Thomas R. Russell

Burnout and career satisfaction among American surgeons.

Objective:To determine the incidence of burnout among American surgeons and evaluate personal and professional characteristics associated with surgeon burnout. Background:Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work. A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among American surgeons. Methods:Members of the American College of Surgeons (ACS) were sent an anonymous, cross-sectional survey in June 2008. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments. Results:Of the approximately 24,922 surgeons sampled, 7905 (32%) returned surveys. Responders had been in practice 18 years, worked 60 hours per week, and were on call 2 nights/wk (median values). Overall, 40% of responding surgeons were burned out, 30% screened positive for symptoms of depression, and 28% had a mental QOL score >1/2 standard deviation below the population norm. Factors independently associated with burnout included younger age, having children, area of specialization, number of nights on call per week, hours worked per week, and having compensation determined entirely based on billing. Only 36% of surgeons felt their work schedule left enough time for personal/family life and only 51% would recommend their children pursue a career as a physician/surgeon. Conclusion:Burnout is common among American surgeons and is the single greatest predictor of surgeons’ satisfaction with career and specialty choice. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the mental health of American surgeons.

Percutaneous gastrostomy: A new simplified and cost-effective technique☆

A refined endoscopically controlled percutaneous tube gastrostomy has been described in detail, and the experience gained in 28 patients has been reported herein. A majority of the patients had severe underlying neurologic disorders, malignancy of the oral pharynx or esophagus or chronic intestinal obstruction due to advanced malignancy. The three groups of patients were analyzed regarding mortality and morbidity. Three minor complications occurred in the entire group, and three in-hospital deaths occurred which were unrelated to the tube. In addition, four other patients died from their underlying disease several months after discharge from the hospital. Analysis of this technique has shown it to be safe, easy to perform, and acceptable to the patients and supporting personnel. A cost analysis showed significant savings when this technique was utilized instead of operative gastrostomy.

Effect of Delay to Operation on Outcomes in Adults With Acute Appendicitis

OBJECTIVE To examine the effect of delay from surgical admission to induction of anesthesia on outcomes after appendectomy for acute appendicitis in adults. DESIGN Retrospective cohort study with the principal exposure being time to operation. Regression models yielded probabilities of outcomes adjusted for patient and operative risk factors. SETTING Data were submitted to the American College of Surgeons National Surgical Quality Improvement Program database from January 1, 2005, through December 31, 2008. PATIENTS Patients with acute appendicitis who underwent an appendectomy. MAIN OUTCOME MEASURES Thirty-day overall morbidity and serious morbidity/mortality. RESULTS Of 32,782 patients, 24,647 (75.2%) underwent operations within 6 hours of surgical admission, 4934 (15.1%) underwent operations more than 6 through 12 hours, and 3201 (9.8%) underwent operations more than 12 hours after surgical admission. Differences in operative duration (51, 50, and 55 minutes, respectively; P < .001) were statistically significant but not clinically meaningful. The length of postoperative stay (2.2 days for the >12-hour group vs 1.8 days for the remaining groups; P < .001) was statistically significant but not clinically meaningful. No significant differences were found in adjusted overall morbidity (5.5%, 5.4%, and 6.1%, respectively; P = .33) or serious morbidity/mortality (3.0%, 3.6%, and 3.0%, respectively; P = .17). Duration from surgical admission to induction of anesthesia was not predictive in regression models for overall morbidity or serious morbidity/mortality. CONCLUSIONS In this retrospective study, delay of appendectomy for acute appendicitis in adults does not appear to adversely affect 30-day outcomes. This information can guide the use of potentially limited operative and professional resources allocated for emergency care.

Use and Outcomes of Laparoscopic-Assisted Colectomy for Cancer in the United States

BACKGROUND Laparoscopic-assisted colectomy (LAC) has gained acceptance for the treatment of colon cancer. However, long-term outcomes of LAC have not been examined at the national level outside of experienced centers. OBJECTIVE To compare use and outcomes of LAC and open colectomy (OC). DESIGN Retrospective cohort study. SETTING National Cancer Data Base. PATIENTS Patients who underwent LAC (n = 11 038) and OC (n = 231 381) for nonmetastatic colon cancer (1998-2002). MAIN OUTCOME MEASURES Regression methods were used to assess use and outcomes of LAC compared with OC. RESULTS Laparoscopic-assisted colectomy use increased from 3.8% in 1998 to 5.2% in 2002 (P < .001). Patients were significantly more likely to undergo LAC if they were younger than 75 years, had private insurance, lived in higher-income areas, had stage I cancer, had descending and/or sigmoid cancers, or were treated at National Cancer Institute-designated hospitals. Compared with those undergoing OC, patents undergoing LAC had 12 or more nodes examined less frequently (P < .001), similar perioperative mortality and recurrence rates, and higher 5-year survival rates (64.1% vs 58.5%, P < .001). After adjusting for patient, tumor, treatment, and hospital factors, 5-year survival was significantly better after LAC compared with OC for stage I and II but not for stage III cancer. Highest-volume centers had comparable short- and long-term LAC outcomes compared with lowest-volume hospitals, except highest-volume centers had significantly higher lymph node counts (median, 12 vs 8 nodes; P < .001). CONCLUSIONS Laparoscopic-assisted colectomy and OC outcomes are generally comparable in the population. However, survival was better after an LAC than after an OC in select patients.

Surgeon distress as calibrated by hours worked and nights on call

BACKGROUND The relationships of working hours and nights on call per week with various parameters of distress among practicing surgeons have not been previously examined in detail. STUDY DESIGN More than 7,900 members of the American College of Surgeons responded to an anonymous, cross-sectional survey. The survey included self-assessment of their practice setting, a validated depression screening tool, and standardized assessments of burnout and quality of life. RESULTS There was a clear gradient between hours and burnout, with the prevalence of burnout ranging from 30% for surgeons working <60 hours/week, 44% for 60 to 80 hours/week, and 50% for those working >80 hours/week (p < 0.001). When correlated with number of nights on call, burnout exhibited a threshold effect at ≥2 nights on call/week (≤1 nights on call/week, 30%; ≥2 nights on call/week, 44% to 46%; p < 0.0001). Screening positive for depression rate also correlated strongly with hours and nights on call (both p < 0.0001). Those who worked >80 hours/week reported a higher rate of medical errors compared with those who worked <60 hours/week (10.7% versus 6.9%; p < 0.001), and were twice as likely to attribute the error to burnout (20.1% versus 8.9%; p = 0.001). Not surprisingly, work and home conflicts were higher among surgeons who worked longer hours or had ≥2 nights on call. A significantly higher proportion of surgeons who worked >80 hours/week or had >2 nights on call/week would not become a surgeon again (p < 0.0001). CONCLUSIONS Number of hours worked and nights on call per week appear to have a substantial impact on surgeons, both professionally and personally. These factors are strongly related to burnout, depression, career satisfaction, and work and home conflicts.

Professionalism in surgery

Russell L Gruen, MBBS, Jyoti Arya, MD, Ellen M Cosgrove, MD, Richard L Cruess, MD, Sylvia R Cruess, MD, A Brent Eastman, MD, FACS, P Jeffrey Fabri, MD, FACS, Paul Friedman, MD, FACS, Thomas D Kirksey, MD, FACS, Ira J Kodner, MD, FACS, Frank R Lewis, MD, FACS, Kathleen R Liscum, MD, FACS, Claude H Organ, MD, FACS, Joel C Rosenfeld, MD, FACS, Thomas R Russell, MD, FACS, Ajit K Sachdeva, MD, FACS, Elvin G Zook, MD, FACS, Alden H Harken, MD, FACS

Low rectovaginal fistulas: Approach and treatment☆

Experience with thirty-two patients with a low rectovaginal fistula with or without attendant sphincter damage is reported. The technic used is advancement of the anterior rectal wall with excision of the infected anal glandular tissue and repair of muscle tissue when indicated. Anorectal infection and childbirth injuries were the common causes. An acceptable recurrence rate was achieved. Colostomy was not used in this series.

Interleukin-1β Activity and Collagen Synthesis in Human Dental Pulp Fibroblasts

Immunopathologic reactions play a significant role in inflammatory diseases of dental pulp. Interleukin-1beta (IL-1beta) is recognized as a key player in mediating cellular immune response. In this study, we measured the content of IL-1beta and its effect on collagen synthesis in cultures of fibroblasts derived from healthy and diseased dental pulps. We found that diseased pulp fibroblasts contain 2.5-fold greater amounts of IL-1beta and synthesized 80% greater amounts of collagen compared with healthy pulp fibroblasts. However, exogenous IL-1beta failed to stimulate collagen synthesis by diseased fibroblasts, whereas collagen synthesis by healthy pulp fibroblasts was stimulated by more than 2-fold. These observations imply that pulp disease induces abnormalities associated with fibroblast response toward IL-1beta.

Appendicitis in acquired immunodeficiency syndrome.

Reports in the surgical literature are few regarding common intra-abdominal disease processes, such as gallstone disease or appendicitis, in patients with AIDS and instead have focused on AIDS-related intra-abdominal diseases that infrequently require surgical intervention unless complicated by bleeding, obstruction, or perforation. A literature review for appendicitis in AIDS patients revealed only 30 well-documented cases drawn from 13 studies, with a 40% perforation rate and frequent delays and errors in diagnosis. A 7-year experience with 28 patients with appendicitis and AIDS from 4 urban San Francisco hospitals is reviewed. There were no perioperative deaths and an 18% postoperative complication rate. Five patients (18%) were found to have normal appendices with other intra-abdominal pathology, and an AIDS-related etiology for appendicitis was discovered in 7 of 23 patients with appendicitis (30%). With the exception of diffuse versus localized abdominal pain, no preoperative symptom or sign was useful in differentiating AIDS-related and non-AIDS-related disease. Aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended.

Inpatient Surgery in California: 1990-2000

BACKGROUND The practice environment for surgery is changing. However, little is known regarding the trends or current status of inpatient surgery at a population level. HYPOTHESIS Inpatient surgical care has changed significantly over the last 10 years. DESIGN Longitudinal analysis of California inpatient discharge data (January 1, 1990, through December 31, 2000). SETTING All 503 nonfederal acute care hospitals in California. PATIENTS All inpatients undergoing general, vascular, and cardiothoracic surgery in California from January 1, 1990, through December 31, 2000, were obtained. MAIN OUTCOME MEASURES Volume, mean age, comorbidity profile, length of hospital stay, and in-hospital mortality were obtained for inpatient general, vascular, and cardiothoracic surgical procedures performed during the period 1990 to 2000. Rates of change and trends were evaluated for the 10-year period. RESULTS Between January 1, 1990, and December 31, 2000, 1.64 million surgical procedures were performed. The number of surgical procedures increased 20.4%, from 135,795 in 1990 to 163,468 in 2000. Overall, patients were older and had more comorbid disease in 2000 compared with 1990. Both crude and adjusted (by type of operation) in-hospital mortality decreased from 3.9% in 1990 to 2.75% (P<.001) and 2.58% (P<.001), respectively, in 2000. Length of hospital stay decreased over the period for all operations analyzed. CONCLUSIONS The total number of inpatient general, vascular, and cardiothoracic surgical procedures has increased over the past decade. Furthermore, our findings indicate that the outcomes of care (eg, in-hospital mortality and length of hospital stay) for patients who undergo general, vascular, and cardiothoracic surgical procedures have improved. However, continued evaluations at the population level are needed.