Validity evidence for flourishing as a measure of global wellbeing: a national multicenter study of academic general surgery residents.

PURPOSE: Physician wellbeing is critical to high-quality sustainable healthcare and optimal patient experience. Few objective measures exist to assay wellbeing (as opposed to just pathology) in surgery, or to evaluate the efficacy of wellbeing interventions. Flourishing (as measured by the Mental Health Continuum, MHC) has been suggested as a concise measure of global wellbeing in surgeons. We aimed to establish validity evidence for flourishing in a large national sample of surgical trainees, explore differences by gender and race, and confirm support for the underlying constructs. METHODS: This cross-sectional study of all General Surgery residents at 16 ACGME-accredited academic programs included an online survey of published measures distributed in February 2021. The Mental Health Continuum (MHC), a three-factor model, assesses emotional, social, and psychological wellbeing and is an established metric of psychosocial thriving in non-physicians. A global score cut-off exists for flourishing which represents high wellbeing. Correlation between flourishing and established measures of risk and resilience in surgery were assessed for validity evidence. Differences by gender and race were explored. A confirmatory factor analysis (CFA) was performed to confirm the three-factor structure in surgical trainees. RESULTS: 300 residents (60% non-male, 41% non-white) responded to the survey. For the overall group, flourishing was significantly positively correlated with all wellbeing resilience factors and negatively correlated with all risk factors. This held true for race and gender subgroups based on interaction analyses. CFA and sensitivity analysis results supported the three-factor structure. CONCLUSIONS: Our findings offer validity evidence for flourishing as a measure of global wellbeing and confirm the three-factor structure of emotional, social, and psychological wellbeing in surgical trainees. Thus, the MHC may be a concise tool for assaying wellbeing, within and across subgroups, and for assessing wellbeing intervention effectiveness within the surgery

Proof-of-concept for intervention to prevent post-operative ileus in patients undergoing ileostomy formation.

BackgroundPreventing post-operative ileus (POI) is important given its associated morbidity and increased cost of care. The authors' prior work showed that POI in patients with newly created ileostomies is associated with a post-operative day (POD) 2 net fluid balance of > + 800 mL. The purpose of this study was to conduct an initial assessment of the efficacy of a pilot intervention.MethodsThis is a single-institution, pre-post-intervention, proof-of-concept study conducted on the Colorectal Surgery service at the University of California, San Francisco. The study included 58 procedures with ileostomy formation by board-certified colorectal surgeons between August 13, 2020 and June 1, 2021. The intervention included three adjustments to the standard Enhanced Recovery After Surgery protocol: addition of diuresis, delay in advancement to solid food, and earlier stoma intubation. Demographics, intraoperative factors, post-operative fluid balance, and outcomes (POI, post-procedure length of stay [LOS], hospitalization cost, and re-admissions) were compared between patients pre- and post-intervention.ResultsEight (13.8%) of the 58 procedures in the intervention period were associated with POI vs. a baseline POI rate of 32.6% (p = 0.004). Compared to patients without intervention, those with intervention had 67% less odds of POI (OR 0.33, 95% CI 0.15-0.73, p = 0.01). This difference remained significant when adjusted for age, gender, body mass index, procedure duration, and operative approach (adjusted OR 0.32, 95% CI 0.14-0.72, p = 0.01). Average POD2 stoma output was 0.3 L greater (1.1 L vs. 0.8L; p < 0.001) and net fluid balance was 1.8 L lower (+ 0.3 L vs. + 2.1 L; p < 0.00001) for these 58 cases. Average post-procedure LOS was 1.9 days lower (5.3 vs. 7.2 days, p < 0.001) and direct cost was $5561 lower ($21,652 vs. $27,213, p = 0.004), with no difference in 30-day readmissions (p = 0.43).ConclusionsThis pilot intervention shows promise for reduction in POI in patients with newly created ileostomies. Additional assessment is needed to confirm these initial findings

Association of Distance, Region, and Insurance With Advanced Colon Cancer at Initial Diagnosis

This cross-sectional study examines factors associated with the stage at which colon cancer is diagnosed

Robotic training for medical students: feasibility of a pilot simulation curriculum

While robotic procedures are growing rapidly, medical students have a limited role in robotic surgeries. Curricula are needed to enhance engagement. We examined feasibility of augmenting Intuitive Surgical (IS) robotic training for medical students. As a pilot, 18 senior students accepted an invitation to a simulation course with a daVinci robot trainer. Course teaching objectives included introducing robotic features, functionalities, and roles. A 1-h online module from the IS learning platform and a 4-h in-person session comprised the course. The in-person session included an overview of the robot by an IS trainer (1.5 h), skills practice at console (1.5 h), and a simulation exercise focused on the bedside assist role (1 h). Feasibility included assessing implementation and acceptability using a post-session survey and focus group (FG). Survey responses were compiled. FG transcripts were analyzed using inductive thematic analysis techniques. Fourteen students participated. Implementation was successful as interested students signed up and completed each of the course components. Regarding acceptability, students reported the training valuable and recommended it as preparation for robotic cases during core clerkships and sub-internships. In addition, FGs revealed 4 themes: (1) perceived expectations of students in the OR; (2) OR vs. outside-OR learning; (3) simulation of stress; and (4) opportunities to improve the simulation component. To increase preparation for the robotic OR and shift robotic training earlier in the surgical education continuum, educators should consider hands-on simulation for medical students. We demonstrate feasibility although logistics may limit scalability for large numbers of students

Flourishing as a Measure of Global Well-being in First Year Residents: A Pilot Longitudinal Cohort Study.

BackgroundPhysician well-being is critical to optimal learning and performance, yet we remain without validated measures to gauge the efficacy of well-being curricula for trainees. This study evaluates initial evidence of flourishing as a valid measure of global well-being in postgraduate-year-1 residents (PGY-1s), providing a means of assessing well-being intervention efficacy.Study designIn this single-site study of PGY-1s participating in Enhanced Stress Resilience Training (ESRT), an online questionnaire of published measures was administered at baseline (T1, just before PGY-1), post-ESRT (T2, 7 weeks later), and at PGY-1 end (T3, 11 months later). The Mental Health Continuum (MHC) was used to assess our primary outcome variable, flourishing, a well-established metric of psychosocial thriving in non-physicians that can be treated continuously or categorically. Correlation between flourishing and both resilience (mindfulness and workplace support) and risk (emotional exhaustion, depersonalization, stress, depressive symptoms, anxiety, and workplace demand) factors was assessed at each time-point and longitudinally.ResultsForty-five interns completed the survey at T1, 37 at T2, and 21 at T3; 21 responded at all time points. MHC score was significantly positively correlated with mindfulness (β = 1.47, SE = 0.35, P < .001) and workplace support (β = 2.02, SE = 1.01, P = .05) longitudinally, and at all time points. Flourishing was significantly negatively correlated with depressive symptoms (β = -7.48, SE = 1.68, P < .001), stress (β = -1.28, SE = 0.29, P < .001), and anxiety (β = -1.74, SE = 0.38, P < .001) longitudinally and at all time points, and significantly negatively correlated with emotional exhaustion (β = -2.65, SE = 0.89, P = .003) longitudinally and at T1 (β = -3.36, SE = 1.06, P = .003).ConclusionFlourishing showed appropriate correlation with established resilience and risk factors, thus supporting its concurrent validity as a measure of global well-being in this population. As such, the MHC may provide a simple, meaningful assay of well-being and an effective tool for evaluating the efficacy of well-being interventions. Further validation requires a larger, multi-center study

Risk factors and outcomes associated with postoperative ileus following ileostomy formation: a retrospective study.

Postoperative ileus (POI) is associated with increased patient discomfort, length of stay (LOS), and healthcare cost. There is a paucity of literature examining POI in patients who have an ileostomy formed at the time of surgery. We aimed to identify risk factors for and outcomes associated with POI following ileostomy formation. We included 261 consecutive non-emergent cases that included formation of an ileostomy by a board-certified colorectal surgeon at our institution from July 1, 2015, to June 30, 2020. Demographic, clinical, and intraoperative factors associated with increased odds of POI were evaluated. Post-procedure LOS, hospitalization cost, and re-admissions between patients with and without POI were compared. Out of 261 cases, 85 (32.6%) were associated with POI. Patients with POI had significantly higher body mass index (BMI) than those without POI (26.6 kg/m2 vs. 24.8kg/m2; p = 0.01). Intraoperatively, patients with POI had significantly longer procedure duration than those without POI (313 min vs. 279 min; p = 0.02). Patients with POI had a significantly higher net fluid balance at postoperative day (POD) 2 than those without POI (+ 2.65 L vs. + 1.80 L; p = 0.004), with POD2 fluid balance greater than + 807 mL (determined as the maximum Youden index for sensitivity over 80%) associated with a higher rate of POI (p = 0.006). This difference remained significant when adjusted for age, gender, BMI, pre-operative opioid use, procedure duration, and operative approach (p = 0.01). Patients with POI had significantly longer LOS (11.40 days vs. 5.12 days; p < 0.001) and direct cost of hospitalization ($38K vs.$22K; p < 0.001). Minimizing fluid overload, particularly in the first 48 h after surgery, may be a strategy to reduce POI in patients undergoing ileostomy formation, and thus decrease postoperative LOS and hospitalization cost. Fluid restriction, diuresis, and changes in diet advancement or early stoma intubation should be considered measures that may improve outcomes and should be studied more intensively