Burnout among physicians affects mental health, performance, and patient outcomes. Surgery residency is a high-risk time for burnout. We examined burnout and the psychological characteristics that ...can contribute to burnout vulnerability and resilience in a group of surgical trainees.
An online survey was distributed in September 2016 to all ACGME-accredited general surgery programs. Burnout was assessed with an abbreviated Maslach Burnout Inventory. Stress, anxiety, depression, resilience, mindfulness, and alcohol use were assessed and analyzed for prevalence. Odds ratios (ORs) were used to determine the magnitude of presumed risk and resilience factors.
Among 566 surgical residents who participated in the survey, prevalence of burnout was 69%, equally driven by emotional exhaustion and depersonalization. Perceived stress and distress symptoms (depression, suicidal ideation, and anxiety) were notably high across training levels, but improved during lab years. Higher burnout was associated with high stress (OR 7.8; p < 0.0001), depression (OR 4.8; p < 0.0001), and suicidal ideation (OR 5.7; p < 0.0001). In contrast, dispositional mindfulness was associated with lower risk of burnout (OR 0.24; p < 0.0001), stress (OR 0.15; p < 0.0001), anxiety (OR 0.21; p < 0.0001), suicidal ideation (OR 0.25; p < 0.0001), and depression (OR 0.26; p = 0.0003).
High levels of burnout, severe stress, and distress symptoms are experienced throughout general surgery training, with some improvement during lab years. In this cross-sectional study, trainees with burnout and high stress were at increased risk for depression and suicidal ideation. Higher dispositional mindfulness was associated with lower risk of burnout, severe stress, and distress symptoms, supporting the potential of mindfulness training to promote resilience during surgery residency.
We previously reported encouraging results of down‐staging of hepatocellular carcinoma (HCC) to meet conventional T2 criteria (one lesion 2–5 cm or two to three lesions <3 cm) for orthotopic liver ...transplantation (OLT) in 30 patients as a test of concept. In this ongoing prospective study, we analyzed longer‐term outcome data on HCC down‐staging in a larger cohort of 61 patients with tumor stage exceeding T2 criteria who were enrolled between June 2002 and January 2007. Eligibility criteria for down‐staging included: (1) one lesion >5 cm and up to 8 cm; (2) two to three lesions with at least one lesion >3 cm and not exceeding 5 cm, with total tumor diameter up to 8 cm; or (3) four to five lesions with none >3 cm, with total tumor diameter up to 8 cm. A minimum observation period of 3 months after down‐staging was required before OLT. Tumor down‐staging was successful in 43 patients (70.5%). Thirty‐five patients (57.4%) had received OLT, including two who had undergone live‐donor liver transplantation. Treatment failure was observed in 18 patients (29.5%), primarily due to tumor progression. In the explant of 35 patients who underwent OLT, 13 had complete tumor necrosis, 17 met T2 criteria, and five exceeded T2 criteria. The Kaplan‐Meier intention‐to‐treat survival at 1 and 4 years after down‐staging were 87.5% and 69.3%, respectively. The 1‐year and 4‐year posttransplantation survival rates were 96.2% and 92.1%, respectively. No patient had HCC recurrence after a median posttransplantation follow‐up of 25 months. The only factor predicting treatment failure was pretreatment alpha‐fetoprotein >1,000 ng/mL. Conclusion: Successful down‐staging of HCC can be achieved in the majority of carefully selected patients and is associated with excellent posttransplantation outcome. (HEPATOLOGY 2008.)
IMPORTANCE: Among surgical trainees, burnout and distress are prevalent, but mindfulness has been shown to decrease the risk of depression, suicidal ideation, burnout, and overwhelming stress. In ...other high-stress populations, formal mindfulness training has been shown to improve mental health, yet this approach has not been tried in surgery. OBJECTIVE: To test the feasibility and acceptability of modified Mindfulness-Based Stress Reduction (MBSR) training during surgical residency. DESIGN, SETTING, AND PARTICIPANTS: A pilot randomized clinical trial of modified MBSR vs an active control was conducted with 21 surgical interns in a residency training program at a tertiary academic medical center, from April 30, 2016, to December 2017. INTERVENTIONS: Weekly 2-hour, modified MBSR classes and 20 minutes of suggested daily home practice over an 8-week period. MAIN OUTCOMES AND MEASURES: Feasibility was assessed along 6 domains (demand, implementation, practicality, acceptability, adaptation, and integration), using focus groups, interviews, surveys, attendance, daily practice time, and subjective self-report of experience. RESULTS: Of the 21 residents included in the analysis, 13 were men (62%). Mean (SD range) age of the intervention group was 29.0 (2.4 24-31) years, and the mean (SD range) age of the control group was 27.4 (2.1 27-33) years. Formal stress-resilience training was feasible through cultivation of stakeholder support. Modified MBSR was acceptable as evidenced by no attrition; high attendance (12 of 96 absences 13% in the intervention group and 11 of 72 absences 15% in the control group); no significant difference in days per week practiced between groups; similar mean (SD) daily practice time between groups with significant differences only in week 1 (control, 28.15 12.55 minutes; intervention, 15.47 4.06 minutes; P = .02), week 2 (control, 23.89 12.93 minutes; intervention, 12.61 6.06 minutes; P = .03), and week 4 (control, 26.26 13.12 minutes; intervention, 15.36 6.13 minutes; P = .04); course satisfaction (based on interviews and focus group feedback); and posttraining-perceived credibility (control, 18.00 4.24; intervention, 20.00 6.55; P = .03). Mindfulness skills were integrated into personal and professional settings and the independent practice of mindfulness skills continued over 12 months of follow-up (mean days SD per week formal practice, 3 1.0). CONCLUSIONS AND RELEVANCE: Formal MBSR training is feasible and acceptable to surgical interns at a tertiary academic center. Interns found the concepts and skills useful both personally and professionally and participation had no detrimental effect on their surgical training or patient care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03141190
Opposition to irresponsible global kidney exchange Delmonico, Francis L.; Ascher, Nancy L.
American journal of transplantation,
October 2017, 2017-10-00, 20171001, Letnik:
17, Številka:
10
Journal Article
IMPORTANCE: Differences in local organ supply and demand have introduced geographic inequities in the Model for End-stage Liver Disease (MELD) score–based liver allocation system, prompting national ...debate and patient-initiated lawsuits. No study to our knowledge has quantified the sex disparities in allocation associated with clinical vs geographic characteristics. OBJECTIVE: To estimate the proportion of sex disparity in wait list mortality and deceased donor liver transplant (DDLT) associated with clinical and geographic characteristics. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used adult (age ≥18 years) liver-only transplant listings reported to the Organ Procurement and Transplantation Network from June 18, 2013, through March 1, 2018. EXPOSURE: Liver transplant waiting list. MAIN OUTCOMES AND MEASURES: Primary outcomes included wait list mortality and DDLT. Multivariate Cox proportional hazards regression models were constructed, and inverse odds ratio weighting was used to estimate the proportion of disparity across geographic location, MELD score, and candidate anthropometric and liver measurements. RESULTS: Among 81 357 adults wait-listed for liver transplant only, 36.1% were women (mean SD age, 54.7 11.3 years; interquartile range, 49.0-63.0 years) and 63.9% were men (mean SD age, 55.7 10.1 years; interquartile range, 51.0-63.0 years). Compared with men, women were 8.6% more likely to die while on the waiting list (adjusted hazard ratio aHR, 1.11; 95% CI, 1.04-1.18) and were 14.4% less likely to receive a DDLT (aHR, 0.86; 95% CI, 0.84-0.88). In the geographic domain, organ procurement organization was the only variable that was significantly associated with increased disparity between female sex and wait list mortality (22.1% increase; aHR, 1.22; 95% CI, 1.09-1.30); no measure of the geographic domain was associated with DDLT. Laboratory and allocation MELD scores were associated with increases in disparities in wait list mortality: 1.14 (95% CI, 1.09-1.19; 50.1% increase among women) and DDLT: 0.87 (95% CI, 0.86-0.88; 10.3% increase among women). Candidate anthropometric and liver measurements had the strongest association with disparities between men and women in wait list mortality (125.8% increase among women) and DDLT (49.0% increase among women). CONCLUSIONS AND RELEVANCE: Our findings suggest that addressing geographic disparities alone may not mitigate sex-based disparities, which were associated with the inability of the MELD score to accurately estimate disease severity in women and to account for candidate anthropometric and liver measurements in this study.
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