Surgical Directors Research Articles

Creating a national breastfeeding and lactation policy for Canadian surgical residents

Background: Despite known benefits of breastfeeding and challenges medical trainees face lactating at work, research specific to Canadian surgical trainees is lacking. Our objectives were to examine existing breastfeeding and lactation policies, query experiences and opinions of surgical trainees and program directors, and propose a comprehensive policy for programs nation-wide. Methods: A multi-disciplinary team developed this two-part study. The scoping review used database and grey literature searches to find North American policies covering surgical residents. The survey study queried lactating Canadian surgical trainees and program directors about experiences and barriers, support provided, and interest in a breastfeeding and lactation policy. Results: Ten policies were found. None comprehensively addressed lactation space and supplies, break times, supports, and resident responsibilities. Among ten PD survey respondents: 60% were female, 70% had lactating trainees during their tenure, 40% discussed lactation accommodations, and all were willing to instate a policy. Among 24 trainees: 45% met breastfeeding goals, 74% stopped breastfeeding prematurely due to work barriers, and 88% had little workplace support. Almost all trainees (96%) wanted a policy. Conclusion: There is opportunity and appetite for a more comprehensive breastfeeding and lactation policy for Canadian surgical residents. Our policy highlights important areas where trainees can be better supported to meet breastfeeding goals.

Evaluating the Factors Influencing Residency Match for Surgical Specialty Applicants and Programs: Challenges and Future Directions.

We aim to evaluate the impact of recent changes in the residency matching process on surgical specialties' applicants and programs to offer recommendations on residency selection and matching processes. We utilized five databases while employing a Boolean query to search for studies from 2015 to March 2024. The search selection focused on factors and recent changes influencing residency match results across surgical specialties, including USMLE Step 1 pass/fail, research productivity, interview structure, and preference and geographic signaling. The shift of the USMLE Step 1 to a pass/fail scoring system revealed a consensus among surgical program directors (PDs) and applicants not in favor of the change due to the emphasis on additional application elements. Research productivity was identified as a significant factor, especially in neurosurgery (with an average of 18.3 publications per applicant) and vascular surgery (8.3 publications), indicating a positive correlation between the number of publications and match outcomes. The adoption of virtual interviews has been well-received by both applicants and PDs, leading to an increase in the number of interviews offered and applicants. The implementation of preference and geographic signaling mechanisms has improved interview rates for applicants who utilize them. The transition to a pass/fail USMLE Step 1 has raised concerns among surgical specialties, necessitating a greater focus on Step 2 scores and research productivity. Virtual interviews and signaling have improved the accessibility and reach of the residency application process, however, the full impact of these changes on the perception of applicant-program fit remains unclear.

Perceptions and Expectations Regarding the Step 1 Score Change Among Surgical and Non-Surgical Program Directors: A Systematic Review and Meta-Analysis.

There are currently no studies examining differences in perceptions and expected impact of the Step 1 score change to pass/fail between surgical and non-surgical program directors (PDs). We conducted a systematic review in May 2023 of PubMed, Scopus, Web of Science, and PSYCInfo to evaluate studies examining PDs' perspectives regarding the Step 1 score change. We performed random-effects meta-analyses to determine differences in perspectives among surgical and non-surgical PDs. Surgical PDs (76.8% [95% CI, 72.1%-82.0%], I2 = 52%) reported significantly greater rates of disagreement with the score change compared to non-surgical (65.1% [95% CI, 57.9%-73.1%], I2 = 69.7%) (P = .01). Surgical PDs also reported significantly greater rates of agreement that the score change will increase the difficulty in objectively comparing applicants (88.1% [95% CI, 84.6%-91.7%], I2 = 16.4%), compared to non-surgical (81.0% [95% CI, 75.6%-86.8%], I2 = 72.6%) (P = .04). There was less heterogeneity among non-surgical PDs (88.7% [95% CI, 86.2%-91.2%], I2 = 0%), compared to surgical (84.7% [95% CI, 79.0%-90.8%], I2 = 67.3%), regarding expected increases in emphasis on Step 2, although the difference in rates of agreement was not statistically significant. Overall, there is significant heterogeneity in the literature regarding expected changes in the residency application review process. Most PDs reported significant disagreement with the score change, greater expected difficulty in objectively evaluating applicants, and greater emphasis on Step 2, with surgical PDs reporting greater rates of disagreement, greater expected difficulty, and heterogeneity regarding expected increases in emphasis on Step 2, compared to non-surgical. Additionally, there is significant heterogeneity in the overall literature regarding expected changes in the residency application review process. Further research is needed to establish evidence-based guidelines that improve the overall residency application process for all stakeholders.

Collaborative leadership in transplantation: Blending clinical, business, and regulatory roles.

Transplantation is a high-risk, high-cost treatment for end-stage diseases and is the most strictly regulated area of healthcare in the United States. Thus, achieving success for patients and the program requires skillful and collaborative leadership. Various factors, such as outcomes, volume, and financial health, may measure the success of a transplant program. Strong collaboration between clinical and administrative leaders is key to achieving and maintaining success in those three categories. Clinical leaders of adult programs, such as medical and surgical directors, bear the primary responsibility for a program's volume, outcomes, and patient safety, while administrative directors are focused on business intelligence and regulatory compliance. This paper aims to provide readers with insights into the critical role of collaborative leadership in running a successful program, with a focus on clinical, business, and regulatory perspectives.

Transplant Center Attitudes Toward Early Liver Transplant for Alcohol-associated Liver Disease.

Many centers have removed 6-mo pretransplant alcohol abstinence requirements to provide early liver transplant (ELT) for individuals with severe alcohol-associated liver disease (ALD), but the practice remains controversial. Using data collected from a nationally distributed survey, this study examines the practices and attitudes of transplant centers in the United States regarding ELT. A 20-item survey designed to assess center practices and provider attitudes was distributed to 225 medical and surgical directors from 143 liver transplant centers via email. Surveys were completed by 28.9% (n = 65) of directors and 39% (n = 56) of transplant centers. All responding centers reported evaluating patients for ELT. Circumstances for considering ELT included <6 mo of survival without a transplant (96.4%) and inability to participate in alcohol addiction therapy pretransplant (75%). Most (66%) directors indicated their center had established criteria for listing candidates with severe ALD for ELT. Regarding important factors for ELT candidate listing, 57.1% indicated patient survival, 37.5% indicated graft survival, and 55.4% indicated having a low risk of relapse. Only 12.7% of directors affirmed the statement, "Six months of pretransplant abstinence decreases the risk of relapse." More centers are providing ELT for severe ALD. Inability to participate in alcohol addiction therapy and <6 mo of survival are commonly reported circumstances for considering ELT. Continued investigation of posttransplant outcomes in patients receiving ELT is essential to establishing a national consensus for distributing this valuable resource.

Impact of Clinical Anatomy Peer Mentorship Program on Student Leaders: A Mixed-Methods Study

IntroductionClinical Anatomy Mentorship Program (CAMP) was developed as a student-led approach to providing hands-on surgical experience and mentorship to third-year medical students during their surgery clerkship at an academic institution. Fourth-year medical students were selected to lead these educational events, teaching underclassmen surgical curriculum and skills in a near-peer method of clinical teaching. MethodsA focus group and survey were administered to the fourth-year medical students who served as CAMP leaders from fall 2021 to spring 2022 to assess how their leadership role impacted their personal and professional development. ResultsA 10-question survey was administered to 19 students, with 14 responding, for a response rate of 74%. Serving as a mentor facilitated the development of students’ professional interests, including increased interest in future teaching roles (93%) and leadership positions (86%), particularly as surgical clerkship director (70%) and program director (90%). All students reported that their involvement in CAMP increased their confidence in teaching and surgical knowledge, and 86% reported improved surgical skills. A subset analysis of seven CAMP leaders via the focus group demonstrated several reported benefits to serving as a peer mentor in CAMP, including increased interaction with peers, improved sense of comradery and support, more authentic peer-mentorship connections, and increased confidence and perceived preparedness for surgical residency. ConclusionsThe confidence, leadership, and improved surgical knowledge and skills obtained through the CAMP leadership role led to improved personal and professional development of student leaders.

Nationwide evaluation of pancreatic cancer networks ten years after the centralization of pancreatic surgery

BackgroundDue to centralization of pancreatic surgery, patients with pancreatic cancer are treated in pancreatic cancer networks, composed of referring hospitals (Spokes) and an expert center (Hub). This study aimed to investigate I) how pancreatic cancer networks are organized and II) evaluated by involved clinicians. MethodsTwo online surveys were sent out between January–May 2022. Part I was sent out to the surgical network directors of all hospitals of the Dutch Pancreatic Cancer Group (DPCG). Part II was sent out to all involved clinicians in the Hubs-and-Spokes networks. ResultsThere was a large variety between the 15 networks concerning number of affiliated Spokes (1-7), annual pancreatoduodenectomies (20-129), and use of a service level agreement (SLA) (40%). More Spoke clinicians considered the Spoke the best location for diagnostic workup (74% vs 36%, P < 0.001). Only 30% of Spoke clinicians attended the Hubs multidisciplinary team meeting frequently. More Hub clinicians thought that exchange of patient information should be improved (37% vs 51%, P = 0.005). ConclusionA large variety in Dutch pancreatic cancer networks was observed concerning number of affiliated Spokes, use of SLAs, and logistic aspects of network care. Improvement of network care concern agreements on diagnostic workup, use of SLA, Spoke participation in the MDT, and patient information exchange.

National survey of second opinions for hospitalized patients in need of liver transplantation.

Decisions about patient candidacy for liver transplant (LT) can mean the difference between life and death. We surveyed LT centers across the United States to assess their perceptions of and barriers to second-opinion referrals for inpatients declined for transplant. The medical and surgical directors of 100 unique US LT programs that had done >20 LTs in 2021 were surveyed with a 33-item questionnaire including both multiple-choice and free-response questions. The response rate was 60% (60 LT centers) and included 28 larger-volume ( ≥100 LTs in 2021) and 32 smaller-volume (<100 LTs in 2021) programs. The top 3 reasons for inpatient denial for LT included lack of social support (21%), physical frailty (20%), and inadequate remission duration from alcohol use (11%). Twenty-five percent of the programs reported "frequently" facilitating a second opinion for a declined inpatient, 52% of the programs reported "sometimes" doing so, and 7% of the programs reported never doing so. One hundred percent of the programs reported that they receive referrals for second opinions. Twenty-five percent of the programs reported transplanting these referrals frequently (over 20% of the time). Neither program size nor program location statistically impacted the findings. When asked if centers would be in favor of standardizing the evaluation process, 38% of centers would be in favor, 39% would be opposed, and 23% were unsure. The practices and perceptions of second opinions for hospitalized patients evaluated for LT varied widely across the United States. Opportunities exist to improve equity in LT but must consider maintaining individual program autonomy.

Editorial introductions.

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors-in-Chief, Associate Editor and Section Editors for this issue. SECTION EDITORS Matthew HartwigMatthew HartwigDr. Hartwig is a thoracic surgeon with a clinical focus in robotic assisted minimally invasive thoracic surgery for the treatment of diseases of the chest. He serves as the Surgical Director of the Esophageal Center at Duke. He is also the Director of the Minimally Invasive Thoracic Surgery Fellowship at Duke, while providing advanced instruction in robotic surgery to surgeons around the world. He also leads a successful program of clinical, basic and translational research in thoracic surgery and lung transplantation. He currently directs the Duke Ex Vivo Organ Laboratory (DEVOL), is the Chief of Lung Transplant Research, and is a faculty member at the Duke Clinical Research Institute (DCRI). John L.R. ForsytheJohn L.R. ForsytheProfessor John Forsythe was first appointed as a Consultant Transplant Surgeon at the Royal Infirmary of Edinburgh, UK in 1995. Prior to this, he was a Consultant Surgeon with special interest in renal transplantation at the Royal Victoria Infirmary, Newcastle upon Tyne, UK. He is currently an Organ Utilisation Consultant for NHSBT, working with all departments of health for the UK. Professor Forsythe has held many professional committee appointments, among them Lead Clinician for Organ Donation and Transplantation in Scotland, Chairman of the Scottish Donation and Transplant Group and Chairman of the Safety of Blood, Tissues and Organs Advisory Committee to all four UK health ministers. He is a Past President of the British Transplantation Society and remains Honorary President of the British Society for Histocompatibility and Immunogenetics. Shunji NagaiShunji NagaiDr. Shunji Nagai is a general surgeon in Detroit, Michigan and is affiliated with Henry Ford Hospital. He received his medical degree from Nagoya University- School of Medicine and has been in practice for more than 20 years.

In this June issue

In line with several other journals we co-publish the Australian Commission on Safety and Quality in Health Care Low Back Pain Clinical Care Standard. It describes the early clinical management of people who present with a new acute episode of low back pain. The background to how the standard was developed and finalised are described in an introductory editorial. Coronial findings and royal commissions have repeatedly identified deficiencies in the emergency health care provided to prisoners in Australia. These deficiencies are operational, clinical and stigmatic and not limited to a single prison or jurisdiction. Applying a health quality of care framework focused on prevention and chronic health management appropriate assessment and escalation when urgent medical assistance is requested, and a structured audit framework could avoid future preventable deaths in prisons. We publish an editorial on this topic to accompany the paper written by a team from Victoria and Queensland. A group from the neurosurgery department of the Royal Brisbane and Women's Hospital report that the availability of cranial access equipment outside Queensland tertiary centres is limited. Inter-hospital transfers are likely to persist in Queensland and so improving access to cranial access equipment in hospitals where it is currently lacking is highly warranted. They surveyed senior theatre nurse or surgical service directors from rural and regional Queensland hospitals located outside the local catchment of a tertiary centre and had a CT scanner. Questions regarded availability, location and storage conditions of mechanical cranial access kits, as well as last usage, and associated patient outcomes. Life-threatening thoracic trauma requires emergency pleural decompression, and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children is challenging, even for experienced clinicians. A team from Melbourne report that the Mid-Arm-Point (MAP) technique, a procedural aid for use with injured adults, is also a safe site for pleural decompression in children <4 years and with a very minor modification is safe in children ≥4 years. An excellent study from Queensland describes the demographics, presentation characteristics, clinical features and cardiac outcomes for Aboriginal and Torres Strait Islander patients who present to a regional cardiac referral centre ED with suspected acute coronary syndrome (ACS). The authors conclude this cohort with suspected ACS have a high burden of traditional cardiac risk factors, regardless of whether they are eventually diagnosed with ACS. These patients may benefit from assessment for coronary artery disease regardless of age at presentation. In a nice paper, James Mallows explores the concept of collegiality, something considered to be any extra-role behaviour that is discretionary, not recognised by a formal reward system and that promotes the effective functioning of the organisation. There are few studies examining collegiality in the medical profession and none looking at collegiality among emergency physicians (EPs). He explores the perceptions of different ED health care professionals on the meaning of collegiality among EPs, the benefits of collegiality and behaviours they identify as indicative of collegiality. He identifies distinct themes and behaviours indicative of collegiality among EPs. Promoting these behaviours could improve staff well-being, ED efficiency, patient safety and productivity. Continuing with the previous theme, team culture underpins team performance. Psychological safety is a critical component of team culture for high performing teams. A group from the Gold Coast Hospital decided to explore this further. They conclude that familiarity of team members and leaders is critical to the development of psychological safety within the ED. Fostering familiarity should be a focus for frontline leadership each shift and a priority in broader departmental decisions for those seeking to enhance the psychological safety of their teams. The focus in this issue is on the anaesthetic component of the Fellowship training programme.

Satisfaction and attrition in Canadian surgical training program leadership: a survey of program directors.

Surgical program directors (PDs) play an integral role in the well-being and success of postgraduate trainees. Although studies about medical specialties have documented factors contributing to PD burnout, early attrition rates and contributory factors among surgical PDs have not yet been described. We aimed to evaluate Canadian surgical PD satisfaction, stressors in the role and areas institutions could target to improve PD support. We administered a cross-sectional survey of postgraduate Canadian surgical PDs from all Royal College of Physicians and Surgeons of Canada accredited surgical specialties. Domains we assessed included PD demographics and compensation, availability of administrative support, satisfaction with the PD role and factors contributing to PD challenges and burnout. Sixty percent of eligible surgical PDs (81 out of 134) from all 12 surgical specialties responded to the survey. We found significant heterogeneity in PD tenure, compensation models and available administrative support. All respondents reported exceeding their weekly protected time for the PD position, and 66% received less than 0.8 full-time equivalent of administrative support. One-third of respondents were satisfied with overall compensation, whereas 43% were unhappy with compensatory models. Most respondents (70%) enjoyed many aspects of the PD role, including relationships with trainees and shaping the education of future surgeons. Significant stressors included insufficient administrative support, complexities in resident remediation and inadequate compensation, which contributed to 37% of PDs having considered leaving the post prematurely. Most surgical PDs enjoyed the role. However, intersecting factors such as disproportionate time demands, lack of administrative support and inadequate compensation for the role contributed to significant stress and risk of early attrition.

Patient, family and professional suggestions for pandemic-related surgical backlog recovery: a qualitative study.

Surgical shutdowns related to the COVID-19 pandemic have resulted in prolonged wait times for nonemergency surgery. We aimed to understand informational needs and generate suggestions on management of the surgical backlog in the context of the ongoing COVID-19 pandemic through focus groups with key stakeholders. We performed a qualitative study with focus groups held between Sept. 29 and Nov. 30, 2021, in Ontario, with patients who underwent or were awaiting surgery during the pandemic and their family members, and health care leaders with experience or influence overseeing the delivery of surgical services. We conducted the focus groups virtually; focus groups for patients and family members were conducted separately from health care leaders to ensure participants could speak freely about their experiences. Our goal was to elicit information on the impact of communication about the surgical backlog, how this communication may be improved, and to generate and prioritize suggestions to address the backlog. Data were mapped onto 2 complementary frameworks that categorized approaches to reduction in wait times and strategies to improve health care delivery. A total of 11 patients and family members and 20 health care leaders (7 nursing surgical directors, 10 surgeons and 3 administrators) participated in 7 focus groups (2 patient and family, and 5 health care leader). Participants reported receiving conflicting information about the surgical backlog. Suggestions for communication about the backlog included unified messaging from a single source with clear language to educate the public. Participants prioritized the following suggestions for surgical recovery: increase supply through focusing on system efficiencies and maintaining or increasing health care personnel; incorporate patient-centred outcomes into triage definitions; and refine strategies for performance management to understand and measure inequities between surgeons and centres, and consider the impact of funding incentives on "nonpriority" procedures. Patients and their families and health care leaders experienced a lack of communication about the surgical backlog and suggested this information should come from a single source; key suggestions to manage the surgical backlog included a focus on system efficiencies, incorporation of patient-centred outcomes into triage definitions, and improving the measurement of wait times to monitor health system performance. The suggestions generated in this study that may be used to address surgical backlog recovery in the Canadian setting.

Improving Medical Student Anatomy Knowledge and Confidence for the Breast Surgical Oncology Rotation.

The anatomy curriculum has undergone considerable reductions in class time, resulting in decreased student anatomical knowledge retention and confidence during their surgical rotations. To counter this deficit in anatomy knowledge, a clinical anatomy mentorship program (CAMP) was developed by fourth-year medical student leaders and staff mentors in a near-peer teaching fashion prior to the surgical clerkship. This study analyzed the impact this program had on third-year medical students (MS3s) self-assessed anatomical knowledge and confidence in the operating room on the Breast Surgical Oncology rotation after this near-peer program. A single-center prospective survey study was performed at an academic medical center. Pre- and post-program surveys were administered to all students who participated in the CAMP and rotated on the breast surgical oncology (BSO) service during the surgery clerkship rotation. A control group of individuals who did not rotate on the CAMP was established, and this group was administered a retrospective survey. A 5-point Likert scale was used to assess surgical anatomy knowledge, confidence in the operating room, and comfort in assisting in the operating room. Control group versus post-CAMP intervention group and pre- versus post-CAMP intervention groups survey results were compared using the Student's t-test with a p-value of <0.05 statistically significant. All CAMP students rated their surgical anatomy knowledge (p < 0.01), confidence in the operating room (p < 0.01), and comfort in assisting in the operating room (p < 0.01) as greater than those who did not participate in the program. Additionally, the program improved the ability of third-year medical students to prepare for operating room cases going into their third-year breast surgical oncology clerkship (p < 0.03). This near-peer surgical education model appears to be an effective way to prepare third-year medical students for the breast surgical oncology rotation during the surgery clerkship by improving anatomic knowledge and student confidence. The program can serve as a template for medical students, surgical clerkship directors, and other faculty interested in efficiently expanding surgical anatomy at their institution.

Combined heart-liver transplantation practices survey in North America: Evaluation and organ listing practices.

We conducted a web-based survey to characterize liver transplant (LT) evaluation and listing practices for patients being evaluated for combined heart-liver transplantation (CHLT), with a specific emphasis on patients with congenital heart disease (CHD), around transplant centers in North America. Very few protocols for liver evaluation and listing in patients undergoing combined heart-liver transplantation are published, and no guidelines currently exist on this topic. A subject of intense debate in the transplant community is the decision of which patients with CHD and liver disease benefit from CHLT compared with heart transplantation. A focus group from the American Society of Transplantation Liver-Intestine Community of Practice Education Subcommittee developed a web-based survey that included questions (1) respondee demographic information; (2) LT evaluation practices in CHLT; (3) liver organ listing practices in CHLT, and (4) 4 clinical vignettes with case-based scenarios in CHLT liver listings among CHD patients who underwent Fontan palliation. The survey was distributed to medical and surgical LT program directors of 47 centers that had completed at least 1 CHLT up to July 2021 in the US and the University of Toronto, Canada. The survey had an excellent 83% response rate (87% for centers that completed at least 1 CHLT in the past 5y). Total 66.7% used transjugular liver biopsy with HVPG measurements, 30% used percutaneous liver biopsy with no consensus on the use of a fibrosis staging system, 95% mandated contrasted cross-sectional imaging, and 65% upper endoscopy. The following isolated findings evaluation mandated CHLT listing: isolated elevated HVPG (61.5%); the presence of portosystemic collaterals on imaging (67.5%); the endoscopic presence of esophageal or gastric varices (75%), and the presence of HCC (80%), whereas the majority of centers did not feel that the presence of isolated splenomegaly (100%), thrombocytopenia (81.6%), endoscopic findings of portal hypertensive gastropathy (66.7%), or highly sensitized patients (84.6%) justified CHLT. In our survey of North American centers that had performed at least 1 CHLT in the past 5 years, we observed heterogeneity in practices for both evaluation and listing protocols in these patients.

Editorial introductions.

Editorial introductions.

Contributions of Surgical Critical Care Program Directors Society to the training of surgeons.

In 1986, Surgical Critical Care (SCC) was formally recognized as a specialty by the American Board of Surgery (ABS), however it took another two decades to develop a formal national training structure in SCC. In 2003, the program directors of SCC fellowships began to meet and the Surgical Critical Care Program Directors Society (SCCPDS) was officially formed in 2004, with recognition of the SCCPDS as a non-profit organization in 2008. Over the next several years, and in conjunction with other interested groups, such as the American Association for the Surgery of Trauma (AAST) and the Society of Critical Care Medicine (SCCM), SCCPDS created a formal curriculum, developed a unified system for the fellowship application process, and increased recruitment and match such that now approximately 1 in 6 general surgery graduates are pursuing training in SCC. In discussion with past and present leadership of SCCPDS, there are several ongoing initiatives to further improve the educational opportunities of the fellows and increase inclusion of other organizations and other specialties interested in SCC. The purpose of this article is to discuss the role of SCCPDS in the development and evolution of SCC and Acute Care Surgery (ACS) training. Expert Opinion; Level V.

Perceptions and Early Outcomes of the Acuity Circles Allocation Policy Among Liver Transplant Centers in the United States.

A 28-item survey was sent to division chiefs and surgical directors of liver transplantation across the United States. Questions assessed the respondents' perceptions regarding center-level metrics and staff satisfaction. We used Organ Procurement and Transplantation Network data to study differences in allocation between the pre-AC implementation period (2019) and the post-AC implementation period (2020-2021). A total of 40 participants completed this ongoing survey study. Most responses were from region 8 (13%), region 10 (15%), and region 11 (13%). Sixty-three percent of respondents stated that the wait time for a suitable offer for recipients with model of end-stage liver disease score <30 has decreased, whereas 50% stated that wait time for a suitable offer for recipients with model of end-stage liver disease score >30 has increased. However, most respondents (75%) felt that the average cost per transplant had increased and that the rate of surgical complications and 1-y graft survival had remained the same. In most states, an observable decrease in in-state liver transplantations occurred each year between 2019 and 2021. In addition, most allocation regions reported an increase in donations after circulatory deaths between 2019 and 2021. Perceptions of the new AC policy among liver transplant surgeons in the United States remain mixed, highlighting the potential strengths and concerns regarding its future impact. Further studies should assess the effects of the AC policy on clinical outcomes and liver transplantation access.

'Burr holes in the bush': Clinician preparedness for undertaking emergency intracranial haematoma evacuation surgery in rural and regional Queensland.

Delayed inter-hospital transfers of deteriorating neurotrauma patients from rural and regional hospitals to tertiary centres have seen the need for non-neurosurgeons to undertake emergency intracranial haematoma evacuation surgery locally. In the present study, the authors contributed to the paucity in the literature regarding the widespread availability of cranial access equipment in non-tertiary centres and patient outcomes in Queensland. We surveyed delegates (senior theatre nurses or surgical service directors) from rural and regional Queensland hospitals if they were located outside the local catchment of a tertiary centre and had a CT scanner. Questions regarded availability, location and storage conditions of mechanical cranial access kits, as well as last usage, and associated patient outcomes. Twenty-six delegates from eligible hospitals responded. Eighteen hospitals offered surgical services. Eleven hospitals housed complete mechanical cranial access kits. Five hospitals housed incomplete kits. Thirteen hospitals housed their equipment sterile in the operating theatre or ED. Eleven hospitals reported using the equipment, with last usage ranging from 4months to over 30 years. Two hospitals reported using the equipment within 12 months while a further five reported using it within 10 years. Two hospitals reported 'good' outcomes, two 'ok' and one 'poor'. The availability of cranial access equipment outside Queensland tertiary centres has been limited. Inter-hospital transfers are likely to persist in Queensland and haematoma evacuation surgery has been a life-saving endeavour, so improving access to cranial access equipment in hospitals where it is currently lacking is highly warranted.

Breast Surgical Oncology Fellowship applicant selection and ranking: A survey of Society of Surgical Oncology programs.

In 2003, the Society of Surgical Oncology (SSO) initiated a breast surgical oncology fellowship, which has now grown to 60 SSO accredited programs as of 2021. Limited knowledge exists on the traits of successful applicants and the factors influencing the rank list. A web-based, anonymous survey was sent to all SSO Breast Surgical Oncology Fellowship program directors. The survey consisted of 26 questions. Descriptive statistics were used to analyze survey responses and evaluate impact on applicant interview and rank list. Thirty-four programs (57% response rate) completed the survey. Programs received an average of 70 applications and granted 24 interviews. Most programs reported a minimum ABSITE cut-off score (n = 28, 82%) and a defined publication requirement (n = 22, 65%), including a first-author requirement (n = 18, 53%) to extend an invitation to interview. For postinterview rank, applicant interpersonal skills were highly valued. The interview was the most important aspect for the rank list. Many programs have ABSITE and publication thresholds before offering an interview. Upon receiving interview invitation, the applicant's interview performance, interpersonal skills, and letters of recommendation were the most important aspect in rank list decision making.

Empowering the Resident Learner

Surgical resident autonomy is an essential element of the transition from supervised training to independent practice. However, in an age of duty hour restrictions, legislative constraints, increased litigation, and heightened societal expectations, training an autonomous resident proves increasingly difficult. To tackle these barriers to training successful surgeons, the American College of Surgeons Committee on Resident Education initiated the Resident Mentored Autonomy Project. As a subdivision of this project, the Empowered Learner research team here presents a framework for training the self-directed and empowered surgical resident learner. There are many strategies by which surgical faculty, program directors and chairs, and residents themselves may engage to improve resident operative autonomy.