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PubMed2006

Sub-specialization in general surgery: the problem of providing a safe emergency general surgical service.

BACKGROUND: The increasing subspecialization of general surgeons in their elective work may result in deskilling and create problems in providing expert care for emergency cases. To evaluate the size of the problem this study determined how often complex emergency surgical cases are treated by general surgeons working outside their own elective subspecialty. METHOD: In a district general hospital in the south of the UK serving a population of 550 000 where there is almost complete subspecialization within general surgery, 1554 patients having emergency general surgical operations were studied in a one-year review. The time an operation occurred, the seniority of the operating surgeon, the subspecialty interest of the consultant responsible for the case compared with the specialist nature of the operation was determined. RESULTS: Of 1554 patients having emergency general surgical operations, 23% (352/1554) were of a high category of complexity. Ninety were vascular procedures and were dealt with by specialist vascular surgeons on a separate rota. Of the remaining 262 operations, 78 (30%) did not match the subspecialty of the consultant surgeon responsible for their care; 56 (72%) of these occurred out of hours of which 14 (18%) had a consultant surgeon present and scrubbed in the theatre; one per month of the study. Seventy-three percent (57/78) of these were complex colorectal operations. CONCLUSION: The mismatch between the subspecialist elective interests of the consultant general surgeon and out of hours specialist major surgery needing consultant involvement occurred infrequently, and was mainly due to major lower gastrointestinal cases managed by upper gastrointestinal and breast surgeons. This has important implications for the future training of general surgeons and the provision of an emergency nonvascular general surgical service.

Emergency Service, Hospital↗
PubMed1989

Critical care education in general surgery residencies.

Surgical critical care (SCC) was recently identified as an essential component of general surgery by the American Board of Surgery (ABS). Previous studies have found limited attention to critical care education in general surgery programs. This survey was developed to determine the changes in critical care education, following the emphasis by the ABS. The survey determined the format for SCC education, the time and resources committed, and the views of the program directors toward SCC. Program directors of all 296 approved general surgery residencies were surveyed, with a 79% response. Most program directors (91%) agree that SCC is an essential component of general surgery, and 72% believe a separate intensive care unit (ICU) rotation should be used in SCC education. Education in SCC was provided by a separate ICU service in 110 (47%) of the programs. The remaining 53% used care of patients in the ICU during traditional services as their educational experience. The average ICU rotation for surgery residents was 9 weeks and usually occurred in the second year of training. In 97% of the 110 programs with an ICU service, lectures and conferences were conducted regularly. Seventeen programs sponsored critical care fellowships, and 25 additional programs were considering them. Ninety percent of surgical ICU services had faculty that consisted exclusively of surgeons or surgeons and other specialists. Only 53% of surgeons attending on an ICU service had a reduction in their other responsibilities. Despite overwhelming agreement that critical care is an essential component of general surgery, less than half of the training programs have an ICU service to coordinate resident education in SCC. If surgeons are to continue to provide total care to their patients, there needs to be increased commitment to SCC education.

Critical Care↗
PubMed2001

Doctor-patient communication in surgery: attitudes and expectations of general surgery patients about the involvement and education of surgical residents.

BACKGROUND: Education is a major function of academic medical centers. At these teaching institutions residents provide a substantial amount of care on medical and surgical services. The attitudes of patients about the training of surgical residents and the impact of residents on patients' perceptions of care in a surgical setting are unknown. STUDY DESIGN: Patients admitted to the gastrointestinal surgery service completed a 30-item survey designed for this study. Patients included in the study underwent operations and had a postoperative inpatient hospital stay. We analyzed patients' answers to determine frequency and correlations among answers. RESULTS: Two hundred patients participated in the study during a 7-month period between July 1999 and January 2000. A majority of patients were comfortable having residents involved in their care (86%) and felt it was important to help educate future surgeons (91%). Most did not feel inconvenienced by being at a teaching hospital (71%) and felt they received extra attention there (74%). Patients were more willing to participate in resident education if they expected to have several physicians involved in their care, felt that they received extra attention, or if the teaching atmosphere did not inconvenience them. Despite the stated willingness of patients to help with surgical resident education, 32% answered that they would not want residents doing any of their operation. CONCLUSIONS: Surgical resident education is well received and considered important by patients. Patient orientation to the resident education process is vital to patients' perceptions of care and may render patients more willing to participate in educational activities.

Academic Medical Centers↗
PubMed2002

Minimally invasive surgery training in Canada: a survey of general surgery.

BACKGROUND: The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments. METHODS: A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments. RESULTS: Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5). CONCLUSION: The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

Adult↗
PubMed2005

Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital.

BACKGROUND: Several models that integrate trauma and emergency general surgery (EGS) have been proposed to provide a diverse and challenging operative practice for trauma surgeons and improve recruitment. In July 2002, our institution established a 24/7 EGS consult service, staffed primarily by critical care/trauma surgeons (CCTS). The objective of this report was to evaluate the impact of this new service on CCTS, general surgeons (GS) and the hospital. METHODS: All admissions to CCTS and GS from July 1, 2000 to June 30, 2003 were reviewed by querying hospital and physician databases for demographics, diagnoses, operative intervention(s), and resource utilization. Data were analyzed using nonparametric methods. RESULTS: [See ]. 9,405 admissions were identified, with GS and EGS admissions increasing over time. In July 2002, EGS became a separate service and captured 26% of GS admissions. Hospital-wide trauma admissions remained stable despite a slight decrease in trauma admissions to CCTS. A decrease in trauma operations by CCTS was offset by an increased EGS operative volume. EGS included "bread and butter" GS procedures including appendectomies and cholecystectomies and complex surgical procedures. EGS patients were often sicker with more than 50% requiring ICU admission compared with GS admissions of which only 10% required ICU care.(Table is included in full-text article.) CONCLUSIONS: Departmental restructuring to include an EGS service: 1) increased CCTS volume despite decreased CCTS trauma admissions and operations; 2) increased elective GS volume; 3) generated increased use of ICU and operating room resources; and 4) demonstrated that CCTS with broad operative GS backgrounds and critical care knowledge can effectively staff an EGS service.

Delivery of Health Care, Integrated↗
PubMed2004

Getting residents in the game: an evaluation of general surgery residents' participation in pediatric laparoscopic surgery.

PURPOSE: In a large children's hospital, the authors evaluated general surgery residents' experience with pediatric laparoscopic procedures and the impact of their participation on patient outcome. METHODS: The records of all children who underwent laparoscopic appendectomy, splenectomy, fundoplication, or pyloromyotomy were reviewed. The level of participation by general surgery residents in each of these operations was determined. Outcome was assessed for these procedures in terms of intraoperative and postoperative complications. RESULTS: A resident was the operating surgeon in 164 of 174 laparoscopic appendectomies (94%), 37 of 38 laparoscopic splenectomies (97%), 78 of 104 laparoscopic fundoplications (75%), and 72 of 97 laparoscopic pyloromyotomies (74%). Adverse outcomes in the cases in which a resident was surgeon were limited to 4 postappendectomy infectious complications, 3 cases of recurrent reflux after fundoplication, and one incomplete myotomy and one mucosal injury after laparoscopic pyloromyotomy. CONCLUSIONS: The authors have shown that well-supervised general surgery residents can perform common, pediatric laparoscopic operations with excellent results. Although it is essential for established pediatric surgeons and fellows in pediatric surgery to acquire expertise in minimally invasive surgery, once they have confidence in their own skills they may safely permit qualified general surgery residents to perform laparoscopic procedures in children.

Child↗
PubMed1995

Calculating the workforce in general surgery.

OBJECTIVE: To provide a reasonable estimate of the patient care and resident physician workforce practicing general surgery in 1994. DESIGN: Data regarding general surgical residents and practicing general surgeons were obtained from four sources and compared with previously published numbers. DATA SOURCES: Information was derived from the American College of Surgeons' Longitudinal Study of Surgical Residents: 1992-1993; the American Medical Association's Physician Characteristics and Distribution in the United States, 1994 Edition; the American Board of Medical Specialties' database on general surgeons; and the American Board of Surgery recertification data from the files of diplomates since 1968. Each of these sources was analyzed separately to derive a count of graduates from general surgery residency programs and an estimate of fully trained general surgeons engaged in patient care activities. RESULTS: We found that approximately 600 graduates of general surgery residency programs enter the practice of general surgery each year, and we found a close correlation between maximum and minimum estimates of the number of fully trained general surgeons engaged in active patient care, certified general surgeons who are not retired, and currently certified general surgeons. This number (17,289 to 23,502) is approximately half that commonly used in calculations of the general surgery workforce (38,239). The larger number includes surgeons with subspecialty training beyond general surgery, surgical residents, and surgeons not engaged in patient care. CONCLUSIONS: Estimations of the workforce in general surgery and predictions of future needs for general surgeons must be derived from the appropriate number of general surgery residents and practicing general surgeons.

Career Choice↗
PubMed1977

Recent advances in general surgery.

In order to give an overview of recent advances in general surgery, it is necessary to define: (i) what is general surgery; (ii) what is recent; and (iii) what constitutes an advance. General surgery appears to have entered an era of conservatism. This is particularly evident in the surgery of breast cancer, peptic ulceration, varicose veins, liver trauma, portal hypertension, upper gastrointestinal bleeding, and hiatal hernia. Controlled clinical trials in surgery have become popular. The following are considered to be advances: parenteral nutrition, suction drainage, control of Gram-negative sepsis, bypass surgery for pathological obesity, and a discriminatory approach to transplant surgery.

Anti-Bacterial Agents↗
PubMed1982

[Peridural anesthesia and analgesia results in general surgery].

Anesthesia for major general surgery should involve the use of anesthetic techniques that might reduce the risk of intraoperative and postoperative complications. The combination of intraoperative epidural anesthesia with local anesthetics (EPA) and the use of epidural opiates for postoperative pain relief shows advantages over the application of pure general anesthesia and over postoperative systemic analgesia. Epidural opiates lead to better quality analgesia with a quicker onset and longer duration than systemical analgesics. The spirographic parameters of ventilatory function PF, FVC, FEV [1], paO2, and paCO2 decreased significantly (p less than 0.05) compared with preoperative values when systemic analgesia was performed. After epidural opiates no significant decrease could be seen. Intraoperative use of EPA has the advantages of better hemodynamic conditions and a blockade of the endocrine-metabolic response to surgery. Postoperative peridural opiates block the endocrine response as well: the serum levels of ADH and cortisol are lower than under systemic analgesia.

Anesthesia, Epidural↗
PubMed1996

Retirement age and the work force in general surgery.

OBJECTIVE: This study examines the age of retirement of general surgery Fellows of the American College of Surgeons from 1984 through 1995 and analyzes the potential effect on the work force in general surgery of age of retirement. SUMMARY BACKGROUND DATA: Data from the Fellowship files of the American College of Surgeons, the American Board of Medical Specialties, and the American Medical Association disclosed that the number of practicing general surgeons in the United States in 1994 was between 17,289 and 23,502, or approximately 7 general surgeons per 100,000 population in the United States. METHODS: The Fellowship files of the American College of Surgeons from 1984 through 1995 were searched for general surgeons who had written to ask for retirement status or who had died before retirement. Calculations were made of the effect of years in practice on the total general surgeon work force. All living retirees from 1984 to 1985 and 1994 to 1995 were questioned to learn the factors leading to a decision to retire. RESULTS: The average age of retirement for general surgeon Fellows has risen from 60.45 in 1984 to 62.97 in 1995. Because of increasing diversion of general surgery graduates into surgical specialties, total practice years are declining despite increasing length of practice time. The principal factors for retirement decisions in 1984 and 1985 were disability (26%), leisure time (20%), and unfavorable changes in surgery (29%). In 1994 and 1995, disability was a major factor in 14% of decisions, leisure time in 20%, and unfavorable changes in surgery in 56%. CONCLUSIONS: Fewer general surgeons enter the work force each year. Thus, despite working longer, the total number of years practiced by each cohort of new general surgeons has decreased.

Age Factors↗
PubMed1991

Training, credentialling, and granting of clinical privileges for laparoscopic general surgery.

Despite the lack of scientific data comparing it with traditional open operations, laparoscopic surgery has gained rapid acceptance and implementation by general surgeons. Individual hospitals, which have the responsibility for developing their own privileging criteria, are searching for guidance as to the amount and type of additional training required to grant clinical privileges in laparoscopic general surgery. Laparoscopic surgery involves techniques different from those learned during general surgery residency training. Therefore, until such techniques are regularly included in general surgery residency programs, additional training for and granting of separate privileges in laparoscopic surgery are appropriate. Adequate training for surgeons already experienced in abdominal and biliary tract surgery can be acquired through a preceptorship in diagnostic laparoscopy, attending a course in laparoscopic surgery that includes both didactic instruction and live animal experience, assisting with the procedures in humans, and being proctored and certified as competent by an experienced general surgeon.

Animals↗
PubMed2002

Contemporary trends in student selection of medical specialties: the potential impact on general surgery.

HYPOTHESIS: Lifestyle is a priority among senior medical students when selecting a career specialty. The trend toward controllable lifestyle vs noncontrollable lifestyle specialties is affecting the number of students desiring a career in general surgery. DESIGN: The Medical Student Graduation Questionnaire is published and distributed by the Association of American Medical Colleges to all US medical schools for senior medical students to complete before graduation. The results from the survey are published each year in the All Schools Report. We evaluated these reports to track the percentage of students pursuing a career in general surgery during the past decade. The National Resident Matching Program also publishes a report each year outlining the match results. We reviewed these results from 1978 through 2001 and used them to determine the percentage of students choosing to enter general surgery. MAIN OUTCOME MEASURES: First choice of specialty among graduating senior students from US medical schools; positions matched by US and foreign medical students and students from osteopathic medical schools; factors that influenced the decision-making process in choice of specialty; and factors that influenced students to change their mind from one career to another. RESULTS: An established trend of decreasing interest in general surgery exists and has the potential to affect the number of positions that are filled each year in the match. Linear projections confirm that, should the current trend continue (negative slope; P =.01), by 2005 only 4.8% of US graduating senior medical students will be interested in general surgery. This established trend of decreasing interest in general surgery, which began in the early 1980s, did not affect the match until 2001, when the number of positions offered exceeded the number of students interested in general surgery. At present, the specialty of general surgery is at risk for significant numbers of positions remaining unfilled. Our match projections estimate that for 2005, only 76.6% of positions will be filled by US senior students (negative slope; P =.001). CONCLUSIONS: If the trend continues, the students matching in general surgery will not be as competitive as in years past, and there will be a potential shortage of these specialists in the United States.

Career Choice↗
PubMed1990

Lasers in general surgery.

Laser use in general surgery has become more popular in the past few years. The contact Nd:YAG laser returns tactile sensation to the surgeon and is used successfully to cut and coagulate during breast, colorectal, and biliary procedures.

Cholecystectomy↗
PubMed1998

Critical assessment of the head and neck clinical skills of general surgery residents.

Head and neck surgery is an important part of general surgery. There is, however, little information about the quality of residents' clinical skills in this important field. In an Objective Structured Clinical Examination (OSCE), residents encounter multiple patients with various clinical problems and are rated by faculty members using objective criteria. This study was undertaken to assess the head and neck surgery skills of a group of general surgical residents. Fifty-one general surgery residents examined the same nine patients with head and neck disease. Faculty members graded each clinical interaction according to preset objective criteria. Both actual (e.g., thyroid nodule, oral cancer follow-up examination) and simulated (e.g., dysphagia) patients were used in the OSCE. The reliability of the examination was assessed by coefficient alpha. The construct validity was determined by a two-way analysis of variance with one repeated measure. The reliability was 0.75 for the clinical examination. Performance varied by level of training: Residents performed at a higher level than interns (p < 0.0001), but overall scores were poor (mean score 55%). Important deficits in skills were identified at all levels of training. It is concluded that more attention should be focused on specific outcome assessments of surgical training programs and on strategies for upgrading the clinical skills of surgical residents.

Analysis of Variance↗
PubMed2003

Do the best students go into general surgery?

BACKGROUND: Recent match trends by medical graduates have revealed a declining interest in general surgery. Our study evaluates the academic strength of recent graduates to determine the quality of those matching to general surgery residencies. METHODS: All third-year students rotating through the 8-week surgical clerkship from July 1998-June 2000 (n = 291) were followed at the University of Wisconsin Medical School. Each student completed 4 weeks of general surgery and 4 weeks of surgical subspecialties. Match data provided residency choices and students were divided into general surgery (GS), surgical subspecialty (SS), and nonsurgical (NS) residencies. Student performance was based upon National Board of Medical Experiences (NBME) surgery exam, class rank and Alpha Omega Alpha (AOA) status. RESULTS: Students at our institution scored at the national mean on the NBME exam. GS team, session, and timing of GS rotation had no relationship to exam score. Total number of operative cases observed was inversely related to exam performance (P = 0.02). Of students entering a GS career, most scored below the mean on the NBME exam, 46% graduated in the bottom two thirds of the class, and only 6% of AOA members entered a GS residency. CONCLUSION: Although many of the strongest medical students select surgical residencies, they choose to enter SS careers and not GS careers.

Career Choice↗