ASE 2024 Abstracts

Purpose: Surgical educators and trainees are facing challenges in the training of surgeons. However, there is no overview of educational needs in surgery to guide the efforts. The aim of this study was to identify the trends of educational needs in surgical education literature to support the training of surgeons.

Methods: To identify the trends of educational needs, we performed a scoping review with three search terms in two databases in tandem with three inclusion criteria, resulting in 213 peer-reviewed journal articles. By conducting content analysis to analyze the abstracts of the identified articles, we inquired about the objectives, data sources, participants or subjects, and conclusions in each article to tease out the trends of educational needs in surgery. Descriptive statistics of frequency were used to present the trends. As the definition of educational needs was lacking in the literature, interviews and focus groups of surgical educators and trainees were included to establish a foundational understanding. Through the Association for Surgical Education email invitations, 14 surgical leaders participated in interviews and 29 surgical educators and trainees attended seven focus groups to describe their own perspectives of educational needs. The interview and focus group data were analyzed using thematic analysis. 

Results: The thematic analysis of the interview and focus group data generated the definition of educational needs as five nuanced domains: leadership, teaching, learning, research, and professional development. The content analysis identified the trends of the needs in four areas: the domains of educational needs, surgical specialties, participants, and gaps. To synthesize the results of both thematic analysis and content analysis, a heat map was created with the cross-section of the five domains of educational needs and eleven topics of gaps that showed the hot topics and potential gaps in surgical education.

Conclusions: The scoping review provides surgical educators and trainees an overview of the trends of educational needs in the literature. Additionally, the heatmap can serve as a roadmap to surgical education to support the training of surgeons for surgical educators and trainees as well as those who exercise practices with them.

Background: It can be tortuously difficult to predict and measure the “success” or performance of a surgical resident in a comprehensive and standardized fashion. There are existing performance indicators that lend to one’s judgement of a surgical resident, but there often seems to be something else factored in that seems almost intangible. Historically, the personality of surgeons has been stereotyped as “mean”, “tough” and “self-absorbed”. With this project, we aimed to characterize the personality traits of surgical residents at an academic institution and determine if there are correlations with existing performance indicators including in-service examination percentile scores (ABSITE).

Methods: Surgical residents at an academic surgical residency program were given the opportunity to volunteer for this study. They were provided gift cards as an incentive for participation. The SAPA Personality Index (SPI-81-27&5) was administered to study participants in either written or electronic format per validated instructions.  Demographic information was also collected. Descriptive statistics were performed, and Spearman correlation coefficients were calculated when comparing personality with ABSITE 2023 percentile, as the percentile data exhibited a non-normal distribution.

Results: 38 residents (47% male, age 26-40, 50% white, 82% non-Hispanic, PGY 1-7) from the study program completed the SPI. Each PGY had at least 4 participants. Figure 1 depicts the distribution of personality results from the group on 5-factor (a) and 27-factor (b) scales. On the 5-factor personality assessment scale, ABSITE 2023 percentile was negatively correlated with extraversion (-.34, p=.041). Neuroticism, conscientiousness, agreeableness, and openness were not found to significantly correlate. On the 27-factor scale, ABSITE 2023 percentile was negatively correlated with charisma (-.36, p=.028) and attention-seeking (-.38, p=.022).

Discussion: The diversity of surgeons is evolving, and based on the wide range of personality assessment results in our study population, it appears the diversity of surgeon personality is also expanding from historical stereotypes. It is also possible that there are significant correlations between personality trait and performance indicators which may impact strategies for evaluation and preparation. Further investigation is warranted with additional performance indicators and multiple institutions.

Figure 1. SPI results from surgical residents at the study institution. (a) 5-factor scale (b) 27-factor scale

Background: 

The intrinsic motivations and concerns of medical students on their surgical clerkship are of high importance to educators. Prior studies have shown that medical students can harbor preconceived notions of the clerkship or surgical field that may prevent them from pursuing a surgical career. Improved understanding of student perceptions can facilitate future clerkship curricula development and improve support of surgical learners. We conducted a qualitative analysis of medical students' pre-clerkship survey responses to understand their concerns and fears. 

Methods:  

A survey was administered to all medical students at a single institution, one week prior to their core surgery clerkship orientation between 2020-2023. Thematic analysis was performed on open-ended responses from the anonymized survey using ATLAS.ti. Themes were developed inductively and refined iteratively. 

Results:  

297 (80.1%) of 371 students completed surveys. 152 (51.2%) students reported strong or moderate interest in pursuing surgery. Thematic analysis identified four themes of pre-clerkship apprehension: 1) ambiguity of their clerkship experience, 2) surgical culture and stereotypes, 3) sense of belonging and psychological safety, and 4) personal well-being. Most frequent codes are demonstrated in Table 1. Within ambiguity of their clerkship experiences, students expressed concern about their time spent in the hospital, navigating the operating room, unclear assessment metrics, and best practices for case preparation. In the domain of surgical culture and stereotypes, students reported concerns of possible mistreatment or hostility. Within the theme of belonging and psychological safety, students expressed fears about their ability to learn in a perceived high stress environment, their lack of perceived surgical knowledge or skills, their role as a contributing member on a surgical team, and the interplay of their personal identity and culture with surgical stereotypes. Finally, students expressed worries about their personal well-being including physical discomfort during operations, access to breaks, excessive fatigue, and possible sacrifice of personal hobbies or interests. 

Conclusions:  

Concerns about unclear expectations, surgical stereotypes, psychological safety, and well-being are commonly reported concerns of medical students entering their surgery clerkship. Efforts should be focused on improving student perceptions of the surgical field and ensuring that surgery is safe and inclusive to all learners. 

Introduction

Imposter syndrome (IS) is a “behavioral health phenomenon described as self-doubt of intellect, skills, or accomplishments among high-achieving individuals” that has been associated with psychological distress, burnout, anxiety, and depression, and has also been shown to negatively impact career retention and job performance. IS remains under identified and underappreciated in medicine, especially amongst trainees.  Previous studies, while rare, have demonstrated remarkably high rates of IS amongst surgical trainees (76-92%), but include little data or insight on factors contributing to this concerning statistic.  The purpose of this study was to more broadly explore imposter syndrome in surgical trainees across specialties.

Methods

A survey aimed at identifying the incidence and intensity of imposter syndrome, as well as underlying factors that contribute to IS in surgical trainees was developed by members of the ASE Graduate Surgical Education Committee.  The survey was electronically administered to surgery residents at three different academic institutions as distributed by individual program directors.

Results

A total of 24 responses were submitted over the pilot period.  Of the respondents, 50% were female and 63% were Caucasian. 18 of the respondents (75%) were General Surgery residents, followed by Urology (n=3, 13%), Orthopedics (n=2, 8%), Thoracic (n=1, 4%) and Plastics (n=1, 4%).  An astounding 92% reported some level of imposter feelings, with 24% (n=6) reporting moderate imposter feelings, 36% (n=9) reporting frequent imposter feelings, and 32% (n=8) reporting intense imposter feelings.  Respondents reported a higher frequency of imposterism related to interaction with fellow residents (75%, n=18) compared to interactions with attendings (58%, n=14) or patients (50%, n=12).  Respondents identified comparison to other resident’s experiences, skills, knowledge, or accomplishments as triggers of IS feelings.

Conclusions

Our data demonstrate high rates of IS amongst surgical trainees across specialties, with a majority of these feelings being identified as frequent or intense.  Interactions with other residents was identified as a common trigger of IS.  Further research is necessary to better understand situations that trigger IS so that they may be addressed in the training environment.

Purpose: Much has been said about the high rates of burnout and poor well-being of surgical residents. Investigation into flourishing, a more holistic report of well-being, may provide unique insights into ways trainees can be best supported.  

Methods: General surgery residents at an academic institution were invited to complete an annual survey including the flourishing measure, a 12-item measure that produces 2 scores: a flourishing index (FI) and secure flourishing index (SFI) (both out of 10 where higher score indicates higher flourishing), two items from the Maslach Burnout Inventory assessing emotional exhaustion and depersonalization, and questions about career calling, belonging, and thoughts of quitting. Descriptive statistics are reported with nonparametric tests.     

Results: Overall, 33 residents responded in 2022 (response rate (RR): 60%) and 18 in 2023 (RR: 33%) with a median FI of 6.5 (IQR [5.1, 7.5]) and SFI of 6.3 (IQR [5.0, 7.1]). Over two-thirds of respondents reported high emotional exhaustion (73%) and high depersonalization (67%). One-third report a strong sense of calling in their work, yet a significant portion (14%) strongly consider leaving surgery. Residents with children were more likely to report lower satisfaction and higher depersonalization; male residents reported higher belonging and satisfaction; residents who reported a strong sense of calling were less likely to report strongly considering leaving surgery; report of strongly considering leaving surgery was associated with a lower FI, SFI, and satisfaction, and higher emotional exhaustion.

Conclusion: Residents at our program report lower flourishing than previously reported population means, as well as a significant amount of burnout. Lower FI and SFI were strongly associated with considering leaving surgery. This points toward the potential utility of the FI for surgical residents, a group not previously studied within the flourishing literature. Our results also identify possible disparities in well-being within subgroups. To improve well-being and character formation, we have implemented a pilot program: the Project on the Good Surgeon. This ongoing initiative creates a community around shared meals with attendings to support residents and promote self-reflection via the arts and humanities.

Background: Surgical residency is a demanding and high-stress phase in a physician's career. The pursuit of excellence in surgical skills, the emotional toll of patient care and life events often lead to a high prevalence of burnout, depression and anxiety among surgical residents. The purpose of this study was to evaluate the impact on mental health after the initiation of group mental health counseling from a psychiatrist into the residency training program.

Methods: Forty general surgery residents at an academic institution were invited to participate in a voluntary survey from December 14th – February 23rd, 2023, seventy percent responded. This survey included questions regarding attitudes toward mental health, associated stigma, and barriers to seeking mental health. This survey was distributed after group counseling sessions with a psychiatrist were added to weekly education. Each PGY class rotated through mental health counseling approximately once a month.

Results: Those who attended group counseling sessions were 7.8 times more likely to recognize signs of burnout in their peers and 3 times more likely to disagree that there is a stigma associated with seeking mental health counseling in the program. In examining program culture, we found that over 70% of survey respondents feel comfortable speaking up, feel able to turn to their co-residents for support, and believe the program emphasizes learning over placing blame. Of all the surveyed barriers to seeking out mental health counseling, a profound majority cite “lack of time” as a barrier to seeking counseling, suggesting a need to have protected time dedicated towards physician wellness.  After “lack of time”, greater than 50% find “lack of accessibility” as a barrier, which suggests a need for readily available resources.

Conclusion: This study demonstrated that the addition of a psychiatrist to surgical training reduces stigma associated with seeking out mental health counseling, and increased support and comradery of co-residents. This was associated with a lower propensity to burnout and increased awareness of physician wellness. Overall, this created a residency-wide focus on well-being by removing barriers of time and access through integrating protected time for mental health counseling.