Gundersen Lutheran Hospital

Despite the dire need for rural surgeons and increasing interest in exposing residents to rural practice, there remains little systematic information about how programs establish and sustain rural rotations. A website review (12/2022-7/2023) of the 342 civilian surgery programs listed by the ACGME identified those offering elective or required U.S. rural rotations. In addition, all programs were contacted by email to confirm or deny that they offered rural rotations to account for webpage inaccuracies. The effort identified 81 programs (24%). A qualitative design was then adopted, whereby the first author interviewed 58 general surgery program leaders (72% participation rate) to explore strategies used to arrange and sustain rural rotations. Interviews focused on the 2023-24 academic year, were conducted from August 2023 to August 2024, and were recorded, transcribed, and analyzed collaboratively to discern program strategies. Programs are more likely to use rural training sites outside their healthcare system (59% or 34/58) than inside (41% or 24/58), but system sites were preferred when available. At both site types, programs drew heavily upon professional ties, primarily to program graduates (64% or 37/58). Alumni were eager to help and knew program traditions and expectations. Their presence also bolstered confidence in the educational value of the rotation. Additional alumni joining rural sites were evidence of rotations as a recruitment pathway, thus fostering sustainable relationships. Within-system rotations were easier to arrange and finance than those outside the system. The results offer practical insights into how a diverse mix of surgery programs across the U.S. select and sustain required and elective rural rotations in the U.S. The prominence of professional ties to program graduates and healthcare-system links are especially notable. Variability across programs in how they select and sustain sites also suggests that many approaches are feasible.

The Covid-19 pandemic has added a new chapter to discussions about the professional duty to care. To understand how Covid-19 may have changed medical students' ethical attitudes towards this duty, we analysed policies written before and during the pandemic by first-year students completing a yearly educational exercise focused on work requirement expectations for healthcare professionals during a hypothetical epidemic. Within a repeated cross-sectional design, consensus coding was performed on policies written over 5 years (2017-2021) using a codebook based on eight questions from the educational exercise for summative content analysis. Frequencies provided summative results and comparisons across years used Fisher's exact test. We analysed 142 written policies from 2017 to 2021 representing 884 first-year students working in small groups. Students' commitment to the duty to care remained stable during the Covid-19 pandemic, but during the pandemic, students were more likely to support exceptions to the duty to care (e.g. for healthcare professionals with medical conditions or concern for household members' health) and more likely to expect institutions to provide safe working conditions. Ethical values supporting students' policies were largely consistent before and during the pandemic, the most common being beneficence, justice, duty to care, non-maleficence and utility. Our results suggest that students' support for the duty to care remained strong during the Covid-19 pandemic. We also found that students supported exceptions to this duty to reflect the needs of healthcare professionals and their families and that they expected institutions to provide safe working conditions. These findings can help inform ethics education and future pandemic preparedness.

Godsey, Claire; Gabor, Rachel; Oelstrom, Matthew; Hagen, Scott; Peterson, Jennifer; Taylor, John; Mikhailov, Theresa Author Information

ECOG-ACRIN EA5181 is a phase III prospective, randomized trial that randomizes patients undergoing chemo/radiation for locally advanced non-small cell lung cancer (LA-NSCLC) to concomitant durvalumab or no additional therapy, with both arms receiving 1 year of consolidative durvalumab. Radiation dose escalation failed to improve overall survival in RTOG 0617. However, conventionally fractionated radiation to 60 Gy with concomitant chemotherapy is associated with a high risk of local failure (38%-46%). It is hoped that concomitant immunotherapy during chemo/radiation can help decrease the risk of local failure, thereby improving overall survival and progression-free survival with acceptable toxicity. In this article, we review conventional chemo/radiation therapy for LA-NSCLC, as well as the quickly evolving world of immunotherapy in the treatment of non-small cell lung cancer and discuss the rationale and study design of EA5181. IMPLICATIONS FOR PRACTICE: This article provides an up-to-date assessment of how immunotherapy is reshaping the landscape of metastatic non-small cell lung cancer (NSCLC) and how the impact of this therapy is now rapidly moving into the treatment of patients with locally advanced NSCLC who are presenting for curative treatment. This article reviews the recent publications of chemo/radiation as well as those combining immunotherapy with chemotherapy and chemo/radiation, and provides a strategy for improving overall survival of patients with locally advanced NSCLC by using concomitant immunotherapy with standard concurrent chemo/radiation.

238 Background: Cancer organizations recommend physical activity as part of therapy to aid in symptom management, reduce recurrence and improve overall quality of life. What the optimal exercise program should look like and what stakeholder barriers exist are unclear. Methods: We convened three focus groups, one with metastatic patients, one with non-metastatic patients, one with the providers in the Cancer Center and conducted individual interviews at Gundersen Health System in La Crosse, Wisconsin. The constant comparative method was used to identify themes about exercise as part of cancer treatment. Results: No statistical differences in demographic characteristics exist between metastatic (N = 9) and non-metastatic (N = 11) patients. Impacts of exercise on cancer, who should instruct patients about exercise and how/where the exercise should take place emerged as the main themes. Discordance between patients and providers (N = 10) was identified in these areas. Patients felt that exercise during treatment provided intrinsic value (“Exercise mentally is important”) whereas providers connect exercise to positive disease outcome (“There are decreased recurrence rates for multiple different malignancies that have been proven in large studies”). Patients resoundingly expressed a desire to receive instructions for exercise from their oncologist (“I rely a lot on my oncologist...they are tuned into you”). Providers expressed a desire for a referral process to a cancer trained physical therapist or trainer who would guide patients through an exercise program (“to have assistance from someone who is trained… would be really beneficial”). Conclusions: Providers recognize the importance of exercise as part of a cancer treatment plan, yet they agree that time constraints associated with a busy practice impacts the priority of exercise instructions. Bridging the gap we identified between patient and providers’ perceptions has potential for cancer care across the nation. We plan to further study the discord after designing standard exercise recommendations at varied levels of intensity through collaboration with oncology providers, physical therapy and Livestrong personnel utilizing venues in our region.