Elizabeth M. Breen

Risk Factors for Perineal Wound Complications Following Abdominoperineal Resection

PURPOSEPerineal wound complications are common following abdominoperineal resection. This study investigates the factors contributing to these complications.METHODSPatients undergoing abdominoperineal resection at our institution from June 1997 to May 2003 were reviewed. Significant predictors associated with minor (separation <2 cm, stitch abscesses, or sinus tracts) or major (>2 cm of separation, reoperation required, or readmission) wound complications were ascertained.RESULTSOf 153 patients, there were 22 major (14 percent) and 32 minor (24 percent) wound complications. Patients with anal cancer had a higher rate of major complications than those with rectal cancer or inflammatory bowel disease. Minor wound complications were more common in patients with anal cancer and inflammatory bowel disease than those with rectal cancer. Factors associated with a higher rate of major wound complications included flap closure, tumor size, body mass index, diabetes, and indication for the procedure. When the subset of patients with rectal cancer was considered, higher rates of major wounds were associated with increased body mass index, diabetes, and stage. Minor complications were associated with a two-team approach and increasing body mass index.CONCLUSIONSThis is currently the largest review of perineal wound complications following abdominoperineal resection. Patients with anal cancer and inflammatory bowel disease were at higher risk for perineal wound complications than those with rectal cancer. Preoperative radiation and primary closure were not associated with increased complications following abdominoperineal resection for rectal cancer.

Career Satisfaction of Women in Surgery: Perceptions, Factors, and Strategies

BACKGROUND With the current and projected shortages of general surgeons, more attention is being paid to the increasing pool of women physicians. This study seeks to understand the variables leading to career satisfaction for women surgeons to better recruit, retain, and support them. STUDY DESIGN Eighteen semi-structured interviews of 12 female and 6 male surgeons 2 to 12 years into practice were qualitatively analyzed and converted to coded, categorized data. Significance was derived by Fishers exact test. Participants were recruited by snowball sampling. RESULTS Our sample represents a highly satisfied group of female and male surgeons. Although both women and men describe with equal frequency having made career tradeoffs for personal and family time, and vice versa, women far more frequently than men cite reasons related to their personal time, predictable time, and family relationships as why they are currently satisfied with their career (34.1% versus 8.7%; p < 0.05). Both cite being satisfied by career content equally. When describing strategies used in developing a successful surgical career, women most frequently cite social networks as a key to success (88% versus 12% by men; p < 0.05), and men more frequently cite reasons related to training (29% versus 0% by women; p < 0.05) and compensation (24% versus 0% by women; p < 0.05). CONCLUSIONS Although both men and women make tradeoffs of career for family and family for career, womens perception of satisfaction comes from viewing their surgical career within the broader context of their lives. Women might be attracted to a career that acknowledges and values the whole person beyond the surgeon, and could benefit from work infrastructures that enhance networking.

Mini-clinical evaluation exercise as a student assessment tool in a surgery clerkship: Lessons learned from a 5-year experience

BACKGROUND The mini-clinical evaluation exercise (mini-CEX) used for clinical skill assessment in internal medicine provides in-depth assessment of single clinical encounters. The goals of this study were to determine the feasibility and value of implementation of the mini-CEX in a surgery clerkship. METHODS Retrospective review of mini-CEX evaluations collected for surgery clerkship students at our institution between 2005 and 2010. Returned assessment forms were tallied. Qualitative feedback comments were analyzed using grounded theory. Principal components analysis identified thematic clusters. Thematic comment counts were compared to those provided via global assessments. RESULTS For 124 of 137 (90.5%) students, mini-CEX score sheets were available. Thematic clusters identified comments on 8 distinct clinical skill domains. On the mini-CEX, each student received an average of 6.5 ± 2.2 qualitative feedback comments covering 4.5 ± 1.2 separate skills. Of these, 42.7% were critical. Comments provided in global evaluations were fewer (2.9 ± 0.6; P < .001), constrained in scope (0.8 ± 0.2 skills; P < .001), and rarely critical (9.1%). CONCLUSION A mini-CEX can be incorporated into a surgery clerkship. The number and breadth of feedback comments make the mini-CEX a rich assessment tool. Critical and supportive feedback comments, both highly valuable, are provided nearly equally frequently when the mini-CEX is used as an assessment tool.

Observation of Clinical Teaching: Interest in a Faculty Development Program for Surgeons

OBJECTIVES Observation of clinical teaching is a powerful tool to develop faculty teaching skills. However, the process of being observed can be intimidating for any educator. Our aim is to assess interest in an Observation of Teaching Program within an academic surgical department. DESIGN An electronic survey asking faculty to indicate interest in participation in a faculty development program that consists of a peer, expert, and/or cross-disciplinary physician observation of teaching was used. Faculty members were also asked whether they would like to observe other faculty as part of a peer-review track. The results were compiled for descriptive statistical analysis. SETTING Electronic survey. PARTICIPANTS In all, 46 faculty, all of whom have assigned medical student and resident teaching responsibilities, were introduced to the Observation of Teaching Program and surveyed on their interest in participating. RESULTS A total of 87% (40/46) of faculty responded after 2 e-mails and 75% (30/40) indicated interest in the Observation of Teaching Program. All faculty who responded positively indicated interest in expert review (30/30), 90% (27/30) in peer review, 87% (26/30) in surgeon review, and 83% (25/30) in cross-disciplinary physician review. A total of 48% (19/40) indicated interest in observing others. Of those who were not interested in the Observation of Teaching Program, restrictions on time (4/10), not enough clinical care responsibilities (2/10), not wanting to be watched (2/10), and program did not seem effective (1/10) were cited as reasons for not participating. CONCLUSIONS Surgical faculty are interested in being observed and receiving feedback about their clinical teaching by experts, peers, colleagues, and cross-disciplinary physicians. Professional development programs for surgeons should consider observation as a teaching methodology.

Interest in and perceived barriers to flexible-track residencies in general surgery: a national survey of residents and program directors.

OBJECTIVE The American Board of Surgery now permits general surgery residents to complete their clinical training over a 6-year period. Despite this new policy, the level of interest in flexible scheduling remains undefined. We sought to determine why residents and program directors (PDs) are interested in flexible tracks and to understand implementation barriers. DESIGN National survey. SETTING All United States general surgery residency programs that participate in the Association of Program Directors in Surgery listserv. PARTICIPANTS PDs and categorical general surgery residents in the United States. MAIN OUTCOME MEASURES Attitudes about flexible tracks in surgery training. A flexible track was defined as a schedule that allows residents to pursue nonclinical time during residency with resulting delay in residency completion. RESULTS Of the 748 residents and 81 PDs who responded, 505 residents and 45 PDs were supportive of flexible tracks (68% vs 56%, p = 0.03). Residents and PDs both were interested in flexible tracks to pursue research (86% vs 82%, p = 0.47) and child bearing (69% vs 58%, p = 0.13), but residents were more interested in pursuing international work (74% vs 53%, p = 0.004) and child rearing (63% vs 44%, p = 0.02). Although 71% of residents believe that flexible-track residents would not be respected as the equal of other residents, only 17% of PDs indicated they would not respect flexible-track residents (p < 0.001). CONCLUSION Most residents and PDs support flexible tracks, although they differ in their motivation and perceived barriers. This finding lends support to the new policy of the American Board of Surgery.

Laparoscopic surgery for Crohn's disease?--a conditional yes.

Beginning with the introduction of laparoscopic cholecystectomy a little more than a decade ago, minimally invasive techniques have revolutionized abdominal surgery. Since that time, it has been established that virtually any abdominal operation can be performed through the laparoscope. For the most part, the introduction of these procedures has been driven by technologic innovation and patient demand in the absence of randomized trials demonstrating their benefits. For some procedures, such as laparoscopic cholecystectomy and Nissen fundoplication, the advantages are obvious. In the case of others, such as splenectomy and probably herniorrhaphy, the benefits are less marked but still demonstrable. Finally, it appears that some complex operations, such as laparoscopic pancreatectomy and esophagectomy, while representing interesting technical exercises, are probably of no real benefit and may even be associated with increased morbidity and/or cost. In the case of laparoscopic surgery for Crohns disease (CD), the verdict is not yet in, although an increasing amount of evidence would suggest that such an approach may be appropriate in selected patients with specific indications for operation. Numerous recent studies have demonstrated the feasibility of minimally invasive intestinal surgery (1). In the case of colorectal cancer, controversies regarding the extent of lymphadenectomy and the incidence of port site recurrence have limited application and prompted randomized trials. In contrast, a range of benign intestinal conditions, including appendicitis, colonic polyps, and diverticular disease, are increasingly being approached with the laparoscope. Presumed benefits include better cosmesis and reductions in pain, and in the extent of physiologic disturbance, leading to an earlier return of gastrointestinal function, discharge, and recovery. However, at a time when earlier feeding, mobilization, and discharge have also become more common after open