June 2025

Synopsis:
Penn Surgery chief resident Dr. Ginzberg and colleagues performed a mixed-methods study to understand how surgeons and surgical trainees are affected by adverse patient events, identify coping mechanisms used to overcome these experiences, and assess whether current forms of support are sufficient. The authors found that adverse events were nearly universally experienced by surgical faculty and trainees and caused significant distress. 

Summary:  
Medical errors are estimated to be the third most common cause of death in the US with most physicians reporting having made at least 1 error during their career. These experiences can be associated with negative psychological consequences, such as shame, anxiety, and self-doubt. They can also contribute to depression, burnout, and future errors. This study explores how these effects may be unique amongst surgeons and surgical residents. 

The authors used an adapted version of The Second Victim Experience and Support Tool to survey surgical trainees. These data were reported using descriptive statistics. One-on-one semi structured interviews were conducted with surgical faculty.
 
Of 216 trainees, 93 (43.1%) completed surveys with the majority from the general surgery and otorhinolaryngology programs. Most participants reported involvement in 1 or more adverse events within the past year with >80% experiencing negative emotional (e.g. embarrassment, rumination, or self-doubt) and physical (e.g. trouble sleeping) consequences. When stratified by gender, female trainees reported higher rates of physical symptoms including difficulty sleeping (38.2% vs. 16.7%, p=0.03) and loss of appetite (38.2% vs. 9.5%, p = 0.003). When stratified by race and ethnicity, trainees who identified as having a minority racial or ethnic background responded yes at higher rates in response to the statement “After my experience, I became afraid to attempt difficult or high-risk procedures” when compared with non-Hispanic White trainees (86.1% vs. 47.1%, p<0.001). Nearly all trainees expressed a desire to discuss the case with an attending physician or trusted senior trainee. Similarly, coping strategies that emerged from faculty interviews included affirmation from peer/senior colleagues or spouses, in addition to compartmentalization, reflection on positive outcomes, or participation in hobbies. Unique to the surgical faculty was discussion about the long-term effects of these events and the effects of malpractice litigation on closure. None of the interviewees discussed using professional mental health services but most expressed the need for more institutional support for faculty and more formal infrastructure for supporting trainees after adverse patient events. 

There are several limitations to this study. Since the data collection was performed at a single institution, the findings may not be generalizable to other surgical trainees/faculty. This also resulted in a small sample size that limited the ability to detect statistically significant differences between sub-groups in the trainee subgroup analysis. Moreover, though survey format allowed for flexibility with surgical trainees’ work schedules, this may have limited the nuances and creativity of the responses and may have introduced nonresponse bias. Finally, demographic data such as gender and race were not collected from faculty to preserve anonymity. 

Bottom Line:  
Nearly all surgical trainees and surgeons experience one or more adverse events in their careers, which may result in embarrassment, guilt, shame, and self-doubt, particularly in trainees from underrepresented groups. Though various coping mechanisms to overcome these experiences, such as peer/senior support, were echoed in both groups, more formal support mechanisms at all levels may help restore confidence.

Synopsis:
Penn Surgery chief resident Dr. Sharon and colleagues conducted a follow-up study of a previously published phase Ib clinical trial evaluating the long-term outcomes of patients with resectable stage III/IV cutaneous melanoma who received a single dose of neoadjuvant pembrolizumab 3 weeks before surgical resection followed by 1 year of adjuvant pembrolizumab. This study demonstrated the long-term efficacy of single-agent neoadjuvant/adjuvant PD-1 blockade in patients with major pathologic response (MPR).

Summary:
For patients with resectable III/IV cutaneous melanoma, standard treatment consists of upfront surgery with consideration for adjuvant treatment. Recently, the use of neoadjuvant targeted and immune therapies has gained interest in recent years. A phase IB clinical trial published by Huang et al. evaluated a single dose of neoadjuvant pembrolizumab in addition to 1 year of adjuvant pembrolizumab for 30 patients with resectable stage III/IV cutaneous melanoma and found a 2-year disease free survival of 100% in those with MPR. However, there is a significant lack of data around long term follow up for patients who have received neoadjuvant immunotherapy.

The present study published 5-year follow-up results from the Huang et al. trial which represents the longest follow-up of single-agent neoadjuvant PD-1 blockade. Thirty patients were included in the analysis with a median follow-up of 61.9 months. No deaths occurred in patients with MPR or complete pathologic response (pCR) (n=8) compared to the remainder of the cohort (72.8% 5-year overall survival, p=0.12). 5-year disease-free survival was 75.0% for patients with MPR compared to 63.6% in the remainder of the cohort (p=0.41).

A total of 10 patients in the cohort developed a recurrence. Of those with recurrence 8 of 22 (36%) were from pathologic non-responders (pNR) and 2 of 10 (20%) from patients with MPR. There were no recurrences in the pCR group. Median time to recurrence in the MPR group was 3.9 years compared to a median of 0.6 years in the patients with >10% viable tumor (P=0.04). Additionally, patients with MPR who develop recurrences appear to be responsive to subsequent treatment without any resulting in deaths after 5 years of follow-up.

This study has some limitations that should be considered. First, the data were generated from a phase Ib trial, which limits the statistical power to detect significant differences due to the small sample size. Additionally, this study lacked the comparison group of adjuvant therapy without the use of neoadjuvant pembrolizumab. Despite these limitations, the study was one of the first to provide long term follow up for patients with melanoma after receiving one dose of neoadjuvant pembrolizumab.

Bottom Line:
This study highlights the long-term efficacy of single-agent neoadjuvant/adjuvant PD-1 blockade in patients with resectable stage III/IV cutaneous melanoma and highlights the importance of long-term follow-up for these patients. Response to neoadjuvant therapy remains an important prognosticator.

Synopsis:
Penn Surgery chief resident Dr. Garcia Whitlock and colleagues performed a cross-sectional study using crime reports from a police department to assess patterns of social media use in violent and nonviolent crimes, and its association with injury. The authors found that social media was involved in 1.4% of violent crimes, and that social media threats were associated with injury.

Summary:
While emerging research indicates that online interactions may escalate in-person conflict and violence, the frequency with which social media plays a role in violent crime remains unclear. Therefore, this cross-sectional study used deidentified crime reports from the Prince George’s County Police Department (PGPD) in Maryland, which routinely collects information about social media use, to quantify the relationship between crime, violence, and social media use among survivors, witnesses, and suspects. For each report, they assessed use of social media, platform, presence of threat, demographics, and categorized offenses into violent and nonviolent.

They analyzed reports of 90,108 offenses, finding that 1,517 (1.7%) of all offenses and 208 (1.4%) of 15,168 violent offenses involved social media use. Of these violent offenses, 91 resulted in injury (42%). Additionally, when social media was used to threaten, 20 of 28 cases (74%) resulted in injury. Instagram was the most implicated platform (19 of 33 threats, 57.6%). Overall, social media was involved in 1.4% of violent crimes and social media threats were associated with injury. Given this association, they posit that identifying online threats could represent a novel focus for developing violence prevention interventions on these platforms. 

This study does have some limitations. Social media and online phenomena change rapidly, which may mean use and patterns are not accurately reported to police in crime reports. Additionally, given that this is a cross-sectional study, it is limited in its ability to provide conclusions of causality between social media use and violent/nonviolent crimes.

Bottom Line:
There is an association between social media threats and real-world violence, and identifying online threats could represent a novel target for violence prevention interventions on these platforms.