Ethics

Concordance and Discordance of an Ethical and Cost-Conscious Surgical Practice Hannah M Phelps, MD, Sean C Wightman, MD, FACS, Baddr Shakhsheer, MD, FACS Washington University in St Louis, St Louis, MO; University of Southern California Keck School of Medicine, Los Angeles, CA; University of Chicago, Chicago, IL Introduction: Cost remains an ever-increasing concern in surgical practice. Surgeons are ill-equipped to manage ethical issues surrounding cost-control efforts. Methods: The literature and guidelines regarding cost-conscious surgical practice were reviewed. Due to a dearth of actionable guidelines, the authors propose a framework for surgeons to approach cost. Results: Current efforts to control surgical cost present a unique ethical challenge to surgeons in balancing responsibility to an individual patient (beneficence) with a responsibility to steward costly resources in service to other patients (distributive justice). Surgical training and professional societies offer little guidance on navigating this central question, which creates a sense of moral ambiguity for surgeons. Addressing cost in surgical practice need not compromise our ethics. It does, however, create an obligation for surgeons to understand that cost and patients cannot be considered separately, requiring surgeons to maintain an active role in conversations related to cost; and to respect both patient autonomy and distributive justice as they relate to cost. Because cost is a limited resource, sacrifices will occur. These must be examined and acknowledged. Finally, surgeons should avoid engaging in cost-control efforts on a case-by-case basis. The bedside is not the appropriate place to steward resources. Conclusion: Surgeons must be equipped to lead discourse on cost-control efforts, lest we forfeit ownership of the issue to non-medically trained stakeholders. Surgeons are asked to balance duty to their current patients with duty to institutions and future patients, which creates moral dissonance, ethical conflict, and potential to violate the essential physician-patient relationship. Conflict of Interest Statements and Disclosure Policies for Surgical Societies Kathryn N Wittrock*, BS, Hassan Aziz, MD University of Iowa Hospitals and Clinics, Iowa City, IA Introduction: This study analyzed the public accessibility of disclosure requirements for surgical meetings and the differences between these requirements. Methods: An analysis of webpages of all surgical societies in the US was performed to find conflict of interest or disclosure policies. These policies were then analyzed to determine whether they addressed the identification, management, resolution, and administrative action related to conflict of interest. The definitions of a significant conflict of interest were compared, and forms used to report possible conflict of interest were identified. The primary outcome of this study relates to the discrepancy between the identification and handling of conflict of interest by different surgical societies. Results: Publicly available websites from 80 surgical societies were accessed to find their conflict of interest or disclosure policies. Only 53% (24/45) of surgical meetings and 50% (40/80) of surgical societies had clear requirements for disclosing conflicts of interest. Of those that had requirements listed, the guidelines varied in length from a single paragraph to 21 pages. Of those with a clear conflict of interest statement, only 21% of surgical meetings provided a readily available form for members, speakers, authors, and leaders to fill out with the required disclosure information. A total of 54% of members disclose conflicts of interest related to the financial relationships of immediate family members. In addition, only 46% of these conflict-of-interest statements defined what constituted a significant conflict of interest. Conclusion: There is a general lack of accessibility, accountability, and consistency in conflict-of-interest statements for different surgical meetings. Evaluation of Race, Ethnicity, and Language Mischaracterization in the Electronic Medical Record at an Academic Medical Center Ricardo Crespo Regalado, BA, Emily Bulik-Sullivan, BS, Andrew G Blank, BS, MPH, Lauren Raff, MD, FACS, Evan Raff, MD, FHM University of North Carolina at Chapel Hill, Chapel Hill, NC Introduction: Language barriers are a leading cause of health disparities in the US. Language access services are meant to provide equitable healthcare to patients whose primary language is not English. However, for patients to use these services with fidelity, hospitals must accurately assess and identify language needs in the electronic medical record. Methods: This was a mixed methods study of adult, hospitalized, non-ICU patients identifying as Hispanic/Latinx and whose primary language is Spanish or English, at a large academic medical center from October 2022 to July 2023. Patients were administered a REDCap survey containing race, ethnicity, and language (REaL) questions, and a health literary portion, to determine whether Epic accurately reflected patients’ language needs and preferences. Results: There were a total of 47/156 patients with interpreter need, 15/156 with preferred language for medical care (PLMC), and 11/156 with ethnicity mischaracterized. Patients were more likely to have their interpreter need mischaracterized if they were male or overestimated their English proficiency. A total of 72/156 patients self-reported having less than “well” English proficiency. Of the 22 patients who took the Short Assessment of Health Literacy in Spanish & English (SAHL-S&E), 10 failed the SAHL-E but passed the SAHL-S, indicating poor English proficiency and the need for an interpreter (Table 1). Table 1. - Survey vs Epic Electronic Health Record Data Measure Epic Self-report Total mischaracterizations Total no. Spanish interpreter need 69/156*4 unsure 88/156*6 unsure 47/156 -- Patients preferring Spanish 94/156 92/155 15/155 -- Patients preferring English 62/156 63/155 (Merge with cell above) -- Patients with poor English proficiency on self-report or SAHL administration -- 72/156 -- 82/156 Ethnicity -- -- 11/156 -- Poor health literacy -- -- -- 48/156 Conclusion: An alarming number of patients had their interpreter need, ethnicity, and language preference mischaracterized in the electronic medical record, oftentimes left blank or unknown. Extrinsic and/or intrinsic factor(s) account for these observations. An improved hospital process is needed to better assess language needs and capture REaL data. Surgeon Perception and Attitude Toward the Moral Imperative of Institutionally Addressing Second Victim Syndrome in Surgery Li-Hsuan Hsiao, MD, FRCSC, Piroska K Kopar, MD, FACS University of British Columbia, Vancouver, BC, Canada; Washington University at St Louis, St Louis, MO *Excellence in Research Award recipient. Introduction: Second victim syndrome (SVS) is described in the literature, where healthcare providers encounter significant moral distress after traumatic patient care events. While broadly recognized in medicine, this remains under-recognized in surgery, and no systemic approaches exist to mitigate potential harm of SVS among surgeons. SVS is especially ethically relevant in surgery given the intimacy and invasiveness of the profession. Methods: This study was conducted at a tertiary-care university hospital using a mixed-methods approach coupling quantitative and qualitative assessments. A 13-item survey composed the quantitative portion of the analysis. Then, follow-up focus group and semi-structured interviews were conducted. Participants included surgeons from diverse specialties. The Wilcoxon signed-rank test was used for the quantitative analysis and content analysis to report the qualitative findings. Results: Surgeons believe that SVS is a universal experience amongst surgeons and medical institutions have a moral obligation to address this. Surgeons further believe that any effective mitigation strategy must receive legal protection similar to morbidity and mortality conferences. The culture, tenor, and tone of review processes after surgical complications can either reduce or exacerbate the burden of SVS with important ethical implications for both surgeons and patients. Successful interventions must be easily accessible, voluntary, and culturally acceptable (Table 1). Conclusion: Surgeons agree that health organizations have a moral imperative to assist surgeons in navigating the psychosocial impacts of SVS after adverse surgical outcomes. The success of mitigation strategies is ethically relevant to patients and surgeons and is dependent on the culture, tenor, and tone of the process.ePosters Assignment of Patients to Hospital Rooms with Two Beds: Does Bias Lead to Segregation by Race? Jorge A Ruiz De Somocurcio, MD, George Silva, MSc, James Wallace, MD, Aaron Fleishman, MPH, Ernest Gomez, MD, FACS, Sidharta P Gangadharan, MD, FACS Beth Israel Deaconess Medical Center, Boston, MA Introduction: Implicit bias impacts health care delivery. We investigated whether race and ethnicity influenced the assignment of patients to double-bed hospital rooms. Methods: We performed a retrospective, quantitative study of inpatients assigned to a roommate at an urban academic medical center from 2017-2020. We studied the impact of implementation of an automated bed-assignment protocol (Teletracking). All wards with double-bed rooms were included. Logistic regressions stratified by sex and corrected for seasonality, age, and language were used for analysis. Results: Of all patients assigned to a double-bed room during the entire study period, 31.8% of females and 27.5% of males identified as non-White. During the pre- and post-Teletracking periods, the percentage of double-bed rooms pairing two non-White patients were 8.68% (2,083 of 23,943) and 8.96% (2,040 of 22,758), respectively. Analyses showed that non-White patients do not have a higher probability than chance of being assigned to a non-White roommate, either before or after Teletracking in either male or female cohorts (female/before p = 0.47; male/before p = 0.7; female/after p = 0.67; male/after p = 0.09). Similar results were present when analyzing patients who self-identify as Black (female/before p = 0.19; male/before p = 0.83; female/after p = 0.5; male/after p = 0.15). Conclusion: Despite anecdotal impressions that racial bias influences the assignment of inpatients to double-bed rooms, analysis of the medical center’s inpatient census does not reveal any evidence of segregation. While this does not imply that the care these patients received was free of any bias, the absence of segregation of roommates by race is potentially one less barrier to equity in healthcare delivery. Disciplinary Action Against Maryland Physicians: Are Surgeons More at Risk? Lindsay A Kohan, BS, BA, Margaret H Sundel, MD, Stephen M Kavic, MD, FACS University of Maryland School of Medicine, Baltimore, MD Introduction: Clinical competence, ethics, and professionalism are essential to high-quality patient care; regulatory bodies oversee the conduct of healthcare providers to detect lapses in these standards. Surgical and procedural specialties are at a higher risk of medical malpractice claims, but literature investigating whether these perceptions hold true in the form of disciplinary actions is limited. The purpose of this study was to examine patterns of disciplinary actions against surgical and non-surgical physicians in the state of Maryland. Methods: Disciplinary alerts from the Maryland Board of Physicians were reviewed between 2014-2023. Basic physician demographics, reasons, and outcomes (license suspension, revocation, or surrender; cease and desist; or monetary fine) for disciplinary action were collected. Chi-squared and Fisher’s Exact tests were used to compare reasons and outcomes for disciplinary actions between groups. Results: Over 9 years, 215 unique disciplinary actions were sanctioned against Maryland physicians. 20.0% of those were against surgeons, despite surgical providers comprising 15.6% of active physicians in Maryland. The majority of surgeons who received disciplinary action were male (88.4%), greater than 20 years post-Maryland licensure (74.4%), and were cited for negligence or incompetence (51.2%). Surrender of medical license (40.5%) was the most common outcome after disciplinary action for all physicians. The reasons for (p = 0.44) and outcomes of (p = 0.69) disciplinary actions against surgeons and non-surgeons were not significantly different. Conclusion: Surgeons and non-surgeons have similar patterns of disciplinary actions. Understanding the characteristics of physicians facing disciplinary actions may aid in the development of interventions to prevent at-risk behaviors. Race-Based Criteria in Transplant Induction Protocols Julia R Skibniewska, BS, Jeffrey D Punch, MD, FACS, Christian J Vercler, MD, FACS University of Michigan Medical School, Ann Arbor, MI Introduction: Race has been used clinically as a proxy for genetic differences that impact disease susceptibility, and as a shortcut to estimating societal impacts on health following historically disparate access to care. Its continued use in medical decision making is controversial because it perpetuates stereotypes of race having a biological impact on disease. One such medical decision is use of anti-thymocyte globulin (ATG) for induction in kidney transplants. ATG is a rabbit-derived antibody that depletes T-cells to prevent graft rejection in high-immunological risk transplant patients. KDIGO, a large non-profit leader in kidney disease, lists African American (AA) race in the USA only as an independent criterion of high-immunological risk. This recommendation is reflected in policies at large tertiary care centers that list AA race as an indication for ATG. Methods: Literature review of Thymoglobulin risks, existing protocols, and alternative risk stratification. Results: This criterion was instituted due to widely reported inferior outcomes for AA organ recipients and donors. ATG recipients have a permanently altered CD4/CD8 (T-cell subtype) ratio, increasing risk for infection and malignancy. Social indices in small populations have shown to more accurately predict graft failure rates than race. Conclusion: Implementation of this protocol in the USA only suggests its serving as a proxy for social impact of race, not genetic differences. Transplant surgery is uniquely positioned to evaluate social adaptability independently of race with an extensive, established pre-procedural evaluation. This study will explore adequacy of race as a criterion for ATG induction, and options for alternative risk stratification. Reporting Mechanisms for Workplace Microaggressions Against Surgeons: Results of a Survey of the American College of Surgeons Members Christine A Heisler, MD, MS, FACS, Amy Godecker, PhD, MS, Deborah Verran, MbChB, MHSM, Michael S Sinha, MD, JD, MPH, Jerome Byam, MD, FACS, Pringl Miller, MD, FACS University of Wisconsin, Madison, WI; Ramsay Healthcare, Sydney, Australia; St Louis University, St Louis, MO; Johns Hopkins University, Washington, DC; Physician Just Equity, Bodega Bay, CA Introduction: Microaggressions in healthcare create a detrimental and disruptive workplace for surgeons. However, no studies describe perpetrator characteristics, type of microaggressions experienced or intention about how microaggressions are addressed. We sought to investigate perpetrator characteristics and reporting mechanisms for surgeons who experienced workplace microaggressions. Methods: We developed and internally validated a web-based survey to assess surgeon experiences with microaggressions. We distributed the survey through nine American College of Surgeons (ACS) online Communities from November 2022 to January 2023. All ACS Communities comprised members with experience in the surgical workforce. Analyses include descriptive and chi-squared statistics, t-tests, and bivariate logistic regression. Results: Of 377 ACS survey respondents, 254 (67.4%) experienced workplace microaggressions. Microaggressions included creating an unwelcoming or unfriendly environment, one’s opinion being overlooked, being ignored, being treated differently, and presumption of inferior performance. Perpetrator characteristics included: supervisors, surgeon colleagues, support staff, students/trainees, and patients/families. A total of 143 (of 254, 56.3%) of respondents reported their microaggression experiences. Supervisors and surgeon colleagues perpetrated all types of microaggressions reported, and support staff perpetrated all types of microaggressions except creating an unwelcoming or unfriendly environment. The most common reporting mechanism included informal reporting to a colleague and directly confronting the perpetrator. Surgeons who reported their experiences with microaggressions were less likely to say they would choose a career in surgery again (p = 0.025). Conclusion: Despite utilizing appropriate mechanisms to address microaggressions, surgeons reporting microaggression experiences expressed career regret. Eliminating workplace microaggressions could improve recruitment and retention of surgeons. What’s in a Name? Protocol Toward Improving Name Pronunciation at a Regional Surgical Society Sidharta P Gangadharan, MD, FACS, Fleming Mathew, MBBS, Giles F Whalen, MD, FACS, Baird Mallory, MD, FACS, Alisa Savetamal, MD, FACS Beth Israel Deaconess Medical Center, Boston, MA; Worcester, MA; Portland, ME; Bridgeport, CT Introduction: In classrooms, and other to and We developed and to improve this at a surgical Methods: In of a surgical were to of A for was to the included for with these provided to in could on their at A survey was distributed to all Results: Of the respondents surgeons, reported their were for in the to of this with self-reported it was important that their be and would who their all of was of that improved and recognized the efforts to during Conclusion: Protocols for were that these efforts and the of at meetings can whose are the from these should be considered for implementation at all surgical conferences. Workplace Microaggressions and the on a Results of a Survey of the American College of Surgeons Members Christine A Heisler, MD, MS, FACS, Amy Godecker, PhD, Deborah Verran, MbChB, MHSM, Michael S Sinha, MD, JD, MPH, Jerome Byam, MD, FACS, Pringl Miller, MD, FACS University of Wisconsin, Madison, WI; Ramsay Healthcare, Sydney, Australia; St Louis University, St Louis, MO; Johns Hopkins University, Washington, DC; Physician Just Equity, Bodega Bay, CA Introduction: Workplace microaggressions in healthcare have been with higher rates of and to an the impact on surgeon career has not been We sought to explore how workplace microaggressions impact surgeon career Methods: We developed and internally validated a web-based survey to assess surgeon experiences with microaggressions. We distributed the survey through nine American College of Surgeons (ACS) online Communities from November 2022 to January 2023. All ACS Communities comprised members with experience in the surgical workforce. Analyses include descriptive and chi-squared statistics, t-tests, and bivariate logistic regression. Results: Of 377 ACS members who the 254 (67.4%) of respondents reported they experienced workplace microaggressions in the current and most Perpetrator included: supervisors, surgeon colleagues, support staff, students/trainees, and patients/families. Over of surgeons who reported their microaggressions in the current where microaggressions a was the career impact included with a There was no between surgeons who and not report microaggressions regarding due to for a career or in where microaggressions improved (p Surgeons who experienced microaggressions = were more likely to say they would not choose surgery as a career again (p = Conclusion: Surgeon career was by the microaggression perpetrator must workplace microaggressions to improve recruitment and retention of surgeons.

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