Objectives
To evaluate a communication tool called “Best Case/Worst Case” (BC/WC) based on an established conceptual model of shared decision‐making.
Design
Focus group study.
Setting
Older adults ...(four focus groups) and surgeons (two focus groups) using modified questions from the Decision Aid Acceptability Scale and the Decisional Conflict Scale to evaluate and revise the communication tool.
Participants
Individuals aged 60 and older recruited from senior centers (n = 37) and surgeons from academic and private practices in Wisconsin (n = 17).
Measurements
Qualitative content analysis was used to explore themes and concepts that focus group respondents identified.
Results
Seniors and surgeons praised the tool for the unambiguous illustration of multiple treatment options and the clarity gained from presentation of an array of treatment outcomes. Participants noted that the tool provides an opportunity for in‐the‐moment, preference‐based deliberation about options and a platform for further discussion with other clinicians and loved ones. Older adults worried that the format of the tool was not universally accessible for people with different educational backgrounds, and surgeons had concerns that the tool was vulnerable to physicians’ subjective biases.
Conclusion
The BC/WC tool is a novel decision support intervention that may help facilitate difficult decision‐making for older adults and their physicians when considering invasive, acute medical treatments such as surgery.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Abstract Background Women represent roughly 50% of US medical students and one third of US surgery residents. Within academic surgery departments, however, women are disproportionately ...underrepresented, particularly at senior levels. The aim of this study was to test the hypothesis that female surgeons perceive different barriers to academic careers relative to their male colleagues. Methods A modified version of the Career Barriers Inventory–Revised was administered to senior surgical residents and early-career surgical faculty members at 8 academic medical centers using an online survey tool. Likert-type scales were used to measure respondents' agreement with each survey item. Fisher's exact test was used to identify significant differences on the basis of gender. Results Respondents included 70 women (44 residents, 26 faculty members) and 84 men (41 residents, 43 faculty members). Women anticipated or perceived active discrimination in the form of being treated differently and experiencing negative comments about their sex, findings that differed notably from those for male counterparts. Sex-based negative attitudes inhibited the career aspirations of female surgeons. The presence of overt and implicit bias resulted in a sense that sex is a barrier to female surgeons' career development in academic surgery. No differences were observed between male and female respondents with regard to career preparation or structural barriers. Conclusions Female academic surgeons experience challenges that are perceived to differ from their male counterparts. Women who participated in this study reported feeling excluded from the dominant culture in departments of surgery. This study may help guide transformative initiatives within academic surgery departments.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
IMPORTANCE: Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the ...end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. OBJECTIVE: To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. DESIGN, SETTING, AND PARTICIPANTS: Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. INTERVENTIONS: A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. MAIN OUTCOMES AND MEASURES: We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. RESULTS: The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient’s problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. CONCLUSIONS AND RELEVANCE: Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.
OBJECTIVE:To identify causes and timing of mortality in trauma patients to determine targets for future studies.
BACKGROUND:In trials conducted by the Resuscitation Outcomes Consortium in patients ...with traumatic hypovolemic shock (shock) or traumatic brain injury (TBI), hypertonic saline failed to improve survival. Selecting appropriate candidates is challenging.
METHODS:Retrospective review of patients enrolled in multicenter, randomized trials performed from 2006 to 2009. Inclusion criteria were as followsinjured patients, age 15 years or more with hypovolemic shock systolic blood pressure (SBP) ≤ 70 mm Hg or SBP 71–90 mm Hg with heart rate ≥ 108) or severe TBI Glasgow Coma Score (GCS) ≤ 8. Initial fluid administered was 250 mL of either 7.5% saline with 6% dextran 70, 7.5% saline or 0.9% saline.
RESULTS:A total of 2061 subjects were enrolled (809 shock, 1252 TBI) and 571 (27.7%) died. Survivors were younger than nonsurvivors 30 (interquartile range 23) vs 42 (34) and had a higher GCS, though similar hemodynamics. Most deaths occurred despite ongoing resuscitation. Forty-six percent of deaths in the TBI cohort were within 24 hours, compared with 82% in the shock cohort and 72% in the cohort with both shock and TBI. Median time to death was 29 hours in the TBI cohort, 2 hours in the shock cohort, and 4 hours in patients with both. Sepsis and multiple organ dysfunction accounted for 2% of deaths.
CONCLUSIONS:Most deaths from trauma with shock or TBI occur within 24 hours from hypovolemic shock or TBI. Novel resuscitation strategies should focus on early deaths, though prevention may have a greater impact.
IMPORTANCE: The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of ...outpatient surgical care, particularly among underserved populations, remains unknown. OBJECTIVE: To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care. DESIGN, SETTING, AND PARTICIPANTS: This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019. INTERVENTIONS: State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act. MAIN OUTCOMES AND MEASURES: Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage. RESULTS: A total of 207 176 patients (106 395 women 51.35% and 100 781 men 48.65%; mean SD age, 45.7 12.4 years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states. CONCLUSIONS AND RELEVANCE: Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.
The rapid and dynamic surgical environment requires leaders that can help guide their teams to desired outcomes while delivering patient-centered care. The need for early implementation of leadership ...curricula has been identified; however, most available leadership curricula are tailored for faculty and not embedded within surgery training. The ideal intervention(s) to close this gap while addressing the unique challenges of the demanding surgical training are yet to be identified. This manuscript reviews the current status of residency leadership programs and the relationship of leadership to other essential aspects for optimal training of future surgeon leaders. The use of best practice medical education frameworks is key to help guide effective and sustainable evidence-based leadership curricula. The collaboration, standardization, and publication of leadership curricula for surgery residents can serve as prototypes to address specific needs at different training institutions with the aim of equipping surgeons with the necessary leadership tools for their success.
•Current status of leadership programs in general surgery.•Education frameworks and evidence-based leadership curricula.•Leadership, well-being, and patient safety.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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