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BACKGROUND AND OBJECTIVES: We evaluated the unmet breast cancer-related lymphedema (BCRL) treatment and education needs at New England's largest safety-net hospital serving a diverse population by assessing prevalence, risk factors, and treatment. METHODS: This was a retrospective cohort study examining breast cancer surgery patients from September 2016 to September 2021. The primary outcome was BCRL diagnosis. Secondary outcomes included BCRL risk factors, and physical and occupational therapy (PT/OT) referral frequency and completion. RESULTS: Of 639 patients, 17% of patients had documented BCRL, which was significantly associated with axillary lymph node dissection (ALND). There were no racial, insurance, breast radiation, or BMI category differences between patients with and without a BCRL diagnosis. Of those with BCRL, 58% received a PT/OT referral, and 56% completed their referral. There were no racial, insurance, or BMI category differences between those who received a PT/OT referral and those who did not. CONCLUSION: In our high-risk population, rates of documented BCRL were higher than expected, approaching rates of ALND, despite the majority undergoing sentinel lymph node biopsy (SLNB). PT/OT referral and completion rates were low, concerning for an unmet BCRL treatment and education need. No disparities in care delivery were seen, but a program that addresses treatment gaps and ensures accessible and patient-centered BCRL care is urgently needed.
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Linfedema del Cáncer de Mama , Neoplasias de la Mama , Proveedores de Redes de Seguridad , Humanos , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/cirugía , Linfedema del Cáncer de Mama/terapia , Linfedema del Cáncer de Mama/diagnóstico , Linfedema del Cáncer de Mama/etiología , Anciano , Escisión del Ganglio Linfático/efectos adversos , Factores de Riesgo , Biopsia del Ganglio Linfático Centinela/efectos adversos , Estudios de Seguimiento , Adulto , Linfedema/etiología , Linfedema/terapia , Linfedema/diagnóstico , Pronóstico , Mastectomía/efectos adversos , Derivación y ConsultaRESUMEN
BACKGROUND: Colorectal cancer screening has been shown effective at reducing stage at presentation, but there is differential uptake of screening based on insurance status. We sought to determine the population-level effect of Medicare and screening guidelines on colorectal screening by race and region. METHODS: Data on Black and white patients with colorectal cancer were obtained from the SEER database. Regression discontinuity was used to assess the causal effect of near-universal health insurance (represented by age 65) and United States Preventive Services Task Force guidelines (age 50) on the proportion of people presenting at advanced stage. This was stratified by race and region. RESULTS: In the Southern United States, Black patients saw a significant decrease in advanced stage at presentation at age 65 (coefficient -0.12, pâ¯=â¯0.003), while white patients did not (coefficient -0.03, pâ¯=â¯0.09). At age 50, neither Black (coefficient 0.09, pâ¯=â¯0.10) nor white patients (coefficient -0.04, pâ¯=â¯0.1) saw a significant decrease in advanced stage. In the Western U.S., neither Black (coefficient 0.02, pâ¯=â¯0.72) or white patients (coefficient -0.02, pâ¯=â¯0.09) saw a significant decrease in advanced stage at age 65; however, both Black (coefficient -0.20, pâ¯=â¯0.008) and white patients (coefficient -0.05, pâ¯=â¯0.03) saw a significant decrease at age 50. CONCLUSIONS: Our data highlight the significant impact that near-universal insurance has on reducing colorectal cancer stage at presentation in areas with poor baseline insurance coverage, particularly for Black patients. To reduce disparities in advanced stage at presentation for colorectal cancer, state-level insurance coverage should be addressed.
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Neoplasias Colorrectales , Medicare , Humanos , Anciano , Estados Unidos/epidemiología , Persona de Mediana Edad , Detección Precoz del Cáncer , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/prevención & control , Población Negra , Disparidades en Atención de Salud , BlancoRESUMEN
BACKGROUND: There is a lack of understanding of the scope and purpose of teaching assistant cases, impact on patients and safety, as well as the facilitators or barriers to resident participation in these cases. METHODS: Four databases (PubMed, Embase, Web of Science, and the Education Resources Information Center), were searched. The references of identified resources were additionally hand-searched. 10 articles were identified and considered in the literature review. RESULTS: The TA case literature focuses on case numbers and safety. The discussions of papers allude to perceived benefits of TA cases. The literature review reveals that residents are more likely to be granted TA opportunities if they show themselves worthy of entrustment. CONCLUSIONS: The work elucidates aspects of TA cases that have not previously been emphasized or highlighted. The literature review can serve to inform attending surgeons and trainees how to optimize the opportunities teaching assistant cases can afford.
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Cirugía General , Internado y Residencia , Competencia Clínica , Educación de Postgrado en Medicina , Cirugía General/educación , Humanos , EnseñanzaRESUMEN
OBJECTIVE: To determine the impact of income mobility on racial disparities in colorectal cancer. BACKGROUND: There are well-documented disparities in colorectal cancer treatment and outcomes between Black and White patients. Socioeconomic status, insurance, and other patient-level factors have been shown important, but little has been done to show the discriminatory factors that lead to these outcomes. METHODS: Data were obtained from the Surveillance Epidemiology and End-Results database for Black and White patients with colorectal cancer between 2005 and 2015. County level measures of Black (BIM) and White income mobility (WIM) were obtained from the Opportunity Atlas as a measure of intergenerational poverty and social mobility. Regression models were created to assess the relative risk of advanced stage at diagnosis (Stage IV), surgery for localized disease (Stage I/II), and cancer-specific mortality. RESULTS: There was no significant association of BIM or WIM on advanced stage at diagnosis in Black or White patients. An increase of $10,000 of BIM was associated with a 9% decrease in hazards of death for both Black (hazard ratio 0.91, 95% confidence interval 0.86,0.95) and White (0.91, 95%CI 0.90,0.93) patients, while the same increase in WIM was associated with no significant difference in hazards among Black patients (hazard ratio 0.99, 95% confidence interval 0.97,1.02). There were no predicted racial differences in hazards of death at high levels of BIM. CONCLUSIONS: Increased Black income mobility significantly improves survival for both Black and White patients. Interventions aimed at increasing economic and social mobility could significantly decrease mortality in both Black and White patients while alleviating disparities in outcomes.
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Negro o Afroamericano , Neoplasias Colorrectales/mortalidad , Renta , Movilidad Social , Población Blanca , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tasa de SupervivenciaRESUMEN
BACKGROUND: The American Association of Endocrine Surgeons Comprehensive Endocrine Surgery Fellowship interview stakeholders previously favored in-person interviews, despite time and expense. This study assessed perception changes given mandated virtual interviews because of coronavirus disease 2019. METHODS: Immediately after the 2020 Match, anonymous surveys were distributed to applicants (n = 37) and program directors (n = 22). Mixed-methods analyses were used to evaluate responses. Results were compared to data from a prior study of the 2013 to 2018 in-person interview process. RESULTS: Response rates were 82% (program directors) and 60% (applicants). Compared with prior applicants, 2020 applicants attended similar numbers of interviews (1-10, 32% vs 37%; P = .61), used fewer vacation days (23% vs 56%; P = .01), and most reported 0 expenses. Burdens included lack of protected time for interviews. The virtual format did not compromise applicant ability to meet faculty (mean rank = 6.8/10) or make favorable impressions (mean rank = 6.8/10). Program directors reported equivalent or improved assessments of applicants. Program directors (72%) and applicants (77%) indicated that future interviews should be partially or completely virtual. CONCLUSION: In contrast to prior survey data, applicants and program directors now express interest in virtual or hybrid interview processes. Virtual interviews were less costly, less time-consuming, and met goals effectively. Integrating virtual interview components will require innovative strategies to reduce redundancies and promote equitable access.
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Becas , Entrevistas como Asunto , Selección de Personal/métodos , Comunicación por Videoconferencia , Actitud del Personal de Salud , Estudios de Seguimiento , Encuestas y Cuestionarios , Estados UnidosRESUMEN
A 41-Year-Old Woman with a Cold FootA 41-year-old woman presented for evaluation of a painful and cold right foot. How do you approach the evaluation, and what is the diagnosis?
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Pie , Femenino , Humanos , Adulto , Pie/patología , Frío/efectos adversos , Diagnóstico DiferencialRESUMEN
BACKGROUND: Teaching is a responsibility of general surgery residents and formal teaching instruction is mandated. This study examines the efficacy of a formal RATP incorporated into our general surgery residency curriculum. METHODS: The RATP was developed locally and delivered longitudinally over the course of the academic year, starting in 2017. Self-assessment surveys were distributed to residents before and after completion of the program each academic year. Medical students were surveyed regarding their impression of teaching on the surgical clerkship. RESULTS: RATP data was collected annually. All sessions were highly rated. Residents reported improved teaching self-efficacy after participation. Medical student agreement with the statement 'Residents provided effective teaching during the [surgery] clerkship' increased from 68.6% prior to RATP implementation to 79.7% in the following years (p < 0.05). CONCLUSIONS: Incorporation of a locally developed RATP improved residents' self-perceptions and medical student perception of residents as teachers. RATPs should be adopted widely.
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Cirugía General/educación , Internado y Residencia/métodos , Curriculum , Educación Médica/métodos , Educación Médica/organización & administración , Evaluación Educacional , Humanos , Internado y Residencia/organización & administración , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Autoeficacia , EnseñanzaRESUMEN
BACKGROUND: There is a long history of segregation in the U.S.A with enduring impacts on cancer outcomes today. We evaluated the impact of segregation on racial disparities in Hepatocellular Carcinoma (HCC) treatment and outcomes. METHODS: We obtained data on black and white patients with HCC from the SEER program (2005-2015) within the 100 most populous participating counties. Our exposure was the index of dissimilarity (IoD), a validated measure of segregation. Outcomes were overall survival, advanced stage at diagnosis (Stage III/IV) and surgery for localized disease (Stage I/II). Cancer-specific survival was assessed using Kaplan-Meier estimates. RESULTS: Black patients had a 1.18 times increased risk (95%CI 1.14,1.22) of presenting at advanced stage as compared to white patients and these disparities disappeared at low levels of segregation. In the highest quartile of IoD, black patients had a significantly lower survival than white (17 months vs 27 months, p < 0.001), and this difference disappeared at the lowest quartile of IoD. CONCLUSIONS: Our data illustrate that structural racism in the form racial segregation has a significant impact on racial disparities in the treatment of HCC. Urban and health policy changes can potentially reduce disparities in HCC outcomes.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Segregación Social , Negro o Afroamericano , Carcinoma Hepatocelular/terapia , Humanos , Neoplasias Hepáticas/terapia , Racismo Sistemático , Resultado del Tratamiento , Población BlancaRESUMEN
BACKGROUND: Training diverse house staff, including those who are underrepresented in medicine, is vital to provide high-quality patient care for the communities that we serve. In 2018, the Accreditation Council for Graduate Medical Education announced new common program requirements for systematic efforts to recruit and retain a diverse workforce. However, questions remain about how to implement such efforts. MATERIALS AND METHODS: Electronic Residency Application Service (ERAS) data from eight residency programs spanning two recruitment cycles (2017-2018, 2018-2019) was reviewed. The number of candidates at each stage in the process (applicant, invited to interview, interviewed, and matched) was examined by self-identified race or ethnicity. These data were presented to residency program directors at our Graduate Medical Education committee meeting before the next recruitment cycle. Data were analyzed following the 2019-20 residency match. Odds ratios and Pearson's chi-squared test were used to assess statistical significance. RESULTS: A total of 10,445 and 10,982 medical students applied to our 8 core residency programs in 2017 and 2018, respectively. Medical students who applied and self-identified as Asian, Black or African American, and Hispanic or Latino or Spanish origin had lower odds of being invited to interview than those who self-identified as White. After data presentation, the odds of inviting Black or African American applicants to interview increased significantly. The odds of attending an interview once invited were the same across groups. CONCLUSIONS: Sharing ERAS data patterns with residency program directors was associated with a significant year over year change in interviewee diversity. Structured analysis of institutional ERAS data can provide insight into the resident selection process and may be a useful tool to improve house staff diversity.
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Diversidad Cultural , Fuerza Laboral en Salud/organización & administración , Internado y Residencia/estadística & datos numéricos , Grupos Minoritarios/estadística & datos numéricos , Selección de Personal/organización & administración , Estudiantes de Medicina/estadística & datos numéricos , Negro o Afroamericano/estadística & datos numéricos , Asiático/estadística & datos numéricos , Estudios de Factibilidad , Fuerza Laboral en Salud/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Internado y Residencia/organización & administración , Solicitud de Empleo , Selección de Personal/estadística & datos numéricos , Estados Unidos , Población Blanca/estadística & datos numéricosRESUMEN
BACKGROUND: There is very limited comprehensive information on disparate outcomes of black and white patients with COVID-19 infection. Reports from cities and states have suggested a discordant impact on black Americans, but no nationwide study has yet been performed. We sought to understand the differential outcomes for black and white Americans infected with COVID-19. METHODS: We obtained case-level data from the Centers for Disease Control and Prevention on 76,442 white and 48,338 non-Hispanic Black patients diagnosed with COVID-19, ages 0 to >80+, outlining information on hospitalization, ICU admission, ventilation, and death outcomes. Multivariate Poisson regressions were used to estimate the association of race, treating white as the reference group, controlling for sex, age group, and the presence of comorbidities. RESULTS: Black patients were generally younger than white, were more often female, and had larger numbers of comorbidities. Compared to white patients with COVID-19, black patients had 1.4 times the risk of hospitalization (RR 1.42, p < 0.001), and almost twice the risk of requiring ICU care (RR 1.68, p < 0.001) or ventilatory support (RR 1.81, p < 0.001) after adjusting for covariates. Black patients saw a 1.36 times increased risk of death (RR 1.36, p < 0.001) compared to white. Disparities between black and white outcomes increased with advanced age. CONCLUSION: Despite the initial descriptions of COVID-19 being a disease that affects all individuals, regardless of station, our data demonstrate the differential racial effects in the United States. This current pandemic reinforces the need to assess the unequal effects of crises on disadvantaged populations to promote population health.
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COVID-19 , Cuidados Críticos/estadística & datos numéricos , Disparidades en el Estado de Salud , Disparidades en Atención de Salud/etnología , Hospitalización/estadística & datos numéricos , Determinantes Sociales de la Salud/etnología , Adulto , Negro o Afroamericano/estadística & datos numéricos , Anciano de 80 o más Años , COVID-19/mortalidad , COVID-19/terapia , Femenino , Humanos , Recién Nacido , Masculino , Mortalidad , Evaluación de Resultado en la Atención de Salud , Índice de Severidad de la Enfermedad , Factores Socioeconómicos , Estados Unidos/epidemiología , Población Blanca/estadística & datos numéricosRESUMEN
Previous geographically limited studies have shown differential impact of COVID-19 on Hispanic individuals. Data were obtained from the Centers for Disease Control and Prevention. We performed multivariate Poisson regression assessing risk of hospitalization and death in Hispanic White (HW), Hispanic Black (HB), and Hispanic Multiracial/Other (HM) groups compared to non-Hispanic Whites (NHW). The relative risk of hospitalization was 1.35, 1.58, and 1.50 (p < 0.001) for HW, HB, and HM individuals respectively when compared to NHW. Relative risk of death was 1.36, 1.72, 1.68 (p < 0.001) times higher in HW, HB, and HM compared to NHW. HW, HB, and HM individuals also had significantly increased risk of requiring mechanical ventilation and ICU admission when compared to NHW. Hispanic individuals are more likely to be hospitalized and die from COVID-19 infection than White, which underscores the need for more precise data and policies aimed at unique Hispanic groups to decrease disparities.
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COVID-19/etnología , Disparidades en Atención de Salud/etnología , Hispánicos o Latinos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , COVID-19/mortalidad , COVID-19/terapia , Niño , Preescolar , Femenino , Disparidades en Atención de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Distribución de Poisson , Grupos Raciales/etnología , Grupos Raciales/estadística & datos numéricos , Factores de Riesgo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVE: Develop and describe a set of low-cost hemorrhoidectomy task trainer prototypes in the setting of inadequate junior resident surgical skill preparation for anorectal cases. DESIGN: This is a study comparing expert and novice performance and opinions. Three task trainers were developed to simulate dissecting, knot-tying, and suturing in a confined space, like the anus. Participants were asked to dissect the peel off of an orange, tie seven 2-handed knots on a weight, and close a defect in a piece of felt with a running stitch. An 8-oz mason jar was used to simulate the confined space. Participants were asked to fill out a 5-point Likert-based evaluation regarding the skills. The primary outcome was time to complete each task in seconds. Secondary outcome measures were number of errors associated with each task, subjective achievability of tasks, and utility of tasks for improving surgical skills. SETTING: General surgery residency program at a safety-net academic center. PARTICIPANTS: Forty subjects participated in this study. There were 20 experts (7 attending surgeons, 13 PGY-1-PGY-5 surgical residents) and 20 novices (11 third- and 9 fourth-year medical students). RESULTS: Experts knot-tied (59s vs 140s, p < 0.001) and sutured (219s vs 295s, p < 0.001) faster than novices. Experts were able to tie 7 knots in fewer attempts than novices (p < 0.001). There was no significant difference in speed of orange dissection between groups. There were no significant differences in the number or frequency of other errors. All participants felt the tasks were achievable (4.90/5) and would be useful in improving skills (4.93/5). CONCLUSIONS: This study demonstrated that a set of low-cost, low-fidelity prototypical hemorrhoidectomy task trainers can discriminate between experts and novices. Simulation models such as these can offer useful practice opportunities for junior general surgery trainees.
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Hemorreoidectomía , Internado y Residencia , Cirujanos , Competencia Clínica , Simulación por Computador , HumanosRESUMEN
BACKGROUND: Medical students increasingly report not feeling meaningfully involved during surgical clerkships. Preceptorship and mentorship through longitudinal experiences ameliorate this problem. A preceptorship model was introduced into the surgery clerkship at our institution to increase contact and improve relationships between students and faculty. METHODS: The preceptorship model was introduced at select sites in 2017. In contrast to the standard structure in which students are assigned to cases and clinics as needed, preceptorship students are assigned to attending surgeons and follow the surgeons' schedules for the rotation. Student performance data, including final grades, clinical evaluations, and shelf examination scores, were collected for clerkship students from May 2017 to November 2018. Formative and summative evaluations for each student were collected. Qualitative content analysis was used to explore evaluations for themes. RESULTS: Two hundred and seventy-four students completed the clerkship during the study period; 41 experienced a preceptorship model. There was no difference in student performance across clerkship structures. Summative and formative evaluations for preceptorship students were longer than for traditional students (137 words vs 78 words; p < 0.0001 and 46 words vs 16 words, p = 0.03 respectively). Preceptorship student evaluations contained higher-quality feedback relating to clerkship objectives than those of traditional students. Preceptorship comments also contained more frequent mentions of response to feedback. CONCLUSIONS: A preceptorship model was successfully implemented on the third-year surgical clerkship at our institution. Although there was no difference between top performers on either clerkship structure, preceptorship students received written evaluations with better feedback as a result of their direct relationship with faculty. Strategies such as this, which improve student-faculty relationships, will be needed as programs find new ways to assess residency applicants.
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Prácticas Clínicas/organización & administración , Educación de Pregrado en Medicina/organización & administración , Cirugía General/educación , Preceptoría/organización & administración , Competencia Clínica , Humanos , AutoeficaciaAsunto(s)
Ablación por Catéter , Nódulo Tiroideo/cirugía , Humanos , Microondas , Ablación por RadiofrecuenciaRESUMEN
BACKGROUND: The objective of this study was to evaluate the impact of resident involvement on surgical outcomes in laparoscopic compared to open procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program 2007-2012 was queried for open and laparoscopic ventral hernia repair (VHR), inguinal hernia repair (IHR), splenectomy, colectomy, or cholecystectomy (CCY). Multivariable regression analyses were performed to assess the impact of resident involvement on surgical outcomes. RESULTS: In total, 88,337 VHR, 20,586 IHR, 59,254 colectomies, 3301 splenectomies, and 95,900 CCY were identified. Resident involvement was predictive for major complication during open VHR (AOR, 1.29; pâ¯<â¯0.001), but not during any other procedure. Resident participation significantly prolonged operative time for open, as well as laparoscopic VHR, IHR, colectomy, splenectomy, and CCY (all pâ¯<â¯0.01). CONCLUSIONS: The results of this study suggest that resident participation has a similar impact on surgical outcomes during laparoscopic and open surgery, and is generally safe.
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Colecistectomía/métodos , Competencia Clínica , Cirugía General/educación , Herniorrafia/educación , Internado y Residencia/estadística & datos numéricos , Seguridad del Paciente/estadística & datos numéricos , Colecistectomía/educación , Colecistectomía Laparoscópica/educación , Colecistectomía Laparoscópica/métodos , Colectomía/educación , Colectomía/métodos , Bases de Datos Factuales , Femenino , Herniorrafia/métodos , Humanos , Laparoscopía/educación , Laparoscopía/métodos , Laparotomía/efectos adversos , Laparotomía/métodos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/educación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Análisis Multivariante , Tempo Operativo , Estudios Retrospectivos , Medición de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Teaching medical students and junior residents are key components of a surgical resident's role. How surgical residents are formally prepared for their teaching role is not well described. The aim of this study was to characterize the status of formal Resident-as-Teacher Programs (RATPs) in U.S. general surgery residency programs. We also sought to understand current attitudes towards teaching by residents. DESIGN: A survey regarding the presence of RATPs and attitudes toward teaching by residents was sent through the Association of Program Directors in Surgery (APDS) to general surgery program directors (PDs). SETTING: The study was conducted using an electronically distributed survey. PARTICIPANTS: Program directors of general surgery residencies were contacted through the APDS. RESULTS: Program directors from 105 institutions completed the survey; one did not respond to the question about RATPs. 27 (26%) indicated they utilized a RATP. Of these programs the majority, 25 (93%), were developed at the institution and only 2 (6%) used a published curriculum. For the programs without a RATP, 47 (61%) of PDs indicated they were interested in establishing one. Respondents not interested most often cited other resident obligations and time constraints as limiting factors. CONCLUSIONS: Fewer than one third of responding programs have an established RATP; of those programs that do not have a RATP, the majority are interested in establishing one. Residents clearly play an important role teaching and PDs acknowledge teaching is an important part of residents' daily job, thus formal preparing residents for their teaching role is important. Development and dissemination of a RATP that can be easily incorporated in to general surgery programs would meet an identified need in general surgery training.
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Actitud , Cirugía General/educación , Internado y Residencia , Estudiantes de Medicina , Formación del ProfesoradoRESUMEN
INTRODUCTION: The Liaison Committee on Medical Education (LCME) requires that residents are trained to fulfill their educational duties toward medical students. This study reviews the literature on resident-as-teacher programs (RATPs) aimed at surgical residents. METHODS: Literature search with MeSH terms internship, residency, general surgery, teaching, education, and curriculum was performed using PubMed, Embase, Web of Science, and ERIC. Curriculum components and how curricula's success was measured were extracted for each study. Quality was scored using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: For the seven relevant publications the average MERSQI score was 9.9 (range 6.5-13.5). The RATPs were either lecture based (4/7) or content was distributed electronically (3/7). Change in attitude toward teaching was the most frequently assessed outcome. Highly rated curricular components were individualized feedback and iterative reminders to make teaching part of practice. CONCLUSIONS: Few published RATPs in general surgery training exist. The literature suggests that pairing lectures with observation and feedback is successful. Distributing the content electronically is a feasible alternative to class-room based teaching in a busy surgical residency.