12 percent alcohol content), or one-and-one-half ounces (a shot) of 80 proof (40 percent alcohol content) distilled spirits or liquor (for example, gin, vodka, rum, or whiskey).†

If a 160-pound man consumes two alcoholic drinks in one hour, his BAC will reach approximately 0.02 percent. The typical effects are some loss of judgment, relaxation, slight body warmth, and an altered mood. Behind the wheel of a motor vehicle, this individual will experience a decline in visual functions and an inability to perform two tasks at the same time (divided attention). After three drinks in one hour, his BAC approaches 0.05 percent, leading to exaggerated behavior, difficulty focusing his eyes, impaired judgment, lowered alertness, and a release of inhibition. When driving, he will experience reduced coordination, reduced ability to track moving objects, difficulty steering, and a reduced response to emergency driving situations.

At about four alcoholic drinks in an hour, his BAC will reach 0.08 percent, resulting in diminished balance, speech, vision, reaction time, and hearing. It will be harder to detect danger, and his judgment, self-control, reasoning, and memory

will be impaired. Getting behind the wheel at this level can be particularly hazardous because of altered concentration, short-term memory loss, difficulty with speed control, reduced information processing capability (for example, signal detection or visual search), and impaired perception. Adding a fifth drink in an hour results in a BAC of approximately 0.1 percent and a reduced ability to maintain lane position and appropriate braking.

Life-altering consequencesTo examine the occurrence of injuries in patients under the influence of alcohol in the National Trauma Data Bank® (NTDB®) research admission year 2017, medical records were searched using BAC. Specifically searched were records of individuals who had a BAC of 0.08 percent or greater. A total of 90,642 records were found, of which 73,435 records contained a discharge status, including 57,440 patients discharged to home, 8,131 to acute care/rehab, 957 to law enforcement, 4,192 to skilled nursing facilities; 2,715 died (see Figure 1, page 62). Of these patients, 78 percent were men, on average 42.3 years of age, had an average hospital

*U.S. Legal. Under the influence law and legal definition. Available at: https://definitions.uslegal.com/u/under-the-influence/. Accessed June 1, 2019.

†Centers for Disease Control and Prevention. Motor vehicle safety. Impaired driving: Get the facts. Available at: www.cdc.gov/motorvehiclesafety/impaired_driving/impaired-drv_factsheet.html. Accessed June 3, 2019.


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NTDB DATA POINTS

by Richard J. Fantus, MD, FACS

Under the influence: Alcohol-related trauma

length of stay of 5.8 days, an intensive care unit length of stay of 5.4 days, an average injury severity score of 10.5, and were on the ventilator for an average of 5.4 days. The top three mechanisms of injury accounting for almost two-thirds of all cases were motor vehicle related (34.8 percent), fall (28.7 percent), and struck by/against (as a result of contact made between one person and another person[s] or object[s]) (11.3 percent). See Figure 2, this page, for more information on alcohol-related mechanisms of injury.

Almost one in 10 records contained in the 2017 research dataset represented an injury that occurred while the patient was under the influence. Although these activities may not be criminal in nature, alcohol consumption continues to be a significant contributor to the injury burden seen in the U.S.

Throughout the year, we highlight these data through brief reports that are published monthly in the Bulletin. The NTDB Annual Report can be found on the American

College of Surgeons website as a PDF file at facs.org/ntdb. In addition, information is available on our website about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at [email protected]. ♦

Acknowledgment Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.


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NTDB DATA POINTS

FIGURE 1. HOSPITAL DISCHARGE STATUS

FIGURE 2. MECHANISM OF INJURY

The American College of Surgeons (ACS) presented the 2019 Jacobson Innovation Award to Henry Buchwald, MD, PhD, FACS, FRCSEng(Hon), at a June 7 dinner held in his honor in Chicago, IL. ACS President Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon), presented the award to Dr. Buchwald for his pioneering work and innovative research in metabolic and bariatric surgery.

The Jacobson Innovation Award honors living surgeons who have been innovators of a new development or technique in any field of surgery and is made possible through a gift from Julius H. Jacobson II, MD, FACS, and his wife Joan. Dr. Jacobson is a general vascular surgeon known for his trailblazing work in the development of microsurgery.

Dr. Buchwald was honored with this international surgical award for his lifelong dedication

to the field of metabolic and bariatric surgery, formerly considered a fringe field for obese patients and excluded from mainstream academic surgical practice. Dr. Buchwald helped transform bariatric surgery into a legitimate field of study and application, and today, bariatric surgery is performed in almost every academic medical center and community hospital in the U.S.

Notable accomplishmentsWhile he was a laboratory resident early in his career, Dr. Buchwald discovered that the ileum is the primary site for the absorption of cholesterol and bile acids. Resultantly, he developed the Buchwald Procedure: the partial ileal bypass (PIB) operation, which bypasses part of the ileum to lower cholesterol levels. The PIB procedure was one of the first

surgical techniques to treat a metabolic disease and remains the most potent therapy to lower plasma cholesterol levels.

Among Dr. Buchwald’s extensive research accomplishments is a landmark paper in circulation that led to the multi-institutional trial on the surgical management of hyperlipidemias: Program on the Surgical Control of the Hyperlipidemias, which received continuous funding from the National Institutes of Health (NIH) from 1973 to 1997. The trial proved the link between cholesterol and heart disease, demonstrating that lowering cholesterol can reduce heart disease and save lives.

Dr. Buchwald has received seven additional NIH grants to study a totally implantable infusion pump device. He founded a separate bioengineering laboratory to produce the first implantable

Dr. Henry Buchwald receives the 2019 ACS Jacobson Innovation Award

NEWS

Dr. Buchwald (right) with Dr. Maier


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infusion pump, a novel peritoneovenous shunt, one-way f low catheters, and other devices. He later patented the infusion pump for widespread use in insulin delivery, continuous delivery of chemotherapy, and further applications. He holds 20 patents and was inducted into the Minnesota Inventors Hall of Fame in 1988.

The 53rd annual Surgical Forum at the 2002 ACS Clinical Congress was dedicated to Dr. Buchwald as “a true surgeon scientist who, through creativity and perseverance, has made seminal contributions to science and society” and who has mentored more than 65 surgical residents and trainees. He has received numerous awards and honors, including a tribute in

the U.S. Senate Congressional Record in 1991. He has been elected to five presidencies of national and international professional societies.

View a list of all Jacobson Innovation Award Recipients at facs.org/about-acs/governance/acs-committees/honors-committee/jacobson-list. ♦

NEWS

Dr. Buchwald and his wife Emilie in front of the ornamental doors of the Murphy Memorial Auditorium

Dr. and Mrs. Buchwald with Dean Sorensen, MD, FACS (right), and his wife, Sheila Sorensen (left), a nurse and former patient of Dr. Buchwald.

Ms. Sorenson spoke at the event, relating that she was a ticking time bomb for a heart attack when Dr. Buchwald saved her life. The Sorensons flew

from their home in Boise, ID, to Minnesota, where Dr. Buchwald at the time was the only one who would and could perform the procedure.

Dr. Buchwald with Walter Pories, MD, FACS—his long-time colleague and friend, and a former

Second Vice-President of the College


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NEWS

Donald D. Trunkey, MD, FACS, long considered one of the most influential trauma surgeons in the U.S., died May 1 in Post Falls, ID, after a protracted illness. Dr. Trunkey truly was a unique individual, in many ways a “free spirit” but grounded by lofty ideals and laudable principles.

Don was a large person and seemed larger than life. Don believed in leadership through service and he followed this tenet throughout his career and numerous leadership positions. He instilled confidence on first meeting and garnered the respect of his peers for his equanimity, moral code, and unwavering commitment to his ideals and doing what was right for trauma patients. His coy smile and warm, upbeat personality, along with his true love and appreciation for his fellow human, were always present and freely shared with old and new friends around the world. Don was a true

friend and mentor for an entire generation of trauma surgeons.

Early influencesDr. Trunkey was born June 23, 1937, in Oakesdale, WA. Growing up in farm country in eastern Washington State instilled in him the work ethic, persistence, and integrity needed to be the successful leader he eventually became. He graduated from Washington State University, Pullman, and earned his doctor of medicine degree from the University of Washington, Seattle, in 1963. Following medical training, he completed a rotating internship at the University of Oregon under the direction of J. Englebert Dunphy, MD, FACS, who inspired Dr. Trunkey to become a surgeon.

After his internship, Dr. Trunkey joined the U.S. Army and served in Bamberg, Germany, for two years.

Upon his return to the U.S., Dr. Dunphy, who had moved to the University of California San Francisco (UCSF) as the chair of the department of surgery, recruited him to the UCSF resident training program. His residency rotations at the San Francisco General Hospital (SFGH) under the mentorship of F. William Blaisdell, MD, FACS, led to his interest in a career in trauma surgery.

After his residency, he spent a year at Parkland Memorial Hospital, Dallas, TX, involved in trauma research on cellular function in shock with G. Thomas Shires, MD, FACS, who would go on to be elected Chair of the Board of Regents of the American College of Surgeons (ACS) and ACS President; C. James Carrico, MD, FACS, who also went on to chair the Board of Regents and to serve as ACS President-Elect; and Peter C. Canizaro, MD, FACS, a renowned expert in trauma and shock.

In memoriam:

Donald D. Trunkey, MD, FACS, a giant in trauma surgery

by Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon)


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Dr. Trunkey returned to SFGH in 1972 and was tapped to serve as chief of surgery in 1978. After serving in that position for eight years, he accepted the chair of surgery at Oregon Health & Science University, Portland, and was named the Mackenzie Professor and Chair, department of surgery, in 1986, a title he held for 15 years.

Advocate for trauma patientsDr. Trunkey achieved national and international stature as a trauma surgeon as a result of his research, publications, and larger-than-life persona. However, Don had a chronic problem—he refused to accept the unacceptable. He was driven to improve the prevailing standard of care of the injured patient. And, to rectify the

inadequacies and inefficiencies he found in trauma care, he became a change agent despite any existing resistance and potential personal repercussions. On his own strength of character and conviction, he led numerous paradigm shifts and improved the care of thousands of injured patients.

While at SFGH, he published a seminal study in 1979 comparing the disparity in preventable deaths from trauma in Southern California against the organized system of care provided at SFGH. His recognition of the need for consistent high-quality care in standard-driven trauma centers as regional resources for an overall systematic approach to trauma care led to today’s modern trauma centers and systems of care.

During his tenure on the ACS Committee on Trauma (COT), which he chaired from 1982 to 1986, Dr. Trunkey and a group of his contemporaries established the Advanced Trauma Life Support® (ATLS®) course, which has become the world-wide standard for the initial care of the injured patient.

In 1976, Dr. Trunkey led the COT’s efforts to publish Optimal Hospital Resources for the Care of the Seriously Injured, the first document aimed at defining and developing trauma centers and trauma systems. Later, he virtually single-handedly created the Trauma Center Verification process within the COT, a process that has been and continues to be used to confirm trauma center level of function and improve care and outcomes from trauma throughout the U.S.

C. Thomas Thompson, MD, FACS (right), Chair of the ACS COT, transferring the

gavel to his successor, Dr. Trunkey

Dr. Trunkey (left) as a resident with Dr. Dunphy

Dr. Trunkey and Carol Williams, ACS Trauma Department, in 1995 with his

National Safety Council Surgeons’ Award for Distinguished Service to Safety


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Don and a group of international colleagues then created the Definitive Surgery for Trauma Care course, which focuses on operative care training following the initial resuscitation defined by ATLS. This course has been provided to thousands of surgeons around the world and is adaptable to low-resource settings.

Demonstrating a deep commitment to our wounded warriors and military medicine throughout his career, Dr. Trunkey was activated to serve in Desert Storm as Commander of the U.S. Army Hospital in Riyadh, Saudi

Arabia. After his experiences in Operation Desert Storm and Desert Shield, he wrote a commentary in the March 1993 edition of Archives of Surgery, “Lessons Learned,” that called out the weaknesses in the military surgical readiness and urged a major restructuring of training and maintenance of competence in military medicine. His proposals are now encoded in federal legislation as an expectation for our wounded warriors. For these and so many other advances in trauma care, he has become known to many in the surgical

community as the “father of modern trauma care systems.”

An Icon in SurgeryIn appreciation for his outstanding leadership, the College honored him with the ACS Distinguished Service Award in 2005 and in 2018 as an “Icon in Surgery” ( facs.org/icons).

Among other recognitions from the College, Dr. Trunkey presented the ACS Scudder Oration on Trauma in 1989, and in 1995 received the National Safety Council Surgeons’ Award for Distinguished Service to Safety.

NEWS

Colonel Trunkey in 1991 in Riyadh in the first Gulf War

In Saudi Arabia in 2008, Dr. Trunkey accepting the King Faisal International Prize for Medicine. He was co-laureate with Basil A. Pruitt, Jr., MD, FACS.

Dr. Trunkey receiving the ACS Distinguished Service Award in 2005 from Kathryn D. Anderson, MD, FACS, then-ACS President


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NEWS

He was recognized for his lifelong career of advancing the care of the injured by his election to the presidency of the American Surgical Association, the Society of University Surgeons, and the American Association for the Surgery of Trauma, as well as a director of the American Board of Surgery.

Don was a great friend to me and to numerous other colleagues, a trusted confidant, and a lifelong mentor. He was always available, always willing to provide insight and advice, and to support my career and that of so many other beneficiaries of his willing

guidance. A great personal honor was being given the Jane and Donald D. Trunkey Chair in Trauma at the University of Washington as chief of surgery at Harborview Medical Center, Seattle. An honor and a challenge for me is to always work and strive to make Harborview the highest quality trauma center possible, one worthy of his gift and his ideals.

At home, Don was recognizable as the one with a parrot habitually on his shoulder. But above all, Don’s highest priority was family. He was a dedicated father and husband for nearly 61 years

to his lifelong love, Jane. Jane was the omnipresent support and sanity throughout Don’s far-f lung career. Our love and prayers reach out to Jane in this time of great loss—one shared by the thousands he touched in so many ways. His tireless devotion to his high ideals and drive for the improvement in care of the injured will live on in the multitude of survivors of severe injury who have benefited from his impact on their care. ♦

Dr. Trunkey and his wife, Jane, in 2006

Dr. Trunkey with Erwin Thal, MD, FACS, in a 2012 version of photos they posed for annually at the COT Dinner

Dr. Trunkey in OHSU operating room, 1986. (Courtesy of OHSU Historical Collections and Archives.)


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Operation Giving Back (OGB) is a program of the Division of Member Services at the American College of Surgeons (ACS). OGB’s mission is to “leverage the passion, skills, and humanitarian ethos of the surgical community to effectively meet the needs of the medically underserved.” Through a variety of activities, OGB provides opportunities for ACS members of all specialties to engage in humanitarian outreach internationally and domestically. This article highlights some of these initiatives and provides information on how to become involved.

OGB Volunteer DatabaseThe OGB Volunteer Database provides a platform for individuals and organizations to partner with the OGB to engage in international humanitarian work. Volunteers have access to a database of opportunities from partner organizations, including nongovernmental organizations (NGOs), academic institutions, and hospitals around the world.

The database contains dozens of active volunteer opportunities to explore, including an ongoing project in Iraq, a resident volunteer position in Tanzania this

September, and a surgical mission trip to Honduras in May 2020. Opportunities exist across levels of training and specialties. To view listings or to register, go to facs.org/ogb/portal.

ACS-COSECSA collaborationsThe ACS has partnered with the College of Surgeons of East, Central and Southern Africa (COSECSA) on a number of projects. Examples are as follows.

ACS-COSECSA Surgical Training Collaborative In January 2019, the ACS-COSECSA Surgical Training Collaborative launched its inaugural hub in Hawassa, Ethiopia. A total of 13 participating U.S. academic institutions are deploying faculty to Hawassa on a monthly basis to provide training and support to local surgical residents and faculty. The goal of the consortium is to strengthen the surgical care system in Hawassa through research, quality, education, and service activities, and ultimately to establish a regional surgical training hub. If your institution is interested in being considered as a partner for a future hub, contact Sadie Bazur-Leidy at [email protected].

Annual COSECSA Examinations Each year, COSECSA recruits surgeon volunteers to administer annual examinations to graduates at the organization’s December meeting. If you are interested in this opportunity, contact Ms. Bazur-Leidy at [email protected]. Preferred specialties include general surgery, orthopaedic surgery, urology, pediatric surgery, otolaryngology, plastic surgery, and neurosurgery.

ACS-Puerto Rico ProjectIn the aftermath of Hurricane Maria on the island of Puerto Rico, the ACS sent a delegation of surgeons to determine how best to address the surgical needs of the population. After significant planning, partnership building, and local input, our first volunteer surgeon arrived in San Juan, PR, this spring. In collaboration with the Puerto Rico Department of Health, Hurricane MARIA, Inc., the United Clergy Task Force, and other local partners, this project is facilitating a consistent mobilization of volunteer surgeons to address a significant backlog of surgical cases. The patient population is specified as those who are uninsured or underserved, focusing on immigrants primarily from the


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NEWS

Your ACS Benefits: Operation Giving Back provides array of volunteer opportunities

by Sadie Bazur-Leidy, MPH

Dominican Republic. If you are interested in contributing to this effort by spending a week or more on the island, contact Ms. Bazur-Leidy at [email protected].

Health Career CollaborativeAlthough African and Hispanic Americans are among the fastest growing segments of the population, they are underrepresented in the health care workforce at all occupation levels. The Health Career Collaborative (HCC) is a three-year pathway program for high school students from low-income and ethnic and racial minority communities. Program goals include increasing academic achievement, health literacy, and interest in health care careers for at-risk high school students. Medical students and faculty serve as volunteer program mentors and instructors. The program is initiated as a partnership between a medical school and a local, underserved high school. The HCC provides validated, web-accessible, easily reproducible curricula intended to minimize preparation time required by volunteers and increase potential for participation.

The HCC operates in 13 cities with involvement from ACS Fellows, with expansion

sites regularly identified. For additional information or to become involved, go to https://healthcareercollaborative.com, or contact Liana Gefter, MD, Program Director, at [email protected].

Clinical Congress 2019Each year at Clinical Congress, OGB provides a variety of Didactic Courses, Panel Sessions, and meetings to discuss the global engagement initiatives of the ACS and to prepare residents and surgeons for careers in global surgery. A selection of offerings this October includes the following:

• Global Health Competencies for Surgeons: Cognitive and System Skills (Didactic Course) 8:30 am–4:00 pm Saturday, October 26 CME Credits: 6

• PS112 Global Engagement (Panel Session) 11:30 am–1:00 pm Monday, October 28

• Resident and Associate Society Global Surgery Working Group (meeting) 2:00−3:00 pm Monday, October 28 RSVP at www.surveymonkey.com/r/TLMK839

Register for Clinical Congress 2019 and learn more about what will be offered at facs.org/clincon2019.

Committee on Global EngagementThe Committee on Global Engagement through OGB provides support for the development and implementation of initiatives through the following subcommittees: Domestic Engagement, International Engagement, Advocacy, and Education. The committee is accepting applications for informal subcommittee positions. To apply, send a curriculum vitae and an outline of your global health experience to Ms. Bazur-Leidy at [email protected].

For more information on OGB and how to become involved with volunteer efforts, contact Ms. Bazur-Leidy at [email protected] or go to facs.org/ogb. ♦


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NEWS

Pre-Congress Bulletin

CLINICAL CONGRESS 2019

W EBCASTSAMERICAN COLLEGE OF SURGEONS | DIVISION OF EDUCATION

Don’t miss out on the sessions you want to attend—even if they’re scheduled at the same time. Webcast sessions are available on any device anytime, anywhere. Maximize your learning opportunities and earn CME Credit, Self-Assessment Credit, and help meet your state content requirements when it’s convenient for you. Choose one of the two webcast packages below:

*Practicing Surgeons are eligible for CME Credit and Self-Assessment Credit.

2019 Complete Package | Pre-Registration PricingAccess all selected webcast sessions from Clinical Congress 2019 and MP3 audio recordings of all Named Lectures and most Panel Sessions.

For Practicing Surgeons* For ResidentsMember Non-Member Member Non-Member

$345 $395 $100 $150

Pick 25 of 2019 | Pre-Registration PricingChoose 25 of the selected webcast sessions from Clinical Congress 2019.

For Practicing Surgeons* For Residents OtherMember Non-Member Member Non-Member Non-Member/Non-Physician

$195 $245 $50 $100 $245

Practicing Surgeons Webcast Packages Webcasts provide AMA PRA Category 1 Credits™, Self-Assessment Credits, and Credits to Address Regulatory Mandates. Receive a CME Certificate documenting credits upon successful completion of viewing the webcast and completing the posttest.

Resident Webcast Packages View webcasts on demand. Individualize your education. Receive a Certificate of Completion.

facs.org/webcasts [email protected] Petinaux 866-475-4696

AMERICAN COLLEGE OF SURGEONSDIVISION OF EDUCATIONBlended Surgical Education and Training for Life®

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Coming next month in JACS and online now

Patient satisfaction and pain control using an opioid-sparing postoperative pathway

Alexander Hallway; Joceline Vu, MD; Jay Lee, MD; and colleagues report in the Journal of the American College of Surgeons (JACS) their findings that patients reported minimal or no opioid use after implementation of an opioid-sparing pathway while still reporting high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids following discharge after minor surgery.

This article and all other JACS content is available at journalacs.org. ♦

The Brandeis Executive master of business administration (EMBA) for Physicians program is offering a 15 percent tuition scholarship for all American College of Surgeons (ACS) Fellows who apply to start the program in January 2020. For the last 15 years, Brandeis University, Waltham, MA, and the ACS have partnered to offer the one-week Leadership Program for Health Policy and Management. The EMBA for Physicians program was developed at the request of the physicians in that shorter program. An accredited 16-month hybrid program, the EMBA provides further opportunity for physicians to build their leadership and managerial toolbox with the goals of improving patient care experiences, clinical outcomes, and decision-making efficiency.

The application deadline for the 2020 EMBA Program is October 1, 2019.For more information, go to https://heller.brandeis.edu/physicians-emba/ or contact Calla Mattox at

[email protected] or 781-736-3999. ♦

Brandeis EMBA for Physicians offers scholarship for ACS Fellows

Get involved with JACSThe Journal of the American College of Surgeons ( JACS) offers multiple outlets for participation for members of the Resident and Associate Society of the American College of Surgeons (RAS-ACS). For example, the RAS-ACS hosts a quarterly discussion of an article in JACS on Twitter, and the conversation continues on Facebook. Previous discussions can be found at journalacs.org/discussions. Be sure to like JACS on Twitter and Facebook (@JAmCollSurg) to stay updated on all JACS content.

In addition, the RAS-ACS and JACS have partnered to create a mentored review program in which mentees have an opportunity to review manuscripts for JACS and receive feedback from senior reviewers. Contact [email protected] if you are interested in being a mentee or mentor. Be sure to include your institution as well as your top three areas of interest (for example, bariatric, colon/rectal, trauma surgery, and so on).

More JACS content is available at journalacs.org. ♦


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RAS-ACS announces inaugural Outstanding Mentor of the Year AwardHas someone inspired you to become involved in the American College of Surgeons (ACS) and been a surgical mentor to you? If so, and you are a Resident Member or Associate Fellow of the ACS, nominate him or her for the inaugural Resident and Associate Society (RAS-ACS) Outstanding Mentor of the Year Award. Nominations are due by August 12, 2019.

The RAS-ACS Outstanding Mentor of the Year Award was created to honor an exceptional ACS Fellow who has had a marked impact on the engagement of a Resident Member or Associate Fellow and has offered the support and encouragement necessary to build the strong foundation for a surgical career. Mentors from any surgical specialty are eligible for the award and encouraged to be nominated.

Nominees should be Fellows of the College, and nominators should be Resident Members or Associate Fellows. Each nominee may be nominated by more than one RAS member.

Nominations should be accompanied by the following materials:

• A nomination letter, not to exceed two pages single-spaced, supporting the nominee’s efforts to engage young surgeons in the ACS and the impact this experience had on the nominator. Examples of mentorship include intellectual, social, and moral support, as well as career development/advancement.

• Name, position, institution, and contact information of the nominee.

• Name, position, institution, and contact information of the nominator(s).

Submit your nominations at www.surveymonkey.com/r/RASMentorAward. For additional details or with questions, contact [email protected]. ♦

NEWS

Surgeon Well-Being

Use the physician well-being index to better understand your overall well-being and identify areas of risk.

Surgeon well-being is vital for you and your patients.

facs.org/wellbeing

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As a surgical resident, you are interested in pursuing educational and professional excellence, both as a surgeon and as a member of the surgical community. Associate Fellowship in the American College of Surgeons (ACS) provides you with access to the tools, resources, and opportunities you need along the way. This membership category is open only to surgeons devoted to practicing surgery according to the College’s professional and ethical standards, as stated in the Fellowship Pledge and the Statements on Principles—both available on the College’s website at facs.org.

Time to apply for Associate FellowshipIf you are moving from training into practice this year, apply for Associate Fellowship. The application requests basic information about your education and training, licensure, board certification, and hospital and academic affiliations—some of which already exists in your Resident Member record and will auto-populate within the application. The ACS will waive the Associate Fellow application fee for current Resident Members as well as

requirements of documentation of training completion.

Once you become an Associate Fellow, your membership at that level will be limited to a period of six years to foster your progression to the Fellowship level. Therefore, Associate Fellows are encouraged to consider applying for full Fellowship once they are eligible.

Application requirementsFor Domestic Fellowship, the requirements are as follows:

• Certification by an appropriate American Board of Medical Specialties Surgical Specialty Board, an American Osteopathic Surgical Specialty Board, or the Royal College of Surgeons in Canada

• One year of surgical practice after the completion of all formal training (including fellowships)

• Current appointment at a primary hospital

For International Fellowship applicants, the requirements are as follows:

• Certification by an appropriate American surgical specialty board

or Canadian or international college of physicians and surgeons, or national surgical board from the applicant’s county of practice

• Three years of surgical practice after the completion of all formal training (including fellowships)

• Current appointment at a primary hospital

Submit an online application for Associate Fellowship at facs.org/associate. You will need your ACS members-only website log-in information to access the application. If you do not have your log-in information, contact the Member Services staff at 800-293-4029 or via e-mail at [email protected] for assistance.

When your application has been processed, an e-mail notification will be sent to provide updated information about your membership status.

We look forward to your transition from Resident Member to Associate Fellow of the ACS. ♦

Residents: Prepare to take your ACS membership to the next level

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facs.org/quality-programs

A LEGACY OF QUALITY IMPROVEMENT

QUALITY PROGRAMSof the AMERICAN COLLEGEOF SURGEONS

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Chapter news

DOMESTIC CHAPTERS


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by Luke Moreau and Brian Frankel

Domestic and international chapters of the American College of Surgeons (ACS) met in the last

several months to host a variety of activities, including annual meetings, skills competitions,

advocacy days, and more. Following are highlights and photos from these programs.

NEWS

Brooklyn-Long Island Chapter (BLIACS): Annual Young Surgeons Dinner, June 4, Garden City, NY. Phillip R. Caropreso, MD, FACS, Second Vice-President of the ACS, delivered the keynote address about the importance of the ACS. Photo: Jeffrey P. Weiss, MD, FACS (left), then-Chapter President, and Dr. Caropreso.

Connecticut Chapter (CTACS): Connecticut Chapter Lobby Day, March 1, Hartford. Legislative issues highlighted included

expanding coverage to bariatric surgery to all insured patients in Connecticut, increasing the state hospital tax, supporting a helmet

law, and opposing a law that prohibits hospitals from charging activation fees.

Photo, from left, front row: Philip Corvo, MD, MA, FACS, Governor at-Large and Past-President;

Shea Gregg, MD, FACS; Kathleen LaVorgna, MD, FACS, Past-President and Co-Chair, Legislative

Committee, and Governor at-Large; and Chris Johnson, State Affairs Associate, ACS

Division of Advocacy and Health Policy.

Back row: Alan Meinke, MD, FACS, Chapter President, and Scott Kurtzman, MD, FACS,

Past Governor at-Large and Past-President.

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Illinois Chapter: First Annual Illinois Surgical Conference, April 26–28, Chicago, hosted by the Illinois Chapter and Chicago Metropolitan Chapter of the ACS, the Illinois Surgical Society, the Chicago Surgical Society, and the Illinois Surgical Quality Improvement Collaborative.

Photo: Founders Competition winners, from left: Lindsey Zhang, MD, University of Chicago, third place; Timothy Daugherty, MD, MS, Southern Illinois University School of Medicine, second place; Ryan A. J. Campagna, MD, Northwestern University̧ first place; and presenter Daniel M. Chase, MD, FACS, Illinois Chapter President.

Louisiana Chapter: Lobby Day, May 22, Baton Rouge. Chapter members spoke with Lieutenant Gov. Billy Nungesser about his support for a bill to

study the expansion of insurance access for bariatric surgery, and met with Speaker of the House Taylor Barras about supporting legislation to require

Stop the Bleed® training and bleeding control kits in public schools. The chapter also partnered with the Louisiana Emergency Response Network

to provide Stop the Bleed demonstrations in the capitol rotunda.

Photo, from left (all MD, FACS): Rebecca Schroll, Chapter Advocacy Chair; Juan Duchesne, Chapter President; Peter Lundberg; Tomas Jacome,

State Committee on Trauma (COT) Chair; and Sharven Taghavi

Massachusetts Chapter (MCACS): Stop the Bleed training, March 26, Boston.

During the event check-in at Boston’s Run to Remember, which pays tribute to fallen law enforcement officers and first responders, the chapter sponsored a Stop the Bleed booth and demonstrations to raise awareness and provide resources to the participants and the general public about bleeding control. Educational outreach was spearheaded by George DeBusk, MD, FACS, Chapter Councilor (pictured), and Kathryn Hughes, MD, FACS, a member of the Chapter’s Advocacy Committee.

Michigan Chapter (MCACS): 66th Annual Michigan Chapter Meeting, May 8–10, Grand Rapids. Meeting highlights included the Top

Gun Surgical Skills Competition; the Resident Jeopardy Competition; the “Mo” Henig

Lecture, An Odyssey in Trauma—1978–2019, by David. V. Feliciano, MD, FACS; and the

Krishna K. & Pamela E. Sawhney Ethics in Surgery Lecture, The Surgeon’s Role in Firearm

Injury Prevention—an Ethical Dilemma, by Nicole A. Stassen, MD, FACS, FCCM.

Photo: The Top Gun Surgical Skills Competition in action


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New York Chapter (NY-ACS) and Brooklyn-Long Island Chapter (BLIACS): Advocacy Day, April 30, Albany. With the support of Albany Medical Center, the chapters hosted a Stop the Bleed training session. As a result of the chapters’ advocacy efforts, the New York State Assembly and the New York State Senate proclaimed May as Stop the Bleed Month in New York. Photo: Assemblyman Colin Schmitt (standing, front), sponsor of the Stop the Bleed proclamation, with members of the chapters.

Oregon Chapter (ORACS): Day at the Capitol, March 4, Salem. Chapter

council members on the steps of the Rotunda between the House and Senate

Chambers at the Oregon Capitol.

Photo, from left: Glen Levine, MD, FACS; Kristen Massimino, MD, FACS;

Sandeep Kumar, MD, FACS; Mark Dodge, EMR, Marion County Medical Reserve

Corps; Harvey Gail, MBA, Chapter Administrator; Christian Johnson,

State Affairs Associate, ACS Division of Advocacy and Health Policy; Robert

Goldman, MD, FACS; James Nealon, MD, PC, FACS; and Monte Stewart, MD, FACS

Utah Chapter: Annual Meeting, May 10, Salt Lake City.

Photo: Winners of the Utah ACS Resident and Trainee Poster Competition included, from left: Liese Pruitt,

MD, general surgery resident, University of Utah, Salt Lake City; Travis Bailey, MS, medical student,

University of Utah School of Medicine; and Mark Taylor, MD, general surgery resident, University of Utah

West Virginia Chapter: Annual Meeting, May 9–11, White Sulphur Springs. The

chapter has been actively promoting medical student

attendance and participation at its annual meeting,

including a medical student simulation session to instruct

students on basic suturing and knot-tying techniques, and exposure to advanced surgical simulation. A total

of 40 medical students from the five medical campuses throughout

the state participated in a three-hour simulation

consisting of central line, laparoscopic robotic, open vascular, and endovascular

simulation stations.

Photo: Megan Davis (left), a vascular resident at West Virginia University, Charleston, mentors Julie Poe, medical student,

Marshall University, Huntington, at the open vascular simulation station sponsored by industry representatives from Getinge.

INTERNATIONAL CHAPTERS


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Australia and New Zealand (ANZ) Chapter: ANZ Chapter Annual Meeting, Royal Australasian College of Surgeons Annual Scientific Congress, May 8, Bangkok, Thailand. Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon), ACS President, updated the chapter on the College’s focus and activities.

Photo, from left: Nick Parrish, MD, ACS Resident International Exchange recipient; Jayme Locke, MD, FACS, ANZ Traveling Fellow; Dr. Maier; and Julian Smith, MB, MS, FACS, Chapter President and Governor

Brazil Chapter: 33rd Brazilian Congress of Surgery of the Brazilian College of Surgeons, May 1–4, Brasília. The Congress focused on the care of the surgical patient and quality in surgery.

Photo (all MD, FACS): David B. Hoyt, ACS Executive Director (middle) between Savino Gasparini, ACS Governor, and Bruno Ottani, Chair, Organizing Committee, 33rd Brazilian Congress of Surgery of the Brazilian College of Surgeons

Chile Chapter: Annual Congress of the Chile Chapter, June 2–5, Viña del Mar.

Photo, from left, standing (all MD, FACS): Augusto León, Director; Carlos Polanco, Chapter Secretary; Francisco Ruiz, Chair, Chile COT; Helmuth Schweizer, Chapter Treasurer; Raúl Berríos, Director; Miguel González, Scientific Coordinator

From left, seated (all MD, FACS): Víctor Bianchi, Second Vice-President; Hugo Núñez, Chapter Past-President; Felipe Catan, Chapter President; Juan Hepp, Governor; and Ricardo Espinoza, Chapter President-Elect

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India Chapter: Basic Surgical Skills Workshop, March 1, New Delhi. The hands-on workshop included basic skills of suturing, knotting, mass closure of abdomen, bowel anastomosis, and vascular and tendon repair

on animal tissues, conducted under the convenorship of Prof. Chintamani, MB, BS, FACS, ACS Governor.

Japan Chapter: Annual Meeting, April 19, Osaka. Dr. Maier attended the event and presented a lecture, Quality Improvement for Trauma: ACS COT Trauma Quality Improvement Program.

Photo: Dr. Maier (front row, second from left) and officers of the Japan Chapter.

United Arab Emirates (UAE) Chapter: The UAE Chapter conducted ACS Fellowship applicant interviews in Abu Dhabi in May.

Photo: Safwan Taha, MD, FACS (left), ACS Governor, and Mohammad Azfar, MB, BS, FACS, Chapter President.

NEWS

AMERICAN COLLEGE OF SURGEONSDIVISION OF EDUCATION

Need to claim CME Credit? JACS makes it easy.

Visit facs.org and click on the link for JACS CME or visit jacscme.facs.org.

Bulletin_7.5x10.25in

A trusted resource since 1905, JACS provides high-quality, peer-reviewed, surgical content our readers rely on.

Claim credit anytime, anywhere, and on any mobile device.

Visit the JACS CME website to read articles, take a brief test, and receive your continuing medical education (CME) certification—all in one place.

Receive 1 AMA PRA Category 1 Credit™ per article

Access 24 months of articles and search for tests on topics that interest you

Print your CME certificate as soon as you pass the test

Connect to MyCME to easily track your CME Credits

Electronically transmit CME Credits to licensing boards

JACS is a free benefit for ACS members.

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Traveling Fellow to Japan reports on experience

I had the distinct honor of serving as the 2019 American College of Surgeons (ACS) Traveling Fellow to Japan. It was a tremendous professional opportunity to share ideas with my Japanese colleagues, which I anticipate will deepen the collaboration between surgeons in our two countries to advance treatment of low-lying rectal cancers and other complex pelvic floor pathology.

Cancer Institute Hospital of the Japanese Foundation for Cancer ResearchIt was cherry blossom season when I arrived in Tokyo, with the city covered in pink petals.

I spent several remarkable days there, observing operations and sharing insights with surgeons and residents from the Cancer Institute Hospital of the Japanese Foundation for Cancer Research (CIH JFCR), the first and largest hospital in Japan to specialize in cancer care. Since it opened in 1934, the hospital has grown from 29 to more than

700 beds and is now the leading center for clinical and biological cancer research in Japan.

My host at CIH JFCR was Tsuyoshi Konishi, MD, PhD, associate professor of surgery at JFCR and a respected international expert in lateral lymph node dissection (LLND) for rectal cancer. LLND is a technique that is widely employed in the Japanese surgical community—and one that is much less familiar to Western colorectal surgeons. Western surgeons generally use chemoradiotherapy to treat cancer patients at high risk for lateral lymph node involvement. Japanese surgeons, in contrast, often approach low-lying rectal cancer by combining total mesorectal excision with LLND. A recent randomized controlled trial reported by Prof. Shin Fujita, MD, PhD, and colleagues highlighted the potential utility of this technique in a study that showed decreased local recurrence in the patients offered LLND, which led to my interest in this surgical technique.*

At CIH, I observed several complex low-lying rectal cancer total mesorectal excisions with LLND, which Dr. Konishi was kind enough to book back-to-

back to match my itinerary. The procedure requires great technical finesse, a strong understanding of the lateral compartment anatomy, and a meticulous and patiently executed laparoscopic approach. I left Tokyo with great respect for the skill of Japanese surgeons, and Dr. Konishi in particular, who kindly shared an anatomical image with me (see top photo, page 85).

I also left with a renewed appreciation for Japanese sushi, which Dr. Konishi and colleagues—Takashi Akiyoshi, MD, PhD; Tomohiro Yamaguchi, MD, PhD; and Hiromichi Ito, MD, FACS—found time to enjoy with me and my son, despite their busy surgical schedules.

Meeting of the Japan Surgical SocietyMy next stop was Osaka, where I attended the 119th Meeting of the Japan Surgical Society (JSS), which provided an amazing opportunity to attend presentations on international surgical advances and to share insights and perspectives with my Japanese hosts.

A personal high point was the opportunity to present from the

*Fujita S, Mizusawa J, Kanemitsu Y, et al. Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): A multicenter, randomized controlled, noninferiority trial. Ann Surg. 2017;266(2):201-207.

by Liliana Bordeianou, MD, MPH, FACS


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podium the lessons learned by our colorectal surgery group at Massachusetts General Hospital, Boston, in the course of the rollout of a new Enhanced Recovery After Surgery (ERAS) pathway for patients. It is a controversial topic, and spirited debate ensued. Some attendees were shocked by the idea of a 24-hour, inhospital recovery following laparoscopic colectomy. The Japanese tend to recover patients in hospitals for much longer periods, in part because they do not have a system of rehabilitation facilities after surgery or visiting nurses. Many perspectives were shared, and the presentation served as

an excellent example of the kind of intellectual cross-fertilization that the Traveling Fellowship is intended to promote. I also took the opportunity to present grand rounds on ERAS during my visits to Tokyo and Kyoto, and the experience was memorable and engaging on each occasion.

In Osaka, I had the opportunity to explore nearby temples, restaurants, and culture on a comprehensive itinerary arranged by the organizers of the meeting. Osaka has been known for centuries as the “kitchen of Japan,” and is known for kuidaore, meaning “ruin oneself by one’s extravagance in food.”

Kyoto University HospitalI concluded my visit with four days in Kyoto, a beautiful city of haunting and majestic temples. While there, I had the privilege of visiting and observing operations at the Gastrointestinal Surgery Department of Kyoto University Hospita. My hosts were Prof. Yoshiharu Sakai, MD, FACS, and assistant professor Shigeo Hisamori, MD, FACS, who went out of their way to introduce me to their colleagues and to arrange for me to observe a series of masterful laparoscopic operations on difficult and complex cases.

Relevant anatomy during lateral lymph node dissection, courtesy of Dr. Konishi

Sushi dinner with Dr. Konishi, Dr. Akiyoshi,

Dr. Yamaguchi, Dr. Ito, and Dr. Bordeianou’s son Ethan


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Particularly impressive was a carefully executed D3 lymph node dissection, which junior associate professor Kenji Kawada, MD, performed on a patient with advanced sigmoid cancer, while associate professor Kazutaka Obama, MD, performed a simultaneous resection on a synchronous gastric cancer in the same patient. Colorectal surgeons in the West have been reembracing the idea of D3 dissection, relabeled as “complete mesocolic excision,” but Japanese surgeons remain world experts at properly performed and anatomically detailed lymph

node harvests in various gastrointestinal node basins.

ConclusionI had many memorable evenings in Japan, including a wonderful dinner of Japanese barbeque in Kyoto with Prof. Kyoichi Takaori, MD, PhD, FACS, president of the International Association of Surgeons, Gastroenterologists and Oncologists, and his remarkable wife Terue; and a delightful farewell dinner, hosted by Dr. Hisamori and his colleagues, Shigeru Tsunoda, MD, PhD; Riki Ganeko, MD; and Keiko Kasahara, MD.

I am deeply honored and grateful to each and every individual I met and am deeply humbled by the hospitality shown to me in this ancient and beautiful, yet very modern, country. I look forward to maintaining these friendships and professional relationships for years to come and to sharing among colleagues in the U.S. the surgical approaches, techniques, and perspectives I encountered on this trip. ♦

Dr. Bordeianou and family exploring the tastes of Dotonbori Street, Osaka

Enjoying sights and experiences in Japan:

gardens, temples, sumo wrestling, and delicious food


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Accreditation from the Commission on Cancer (CoC), National Accreditation Program for Breast Centers (NAPBC), and National Accreditation Program for Rectal Cancer (NAPRC) means your organization has voluntarily undergone an evaluation to ensure that patients have access to the cancer services that are required to prevent, screen, diagnose, treat, rehabilitate, and support cancer patients. CoC and NAPBC standards guide the program structure, while data tools they offer help you monitor, evaluate, and improve the cancer care you deliver.

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Accreditation by the American College of Surgeons Cancer Programs can help your organization gain a competitive advantage

and lead the way to better cancer care for your patients.

Accreditation makes a difference.

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Calendar of events*

*Dates and locations subject to change. For more information on College events, visit facs.org/events or facs.org/member-services/chapters/meetings.

AUGUSTTennessee Chapter

August 8–11Chattanooga, TN

Contact: Wanda McKnight,[email protected], tnacs.org

Georgia Society of the ACSAugust 16–18

St. Simons Island, GAContact: Kathryn Browning,

[email protected],georgiaacs.org

XLV National Congress Advances in Surgery

August 18–21Bogota, Colombia

Contact: Sonia Babativa,[email protected],

ascolcirugia.org

India Chapter August 30–September 1

New Delhi, IndiaContact: Prof. Chintamani,

[email protected],http://acsindianchapter.com

SEPTEMBERTurkey ChapterSeptember 5–6Ankara, Turkey

Contact: Congress Secretariat,[email protected]

UAE ChapterSeptember 12–13

Dubai, UAEContact: Prof. Safwan Taha,[email protected],

acs-uae2019.com

France ChapterSeptember 12–13

Dijon, FranceContact: Dr. Olivier Jean-Yves Joseph Monneuse,

[email protected]

Jordan ChapterSeptember 12–13Amman, Jordan

Contact: Dr. Majdi Al Soudi,[email protected],http://acsjordan.com

Kansas ChapterSeptember 13–14

Lenexa, KSContact: Denise Lantz,[email protected],kansaschapteracs.org

New Mexico ChapterSeptember 13–14Albuquerque, NM

Contact: Nallely Gomez,[email protected]

Arizona ChapterSeptember 21–22

Scottsdale, AZContact: Joni Bowers,

[email protected], azacs.org

Kentucky ChapterSeptember 27Louisville, KY

Contact: Linda Silvestri,[email protected],

kentuckychapter.facs.org

Nevada ChapterSeptember 28Las Vegas, NV

Contact: Camille Spenner,[email protected],

nevadaacs.org

OCTOBERMinnesota Surgical Society

October 4–5Minneapolis, MN

Contact: Janna Pecquet,[email protected],www.mnsurgicalsociety.org

Argentina ChapterOctober 14–17

Buenos Aires, ArgentinaContact: Clara Mojica,[email protected]

FUTURE CLINICAL CONGRESSES

2019October 27–31

San Francisco, CA

2020October 4–8Chicago, IL

2021October 24–28Washington, DC


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MEETINGS CALENDAR

You have the passion. You have the drive. We have the road map.

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