INTRODUCTION:The American Board of Surgery (ABS) recertification process is required to maintain certification. We hypothesized that the percentage of women becoming certified in General Surgery (GS) has increased over the past 40 years and that they stay in the workforce for a shorter period of time than their male counterparts. METHODS:This is a retrospective study using deidentified ABS data. Descriptive statistics and Chi-square were used to compare male and female recertification rates. Significance was set at a p-value less than 0.05. RESULTS:The percentage of women obtaining initial certification had a statistically significant increase over time. Female surgeons that achieved initial certification between 1998 and 2007 were seen to achieve first recertification at a higher rate. Despite that, maintaining recertification over subsequent decades lags behind that of male surgeons, specifically at the second recertification - 20-year time point. CONCLUSION:Overall, these data align with studies showing that female physicians exit the workforce at higher rates. This discrepancy in long-term recertification represents an opportunity to improve our clinical work environments so that all surgeons can thrive and have long, productive careers.

BACKGROUND:Existing research exploring predictors of success on American Board of Surgery (ABS) examinations focused on either resident or residency program characteristics, but limited studies focus on both. This study examines relationships between both resident and program characteristics and ABS qualifying (QE) and certifying examination (CE) outcomes. STUDY DESIGN:Multilevel logistic regression was used to analyze the relationship between resident and program characteristics and ABS QE and CE first attempt pass and eventual certification. Resident characteristics were gender, international medical graduate (IMG) status, and previous performance, measured by the first attempt US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge and Step 3 scaled scores. Program characteristics were size, %female, %IMG, and program type. The sample included surgeons with QE and CE data from 2007 to 2019 and matched USMLE scores. RESULTS:Controlling for other variables, previous medical performance positively related to all ABS examination outcomes. The relationships between USMLE scores and success on ABS examinations varied but were generally strong. Other resident characteristics that predicted ABS examination outcomes were gender and IMG (QE first attempt pass). The only program characteristic that significantly predicted ABS outcomes was %IMG (QE and CE first attempt pass). Despite statistical significance, gender, IMG, and %IMG translated to small differences in predicted probabilities of ABS examination success. CONCLUSIONS:This study highlights resident and program characteristics that predict success on ABS examinations. USMLE scores consistently and strongly related to ABS examination success, providing evidence that USMLE scores relate to future high-stakes consequences like board certification. After controlling for previous performance, gender, IMG, and program %IMG significantly related to ABS examination success, but effects were small.

OBJECTIVE:To apply the EQual rubric to the American Board of Surgery General Surgery EPAs in order to evaluate their quality and identify opportunities for refinement. DESIGN:The EPAs were evaluated using the EQual rubric by 4 current or former program directors. All items from the rubric which were shown to have generalizability were included in the assessment on 5-point Likert scales. Raters were trained to ensure consistent application of the rubric. Each participant independently completed the rubric and statistical analysis was performed. SETTING:Current or former program directors at tertiary academic centers. PARTICIPANTS:Raters were identified based on their leadership roles in general surgery programs and scholarship in surgical education research. RESULTS:The composite mean score of all EPAs was 4.63 (0.19), which is greater than the EQual study cutoff of 4.07 used to identify EPAs requiring major revisions. Each EPA also individually scored above this cutoff. However, 3 EPAs: Provide Surgical Consultation, Gastrointestinal Endoscopy, and Peri-operative Care of the Critically Ill Surgical Patient scored below the cutoff score for the Discrete Unit of Work domain. Each of these 3 EPAs additionally scored one or more standard deviations below the composite mean. CONCLUSIONS:While all of the ABS General Surgery EPAs scored above the major revision cutoff, 3 EPAs scored significantly lower than the others, indicating an opportunity for revisions or restructuring. Use of this objective tool could be valuable in the iterative development and revision of future EPAs.

BACKGROUND:We aimed to identify clinical features of patients who most benefitted from resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS:Adult patients treated with REBOA were identified in the Japan Trauma Data Bank (2019-2022), and phenotype analyses were conducted. An estimated survival rate was calculated for each patient treated with REBOA adjusting for background and institution characteristics, which was compared with a general probability of survival calculated with Trauma and Injury Severity Score probability of survival. Patients were divided into four groups: notably higher, higher, notably lower, and lower survival than expected (>15% higher, 0-15% higher, ≥15% lower, and 0-15% lower than Trauma and Injury Severity Score probability of survival, respectively) groups. Then, clinical features were identified in patients with notably higher survival as significantly inclining/declining variables across the groups. In the validation using 2010 to 2018 database, patients with these clinical features were selected, and in-hospital survival was compared between those with and without REBOA. RESULTS:Among 805 patients treated with REBOA, 180 (22.4%) had notably higher, and 240 (29.8%) had higher survival than expected. Glasgow Coma Scale score of ≤6, systolic blood pressure of ≤70 mm Hg, Abbreviated Injury Scale (AIS) in abdomen score of ≥3, and AIS in extremity/pelvis score of ≥4 were identified as the clinical features of patients with notably higher survival than expected. In the validation, 236 patients met all the identified features, and those with REBOA showed higher survival to discharge than those without (8/39 [21.6%] vs. 13/197 [7.3%]; odds ratio, 3.52 [1.34-9.25]) and more frequently underwent laparotomy and angiography for pelvis (odds ratio, 2.52 [1.24-5.11] and 2.31 [1.08-4.95], respectively). CONCLUSION:Patients with Glasgow Coma Scale score of ≤6, systolic blood pressure of ≤70 mm Hg, AIS in abdomen score of ≥3, and AIS in extremity/pelvis score of ≥4 were most likely to benefit from REBOA and had a higher survival rate by >30% than general trauma population treated without REBOA. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.

Objective: Historically, the American Board of Surgery required surgeons to pass the qualifying examination (QE) before taking the certifying examination (CE). However, in the 2020-2021 academic year, with mitigating circumstances related to COVID-19, the ABS removed this sequencing requirement to facilitate the certification process for those candidates who were negatively impacted by a QE delivery failure. This decoupling of the traditional order of exam delivery has provided a natural comparator to the traditional route and an analysis of the impact of examination sequencing on candidate performance. Methods: All candidates who applied for the canceled July 2020 QE were allowed to take the CE before passing the QE. The sample was then reduced to include only first-time candidates to ensure comparable groups for performance outcomes. Logistic regression was used to analyze the relationship between the order of taking the QE and the CE, controlling for other examination performance, international medical graduate status, and gender. Results: Only first-time candidates who took both examinations were compared (n=947). Examination sequence was not a significant predictor of QE pass/fail outcomes, OR=0.54; 95% CI, 0.19–1.61, P =0.26. However, examination sequence was a significant predictor of CE pass/fail outcomes, OR=2.54; 95% CI, 1.46–4.68, P =0.002. Conclusions: This important study suggests that preparation for the QE increases the probability of passing the CE and provides evidence that knowledge may be foundational for clinical judgment. The ABS will consider these findings for examination sequencing moving forward.

The practice of surgical critical care (SCC) has traditionally necessitated additional in-house, extended night and weekend clinical commitments, which can be viewed as less desirable for many surgeons. Therefore, the authors have observed that some SCC surgeons elect to transition their practice to focus solely on general surgery (GS) rather than continuing practicing both SCC and GS. We hypothesized that surgeons with a practice focused on SCC are more likely to make the transition to a GS practice than those who have certification in other subspecialties that are certified through the American Board of Surgery.

INTRODUCTION:North American pit viper envenomation occurs over 4,000 times annually in the United States, with polyvalent Fab antivenom being the primary treatment. Fasciotomy is occasionally performed due to concerns about compartment syndrome. We utilized our direct access to Texas Poison Center Network data to create a new snakebite abstraction form and database on relevant available information between 2004 and 2021 and to identify, describe, and estimate the incidence of fasciotomy following pit viper envenomation in Texas. METHODS:We searched the Texas Poison Center Network database for cases during 2004-2021 using keywords such as fasciotomy, surgery, compartment pressure, and compartment syndrome. Descriptive statistics summarized the data. RESULTS:Of 16,911 reported envenomations, 0.69 percent involved fasciotomies (n = 117). Most common bite sites were digits/hands and lower extremities. Patients who underwent fasciotomy were typically male, aged 20-59, and 10 years younger than the total snakebite population. Only 6 percent of reported compartment syndrome cases had a compartment pressure measurement. Antivenom was administered in 101 (86.3 percent) cases, 92 (91.1 percent) of which received only Fab antivenom product. Patients with bites from rattlesnakes (47.9 percent) were associated with most fasciotomies. DISCUSSION:Our findings suggest a potential increase in snakebite exposures, accompanied by a decrease in fasciotomies. Overall, copperheads constituted the majority of snakebites, but most fasciotomies were from rattlesnake envenomations (47.9 percent). In this cohort, compartment syndrome diagnosis and decisions regarding fasciotomy were primarily based on clinical evaluation/surgeon expertise without compartment pressure measurements. Despite the efficacy of antivenom, only 86.3 percent of patients in our study received antivenom. CONCLUSIONS:Fasciotomy after North American pit viper envenomation in Texas is uncommon (0.69 percent) and has decreased over time, possibly due to increased antivenom use or surgeon comfort with nonsurgical management.

No abstract is necessary for an invited commentary.

OBJECTIVEThe goals of this study were (1) to assess if examiner ratings in the American Board of Surgery (ABS) General Surgery Cetifying Exam (CE) are biased based on the gender, race, and ethnicity of the candidate or the examiners, and (2) if the format of delivering of the exams, in-person or virtual, affects how examiners rate candidates.DESIGNWe included every candidate-examiner combination for first time takers of the general surgery oral exam. Total scores and pass/fail outcomes based on the 4 scores given by examiners to candidates were analyzed using multilevel models, with candidates as random effects. Explanatory variables included the gender, race, and ethnicity of candidates and examiners, and the format of the exam (in-person or virtual). Candidates’ first attempt scores on the ABS General Surgery Qualifying Exam (QE) were also included in the models to control for the baseline knowledge of the candidate. Three sets of models were evaluated for each demographic variable (gender, race, ethnicity) due to missingness in data. p-values and coefficients of determination R2 were used to quantify the statistical and practical significance of the model coefficients (an existent relationship between the explored variables on CE scores was considered statistically and practically significant if the p-value was lower than 0.01 and R2 higher than 1%).PARTICIPANTSAll first-time takers of the American Board of Surgery General Surgery Certifying Exam from 2016 to 2022 that had demographic data, and the examiners that participated in those exams.RESULTSThe number of candidates/examiners for the 3 sets of models was 8665/514 (gender), 5906/465 (race), and 4678/295 (ethnicity). The demographic variables, format of the exam, or their interactions were not found to significantly relate to examiner-candidate ratings or pass/fail outcomes. The only variable that was significantly related to CE scores was candidates’ QE scores, which was added to the models as a measure of candidates’ initial knowledge; this held for all models for total scores (F[1,8659] = 1069.89, p-value < 0.01, R2 = 5% [gender models], F(1,5696.3) = 589.13, p-value < 0.01, R2 = 5% [race models], F(1,4459.5) = 278.33, p-value < 0.01, R2 = 5% [ethnicity models]), and pass/fail outcomes (CI = 1.61-1.73, p-value < 0.01, R2 = 3% [gender models], CI = 1.67-1.85, p-value < 0.01, R2 = 3% [race models], CI = 2.17-2.90, p-value < 0.01, R2 = 3% [ethnicity models]).CONCLUSIONSThis study shows that there is not a relationship between candidate and examiner gender, race, or ethnicity, and exam outcomes based on statistical models looking at examiner-candidate ratings and pass/fail outcomes. In addition, the delivery of the certifying exam in a virtual format appears to have no statistical impact on outcomes compared to in-person delivery. This suggests that the ABS is performing well in both demographic bias and virtual space.

Injuries to the small intestine and colon are found in less than 5% of victims of blunt abdominal trauma but are the most common injuries sustained after penetrating abdominal trauma. There is no consensus on the issue of stapled versus hand-sewn anastomosis after small bowel or colon resection for trauma. The hand-sewn anastomosis may be preferable in situations where the portion of the intestine under consideration for anastomosis is edematous or is at risk of becoming edematous, such as in a patient requiring a large-volume resuscitation. Injury to the small intestine has not been shown to result in a high rate of infectious complications, and skin closure after small bowel trauma is generally recommended. The debate of antibiotic duration following trauma laparotomy in general and colon injury in particular continues. Despite the lack of truly definitive trials, it is advisable to limit antibiotic prophylaxis to no more than 24 hours after laparotomy for intestinal injury.

Introduction: To explore gender discrepancies in publications at general surgery departments, we performed a cross-sectional comparing the number of women and men at each academic rank and their number of first author (FA), middle author (MA), last author (LA), and total publications.Methods: Thirty academic general surgery departments were randomly selected. For each faculty, we tabulated: first, middle, last names, gender, academic rank, educational leadership, year of medical school graduation, and additional graduate degrees. Bibliography, H-index, and citations were downloaded from the Scopus database.Results: One thousand three hundred twenty-six faculty sampled, 881 (66.4%) men and 445 (33.5%) women. Men outnumbered women at all ranks, with increasing disparity at higher ranks. Men outnumbered women in all subspecialtiesdlargest difference in transplant surgery (84.4% versus 15.6%, P < 0.001). Men at all ranks had more MA publications: assistant professor (rate ratio 1.20; 95% confidence interval, 1.01-1.43, P = 0.024), associate professor (1.65; 1.31-2.06, P < 0.001), and professor (1.50; 1.20-1.91, P = 0.008). Men associate professors had more LA publications (1.74; 1.34-2.37, P < 0.001). No differences found in FA publications at any rank, nor LA publications at assistant professor and professor ranks. At subspecialty level, men in surgical oncology (1.95; 1.55-2.45, P < 0.001) and transplant surgery (1.70; 1.09-2.66, P = 0.02) had more MA publications.Conclusions: While FA and LA publications did not differ significantly across genders, the largest difference lies in MA publications, beginning at junior ranks and persisting with seniority. Discrepancies in MA publications may reflect gender discrepancies in collaborative opportunities, hence total publications should be used cautiously when determining academic productivity.

INTRODUCTION: Explored the diversity and inclusion of our annual meeting. The authors compared our mem-bers' diversity to the participation in the impactful por-tions of our annual conference as a measure of our organizational inclusion. METHODS: The authors retrospectively reviewed and calculated the diversity demographics of our member-ship based on our 2022 data. Demographics consisted of institutional affiliation and gender. Also the authors ret-rospectively analyzed the topics discussed at our annual meeting from 2010 to 2022. RESULTS: In 2022, the Association of Program Directors in Surgery (APDS) had 308 members; while we had 100% of the institutional affiliation, most members did not self-report gender or ethnicity information. One hun-dred eleven members self-reported gender information in 2022: 76% were men and 24% were women. Fifty-seven percent of our institutions had a medical school affiliation, 40% had a nonmedical school affiliation, and 3% had a military instillation affiliation. CONCLUSION: The authors' current analysis demon-strates disparities in the distribution of meaningful space in the APDS meeting program. Future efforts are ongoing to identify members and their demographics, track par-ticipation, and encourage more diverse involvement across membership. ( J Surg Ed 80:1648-1652. (c) 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

OBJECTIVE: Mistreatment is widespread in graduate medical education, and much attention has been gener-ated on this topic and its relationship to burnout in gen-eral surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma -as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solv-ing difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreat-ment in a surgery residency. FT starts with the perfor-mance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the sit-uation ending in a collective solution. DESIGN: Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the resi-dents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, correc-tive feedback with the understanding this would be pre-sented to the residency at large. Following this, they developed a scenario for enactment which was imple-mented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situa-tion until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered. SETTING: General surgery residency at University of Texas Health San Antonio. PARTICIPANTS: General surgery residents. 32 of 66 (48.5%) residents participated. RESULTS: Participants noted an improved understanding of mistreatment, felt more confident in recognizing mis-treatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to rec-ognize when they themselves were involved in mistreat-ment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended par-ticipating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professional-ism. These trends remained steady in the survey 6 months after the intervention as well. CONCLUSIONS: We found FT was feasible to imple-ment in a busy general surgery residency and well received with sustained, self-reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT inter-ventions can be tailored to the local culture to address conflicts specific to that setting. (J Surg Ed 80:563-571. (c) 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction A 2020 survey of post-graduate year 5 (PGY5) general surgery residents linked to the American Board of Surgery In-Training Examination (ABSITE) revealed significant deficits in self-efficacy (SE), or personal judgment of one’s ability to complete a task, for 10 commonly performed operations. Identifying whether this deficit is similarly perceived by program directors (PDs) has not been well established. We hypothesized that PDs would perceive higher levels of operative SE compared to PGY5s. Methods A survey was distributed through the Association of Program Directors in Surgery listserv; PDs were queried about their PGY5 residents’ ability to perform the same 10 operations independently and their accuracy of patient assessments and operative plans for components of several core entrustable professional activities (EPAs). Results of this survey were compared to PGY5 residents’ perception of their SE and entrustment based on the 2020 post-ABSITE survey. Chi-squared tests were used for statistical analysis. Results 108 responses were received, representing ∼32% (108/342) of general surgery programs. Perceptions from PDs of PGY5 residents’ operative SE were highly concordant with resident perceptions; no significant differences were observed for 9 of 10 procedures. Both PGY5 residents and PDs perceived adequate levels of entrustment; no significant differences were observed for 6 of 8 EPA components. Conclusions These findings show concordance between PDs and PGY5 residents in their perceptions of operative SE and entrustment. Though both groups perceive adequate levels of entrustment, PDs corroborate the previously described operative SE deficit, illustrating the importance of improved preparation for independent practice.

Dr. Steven Wexner: I would like to welcome everyone to this month's episode of the Diversity, Equity, and Inclusion series, in alliance with the American College of Surgeons, proceedings From the Advances in Surgery (AIS) Channel's Diversity, Equity, and Inclusion Series: Microaggressions: Lessons Learned from Black Academic Surgeons. 1 Advances in Surgery Channel Diversity Equity and inclusion series: microagressions Lessons Learned from black academic surgeons. https://aischannel.com/Date accessed: April 29, 2022 Google Scholar I am very gratified that each of these broadcasts during the last several months have attracted over 30,000 surgeons from over 100 countries.

OBJECTIVE: To develop the future of United States (US) surgical education leadership, surgical trainees and early career faculty who aspire to become program directors (PDs) must understand the potential career pathways and requisite skills and experience to become a general surgery residency PD. The objective of this study was to understand the demographics, career experiences, and professional satisfaction of US PDs in general surgery.DESIGN: An anonymous, cross-sectional survey utilizing a novel instrument.SETTING: An electronic survey distributed to US general surgery PDs between June and November 2022PARTICIPANTS: PDs of US general surgery residency programs. A list of the Accrediting Council for Graduate Medical Education (ACGME)-accredited general surgery PDs was created from the ACGME list from the 2022 to 23 academic year.RESULTS: The survey achieved a response rate of 46.2% (159/344). Only 32.1% of PDs identified as female and 67.3% identified as male with 1 respondent preferring not to identify their gender. PDs were White or Caucasian (68.6%), Asian (13.8%), and Black (3.7%); 4.4% were Hispanic or Latino. Only 83.7% of PDs completed fellowship training. PDs have been in the role for an average of 5.5 +/- 4.9 years. The PDs were compensated for an average of 54.7% (+/- 14.9% SD, 0%-100% range) of their time towards clinical duties. They were compensated on average for 35.7% (+/- 12.6%, 0%-100%) of effort for residency related administrative duties. Only 5% of PDs had obtained or were enrolled in an education-related degree. Only 55.4% of PDs had received formal surgical education training in teaching and assessment. 54.1% of PDs were interested in obtaining a more senior leadership position in the future. Most PDs (38.4%) expect to serve as PD for 5 to 8 years in total. Overall, the majority of PDs were very satisfied (29.6%) or satisfied (51.6%) professionally; similarly 28.9% were very satisfied and 48.4% satisfied personally.CONCLUSIONS: This study represents the most up-todate characterization of the personal, academic, and career-related features of current surgical residency PDs across the US. PDs enjoy a high degree of professional and personal satisfaction and most aspire to increasing leadership within their organizations. Compared to prior data, PDs have become more diverse in terms of both gender and race over time. Opportunities exist for increased mentorship of aspiring and current PDs as well as increased training in teaching and assessment. (J Surg Ed 80:1653-1662. (c) 2023 Published by Elsevier Inc. on behalf of Association of Program Directors in Surgery.)

BACKGROUND:Mentorship plays a critical role in the career development of surgical trainees and faculty. As the surgical workforce continues to diversify, mentoring trainees who differ) race, ethnicity, country of origin, socioeconomic status, educational background, religion, gender, sexual orientation or ability) can pose challenges to the experience for both mentor and mentee.OBJECTIVE:The aim of this manuscript is to introduce surgical educators to the systemic barriers faced by trainees and to models of effective mentorship.METHODS:At the 2022 APDS Meeting, a panel convened to highlight the current challenges of mentoring across differences and effective models for surgical educators. This paper highlights and expands the summary of this panel.RESULTS:Examples of novel mentoring models are described.CONCLUSIONS:Acknowledgment of barriers, Implementation of deliberate mentoring strategies, and collaboration with national surgical organizations and surgery departments and faculty may help to reduce physician attrition.

Background: The COVID-19 pandemic decreased the operative case volume for surgical residents. Our institution implemented Entrustable Professional Activities (EPAs) in all core surgical training programs to document the competency of graduating residents. Continuation of this project aimed to improve implementation. Methods: This project occurred at a large academic center with eight surgical specialties during the 2020-21 (Year 1) and 2021-22 (Year 2) academic years. Each specialty chose five EPAs, and residents were asked to obtain three micro-assessments per EPA. After the initial pilot year, program directors were surveyed regarding perceptions of EPA utility and barriers to implementation. Results: Seventy senior residents completed 732/906 (80.8%) micro-assessments. Of these, 99.6% were deemed practice ready. Total micro-assessment completion rates in four specialties, four specific EPAs (including one EPA identified "at risk" due to the COVID-19 pandemic), and overall were significantly higher in Year 2 than Year 1 (p < 0.05) Conclusions: Implementing EPAs in all core surgical specialties at an institution is achievable, though expectedly initially imperfect. An ongoing quality collaborative initiative focused on barriers to implementation can improve completion rates.