The development of anti-bullying, discrimination and harassment guidance: a survey among the Association of Surgeons in Training (ASiT) council members.

INTRODUCTION: Surgical trainees have a reasonable expectation to feel safe and valued in their workplace. Previous reports proved that poor behaviour and misconduct existed in national health systems. This study aimed to conduct a survey among the Association of Surgeons in Training (ASiT) council members to identify the need for guidance to report bullying, discrimination and harassment for trainees who experienced any type of poor behaviour in the workplace. METHODS: Data among executive and council members were collected. Questions were related to trainee demographics, level of training, specialties, and experience of, witnessed or reported poor behaviours including bullying, discrimination and harassment. We asked if participants lacked direction when experiencing poor behaviours, and if support strategies were needed such as a standardised guidance for reports. RESULTS: A total of 58 survey responses were received: 55.17% of participants experienced bullying, 77.58% witnessed it and 67.25% did not report the incidents. Furthermore, 37.93% experienced discrimination, 62.07% witnessed it and 68.97% did not report. A total of 24.14% experienced sexual harassment, 29.69% witnessed it, while 72.41% did not report. Over 80% mentioned they need more guidance to support trainees. Almost all participants (98%) agreed that surgical trainees should be made aware of routes for reporting, and 88% agreed that ASiT should develop the guidance to support trainees against poor behaviours. CONCLUSION: Most of the trainees who experienced or witnessed poor behaviours did not report the incidents. A new standardised anti-bullying, anti-discrimination and anti-harassment guidance was developed based on our study results. We envisage that its use may play a role in eliminating misconduct in surgical training

The innate aptitude's effect on the surgical task performance: a systematic review.

Surgery is known to be a craft profession requiring individuals with specific innate aptitude for manipulative skills, and visuospatial and psychomotor abilities. The present-day selection process of surgical trainees does not include aptitude testing for the psychomotor and manual manipulative skills of candidates for required abilities. We aimed to scrutinize the significance of innate aptitudes in surgical practice and impact of training on skills by systematically reviewing their significance on the surgical task performance. A systematic review was performed in compliance with PRISMA guidelines. An initial search was carried out on PubMed/Medline for English language articles published over 20 years from January 2001 to January 2021. Search strategy and terms to be used included 'aptitude for surgery', 'innate aptitude and surgical skills, 'manipulative abilities and surgery', and 'psychomotor skills and surgery'. MERSQI score was applied to assess the quality of quantitatively researched citations. The results of the present searches provided a total of 1142 studies. Twenty-one studies met the inclusion criteria out of which six citations reached high quality and rejected our three null hypothesis. Consequently, the result specified that all medical students cannot reach proficiency in skills necessary for pursuing a career in surgery; moreover, playing video games and/or musical instruments does not promote skills for surgery, and finally, there may be a valid test with predictive value for novices aspiring for a surgical career. MERSQI mean score was 11.07 (SD = 0.98; range 9.25-12.75). The significant findings indicated that medical students with low innate aptitude cannot reach skills necessary for a competent career in surgery. Training does not compensate for pictorial-skill deficiency, and a skill is needed in laparoscopy. Video-gaming and musical instrument playing did not significantly promote aptitude for microsurgery. The space-relation test has predictive value for a good laparoscopic surgical virtual-reality performance. The selection process for candidates suitable for a career in surgery requests performance in a simulated surgical environment

Anxiety and depression in surgeons: A systematic review.

INTRODUCTION: The unique pressures of a surgical career put surgeons at particular risk of mental health conditions, including anxiety and depression. Surgeons have previously been shown to have a high prevalence of psychological distress. This study aimed to systematically review the prevalence of anxiety and depression amongst surgeons, and to identify factors that can modify the risk of anxiety and depression in surgeons. METHODS: A 10-year systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines to identify citations related to the keywords "anxiety" OR "depression" AND "surgeon" in PubMed/Medline and ScienceDirect databases. Inclusion and exclusion criteria were applied to produce a final list of citations. RESULTS: Thirty-one citations were included with a total of 11,399 participants. The median percentage of anxiety in surgeons was 20 with a range of 54.6%. While the median percentage of depression was 24 with a range of 59%. Risk factors associated with a higher risk of anxiety and depression include female gender, younger age, concurrent burnout, and occupational concerns regarding the COVID-19 pandemic. Protective factors include institutional support and a sense of social belonging. CONCLUSIONS: There was a high prevalence of anxiety and depression amongst surgeons over the past decade. It is imperative to develop strategies to mitigate the effect of anxiety and depression in surgeons

Surgeons' personality, characteristics and presence of meaning in life.

BACKGROUND: Surgeons work long shifts and are frequently on call. Pressure to make quick and accurate decisions along with the responsibility of performing complex procedures contribute to surgeons' high stress-levels, anxiety and altered empathy level. We aimed to study surgeons' personality and meaning in life at two different centres. METHODS: General surgeons completed 47 questions. Visual analogous scale-items with controlled internal consistency (Cronbach alpha) coefficients varying from .77 to .85 were used from the following scales: Global Measure of Perceived Stress; Hostility Questionnaire; Jefferson Scale of Physician Empathy; Meaning in Life Questionnaire-SF; Rosenberg Self-Esteem Scale; Spielberger State Anxiety Scale and Quality of Work life Scale. Multiple linear regression analyses, parametric or non-parametric tests were employed when considered adequate. RESULTS: Fifty-four participants were recruited from 3 different levels of training. Gender differences in Anxiety, Physician Empathy and presence of meaning in life (MIL-P) were revealed. Junior trainees differed from senior trainees and consultants as regards MIL-P, Anxiety, Stress and work-related factors. The surgeons' self-rated self-esteem was work-related. Surgeons' Quality of Work Life was best predicted by Physician Empathy but also their self-rated Self-Esteem contributed significantly to the prediction. Surgeons' MIL-P was significantly predicted by Physician Empathy and State Anxiety. CONCLUSION: Surgeons' current personality attributes might not apply to all of them. Female surgeons were more empathetic and felt more presence of meaning in life than male surgeons, and men were less anxious than female surgeons. Junior trainees experienced less anxiety than senior trainees but were more stressed than consultants. The most significant predictors of surgeons' personality were their experience of presence of meaning in life along with their level of empathy

Racial discrimination in surgery: A systematic review.

INTRODUCTION: Racial/ethnic discrimination indicates the stereotyped or unkind conduct of superiority towards other persons based on their race or skin color. The UK General Medical Council published a statement supporting zero-tolerance approach to racism in the workplace. We aimed to systematically review racial discrimination in surgery and answer the following questions: (1) Does racial/ethnic discrimination in surgery exist in citations from the last 5 years. (2) If yes, are ways suggested to reduce racial/ethnic discrimination in surgery? METHODS: The systematic review was performed in compliance with the PRISMA guidelines along AMSTAR 2. A 5-year literature search was carried out on PubMed for articles published from 1/1/2017 to 01/11/2022. Search terms were 'racial discrimination and surgery', 'racism OR discrimination AND surgery', 'racism OR discrimination AND surgical education'. The retrieved citations were quality assessed by MERSQI and evidence graded by GRADE. RESULTS: A total of 9116 participants responded with a mean of 1013 (SD = 2408) responses per citations reported in 9 studies from a final list of 10 included citations. Nine studies were from USA and 1 from South Africa. There was evidence of racial discrimination in the last 5 years and the results were justified on strong scientific evidence constituting the basis for evidence grade I. The second question's answer was 'yes' which was defendable on moderate scientific recommendation and thereby establishing the basis for evidence grade II. CONCLUSION: There was sufficient evidence for the presence of racial discrimination in surgical practice in the last 5 years. Ways to decrease racial discrimination in surgery exist. Healthcare and training systems must increase the awareness of these issues to eliminate the harmful effect on the individual as well as on the level of the surgical team performance. The existence of the discussed problems must be managed in more countries with diverse healthcare systems

Bouveret syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum.

INTRODUCTION AND IMPORTANCE: Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. Although rare, this condition carries a high mortality rate and no current standardised guidelines for management. CASE PRESENTATION: We present a case of a patient in their 60s with recurrent small bowel obstruction secondary to a cholecysto-duodenal fistula and large gallstone which became impacted in the fourth part of the duodenum. The patient had a P-POSSUM Score of 14% mortality and 60% morbidity risk, had multiple co-morbidities, was bedbound, BMI 59 and had been deemed high risk for general anaesthetic at oncology centre for a 10 × 10 cm likely gynaecological malignancy a month prior to this admission. CLINICAL DISCUSSION: In contrast to existing literature, endoscopic lithotripsy was considered but not attempted due to unavailability of this service locally. Surgical intervention was decided based on radiological features of impending duodenal perforation on CT imaging and multiple disciplinary team discussion. The patient was managed with open enterolithotomy at the duodeno-jejunal (DJ) flexure and discharged 3 weeks post-operatively at her pre-operative baseline. CONCLUSION: This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. In cases where anatomical location of impaction precludes retrieval via simple gastrostomy, we suggest using high pressure flush to mobilise the stone to more favourable location distally. We emphasise that stone size should be considered when planning surgical management

Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in clinical practice

Background. Acute cutaneous abscess is a common surgical condition that mostly requires incision and drainage. Despite this, there is no standardized national or international guidance on post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice for post-operative antibiotics prescription for cutaneous abscesses in a UK university teaching hospital. Methods. Retrospective data collection for emergency general surgical admissions for a period of 6 months was carried out. All patients with cutaneous abscesses were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, co-morbidities and complications, including local (cellulitis, necrosis) and systemic (e.g sepsis), were studied. Approval for access to patient data was granted by the local clinical governance department prior to the commencement of this study. Computations were performed using IBM SPSS version 26. Chi square (X 2), Pearson correlation (r), one or two samples t-test (one or two tailed) were applied. Results. A total of 148 patients were included. The mean age was 40 years (55 % males). The most common site of abscess was perianal (27.7 %), followed by pilonidal (20.3 %) and axilla (16.9 %). A total of 107 (73 %) were managed surgically with incision and drainage, and of these 92 (86 %) were managed within 24 h. Altogether, 83 (76 %) were prescribed post-operative antibiotics, while only 25 (23 %) had indications. The most used post-operative empirical antibiotics was co-amoxiclav (59 %). There was a significant relationship between ‘abscess site’ × ‘antibiotics’ [X 2 (36)=54.8, P=0.023]. A total of 103 patients’ average duration of post-operative antibiotics was 7.2 (sd 2.9) days. Ten patients subject to readmission spent an average of 8.4 (sd 3.8) days on antibiotics. Conclusions. There were variations in clinical practice regarding post-operative antibiotic prescription for cutaneous abscesses. Research is required in the future in cooperation with microbiologists to develop a standardized evidence-based treatment protocol for the management of such a common surgical condition

Academic requirements for Certificate of Completion of Training in surgical training: Consensus recommendations from the Association of Surgeons in Training/National Research Collaborative Consensus Group.

BACKGROUND: Surgical trainees are expected to demonstrate academic achievement in order to obtain their certificate of completion of training (CCT). These standards are set by the Joint Committee on Surgical Training (JCST) and specialty advisory committees (SAC). The standards are not equivalent across all surgical specialties and recognise different achievements as evidence. They do not recognise changes in models of research and focus on outcomes rather than process. The Association of Surgeons in Training (ASiT) and National Research Collaborative (NRC) set out to develop progressive, consistent and flexible evidence set for academic requirements at CCT. METHODS: A modified-Delphi approach was used. An expert group consisting of representatives from the ASiT and the NRC undertook iterative review of a document proposing changes to requirements. This was circulated amongst wider stakeholders. After ten iterations, an open meeting was held to discuss these proposals. Voting on statements was performed using a 5-point Likert Scale. Each statement was voted on twice, with ≥80% of votes in agreement meaning the statement was approved. The results of this vote were used to propose core and optional academic requirements for CCT. RESULTS: Online discussion concluded after ten rounds. At the consensus meeting, statements were voted on by 25 delegates from across surgical specialties and training-grades. The group strongly favoured acquisition of 'Good Clinical Practice' training and research methodology training as CCT requirements. The group agreed that higher degrees, publications in any author position (including collaborative authorship), recruiting patients to a study or multicentre audit and presentation at a national or international meeting could be used as evidence for the purpose of CCT. The group agreed on two essential 'core' requirements (GCP and methodology training) and two of a menu of four 'additional' requirements (publication with any authorship position, presentation, recruitment of patients to a multicentre study and completion of a higher degree), which should be completed in order to attain CCT. CONCLUSION: This approach has engaged stakeholders to produce a progressive set of academic requirements for CCT, which are applicable across surgical specialties. Flexibility in requirements whilst retaining a high standard of evidence is desirable