Publications

Background:

Our objective was to compare the use of agentic (“I”) and communal (“we”) spoken intraoperative discourse between male and female attending and resident surgeons.

Methods:

We analyzed transcripts involving attending and resident surgeons from 5 specialties at a single Midwestern academic teaching hospital. We adapted and expanded Grebelsky-Lichtman’s codes, assessed rater agreement, and systematically coded transcripts for agentic and communal terms. Differences between genders and roles were evaluated using Mann-Whitney U tests.

Results:

In the operating room, attendings used significantly more Action Demands, Rationality, Collective Speech, Passive Speech, Nurturing Speech, and Degree Modifiers. Conversely, residents used significantly more Assertive Speech, and Display Solution. Attendings were also more likely to use Action Demands combined with Passive Speech. No significant gender differences were found in any categories.

Conclusions:

Language use in the OR is more closely associated with professional role rather than gender and may reflect underlying power dynamics and the nature of the surgical teaching environment.

Keywords: Communication; surgery; surgical education; gender; language

Importance: 

Sacral neuromodulation (SNM) requires removal for infectious complications in 3-11%.

Objective: Does preoperative antibiotic choice impact device removal rates?

Study Design: 

This was a retrospective cohort analysis, using the Health Facts® Database, representing >750 hospitals. We included female patients undergoing SNM
implantation 2010-2018. Univariate and multivariate logistic regression identified factors associated with removal. 35 comorbidities were evaluated. Those with p<0.2 on univariate analysis were included in the multivariate analysis. We decided a priori to include prophylactic antibiotic choice in the final model.

Results: 

Of 1,433 patients, 170 (11.9%) had device removal. Subjects were 70.0 ± 14.9 years old, predominantly Caucasian (90.0%), treated in urban hospitals (94.1%),
and married (54.2%). 11.8% were obese, and 18.0% smoked. Those in the removal cohort were more likely from the Northeastern U.S. 52.3% received 1st gen cephalosporins (CPSN), 7.4% 2nd or 3rd gen CPSNs, 9.1% vancomycin, 13.4% aminoglycosides, 4.6% clindamycin, and 13.3% fluoroquinolones. Compared to vancomycin, more removals were associated with first generation CPSNs (OR=3.1, 95% confidence interval [1.4, 6.8]); clindamycin (OR=3.2, [1.2, 8.4]); second/third generation CPSNs (OR=3.1, [1.3, 7.6]); and aminoglycosides (OR = 3.1, [1.3, 7.4]). Additionally, patients treated in the Northeast were more likely to undergo removal (OR = 1.9, [1.0, 3.7]).

Conclusions: Vancomycin as a prophylactic antibiotic was associated with fewer device removals compared to most antibiotics in this retrospective cohort analysis. While prospective trials could confirm this benefit, low removal rates may make this impractical.

Keywords: Sacral Neuromodulation, antibiotics, urinary incontinence, postoperative complications, device removal, infection

OBJECTIVE:

We aimed to: 1) create a Surgical Education Time-Out Tool (SET-OuT) checklist training module for faculty utilizing a highly-realistic simulation and 2) assess faculty and resident perioperative educational experiences pre- and post-SET-OuT intervention.

DESIGN, SETTING, AND PARTICIPANTS:

We recruited gynecologic surgical faculty and PGY1 to PGY3 obstetrics and gynecology (OBGYN) residents from the University of Utah. Each enrolled participant completed a baseline and 9-month survey about their educational experiences and SET-OuT satisfaction. Faculty enrollment required completion of highly-realistic SET-OuT simulation with a simulated resident actor. We compared individual measures and composite teacher self-efficacy scale and composite resident procedural self-confidence scale between time points using rank sum tests. We converted Likert-scale items to 5-point scales and used mixed linear models to investigate whether relationships persisted after accounting for individual surgeons' and residents' effects.

RESULTS:

Twenty-five of 62 (40%) faculty and 15/17 (88%) residents enrolled with 100% baseline survey completion. Twenty of 25 (80%) faculty and 12/15 (80%) residents completed the 9-month survey. Faculty scored a median 34/45 points on the self-efficacy scale at baseline and 41/45 points at 9 months (p < 0.01). Faculty demonstrated a 0.9-point improvement in teaching performance satisfaction (p < 0.01). Residents' procedural self-confidence was 16.5/30 at baseline and 22/30 at 9-months (p = 0.01) and felt their value and input in the surgical education experience improved. Residents reported improved satisfaction with feedback at 9-months compared to baseline (p = 0.01). Faculty and residents reported 85% and 100% satisfaction with the ETO as a teaching tool, respectively.

CONCLUSIONS:

Implementation of a perioperative SET-OuT improved faculty teaching self-efficacy and resident procedural confidence. Both groups highly rated the SET-OuT as an acceptable perioperative teaching tool.

PURPOSE:

The surgical clerkship provides medical students with valuable hands-on experience. This study examined why medical students speak or remain silent in the OR to improve progression from novice to engaged surgical team member.

METHODS:

Using Constructivist Grounded Theory 37 interviews were conducted concerning expectations and behaviors that encourage or discourage students from speaking during their clerkship. Transcripts were coded, analyzed, and triangulated to develop a conceptual model.

RESULTS:

Students' decision to speak or remain silent was based on their perception of the OR as a safe learning space. Our findings suggest that better preparation, awareness of critical moments, and informal communication with team members encouraged student speech.

CONCLUSIONS:

Medical students remain conflicted about their speaking in the OR and their evaluation. Key to improving students' psychological safety is establishment of interpersonal relationships, awareness of OR mood, and assignment of case-related tasks to assist with OR assimilation and improved learning.

Introduction and hypothesis:

Surgeon kinematics play a significant role in the prevention of patient injury. We hypothesized that elbow extension and ulnar wrist deviation are associated with bladder injury during simulated midurethral sling (MUS) procedures.

Methods:

We used motion capture technology to measure surgeons’ flexion/extension, abduction/adduction, and internal/external rotation angular time series for shoulder, elbow, and wrist joints. Starting and ending angles, minimum and maximum angles, and range of motion (ROM) were extracted from each time series. We created anatomical multibody models and applied linear mixed modeling to compare kinematics between trials with versus without bladder penetration and attending versus resident surgeons. A total of 32 trials would provide 90% power to detect a difference.

Results:

Out of 85 passes, 62 were posterior to the suprapubic bone and 20 penetrated the bladder. Trials with versus without bladder penetration were associated with more initial wrist dorsiflexion (−27.32 vs −9.03°, p = 0.01), less final elbow flexion (39.49 vs 60.81, p = 0.03), and greater ROM in both the wrist (27.48 vs 14.01, p = 0.02), and elbow (20.45 vs 12.87, p = 0.04). Wrist deviation and arm pronation were not associated with bladder penetration. Compared with attendings, residents had more ROM in elbow flexion (14.61 vs 8.35°, p < 0.01), but less ROM in wrist dorsiflexion (13.31 vs 20.33, p = 0.02) and arm pronation (4.75 vs 38.46, p < 0.01).

Conclusions:

Bladder penetration during MUS is associated with wrist dorsiflexion and elbow flexion but not internal wrist deviation and arm supination. Attending surgeons exerted control with the wrist and forearm, surgical trainees with the elbow. Our findings have direct implications for MUS teaching.

Keywords: Biomedical engineering; Kinematics; Midurethral sling; Motion capture; Patient safety; Surgical education; Surgical simulation.

Objective: 

In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction.

Design: 

We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR.

Setting: 

Midwestern academic university teaching hospital.

Participants: 

Six attending and 6 resident surgeons.

Results: 

Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech.

Conclusions: 

Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.

Keywords: communication; linguistics; semantics; surgery; surgical education.

Highlights

• This is the first study applying linguistic inquiry and word count to intraoperative spoken language.

• Attending surgeons spoke more words and used more language of clout.

• Residents used more informal speech with an emotional tone and assent.

• There were no meaningful differences in language use according to gender.

Objective

Previous work has analyzed residency letters of recommendation for agentic and communal language, but this has not been applied to spoken language. Our objective was to analyze intraoperative spoken language by attending and resident surgeons for the use of agentic and communal language.

Design

We completed a linguistic inquiry and word count (LIWC) analysis on 16 operating room transcripts (total time 615 minutes) between attendings and resident surgeons for categories associated with agentic and communal speech. Wilcoxon signed rank and Mann-Whitney U tests were used to compare attending versus resident and male versus female speech patterns for word count; “I,” clout, and power (agentic categories); and “we,” authentic, social (communal categories).

Setting

Midwestern academic university teaching hospital.

Participants

Sixteen male (9 attendings, 7 residents) and 16 female (7 attendings, 9 residents) surgeons, from 6 surgical specialties, most commonly from General Surgery.

Results

Attending surgeons used more words per minute than residents (40.01 vs 16.92, p < 0.01), were less likely to use “I” (3.18 vs 5.53, p < 0.01), and spoke more language of “clout” (75.82 vs 55.47, p < 0.01). There were no significant differences between attendings and residents in use of analytic speech (23.72 vs 24.67, p = 0.32), “causation” (1.20 vs 1.08, p = 0.72), or “cognitive processing” (10.20 vs 10.54, p = 0.74). Residents used more speech with “emotional tone” (92.91 vs 79.92, p = 0.03), “positive emotion” (4.98 vs 3.86, p = 0.04), more “assent” language (4.89 vs 3.09, p < 0.01), and more “informal” language (9.27 vs 6.77, p < 0.01). There were no gender differences, except for male residents speaking with greater certainty than female residents, although by less than 1% of the total word count.

Conclusions

In the operating room, attending surgeons were more likely to use agentic language compared to resident surgeons based on LIWC analysis. These differences did not depend on gender and likely relate to surgeon experience and confidence, learning versus teaching, and power dynamics.

Key words

communication, surgery, surgical education, gender, language

BACKGROUND: Our objective was to compare the use of agentic ("I") and communal ("we") spoken intraoperative discourse between male and female attending and resident surgeons.

METHODS: We analyzed transcripts involving attending and resident surgeons from 5 specialties at a single Midwestern academic teaching hospital. We adapted and expanded Grebelsky-Lichtman's codes, assessed rater agreement, and systematically coded transcripts for agentic and communal terms. Differences between genders and roles were evaluated using Mann-Whitney U tests.

RESULTS: In the operating room, attendings used significantly more Action Demands, Rationality, Collective Speech, Passive Speech, Nurturing Speech, and Degree Modifiers. Conversely, residents used significantly more Assertive Speech, and Display Solution. Attendings were also more likely to use Action Demands combined with Passive Speech. No significant gender differences were found in any categories.

CONCLUSIONS: Language use in the OR is more closely associated with professional role rather than gender and may reflect underlying power dynamics and the nature of the surgical teaching environment.

Importance: 

Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications.

Objective: 

The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP).

Study design: 

We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8.

Results: 

Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years.

Conclusion: 

Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

Introduction: 

Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events.

Methods:

 In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.

Results: 

The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC¹ was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete.

Conclusions: 

Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

Keywords: Anesthesia; Communication; Interprofessional teamwork; OR nursing staff; Surgery; Surgical error.