There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Background Burnout is a complex syndrome of emotional distress that can disproportionately affect individuals who work in healthcare professions. Study Design For a national survey of burnout in US general surgery residents, we asked all Accreditation Council for Graduate Medical Education-accredited general surgery program directors to email their general surgery residents an invitation to complete an anonymous, online survey. Burnout was assessed with the Maslach Burnout Inventory; total scores for Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA) subscales were calculated. Burnout was defined as having a score in the highest tertile for EE or DP or lowest tertile for PA. Chi-square tests and one-way analyses of variance were used to test associations between burnout tertiles for each subscale and various resident and training-program characteristics as appropriate. Results From April–December, 2014, 665 residents actively engaged in clinical training had data for analysis; 69% met the criterion for burnout on at least one subscale. Higher burnout on each subscale was reported by residents planning private practice compared with academic careers. A greater proportion of women than men reported burnout on EE and PA. Higher burnout on EE and DP was associated with greater work hours per week. Having a structured mentoring program was associated with lower burnout on each subscale. Conclusions The high rates of burnout among general surgery residents are concerning given the potential impact of burnout on the quality of patient care. Efforts to identify at-risk populations and to design targeted interventions to mitigate burnout in surgical trainees are warranted.

IMPORTANCE The Implicit Association Test (IAT) is a validated tool used to measure implicit biases, which are mental associations shaped by one's environment that influence interactions with others. Direct evidence of implicit gender biases about women in medicine has yet not been reported, but existing evidence is suggestive of subtle or hidden biases that affect women in medicine. OBJECTIVES To use data from IATs to assess (1) how health care professionals associate men and women with career and family and (2) how surgeons associate men and women with surgery and family medicine. DESIGN, SETTING, AND PARTICIPANTS This data review and cross-sectional study collected data from January 1, 2006, through December 31, 2017, from self-identified health care professionals taking the Gender-Career IAT hosted by Project Implicit to explore bias among self-identified health care professionals. A novel Gender-Specialty IAT was also tested at a national surgical meeting in October 2017. All health care professionals who completed the Gender-Career IAT were eligible for the first analysis. Surgeons of any age, gender, title, and country of origin at the meeting were eligible to participate in the second analysis. Data were analyzed from January 1, 2018, through March 31, 2019. MAIN OUTCOMES AND MEASURES Measure of implicit bias derived from reaction times on the IATs and a measure of explicit bias asked directly to participants. RESULTS Almost 1 million IAT records from Project Implicit were reviewed, and 131 surgeons (64.9% men; mean [SD] age, 42.3 [11.5] years) were recruited to complete the Gender-Specialty IAT. Healthcare professionals (n = 42 991; 82.0% women; mean [SD] age, 32.7 [11.8] years) held implicit (mean [SD] D score, 0.41 [0.36]; Cohen d = 1.14) and explicit (mean [SD], 1.43 [1.85]; Cohen d = 0.77) biases associating men with career and women with family. Similarly, surgeons implicitly (mean [SD] D score, 0.28 [0.37]; Cohen d = 0.76) and explicitly (men: mean [SD], 1.27 [0.39]; Cohen d = 0.93; women: mean [SD], 0.73 [0.35]; Cohen d = 0.53) associated men with surgery and women with family medicine. There was broad evidence of consensus across social groups in implicit and explicit biases with one exception. Women in healthcare (mean [SD], 1.43 [1.86]; Cohen d = 0.77) and surgery (mean [SD], 0.73 [0.35]; Cohen d = 0.53) were less likely than men to explicitly associate men with career (B coefficient, −0.10; 95% CI, −0.15 to −0.04; P < .001) and surgery (B coefficient, −0.67; 95% CI, −1.21 to −0.13; P = .001) and women with family and family medicine. CONCLUSIONS AND RELEVANCE The main contribution of this work is an estimate of the extent of implicit gender bias within surgery. On both the Gender-Career IAT and the novel Gender-Specialty IAT, respondents had a tendency to associate men with career and surgery and women with family (continued) Key Points Question Do surgeons and health care professionals hold implicit or explicit biases regarding gender and career roles? Findings A review of 42 991 Implicit Asso...

Background While medical marijuana use is legal in more than half of U.S. states, evidence is limited about the preparation of physicians-in-training to prescribe medical marijuana. We asked whether current medical school and graduate medical educational training prepare physicians to prescribe medical marijuana. Methods We conducted a national survey of U.S. medical school curriculum deans, a similar survey of residents and fellows at Washington University in St. Louis, and a query of the Association of American Medical Colleges (AAMC) Curriculum Inventory database for keywords associated with medical marijuana. Results Surveys were obtained from 101 curriculum deans, and 258 residents and fellows. 145 schools were included in the curriculum search. The majority of deans (66.7%) reported that their graduates were not at all prepared to prescribe medical marijuana, and 25.0% reported that their graduates were not at all prepared to answer questions about medical marijuana. The vast majority of residents and fellows (89.5%) felt not at all prepared to prescribe medical marijuana, while 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. Finally, only 9% of medical school curriculums document in the AAMC Curriculum Inventory database content on medical marijuana. Conclusions Our study highlights a fundamental mismatch between the state-level legalization of medical marijuana and the lack of preparation of physicians-in-training to prescribe it. With even more states on the cusp of legalizing medical marijuana, physician training should adapt to encompass this new reality of medical practice.

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During normal development in the rat, hepatocytes undergo marked changes in the rate of proliferation. We have previously observed transient G 1 growth arrest at term, re-activation of proliferation immediately after birth, and a gradual transition to the quiescent adult hepatocyte phenotype after postnatal day 4. We hypothesized that these changes in proliferation are due in part to growth inhibitory effects mediated by the p38 mitogen-activated protein kinase pathway. p38 kinase activity measurements showed an inverse relationship with hepatocyte proliferation during the perinatal and postnatal transitions, whereas p38 content remained constant. Anisomycin activated the p38 pathway in fetal hepatocyte cultures while inducing growth inhibition that was sensitive to the p38 inhibitor, SB203580. Activation of p38 in these cultures, via transient transfection with a constitutively active form of its upstream kinase MKK6, also inhibited DNA synthesis as well as reducing cyclin D1 content. Transfection with inactive MKK6 did neither. Furthermore, MKK6-induced growth arrest was sensitive to SB203580. Finally, administration of SB203580 to near-term fetal rats in utero abrogated the transient hepatocyte growth arrest that occurs at term. These findings indicate a role for the p38 mitogen-activated protein kinase pathway in the physiological regulation of hepatocyte proliferation during normal development in the rat.The developing liver undergoes marked changes in growth during and after the perinatal period. In the rat, a burst of hepatocyte proliferation results in the tripling of liver mass over the last 3 days prior to term (1). This is followed by a marked decrease in hepatocyte proliferation during the 1st postnatal week (2). Although late gestation fetal hepatocytes are highly proliferative both in vivo and in culture (2), the hepatocytes in adult liver are quiescent, with only 1 in 20,000 showing cell cycle activity. In addition to this fetal-to-adult transition, we have observed a period of temporary hepatocyte growth arrest that occurs just prior to parturition in the rat (2, 3). This is followed by a brief period of synchronized hepatocyte proliferation in the immediate postnatal period and a subsequent transition to the quiescent adult rat hepatocyte phenotype beyond the 1st postnatal week. The mechanisms that regulate these developmental changes in hepatocyte proliferation have not been characterized. Our work was motivated by the assumption that the elucidation of these mechanisms would contribute to understanding the pathophysiology of liver injury and carcinogenesis.The present series of experiments was based on studies demonstrating that perinatal rat hepatocytes are arrested in the G 1 phase of the cell cycle and that this cell cycle arrest coincides with a decline in cyclin D1 content. Based on evidence indicating that control of cyclin D1 abundance may be downstream from the p38 mitogen-activated protein (MAP) 1 kinase pathway (4), we examined the role of this signaling pathway in the perinatal and ...

Microwave ablation with a novel device results in consistently sized and shaped lesions. Importantly, we did not observe any significant heat-sink effect using this device, a major difference from RFA techniques. This system offers a viable alternative for creating fast, large ablation volumes for treatment in liver cancer.

Postoperative patients might consume less than half of the opioid pills they are prescribed. More research is needed to standardize opioid prescriptions for postoperative pain management while reducing opioid diversion.