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Surgery_Schwartz. the ACGME and American Board of Surgery mandate for program assessment of resident performance in the operating room.134Nontechnical skills often erode during stressful events, particularly in surgery where bleeding, complexity of the opera-tion, time-constraints, and equipment problems can have a nega-tive effect. Additionally, roadblocks with insurance and other third parties, critical illness, and delivering bad news add differ-ent kinds of stress.135 Indeed, video analysis of real operations indicates that attending surgeons typically take over, change their style of leadership, and decrease their teaching in the oper-ating room once unintended events occur.136Brunicardi_Ch01_p0001-p0026.indd 1529/01/19 10:58 AM 16BASIC CONSIDERATIONSPART IBy using simulated patients, patient-centered models, and intensive and immersive training, nontechnical skills including communication can improve interview techniques.137,138 Post com-munication skills training at the 12-month follow-up


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Surgery_Schwartz. models, and intensive and immersive training, nontechnical skills including communication can improve interview techniques.137,138 Post com-munication skills training at the 12-month follow-up demonstrated that the training was effective, and with real clinical practice after the training communication skills had improved even more.139Lastly, there appears to be a positive feedback loop tying nontechnical leadership skills with self-perceived operating room prowess. Those surgeons who rate their own technical skills highly are also more likely to engage in positive leader-ship skills, including teaching in the operating room, handle difficult situations, and provide more clear instructions.140 Simulation may be particularly critical for preventing techni-cal skill decline in residents on dedicated research time or for attending surgeons whose research, clinic, or administrative duties decrease the amount of time they can spend in the operating room. Simulation represents the future of


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Surgery_Schwartz. research time or for attending surgeons whose research, clinic, or administrative duties decrease the amount of time they can spend in the operating room. Simulation represents the future of medicine and an excellent opportunity for research and development. Medicine, including surgery, has much ground to make up in regards to simulation training compared to other high-risk fields, such as the military, space, and aeronautics. Modern surgical leaders should recognize surgical simulation as criti-cal to their organization’s success.Evaluation of Surgeon PerformanceMultiple organizations are evaluating the technical and nontechnical skills of surgeons in a real-time basis. We have included this com-prehensive list of organizations (Table 1-4) with a brief description of their purpose and mechanisms of evaluation. Several of these involve technical skills evaluations and most involve nontechnical Table 1-4Multiple organizations have been created to evaluate both the technical and


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Surgery_Schwartz. and mechanisms of evaluation. Several of these involve technical skills evaluations and most involve nontechnical Table 1-4Multiple organizations have been created to evaluate both the technical and nontechnical skills of surgeons141ORGANIZATION NAMEDESCRIPTIONMAIN SKILLS, CONDITIONS, OR QUALITIES EVALUATEDEVALUATION OF TECHNICAL SKILLS?EVALUATION OF NONTECHNICAL SKILLS?Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)A public reporting initiative that measures patient perspectives on and satisfaction with hospital care based on qualities of healthcare that patients view as important.Communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, discharge information, care transitionNoYesClinical and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS)A public reporting initiative that measures patient perspectives on and satisfaction with care provided in an office


Surgery_Schwartz

Surgery_Schwartz. and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS)A public reporting initiative that measures patient perspectives on and satisfaction with care provided in an office setting based on qualities of healthcare that patients view as important.Access to care, provider communication, test results, office staff, overall provider ratingNoYesDatix, Incident ReportingA database of incidents that improves reliability of physicians by improving rates of reporting, promoting ownership of mistakes, and improving patient safety.System issues, patient safety and quality issues, provider behavior, leadership styleYesYesPatient Advocacy Reporting System (PARS)A system that compiles patient complaints into a complaint index for each physician for comparison with other medical group members and to help identify high-malpractice-risk physicians who may benefit from peer intervention.Unprofessional behavior deemed as disrespectful and rudeNoYesCo-worker Observation Reporting


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Surgery_Schwartz. group members and to help identify high-malpractice-risk physicians who may benefit from peer intervention.Unprofessional behavior deemed as disrespectful and rudeNoYesCo-worker Observation Reporting SystemA system in which physicians document coworker unprofessional conduct in order to provide nonjudgmental and timely feedback and to encourage self-reflection and change.Unprofessional behavior deemed as disrespectful and unsafeYesYes(Continued)Brunicardi_Ch01_p0001-p0026.indd 1629/01/19 10:58 AM 17LEADERSHIP IN SURGERYCHAPTER 1Table 1-4Multiple organizations have been created to evaluate both the technical and nontechnical skills of surgeons141ORGANIZATION NAMEDESCRIPTIONMAIN SKILLS, CONDITIONS, OR QUALITIES EVALUATEDEVALUATION OF TECHNICAL SKILLS?EVALUATION OF NONTECHNICAL SKILLS?American Board of Surgery (ABS) Maintenance of Certification (MOC) ProgramA program that documents a surgeon’s ongoing commitment to professionalism, lifelong learning, and practice improvement through


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Surgery_Schwartz. Board of Surgery (ABS) Maintenance of Certification (MOC) ProgramA program that documents a surgeon’s ongoing commitment to professionalism, lifelong learning, and practice improvement through self-report.Restrictions on medical license, restrictions on hospital privileges, continuing medical education, self-assessment of continuing medical education, cognitive expertise, ongoing participation in quality assessment program relevant to the surgeon’s practiceYesYesHospital CompareA database that is part of the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Initiative and provides information on hospital performance and quality of care based on consumer perspectives so that patients can assess and compare hospitals.Hospital Compare is based on data from HCAHPS and evaluates hospitals by the same guidelines as HCAHPSNoYesFederation of State Medical Boards (FSMB)An organization representing all state medial and osteopathic boards in the United States that license


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Surgery_Schwartz. hospitals by the same guidelines as HCAHPSNoYesFederation of State Medical Boards (FSMB)An organization representing all state medial and osteopathic boards in the United States that license physicians and sponsors the United States Medical Licensing Examination.Medical knowledge, patient complaints, violations of the lawYesYesInternet clinical scoresA database of direct patient opinions of physicians, provided through various sources, including Healthgrades.com, RateMDs.com, and Yelp.Professionalism, communication, timelinessNoYesHospital-Acquired Condition Reduction ProgramA government program that provides incentives for hospitals to reduce the number of undesirable patient conditions resulting from their stay in the hospital and that could have been avoided by adjusting hospital reimbursement rates accordingly.Foreign objects retained after surgery, air embolism, blood incompatibility, pressure ulcers, falls, poor glycemic control, catheter-associate infections, surgical site


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Surgery_Schwartz. rates accordingly.Foreign objects retained after surgery, air embolism, blood incompatibility, pressure ulcers, falls, poor glycemic control, catheter-associate infections, surgical site infections, deep vein thrombosis, pulmonary embolism, pneumothoraxYesNoAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)A program that collects information on and provides a risk-adjusted ranking of preventable surgical complication rates to encourage providers to improve care.Surgical complications rates, surgical site infections, urinary tract infections, readmission rates, surgical outcomesYesNoCenters for Medicare & Medicaid Services Surgical Care Improvement Project (CMS SCIP)A collaborative healthcare organization that collects data on surgical complication rates based on established guidelines.Rates of infection, cardiac, venous thromboembolism, vascular, and respiratory, complications of surgeryYesNo(Continued)Brunicardi_Ch01_p0001-p0026.indd 1729/01/19


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Surgery_Schwartz. based on established guidelines.Rates of infection, cardiac, venous thromboembolism, vascular, and respiratory, complications of surgeryYesNo(Continued)Brunicardi_Ch01_p0001-p0026.indd 1729/01/19 10:58 AM 18BASIC CONSIDERATIONSPART Iskills. Additionally, most have been tied to performance evalua-tions and even salary and discipline up to and including loss of licensure. To our knowledge, this is the first comprehensive listing of the various agencies that evaluate surgeon performance.141MENTORING AND DEVELOPMENTMentoringA formal leadership training program for surgical trainees should include mentoring. Mentoring is the active process by which an experienced, empathetic person guides another indi-vidual in the development and self-recognition of their own vision, learning, core competencies, and professional develop-ment. Halstead established the concept of a surgical mentor who directly provided the trainees with professional and technical guidance. Halstead’s concept went beyond


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Surgery_Schwartz. and professional develop-ment. Halstead established the concept of a surgical mentor who directly provided the trainees with professional and technical guidance. Halstead’s concept went beyond a simple preceptor-ship by emphasizing clinical decision making based on scien-tific evidence. His goal was to develop surgeons who would go on to become outstanding leaders and innovators in the field. Although surgery has changed dramatically since Halstead’s era, mentorship remains crucial in surgical training. In addition to teaching technical skills, clinical judgment, and scientific inquiry, modern-day mentors must also model effective com-munication, empathy, humanism, and the prioritization of com-peting professional and personal activities.The mentor must also be an experienced and trusted advi-sor committed to the success of the mentee. A greater level of trust and commitment distinguishes the mentor from the teacher. More than a teacher, a mentor is a coach. The goal of a teacher is


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Surgery_Schwartz. advi-sor committed to the success of the mentee. A greater level of trust and commitment distinguishes the mentor from the teacher. More than a teacher, a mentor is a coach. The goal of a teacher is to pass on a defined level of knowledge for each stage of a student’s education. The underlying premise is a limited level of advancement for the student. The coach, on the other hand, has the sole purpose to make his or her student the best at their game, with an unlimited level of advancement. Modern men-torship implies a partnership between the mentor and the men-tee. Surgical residency program chairs and program directors must recruit and develop faculty “coaches” to mentor residents to optimize their potential. Emeritus Chair of the University of California, Los Angeles Head and Neck Surgery, Dr. Paul Ward, said it best: “We strive to produce graduates of our resi-dency program who are among those who change the way we think and practice.”142 Having more than 25 former residents


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Surgery_Schwartz. Surgery, Dr. Paul Ward, said it best: “We strive to produce graduates of our resi-dency program who are among those who change the way we think and practice.”142 Having more than 25 former residents become chairs of academic head and neck surgical programs, Dr. Ward embodied the role as a surgeon’s coach. The respon-sibilities of an effective mentor are summarized by Barondess: “Mentoring, to be effective, requires of the mentor empathy, maturity, self-confidence, resourcefulness, and willingness to commit time and energy to another. The mentor must be able to offer guidance for a new and evolving professional life, to stimulate and challenge, to encourage self-realization, to fos-ter growth, and to make more comprehensible the landscape in which the protégé stands.”143One of the major goals of mentors is to assess the aptitudes and abilities of mentees with regard to the appropriateness of their vision for their surgical career. Proper selection of the appropriate mentor can bring to


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Surgery_Schwartz. of mentors is to assess the aptitudes and abilities of mentees with regard to the appropriateness of their vision for their surgical career. Proper selection of the appropriate mentor can bring to the mentee much needed wisdom, guidance, and resources and can expand the scope of his or her vision. In addition, the mentor can refine the leadership skills taught to mentees in formal training programs. Highly successful surgeons most often have had excellent surgical mentors. It is impressive to note that more than 50% of United States’ Nobel laureates have served under other Nobel laureates in the capacity of student, postdoctoral fellow, or junior collaborator.144 In academic medicine, evidence-based studies have shown benefits to the mentees that include enhanced research productivity, higher likelihood of obtaining research grants, and greater success in obtaining desired positions in practice or at academic institutions.145 Mentoring provides benefits to the mentors themselves,


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Surgery_Schwartz. higher likelihood of obtaining research grants, and greater success in obtaining desired positions in practice or at academic institutions.145 Mentoring provides benefits to the mentors themselves, including refinement of their own personal leadership skills and a strong sense of satisfaction and accomplishment.Mentorship is essential to accomplish the successful development of surgical trainees and to help cultivate their vision. Therefore, formal leadership training programs that have a goal of training the future leaders in surgery should include mentoring.Modeling Leadership for Medical Students and the “Hidden Curriculum”Medical students enter school with great empathy, excitement, optimism, and an idealistic vision. They have self-selected to enter a profession of healing and achieved entry into a highly coveted graduate training program with centuries of tradition. Yet, these medical students are naive to the actual practice of medicine and its professional norms. Along the


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Surgery_Schwartz. entry into a highly coveted graduate training program with centuries of tradition. Yet, these medical students are naive to the actual practice of medicine and its professional norms. Along the way to becoming a doctor, many medical students lose some of the optimism, empathy, and excite-ment, particularly during their first and third years of school. Some students come to see the patient-physician relationship as an after-thought to providing care.145,146 Through the “hidden curriculum,” formal leadership training, and modeling of professional behavior, surgical residents, and attendings can help medical students to real-ize their vision of becoming empathic physicians.Traditionally, medical schools and professors have unknowingly relied on a hidden curriculum to mold these ide-alistic students into capable professionals. The hidden curricu-lum is the informal social norms learned by students implicitly, based on their observations of resident and attending behavior. The hidden


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Surgery_Schwartz. students into capable professionals. The hidden curricu-lum is the informal social norms learned by students implicitly, based on their observations of resident and attending behavior. The hidden curriculum has always been present in education, for better or worse, and may be unmasked and studied, but cannot be eliminated. Medical students actively engage in seeking out mentors, and naturally and subconsciously look to their men-tors for cues on how to conduct themselves as physicians, the same way in which a child learns how to behave from a parent or older sibling. Whether or not the witnessed behavior is a positive example of professionalism, the student will begin to perceive that behavior as normal and acceptable. For better or worse, the professional norms of medicine (the Hippocratic oath, respect to patients and colleagues, ethical conduct, personal accountability, empathy, and altruism) are modeled in every personal encounter. It is imperative that all resident and attending


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Surgery_Schwartz. oath, respect to patients and colleagues, ethical conduct, personal accountability, empathy, and altruism) are modeled in every personal encounter. It is imperative that all resident and attending surgeons under-stand that the medical students are observing them closely. When resident and attending surgeons model professional behavior, the hidden curriculum becomes a useful tool for professional devel-opment.147-150 This consistent modeling of professional behavior is one necessary component of leadership.During their clinical years, medical students experience both an exponential growth in knowledge and a measurable decline in empathy towards their patients. Initially, medical stu-dents are filled with excitement and wonder during their first patient encounters. The rapid pace of clinical work, acquisition of knowledge, and intense experiences create stress for the stu-dent, both positively and negatively. Scrubbing into the operat-ing room, witnessing the passing of a patient,


Surgery_Schwartz

Surgery_Schwartz. work, acquisition of knowledge, and intense experiences create stress for the stu-dent, both positively and negatively. Scrubbing into the operat-ing room, witnessing the passing of a patient, helping deliver a baby, and studying for boards are impactful milestones that each student experiences in a matter of months. Due to the 9Brunicardi_Ch01_p0001-p0026.indd 1829/01/19 10:58 AM 19LEADERSHIP IN SURGERYCHAPTER 1challenges of their work, students naturally have doubts about their own career choices and abilities, even as they experience growth and success. However, as students gain knowledge and abilities, they also come to see commonly encountered clinical problems as routine work. As familiarity and comfort with clini-cal problems increases, the excitement and wonder experienced by the student decreases. It is during this time that a decline in student empathy occurs, typically in their third year of medical school.151 In medicine, even routine clinical work still requires


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Surgery_Schwartz. by the student decreases. It is during this time that a decline in student empathy occurs, typically in their third year of medical school.151 In medicine, even routine clinical work still requires extraordinary attention to detail, and compassionate care must be delivered to every patient, every time. This attention to detail and compassionate delivery of care are the hallmark of the true professional. It is important that surgical residents and attend-ings always model positive behavior.Previously, medical schools instructed students in anat-omy, physiology, pathology, and clinical medicine, but left the acquisition of professionalism to the informal hidden curricu-lum. The Carnegie Report, published in 2010 at the 100-year anniversary of the Flexner Report, called for medical education to promote “the progressive formation of the physician’s profes-sional identity.”152 To this end, many medical schools nation-wide emphasize early professional education and an integrated curriculum.


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Surgery_Schwartz. to promote “the progressive formation of the physician’s profes-sional identity.”152 To this end, many medical schools nation-wide emphasize early professional education and an integrated curriculum. The Liaison Committee on Medical Education (LCME) sets standards for administrative and faculty leader-ship that manage the curricular model and educational affairs of students; however, formal leadership education is not explicitly required at this time. However, career exploration, mentoring, and advising are instrumental responsibilities of each medical school and a requirement of the LCME. Establishing a leader-ship program that is perpetual and coexists within an integrated curriculum will support this endeavor.153 A longitudinal lead-ership program beginning at the onset of medical school can establish a pattern of ethical behavior, professionalism, balance, Table 1-5Leadership assessment toolboxMETHOD OF LEADERSHIP MEASUREMENTDESCRIPTIONMultifactor Leadership Questionnaire (MLQ)The


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Surgery_Schwartz. can establish a pattern of ethical behavior, professionalism, balance, Table 1-5Leadership assessment toolboxMETHOD OF LEADERSHIP MEASUREMENTDESCRIPTIONMultifactor Leadership Questionnaire (MLQ)The MLQ is a questionnaire based on the differences between transformation and transactional approaches of leadership. It identifies leadership qualities through the rater’s beliefs about effective leadership.NEO Five-Factor Personality Inventory (NEO)NEO explores different facets of five different personality traits—neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness—through a questionnaire.Surgeon’s Leadership Inventory (SLI)The SLI is a questionnaire based on literature on leadership in surgery and surgeon’s leadership behaviors observed in the operating room. It includes eight elements of surgeon’s leadership in the operating room, which are maintaining standards, managing resources, making decisions, directing, training, supporting others, communicating,


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Surgery_Schwartz. It includes eight elements of surgeon’s leadership in the operating room, which are maintaining standards, managing resources, making decisions, directing, training, supporting others, communicating, and coping with pressure.Patient feedbackPatient complaints are inversely related to leadership effectiveness and can thus be used as opportunities to improve and as a measure of leadership.Objective Structured Clinical Examination (OSCE)The OSCE can be administered in a controlled environment with attending feedback on various aspects of leadership tackled in the practice cases. Videotaped sessions provide further opportunities for improvement as residents will be able to later observe their own behaviors and reflect on ways to improve their approach to the case presented.Consumer Assessment of Healthcare Providers and Systems (CAHPS)CAHPS surveys are based on aspects of healthcare that matter most to patients, such as physician communication. The results are made public and can be used


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Surgery_Schwartz. of Healthcare Providers and Systems (CAHPS)CAHPS surveys are based on aspects of healthcare that matter most to patients, such as physician communication. The results are made public and can be used to shed light on areas of leadership physicians can improve on to work towards a patient-centered approach to care.Reproduced with permission from Jacobs LA: Practical Ethics for the Surgeon. Philadelphia, PA: Wolters Kluwer; 2018.wellness, and strong character. Indeed, many medical schools are shifting to a new, integrated style curriculum with early pro-fessional development as the standard.154This chapter has emphasized, in an intentional way, the importance of establishing a vision and goals. Throughout the process of becoming a physician, medical students will trade some of their idealism and optimism for a refined vision and a set of goals that become a part of their professional identity. This newly matured vision will guide the future these students create. The future leaders of


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Surgery_Schwartz. and optimism for a refined vision and a set of goals that become a part of their professional identity. This newly matured vision will guide the future these students create. The future leaders of medicine and surgery are current medical students. To foster a climate of professionalism and empathy, medical students should be taught in an environment of formal leadership training, from the first day of medical school through graduation. In addition to leadership training, medical students will inevitably acquire some of the traits and habits of their resi-dent and attending mentors through the hidden curriculum. In this way, the modeling of professional behaviors by surgical residents and attendings can serve to reinforce professionalism and may help to ward off the empathy decline experienced by medical students in their clinical years.Tools to Measure Leadership Outcomes in HealthcareThere is evidence that leadership training improves healthcare quality. The ACGME, via its core


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Surgery_Schwartz. by medical students in their clinical years.Tools to Measure Leadership Outcomes in HealthcareThere is evidence that leadership training improves healthcare quality. The ACGME, via its core competencies, has recognized technical skills, surgical judgement, and nontechnical skills as qualities essential to develop in residents.155,156 The objec-tive measurement of nontechnical skills is difficult. Table 1-5 includes a list of methods for assessing nontechnical skills cur-rently in use by some residency programs. The Consumer Assess-ment of Healthcare Providers and Systems (CAHPS) survey is in the early phases of being applied to individual physicians, but it has been applied to hospitals as a whole for several years.Brunicardi_Ch01_p0001-p0026.indd 1929/01/19 10:58 AM 20BASIC CONSIDERATIONSPART ILeadership can be evaluated through instruments such as the Multifactor Leadership Questionnaire, the NEO Five–Factor Inventory, and the Surgeon’s Leadership Inventory. The Mul-tifactor


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Surgery_Schwartz. can be evaluated through instruments such as the Multifactor Leadership Questionnaire, the NEO Five–Factor Inventory, and the Surgeon’s Leadership Inventory. The Mul-tifactor Leadership Questionnaire (MLQ) analyzes leadership aptitude as either a transactional or a transformational style.157 Leadership based on transaction focuses on completing and rewarding the tasks, whereas leadership based on transforma-tion focuses more on the motivation for completing the tasks and emphasizes a positive and encouraging working environ-ment for the team.158,159 In a study applying the questionnaire to five surgeons in a single hospital, surgeons who scored higher on the transformational section were more focused on promot-ing an open environment for all the attendings, residents, nurses and other staff in the operating room. This transformational style correlated with greater communication. These findings are important in showing that lack of communication is often a leading factor in surgical


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Surgery_Schwartz. in the operating room. This transformational style correlated with greater communication. These findings are important in showing that lack of communication is often a leading factor in surgical errors.The use of an MLQ in 2008 studying surgical residents showed a significant association between transformational lead-ership and overall perceived team effectiveness and resident sat-isfaction.158-159 The questionnaire also found that the residents, as leaders, placed less value on the individual needs of their colleagues, possibly reflecting a high sense of independence and frequent changes in teams due to rotations among services. This finding helped identify an area of leadership training on which the program can focus to help further develop a more supportive team atmosphere amongst the residents. In 2011, a study administered the NEO Five-Factor Personality Inventory (NEO) to a group of surgical residents. NEO, which assesses personality on five broad strokes, including neuroticism,


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Surgery_Schwartz. In 2011, a study administered the NEO Five-Factor Personality Inventory (NEO) to a group of surgical residents. NEO, which assesses personality on five broad strokes, including neuroticism, open-ness, agreeableness, extroversion, and conscientiousness, found that the surgeons scored above the national average on most of the factors tested but below average on agreeableness. This is a measure of altruism and tolerance, among other related factors. This result corresponded with the MLQ administered to the same group of residents and therefore highlighted areas of lead-ership that required modification.158,159The Surgeon’s Leadership Inventory (SLI) is a helpful guide for residency programs.160 The SLI grades surgeons on eight different elements of leadership, as listed in Table 1-6. As with the MLQ and NEO questionnaires, the SLI can be used to assess the growth of leadership ability in surgery residents. Table 6 provides a list and description of the different elements assessed by the


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Surgery_Schwartz. the MLQ and NEO questionnaires, the SLI can be used to assess the growth of leadership ability in surgery residents. Table 6 provides a list and description of the different elements assessed by the SLI.141LEADERSHIP TRAINING FOR THE PROSPECTIVE SURGEONProspective surgeons such as medical students and premedical students may have no better source for developing the personal attributes necessary for a successful career than current surgical attending surgeons and current residents. When surveyed, these doctors emphasized accountability, resilience, and high personal standards for oneself as critical tools. Prospective surgeons are advised to pursue perfectionism and be self-critical, cautioning against taking these traits to far towards neurotic behavior. Criti-cal leadership skills of teamwork and learning to take initiative are mandatory in modern medicine and must be learned early. Innovation is highly desirable.162Residents, on the other hand, are closer to becoming inde-pendent.


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Surgery_Schwartz. and learning to take initiative are mandatory in modern medicine and must be learned early. Innovation is highly desirable.162Residents, on the other hand, are closer to becoming inde-pendent. To some extent, they have already been selected for their leadership, innovation, and resiliency through the process Table 1-6Surgeons Leadership Inventory (SLI)ELEMENTDESCRIPTIONMaintaining standardsPracticing safe and quality patient care by following established protocols and asking for help when neededMaking decisionsMaking informed judgments and communicating decisions with relevant personnelManaging resourcesAppropriately assigning resources and tasks to team membersDirectingClearly communicating expectations and instructions and demonstrating confidence in leadership abilityTrainingEducating and training team members when the opportunity arisesSupporting othersOffering assistance where appropriate and encouraging open communicationCommunicatingSharing information in a timely manner and


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Surgery_Schwartz. and training team members when the opportunity arisesSupporting othersOffering assistance where appropriate and encouraging open communicationCommunicatingSharing information in a timely manner and encouraging input from othersCoping with pressureShowing flexibility when required to meet goalsData correlating patient complaints in a large number of hospitals show that improved leadership is associated with better hospital climate, improved performance, and a lower number of complaints.161Reproduced with permission from Jacobs LA: Practical Ethics for the Surgeon. Philadelphia, PA: Wolters Kluwer; 2018.of the match. During training their progression from novice to expert is necessarily rapid. A graded tool for all procedure based specialties including surgery – OpTrust – has been recently vali-dated to facilitate the resident’s transition to leadership across five domains including questioning, planning, instruction, prob-lem solving, and leadership.163As emphasized throughout this


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Surgery_Schwartz. vali-dated to facilitate the resident’s transition to leadership across five domains including questioning, planning, instruction, prob-lem solving, and leadership.163As emphasized throughout this chapter, the concept of training leadership skills early applies particularly to junior fac-ulty and residents. The resident-surgeon-manager conference is one model for integrating department members of various experience levels into a results-based leadership conference. In this conference, various stakeholders including attorneys, per-sons with business experience, and risk management experts are brought in as guest participants. Exercises were immersive and included case-based discussions, role-playing, simulation, and interactive lecture. Topics included teamwork, learning negoti-ating techniques, time management, risk management, balance, giving feedback, and creating immediate, goal-oriented action plans.86EARLY CAREER DEVELOPMENT AND ESTABLISHING ONESELFA variety of methods have been


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Surgery_Schwartz. time management, risk management, balance, giving feedback, and creating immediate, goal-oriented action plans.86EARLY CAREER DEVELOPMENT AND ESTABLISHING ONESELFA variety of methods have been proposed for the professional development of new attending surgeons. “Speed Mentoring”— 10-minute pairings of senior and junior surgeons answering pre-set questions—have been studied at national conferences with promising results. These sessions could be spread out over several days and integrated into a busy surgeon’s schedule.164Brunicardi_Ch01_p0001-p0026.indd 2029/01/19 10:58 AM 21LEADERSHIP IN SURGERYCHAPTER 1A study of department chairs and award-winning surgeon-scientists identified perseverance and team leadership skills as critical factors for development in the young attending surgeon. Chairs advocated protected time for research, financial support, and mentorship as departmental level support that the surgeon scientist should actively seek out in their first position. The


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Surgery_Schwartz. surgeon. Chairs advocated protected time for research, financial support, and mentorship as departmental level support that the surgeon scientist should actively seek out in their first position. The sur-geon-scientist compared to the pure clinician faces a different set of challenges, particularly the financial challenge of funding research and clinical duties competing for time and attention with research interests.165One study addressed surgeon behavior in the operating room to assess the leadership style most associated with strong leadership. Based off of this study, surgeons who are trained to collaborate, consult others appropriately, be polite (simple “please” and “thank you”), and create a safe space for their operating room staff to voice concerns will demonstrate good leadership. However, surgeons who demonstrate nonconstruc-tive criticism, destructive humor, steer conversation away from the current case, and express frustration will be perceived as demonstrating poor


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Surgery_Schwartz. However, surgeons who demonstrate nonconstruc-tive criticism, destructive humor, steer conversation away from the current case, and express frustration will be perceived as demonstrating poor leadership. Under this system, surgeon behavior can be categorized—conductor, elucidator, delegator, engagement facilitator, tone setter, being human, and safe space maker—in order to provide individual feedback for professional development.166SENIOR FACULTY DEVELOPMENT: TRANSITIONING TO DEPARTMENTAL LEADERSHIP AND LEGACY BUILDINGThe presence of experienced, senior academic surgeons within a department represents an opportunity. The formal develop-ment of a plan for late career transitioning through departmental leadership roles all the way to emeritus status naturally initi-ates a constructive process when thought out years in advance. The plan should be agreeable to the senior faculty member in question as well as departmental leadership and hospital stakeholders. Once in place, the senior


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Surgery_Schwartz. when thought out years in advance. The plan should be agreeable to the senior faculty member in question as well as departmental leadership and hospital stakeholders. Once in place, the senior academic surgeon and department will both thrive thanks to a shared vision, mutual understanding, and clear goals and transition points. Depart-mental leadership can use the transition plan to look ahead at the future of their department years down the line.167Recognition of senior academic surgeons with departmen-tal leadership, promotions, and emeritus status is a privilege earned by the academician over a lifetime of work; however, for the department it represents an opportunity to shape the values and culture of the faculty body as a whole. The continued vis-ibility, model, and influence of such leaders will have a trickle-down effect on the rest of the department. Surgical leaders are part of a large and extraordinary network facilitated by men-torship and decades of professional


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Surgery_Schwartz. of such leaders will have a trickle-down effect on the rest of the department. Surgical leaders are part of a large and extraordinary network facilitated by men-torship and decades of professional collaboration. Exceptional senior academic surgeons may often experience the “multiplier-effect” whereby one excellent leader trains several, who go on to train several more until the culture of surgery nationwide is influenced.168Although there are no mandatory ages for which surgeons must retire as in other professions, such as airline pilots, the issue of aging and when to cease practice has been controver-sial. There are some, however few, reports of physicians prac-ticing after the decline of their skill and becoming dangerous. As a whole, the profession has been unable to prevent this. Nationwide, from 1975 to 2015, the number of physicians prac-ticing after age 65 has increased by 374%. Some hospitals and healthcare organizations have implemented mandatory cognitive and physical


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Surgery_Schwartz. Nationwide, from 1975 to 2015, the number of physicians prac-ticing after age 65 has increased by 374%. Some hospitals and healthcare organizations have implemented mandatory cognitive and physical evaluations as a condition of continued practice. In the absence of more robust professional initiatives our field may see legislative oversight in the future.169 The authors believe that a formally planned transition emphasizing the values of leader-ship and legacy-building offers a more palatable alternative.CONCLUSIONAlthough there are several definitions of leadership and a vari-ety of leadership styles, all share the common goal of improving patient care in the modern era. All forms of leadership require a vision and willingness—the willingness to assume the respon-sibility to lead, continue learning, practice effective commu-nication styles, and resolve conflict. Effective leadership can change surgical departments and improve patient care through innovation. A growing body of


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Surgery_Schwartz. continue learning, practice effective commu-nication styles, and resolve conflict. Effective leadership can change surgical departments and improve patient care through innovation. A growing body of evidence suggests the mastery of leadership requires practice through intentional curricula and reinforcement through mentorship.Surgical leadership is bred through its training programs. Thus, innovation in surgical training programs is needed to enhance the development of leadership skills of surgical train-ees, to prepare them for practice in modern healthcare systems, and to optimize patient care, as well as compliance with require-ments set forth by regulatory institutions governing surgery and surgical education. A growing body of literature supports the value of effective leadership in improving patient care, produc-tivity, and the work environment while it validates the ability to measure the impact of leadership training. Therefore, it is of paramount importance to teach modern


Surgery_Schwartz

Surgery_Schwartz. improving patient care, produc-tivity, and the work environment while it validates the ability to measure the impact of leadership training. Therefore, it is of paramount importance to teach modern leadership principles and skills to surgical trainees in order to create a new generation of surgeon leaders who will shape the modern era of surgery in the context of rapidly evolving science, technology, and systems of healthcare delivery.REFERENCESEntries highlighted in bright blue are key references. 1. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery. 1999;125(2):127-134. 2. Itani KM, Liscum K, Brunicardi FC. Physician leader-ship is a new mandate in surgical training. Am J Surg. 2004;187(3):328-331. 3. Jensen AR, Wright A, Lance A, et al. The emotional intel-ligence of surgical residents: a descriptive study. Am J Surg. 2008;195(1):5-10. 4. Lee L, Brunicardi FC, Scott BG, et al. Impact of a novel education curriculum on surgical


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Surgery_Schwartz. Medical Examiners. COM-LEX-USA Level 2-PE. Available at: https://www.nbome.org/exams-assessments/comlex-usa/comlex-usa-level-2-pe/. Accessed June 16, 2018. 120. Cerilli GJ, Merrick HW, Staren ED. Objective Structured Clin-ical Examination technical skill stations correlate more closely with postgraduate year level than do clinical skill stations. Am Surg. 2001;67(4):323-326; discussion 326-327. 121. Turner JL, Dankoski ME. Objective structured clinical exams: a critical review. Fam Med. 2008;40(8):574-578. 122. Zyromski NJ, Staren ED, Merrick HW. Surgery residents’ perception of the Objective Structured Clinical Examination (OSCE). Curr Surg. 2003;60(5):533-537. 123. Schwartz RW, Witzke DB, Donnelly MB, Stratton T, Blue AV, Sloan DA. Assessing residents’ clinical performance: cumula-tive results of a four-year study with the Objective Structured Clinical Examination. Surgery. 1998;124(2):307-312. 124. Doumouras AG, Hamidi M, Lung K, Tarola CL, Tsao MW, Scott JW, Yule S. Non-technical


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Surgery_Schwartz. results of a four-year study with the Objective Structured Clinical Examination. Surgery. 1998;124(2):307-312. 124. Doumouras AG, Hamidi M, Lung K, Tarola CL, Tsao MW, Scott JW, Yule S. Non-technical skills of surgeons and anaes-thetists in simulated operating theatre crises. Br J Surg. 2017;104(8):1028-1036. 125. Nicksa GA, Anderson C, Fidler R, Stewart L. Innovative approach using interprofessional simulation to educate sur-gical residents in technical and nontechnical skills in high-risk clinical scenarios. JAMA Surg. 2015;150(3):201-207. 126. Laufer S, Ray RD, D’Angelo AL, Jones GF, Pugh CM. Use of simulators to explore specialty recommendation for a palpable breast mass. Am J Surg. 2015;210(4):618-623. 127. Laufer S, Cohen ER, Kwan C, et al. Sensor technology in assess-ments of clinical skill. N Engl J Med. 2015;372(8):784-786. 128. D’Angelo AL, Ray RD, Jenewein CG, Jones GF, Pugh CM. Residents’ perception of skill decay during dedicated research time. J Surg Res.


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Surgery_Schwartz. of clinical skill. N Engl J Med. 2015;372(8):784-786. 128. D’Angelo AL, Ray RD, Jenewein CG, Jones GF, Pugh CM. Residents’ perception of skill decay during dedicated research time. J Surg Res. 2015;199(1):23-31. 129. Martin JA, Regehr G, Reznick R, et al. Objective Structured Assessment of Technical Skill (OSATS) for surgical residents. Br J Surg. 1997;84(2):273-278. 130. Hatala R, Cook DA, Brydges R, Hawkins R. Constructing a validity argument for the Objective Structured Assess-ment of Technical Skills (OSATS): a systematic review of validity evidence. Adv Health Sci Educ Theory Pract. 2015;20(5):1149-1175. 131. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative “bench station” exam-ination. Am J Surg. 1997;173(3):226-230.Brunicardi_Ch01_p0001-p0026.indd 2429/01/19 10:58 AM 25LEADERSHIP IN SURGERYCHAPTER 1 132. Hopmans CJ, den Hoed PT, van der Laan L, et al. Assessment of surgery residents’ operative skills in the operating theater


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Surgery_Schwartz. 2429/01/19 10:58 AM 25LEADERSHIP IN SURGERYCHAPTER 1 132. Hopmans CJ, den Hoed PT, van der Laan L, et al. Assessment of surgery residents’ operative skills in the operating theater using a modified Objective Structured Assessment of Techni-cal Skills (OSATS): a prospective multicenter study. Surgery. 2014;156(5):1078-1088. 133. Glarner CE, McDonald RJ, Smith AB, et al. Utilizing a novel tool for the comprehensive assessment of resident operative performance. J Surg Educ. 2013;70(6):813-820. 134. Wagner JP, Chen DC, Donahue TR, et al. Assessment of resident operative performance using a real-time mobile Web system: preparing for the milestone age. J Surg Educ. 2014;71(6):e41-e46. 135. Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R. The impact of stress on surgical performance: a systematic review of the literature. Surgery. 2010;147(3): 318-330, 330.e1-e6. 136. Parker SH, Flin R, McKinley A, Yule S. Factors influenc-ing surgeons’ intraoperative leadership:


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Surgery_Schwartz. performance: a systematic review of the literature. Surgery. 2010;147(3): 318-330, 330.e1-e6. 136. Parker SH, Flin R, McKinley A, Yule S. Factors influenc-ing surgeons’ intraoperative leadership: video analysis of unanticipated events in the operating room. World J Surg. 2014;38(1):4-10. 137. Smith RC, Lyles JS, Mettler J, et al. The effectiveness of inten-sive training for residents in interviewing. A randomized, con-trolled study. Ann Intern Med. 1998;128(2):118-126. 138. Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev. 2001;(4):CD003267. Review. 139. Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I. Enduring impact of communication skills training: results of a 12-month follow-up. Br J Cancer. 2003;89(8):1445-1449. 140. Gannon SJ, Law KE, Ray RD, et al. Do resident’s leader-ship skills relate to ratings of technical skill? J Surg Res.


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Surgery_Schwartz. training: results of a 12-month follow-up. Br J Cancer. 2003;89(8):1445-1449. 140. Gannon SJ, Law KE, Ray RD, et al. Do resident’s leader-ship skills relate to ratings of technical skill? J Surg Res. 2016;206(2):466-471.141. Baroukim S, Merrick HW, Brunicardi FC, Hammerling L: Fundamental Principles of Leadership Training in Surgery and the Moral Imperative IN Jacobs LA: Practical Ethics for the Surgeon. Pennsylvania, PA: Wolters Kluwer; 2018. 142. UCLA Health. Residency program—CLA head and neck sur-gery. Available at: www.uclahealth.org/head-neck-surgery/residency-program. Accessed on June 16, 2018. 143. Barondess JA. On mentoring. J R Soc Med. 1997;90:347-349. 144. Zuckerman H. Scientific Elite: Nobel Laureates in the United States. New York: Free Press; 1977:335. 145. Bennett N, Lockyer J, Mann K, et al. Hidden curriculum in continuing medical education. J Contin Educ Health Prof. 2004;24(3):145-152. 146. Holmes Cheryl L, Miller H, Regehr G. (Almost) forgetting to care: an


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Surgery_Schwartz. Lockyer J, Mann K, et al. Hidden curriculum in continuing medical education. J Contin Educ Health Prof. 2004;24(3):145-152. 146. Holmes Cheryl L, Miller H, Regehr G. (Almost) forgetting to care: an unanticipated source of empathy loss in clerkship. Med Educ. 2017;51(7):732-739. 147. Martimianakis MA, Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the hidden curriculum, and edu-cational reform: a scoping review and thematic analysis. Acad Med. 2015;90(11 suppl):S5-S13. 148. Hafferty FW, Gaufberg EH. The hidden curriculum. In: Dent JA, Harden RM, Hunt D, eds. A Practical Guide for Medical Teachers, 4th ed. Philadelphia: Elsevier; 2017. 149. Hafferty FW. Beyond curriculum reform: confronting medi-cine’s hidden curriculum. Acad Med. 1998;73:403-407. 150. Hafferty FW, Hafler JP. The hidden curriculum, structural disconnects, and the socialization of new professionals. In: Hafler JP, ed. Extraordinary Learning in the Workplace. Innovation and Change in Professional


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Surgery_Schwartz. Hafler JP. The hidden curriculum, structural disconnects, and the socialization of new professionals. In: Hafler JP, ed. Extraordinary Learning in the Workplace. Innovation and Change in Professional Education. Vol. 6. New York: Springer; 2011:17-35. 151. Holmes C, Harris IB, Schwartz AJ, Regehr G. Harnessing the hidden curriculum: a four-step approach to developing and reinforcing reflective competencies in medical clinical clerkship. Adv Health Sci Educ Theory Pract. 2015;20:1355-1370. 152. Irby DM, Cook M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010;85(2):220-227. 153. Liason Committee on Medical Education. Functions and struc-ture of a medical school: standards for accreditation of medical education programs leading to the MD degree. Association of American Medical Colleges and the American Medical Association. March 2018. Available at: http://lcme.org/ publications/. Accessed June


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Surgery_Schwartz. education programs leading to the MD degree. Association of American Medical Colleges and the American Medical Association. March 2018. Available at: http://lcme.org/ publications/. Accessed June 16, 2018. 154. Heiman HL, O’Brien CL, Curry RH, et al. Description and early outcomes of a comprehensive curriculum redesign at the Northwestern University Feinberg School of Medicine [pub-lished online ahead of print September 26, 2017]. Acad Med. doi: 10.1097/ACM.0000000000001933. 155. Combes JR, Arespacochaga E. Physician competencies for a 21st century health care system. J Grad Med Educ. 2012;4(3):401-405. 156. Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. Available at: http://www.acgme.org/What-We-Do/Accreditation/ Common-Program-Requirements. Accessed June 16, 2018. 157. Rowald J. Multifactor leadership questionnaire. Psychomet-ric properties of the German translation. Available at:


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Surgery_Schwartz. Common-Program-Requirements. Accessed June 16, 2018. 157. Rowald J. Multifactor leadership questionnaire. Psychomet-ric properties of the German translation. Available at: https://www.mindgarden.com/documents/MLQGermanPsychomet-ric.pdf. Accessed June 16, 2018. 158. Horwitz IB, Horwitz SK, Brunicardi FC, Awad SS. Improv-ing comprehensive surgical resident training though use of the NEO-Five Factor Personality Inventory: results from a cohort-based trial. Am J Surg. 2011;201(6);828-834. 159. Horwitz IB, Horwitz SK, Daram P, Brandt ML, Brunicardi FC, Awad SS. Transformational, transactional, and passive-avoid-ant leadership characteristics of a surgical resident cohort: analysis using the multifactor leadership questionnaire and implications for improving surgical education curriculums. J Surg Res. 2008;148(1):49-59. 160. Henrickson PS, Flin R, McKinley A, Yule S. The Surgeons’ Leadership Inventory (SLI): a taxonomy and rating system for surgeons’ intraoperative leadership skills. Am J


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Surgery_Schwartz. Res. 2008;148(1):49-59. 160. Henrickson PS, Flin R, McKinley A, Yule S. The Surgeons’ Leadership Inventory (SLI): a taxonomy and rating system for surgeons’ intraoperative leadership skills. Am J Surg. 2013;205(6):745-751. 161. Shipton H, Armstrong C, West M, Dawson J. The impact of leadership and quality climate on hospital performance. Int Qual Health Care. 2008;20(6):439-445. 162. Cope A, Bezemer J, Mavroveli S, Kneebone R. What attitudes and values are incorporated into self as part of professional identity construction when becoming a surgeon? Acad Med. 2017;92(4):544-549. 163. Sandhu G, Nikolian VC, Magas CP, et al. OpTrust: validity of a tool assessing intraoperative entrustment behaviors. Ann Surg. 2018;267(4):670-676. 164. Britt RC, Hildreth AN, Acker SN, Mouawad NJ, Mammen J, Moalem J. Speed mentoring: an innovative method to meet the needs of the young surgeon. J Surg Educ. 2017;74(6):1007-1011. 165. Kodadek LM, Kapadia MR, Changoor NR, et al. Educating the


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Surgery_Schwartz. NJ, Mammen J, Moalem J. Speed mentoring: an innovative method to meet the needs of the young surgeon. J Surg Educ. 2017;74(6):1007-1011. 165. Kodadek LM, Kapadia MR, Changoor NR, et al. Educating the surgeon-scientist: a qualitative study evaluating challenges and barriers toward becoming an academically successful surgeon. Surgery. 2016;160(6):1456-1465. 166. Stone JL, Aveling EL, Frean M, et al. Effective leadership of surgical teams: a mixed methods study of surgeon behaviors and functions. Ann Thorac Surg. 2017;104(2):530-537. 167. Richards R, McLeod R, Latter D, et al. Toward late career transitioning: a proposal for academic surgeons. Can J Surg. 2017;60(5):355-358. 168. Klingensmith ME. Leadership and followership in surgical education. Am J Surg. 2017;213(2): 207-211. 169. Delinger EP, Pellegrini CA, Gallagher TH. The aging phy-sician and the medical profession: a review. JAMA Surg. 2017;152(10):967-971.Brunicardi_Ch01_p0001-p0026.indd 2529/01/19 10:58 AM


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Surgery_Schwartz. Systemic Response to Injury and Metabolic SupportSiobhan A. Corbett This chapter is dedicated to Dr. Stephen Lowry, my mentor and friend.2chapterOVERVIEW: INJURY-ASSOCIATED SYSTEMIC INFLAMMATORY RESPONSEThe inflammatory response to injury occurs as a consequence of the local or systemic release of “damage-associated” molecules to mobilize the necessary resources required for the restoration of homeostasis. Minor host insults result in a localized inflam-matory response that is transient and, in most cases, benefi-cial. Major host insults follow a different trajectory. A subset of these patients will die within 24 hours of hospital admis-sion, succumbing to overwhelming tissue injury and immediate organ damage. With advances in prehospital care and improved trauma management, these numbers have diminished. A second subgroup of patients who suffer a major host insult succumb to secondary organ damage remote from the injury site and die later (weeks) in their hospital course. They form


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Surgery_Schwartz. have diminished. A second subgroup of patients who suffer a major host insult succumb to secondary organ damage remote from the injury site and die later (weeks) in their hospital course. They form an increasing percentage of the in hospital trauma-related deaths. A dysreg-ulated, overwhelming systemic inflammatory response to the injury/hemorrhage and associated ischemia/reperfusion events has been implicated as the cause of multiple organ failure in these patients. Moreover, it has been linked to immune suppres-sion that increases the risk of infectious complications and poor outcome. Finally, a third subgroup, characterized by extended length of stay in the ICU, complicated postdischarge courses, and failure to regain/recover to their preinjury status, has been described and also linked to persistent inflammation and sup-pressed host protective immunity. The term persistent inflamma-tion, immunosuppression, and catabolism syndrome (PICS) has Overview: Injury-Associated Systemic


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Surgery_Schwartz. to persistent inflammation and sup-pressed host protective immunity. The term persistent inflamma-tion, immunosuppression, and catabolism syndrome (PICS) has Overview: Injury-Associated Systemic Inflammatory Response 27The Detection of Cellular Injury 28The Detection of Injury is Mediated by Members of the Damage-Associated Molecular Pattern Family / 28DAMPs Are Ligands for Pattern Recognition Receptors / 32Central Nervous System Regulation of Inflammation in Response to Injury 34Neuroendocrine Response to Injury / 35The Cellular Stress Responses 39Reactive Oxygen Species and the Oxidative Stress Response / 39The Unfolded Protein Response / 39Autophagy / 40Apoptosis / 40Necroptosis / 40Pyroptosis / 41Mediators of Inflammation 42Cytokines / 42Eicosanoids / 47Plasma Contact System / 48Serotonin / 50Histamine / 50Cellular Response to Injury 50Cytokine Receptor Families and Their Signaling Pathways / 50JAK-STAT Signaling / 50Suppressors of Cytokine Signaling / 50Tumor Necrosis


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Surgery_Schwartz. / 48Serotonin / 50Histamine / 50Cellular Response to Injury 50Cytokine Receptor Families and Their Signaling Pathways / 50JAK-STAT Signaling / 50Suppressors of Cytokine Signaling / 50Tumor Necrosis Factor Superfamily / 51Transforming Growth Factor-β Family of Receptors / 51Transcriptional and Translational Regulation of The Injury Response 52Transcriptional Events Following Blunt Trauma / 52Transcriptional Regulation of Gene Expression / 52Epigenetic Regulation of Transcription / 53Translation Regulation of Inflammatory Gene Expression / 53Cell-Mediated Inflammatory Response 54Neutrophils / 54Monocyte/Macrophages / 54Lymphocytes and T-Cell Immunity / 55Dendritic Cells / 55Platelets / 56Mast Cells / 56Endothelium-Mediated Injury 56Vascular Endothelium / 56Neutrophil-Endothelium Interaction / 56Chemokines / 57Nitric Oxide / 58Prostacyclin / 58Endothelins / 59Platelet Activating Factor / 59Natriuretic Peptides / 60Surgical Metabolism 60Metabolism During Fasting / 60Metabolism


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Surgery_Schwartz. Interaction / 56Chemokines / 57Nitric Oxide / 58Prostacyclin / 58Endothelins / 59Platelet Activating Factor / 59Natriuretic Peptides / 60Surgical Metabolism 60Metabolism During Fasting / 60Metabolism After Injury / 62Lipid Metabolism After Injury / 63Ketogenesis / 64Carbohydrate Metabolism / 65Protein and Amino Acid Metabolism / 66Nutrition in The Surgical Patient 66Estimation of Energy Requirements / 66Vitamins and Minerals / 68Overfeeding / 68Enteral Nutrition 68Rationale for Enteral Nutrition / 68Early vs. Late Feeding / 68Intermittent vs. Continuous Enteral Feeding / 69Enteral Formulas / 69Access for Enteral Nutritional Support / 71Parenteral Nutrition 72Rationale for Parenteral Nutrition / 73Total Parenteral Nutrition / 73Peripheral Parenteral Nutrition / 73Initiation of Parenteral Nutrition / 73Complications of Parenteral Nutrition / 74Brunicardi_Ch02_p0027-p0082.indd 2701/03/19 6:49 PM 28been applied to this group.1 Recent data suggest that severely injured patients who


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Surgery_Schwartz. Nutrition / 73Complications of Parenteral Nutrition / 74Brunicardi_Ch02_p0027-p0082.indd 2701/03/19 6:49 PM 28been applied to this group.1 Recent data suggest that severely injured patients who are destined to die from their injuries, whether late in their hospital course or after discharge, differ from survivors only in the degree and duration of their dysregu-lated acute inflammatory response.1-3As trauma is the leading cause of mortality and morbidity for individuals under age 45, understanding the complex path-ways that regulate the local and systemic inflammatory response following severe traumatic injury is necessary to develop appro-priate and targeted therapeutic strategies that will improve out-comes for these patients.In this chapter, we will review what is known about the soluble and cellular effectors of the injury-induced inflamma-tory response, how the signals are sensed, transduced, and mod-ulated, and how their dysregulation is associated with alterations in the


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Surgery_Schwartz. soluble and cellular effectors of the injury-induced inflamma-tory response, how the signals are sensed, transduced, and mod-ulated, and how their dysregulation is associated with alterations in the immune system. We will also discuss how these events are monitored regulated by the central nervous system. Finally, we will review how injury reprograms cellular metabolism, in an attempt to mobilize energy and structural stores to meet the challenge of restoring homeostasis.THE DETECTION OF CELLULAR INJURYThe Detection of Injury is Mediated by Members of the Damage-Associated Molecular Pattern FamilyTraumatic injury activates the innate immune system to pro-duce a systemic inflammatory response (SIR) in an attempt to limit damage and to restore homeostasis. It includes two general responses: (a) an acute proinflammatory response resulting from innate immune system recognition of ligands, and (b) an anti-inflammatory response that may serve to modulate the proin-flammatory phase and


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Surgery_Schwartz. (a) an acute proinflammatory response resulting from innate immune system recognition of ligands, and (b) an anti-inflammatory response that may serve to modulate the proin-flammatory phase and direct a return to homeostasis (Fig. 2-1). This is accompanied by a suppression of adaptive immunity.4 Rather than occurring sequentially, recent data indicate that all three responses are simultaneously and rapidly induced follow-ing severe traumatic injury.3The degree of the systemic inflammatory response follow-ing trauma is proportional to injury severity and is an inde-pendent predictor of subsequent organ dysfunction and resultant 1mortality. Recent work has provided insight into the mecha-nisms by which immune activation in this setting is triggered. The clinical features of the injury-mediated systemic inflamma-tory response, characterized by increased body temperature, heart rate, respirations, and white blood cell count, are similar to those observed with infection (Table 2-1).


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Surgery_Schwartz. systemic inflamma-tory response, characterized by increased body temperature, heart rate, respirations, and white blood cell count, are similar to those observed with infection (Table 2-1). However, it is widely accepted that systemic inflammation following trauma is sterile, resulting from endogenous molecules that are produced as a consequence of tissue damage or cellular stress.5 Termed damage-associated molecular patterns (DAMPs) or alarmins, DAMPs interact with specific cell receptors that are located both on the cell surface and intracellularly.6Trauma DAMPs are structurally diverse endogenous mol-ecules that are immunologically active. Table 2-2 includes a par-tial list of DAMPs that are released either passively from necrotic/damaged cells or actively from physiologically “stressed” cells by upregulation or overexpression. Once they are outside the cell, DAMPs promote the activation of innate immune cells, as well as the recruitment and activation of antigen-presenting cells,


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Surgery_Schwartz. cells by upregulation or overexpression. Once they are outside the cell, DAMPs promote the activation of innate immune cells, as well as the recruitment and activation of antigen-presenting cells, which are engaged in host defense.7 The best-characterized DAMP with significant preclinical evidence for posttrauma release, as well as a direct link to the systemic inflammatory response, is high-mobility group protein B1 (HMGB1). Additional evidence for other important DAMP molecules that participate in postin-jury inflammation is also presented.High-Mobility Group Protein B1. The best-characterized DAMP in the context of the injury-associated inflamma-tory response is high-mobility group B1 (HMGB1) protein. HMGB1 is highly conserved across species. It is a constitutively expressed, nonhistone chromosomal protein that participates in a variety of nuclear events, including DNA repair and transcrip-tion. Inflammatory signaling can redirect HMGB1 to the cytosol in both monocytes and


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Surgery_Schwartz. chromosomal protein that participates in a variety of nuclear events, including DNA repair and transcrip-tion. Inflammatory signaling can redirect HMGB1 to the cytosol in both monocytes and macrophages, as a result of posttransla-tional modification. HMGB1 is released passively from dam-aged or necrotic cells and is detected rapidly in the circulation within 30 minutes post injury. It can also be actively secreted from immune-competent cells stimulated by bacterial-derived lipoproteins (e.g., endotoxin) or by inflammatory cytokines (e.g., tumor necrosis factor). For example, macrophages release HMGB1 following the activation of the inflammasomes.8,9 Key Points1 Endogenous damage-associated molecular patterns (DAMPs) are produced following tissue and cellular injury. These molecules interact with immune and nonimmune cell receptors to initiate a “sterile” systemic inflammatory response following severe traumatic injury.2 In many cases, DAMP molecules are sensed by pattern rec-ognition


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Surgery_Schwartz. with immune and nonimmune cell receptors to initiate a “sterile” systemic inflammatory response following severe traumatic injury.2 In many cases, DAMP molecules are sensed by pattern rec-ognition receptors (PRRs), which are the same receptors that cells use to sense invading pathogens. This explains in part, the similar clinical picture of systemic inflammation observed in injured and/or septic patients.3 The central nervous system receives information with regard to injury-induced inflammation via soluble mediators as well as direct neural projections that transmit informa-tion to regulatory areas in the brain. The resulting neuro-endocrine reflex plays an important modulatory role in the immune response.4 Inflammatory signals activate key cellular stress responses (the oxidative stress response; the heat shock protein response; the unfolded protein response; autophagy; pyroptosis), which serve to mobilize cellular defenses and resources in an attempt to restore homeostasis.5 The


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Surgery_Schwartz. response; the heat shock protein response; the unfolded protein response; autophagy; pyroptosis), which serve to mobilize cellular defenses and resources in an attempt to restore homeostasis.5 The cells, mediators, signaling mechanisms, and pathways that comprise and regulate the systemic inflammatory response are closely networked and tightly regulated by tran-scriptional events as well as by epigenetic mechanisms, post-translational modification, and microRNA synthesis.6 Management of critically ill and injured patients is optimized with the use of evidence-based and algorithm-driven therapy.7 Nutritional assessments, whether clinical or laboratory guided, and intervention should be considered at an early juncture in all surgical and critically ill patients.Brunicardi_Ch02_p0027-p0082.indd 2801/03/19 6:49 PM 29SYSTEMIC RESPONSE TO INJURY AND METABOLIC SUPPORTCHAPTER 2MOFPICSInjuryImmunehomeostasisEarly deathDischarge to LTACPoor quality of lifeIndolent deathCatabolic


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Surgery_Schwartz. 2801/03/19 6:49 PM 29SYSTEMIC RESPONSE TO INJURY AND METABOLIC SUPPORTCHAPTER 2MOFPICSInjuryImmunehomeostasisEarly deathDischarge to LTACPoor quality of lifeIndolent deathCatabolic statePersistence inflammationProgressive immunosuppressionAnti-inflammatoryPro-inflammatoryRapid recoveryChronic critical illnessTimeUncomplicatedclinical courseFigure 2-1. Postinjury systemic response can follow multiple trajectories. MOF = multiple organ failure; PICS = persistent inflammation, immunosuppression, and catabolism syndrome; LTAC = long-term acute care facility. (Reproduced with permission from Loftus TJ, Mira JC, Ozrazgat-Baslanti T, et al: Sepsis and Critical Illness Research Center investigators: protocols and standard operating procedures for a prospec-tive cohort study of sepsis in critically ill surgical patients, BMJ Open. 2017 Aug 1;7(7):e015136.)Table 2-1Clinical spectrum of infection and systemic inflammatory response syndrome (SIRS)TERMDEFINITIONInfectionIdentifiable source of


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Surgery_Schwartz. ill surgical patients, BMJ Open. 2017 Aug 1;7(7):e015136.)Table 2-1Clinical spectrum of infection and systemic inflammatory response syndrome (SIRS)TERMDEFINITIONInfectionIdentifiable source of microbial insultSIRSTwo or more of following criteria are met: Temperature ≥38°C (100.4°F) or ≤36°C (96.8°F) Heart rate ≥90 beats per minute Respiratory rate ≥20 breaths per minute or Paco2 ≤ 32 mmHg or mechanical ventilation Abnormal white blood cell count (≥12,000/μL or ≤4000/μL or ≥10% immature band forms)SepsisIdentifiable source of infection + SIRSSevere sepsisSepsis + organ dysfunctionSeptic shockSepsis + cardiovascular collapse (requiring vasopressor support)Paco2 = partial pressure of arterial carbon dioxide.Table 2-2Damage-associated molecular patterns (DAMPs) and their receptorsDAMP MOLECULEPUTATIVE RECEPTOR(S)HMGB-1TLRs (2,4,9), RAGEHeat shock proteinsTLR2, TLR4, CD40, CD14,SiglecsS100 proteinTLR4, RAGEMitochondrial DNATLR9HyaluranTLR2, TLR4, CD44BiglycanTLR2 and TLR4Formyl


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Surgery_Schwartz. MOLECULEPUTATIVE RECEPTOR(S)HMGB-1TLRs (2,4,9), RAGEHeat shock proteinsTLR2, TLR4, CD40, CD14,SiglecsS100 proteinTLR4, RAGEMitochondrial DNATLR9HyaluranTLR2, TLR4, CD44BiglycanTLR2 and TLR4Formyl peptides (mitochondrial)Formyl peptide receptor 1IL-1αIL-1 receptorOnce outside the cell, HMGB1 has been shown to signal via the Toll-like receptors (TLR2, TLR4, TLR9), the receptor for advanced glycosylation end products (RAGE), CD24, and others. The activation of TLRs by HMGB1 occurs mainly in myeloid cells, whereas RAGE is thought to be the receptor tar-get for HMGB1 in endothelial cells.The diverse proinflammatory biological responses that result from HMGB1 signaling include: (a) the release of cytokines and chemokines from macrophage/monocytes and dendritic cells; (b) neutrophil activation and chemotaxis; (c) alterations in epithelial barrier function, including increased permeability; and (d) increased procoagulant activity on plate-let surfaces; among others.10 In addition, HMGB1


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Surgery_Schwartz. and chemotaxis; (c) alterations in epithelial barrier function, including increased permeability; and (d) increased procoagulant activity on plate-let surfaces; among others.10 In addition, HMGB1 binding to TLR4 triggers the proinflammatory cytokine release that medi-ates “sickness behavior.”11The biologic function of HMGB1 is regulated by its redox state. For example, a thiol at C106 is required for HMGB1 to promote macrophage TNF release, while a disulfide bond between C23 and C45 confers proinflammatory properties. With all three cysteines in the thiol (reduced) state, HMGB1 loses its DAMP function, but gains the capacity to serve as a chemotactic mediator. Importantly, shifts between the redox states have been demonstrated and indicate that redox state dynamics are impor-tant regulators of HMGB1.12Brunicardi_Ch02_p0027-p0082.indd 2901/03/19 6:49 PM 30BASIC CONSIDERATIONSPART IHMGB1 levels in human subjects following injury corre-late with the Injury Severity Score and


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Surgery_Schwartz. regulators of HMGB1.12Brunicardi_Ch02_p0027-p0082.indd 2901/03/19 6:49 PM 30BASIC CONSIDERATIONSPART IHMGB1 levels in human subjects following injury corre-late with the Injury Severity Score and complement activation, as well as with increases in circulating inflammatory mediators such as tumor necrosis factor.13 Exogenous administration of HMGB1 to normal animals produces fever, weight loss, epithe-lial barrier dysfunction, and, possibly, death. Further supporting the HMGB1 role in sterile inflammation, traumatic brain injury (TBI) induced by a cortical injury model has been shown to result in acute lung injury with increased alveolar hemorrhage, neutrophil infiltration, and poor oxygenation. This acute lung injury (ALI) was accompanied by a doubling in serum HMGB1 concentrations along with evidence that neocortical brain cells were a source of HMGB1 following TBI.14 More recently, in an animal model of hemorrhagic shock, HMGB1 release from intestinal epithelium was linked to