Departmental Retreat: The Big Four and Integration

Fall is here, excitement is in the air, and we in the Department of Surgery have begun the journey towards clinical integration with our partners at Abington and Aria. On Saturday, September 24, 2016, nearly 100 attendees joined us in the Hamilton Building for our second Department of Surgery retreat in the last 18 months. This retreat differed from our first as we focused on two topics: The Big Four and Jefferson Health System Integration. The morning commenced with a reminder of our vision and mission statements, a review of the fiscal exigencies which prompted a need for change, and the charge to the participants. Dean David Nash then spoke on “Population Health: Is it the Secret Sauce?” and Dr. Anne Docimo, CMO, followed on the topic of “The Search for Value in the Healthcare Marketplace.” Next, Jasmine Arfaa, PhD, MHSA, and Terry Lynch (Press Ganey Associates) spoke on “The Patient Experience at Jefferson.” Finally, Mr. Neil Lubarsky, SVP for Finance, expertly discussed “Healthcare Cost Consciousness.” Following these four thought provoking talks, breakout sessions were held to encourage brainstorming and the prioritizing of our action plans. Following lunch, Hugh Lavery, SVP for Government Affairs, spoke on “Federal and State Landscapes.” President Steven Klasko, MD, MBA, speaking on his 3rd Anniversary at Jefferson (applause!) reviewed the numerous governance alterations that have taken place creating a more nimble and expansive Jefferson Health System. The half day retreat ended with a summary and action plan by each of the group facilitators. It was wonderful to sit in the same room with our colleagues from Jefferson, Methodist, Abington, Aria, and the Main Line. The interactions were robust, introductions were made, shared threats and opportunities were discussed, and…now the work begins! Soon, Jefferson’s Integration Management Office (JIMO) will nucleate surgical integration teams to help develop and implement changes to support our Jefferson Integration 2.0 goal. We will need timelines, milestones, and deliverables. Various project managers will be assigned. There is excitement in the air and hard work to do. We in the Department of Surgery have the opportunity to help lead this integration process. Recordings of the morning presentations are available at: jdc.Jefferson.edu/surgeryretrea

The Spring of 2017…Change and Hope

There is excitement in the air at Jefferson this spring. We had a superb “Match” on March 17, and will be welcoming 6 terrific categorical general surgery residents come July. The Philadelphia Phillies just completed spring training well above .500, and there are high hopes for an improved year. In late April, the American Surgical Association − co-founded by our very own Dr. Samuel D. Gross (Chair of Surgery, 1856-1882) − hosted their 137th Annual Meeting here in Philadelphia. As part of the social program, attendees toured Lubert Plaza in the heart of our Center City campus, which includes the magnificent Samuel Gross Monument by Alexander Calder. Jefferson Health continues to sustain momentum towards further expansion, with the planned addition of Kennedy Health in New Jersey and Philadelphia University to our Jefferson family soon. Some work is already underway with Philadelphia University (see the Enterprise Integration column), taking advantage of their expertise in creative design, innovation, and space planning. Add to this the work being done at our Center City, Abington and Aria campuses by our 7 surgical 2.0 Integration teams focusing on patient-centered, highest quality care… much is happening. April 1 marked the launch of our Wave 2 EPIC implementation (inpatient EPIC) at our Jefferson Hospitals in Center City and on our Methodist campus. The power of this electronic health record (EHR) is quite amazing. Patients are being encouraged to sign up online for the “MyChart” patient portal, we are linked to other organizations via the Care Everywhere platform, and we now have one unified EHR for our outpatient and inpatient environments. As you might imagine, the surgical residents have embraced this new technology with great enthusiasm, while at least some of us (attending surgeons) are finding we have to work a bit harder to become facile. We look forward to further optimization of these systems, so that we can truly see the power of this far reaching, multi-layered EHR. Please enjoy the various articles which compose this issue and keep up with our news on Facebook.com/JeffersonSurgery and Twitter@JEFFsurgery in between issues

The Many Roles of an Academic Surgeon

One of our most important responsibilities is training the next generation of fellows, residents, medical students, and undergraduate students aspiring to a career in medicine. Last summer Sidney Kimmel Medical College launched our new educational curriculum, termed JeffMD (Jefferson.edu/JeffMD). There is great excitement as we have welcomed 270 new medical students, who will be engaged in an entirely new and improved curriculum focused on problem-based learning, small group sessions, lifetime learning, longitudinal threads and experiences. The Department has helped develop the new curriculum, and also hopes to bring to fruition a surgically-focused curriculum, for those medical students who differentiate early into a surgical field. Stay tuned for more, as this materializes under the direction of Drs. Gerald Isenberg and Harrison Pitcher. We also educate our learners by publishing books and journals focused on surgery. Congratulations to the many members of our Department who have led the way and brought to fruition the following major endeavors: • Cataldo Doria, MD, PhD, MBA, FACS, published Contemporary Liver Transplantation (book) • Alec Beekley, MD, FACS, published the 2nd edition of Front Line Surgery (book) • Gerald Isenberg, MD, FACS, released the first issue of the ACS online publication: Case Reviews in Surgery (journal) • Nicholas Cavarocchi, MD, FACS, FCCP, published Critical Care Clinics, Extracorporeal Membrane Oxygenation (e-book) • Francesco Palazzo, MD, FACS, and Michael Pucci, MD, FACS, are working on a new book The Fundamentals of General Surgery with many chapters already submitted. • Just two years ago Adam Berger, MD, FACS, edited a monograph on Melanoma, and David Tichansky, MD, MBA, FACS, edited The SAGES Manual of Quality, Outcomes, and Patient Safety • My personal project, the 8th Edition of Shackelford’s Surgery of the Alimentary Tract just celebrated the submission of the last of the 184 chapters that will make up this 2 volume set. Lastly, having just concluded my summer faculty chats with all 61 of our Jefferson-based faculty members, it is impressive to reflect on their accomplishments and achievements to date. It is certainly clear to me that our Department makes critical contributions to Thomas Jefferson University Hospital being named to the U.S.News & World Report Honor Roll, as the 16th best hospital in America. Please enjoy the various articles which compose this issue and keep up with our news on Facebook.com/JeffersonSurgery and Twitter@JEFFsurgery in between issues

Health Care Worker: Burnout Versus Moral Injury

Much has been written about health care worker (HCW) burnout – defined as a constellation of symptoms which include exhaustion, cynicism and decreased productivity; it has been clearly linked to increased rates of depression, suicide and departure from health care employment. Surveys show that large percentages of HCWs report burnout. We have all read the various studies. But Talbot and Dean* suggest a different perspective – they opine that the concept of burnout resonates poorly with many HCWs, as it suggests a failure of resilience, grit and resourcefulness (traits present in most HCWs; learned and practiced through long training and demanding work). They posit that burnout is itself a symptom of a larger issue – our inefficient health care system, where HCWs navigate a complex web of conflicted allegiances (patients, self, employers, insurers, third parties, etc.) – resulting in moral injury. The term moral injury originates in the language of war, and was used to describe soldiers’ personal responses to their actions in war – codified by journalist Diane Silver as “a deep soul wound that pierces a person’s identity, sense of morality and relationship to society.” Such a definition resonates with me, as I discuss weekly the challenges we face as HCWs with staff, faculty, trainees and students. The moral injury of health care is not the offense of killing another human being in the context of war – rather it is being unable to consistently and without excessive burden provide high quality care, preventative health and healing in the context of contemporary U.S. health care. There is accumulating evidence that progress on this topic in the context of HCWs requires more than employee surveys, wellness programs, teaching mindfulness and meditation, and minor adjustments to schedules and scheduling templates. HCWs deserve leaders (on the national, state and local scene) that acknowledge the human costs and moral injury that stem from a health care system that is challenged with excessive regulation, fails to provide for all citizens and is fraught with multiple competing allegiances. HCWs are a critically valuable commodity for our industrialized society, and they should be treated with respect, allowed autonomy and encouraged to make rational, safe and evidence-based decisions in the best interest of patients. I am optimistic that time and intelligent reform will create a future win-win scenario, where the wellness of our patients is linked to the wellness of all providers. *Suggested reading – Talbot SG and Dean W. “Physicians aren’t ‘burning out’. They are suffering from moral injury.” July 26, 2018. STAT

The Phillies, the Union, the Eagles and Jefferson Health

We are in the midst of a very successful spectator sports year in the City of Brotherly Love. The Phillies defied the odds, ended the regular season strong, and treated us to a World Series spectacle – playing baseball in November. (The World Series is now a November event; so much for the old moniker “Mr. October.”) The Union were there right up to the last minutes, in the MLS Cup, the championship game. Finally, the Eagles won the National Football Conference championship and headed to Super Bowl LVII. The winning analogy is to Jefferson Health and our Department. We too are competitors and champions. We compete for terrific fourth year medical students who join us as interns and train in Surgery. We have been successful in recruiting “top talent” to our Department as faculty. We have been winners when it comes to the Dean’s Awards for Education, Mentoring, and Clinical Excellence. Working with our Office of Institutional Advancement team, we have had another very successful year, garnering philanthropic dollars to support our education and research missions. We have had some nice measure of success with grant proposals to support our young faculty. Many other examples of our successes exist. Kudos to all in the Department, as we emerge from the negative specter of the COVID-19 pandemic, and embark upon our post-COVID activities. Soon to come - the year 2024, where we will be seeing our outpatients in the new 19 floor Honickman Center at 1101 Chestnut Street and celebrating the 200th anniversary of our Department and our Medical School: the bicentennial celebration of Jefferson Medical College (now Sidney Kimmel Medical College) – founded by a surgeon, Dr. George McClellan. Onward and upward

Writers Workshop-How to Write a Paper for Publication

Objectives: 1. Recognize the key elements of the properly submitted manuscript for submission to a surgical journal. 2. Discuss the many common errors made in manuscript submission, which typically lead to manuscript rejection. 3. How do you respond to criticism from the journal\u27s editorial board? Presentation: 12:21 Entire PowerPoint slide deck is located at bottom of page

Reflection: A Long Lasting Birthday Present

I wrote a check this week. I do it yearly; this time, $169, for my annual subscription renewal to the New England Journal of Medicine (NEJM). Writing this check reminds me of my dad… he started me on this tradition. During the autumn of my senior year in medical school I was approaching my 25th birthday (1978) and my father asked if there was anything I “needed” for my birthday. My initial list was met with his comment that I didn’t need the items requested (new car, new stereo system, my own pair of new snow skis.) He was correct – I just wanted them. I then altered my approach, and told him that I really could use a subscription to the NEJM. After he heard my rationale, he started me off with my first issues: a 3 year subscription, at student rates, which I have renewed religiously… this will be my 35th year! I love reading it. Filled with op-ed pieces on health care or global health issues, landmark original articles, review articles and of course the weekly mysterious clinicopathological conference (CPC) cases, it provides me an hour of broad medical education amidst the usual hectic work week. I recommend it to all physicians, and especially to all surgeons. I can’t tell you how much I have learned from this amazing journal on a year to year basis. A very belated thanks to my now departed father, for starting me on this weekly tradition. P.S. The NEJM is celebrating its 200th birthday this year

Early Perioperative Fluid Benchmarking to Predict Pancreaticoduodenectomy (PD) Outcomes

Introduction: PD is a complex operation associated with a marked systemic inflammatory response and significant fluid shifts. Establishing a benchmark for ideal perioperative fluid management is critical to optimising PD patient recovery. Methods: In this retrospective study, we evaluated perioperative fluid data for patients undergoing PD. We compared an optimal benchmark group who were discharged home by postoperative day five (≤5day) to a group of patients with an in hospital recovery greater than ten days (≥10day). Results: Seventy-six patients who underwent PD between June 2015 and November 2016 were evaluated. The ≤5day group had a significantly lower intraoperative fluid administration (5.4 vs. 6.6 L, p= 0.012), despite similar operative times (447 mins and 476 mins, respectively). POD1 cumulative fluid balance was lower in the ≤5day group compared to the ≥10day group, 7.8L (97 mL/kg) vs. 9.7L (148 mL/kg) (p= 0.002), respectively. As expected, the postoperative complication rate was reduced in the ≤5day group (5% vs. 95%). Complications included pancreatic fistula (40%), delayed gastric emptying (53%), and intra-abdominal infection (16%). The median weight change from baseline to POD5 was -0.2 Kg for the ≤5day group compared to +2.9 Kg for ≥10day group (p= 0.000006). Conclusions: Patients in the benchmark PD group received less fluid intraoperatively, had a lower cumulative fluid balance by POD1, and were able to return to their preoperative weight by POD5 when compared to ≥10day group. These data offer insights into optimal fluid administration for PD patients

John Chalmers DaCosta (1863-1933): restoration of the old operating table.

John Chalmers DaCosta was an influential chairman and the first Samuel D. Gross Professor of Surgery at Jefferson Medical College in Philadelphia. He was well known throughout the field as a skilled surgeon, passionate speaker, and exceptional writer. In addition to countless accomplishments during his career, DaCosta was deeply dedicated to the preservation and commemoration of surgical history. This ideology was exemplified when he set out on a mission to recover the old wooden operating table used by many of his iconic mentors including Samuel D. Gross, Joseph Pancoast, and William W. Keen. This table was originally used for surgical demonstrations and anatomy lessons in a lecture room of the Ely Building and later in the great amphitheater of the Jefferson Sansom Street Hospital. It was found forgotten in the basement of the College Building and was promptly refurbished, donned with dedicatory plaques, and returned to its honored position in the medical college. Dr. DaCosta also contributed a detailed article recalling the history of the table and the notable leaders in surgery who taught and practiced on its surface. The old table currently stands proudly in the entranceway of the Department of Surgery where it will remain as a cherished symbol of the early beginnings of surgical practice and education

The Role of the Uncinate Margin in Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Survival Analysis

Introduction: Positive margins during pancreaticoduodenectomy for pancreatic cancer portend worse survival, but additional resection of the uncinate margin is typically unfeasible without major vascular reconstruction. The survival benefit of resecting additional neck or bile duct margins in the face of a positive uncinate is also unknown. We examined the impact of re-resection of these margins on survival. Methods: Patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy from 2006-2015. Pancreatic neck, bile duct, uncinate, and duodenal frozen section margins were assessed before and after resection of positive margins. Kaplan-Meier survival curves were compared with log-rank tests. Multivariable Cox regression was used to assess the effect of margin status on overall survival. Results: Among 508 patients identified, 388 (76.4%) underwent a pylorus-preserving procedure, 435 (85.6%) had T3 tumors, and 379 (74.6%) had nodal involvement. There were 21 instances where an uncinate margin was concurrently positive with a neck or bile duct margin; this additional neck or bile duct margin was resected in 13 cases (61.9%). Resection of additional margins when the uncinate was concurrently positive was not associated with improved survival (p=0.36). Median survival with and without positive uncinate margins was 13.8 vs. 19.7 months (p=0.04). A positive uncinate margin was associated with decreased survival independent of other margins and cancer stage (HR 1.28 [95% CI 1.00-1.65]). Conclusion: In patients with pancreatic adenocarcinoma, positive uncinate margins are associated with decreased overall survival; resection of additional margins at the neck and bile duct in those with a positive uncinate margin is not warranted