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PubMed2005

Characterizing the general surgery workforce in rural America.

BACKGROUND: General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas. HYPOTHESIS: We hypothesize that the rural areas of the United States are relatively undersupplied with general surgeons. DESIGN AND SETTING: The American Medical Association's Physician Masterfile was used to identify all clinically active general surgeons as well as their locations and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas. Surgeons were classified as practicing in urban areas, large rural areas, or small/isolated rural areas. RESULTS: There are currently 17 243 general surgeons practicing in the United States. Nationally, the number of general surgeons per population of 100 000 varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation's general surgeons are female. Wide variations in numbers of general surgeons were found between and within individual states. General surgeons in the smallest rural areas are more likely than those in urban areas to be male (92.7% vs 88.3%, P<.001), 50 years of age or older (51.6% vs 42.1%, P<.001), or international medical graduates (25.2% vs 20.1%, P<.001). CONCLUSIONS: The overall size of the rural general surgical workforce has remained static over the last decade, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. Steps to reverse this trend are needed to preserve the viability of health care in many parts of rural America.

Adult↗
PubMed1991

Medical students who enter general surgery residency programs: a follow-up between 1972 and 1986.

Although a few surgical residents do leave the surgical field, little research has been done into the eventual whereabouts of all surgical residents. We undertook this follow-up to find out what proportion of them enter the surgical field and to identify changing patterns over the past 15 years. We compared 593 medical school graduates on demographics, academic credentials, and surgery program directors' rating of their performance in the first postgraduate year (PGY-1). Sixty percent remained in general surgery, and about 26% moved to another specialty within the surgical field. During the mid-1970s, those who remained within the surgical field had better academic credentials on average than those who switched out of the surgical field. However, more recently, the trend has reversed. There were no differences between the groups on age or sex. These results suggest that some good students are being recruited into surgical programs but are later lost in major career switches. Perhaps these changes are related to residents' preferences for specialties that offer more controllable lifestyles than the surgical field.

Achievement↗
PubMed1985

Nd-YAG laser for general surgery.

We report here our clinical experiences with Nd-YAG laser on general surgery, and evaluate the results of this procedure. From December 1979 to December 1981, we applied Nd-YAG laser to various operations as a hemostatic and cutting tool. For hemostasis, we used conventional quartz fiber which was covered with sterile tube, and hemostatic efficacy was examined especially in the subcutaneous bleeding and the bleeding from solid organs. For cutting, we used special devices, ie, Medilas YAG surgical probe (noncontact-type probe), and a laser blade (contact-type probe), and performed four liver resections. It is concluded that the hemostatic efficacy of Nd-YAG laser to various bleeders was proved in general surgical procedures, and furthermore this laser can cut tissue if we utilize these devices. When comparing these two devices, we would prefer the contact-type probe.

Carcinoma, Hepatocellular↗
PubMed2002

Smoking cessation counseling: a missed opportunity for general surgery trainees.

PURPOSE: The purpose of this study was to evaluate and compare the attitudes, practices, technique utilizations, and barrier perceptions of smoking cessation counseling (SCC) in general surgery (GS) and primary care (PC) residents. METHODS: One hundred house staff officers (45 GC and 55 PC residents, consisting of internal medicine and family medicine disciplines) were randomly surveyed. chi(2) and t tests were used for comparative analysis where appropriate. The National Cancer Institute's recommendation that physicians follow the "four A's" for SCC (Ask, Advise, Assist, and Arrange follow-up) was examined with respect to compliance by surgical and medical residents. RESULTS: Fewer GS than PC residents thought physicians were responsible for SCC (64% versus 85%; P <.02), and fewer felt well prepared to counsel their patients (38% versus 58%; P <.05). Nevertheless, about 85% of both groups reported a higher inclination to provide SCC to patients who expressed an interest for cessation. Although many GC residents Ask (89% GS versus 100% PC residents; P <.03) and Advise (64% versus 89%; P <.003) new patients about smoking, they did so less frequently than PC residents. GC residents used fewer SCC techniques than did PC residents (3.96 versus 6.00; P <.001) and Arranged fewer follow-up visits for SCC (7% versus 44%; P <.001). Postgraduate year did not correlate with SCC in either GS or PC residents. Residents from both groups perceived time constraints, lack of patient desire, and poor patient compliance to be the main barriers in SCC. CONCLUSION: In this study, many GC residents agreed that physicians were responsible for SCC, but few followed through by arranging SCC follow-up visits compared with their PC resident counterparts. Behavior does not appear to change as residents mature, despite greater exposure to smoking-related diseases. In every dimension of SCC studied, GS residents played a less assertive role when compared with PC residents. GC residents should be more proactive in SCC because the diseases they treat are often related to cigarette smoking.

Adult↗
PubMed1996

Operative experience of U.S. general surgery residents with diseases of the adrenal glands, endocrine pancreas, and other less common endocrine organs.

The aim of this study was to determine if the experience of general surgery residents is adequate and effective. The Resident Statistic Summaries (Report C) of the Residence Review Committee (Surgery) for eight academic years from 1986 to 1994 were analyzed. The main outcome measurements were total number of residents and programs, average number of operations performed, maximum number of operations performed, standard deviation, and the most common number of operations performed. For adrenalectomy, the average per resident was 0.98. The maximum range was from 7 to 15. The standard deviations ranged from 1.12 to 2.00. For pancreatic endocrine operations the average per resident was 0.15 with maximums of 3 to 10. For other endocrine procedures (nonthyroid and nonparathyroid) the average per resident was 0.14, with the maximums ranging from 7 to 19. The most common number of any of these procedures performed by U.S. graduates was 0. The number of adrenal, endocrine pancreas, and other less common endocrine procedures available for graduates of U.S. residency training programs is limited. As a consequence, most U.S. resident graduates have little or no experience with any of these procedures. Our findings suggest a strong need for fellowship training for any surgeon hoping to develop expertise in the management of these unusual and infrequent endocrine surgical diseases.

Adrenal Gland Diseases↗
PubMed2005

[Influence of superspecialization in endocrine surgery on outcomes of thyroidectomy in a general surgery department].

INTRODUCTION: The aim of this study was to analyze the influence of superspecialization in endocrine surgery on the standard of thyroidectomy, both before and after the creation of an endocrine surgery unit. PATIENTS AND METHODS: We performed a retrospective, comparative study of two 7-year periods. Three hundred forty thyroidectomies (G1) were performed before the instauration of the unit, and 583 were carried out afterwards (G2). The variables of age, gender, anesthesia risk, surgeon expertise (staff vs. resident), thyroid function, pathological features, intrathoracic growth, extent of the procedure (unilateral or bilateral), neck drainage, morbidity and mortality and length of hospital stay were compared. RESULTS: Age was older in G2 (G1: 44.7 +/- 15 years old, G2: 48.09 +/- 16.3 years old; p < 0.001). There were no differences (p NS) between the two groups in gender, anesthesia risk, thyroid function or rate of benign/malignant disease, but there was a greater frequency of nodular (p = 0.009) and intrathoracic goiters (p = 0.0004) in the second period. Residents operated on more patients in G2 (p < 0.001). Bilateral thyroidectomy was more frequent in G2 (G1: 155, G2: 315; p = 0.016) as was the rate of total thyroidectomy vs. subtotal or near total thyroidectomy (p < 0.001). Neck drainage also showed statistically significant differences (G1: 75.29%, G2: 12.18%; p < 0.001). No differences were found in overall postoperative complications. Although the procedures used were more aggressive in G2, similar rates of transient asymptomatic hypocalcemia (p NS) and transient symptomatic (p NS) and permanent hypocalcemia were found (G1: 1.17%, G2: 0.68%, p NS). The rate of transitory recurrent laryngeal nerve paralysis was similar with regard to patients (p NS) or nerves at risk (p NS). Permanent inferior laryngeal nerve paralysis was no different regarding patients (p = 0.083) but statistically significant differences were found with regard to nerves at risk (G1: 1.44%, G2: 0.33%; p = 0.04). One patient in G2 died (p NS). Length of hospital stay was shorter in G2 (p < 0.001) and more patients in this group stayed in hospital for only one day (p < 0.001) or were operated on in the outpatient setting (0 versus 71; p < 0.001). CONCLUSIONS: An endocrine surgical unit allows more efficient management of thyroidectomy. It increases the rate of total thyroidectomy, reduces definitive complications and improves training of resident surgeons. In addition, it reduces resource use and allows the development of programs of outpatient thyroid surgery.

Adult↗
PubMed1977

The value of laparoscopy in general surgery.

Fifty-six general surgical patients were evaluated by laparoscopy, primarily for diagnostic problems, ascites or liver assessment for potential metastatic disease. There was minimal morbidity and no mortality from the procedure. Overall laparoscopic accuracy was 87%. In properly selected cases, laparoscopy can often resolve a diagnostic problem, determine the extent of disease and permit initiation of appropriate therapy.

Adenocarcinoma↗
PubMed1988

Evaluation of endoscopy training in a general surgery residency.

To evaluate the gastrointestinal endoscopy training program, a survey of the 33 former chief residents, who finished our program in 1981-1986, was conducted. All 33 graduates responded; 22 graduates are general surgeons, 11 completed or are completing training in a surgical specialty. Eighteen of the 22 general surgeons routinely perform endoscopy in their practice. Graduates in cities with a population greater than 250,000 are as likely to perform endoscopy as the surgeons who live in smaller communities. Ninety one per cent consider endoscopy training to have been an important part of their surgical training. Based on this assessment, endoscopy training is an important part of a general-surgery residency.

Colonoscopy↗
PubMed1991

General surgery with a special interest in vascular surgery: an audit of relative workload.

In a district general hospital (DGH) almost all vascular surgery is provided by general surgeons with a vascular interest and training. There is a growing view, however, that vascular surgeons should be 'pure' to the exclusion of other surgery. In an attempt to define the relationship between general and vascular work in a DGH we have analysed, prospectively, out-patient, in-patient and theatre workload over a three-month period. Eight-hundred-and-forty-four patients (277 new, 567 follow-up) were seen in the clinics. Nine per cent of new vascular referrals and 33 per cent of new general referrals were booked for admission. There were 356 admissions (50 per cent 'emergencies') representing a wide spectrum of general surgery. Elective and emergency vascular cases stayed in hospital for twice and four times longer, respectively, than general patients. Vascular patients represented 26 per cent of the caseload but accounted for 46 per cent of the bed occupancy. Vascular operations made up only 21 per cent of the total theatre caseload (233 procedures) but consumed 34 per cent of theatre time. The vascular unit in a DGH deals with a substantial number and wide variety of general surgical cases. Vascular surgery, however, consumes disproportionately large amounts of out-patient and theatre time and hospital beds. This has implications both for the planning of vascular services and also for the resource allocation within the hospital.

Aged↗
PubMedDate not supplied

Risk factors of morbidity in thyroid surgery: analysis of the last 5 years of experience in a general surgery unit.

The aim of this retrospective study is to analyze the risk factors of morbidity in thyroid surgery. From January 1997 to December 2001, 343 patients (69 males and 280 females, mean age 46.1) who underwent surgery under general anesthesia for thyroid disease were analyzed. In 22 (6.4%) cases the operation was a second thyroidectomy. The mean post-operative stay was 2 days (range: 1-7) and the mean follow-up was 21 months (range: 1-60 months). Statistical analysis of our data was performed by chi-square test and confirmed by Fisher exact test. The statistical analysis showed the significance of malignancy and re-surgery as risk factors of hypoparathyroidism and recurrent laryngeal nerve palsy. Sex, age, and type of operation had no influence on the medical records. The completion of thyroidectomy and histological malignancy increase the morbidity of thyroid surgery.

Adolescent↗
PubMed1996

Preoperative risk assessment in elective general surgery.

Despite improved surgical techniques there is still a risk of mortality in elective general surgery. In a prospective study preoperative data from 3250 patients were collected and compared with postoperative systemic complications, using univariate chi 2 analysis. Highly significant (P < 0.00001) variables were subjected to stepwise logistic regression analysis. The severity of operative procedure, higher American Society of Anesthesiologists (ASA) grade, symptoms of respiratory disease and malignancy were found to be significant risk factors predicting postoperative morbidity (P < 0.05). Using these four variables, a simple preoperative risk scoring system has been defined. Class A (up to 5 points) was defined as a low-risk group (systemic complication rate 5.0 per cent), class B (5-7 points) was intermediate risk (systemic complication rate 17.9 per cent) and class C (8-10 points) was high risk (systemic complication rate 33.3 per cent). Patients at high risk for perioperative and postoperative complications are more likely to be identified by this analysis than by using the ASA classification alone.

Elective Surgical Procedures↗
PubMedDate not supplied

Feeling the stress: perceptions of burnout among general surgery program directors.

PURPOSE: To document the types and levels of stress experienced by general surgery program directors as they fulfill their education and administrative responsibilities. METHODS: This study consisted of a 3-part survey that incorporated 2 established instruments to help determine the presence of burnout in program directors. A personal projects analysis was used to help identify the tasks most relevant to the role of program director as well as to evaluate their perceptions of these tasks. The Maslach Burnout Inventory (MBI) was used to measure the degree of burnout among program directors. Demographic data were gathered to develop a picture of the background of the program directors and how they spent their time. RESULTS: A total of 71.8% of program directors responded. Of all tasks, teaching received the highest ratings for importance, enjoyment, and control, as well as the lowest ratings for stress. Emotional exhaustion was the most notable aspect of burnout in program directors on the MBI. Program directors scoring high in burnout were younger, had been in their current position fewer years, and had fewer years overall as a program director. CONCLUSIONS: Burnout is more related to age and experience of program director than to features of the program itself.

Journal Article↗
PubMed1996

Studies on nutritional status in general surgery patients by clinical, anthropometric, and laboratory parameters.

We assessed the nutritional status of general surgery patients with and without cancer from a western European population in this prospective study. Anamnestic (weight development, abdominal complaints) and anthropometric (fat tissue measurements) data were collected on six groups of patients: cancer of the stomach (n = 13), pancreas (n = 13), colorectal (n = 23), breast (n = 12), and two control groups with benign diseases, ages 20-45 and 50-75 y. From these data, body mass index and ideal body weight were calculated. Concentrations of albumin, transferrin, retinol-binding protein, prealbumin, and creatinine height index were determined by biochemical tests. A weight loss of more than 10% was found in only 31% of gastric and 61% of pancreatic cancer patients. Significant values from anthropometric data were also found only in these groups. In biochemical tests, only the creatinine height index was reduced in all patients with pancreatic cancer. The remaining laboratory changes were so unspecific in all other parameters that no conclusions could be drawn as to the status of the patient's nutritional condition. For the evaluation of nutritional status, only relatively simple and inexpensive anamnestic and anthropometric measurements are necessary.

Adult↗
PubMed1990

[Perioperative hypophosphatemia in general surgery].

Blood phosphorus was measured in consecutive 136 admitted patients in the department of general surgery between Oct. 1987 and Jan. 1988. It was found that 32 cases (23.5%) were with hypophosphatemia on perioperative period. Sixteen patients with normal preoperative blood phosphorus level undergoing digestive tract surgery were randomly divided into 3 groups, each was fasted for 7 days postoperation and given different kind of transfusions. Group 1, patients were given 250 g of glucose daily with no phosphorus, blood phosphorus level was significantly decreased. Group 2, 250 g of glucose with 7.5 mmol of phosphate daily, blood phosphorus level decreased slightly on the 2nd-4th day and returned back to normal on day 7. Group 3,500 g of glucose with 15 mmol of phosphate daily, blood phosphorus level decreased moderately on the 2nd-4th day, and returned to normal level on day 7. Perioperative hypophosphatemia was attributed to: (1) Poor absorption or massive loss of phosphorus through digestive tract. (2) Intracellular transferring of blood phosphorus accompanied by the phosphorylation of saccharide. (3) Excessive excretion of phosphorus through urine. The authors suggested that 7-9 mmol of phosphates per 100 kcal daily for the prevention and 7-15 mmol of phosphates per 1000 kcal daily for the treatment of hypophosphatemia.

Humans↗
PubMed2002

How long do patients wait for elective general surgery?

OBJECTIVE: Because data published on waiting times are largely determined from questionnaire-type surveys, which generate inconclusive opinion-based results, the objective of this study was to provide a quantitative measure of the extent and variance of waiting times among 3 elective general surgery procedures DESIGN: A prospective case study. SETTING: The Royal Alexandra Hospital, Edmonton. PATIENTS: From Feb. 1 to Mar. 15, 1999, all cases (90 patients) for each designated procedure--open or laparoscopic cholecystectomv for biliary colic or cholelithiasis, segmental resection or modified radical mastectomy for breast carcinoma and colon or rectal resection for colorectal carcinoma--were tabulated daily from the hospital elective operating lists. Data were prospectively acquired from individual surgeon offices (11 surgeons). Sixteen of the 90 patients were excluded, leaving 74 for analysis. OUTCOME MEASURES: Time in days from initial referral by the general practitioner to the surgeon (T1), time in days from the initial visit with the surgeon to operation for patients requiring no further diagnostic work-up by the surgeon (T2A), and time in days from the initial visit with the surgeon to operation for patients requiring further diagnostic work-up (T2B). RESULTS: The waiting period for patients who underwent non-cancer-related procedures (cholecystectomy) ranged from 83 to 106 days; patients with breast cancer waited an average of 24 (T1 + T2A) to 66 (T1 + T2B) days from the day of referral to the date of surgery and those with colorectal cancer waited an average of 32 (T1 + T2A) to 51 (T1 + T2B) days from the time of referral to operation (p < 0.05). CONCLUSION: This preliminary report aimed at quantitative measurement of time spent waiting for elective general surgery indicates that patients who underwent non-cancer-related procedures waited significantly longer for their surgery than patients who required procedures for cancer.

Alberta↗
PubMed2003

Incidence of medical error and adverse outcomes on a pediatric general surgery service.

BACKGROUND/PURPOSE: The Institute of Medicine has identified medical error as a leading cause of death and injury, with deaths resulting from medical error exceeding those caused by motor vehicle collisions, breast cancer, or AIDS. The authors examined the incidence and sources of medical error in relation to adverse events on a pediatric general surgery service. METHODS: All intensive care unit (ICU) and ward admissions to 2 staff pediatric general surgeons during a 1-month period were identified prospectively and in-patient care was reviewed daily by a 3-person panel consisting of a staff surgeon, a surgical fellow, and a nonmedical observer. Medical errors, identified through daily patient encounters, nursing rounds, medical rounds, and chart examinations, were evaluated based on type, hospital setting, personnel involved, and outcome. Adverse outcomes were evaluated based on type and contributing factors. RESULTS: Our study group included 64 patients. A total of 108 errors were identified; 28% of these errors resulted in adverse outcomes. One or more medical errors were identified in the care of two thirds of patients (43 of 64), with medical error contributing to adverse outcomes in one third of patients (21 of 64). Errors occurred most frequently in communication, postoperative monitoring and care, and diagnosis, with errors in postoperative care and diagnosis having the highest likelihood of resulting in an adverse outcome. Seventy-four adverse outcomes were identified in 31 patients; 35 (47%) of these outcomes, occurring in 21 patients, were attributable to medical error. The most common adverse outcomes identified were additional nonoperative procedures, of which, 92% resulted from medical error. There were no deaths. CONCLUSIONS: Medical error occurs in more than one half of hospital admissions on a general pediatric surgery service and contributes to a substantial number of adverse outcomes.

Adolescent↗