ASE 2024 Abstracts

Poster Session IV - Recruitment & Selection / Other

(P023) SELF-DOUBT IN SURGERY: DISSECTING IMPOSTER SYNDROME IN SURGICAL RESIDENTS
Sarah Lund, MD¹, Rebecca Brown, MD², Tasha Posid, PhD³, Amanda Cooper, MD⁴, Joseph L'Huillier, MD, MSHPEd⁵, Olabisi Ololade Sheppard, MD⁶, Esther Wu, MD⁷, Jeannette Zhang, MD⁸, Sophia McKinley, MD, EdM⁹, Theofano Zompou, MD¹⁰, Minna Wieck, MD¹¹, Christie Bialowas, MD¹², Deborah Jackson¹³, Kimberly Hendershot, MD¹⁴; ¹Mayo Clinic, ²University of Maryland School of Medicine, ³Ohio State University Wexner Medical Center, ⁴Penn State Milton S. Hershey Medical Center, ⁵University of Buffalo, ⁶University of Nebraska Medical Center, ⁷Loma Linda University Health, ⁸Tulane University School of Medicine, ⁹Massachusetts General Hospital, ¹⁰Rutgers New Jersey Medical School, ¹¹University of California Davis Children’s Hospital, ¹²Albany Medical Center, ¹³University of Utah, ¹⁴University of Alabama at Birmingham

Background: Imposter syndrome is a common phenomenon associated with burnout, attrition, and worse job performance. While studies demonstrate a high prevalence of imposter syndrome in surgical trainees, few studies have investigated methods for decreasing imposter syndrome. Therefore, we aimed to determine which resident characteristics and experiences are associated with feelings of imposterism to identify targets for intervention.

Methods: We designed a cross-sectional multi-institutional survey-based study to investigate imposter syndrome in surgical residents. Survey items included the Clarence Imposter Phenomenon Survey (CIPS) and trainee characteristics/experiences. Descriptive analysis was performed to identify the prevalence and severity of imposterism within surgical residents. Comparative analysis was performed to identify inherent resident characteristics (methods to identify at-risk populations) and modifiable resident experiences (intervention targets) that were associated with imposter syndrome.

Results: We received a total of 155 responses from surgical trainees across 12 institutions, spanning 10 surgical specialties. Imposter syndrome was highly prevalent within the cohort, with only 7% having no-to-mild levels of imposter syndrome. Feelings of imposterism were most commonly experienced during interactions with other residents (69%). With respect to inherent resident characteristics, gender was identified as a risk factor for imposter syndrome (mean CIPS score: male=63 [SD=17.9], female=69 [SD=12.4], p=0.02), while other characteristics (first-generation student, post-graduate year, race, or nationality) were not. With respect to modifiable characteristics, imposterism significantly decreased as anxiety decreased (p=0.002) and was associated with experiences of micro-aggressions (i.e., assumption from others that you would not be performing a patient’s surgery [p=0.013] and having your opinion overlooked or ignored in a group discussion [p=0.008]). Certain events were associated with higher levels of imposterism: starting residency (p<0.001), starting a new rotation (p<0.001), taking ABSITE (p<0.001), and doing a difficult case (p<0.001). 

Conclusion: Imposter syndrome is highly prevalent in surgical trainees, with women at higher risk than men. We identifed potential targets for decreasing the impact of imposter syndrome. These modifiable variables provide both targets (e.g., micro-aggressions interventions, anxiety management) to decrease imposter syndrome in surgical residents and specific time points (e.g., when starting a new rotation or program or after a difficult case) ideal for intervention.

(P024) COMMUNICATION AND MISUNDERSTANDING IN ROBOTIC SURGICAL INSTRUCTION
Riley Brian, MD, MAEd¹, Alyssa Murillo, MD, MSc¹, Ivori White¹, Laura Sterponi, PhD², Hueylan Chern, MD¹, Daniel Oh, MD³, Patricia O'Sullivan, EdD¹; ¹University of California San Francisco, ²University of California Berkeley, ³University of Southern California

Introduction: Prior research has shown that a substantial portion of instructional language in the operating room contains ambiguous words and phrases. However, it remains unclear how those ambiguities contribute to misunderstandings, particularly during robotic operations in which physical separation between instructors and learners removes basic non-verbal communication cues. Therefore, this study aimed to identify misunderstandings in simulated robotic communication. By classifying components of these misunderstandings, we sought to provide blueprints for clearer intra-operative instruction.

Methods: We audio and video recorded the communication between instructors and learners during simulated robotic surgical procedures. Using techniques from discourse analysis, we selectively transcribed portions of the sessions. Within transcripts, we searched for repair sequences, defined as dialogue that involved addressing misunderstandings. Our analysis focused on three elements of repair sequences: (1) the trouble source, or cause of the misunderstanding, (2) the initiation of repair, or way the learner signaled misunderstanding, and (3) the repair proper, or method by which the instructor addressed misunderstanding. Two authors independently categorized then reconciled these components of repair sequences.

Results: Fifty learners and 17 instructors participated in 28 simulated robotic cases at two sites. Learners comprised junior residents (n=17), senior residents (n=19), and fellows (n=14). We reviewed 2,596 minutes of video and audio data, from which we transcribed 288 pages using conventions of discourse analysis. First, we identified eight trouble sources leading to misunderstanding (Figure). Second, we found that learners initiated repair, thus signaling misunderstanding, in six key ways: question/request for more information, statement of confusion, noncommittal statement, restating a directive as a question, inappropriate action, and silence/inaction. Third, we found that instructors performed the repair proper – addressing misunderstanding – using a variety of strategies, including simple repetition, more specific directives, directives responsive to the learner’s action, explanations with rationale, visual cues, “time outs” with explanation, and “take overs” with demonstration.

Discussion: By analyzing repair sequences in instructor-learner communication, we identified sources of instructional misunderstanding, the methods learners used to signal misunderstanding, and the strategies instructors employed to address misunderstandings. These concepts can elucidate pitfalls for robotic instructors seeking to develop clear communication strategies.

(P025) MEDICAL STUDENTS’ PERCEPTION OF FAMILY PLANNING DURING SURGICAL TRAINING: A MIXED METHODS ANALYSIS
Grace E Lawson, Sophia Dittrich, Madeline Ebert, Monica Lewis, Sophie Dream; Medical College of Wisconsin

Background: An increasing number of medical students rank “future family plans” as a strong influence on specialty choice. As the proportion of female medical students and the average age of matriculating students increases, it is important to investigate the impact of family planning on specialty choice. Our previous work demonstrated that students are interested in having children during residency but are concerned about the impact on training. We aimed to analyze how demographic factors impact barriers to family planning and to explore opinions related to family planning during surgical training.  

Methods: This was a mixed-methods study using a subset of data from a prior study investigating students' perceptions of family planning. The survey was distributed to all medical students at a single institution in the Midwest. Results from the survey were used to inform development of interview questions. Individual virtual interviews were conducted at the same institution as the original survey and deidentified. Codes were generated through consensus between three authors using one interview transcript and then modified after all interviews were completed. Codes were analyzed to identify themes. Quantitative analysis was done to investigate frequency of codes and themes by demographic characteristics.  

Results: One hundred students completed surveys. Seventy-four (74%) respondents identified as female and 57 (57%) were interested in surgery. The highest perceived barriers to having children during training were work-time demands, childcare barriers, and time away from training. Barriers were impacted by demographics, relationship status, stage of training, and interest in surgery. Twenty-one individual interviews were conducted. Fifty-seven unique codes were identified and grouped into three major themes: interactions between family planning and career goals, program and institutional factors, and cultural and social perceptions (Figure).  

Conclusion: There are many barriers to family planning during training, however, students interested in surgery were more concerned about childcare and strain on the residency program. They also discussed program and institutional factors more often, including institutional actions that could help alleviate these barriers. These may be areas of focus for surgical training programs to continue recruiting excellent students. 

(P026) PROGRAM DIRECTOR PERCEPTIONS AND UTILIZATION OF PERI-INTERVIEW COMMUNICATION FROM GENERAL SURGERY APPLICANTS
Pooja Varman, MD, MS, Nicole Brooks, MD, MEHP, Judith French, PhD, Jeremy Lipman, MD, MHPE; Cleveland Clinic Foundation

Purpose
While 85% of residency applicants send peri-interview communication, program directors’ (PDs) reception of this correspondence has not been described in the literature. This study analyzes the perceptions and practices of program directors regarding pre- and post-interview communication with the aim of elucidating an opaque aspect of the residency application process.

Methods
We conducted a cross-sectional, anonymous survey of PDs from ACGME-accredited general surgery residency programs from August to September 2024. The survey contained 20 Likert-type and open-ended questions on how peri-interview communication is perceived and utilized in applicant review and ranking, support for policies regulating communication, and recommendations for mentoring medical students on best practices. Descriptive statistics summarized quantitative responses, and qualitative data were analyzed for thematic trends.

Results

The survey was sent to a representative sample of 54 PDs, of whom 68.5% completed the entire survey. Respondents include PDs from university-based (40.5%), community-based university-affiliated (37.8%), and community-based (21.6%) programs. 45.9% noted no impact from pre-interview communications on interview decisions, while 40.5% noted the impact could be influenced by other factors such as message personalization, geographic ties, and special interest in the program. Communications from an attending surgeon on behalf of the applicant were perceived positively by 40.5% of PDs, with more weight if the writer were known to the program. Post-interview thank-you notes had minimal impact on ranking (73.0%), though 51.4% found letters of intent (LOIs) somewhat influential. Many PDs (56.8%) support at least some limits on peri-interview communication due to concerns about inequity, dishonesty, and message volume. PDs of larger, university-based programs were more likely to support policies limiting communication than PDs of smaller, community-based programs.

Conclusion

The study highlights the mixed reception and influence of peri-interview communication on the residency application process. PDs note benefits for applicants aiming to stand out in a highly competitive process, while acknowledging challenges of equity, sincerity, and message volume. There is support for policy restrictions to manage the volume and impact of these messages. Future research should explore advising strategies and communication guidelines for applicants and programs.

(P028) PUBLIC SENTIMENT ANALYSIS AND TOPIC MODELING REGARDING SURGICAL WORKPLACE CULTURE ON REDDIT
Aakrsh C Misra¹, James X Wu, MD¹, Formosa Chen, MD, MPH¹, Areti Tillou, MD, MEd¹, Ian T MacQueen, MD¹, David A Rogers, MD, MHPE², Justin P Wagner, MD¹; ¹David Geffen School of Medicine of UCLA, ²University of Alabama Birmingham Heersink School of Medicine

Background 

Negative perceptions of surgical culture are prevalent among medical school matriculants. Reddit is a discussion forum hosting robust discourse on contemporary culture highly accessible to those considering careers in healthcare. In this study, we sought to analyze sentiment among Reddit contributors regarding surgical culture using natural language processing and thematic topic modeling. We aimed to determine whether online discourse reflects prevailing sentiments of medical students.

Methods 

In September 2024 we queried Reddit with search terms regarding surgical workplace culture, education, and career interest. Resulting posts and comments were reviewed for study inclusion. We analyzed content using a natural language processing model assigning sentiment polarity scores (scale -1—+1) signifying degree of negative or positive sentiment. Study authors manually reviewed scores for internal validation. This method was repeated with searches regarding the culture of Family Medicine. Positive, mixed, neutral, and negative sentiment proportions were compared between specialties using χ-square test. We performed Latent Dirichlet Allocation (LDA) topic modeling to infer major themes regarding perceived surgical culture by word frequencies. 

Results 

We reviewed 44 original posts with 2641 comments regarding surgery and 23 posts with 1909 comments on family medicine. Polarity analysis demonstrated high rates of positive sentiment regarding family medicine and extremely low rates of positive sentiment regarding surgery (Table 1). LDA modeling revealed the following most frequent topics contained in discourse on Surgical culture: Toxicity (51.2%), Lack of Support (30.2%), Abuse/Harassment (27.9%), Stress/Burnout (27.9%), and Hierarchical Work Environment (25.6%).  

Conclusions 

We observed disproportionately negative sentiment and associations among Reddit contributors regarding Surgical Culture. Medical school faculty and administrators should be aware of and contribute to public-facing discourse on healthcare workplace culture. Future medical school matriculants may benefit from greater contributions by those familiar with healthcare culture in online forums.

(P029) HARNESSING THE LEFT-HANDED SURGEON EXPERIENCE TO TRAIN THE AMBIDEXTROUS SURGEON: “ALL SKILLS, BOTH HANDS"
Shannon M Barter, MD, Nagham Bazzi, MD, Lillian Kang, MD, Vanessa Schroder, MD, Thomas L Novick, MD, Dan G Blazer III, MD, Kevin Shah, MD, Sabino Zani, MD, Katharine L Jackson, MBBS; Duke University

Introduction: Many left-handed (LH) surgeons ultimately develop ambidextrous skills. There is no standardized method to train LH residents, and ambidextrous training tools are lacking. To address these gaps, we assessed the experiences, successes, and challenges of LH surgeons to enhance ambidextrous training.

Materials and Methods: A single institution survey was completed by LH general surgery residents and attendings, which queried respondents’ handedness for surgical tasks in open, laparoscopic, and robotic surgery. Participants were asked to provide open-ended responses regarding (1) what is challenging as a LH surgeon, (2) what can right-handed (RH) faculty do to support LH trainees, (3) what can LH trainees do to prepare for the operating room. A thematic analysis of these responses was performed to generate a list of tips to improve the LH training experience and improve ambidexterity in both RH and LH trainees.

Results: A total of 12 LH participants (4 residents and 8 faculty) completed the survey. Notably, 75% of participants were ambidextrous in laparoscopic cautery and robotic suturing, while 83.3% reported ambidexterity in knot tying.

The most frequently reported challenge of being a LH surgeon was the right-handed design of many operations and equipment. Negative perceptions and trainer discomfort teaching LH trainees was the second most-cited challenge. The most frequently suggested way to support LH trainees as a RH trainer was “patience,” acknowledging the trainee’s hand dominance and allowing time to adjust as appropriate. Opinions varied about the optimal way to train LH with some feeling that trainees should master their dominant hand before moving to the non-dominant hand, while others advocated for learning a new skill on the non-dominant hand which will make the inverse easier. Regardless of the timing of non-dominant hand training, all agreed that both hands need to be trained to the same level, with one respondent stating “all skills, both hands.”

Conclusion: The LH surgeons of this cohort provide insightful tips for both trainers and trainees to improve the LH experience, of which practicing patience and developing ambidexterity predominated. The experiences of these surgeons will be used to develop an ambidextrous training curriculum.

(P030) BURNOUT AMONG MEDICAL STUDENTS: A COMPARISON BETWEEN THOSE INTERESTED IN SURGICAL SUBSPECIALTIES AND NON-SURGICAL FIELDS
Hannah Bard, BA¹, Raisa Rauf, BA¹, Khu Aten Maaneb De Macedo, MD², Matthew A DePamphilis, BS¹, Alan I Shain, BS¹, Tejal Brahmbhatt, MD³, Tracey Dechert, MD², Alaina Geary, MD, MPHE², Danby Kang, MD², Dane Scantling, DO, MPH², Sheina Theodore, MD²; ¹Boston University Chobanian and Avedisian School of Medicine, ²Boston Medical Center, Department of Surgery, ³Cedars Sinai Medical Center, Department of Surgery

Objectives: Burnout is a chronic state of emotional exhaustion from prolonged workplace stress, characterized by fatigue, cynicism, and reduced professional efficacy. Surgery shows high burnout rates among residents and attendings compared to other specialties in medicine. This study compares burnout levels between medical students interested in surgical versus non-surgical fields.  

Methods: This study evaluates students at a single accredited US medical school. A web-based questionnaire was administered in two parts: career characteristic preferences and burnout assessment using the Maslach Burnout Inventory Student Survey. Students were surveyed at three time points: before second year (pre-MS2), after second year (post-MS2), and after third year (post-MS3). Kruskal-Wallis and Mann Whitney tests were performed to assess statistical differences between students interested in surgical and non-surgical specialties over time and between groups at each timepoint, respectively.  

Results: A total of 138 surveys were completed: 53 pre-MS2, 50 post-MS2, and 35 post-MS3. Among these, 44 responses were from the same participants at multiple timepoints. Of the 94 unique participants, 44 were interested in surgical specialties and 50 were interested in non-surgical fields. Significant differences emerged in career priorities between surgical and non-surgical students in personality fit (5.5 vs. 6.2, p=0.001), training length (3.9 vs. 5.1, p<0.0001), work-life balance (5.1 vs. 6.2, p<0.0001), and burnout potential (4.7 vs. 5.5, p=0.005). However, burnout measures showed no significant change over time within or between groups across pre-MS2, post-MS2, and post-MS3 surveys. The only significant difference found was in professional efficacy after the third year (3.4 vs. 4.5, p=0.024) between the two groups. 

Conclusion: It is established that burnout rates are high among surgical residents and attending surgeons. While this study has certain limitations, burnout levels among students were found to remain consistent throughout medical school, regardless of specialty interest. This suggests that increased burnout among surgeons may begin after committing to a surgical specialty, rather than reflecting a pre-existing predisposition among preclinical medical students interested in surgery. However, the precise timeline and progression of burnout remain unclear and warrants further investigation.  

(P031) WEBSIDE MANNER: ASSESSING THE PRESENCE OF WELL-BEING RESOURCES ON GENERAL SURGERY RESIDENCY WEBSITES
Alexandria L Soto¹, Kendall Reitz¹, Akosua D Odei¹, Holly C Lewis, MD, PhD², Shannon Barter, MD², Katharine Louise Jackson, MD¹, Gayle A DiLalla, MD²; ¹Duke University School of Medicine, ²Department of Surgery, Duke University Hospital

Introduction: An applicant's perception of a program's environment is critical to their assessment of general surgery residencies. Applicants increasingly value programs that support interpersonal relationships and family life, both of which are acknowledged to help prevent burnout. With the introduction of program signaling, it is now essential that applicants identify programs which align with their values early in the application process. Program websites are among the most frequently used resources for assessing these factors. This study evaluates the presence of family and interpersonal wellness programming on general surgery residency websites, identifying gaps and areas for improvement.

Methods: The websites of 106 general surgery residencies were evaluated by three reviewers for program-advertised resources (PAR) supporting resident wellness outside of clinical training. These resources included publicly available information on mental health, wellness initiatives, team-building events, family support (e.g., spousal community, childcare, reproductive health benefits), leave policies (e.g., parental, vacation, emergency), and financial assistance (e.g., reimbursements for fitness/wellness activities). If resources were listed but linked to non-general surgery sites (e.g., GME or another institution sites), they were documented as institution-advertised resources (IAR).

Results: Wellness initiatives were advertised by 60% of reviewed programs, with only one-half being PARs. Similarly, mental health initiatives were listed by 61% of programs; of these, 79% were IARs. Mental health contacts were available 52% of the time (excluding crisis lines). Less than a third of programs mentioned work-life balance; among those that did, 58% identified it as a core value but did not describe specific resources. Additionally, few programs listed any family or reproductive resources [parental leave (38%), childcare benefits (25%), lactation policies (14%), family programming (13%), spousal benefits/group (9%), family planning/reproductive health resources (9%)] (Figure).

Conclusion: A minority of sampled residencies advertise interpersonal and family support programming on their websites. Among those that do, the resources advertised are predominantly hosted on another non-program webpage. There is significant variation in the type of programs and resources allocated. Enhancing the visibility and comprehensiveness of wellness and family resources on program websites holds potential for improving recruitment and future well-being of trainees in the era of program signaling.

(P095) GENDER CONCORDANCE IN SURGICAL MENTORSHIP AND AUTHORSHIP
Onyekachi E Anyagwa, MD¹, Brandon T Smith, MD, PhD², Javier Villela-Castrejon, PhD³, Larissa Rodriguez², Prathik Kalva², Taylor Beal², Taylor Lee³, Jason T George, MD, PhD³, Lily S Cheng, MD⁴; ¹New Vision University, Tbilsi, Georgia, ²Baylor College of Medicine, ³Texas A&M University, ⁴University of Virginia

Introduction: In recent decades, more women have entered in the surgical workforce. Despite this, women remain underrepresented in academic surgery, particularly in senior academic positions. Here we describe a pattern of gender concordance between authors in surgical literature that may shed light on the role of mentorship in surgical gender disparity.

Methods: We analysed authorship trends in 10-year intervals over three decades (from 1991 to 2021) in two preeminent peer-reviewed general surgical interest journals, Journal of the American Medical Association (JAMA) Surgery and the Annals of Surgery. The following data were collected for all original research articles: total number of authors, authors' genders, and senior authors’ geographical location. Authors' gender was ascertained by pronouns used in online profiles. If gender could not be determined based on the above, then Gender-API, a web-based artificial intelligence platform, was used to predict gender based on name. Student’s t-test and Chi-squared test were performed for statistical comparisons and a p-value of < 0.05 was considered significant.

Results: A total of 361 journal articles were examined. The percentage of woman authors per article more than doubled over time (13.8±19.4% in 1991 vs. 28.7±25.0% in 2021, p<0.05). Articles with women senior authors increased (12.7% to 23.6%, p=NS), articles with women first authors increased (3.6% to 31.1%, p<0.05), and articles with at least one woman author also increased (41.8% to 75.8%, p<0.05) over the same time period. Interestingly, journal articles with a woman senior author had both a greater proportion of women first-authors (69.7% vs. 12.2%, p<0.05) and a greater proportion of women co-authors (44.4±7.5% vs. 14.2±4.9%, p<0.05) than journal articles with a man senior author for all years examined (Figure 1). While the proportion of articles with a man senior author and at least one woman co-author has doubled over the past 30 years (33.3% in 1991 to 68.3% in 2021, p<0.05), only 10.6% of articles in 2021 with a man senior author had an equal or greater proportion of women co-authors.

Conclusion: Gender concordance between senior, first, and co-authors in surgical literature highlights an important pattern in mentorship that may perpetuate gender disparities.