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PubMed1993

Patient satisfaction with communication in general surgery: problems of measurement and improvement.

The research reported here is taken from a pilot inquiry into patient experiences of general surgery provided in National Health Service hospitals. This study sought to identify how the cross section of patients facing general surgery experienced communication and information problems particular to their surgical 'settings', how such discontent is understood or rationalised by them, and consequently how it would be reported to relatives or researchers. Drawing on interviews with patients and surgical staff, the paper explores the range of communication difficulties facing certain types of patient which arise from the hospital setting and the routines and rituals of service providers. While it is concluded that communication should be explored with some reference to disease classification, this should not divert attention from the general context of care to the unique circumstances of patient or surgeon. It is questioned whether patients are always disposed to rationalise their difficulties in terms of 'dissatisfaction' in the way required by survey research. Drawing on interview-generated comments by patients and staff, the paper illustrates less obvious validity problems for patient satisfaction studies, and addresses briefly questionnaire design which may account for them.

Adult↗
PubMed2004

Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship.

BACKGROUND: There has been declining interest in surgery among medical students and one reason might be the third-year clerkship experience. The aim of this study was to clarify the perceptions and expectations of attendings, residents, and medical students on the clerkship experience. STUDY DESIGN: A survey was distributed to all general surgery attendings, the entire general surgery house staff, and an entire third year medical school class inclusive of the 2001-2002 academic year at a single institution. Statistic analysis consisted of chi-square and Kruskal-Wallis-ANOVA on ranks with Dunn's test for multiple comparisons. A p < 0.05 was significant. RESULTS: Responses were obtained from 59 attending surgeons (50%), 38 surgical residents (32%), and 107 medical students (66%). Of this student cohort, 35% were planning to choose a surgical specialty as a career. Agreement was high among faculty, students, and residents about factors considered important in evaluation, expectations of skills, and level of skills needed before the clerkship. Medical students desired more hours of instruction, believed they performed fewer procedures per week, and thought that feedback was poor compared with the opinions of faculty and residents (p < 0.002). Nearly 50% of medical students believed they were an inconvenience to the service; 30% of house officers and 27% of faculty (p < 0.001) believed this also. Almost all faculty and residents, however, wanted medical students on the service (> 95%). Faculty believed residents did a better job teaching than either the students or residents themselves did (p < 0.001), and students thought that residents were the primary source of education in patient care. CONCLUSIONS: Considerable differences exist between faculty, surgical resident, and medical student perceptions and expectations of medical student education. Structured direct faculty contact, definition of medical student roles on the surgical team, and more consistent feedback can be rapidly improved.

Attitude of Health Personnel↗
PubMed2001

Laser use and research in gastroenterology, gynecology, and general surgery: a status report.

OBJECTIVE AND BACKGROUND DATA: Despite the burgeoning growth of laser applications in dermatology and plastic surgery, applications in other specialties have declined. Laser use in gastroenterology, general surgery, and gynecology was examined over the past 3 years. Future trends and opportunities are discussed. METHODS: The MEDLINE database was scanned for scholarly publications between January 1, 1997, and January 1, 2000, and the number of publications in these specialties was determined. A questionnaire was distributed to 362 general surgeons from the American Society for Laser Medicine and Surgery (ASLMS) to assess current use and future needs. These results were compared to the actual cases performed at a laser center over the same period. RESULTS: Of 3,331 publications, 21 (0.6%) covered gastroenterology (GE), general surgery (GS), gynecology (GYN), or laparoscopy (LAP). Keyword citations were 2 GS, 3 GYN, 7 GE, and 12 LAP. Questionnaire results and actual utilization were well correlated. CONCLUSIONS: Lasers are being used in these specialties despite slow development of novel uses. Opportunities exist for future applications.

Adult↗
PubMed2003

Does a general surgery clerkship influence student perceptions of surgeons and surgical careers?

BACKGROUND: Student perceptions of surgeons and surgical careers may influence their decision to pursue a surgical career. We evaluated the impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers and of the clerkship on student interest in surgical careers. METHODS: We conducted voluntary pre- and postclerkship surveys of third-year medical students who were enrolled in their required general surgery clerkship and used 5-point Likert scale rankings to capture agreement with declarative statements (1 = strongly agree; 5 = strongly disagree). T-tests were used to evaluate both paired and individual items. RESULTS: Students indicated that their surgical clerkship improved their opinion of surgeons (2.47; P <.001). Several perceptions changed after the clerkship. First, students agreed more strongly that surgeons were compassionate physicians (ranking, 2.87 vs 2.53; P =.003) and that patients respected surgeons (ranking, 1.84 vs 1.62; P =.026). Acknowledgment of career satisfaction by students increased (ranking, 2.57 vs 2.22; P =.008). Students more strongly disagreed that "surgeons [were] respectful of other physicians" (ranking, 3.29 vs 3.62; P =.009). Interest in surgical careers did not change significantly during the clerkship (ranking, 2.83 vs 2.68; P =.218). CONCLUSIONS: Medical student perceptions of surgeons and surgical careers generally improve during the surgical clerkship. However, student impressions of surgeons' collegial behavior and commitment to teaching deteriorate significantly during the surgical clerkship.

Adult↗
PubMed1994

Fundholders' referral patterns and perceptions of service quality in hospital provision of elective general surgery.

BACKGROUND: The introduction of fundholding established an internal market in public sector health care, involving purchasers and providers contracting for the supply of health care. AIM: This study set out to examine fundholders' hospital referral patterns, and to evaluate the quality of the service provided to patients undergoing elective general surgery, as perceived by fundholding general practitioners. METHOD: A questionnaire was posted to the senior partners of all fundholding practices in the Trent Regional Health Authority area. This questionnaire requested assessments of the importance of 13 specified aspects of service quality and the quality of provision by general practitioners' most frequently-used hospitals. Five-point scales were employed in each case. Respondents were asked to provide additional details about their practice. RESULTS: A 67% response rate was achieved. Confidence in the consultant's ability, short waiting times and informative feedback from the providers emerged as the most important elements in referral decisions, while the cost of treatment and patient convenience received lower importance ratings. In terms of how well their providers were seen to perform, fundholders ranked confidence in the consultant and patient convenience highest, and style of hospital management lowest. The majority of referrals seemed to be local. CONCLUSION: Judged in terms of fundholders' perceptions, sizeable variations in service quality between hospital providers of general surgery are evident.

Elective Surgical Procedures↗
PubMed2004

Comparison of perioperative complications between reconstructive pelvic surgery and general gynecologic surgery.

The purpose of this study was to compare the perioperative complication rates of reconstructive pelvic surgery and general gynecologic surgery, and to identify the predictive risk factors for perioperative complications in reconstructive pelvic surgery. The medical records of 148 reconstructive pelvic surgery patients and 146 general gynecologic surgery patients were reviewed, and the types of complications, along with their rates and predictive risk factors were examined. The statistical analysis included descriptive statistics and logistic regression. There was no difference in the type of complications between reconstructive pelvic surgery and general gynecologic surgery. The prevalences of perioperative complications were 34.4% in the reconstructive pelvic surgery group and 26.7% in the general gynecologic surgery group. Intraoperative blood loss (p= 0.006) and the duration of surgery (p=0.014) were independent risk factors for perioperative complications in the reconstructive pelvic surgery group. The perioperative complication rates for the patients undergoing reconstructive pelvic surgery were not higher than those of the patients undergoing general gynecologic surgery, even though more procedures were performed and a longer duration of surgery was needed in the former cases. Since the duration of surgery and the amount of blood loss are the major factors affecting the complication rate, decreasing these two factors would be the key to improving the outcomes of patients undergoing reconstructive pelvic surgery

Adult↗
PubMed2000

Incisional endometriosis: an underappreciated diagnosis in general surgery.

BACKGROUND: Incisional endometriosis is a described dinical entity in the gynecologic literature, but it is not well recognized among general surgeons; only 32 cases have been reported in the general surgery literature. The preoperative diagnosis is often mistaken for a suture granuloma, lipoma, abscess, cyst, or incisional hernia. STUDY DESIGN: We performed a retrospective review of 10 cases of incisional endometriosis at our institution to determine which, if any, clinical factors would suggest the diagnosis preoperatively. All general surgery patients who had the diagnosis of endometriosis in their pathology specimens from January 1990 to December 1998 were reviewed. RESULTS: All 10 patients had previous cesarean sections through either a Pfannenstiel (n = 8) or a lower midline (n = 2) incision. Ages ranged from 27 to 41 years (mean 33.4 years). The most common presenting symptom was a slow-growing, painful lump in the lateral aspect of the Pfannenstiel incision. Two of the patients had a change in symptoms with their menstrual cycle. The duration of symptoms ranged from 2 months to 3 years. All patients underwent surgical excision. The size of the excised endometriomas ranged from 1.5 cm to 4.8 cm (mean 3.1 cm). CONCLUSIONS: Incisional endometriosis may be more common than previously recognized. In all cases it was found to occur in women with a history of cesarean section. Most patients presented with a painful, slow-growing lump at the lateral edge of their incision. Cyclic changes in pain and size of the mass with menses was elicited in only two of these patients, but this may be from a lack of awareness and questioning on the part of the physician. If the diagnosis is made preoperatively, additional diagnostic studies may be avoided. An awareness of this disease process on the part of general surgeons is necessary to guide preoperative evaluation and therapy appropriately.

Adult↗
PubMed2004

Role of parecoxib in pre-emptive analgesia: comparison of the efficacy and safety of pre- and postoperative parecoxib in patients undergoing general surgery.

Management of acute postoperative pain remains sub-optimal despite the availability of multiple analgesics and improved pain management strategies (with nearly 80 % of patients reporting moderate to extreme pain following surgery). To evaluate the role of parecoxib as a pre-emptive analgesic in patients undergoing general surgery, the present study was undertaken. Eighty patients of either sex, aged 18 to 70 years, requiring elective ambulatory general surgery like hernioplasty, appendicectomy, cholecystectomy, etc, were enrolled in this prospective, randomised, assessor-blind, parallel-group, comparative trial. Eligible patients were randomised to receive a single dose of 40 mg of parecoxib IM/IV either 30-45 minutes prior to induction of anesthesia (pre-emptive analgesia) or in the postoperative period when one reported pain or when the effects of anesthesia were worn off (whichever was earlier). The primary measures of efficacy were pain intensity scores measured on a visual analog scale (VAS) and pain relief before and after therapy. Adverse event monitoring, physical examination and changes in laboratory tests, chest x-ray and ECG were used to evaluate safety. A comparison of the pain intensity scores between the two groups revealed that patients treated with parecoxib preoperatively did not complain of pain in the entire postoperative period up to 12 hours. Mild pain (1.05+/-1.36) was reported by patients in this group only at the 24 hours assessment. On the other hand, patients treated with parecoxib in the postoperative period, experienced severe pain at baseline, which declined gradually up to 12 hours. The difference in the pain intensity scores between the two groups was statistically significant at all the time intervals from 0 hour to 24 hours. All the 40 patients (100%) in the pre-operatively treated group reported total pain relief at 12 hours compared to only 22 patients (55%) in the postoperative period. At 24 hours total pain relief was reported by 70% of the patients in the pre-operatively treated group, compared to only 20% (8) patients in the postoperatively treated group. The difference between the two groups was statistically significant in favour of the pre-operatively treated group (p<0.05). Present results suggested that pre-operative administration of parecoxib was more effective than a postoperative use in providing pain relief in postoperative period in patients undergoing elective general surgical procedures. Both the regimens were well tolerated. Based on the above data, it appears that pre-operative dose of parecoxib 40 mg IV/IM is a useful optionfor pre-emptive analgesia in general surgical practice.

Adolescent↗
PubMed1988

Cost justification of clinical pharmacy services on a general surgery team: focus on diagnosis-related group cases.

We used a novel approach to cost-justify clinical pharmacy services on a general surgery team in nine diagnosis-related group cases. The clinical pharmacist monitored nine patients longitudinally on a general surgery team from admission to discharge and intervened in their therapeutic management. Each recommendation was analyzed for rationale, acceptance, perceived impact on quality and/or cost of patient care, whether self-initiated or solicited, and impact on patient outcome. Types of recommendations and outcomes were categorized by process and outcome measurement criteria. Total cost avoidance per patient was calculated using costs of drug therapy, laboratory tests, and length of stay. Accounting for cost of clinical pharmacy services, net cost avoidance per patient was calculated. The clinical pharmacist made 101 recommendations on nine patients. Physicians accepted 82 percent of the recommendations; 77 percent of the recommendations were self-initiated and 23 percent were solicited. Recommendations had a perceived impact on cost, quality, or both at 13, 31, and 56 percent, respectively. Most recommendations (79 percent) brought patient therapy to a level of conformance with current standards of practice as documented in the medical literature. Recommendations that potentially preserved a major organ function by preventing drug-induced toxicity or the exacerbation of existing problems constituted 16 percent of the total. None of the accepted recommendations adversely affected patient outcome and 23 percent directly resulted in a measurable positive outcome in patient care. A total of four hospital days was potentially saved for two cases. Based on objective outcome criteria, a 1.9-day increase in therapeutic control was documented per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-Benefit Analysis↗
PubMed1991

[The effect of Federal Public Health Service guidelines on air, surface and floor germ count in a general surgery and an orthopedic operating room].

In a prospective study the environmental contamination in an old and a new operating theatre was investigated. The old operating rooms were constructed in 1936 whereas the new rooms were built in 1986. The study was conducted in surgical and orthopedic surgical operating rooms. There was a slight increase in floor as well as in surface contamination in the new operating rooms. On the other hand there was a slight decrease in the airborne microorganisms in the orthopedic surgery and nearly identical colony counts in the general surgery operating rooms. All the differences were statistically not significant. The spectrum of microorganisms and the occurrence of Staphylococcus aureus in the old and the new operating rooms showed no difference.

Air Microbiology↗
PubMed1988

The future of general surgery in Canada.

Manpower studies carried out by the Canadian Association of General Surgeons revealed a need for approximately 70 new general surgeons to enter practice each year to replace those who will discontinue practice for various reasons. The Royal College of Physicians and Surgeons of Canada certifies about 70 general surgeons each year; however, two-thirds of these pursue further specialty training, leaving only 20 to 25 to continue in general surgery. Training programs in Canada are of variable length and content. Less than half the trainees have substantial research experience. Programs designed to train the comprehensive community general surgeon are lacking in Canadian medical schools and reductions in residency training posts and other governmental constraints may worsen the anticipated shortage of general surgeons. Strong leadership is needed to bring together organized medicine, the surgical specialties, universities and government to address the training and manpower requirements for general surgeons in Canada.

Canada↗
PubMed1993

[Surgery of abdominal aortic aneurysm in a department of vascular surgery integrated into a department of general surgery--is it satisfactory?].

Seventy-two operations for abdominal aortic aneurysm (AAA), i.e 104 per mill. per year, were carried out by a vascular surgical unit integrated into a general surgical department. Mortality rate for elective operation was 3.8%, for acute operation without rupture 3.8% and with rupture 31.6%. Fifty percent of patients with rupture reached operation, which gives an overall mortality of about 66% and an incidence of 56 per mill. per year. Twice as many acute operations were carried out in this area compared to the rest of Denmark, and no haemodialysis-demanding complications occurred. These observations suggest that short transfer time is an important prognostic factor when treating ruptured AAA.

Aged↗
PubMed2002

Developing priority criteria for general surgery: results from the Western Canada Waiting List Project.

OBJECTIVE: The Western Canada Waiting List Project (WCWL) is a federally funded partnership of 19 organizations, including medical associations, health authorities, ministries of health and research organizations that was created to develop tools for improving the management of waiting lists. The WCWL general surgery panel was 1 of 5 panels constituted under this project. METHOD: The panel developed and tested a set of standardized clinical criteria for setting priorities among patients awaiting elective general surgery of all kinds. The criteria were applied to 561 patients in 3 western provinces. Regression analysis was used to determine the set of criteria weights that collectively best predicted clinicians' overall urgency ratings. RESULTS: The priority criteria accounted for almost two-thirds of the observed variance in clinicians' urgency ratings (adjusted R2 = 64.1%) for a mixed group of patients. The panel modified the criteria and weights based on empiric findings and clinical judgment. Interrater and test-retest reliability of criteria items appeared to be good, based on clinicians' ratings of 6 videotaped, standardized patient interviews. CONCLUSIONS: The panel considered the criteria easy to use and reasonably reflective of expert surgical judgement regarding clinical urgency. Further development and testing of the tool appears warranted.

Canada↗
PubMed2005

The economic impact of incorporating flexible endoscopy into a community general surgery practice.

BACKGROUND: Flexible endoscopy is a vital component of gastrointestinal surgery. It has and will replace many of the surgical procedures now commonly performed. Flexible endoscopy, unfortunately, is not an integral part of surgical residency training based on resident operative experience as reported by the Residency Review Committee. Moreover, general surgeons have deferred the practice of flexible endoscopy to the gastroenterologists because of concerns over turf battles and referral patterns. The purpose of this study was to assess the overall case load and the economic impact of flexible endoscopy on the practice of general surgery in a community hospital setting. METHODS: This retrospective review was performed over a 6-month period. The total cases and the total billings of inpatient and outpatient procedures for a group practice of five general surgeons in a community hospital were evaluated. The billings were the actual charges based on current procedural terminology (CPT) codes for these procedures using the Medicare fee schedule. RESULTS: Of the 2,159 procedures performed, 1,154 involved flexible endoscopy cases accounting for 54% of all cases (1,154 of 2,159) performed from February 1, 2003 to July 31, 2003. Flexible endocopy accounted for 43% of the total charges. A. total of 46 surgical procedures and 216 future endoscopies were generated from the flexible endoscopic procedures. Future endoscopic cases were for surveillance of colonic neoplasia and Barrett's esophagus. CONCLUSIONS: Flexible endoscopy contributed to a major portion of the caseload and revenue generated by the general surgery group studied. The overall impact of flexible endoscopy is even greater than reported because of the future endoscopic surveillance cases or surgical interventions generated on the basis of endoscopic findings.

Ambulatory Surgical Procedures↗
PubMed1988

[Femoral neck fractures--treatment and results at a general surgery department].

This is a report about 50 fractures of the femoral neck, treated in a ward for general surgery. Impacted valgus fractures generally do not need surgery. Osteosynthesis only with Böhler nail have no good results. Hemiprosthesis of femoral head on elderly patients is a good method and generally not followed by protrusio acetabuli.

Adult↗
PubMed1998

Comparing nosocomial infection rates among surgical intensive-care units: the importance of separating cardiothoracic and general surgery intensive-care units.

Among surgical intensive-care units (ICUs), we assessed differences in risk-adjusted nosocomial infection rates between cardiothoracic (CT) and general surgery ICUs, using National Nosocomial Infection Surveillance data from 1987 to 1995. Device-associated rates and average length of stay were significantly lower in CT ICUs. Comparisons of risk-adjusted nosocomial infection rates among CT ICUs should be made separately from rates from general surgery ICUs.

Cross Infection↗