Pediatric Surgery Fellowship Research Articles

Barriers to diffusion and implementation of pediatric minimally invasive surgery in Brazil

BackgroundThe main barriers to the broad implementation of pediatric minimally invasive surgery (MIS) are technological, technical, and epistemological barriers, as well as the rarity of certain pathologies. These issues are presumed to be more significant in low- and middle-income countries. This study aimed to identify and analyze the factors limiting the diffusion and implementation of pediatric MIS in Brazil.MethodsA nationwide cross-sectional survey was conducted via an online questionnaire in Brazil from January 2022 to July 2022. The sample was taken by convenience from the population of pediatric surgeons in Brazil. A total of 187 surgeons were included. The collected data were divided into three sections to evaluate technological, technical, and epistemological limitations to pediatric MIS implementation.ResultsAlthough 85% of the participants had previous training, a lack of adequate training was identified as a significant limiting factor, particularly among those who had taken only short courses (42.3% vs. 64.3%, p = 0.033). Only 14% of the participants reported performing MIS for major pediatric procedures. With respect to intracorporeal suturing, 38.1% of the surgeons with extensive training considered it a limiting factor compared with 60.7% (p = 0.029) of those without prior training. Among those without previous training, 61% cited a lack of financial support or encouragement from their department as the reason. Additionally, 65% of the surgeons considered the lack of basic instruments a limiting factor. Although 95% of the participants agreed that simulation training is indispensable, pediatric surgery fellowship programs in Brazil do not include a standardized curriculum or mandatory training in MIS, and only 47% reported providing training space for their current fellows.ConclusionA combination of technological, technical, and epistemological barriers hinders the implementation of pediatric MIS. Despite its limitations, this study serves as a foundational guide for future analysis and overcoming the identified barriers.

Invited Commentary on: Tremonti, et al: Early Lessons From Implementation of Holistic Review for Pediatric Surgery Fellowship Applicants

Invited Commentary on: Tremonti, et al: Early Lessons From Implementation of Holistic Review for Pediatric Surgery Fellowship Applicants

Impact of Program Region and Prestige on Industry Supplemental Earnings for Pediatric Orthopedic Surgery Fellowships in the United States: A Retrospective Analysis

Introduction: With the passage of the Physician Payment Sunshine Act, there has been increased transparency regarding the industrial financial relations that physicians have. Orthopedic surgeons have been highly studied in this domain with approximately 50% of all orthopedic surgeons engaging in industrial financial relationships. Furthermore, an increasing number of orthopedic surgeons are seeking fellowship training with pediatric fellowship programs gaining popularity in recent years. The purpose of this study is to evaluate the impact various pediatric orthopedic fellowship programs have on industry earnings and academic productivity. Methods: Pediatric orthopedic fellowship programs were identified via the Orthopedic Society of North America (POSNA) website. Information on individual fellowship programs was obtained from their respective websites. Academic productivity was measured via an aggregate of all employed physicians’ H-index at a specific fellowship as found on the Scopus website. The Open Payments Database (OPD) website was used to assess lifetime industry earnings. Other variables such as Newsweek or Doximity ranking were taken directly from relevant websites. Statistical analysis was performed using a Kruskal–Wallis test with Bonferroni correction and Mann–Whitney U-test. Results: A total of 43 pediatric orthopedic surgery fellowships in the United States were identified with a total of 392 physicians as fellowship faculty. Complete OPD and H-index information were available for 336 of those physicians (85.7%). On average, there were 7.81 ± 5.18 physicians and 1.56 ± 0.93 fellows per program. The mean combined physician H-index was 117.23 ± 122.51, and the mean combined physician lifetime supplemental earnings in dollars was $646,684.37 ± $1,159,507.17. There was no significant relationship between region of pediatric orthopedic fellowship, Newsweek ranking of affiliated hospital, Doximity ranking of affiliated hospital, presence of MBA program, type of program (public, private, mixed), and the lifetime industry earnings or academic productivity of program graduates. Conclusions: Despite the observed lack of statistical significance, there were clear trends observed with fellowship programs in the northeast and west coast regions being the highest earning and fellowship programs with top 10 Newsweek ranking of affiliated hospital having by far the greatest industry earnings. Sample size limitations likely prevented the detection of statistical significance. Future studies should examine if any relation exists when accounting for type of industry payment received and case volume per fellowship program.

A prospective observational study of sleep patterns and work-related communications during home call for a pediatric surgery fellow

ObjectiveA pediatric surgery fellow is often regarded as a cornerstone of an academic children's hospital due to the need for their clinical services with overnight coverage being an important aspect of the care provided. There is little known about the objective sleep patterns and work-related communications of a pediatric surgery fellow during overnight home call. The aim of this study is to better understand the sleep patterns and interruptions of an on-call pediatric surgery fellow. DesignA prospective observational study of 60 call nights and 60 non-call nights of a pediatric surgery senior fellow was performed from September 2022 to February 2023. SettingAn academic Children's Hospital. ParticipantAn ACGME-accredited clinical pediatric surgery fellow. ResultsOn average, the pediatric surgery fellow spent 6.9 and 5.8 total hours in bed and asleep each night, respectively. The total sleep time was less for call nights compared to non-call nights (5.4 versus 6.3 h, p < 0.0001). The mean number of work-related communications per 12-hour night shift was four. The majority of communications were regarding new consults (63.8 %). The pediatric surgery fellow spent an average of 5.9 min per communication and approximately 23.8 min total during each 12-hour night shift. Approximately half of these communications occurred during sleep hours. ConclusionsThis study reveals overall sleep duration was below recommended levels. There were significant alterations in sleep patterns during call nights. Work-related communications further compounded sleep disturbances. Further research and interventions in this area are warranted.

Early Lessons From Implementation of Holistic Review for Pediatric Surgery Fellowship Applicants

PurposeHolistic review (HR) considers applicants’ unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS). MethodsUsing a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) [2015–2017] were compared to HR [2018–2022]. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate. ResultsFor 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR. ConclusionHolistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort. Level of EvidenceIV.

Incorporating a Three-Dimensional Printed Airway into a Pediatric Flexible Bronchoscopy Curriculum.

Although hands-on simulation plays a valuable role in procedural training, there are limited tools available to teach pediatric flexible bronchoscopy (PFB). Fellowship programs rely on patient encounters, with inherent risk, or high-cost virtual reality simulators that may not be widely available and create education inequalities. Our objective was to study the educational value and transferability of a novel, low-cost, three-dimensional-printed pediatric airway model (3D-AM) for PFB training. Our central hypothesis was that the 3D-AM would have high educational value and would be easily transferrable to learners at different teaching hospitals. The 3D-AM was designed to teach technical bronchoscopy skills, airway anatomy, airway pathology, and bronchoalveolar lavage (BAL). The curriculum was offered to incoming fellows in pediatric pulmonology, pediatric surgery, and pediatric critical care across three different teaching institutions. After course completion, each participant assessed the simulation model(s) with a 5-point Likert scale across six domains: physical attributes, realism of experience, ability to perform tasks, value, relevance, and global impression. The expert instructors assessed the learners' competency using a modified version of the Bronchoscopy Skills and Tasks Assessment Tool. A total of 14 incoming fellows participated in the course. The mean scores for the 3D-AM across all six domains and across the three institutions was between 4 and 5, suggesting that learners generally had a favorable impression and a similar experience across different institutions. All learners "agreed" or "strongly agreed" that the course was a valuable use of their time, helped teach technical skills and airway anatomy, and would be useful for extra training during fellowship. Most of the learners correctly identified anatomy, bronchomalacia, and performed a BAL. Wall trauma was observed in 36% of learners. The utility, low cost, and transferability of this model may create opportunities for PFB training across different institutions despite resource limitations in the United States and abroad.

Gender diversity in pediatric surgery: academic ranks and scholarly productivity amongst pediatric surgeons.

Despite a growing number of women entering medical school, a small proportion of women pursue surgical specialties, including pediatric surgery. This multi-center study assesses gender-based differences in measures of scholarly productivity and distribution of faculty positions. This is a retrospective web-based study of all pediatric surgeons at twelve large institutions across the United States. Data published by the American Association of Medical Colleges was compiled and analyzed to understand the gender distributions of medical students, general surgery residents, and pediatric surgery fellows. P-values were calculated using two-sided Student's independent t-tests and chi-squared tests. There have been a growing number of women applying into pediatric surgery, but the proportion of women matriculating into these fellowships is not concordant. Women are still underrepresented (28%) amongst the pediatric surgeon workforce. A total of 111 pediatric surgeons were identified for this study, which included 31 women (28%) and 80 males (72%). There was a significant difference in the distribution across academic ranks between genders (p < 0.001). Women had significantly fewer publications per year after residency, fewer total publications, and a lower h-index in comparison to men (p < .001, p = .005, p = .002, respectively). Women are not only underrepresented in pediatric surgery, but there are also significant differences in the distribution of faculty positions and scholarly productivity when comparing men and women. There is a pressing need to improve gender diversity and identify barriers that may prevent women from advancing to leadership positions and achieving professional success.

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients

IntroductionEvidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States. MethodsWe completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap. ResultsWe included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different. ConclusionsStudying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

Predicting future meaningful autonomy using prior autonomy ratings for pediatric surgery fellows

Predicting future meaningful autonomy using prior autonomy ratings for pediatric surgery fellows

Language Differences by Race on Letters of Recommendation for the Pediatric Surgery Match

This study aims to evaluate if there is any significant linguistic difference in LoR based on applicant's race/ethnicity. Retrospective review of applications to pediatric surgery fellowship at a single institution (2016-2020). Race was self-reported by applicants. LoR were analyzed via the Linguistic Inquiry and Word Count (LIWC) software program. Johns Hopkins All Children's Hospital, St. Petersburg, Florida USA. A free-standing tertiary pediatric hospital. Pediatric surgery fellowship applicants from 2016 to 2020. A total of 1086 LoR from 280 applicants (52% female) were analyzed. Racial distribution was Caucasians 62.1%, Asian 12.1%, Hispanics 7.1%, multiracial 6.4% African Americans 5%, and other/unknown 7.1%. Letter writers were largely male (84%), pediatric surgeons (63%) and professors (57%). There was no difference in LoR word count across races. LoR for female multiracial candidates contained higher use of affiliation and negative emotion terms compared to Hispanic females (p = 0.002 and 0.048, respectively), and past focus terms when compared to Caucasian and Asian female applicants (p < 0.001 and p = 0.003, respectively). Religion terms were more common in LoR for Asian females when compared to Caucasian females (p < 0.001). This study demonstrates linguistic differences in LoR for pediatric surgery training programs based on applicant race/ethnicity. While differences are present, these do not suggest overt bias based on applicants race or ethnicity.

How Many Operative Performance Ratings Does a Pediatric Surgery Fellow Need to Be Deemed Practice Ready?

PurposeIdentifying the number of cases required for a fellow to achieve competence has been challenging. Workplace-based assessment (WBA) systems make collecting performance data practical and create the opportunity to translate WBA ratings into probabilistic statements about a fellow's likelihood of performing to a given standard on a subsequent assessment opportunity. MethodsWe compared data from two pediatric surgery training programs that used the performance rating scale from the Society for Improving Medical Professional Learning (SIMPL). We used a Bayesian generalized linear mixed effects model to examine the relationship past and future performance for three procedures: Laparoscopic Inguinal Hernia Repair, Laparoscopic Gastrostomy Tube Placement, and Pyloromyotomy. ResultsFor site one, 26 faculty assessed 9 fellows on 16 procedures yielding 1094 ratings, of which 778 (71%) earned practice-ready ratings. For site two, 25 faculty rated 3 fellows on 4 unique procedures yielding 234 ratings of which 151 (65%) were deemed practice-ready. We identified similar model-based future performance expectations, with prior practice-ready ratings having a similar average effect across both sites (Site one, B = 0.25; Site two, B = 0.25). Similar prior practice-ready ratings were needed for Laparoscopic G-Tube Placement (Site one = 13; Site two = 14), while greater differences were observed for Laparoscopic Inguinal Hernia Repair (Site one = 10; Site two = 15) and Pyloromyotomy (Site one = 10; Site two = 15). ConclusionOur approach to modeling operative performance data is effective at determining future practice readiness of pediatric surgery fellows across multiple faculty and fellow groups. This method could be used to establish minimum case number requirements. Type of StudyOriginal manuscript, Study of Diagnostic Test. Level of EvidenceII.

Nationwide Effect of COVID-19 on Cases Performed During Pediatric Orthopaedic Surgery Fellowship Training in the United States.

The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak. The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes. A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year. A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks.

Attitudes Toward Surgical Innovation Research in the Pediatric Surgery Fellowship Match

IntroductionPediatric surgery applicants are increasingly pursuing research in non-traditional fields including surgical innovation. This study aims to evaluate the relative value that pediatric surgeons involved in fellow selection place on innovation experience compared to traditional research. MethodsA cross-sectional web-based survey of American Pediatric Surgical Association members involved in the selection of pediatric surgical fellows was conducted. Respondents reported their own innovation experience and were asked to identify valuable traits of applicants who completed an innovation fellowship. They rated the value of traditional research metrics including publications, presentations, and advanced degrees compared to patents and other innovation-related metrics. Comparisons were made between those with and without innovation experience with respect to gender, years in practice, and institutional role. ResultsOne hundred thirty respondents were involved in pediatric surgery fellow selection. Innovation work was felt to be equal to or more valuable than basic science by 75% of respondents (84% vs. clinical/outcomes, 93% vs. other non-traditional, 72% vs. other clinical fellowships). Commonly cited concerns included “fewer publications” (21%) and “preoccupation with financial reward” (19%). The most valuable innovation-related metrics were “developing a novel surgical procedure” (67%) and “developing a novel device” (58%). When asked if the respondent would advise a junior resident to pursue an innovation fellowship, 49% would, 9% would not, and 43% were unsure. Seventeen percent expressed concern for match success. ConclusionInnovation experience is generally viewed positively by pediatric surgeons involved in fellow selection. However, applicants and mentors would benefit from focusing on traditional academic outputs to ensure competitiveness. Type of StudyCross-sectional observational study. Level of EvidenceIII.

Decreased Case Volumes for Pediatric Orthopaedic Surgery Fellows during the Early Stages of the Coronavirus-19 Pandemic

Background: In the early months of the coronavirus disease 2019 (COVID-19) pandemic, elective procedures were suspended to reallocate resources, notably impacting 1-year surgical fellowship programs. The purpose of this study is to compare the case volume of pediatric orthopaedic surgery fellows during the pandemic's peak year to the years before and after.Materials and Methods: Accreditation Council for Graduate Medical Education (ACGME) case log reports of key procedures in pediatric orthopaedic surgery were compared between the fellowship classes of 2018-2019 (pre-pandemic), 2019-2020 (peak pandemic), and 2020-2021 (post-peak pandemic). Both overall case volume and individual key procedures were analyzed for significant differences between each of the three class years.Results: There was a significant decrease (−43.7 cases, −15.5%) in the overall number of key procedures completed by the fellowship class of 2020 compared to 2019 (p=0.014), with similar significant decreases in various individual key procedures (foot and ankle deformity, limb deformity, and soft tissue: transfer, lengthening, and release). In the subsequent year, there was a significant increase (+98.8 cases, +41.5%) in the average case volume for the class of 2021 (p<0.001), with significant increases in procedures for foot and ankle deformity, clubfoot, limb deformity, hip, and soft tissue: transfer, lengthening, and release. Additionally, the rebound in overall case volume for the class of 2021 surpassed the pre-pandemic caseload completed by the class of 2019 (p=0.008).Conclusion: During the peak of the pandemic when elective cases were suspended, pediatric orthopaedic surgery fellows logged fewer surgical cases compared to the pre-pandemic class of 2019. While the case volume rebounded in the subsequent year, further research is needed to quantify the overall impact of the decreased caseload for the pediatric orthopaedic fellowship class of 2020.Level of Evidence: Level IVKey Concepts•With the onset of the unprecedented COVID-19 pandemic, the ensuing shutdowns' effects on the training and case volumes of pediatric orthopaedic fellows remain unclear.•This study quantified the change in case volume of pediatric orthopaedic fellows during the first year of the COVID-19 pandemic and identified a significant decrease of nearly 44 total cases (15.5%) performed by fellows of the graduating class of 2020 when compared to those who graduated in 2019.•This study quantified the rebound in case volume for the fellows of the 2021 graduating class when compared to the graduates of the 2020 fellowship class.

Pediatric Liver and Transplant Surgery: Results of an International Survey and Expert Consensus Recommendations.

Pediatric liver surgery is a complex and challenging procedure and can be associated with major complications, including mortality. Best practices are not established. The aims of this study were to evaluate surgeons' individual and institutional practices in pediatric liver surgery and make recommendations applicable to the management of children who require liver surgery. A web-based survey was developed, focusing on the surgical management of children with liver conditions. It was distributed to 34 pediatric surgery faculty members of the Biliary Atresia and Related Disorders (BARD) consortium and 28 centers of the European Reference Network-Rare Liver. Using the Delphi method, a series of questions was then created to develop ideas about potential future developments in pediatric liver surgery. The overall survey response rate was 70.6% (24/34), while the response rate for the Delphi questionnaire was 26.5% (9/34). In centers performing pediatric liver surgery, most pediatric subspecialties were present, although pediatric oncology was the least present (79.2%). Nearly all participants surveyed agreed that basic and advanced imaging modalities (including ERCP) should be available in those centers. Most pediatric liver surgeries were performed by pediatric surgeons (69.6%). A majority of participants agreed that centers treating pediatric liver tumors should include a pediatric transplant program (86%) able to perform technical variant grafts and living donor liver transplantation. Fifty-six percent of responders believe pediatric liver transplantation should be performed by specialized pediatric surgeons. Pediatric liver surgery should be performed by specialized pediatric surgeons and should be centralized in regional centers of excellence where all pediatric subspecialists are present. Pediatric hepatobiliary and transplant training needs to be better promoted amongst pediatric surgery fellows to increase this subspecialized workforce.

Canadian Pediatric Surgeon Workforce: Characterization of Training, Trends Over Time, and 10-year Model for Pediatric Surgery Need

BackgroundGraduate and fellowship training trends for Canadian pediatric surgeons remain uncharacterized. Similarly, updated workforce planning for pediatric surgeons is required. We aimed to characterize graduate degree and fellowship trends for Canadian pediatric surgeons, with modelling to inform workforce planning. MethodsWe performed a cross sectional observational study evaluating Canadian pediatric surgeons in January 2022. Surgeon demographics collected included year of medical degree (MD) conferment, MD location, fellowship location, and graduate degree achievement. Our primary outcome was to evaluate training characteristics over time. Secondary outcomes evaluated surgeon supply and demand from 2021 to 2031. Supply was extrapolated from current Canadian pediatric surgery fellows assuming static fellowship matriculation, while retirement was estimated using a 31-, 36-, or 41-year career following MD conferral. ResultsOf included surgeons (n = 77), 64 (83%) completed fellowship training in Canada and 46 (60%) have graduate degrees. No surgeons graduating ≤1980 hold graduate degrees, compared to 8 (100%) surgeons with MD ≥ 2011 (p < 0.001). Similarly, more surgeons with MD ≥ 2011 appear to have a Canadian MD (n = 7, 87.5%) and Canadian fellowship (n = 8, 100%). Modelling predicts that 19–49 (25%–64%) surgeons will retire between 2021 and 2031, while 37 fellows will graduate with intention to work in Canada, creating between a 12 surgeon deficit up to an 18 surgeon surplus depending on career length. ConclusionsTrends in graduate degree achievement and fellowship location suggest increasing competition for Canadian pediatric surgery positions. Additionally, a substantial number of Canadian-trained fellows will need positions outside of Canada in the next decade. Overall, results support previous work demonstrating saturation of the Canadian pediatric workforce. Level of EvidenceLevel IV. ACGME Competency AddressedMedical Knowledge.

Are pediatric surgery fellowship websites ready for the changing paradigms in the virtual interview era?

PurposeWith the COVID-19 pandemic, in-person fellowship interviews were curtailed, leading candidates to seek information from other resources. Our main purposes were (1) to determine what information recent participants in the match needed to evaluate programs and (2) to assess which of these were available online.MethodsA focus group of ten recent graduates/applicants identified information that was important in choosing a fellowship program. In August 2020 and December 2021, websites belonging to the American Pediatric Surgical Association (APSA) and individual programs were assessed.ResultsRecent applicants identified 55 pieces of information considered important to their decision making. Of 57 pediatric surgery fellowships, 98% were listed on APSA’s website. Program descriptions on APSA’s website listed on average 60% of program information desired by applicants. All listed fellowship director, accreditation status, faculty list, and current fellow(s). Other descriptors frequently noted were alumni (95%), graduate’s board performance (83%), ECMO exposure (77%), and curriculum (70%). Information desired but less frequently available were fellow case logs (63%), trauma center designation (53%), burn center designation (40%), research opportunities (30%), candidate interview assistance (25%), and supplemental fellowships (12%). There were 7% of program descriptions that were not updated for at least a year.ConclusionsAPSA and individual program websites were complimentary. Websites often lacked data that applicants sought to inform their rank list. To best adapt to the evolving virtual interview paradigm, we suggest reporting key information on a central APSA website with more nuanced information available via links to program specific websites.

10 Year Analysis of Pediatric Surgery Fellowship Match and Operative Experience: Concerning Trends?

This paper aims to evaluate the pediatric surgery training pipeline vis-à-vis the pediatric surgery match and operative experience of pediatric surgery fellows. Pediatric surgery remains a competitive surgical subspecialty. However, there is concern that operative experience for pediatric surgery fellows is changing. This paper examines the selectivity of the pediatric surgery match, along with the operative experience of pediatric surgery fellows to characterize the state of pediatric surgery training. The pediatric surgery fellowship match was analyzed from the National Resident Matching Program data from 2010 to 2019. Selectivity among fellowships was compared using analysis of variance with Dunnett test. Operative log data for pediatric fellows was analyzed using the Accreditation Council for Graduate Medical Education case logs from 2009 to 2019. Linear regression analysis was used to evaluate trends in operative volume over time. Pediatric surgery had the highest proportion of unmatched applicants (47.2% ± 5.3%) and lowest proportion of unfilled positions (1.4% ± 1.6%) when compared to other National Resident Matching Program surgical fellowships. Accreditation Council for Graduate Medical Education case log analysis revealed a statistically significant decrease in cases for graduating fellows (-5.3 cases/year, P < 0.05). Total index cases decreased (-4.7 cases/year, P < 0.01, R 2 = 0.83) such that graduates in 2019 completed 59 fewer index operations than graduates in 2009. Although pediatric surgery fellowship remains highly selective there has been a decline in the operative experience for graduating fellows. This highlights the need for evaluation of training paradigms and operative exposure in pediatric surgery to ensure the training of competent pediatric surgeons.

Examining Implicit Bias Differences in Pediatric Surgical Fellowship Letters of Recommendation Using Natural Language Processing

We analyzed the prevalence and type of bias in letters of recommendation (LOR) for pediatric surgical fellowship applications from 2016-2021 using natural language processing (NLP) at a quaternary care academic hospital. Demographics were extracted from submitted applications. The Valence Aware Dictionary for sEntiment Reasoning (VADER) model was used to calculate polarity scores. The National Research Council dataset was used for emotion and intensity analysis. The Kruskal-Wallis H-test was used to determine statistical significance. SETTING: This study took place at a single, academic, free standing quaternary care children's hospital with an ACGME accredited pediatric surgery fellowship. Applicants to a single pediatric surgery fellowship were selected for this study from 2016 to 2021. A total of 182 individual applicants were included and 701 letters of recommendation were analyzed. Black applicants had the highest mean polarity (most positive), while Hispanic applicants had the lowest. Overall differences between polarity distributions were not statistically significant. The intensity of emotions showed that differences in "anger" were statistically significant (p=0.03). Mean polarity was higher for applicants that successfully matched in pediatric surgery. This study identified differences in LORs based on racial and gender demographics submitted as part of pediatric surgical fellowship applications to a single training program. The presence of bias in letters of recommendation can lead to inequities in demographics to a given program. While difficult to detect for humans, natural language processing is able to detect bias as well as differences in polarity and emotional intensity. While the types of emotions identified in this study are highly similar among race and gender groups, the intensity of these emotions revealed differences, with "anger" being most significant. From this work, it can be concluded that bias in LORs, as reflected as differences in polarity, which is likely a result of the intensity of the emotions being used and not the types of emotions being expressed. Natural language processing shows promise in identification of subtle areas of bias that may influence an individual's likelihood of successful matching.

551. Antibiotic Use Among Surgical Patients in the Neonatal Intensive Care Unit (NICU): The NO-More-AntibioticS and Resistance in Surgery (NO-MAS-R-S) Study

Abstract Background Although antibiotic exposure among infants in the NICU is associated with short- and long-term adverse effects, the burden of antibiotic use in neonatal surgical patients has not been well described. The pediatric surgical team at Nationwide Children’s Hospital (NCH) provides all surgical consultations for central Ohio in the level 4 outborn referral NICU at NCH. Our objective was to quantify the total use of antibiotics in surgical NICU patients and thus inform antimicrobial stewardship opportunities. Methods This was a prospective observational study of all infants in the NCH NICU who underwent pediatric surgical evaluation and received antibiotic therapy from 1/3/2022 to 4/29/2022. The pediatric surgery fellow informed the neonatal clinical pharmacist about all consultations and provided qualitative data on antibiotic prescribing (diagnosis, indication and reasoning for antibiotic selection, dosing, and duration) using a set questionnaire. Pertinent demographic maternal/infant data were obtained from the electronic health records. Results During the 4-month study period, 59 infants (median gestational age, 35 wks, IQR 28-35 wks; median birth weight, 2275 g, IQR 1085-3107 g) underwent surgical evaluation at a median postnatal age of 2 days (IQR, 1-12 d). 33 (56%) infants were male; 9 (22%) had antibiotic exposure for &amp;gt;48 hours before surgical consultation. Of the 59 infants, 28 (47%) had a surgical procedure performed (Figure 1) with indications for antibiotic use provided in Figure 2. 34 (58%) infants had antibiotics started by surgical team for a median treatment duration of 7 days (IQR, 5-14). Surgeons considered 74% (20/27) of antibiotic initiation courses to be evidence-based. Of the 59 infants, the most commonly used antibiotics were gentamicin (32%), ampicillin-sulbactam (29%), cefazolin (19%), and piperacillin-tazobactam (14%). The most frequent blood isolate was E. coli (n=4). Mortality was 2% (n=1) and was not infection-related. Figure 1Surgical procedures performed in 28 of 59 infants who underwent surgical evaluation. Figure 2 Indications for antibiotic use in 59 infants who underwent surgical evaluation Conclusion Antibiotics were utilized in the majority of infants who had surgical consultation. Surgical prophylaxis was the main indication and may serve as a potential opportunity for ongoing surgical stewardship efforts. (Supported by Merck &amp; Co research grant) Disclosures Debra A. Goff, Pharm.D, FIDSA, FCCP, Merck Sharp &amp; Dohme (MSD): Grant/Research Support Alexandra K. Medoro, MD, Merck: Grant/Research Support Pavel Prusakov, PharmD, Merck Sharp &amp; Dohme: Grant/Research Support.