Authors: Rosemary Nabaweesi, Jonathan Goree, Kevin Sexton, Brian Gittens

Abstract

Purpose of Study

In the US, opioids have caused significant morbidity and mortality over the last decade. In 2017 drug overdose accounted for 70,237 deaths and 67.7% of these involved an opioid. In 2016, the Centers for Disease Control and Prevention developed an opioid prescribing guideline with twelve recommendations for chronic pain management intended to improve communication between providers and patients, about opioid therapy safety and effectiveness and opioid use disorder risks.

Long-term opioid use typically begins with treatment of acute pain. Opioids can effectively relieve pain but judicious use should be taken to minimize the risk of abuse. Research indicates that 6% of patients have continued opioid use 90 days post-surgery, even though the length of initial opioid prescription directly correlates with chronic opioid use risk. Conversely, poorly controlled acute post-surgical pain increases rates of chronic post-surgical pain syndromes; thus adequately controlling acute pain is vital to preventing long-term opioid use.

Black and Latino patients are commonly prescribed less opioids than White patients for similar chief complaint and diagnosis. A retrospective review of pediatric emergency department admissions for appendicitis, found that White patients were twice as likely to be prescribed opioids compared to Black patients. Factors associated with racially disparate opioid-prescribing practices include implicit bias, provider patient communication gaps, lack of trust, historical trauma, lack of or limited healthcare access. In order to improve acute post-surgical pain management, decrease opioid use and eliminate prescribing disparities, many academic centers have developed standardized pain protocols. The pain protocols often include anesthetic plan standardization, acute pain regimens, and post-surgical opioid and adjuvant prescriptions. While literature demonstrates that the pain protocols have decreased peri-operative opioid prescription, there is a knowledge gap on the effect of pain protocols on improving opioid-prescribing racial disparities.

Aims

1) Identify opioid prescribing racial disparities among patients admitted to the trauma surgery service at a Level I Trauma Center
2) Determine the impact of implementing a standardized acute pain protocol intervention on identified prescribing disparities

Data and Methods

The trauma acute pain protocol to standardize opioid prescribing (ordering) was established mid-2017. We conducted a retrospective review of all adult trauma admissions at Level I trauma center between 2015 and 2018. Opioid prescription was our primary outcome for the logistic regression. Patients were matched for age, gender and injury severity. Eligibility criteria were adult patients admitted to a level I Trauma Center.

Key Findings

Of eligible patients, 7,581 met inclusion criteria, 5,115 pre-intervention and 2,466 post intervention. African American patients were significantly less likely to receive opioids than Caucasian patients after controlling for injury severity, age and gender; Odds ratio (OR) 0.61 95% Confidence Interval (CI) 0.49, 0.74; p-value <0.001. Similarly, Asian and Latino patients also were significantly less likely to receive opioids than Caucasian patients post intervention; OR 0.65, CI: 0.42, 0.98, p-value 0.042.

Table 1: Logistic Regression of Opioid Administration by Admitted Patients’ Race

Pre- Intervention Race Odds Ratio

(95% Confidence Interval)
(95% Confidence Interval)
African American 0.64 (0.56, 0.73) Latina/ Asian 0.78 (0.59, 1.03)

Post-Intervention

P-Value P-Value

Odds Ratio

<0.001 <0.001
0.084 0.65 (0.42, 0.98) 0.042

Submitted to GDI 12/16/2019

Implications

When trauma surgeons used a standardized acute pain protocol, the odds of African American, Asian and Latino patients being prescribed opioids following a traumatic event remained lower compared to Caucasian patients with matched injury severity, age and gender.

Next Steps

We posit that since prescribers adhered to the acute pain protocol, we have to examine the dispensation practices of nurses for as-needed medications. We propose to implement three educational interventions to mitigate the problem of disparate opioid dispensing and recommendation by nurses working with Trauma Surgery inpatients.

Conference/Symposium/Course name, dates and location where the work was supposed to be presented:

16th Annual AAMC Health Workforce Research Conference, Bethesda, MD May 6-8, 2020

Authors: Henry T, Kimbrough MK, Thrush CR.

Abstract

Background

National trends continue to show gender disparities among students entering general surgery careers, decreasing rates overall regardless of gender, and predictions for future surgeon shortages.¹  Early exposure to surgery career options and mentors are critical for informed decision-making, yet surgical experiences in medical school are typically limited to the third or fourth years.² Given these challenges, earlier exposure to surgery and understanding barriers and factors influencing students’ career decisions remain topics of research interest.

Goals

Summer-In-Surgery (SIS) is a 4-week elective we created for rising second-year medical students to acquire first-hand experience in general surgery specialties.^3-4  The goal of this project is to explore gender differences in SIS participant responses to pre- and post-program surveys evaluating interest in surgical careers and research, comfort level in the operating room (OR), and perceptions of barriers or influencing factors to a career in surgery.

Methods

Between 2016-18, 72 students (56%, n=27 men/44%, n=21 women) have participated in SIS and completed pre (n=70) and post (n=72) evaluation measures to assess surgical career/lifestyle interest levels, influencing factors and barriers. Non-parametric Wilcoxon tests were used to assess gender differences in participants’ survey responses. 

Results

Men and women equally indicated the most influential factor in selecting a surgical career was that it matched with their personality, skills, and interests. Post-SIS responses indicated women perceived their competitiveness and board scores (48%) to be the most significant barrier to pursuing a surgical career, while for men the most prominent barrier was family-work-life balance (43%). Both male and female participants reported significantly increased (p<0.001) comfort in the OR.  Men’s perceptions of surgeon quality of life declined significantly (p<0.05), whereas women’s perceptions improved (though not significantly). Females also reported significant improvements in perceptions of work-life balance (p<0.05) whereas males did not.

Conclusion

The surgical experience provided by SIS showed statistically significant and practical effects on comfort levels in the OR across both genders and identification of students’ perceived barriers to surgical careers. Perceptions of work-life balance and surgeons’ quality of life were significantly improved for women.  Dispelling misperceptions about surgical careers is an important step to improve the surgeon shortage.  

References

1. Peel JK, Schlachta CM, Alkhamesi NA. A systematic review of the factors affecting choice of surgery as a career. Canadian Journal of Surgery. 2018 Feb;61(1):58.Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Medicine, 2013;88(4), 468-474.

• Cloyd J, Holtzman D, O’Sullivan P, Sammann A, Tendick F, Ascher N. Operating room assist: surgical mentorship and operating room experience for preclerkship medical students. J Surg Educ. 2008 Jul-Aug;65(4):275-82. 

• Kimbrough M, Thrush CR, Smeds M, Bentley F.  Early Exposure to Surgical Careers:  A Pre-Clinical “Summer in Surgery” Program.  (Innovation Poster). 2016 AAMC Annual Meeting – Learn Serve Lead, Seattle, WA, November 11–15, 2016. 

• Cobos RJ, Thrush CR, Harris TJ, Smeds MR, Bentley FR, Kimbrough MK. Shaping Medical Student Perceptions: A Pre-Clinical ‘Summer in Surgery’ Program. Journal of The American College of Surgeons. 2017; 225(4, Supplement 2), e160. DOI: https://doi.org/10.1016/j.jamcollsurg.2017.07.960

Conference/Symposium/Course name, dates and location where the work was supposed to be presented:
Association for Surgical Education Annual Conference 2020, April 27-30, Seattle, WA.

Authors: Gammill S, Phelan K, Bennett T, Thrush C, Golinko M, Hartzell L, Bhavaraju A.

Abstract

BACKGROUND

The ability to suture simple lacerations is a basic expectation for many residents, but recent medical school graduates often feel unprepared to perform this skill.¹ Various curricula have been developed by medical schools to facilitate the acquisition of procedural skills such as suturing,^2-4 unfortunately, these courses are typically offered only on an elective basis for interested students.⁵  To address this deficiency amongst incoming interns, many graduate medical education programs have implemented boot camps aimed at teaching basic procedural skills.^6-9  To better prepare our medical students for clinical clerkships and beyond, we implemented a mandatory progressive, longitudinal suturing curriculum and present survey results from the initial cohort of students.

METHODS

All students are provided online video resources and suturing materials for independent practice, followed by six hours of hands-on instruction starting on their own gross-laboratory cadavers ,during divided sessions throughout the M1 and M2 years covering key suturing skills (ex. correct instrument position, instrument and hand knot tying, various suturing techniques). With each session, students are checked off on what they have learned the previous session and then focus on practicing the next set of skills. Finally, a 2-hour refresher session is provided immediately prior to starting M3 clinical clerkships. FOSS sessions are led by clinical faculty, residents, and peer tutors. M1 students completed course evaluation surveys before (n=167) and after (n=148) the first FOSS session to assess pre-course suturing experience, comfort level with previously stated skills, and impressions about the overall course design. 

RESULTS

Prior to the course, just over one-third (37%) had no suturing exposure or direct suturing experience. Of the 63% of students with prior exposure, less than 5% had any direct suturing experience. There was a statistically significant improvement in students’ ratings of their comfort with proper instrument position, performing simple interrupted sutures, and performing instrument ties (p<0.0001). 83% of students rated the gross lab sessions as excellent. The majority of students found the FOSS resources very helpful: materials and self-study guides (91%); clinical faculty (99%); session time (99%).

CONCLUSIONS

Based on positive responses and improved comfort level with basic suturing skills, the program appears to be a worthwhile use of both faculty resources and students’ time. Students were also exposed to suturing much earlier than otherwise expected during their medical education. Future work will examine the potential impact on students’ performance during clinical rotations.

References

1. Fargo MV, Edwards JA, Roth BJ, Short MW. Using a simulated surgical skills station to assess laceration management by surgical and nonsurgical residents. J Grad Med Educ. 2011 Sep;3(3):326-31.
2. Lemke M, Lia H, Gabinet-Equihua A, et al. Optimizing resource utilization during proficiency-based training of suturing skills in medical students: a randomized controlled trial of faculty-led, peer tutor-led, and holography-augmented methods of teaching. Surgical endoscopy. 2019 Jul 8:1-0.
3. Manning E, Mishall P, Weidmann M, et al. Early and prolonged opportunities to practice suturing increases medical student comfort with suturing during clerkships: Suturing during cadaver dissection. American association for anatomy. 2018 Mar;11(6)
4. Miller S, Shipper E, Hasty B, et al. Introductory Surgical Skills Course: Technical Training and Preparation for the Surgical Environment. MedEdPORTAL. 2018;14:10775. Published 2018 Nov 28. doi:10.15766/mep_2374-8265.10775
5. Antonoff M, Green C, D’Cunha J. Operative and technical skills for the senior medical student entering surgery. MedEdPORTAL. 2013;9:9470.
6. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents. Care of the Surgical Patient. 2008. Obtained from:  https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint259_Surgical.pdf
7. Dean KM, DeMason CE, Choi SS, Malloy KM, Malekzadeh S. Otolaryngology boot camps: Current landscape and future directions. Laryngoscope. 2019; 9999:1–6. [Epub ahead of print]
8. Ataya R, Dasgupta R, Blanda R, Moftakhar Y, Hughes PG, Ahmed R. Emergency medicine residency boot Camp curriculum: a pilot study. West J Emerg Med. 2015 Mar;16(2):356-61.
9. Promes SB, Chudgar SM, Grochowski CO, Shayne P, Isenhour J, Glickman SW, Cairns CB. Gaps in procedural experience and competency in medical school graduates. Acad Emerg Med. 2009 Dec;16 Suppl 2:S58-62.

Conference/Symposium/Course name where the work was supposed to be presented:
AAMC Southern Group on Educational Affairs (SGEA) Annual Meeting