The study of physician wellbeing and how best to assess it is still very much a work in progress. In this chapter, we describe several innovative approaches to the promotion of physician wellness which have been implemented at various institutions. Specifically, we identify both organizational and individual interventions and discuss their outcomes and limitations.

Abstract Reappraisal is an effective emotion regulation strategy that draws on cognitive processes–like changing one’s thoughts to change one’s feelings–that are similar to those implicated in humor. Yet, very little is known about the links between the dispositional tendency to use reappraisal and individuals’ humor styles (e. g. aggressive, affiliative, self-deprecating, self-enhancing). Importantly, there are gender differences both in emotion regulatory processes and in the use of humor styles. We examined gender differences in reported use of humor styles, the associations between reappraisal and humor styles, and whether gender moderated those associations. Participants (N=250) were recruited through Amazon Mechanical Turk and self-reported their dispositional use of reappraisal and four humor styles. Men reported greater use of aggressive humor compared to women. Dispositional use of reappraisal was positively associated with self-enhancing humor. In addition, reappraisal use was positively related to greater use of affiliative humor, and this association was stronger for men than women. For men, greater use of reappraisal was associated with greater use of self-defeating humor, but reappraisal was negatively associated with self-defeating humor for women. Findings extend insight from prior work and suggest that both reappraisal and specific ways of using humor draw on aspects of self-regulatory competence rooted in cognitive change abilities, and the patterns of association differ in interesting ways for men and women.

Background Terms such as “glass ceiling” and “sticky floor” are still commonly used to describe women’s role in academic surgery. Despite continued efforts to address disparities between men and women in the field, gender inequalities persist. Methods In this investigation we highlight gender differences in published surgical literature by both quantity and impact. Websites for departments of surgery of three academic centers were reviewed to assess the bibliometrics of publications by gender over a two-week period. Results A one-way ANOVA showed a significantly higher H-index for men than women ( p > .05). Further, one-way ANOVA showed significantly more articles published by men than women ( p = .019). These differences are most dramatic at the rank of associate professor where the H-index for men is three times that of the women. The rank of full professor showed men had double the number of articles published. Conclusions These findings align with the previous research that shows a disparity between males and females as they climb the academic ladder. Conducting and publishing research is a vital part of advancement in academic medicine. This study suggests that publication productivity may be a factor that hinders women from advancing within surgery compared to men. Continuing to explore and identify reasons for this gender difference in academic surgery may highlight ways to address the imbalance.

BACKGROUND:Declining glycemic control in type 1 diabetes (T1D) during adolescence persists despite treatment advances. Non-adherence, peer relations, diabetes burnout, risk taking, transition to autonomy, family conflict, and poor quality of life (QOL) are recognized barriers. Shared medical appointments (SMAs) in adolescent T1D may offer benefits, but data are limited. Our objective was to determine whether SMAs, with multi-component interventions utilizing multidisciplinary teams, improve glycemic control and psychosocial outcomes in poorly controlled adolescent T1D. METHODS:SMAs focused on self-management, communication skills, goal setting, glucose pattern recognition, and peer/diabetes team support. SMAs included: individual history and physical, labs, surveys, multidisciplinary educational ice breakers, group session, and individual wrap up. Outcomes were QOL, adherence, and retrospective and prospective glycemic control. Three to six subjects and families came to 3 SMAs and 1 individual appointment every 3 months over 9 months. SUBJECTS:A total of 37 English speaking subjects, ages 12-16 yrs, with T1D ≥ 1 year, and hemoglobin A1c (HbA1c) 7.5-11% enrolled. Thirty-two subjects attended 75% of visits, meeting inclusion criteria. RESULTS:HbA1c worsened in the 9 months before study (ΔHbA1c= 0.7 ± 1.2; p < 0.01), but remained stable during study (ΔHbA1c = 0.01 ± 1.2; p > 0.05). There were significant improvements in overall QOL (p = 0.005), school function (p = 0.006), psychosocial function (p = 0.008), barriers (p = 0.02), adherence (p = 0.01), and communication (p = 0.02). Improvements in school function and communication reached clinical significance. CONCLUSION:SMAs are feasible replacements to individual appointments in adolescent T1D, stabilizing glycemic control and improving QOL. Randomized controlled trials with optimizations are needed to further explore and refine this intervention.

Introduction: 26 million Americans have limited English proficiency (LEP). It is well established that language barriers adversely affect health and health care. Despite growing awareness of language barriers, there is essentially a void in the medical literature regarding the influence of language disparity on pediatric surgery patients. This study was designed to assess the impact of patient-provider language concordance on question-asking behavior and patient satisfaction for pediatric surgery patients.Methods: Participants included families of patients in a General Pediatric Surgery Clinic categorized into 3 groups by patient-provider language concordance: concordant English-speaking, LEP concordant Spanish-speaking, and LEP discordant Spanish-speaking using an interpreter. Clinical visits were audio recorded and the number of patient-initiated questions and the length of clinical encounter were measured. Families were administered a surgery-specific, 5-point Likert scale questionnaire modeled after validated surveys concerning communication, trust, perceived discrimination and patient-provider language concordance. Regression models were performed to analyze associations between language concordance and patient's question-asking behavior and between language concordance and survey results.Results: A total of 156 participants were enrolled including 57 concordant-English, 52 LEP concordant-Spanish and 47 LEP-discordant-Spanish. There was significant variation in the mean number of patient-initiated questions among the groups (p = 0.002). Both the English and Spanish concordant groups asked a similar number of questions (p = 0.9), and they both asked more questions compared to the Spanish-discordant participants (p= 0.002 and p = 0.001). Language discordance was associated with fewer questions asked after adjustment for socioeconomic status. Language concordant participants rated higher scores of communication. Both Spanish-concordant and Spanish-discordant patients reported significantly increased preference for, and value of language concordant care. Language discordant participants reported that they desired to ask more questions but were limited by a language barrier (p= 0.001).Conclusions: In a pediatric surgery clinic, language concordant care increases the number of patient-asked questions during a clinical visit and improves communication suggesting that discordant care is a potential source of disparities in access to information. Future efforts should focus on expanding access to language concordant providers in other surgery subspecialties as a step towards limiting disparities in surgical care for all patients. (c) 2016 Elsevier Inc. All rights reserved.

Background: Laparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, improve cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair.Methods: After obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collection included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up.Results: Median follow-up was 24 months (range 2-52 months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients. Demographics: mean age 29.5 months (range 1192 months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with severe congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subsequently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously).Conclusion: Laparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparoscopic skills, and result in excellent outcomes with acceptable recurrence rates. (C) 2015 Elsevier Inc. All rights reserved.

B H ereditary pancreatitis (HP) usually presents in the first or second decades of life. R122H and N29I mutations are the most common PRSS1 mutations that cause HP by enhanced trypsinogen autoactivation (1). The complications of HP include weight loss, pancreatic stones, ductal obstruction and dilatation, pseudocyst formation, ascites, insufficiency, and adenocarcinoma. We describe a child with HP and complete obstruction of the pancreatic duct by a stricture that was successfully dilated using an improvised therapeutic endoscopy method. A 7-year-old boy with a PRSS1 mutation at N291 presented to our institution in February 2008 because of sequelae from his HP. The patient was hospitalized for a large pseudocyst requiring endoscopic cystogastrostomy and later for a post-traumatic splenic hematoma. Since May 2011, the patient was seen repeatedly in the emergency department every 2 months for acute pancreatitis while on conservative medical therapy. In April 2012, the patient had unremitting epigastric pain causing prolonged school absence and weight loss. Ultrasonography revealed an increase in pancreatic duct size to 6.7 mm from 1.5 mm 2 months prior. Magnetic resonance cholangiopancreatography demonstrated dilation of the pancreatic duct in the body and tail with an abrupt cutoff in the region of the pancreatic head. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed complete obstruction of the pancreatic ducts within the head of the pancreas. The patient’s mother refused consent for his surgery because of lack of relief from total pancreatectomy for her own HP. Informed consent was thus obtained for endoscopic intervention. Cannulations of both the minor and major papillae using a sphincterotome and different guide wires failed. Hence, an attempt was made to access the pancreatic stricture by a rendezvous approach. Under endoscopic ultrasound view, the proximal pancreatic duct was punctured with the tip of a 19-gauge needle through which a 0.035 Jagwire (Boston Scientific) was advanced into the lumen of the pancreatic duct, in an attempt to manipulate across the stricture into the duodenum via the papillae. The procedure was unsuccessful, and the patient was discharged home on a clear liquid diet and parenteral nutrition.

Gastrocutaneous fistula (GCF) occurs commonly in pediatric patients after removal of long-term gastrostomy tubes. Although open repair is generally successful, endoscopic approaches may offer benefits in terms of incisional complications, postoperative pain, and procedure time. In addition, endoscopic approaches may offer particular benefit in patients with varied degrees of skin irritation or erosion surrounding a GCF, making surgical repair difficult, or patients with significant comorbidities, making minimal intervention and anesthesia time preferable. Over-the-scope (OSC) clips are a new technology that enables endoscopic closure of intestinal fistulas up to 2 cm in diameter. Six pediatric patients underwent endoscopic GCF closure using OSC clips under Institutional Review Board approval. The procedure was technically successful in 5 of 6 cases with an average operating time of 29 minutes. The technical failure required an open revision, whereas all other patients reported full healing of the GCF site at 1 month. All successful cases were performed as outpatients without postoperative narcotics. In addition, all patients reported high satisfaction with the procedure and cosmetic results. Endoscopic GCF closure using an OSC clip is technically feasible in the pediatric population. Based on limited cases with a 1-month follow-up, the functional and cosmetic results of technically successful cases are excellent. Endoscopic GCF closure is a potential alternative to standard surgical closure in patients with skin irritation or erosion and/or significant comorbidities.

Per-oral Endoscopic Myotomy (POEM) is a transmural endoscopic surgical technique that is gaining widespread adoption in the management of adult achalasia. The endoscopic approach offers excellent access to the muscular wall of the esophagus enabling division of the abnormal circular fibers. The procedure offers the benefits of having no visible scars, preserving the outer longitudinal esophageal muscle fibers and avoiding a hiatal dissection. After extensive advanced endoscopy training sessions and IRB review, a POEM was successfully performed in a 16 yo female with achalasia. The POEM was performed without complication by a pediatric surgeon with an operative time of 184 min. The patient has had significant improvement in both dysphagia and regurgitation at 1 month. Advanced endoscopy is developing the capacity to treat what are currently considered surgical diseases including achalasia. As intraluminal, transmural, and transluminal endoscopic procedures evolve, pediatric surgeons will have to define their role in advanced endoscopy. (C) 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Per-oral Endoscopic Myotomy (POEM) is a transmural endoscopic surgical technique that is gaining widespread adoption in the management of adult achalasia. The endoscopic approach offers excellent access to the muscular wall of the esophagus enabling division of the abnormal circular fibers. The procedure offers the benefits of being incisionless, preserving the outer longitudinal esophageal muscle fibers and avoiding a hiatal dissection. Endoscopic functional luminal imaging probes enable real-time measurement of luminal diameter and pressure. These probes offer intraoperative guidance to the extent and completeness of the POEM procedure. Post-operative measurements have been correlated to outcomes of dysphagia and reflux in the adult population. No functional luminal imaging exists for the pediatric population. 2 POEM procedures were performed at our children’s hospital using luminal imaging.