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PubMed2005

What price for general surgery?

BACKGROUND: This study aims to determine the cost-benefit analysis of adding a full emergency general surgery (EGS) arm to a trauma/critical care (TCC) service with limited EGS activity in a Level I trauma center. METHODS: Data on the composition, activity, and billings of a TCC were collected and compared before (January 1, 2002-June 30, 2003) and after (July 1, 2003-December 31, 2003) it assumed the care of all unassigned EGS patients. These included patient volume and demographics, service, procedures, on-call/service activity, and professional billings and collections. Data are means +/- SD or percentages. Intergroup comparisons were performed by using t test or chi2 as appropriate; significance was assumed for values of p < 0.05. RESULTS: Deploying an EGS arm increased coverage weeks (+52 weeks) and necessitated additional staffing (pre-EGS, n = 5; post-EGS, n = 6). Trauma operative volume remained constant (8.2 vs. 10.3 per month), EGS and elective case load increased (28.7 vs. 60 per month; p < 0.01), and the EGS case/consult ratio decreased from 0.81 to 0.64 (p < 0.01). This expanded activity was associated with reduced on-call nonclinical hours, from 3.2 +/- 0.9 to 1.1 +/- 0.8 (p < 0.01), and increased outpatient visits (68.6 vs. 91.1 per month; p < 0.01) and off-service time used for elective operations (22.3 vs. 76%; p < 0.01). Billings significantly increased in each arm compared with the pre-EGS study period (operating room, +44.8; intensive care unit, +12.5; outpatient, +48.7%; p < 0.01). CONCLUSION: Integrating a full EGS into a TCC service encumbers increased nontrauma unscheduled clinical activity in the operating room, clinic, and floors, which resulted in enhanced billings. These beneficial effects were accrued at the expense of individual time and investment in recruiting additional faculty.

Connecticut↗
PubMed2000

The effects of TRICARE implementation on general surgery residency training at Travis Air Force Base.

TRICARE is the military version of health care insurance. The conversion from CHAMPUS (the former version) to TRICARE was completed at David Grant Medical Center (DGMC) in October 1995. Because of a perceived decrease in the overall surgical caseload at DGMC in recent years, a review of the operative case logs of all graduating chief residents in general surgery was undertaken. The goal was to determine if institution of TRICARE was adversely affecting the surgical experience of our residents.A retrospective review of the residency review committee (RRC) case logs of all graduating chief residents in general surgery at David Grant Medical Center was performed from 1990 to 1999. The review was divided into 2 groups: group 1 included all individuals who graduated in those years before initiation of TRICARE (1990 to 1995); group 2 included those who graduated after the initiation of TRICARE (1996 to 1999). Each of the 16 separate RRC reporting categories and 3 summary categories were compared to detect differences in overall caseloads between group 1 and group 2.Compared with group 1, group 2 had significantly fewer aortic, pediatric surgery, endoscopy, and total cases done in the chief year.Since the initiation of the TRICARE health plan at David Grant Medical Center, overall caseloads have not declined. However, there has been a concerning decline in chief resident-year cases. This decline may not become fully apparent for several more years as the current junior residents report their caseloads upon their graduation. (Curr Surg 57:359-362)

Journal Article↗
PubMed1993

Is there a need for long-term thromboprophylaxis following general surgery?

Thromboprophylaxis to surgical patients is generally accepted, and used in the perioperative period by many surgeons as effective means of reducing postoperative thromboembolic complications. Often the prophylaxis is stopped at the time of mobilization or discharge of the patient, although late thromboembolic complications after cessation of the postoperative prophylaxis are known to occur up to 7 weeks after surgery. By scrutinizing thromboprophylactic studies performed in general surgery during the last 20 years, we found the incidence of late thromboembolic complications reported to be about 1% when clinical diagnostics was applied. In studies where the patients were screened for late thromboembolic complications using paraclinical diagnostic methods the incidence is 10 times higher. The clinical relevance of these late postoperative thromboembolic complications is still uncertain, as is the value of long-term prophylaxis.

Bandages↗
PubMed2004

Broad-based general surgery training is a model of continued utility for the future.

SUMMARY BACKGROUND DATA: Our program has emphasized broad-based training that potentially allows residents to pursue a variety of career paths, with or without additional surgical training. Diverse experiences have emphasized a variety of rotations, including a university hospital with a large trauma service, several tertiary private institutions, and suburban and rural experiences with private practitioners. Our faculty includes surgeons with both broad-based and narrowly focused practices. In light of duty-hour restrictions and proposed changes in surgical training, we assessed the results of this model over an extended period. MATERIALS AND METHODS: The case volume from the Residency Review Committee (RRC) operative logs, ABSITE scores, ABS performance, fellowship training, and subsequent career choices were examined for all graduating chief residents in general surgery from our program over the past 17 years. The impact of specialty faculty was assessed and data from 5 index (aortic, major esophagogastric, liver, pancreatic, and pelvic resections) cases were also abstracted from the logs. A survey was then sent to all 208 of the 212 surgeons who had completed the program since 1971. RESULTS: Of the 115 residents who completed training in the last 17 years, 60 pursued fellowship training and 55 went directly into general surgical practice in 20 states. Fifteen of the 29 residents who had an elective laboratory experience were among the 23 who remained in academic careers. The operative experience has been excellent (1090 +/- 42 total major; 240 +/- 21 surgeon chief). Experience did not vary, even though the number of graduating chiefs ranged from 5 to 8 per year, and there have been no deficiencies in RRC index cases. The addition of specialty faculty (n = 5) at various intervals promptly increased the volume of complex cases in pelvic, liver, pancreas, and vascular surgery. Since all residents promptly passed the ABS examinations, it was not possible to discern factors associated with Board performances other than broad-based training. The survey demonstrated that most continued to practice broad-based general surgery and believed that such training was highly relevant to their current practice. CONCLUSIONS: The provision of broad-based training with generalists and specialty faculty has allowed for excellent breadth and depth in case volume. While many residents pursued fellowships, those who did not have indeed achieved successful careers. Most continue to practice general surgery, indicating the value of complete training in this field. It will be important to monitor these outcomes as changes in residency training occur.

Career Choice↗
PubMed1996

Technology assessment in laparoscopic general surgery and gastrointestinal endoscopy: science or convenience?

Gastrointestinal endoscopy and laparoscopic general surgery have been significantly affected by the emergence of new techniques. These two disciplines share many similarities, including the use of sophisticated and expensive technologies. Their proper assessment is essential because they are developed amidst ever-decreasing health care budgets. Gastroenterologists and general surgeons must both participate in such evaluations and feel confident in interpreting pertinent published data. The present review uses a clinician's point of view with relevant examples to discuss the methodologies adopted in technology assessment and to highlight common pitfalls encountered in study design, patient selection, timing and selection of the study, blinding, and outcome measurement. Cost and statistical considerations, as well as ethical issues, are also reviewed in the context of technology assessment.

Costs and Cost Analysis↗
PubMed1986

The management of infancy and childhood intussusception in a department of general surgery.

The experience with 24 intussusceptions observed in a Department of General Surgery has been reviewed. The delay between onset of symptoms and hospitalization was less than 24 hours in 58% of cases, from 24 to 48 hours in 28%, and more than 48 hours in 14% of children. 23 patients were submitted to barium enema. Hydrostatic reduction was obtained in 19 cases. Laparotomy was performed in 13 patients after failure of hydrostatic reduction and in 5 emergency cases while only 4 underwent resection. The controversies about the management of intussusception are discussed, based on a review of literature (6,542 cases). A safe diagnostic and therapeutic approach to the disease is proposed.

Child, Preschool↗
PubMed2003

[Specialist of general surgery and gastroenterological surgery].

The educational committee of the society of gastroenterological surgery made a rule that the specialist of gastroenterological surgery must have a title of a general surgeon which was approved by the educational committee of the Japan surgical society. This means that a specialist of gastroenterological surgery should be able to treat diseases in the area of the general surgery and should be able to do the primary cares for whole areas of gastroenterological diseases which are the upper and the lower intestinal diseases, hepato-bilial and pancreatic diseases in addition. The Japan society of gastroenterological surgery offers a 7 years long gastroenterological surgery training curriculum after graduate from a medical school to train the specialist of Gastroenterological surgery. In this 7 years training period, the Japan surgical society also offers a 5 years long general surgery training course in the first 5 years. These two courses are proceeding in parallel. The essential contents of these two courses are overlapped, so these common contents may count as experiences for both courses respectively.

Education, Medical, Graduate↗
PubMed1993

[Qualification in general surgery. Experience of the National Commission with the first action by the Counsel of licensure of physicians].

The french board of qualification in general surgery examines requests from physicians who have neither a University French diplome of surgery, nor a similar diplome of a country of the European Community. From 1989 to 1991, 184 requests were submitted to the board, coming from military surgeons (n = 18), residents of university hospitals (n = 37) or general hospitals (n = 10) or from other physicians (n = 119). These latters originate mainly from non European foreign countries, and are naturalized as French citizens afterwards. The board gave 54 favourable recommendations (29%), ranging from 100% for military surgeons, to 8% for other physicians who had not been resident. Out of these requests, 18 were applied by physicians who were appointed as staff surgeon, usually in small public hospitals. Rather to appoint physicians without any surgical qualification to artificially provide jobs it would be cheaper for the care insurance system, and more secure for the patients, to close or transform hospitals which cannot find qualified surgeons. However, it is a difficult political challenge as, in France, mayors are systematically President of the administrative board of the public hospital.

France↗
PubMedDate not supplied

[The use of autotransfusion in general surgery].

Authors expose their experience with autotransfusion, made during several years in a general surgery university department. Discussion is made about ethic and economical aspect of the philosophy guiding the most general concept of blood sparing, and different methods of autotransfusion; attention is then focused on practical experience made during two years (1995-1997) when the program worked well. On the whole, in 94 patients, 172 blood units were collected plus 10 plasma units obtained by aferesis. No method-related complications are have been observed. Elements who corresponded to difficulties or obstacles to the fully application of the method have been critically analyzed. Authors propose finally guide-lines which want to be valid proposal to increase method use while respecting at the best ethics, economics, efficacy and efficiency that must guide our work.

Blood Transfusion, Autologous↗
PubMedDate not supplied

A 360 degrees evaluation of a night-float system for general surgery: a response to mandated work-hours reduction.

PURPOSE: New York State Code 405 and societal/political pressure have led the RRC and ACGME to mandate strict limitations on resident work hours. In an attempt to meet these limitations, we have switched from the previous Q3 call schedule to a specialized night float (NF) system, the continuity-care system (CCS). The purpose of this CCS is to maximize resident duty time spent on direct patient care, operative experience, and outpatient clinics, while reducing duty hours spent on performing routine tasks and call coverage. The implementation of the CCS is the fundamental step in the restructuring of our residency program. In addition to a change in the call system, we added physician assistants to aid in performing some service tasks. We performed a 360 degrees evaluation of this work in progress. METHODS: In May 2002, the standard Q3 call system was abolished on the general surgery services at the New York Presbyterian Hospital, Columbia campus. Two dedicated teams were created to provide day and night coverage, a day continuity-care team (DCT) and a night continuity-care team (NCT). The DCTs, consisting of PGY1-5 residents, provide daily in-house coverage from 6 AM to 5 PM with no regular weekday night-call responsibilities. The DCT residents provide Friday night, Saturday, and daytime Sunday call coverage 3 to 4 days per month. The NCT, consisting of 5 PGY1-5 residents, provides nightly continuous care, 5 PM to 6 AM, Sunday through Thursday, with no other weekend call responsibilities. This system creates a schedule with less than 80 duty hours per week, on average, with one 24-hour period off a week, one complete weekend off per month, and no more than 24 hours of consecutive duty time. After 1 year of use, the system was evaluated by a 360 degrees method in which residents, residents' spouses, nurses, and faculty were surveyed using a Likert-type scale. Statistical significance was calculated using the Student t-test. Patient satisfaction was measured both by internal review of a patient complaint database as well as by the Press Ganey patient satisfaction surveys. RESULTS: Twenty-one residents, 10 residents' spouses, 11 general surgery faculty, and 16 nurses were surveyed. Statistically significant findings included reduced resident fatigue noted by all groups (residents, p = 0.01; resident spouses, p = 0.05; faculty, p < 0.0001; nurses, p < 0.0001). Further, residents reported more time for sleep at home (p = 0.0005) and more time for independent reading (p = 0.01). Residents' spouses reported increased availability for family events (p = 0.01). Nurses reported increased availability of residents (p = 0.0002), shorter times to physician identification of patient problems (p = 0.0086), improved resident-nursing communications (p = 0.0096), and increased ease of nursing duties (p < 0.0001). Faculty were the only responders who felt that continuity of patient care suffered with the new system (p = 0.02). The Press Ganey review showed improvement in the quality of care rendered as perceived by patients. CONCLUSIONS: The institution of a specialized NF or CCS for in-house coverage of general surgical services in a large metropolitan university hospital has had initial success in meeting the mandated changes in resident work hours. The CCS reduced resident fatigue, improved quality of resident life, and improved patient care as judged by patients and nurse.

Appointments and Schedules↗
PubMedDate not supplied

[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation].

We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.

Adult↗
PubMedDate not supplied

Whatever happened to the General Surgery graduating class of 2001?

PURPOSE: Nationally approximately 20% of all categorical General Surgery (GS) residents do not complete their GS training. We ranked 57 applicants in the National Residency Match Program (NRMP) in 1996 and matched our final eighth candidate with slot 22. Although clinically stellar, 4 of these 8 residents (50%) opted to switch to different medical specialties. We pondered if other programs had difficulties with the 1996 applicant pool and hypothesized that perhaps higher ranked applicants have greater attrition rates. METHODS: Programs in which our ranked applicants matched were contacted and asked for feedback on trainee performance, research time, attrition, and future plans. RESULTS: Four applicants did not match in GS. Fifty-three surgical interns (46 men, 7 women) in 1996 are now 23 chief residents, 18 senior residents (16 did research time, 1 did an intensive care unit fellowship, and 1 required a year of remediation), and 12 non-GS trainees (orthopedic surgery = 3, anesthesiology = 3, ENT = 1, family medicine = 1, internal medicine = 1, radiology = 1, pathology = 1, and Ph.D. researcher = 1). Clinical performance was similar for both GS trainees and those who dropped out. Residents dropped out after the PG-1 year (n = 7), PGY-2 (n = 3), and 1 each after PGY-3 and PGY-4. Higher ranked applicants were no more likely to drop out than were lower ranked applicants. CONCLUSIONS: Of Mayo Clinic-Rochester-ranked GS categorical applicants in 1996, 23% dropped out of GS. Eleven of 12 dropouts selected a different field of medicine to finish their training. Attrition remains common and problematic both nationally and in individual programs.

Journal Article↗
PubMed1982

Beta-receptor blocker withdrawal. A preoperative problem in general surgery?

A prospective randomized study was performed in 91 patients scheduled for general surgery on 99 occasions. The patients were chronically (greater than 3 months) treated with beta-receptor blockers because of ischaemic heart disease and/or hypertension and the beta-receptor blockade was either gradually withdrawn (n = 51) during 4 days preoperatively or continued until surgery (n = 48). The effects on arterial blood pressure (BP), heart rate (HR) and rate-pressure product (RPP) at rest and the incidence of chest pain during daily activities were registered. A withdrawal of the beta-receptor blockade was associated with increases of HR (in eight patients greater than 30 beats min-1) and RPP and in patients treated for hypertension there were also increases of systolic and diastolic BP (in five patients greater than or equal to 30/15 mmHg). Patients who continued the beta-receptor blockade until surgery showed no changes. Nine out of 23 patients with a previous history of ischaemic heart disease had an increase of chest pain after withdrawal of the beta-receptor blockers, whereas none of the corresponding 25 patients who continued the therapy suffered from an increased chest pain. Due to the severity of symptoms after beta-receptor blocker withdrawal, surgery had to be postponed in 4 patients. The observations suggest that a 4-day preoperative withdrawal of long-term beta-receptor blockade is potentially hazardous in ischaemic and/or hypertensive patients.

Adrenergic beta-Antagonists↗
PubMed1977

A 14-month study of severe non-wound infectious complications in general surgery.

A retrospective study of serious non-wound infectious complications in general surgery during at 14-month period is reported. A prospective study on wound infections in available from the same institution and period. Septicemia, intraabdominal and intrathoracal abscesses and rare cases of osteomyelitis occurred in 1.3% of all treated patients, whereas postoperative wound infection developed in 7.5% of primarily non-infected patients. Mortality was significantly higher among patients with serious infections than in all patients nursed during the same period. Severe postoperative infectious complications was in fact the third most common cause of death and accounted for 14% of the mortality of the clinic. This rate rises to close to 50% when death from incurable disease is excluded. Septicemia carried a significantly higher mortality rate than intraabdominal abscesses. The risk of a serious infection developing was significantly higher in operations on the small or large intestine than after appendectomies or biliary operations. Gram negative bacteria dominated, especially in cases with a fatal outcome. Contributing factors such as malignancy, preoperative infection or macroscopic peroperative wound soiling, were more common in patients where a serious infectious complication developed postoperatively.

Abscess↗
PubMed1997

[Etiology and clinical relevance of hyponatremia in general surgery intensive care patients].

For 1 year all patients in the Department of General Surgery who were transferred to the intensive care unit (n = 237) were prospectively studied as to the development of hyponatremia. Relevant hyponatremia developed in 6.3% of the patients. The lowest sodium concentration observed was 121 mmol/l, the mean duration was 1.2 days. In general, hyponatremia is related to hypovolemia and diuretics are often involved. In no patient were there any clinical consequences.

Critical Care↗
PubMedDate not supplied

The remedial year in the general surgery board certification process: how effective is it?

BACKGROUND: The American Board of Surgery (ABS) intends to assure high standards for knowledge and experience in every graduate from an approved general surgery program. They have gone to great lengths to devise an optimal remediation process for every candidate failing to reach these standards. But what is the effectiveness of the remediation process? METHODS: ABS data outlined the history and development of the remediation process up to its current form. A core component of this process is a specifically structured additional year of training at selected institutions. Ten institutions, which were classified as outstanding by the ABS, received a standardized confidential questionnaire to collect data that included the institution's impetus to administer a remedial year (RY), organization of their RY, specific emphasis points, role of advisors, funding, and choice of RY candidates. Each institution was asked to mail a letter to their RY graduates, asking for their participation in a follow-up study aimed at characterizing the failing candidate. RESULTS: ABS data have been available since 1980. Pass rates for the qualifying written examination (QE) improved steadily from about 63% in 1985 to 78% in 2003. Pass rates for the certifying oral examination (CE) have been consistently around 75% since 1985 with improvement to just above 80% within the last 4 years. In 1995, a new ABS policy was announced requiring an additional year of structured training with specific elements. For the QE, the general pool pass rates continued their steady improvement. Although the results for RY candidates did reveal a 20% improved pass rate, they were still 30 percentage points lower when compared with the general pass rates. No improvement was noted in the CE results. In 2003, ABS enacted the latest policy change, which consists of an alternative pathway for QE. The initial experience for 2003 is disappointing. Less than 10 candidates have taken advantage of this alternative, and pass rates have not improved. The policy for CE was changed to allow 5 attempts (up from 3 attempts) in 5 years, and currently it is too early to determine the impact of this change. Nine of 10 institutions agreed to participate in our study. They identified the essential elements of a successful RY. They also emphasized that CE remediation has to go beyond correction of simple knowledge deficits. And they characterized the ideal candidate for remediation. No RY graduates agreed to participate in the planned follow-up study to characterize the failing candidate. CONCLUSION: The RY process seems to have a valid potential if specific conditions are met. We do believe that differentiation is needed between the QE and the CE remedial year programs. Because the CE incorporates rhetorical skills, an emphasis should be placed on public speaking and presentation skills in a remedial year for the CE. We recommend several possible avenues for consideration: identifying the resident at risk and intervening during residency, incorporating the RY process into the ongoing practice routine of the individual candidate, and actively recruiting participation of candidates in a needs assessment study.

Certification↗
PubMed2005

Effect of the 80-hour work week on cases performed by general surgery residents.

The Accreditation Council for Graduate Medical Education (ACGME) implemented mandatory work week hours restrictions in 2003. Due to the traditionally long hours in general surgery, the effect of restrictions on surgical training and case numbers was a matter of concern. Data was compiled retrospectively from ACGME logs and operating room (OR) records at a university hospital for 2002 and 2003. Work week restrictions began in January 2003. This data was reviewed to determine resident case numbers, both in whole and by postgraduate year (PGY). Mean case numbers per resident-month in 2002 were 8.8 +/- 8.2 for PGY1s, 16.2 +/- 15.7 for PGY2s, 31.4 +/- 12.9 for PGY3s, 31.5 +/- 17.6 for PGY4s, and 31.5 +/- 17.6 for PGY5s. In 2003, they were 8.8 +/- 5.2 for PGY1s, 16.6 +/- 13.9 for PGY2s, 27.8 +/- 12.5 for PGY3s, 38.2 +/- 18.8 for PGY4s, and 26.1 +/- 9.6 for PGY5s. PGY1s, PGY2s, PGY3s, PGY4s, or all classes were not statistically different. PGY5s did have statistically fewer cases in 2003 (P = 0.03). PGY5s did have statistically fewer cases after the work-hours restriction, which likely represented shifting of postcall afternoon cases to other residents. Comparing other classes and all PGYs, case numbers were not statistically different. Operative training experience does not appear to be hindered by the 80-hour work week.

Burnout, Professional↗