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PubMed1998

The surgeon as a risk factor for complications of midline incisions.

OBJECTIVE: To compare among surgeons the risk-adjusted rates of wound infection and incisional hernia after midline incisions. DESIGN: Prospective clinical study. SETTING: County hospital, Sweden. SUBJECTS: 1013 patients who underwent midline laparotomy between August 1989 and June 1993. INTERVENTIONS: Wounds were sutured by a continuous technique and details of patients and operations were recorded. The suture technique was monitored by the suture length:wound length ratio. MAIN OUTCOME MEASURES: . Postoperative wound infection, and incidence of incisional hernia at 12 months. RESULTS: The details of patients and operations varied significantly among surgeons. Senior surgeons sutured with a lower suture length:wound length ratio than juniors (mean (SD) 4.1 (1.4) compared with 5.3 (2.1), p < 0.01). The individual rates of wound infection varied from 0 to 27% (mean 10%) and that of incisional hernia from 5% to 26% (mean 15%). After correction for patient selection three surgeons had significantly higher rates of wound infection and one significantly lower than the others, two surgeons had significantly higher rates of incisional hernia and two significantly lower. Only one surgeon differed significantly in the rate of incisional herniation after also adjusting for the suture technique. The length of surgical experience did not affect the rate of wound complications. CONCLUSION: The suture technique, monitored by the SL:WL ratio, is the most important factor for variability in the incidence of incisional hernia among surgeons in continuously sutured midline incisions. The suture technique may also help to explain the variability in rates of wound infection.

Clinical Competence↗
PubMed2006

Comparison of sensorineural symptoms between UK orthopaedic surgeons and gynaecologists.

BACKGROUND: We have previously described significant differences in self-reported neurological symptoms of orthopaedic surgeons when compared to a group of gynaecologists. We suggested that this may be secondary to occupational sources of hand-transmitted vibration. The original study was intentionally brief and failed to address potential confounders. AIMS: To compare the prevalence of sensorineural symptoms between UK orthopaedic surgeons and gynaecologists and adjust for potential confounding factors. METHODS: Postal questionnaires were sent to 2040 members of the British Orthopaedic Association and 1797 members of the Royal College of Gynaecologists requesting information about demographics and self-reported neurological symptoms. Demographics of the orthopaedic surgeons and gynaecologists were compared using chi-squared tests and independent t-tests. Multiple logistic regressions were carried out to compare the prevalence of symptoms while adjusting for potential confounding factors. RESULTS: Differences in the demographic profile of the orthopaedic surgeons and gynaecologists were identified: orthopaedic surgeons were predominantly male, were more junior in grade, were younger, used double gloving more often, had larger glove size, were more likely to be ambidextrous, to use vibrating tools outside of work and to consume greater amounts of alcohol. Orthopaedic surgeons reported a higher prevalence of tingling and numbness of fingers while at work and at other times. These differences were significant even after adjusting for potential confounding factors. CONCLUSION: Observed differences could be related to exposure to hand-transmitted vibration at work. Further assessment of risk to orthopaedic surgeons from hand-held power tools used in the course of their work is recommended.

Adult↗
PubMed2001

Defining the optimal surgeon experience for breast cancer sentinel lymph node biopsy: a model for implementation of new surgical techniques.

OBJECTIVE: To determine the optimal experience required to minimize the false-negative rate of sentinel lymph node (SLN) biopsy for breast cancer. SUMMARY BACKGROUND DATA: Before abandoning routine axillary dissection in favor of SLN biopsy for breast cancer, each surgeon and institution must document acceptable SLN identification and false-negative rates. Although some studies have examined the impact of individual surgeon experience on the SLN identification rate, minimal data exist to determine the optimal experience required to minimize the more crucial false-negative rate. METHODS: Analysis was performed of a large prospective multiinstitutional study involving 226 surgeons. SLN biopsy was performed using blue dye, radioactive colloid, or both. SLN biopsy was performed with completion axillary LN dissection in all patients. The impact of surgeon experience on the SLN identification and false-negative rates was examined. Logistic regression analysis was performed to evaluate independent factors in addition to surgeon experience associated with these outcomes. RESULTS: A total of 2,148 patients were enrolled in the study. Improvement in the SLN identification and false-negative rates was found after 20 cases had been performed. Multivariate analysis revealed that patient age, nonpalpable tumors, and injection of blue dye alone for SLN biopsy were independently associated with decreased SLN identification rates, whereas upper outer quadrant tumor location was the only factor associated with an increased false-negative rate. CONCLUSIONS: Surgeons should perform at least 20 SLN cases with acceptable results before abandoning routine axillary dissection. This study provides a model for surgeon training and experience that may be applicable to the implementation of other new surgical technologies.

Breast Neoplasms↗
PubMed1998

Impact of trauma attending surgeon case volume on outcome: is more better?

OBJECTIVE: To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. METHODS: The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. RESULTS: There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. CONCLUSIONS: Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.

Emergencies↗
PubMed1999

Surveyed opinion of American trauma surgeons on the prevention of the abdominal compartment syndrome.

OBJECTIVE: To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS). METHODS: On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing fascial closure at trauma celiotomy, surgeons graded their willingness to close the fascia in various scenarios on a scale of 1 to 5. The impact of six signs of clinical deterioration on willingness to perform abdominal decompression in a patient with postceliotomy elevated intra-abdominal pressure (IAP) was also queried. Of 292 members of the American Association for the Surgery of Trauma active in abdominal trauma management, 248 members (85%) had experience with ACS one or more times in the previous year. RESULTS: Surgeons' responses to factors found at trauma celiotomy were divided into two distinct categories: factors decreasing willingness to close the fascia, and factors not changing or increasing willingness to close the fascia (p < 0.001). Factors disfavoring fascial closure were pulmonary or hemodynamic deterioration with closure, massive bowel edema, subjectively tight closure, planned reoperation, and packing. Factors not changing or favoring fascial closure were fecal contamination/peritonitis, massive transfusion, hypothermia, multiple abdominal injuries, acidosis, and coagulopathy. Five of the six signs of clinical deterioration increased surgeons' willingness to decompress a patient with elevated IAP (increased O2 requirement, decreased cardiac output, increased acidosis, increased airway pressures, and oliguria). Lowered gastric mucosal pH did not affect willingness. Seventy-one percent of surgeons indicated they would decompress elevated IAP in postceliotomy patient if one or two signs of clinical deterioration were present, but only 14% would decompress a patient for elevated IAP alone. CONCLUSION: A majority of expert American trauma surgeons have experience with ACS and would leave the abdomen open if ACS occurred. A majority would reopen a closed abdomen in cases of elevated IAP with signs of clinical deterioration. A minority would leave the abdomen open when there was only a risk of developing ACS.

Abdominal Injuries↗
PubMed1995

Diffusion of laparoscopic cholecystectomy among general surgeons in the United States.

Introduced in 1989, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic gallstones. This study describes the diffusion of laparoscopic cholecystectomy among general surgeons; assesses the importance of various reasons for surgeons adopting the procedure; and examine the influence of surgeon, practice, and health care market characteristics on the timing of adoption. The data were obtained from a survey of a national sample of surgeons. Most surgeons (81%) adopted laparoscopic cholecystectomy by early 1992. More than three fourths of adopters identified the desire to keep up with the state-of-the-art and improved patient outcomes as very or extremely important reasons for adoption. Results of proportional hazards regression analysis indicate that individual surgeons' adoption behavior generally was consistent with expected utility maximization in an uncertain new technological environment. Of particular interest, fee-for-service payment and more competitive practice settings and markets were associated with earlier adoption. These findings suggest that the "technological imperative" and surgeons' perception of the relative clinical and financial advantages of laparoscopic cholecystectomy were important reasons for the rapid diffusion of laparoscopic cholecystectomy. Policies that accelerate current trends toward payment of physicians based on salary or capitation and promote the growth of multispecialty group practice could slow the diffusion of new physician-based product innovations in health care.

Adult↗
PubMed1997

Plastic surgeons: a gender comparison.

This study surveyed plastic surgeons for the purpose of identifying gender-related differences within the specialty. A confidential 108-item questionnaire was mailed to all female members and candidates of the American Society of Plastic and Reconstructive Surgeons (ASPRS) and to an equal number of male colleagues. The survey was conducted between September of 1992 and October of 1993 using a modified Dillman five-step computerized method. The response rate was 73 percent for women (157 of 216) and 57 percent for men (124 of 216). Of those who responded, 65 percent of women and 89 percent of men were married (p < 0.01). Fifty-two percent of women and 86 percent of men had biologic children (p < 0.001). The majority of surgeons surveyed (97 percent) were in full-time surgical practice. Many women reported delaying childbearing until they had begun full-time practice of plastic surgery (p < 0.001). No significant gender-related differences were noted with respect to medical school rank, training history, advanced degrees, subspecialty practiced, hospital affiliation, or hours worked. Women surgeons in academic practice held lower rank than men and were less likely to be tenured (p < 0.04). Gross annual income was lower for women (p < 0.001). In contrast to men (27 percent), most women (89 percent) perceived sexual discrimination and harassment (p < 0.001). The majority of plastic surgeons were satisfied with their financial situation (80 percent), work (94 percent), and family life (76 percent). Over 90 percent of both women and men were happy with their career choice and would encourage medical students to become surgeons. Plastic surgeons do not differ in training or professional practice characteristics. Discrimination and harassment and unequal promotion and remuneration of women in the university environment are problems that need to be eliminated.

Adult↗
PubMed1997

A comparison of surgeon's assessment to patient's self analysis (short form 36) after far lateral lumbar disc surgery. An outcome study.

STUDY DESIGN: Between 1984 and 1994, 170 patients had surgery for far lateral discs. Patients were assessed by the surgeon as having poor (no improvement, increased deficit), fair (mild improvement, moderate residual deficit), good (moderate improvement, mild residual deficit) or excellent (marked improvement, no deficit) physical outcomes. The Medical Outcome Trust's SF-36 survey was completed by 76 (45%) patients, using one interviewer. OBJECTIVES: Patient-based outcome studies are becoming increasingly important. A surgeon's assessment of outcome was compared with the patients' self assessment (Short Form 36) after far lateral lumbar disc surgery. SUMMARY OF BACKGROUND DATA: The SF-36 survey provides measures on eight dimensions: physical function, role physical, bodily pain, general health, vitality, social function, role-emotional, and mental health. METHODS: Patients averaged 60.1 years of age, and included 43 men and 33 women. Patients were last examined an average of 9.1 months after their surgery, and were interviewed by telephone an average of 2.8 years later. RESULTS: Patients completing the survey were evaluated on their last visit to the surgeon as having excellent (32 patients), good (24), fair (12), and poor (8) outcomes. Overall correlations between the surgeon's assessment and all 76 patients' SF-36 scores were modest. However, for those patients examined within 4.5 years of the surgeon's assessment (n = 56), correlations were statistically significant for 6 of the SF-36 measures. Only general health and social function showed correlations less than 0.25. CONCLUSIONS: The surgeon's assessment was a particularly good predictor of SF-36 measures if the surgeon assessed the patient within the past 4.5 years. The SF-36 should be useful for large-scale outcome studies.

Aged↗
PubMed1999

William Cheselden: anatomist, surgeon, and medical illustrator.

William Cheselden was Great Britain's foremost surgeon/scientist in the first half of the 18th century. Cheselden directly challenged the Company of Barber-Surgeons' exclusive right to control dissection in London by being the first to conduct a regular series of anatomy lectures and demonstrations outside of the Company's Hall. He incorporated his lecture syllabus into a handbook of anatomy, The Anatomy of the Humane Body, which was used by students for nearly 100 years. Cheselden also wrote the text and drew the illustrations for a majestic atlas of comparative osteology, the Osteographia, or the Anatomy of the Bones. Cheselden used his superior knowledge of anatomy to reduce the morbidity and mortality associated with perineal lithotomy, one of the few operations possible in his era. Sagacious and pragmatic, Cheselden recognized that the enlightened practice of surgery beginning to take root in 18th-century London could flourish only under an autonomous body of surgeons. Cheselden used his personal funds and political skills to urge Parliament to pass legislation for the dissolution of the combined Company of Barber-Surgeons and the establishment of separate and distinct Surgeons' and Barbers' Companies. After disjoinder of the two groups on May 2, 1745, Cheselden served as one of the Wardens of the new Company of Surgeons--a predecessor of the Royal College of Surgeons of England. In 1746, Cheselden, who helped design the first Surgeons' Hall, served as the Company's Master.

Anatomy↗
PubMed2000

Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion.

STUDY DESIGN: In vitro study to determine occupational radiation exposure during lumbar fluoroscopy. OBJECTIVES: To assess radiation exposure to the spine surgeon during fluoroscopically assisted thoracolumbar pedicle screw placement. SUMMARY OF BACKGROUND DATA: Occupational radiation exposure during a variety of fluoroscopically assisted musculoskeletal procedures has been previously evaluated. No prior study has assessed fluoroscopy-related radiation exposure to the spine surgeon. METHODS: Bilateral pedicle screw placement (T11-S1) was performed in six cadavers using lateral fluoroscopic imaging. Radiation dose rates to the surgeon's neck, torso, and dominant hand were measured with dosimeter badges and thermolucent dosimeter (TLD) rings. Radiation levels were also quantified at various distances from the dorsal lumbar surface using an ion chamber radiation survey meter. RESULTS: The mean dose rate to the neck was 8.3 mrem/min. The dose rate to the torso was greatest when the surgeon was positioned ipsilateral to the beam source (53.3 mrem/min, compared with 2.2 mrem/min on the contralateral side). The average hand dose rate was 58.2 mrem/min. A significant increase in hand dose rate was associated with placement of screws ipsilateral to the beam source (P = 0.0005) and larger specimens (P = 0.0007). Radiation levels significantly decreased as distance from the beam source and dorsal body surface increased. The greatest levels of radiation were noted on the side where the primary radiograph beam entered the cadaver. CONCLUSION: Fluoroscopically assisted thoracolumbar pedicle screw placement exposes the spine surgeon to significantly greater radiation levels than other, nonspinal musculoskeletal procedures that involve the use of a fluoroscope. In fact, dose rates are up to 10-12 times greater. Spine surgeons performing fluoroscopically assisted thoracolumbar procedures should monitor their annual radiation exposure. Measures to reduce radiation exposure and surgeon awareness of high-exposure body and hand positions are certainly called for.

Bone Screws↗
PubMed2003

The efficacy of anterior spine exposure by an orthopedic surgeon.

This retrospective study was designed to document the incidence and types of perioperative complications that occurred with anterior spinal fusion surgery performed solely by an orthopedic spine surgeon. This study is contrasted to previous studies that document complications from anterior approaches performed by an orthopedic surgeon with the assistance of a general or a vascular surgeon. Specifically, the procedures included thoracotomies, thoracolumbar retroperitoneal, and lumbosacral approaches. Our sample consisted of 450 patients who underwent anterior spinal fusion between levels T1 and S1, from 1985 to 1997. Patient and surgery characteristics included age, sex, diagnosis, levels of fusion, blood loss, operative time, hospitalization time, complications, American Society of Anesthesiologists state, assessment of risk factors, previous surgery, and surgical approach used. Average follow-up was 41.69 months, with a minimum of 12 months and a maximum of 132 months. Our results indicated that anterior procedures performed solely by our senior orthopedic surgeon had a lower incidence of complications, less blood loss, and shorter operative time than anterior procedures performed by an orthopedic surgeon and a vascular or a general surgeon. Our findings suggest that the anterior spinal exposure is a safe approach that may be performed solely by a spinal surgeon who is knowledgeable and experienced.

Abdomen↗
PubMed2004

A systematic review and critique of the literature relating hospital or surgeon volume to health outcomes for 3 urological cancer procedures.

PURPOSE: We performed a systematic review and critique of the literature of the relationship between hospital or surgeon volume and health outcomes in patients undergoing radical surgery for cancer of the bladder, kidney or prostate. MATERIALS AND METHODS: Four electronic databases were searched to identify studies that describe the relationship between hospital or surgeon volume and health outcomes. RESULTS: All included studies were performed in North America. A total of 12 studies were found that related hospital volume to outcomes. For radical prostatectomy and cystectomy all 8 included studies showed improvement in at least 1 outcome measure with increasing volume and never deterioration. For nephrectomy the 4 included studies produced conflicting results. Four studies were found that related surgeon volume to outcomes. All radical prostatectomy and cystectomy studies showed that some outcomes were better with higher surgeon volume and never deterioration. We did not find any studies of the effect of surgeon volume on outcomes after nephrectomy. The 3 studies of the combined effect of hospital and surgeon volume on outcomes after radical prostatectomy or cystectomy suggest that high volume hospitals have better outcomes, in part because of the effect of surgeon volume and vice versa. CONCLUSIONS: Outcomes after radical prostatectomy and cystectomy are on average likely to be better if these procedures are performed by and at high volume providers. For radical nephrectomy the evidence is unclear. The impact of volume based policies (increasing volume to improve outcomes) depends on the extent to which "practice makes perfect" explains the observed results. Further studies should explicitly address selective referral and confounding as alternative explanations. Longitudinal studies should be performed to evaluate the impact of volume based policies.

Cystectomy↗
PubMed2006

The association between breast surgeons' attitudes toward breast reconstruction and their reconstruction-related information-giving behaviors: a nationwide survey in Japan.

BACKGROUND: Breast reconstruction after breast cancer surgery has come to be regarded as an achievable treatment option to improve patients' quality of life. Although it has been pointed out that surgeons' information-giving behaviors affect women's decision to undergo breast reconstruction surgery, little is known about the factors that influence these behaviors. This study investigated Japanese surgeons' reconstruction-related information giving to patients and the factors that affect these behaviors. METHODS: A nationwide postal survey of 1313 board-certified Japanese breast surgeons was conducted. In the questionnaire, surgeons were asked about their reconstruction-related information-giving behaviors and their attitudes toward six hypothetical critical statements regarding breast reconstruction. RESULTS: Among 635 responding surgeons, 199 (31.3 percent) answered that they did not give reconstruction-related information at all when explaining breast cancer treatment options, and 291 (45.8 percent) stated that they selectively choose patients with whom they provide information based on patients' backgrounds such as age and marital status. Results from the multiple logistic regression analysis indicated that respondents who agreed to the statements "Breast reconstruction may delay the detection of local recurrence," "The aesthetic results of reconstructed breasts are not worth the cost and effort involved," "Breast reconstruction is a luxury," and "Surgeons should pursue breast conserving surgery rather than breast reconstruction" showed significantly decreased likelihood to give reconstruction-related information to patients. CONCLUSION: Surgeons need to be aware of the adverse effect that their own attitudes and values with regard to breast reconstruction may have on a patient's ability to choose treatment options.

Adult↗
PubMed2005

Sentinel node skills verification and surgeon performance: data from a multicenter clinical trial for early-stage breast cancer.

OBJECTIVE: Marked variations in sentinel lymph node dissection (SLND) technique have been identified, and definitive qualifications for SLND performance remain controversial. Based on previous reports and expert opinion, we predicted that 20 to 30 cases of SLND with axillary lymph node dissection (ALND) would enable surgeons to identify sentinel lymph nodes (SLN). SUMMARY BACKGROUND DATA: In 1999, the American College of Surgeons Oncology Group initiated a prospective trial, Z0010, to evaluate micrometastatic disease in the SLN and bone marrow of women with early-stage breast cancer. Eligible patients included women with biopsy-proven T1/T2 breast cancer and clinically negative lymph nodes who were candidates for lumpectomy and SLND. METHODS: Participating surgeons were required to document 20 to 30 SLNDs followed by immediate ALND with failure rates less than 15%. Prior fellowship or residency training in SLND provided exemption from skill requirements. Data for 5237 subjects and 198 surgeons were available for analysis. RESULTS: Surgeons from academic (48.4%), community (28.6%), or teaching-affiliated (19.8%) institutions qualified with 30 SLND + ALND cases (64.6%), 20 cases (22.2%), or exemption (13.1%). Participants used blue dye + radiocolloid in 79.4%, blue dye alone in 14.8%, and radiocolloid alone in 5.7% of cases, achieving a 98.7% SLN identification rate. Patient factors associated with increased SLND failure included increased body mass index and age, whereas tumor location, stage, and histology, presence of nodal metastases, and number of positive nodes were not. Surgeon accrual of fewer than 50 patients was associated with increased SLND failure; however, SLND technique, specific skill qualification, and institution type were not. CONCLUSIONS: Using a standard skill requirement, surgeons from a variety of institutions achieved an acceptably low SLND failure rate in the setting of a large multicenter trial, validating the incorporation of SLND into clinical practice.

Adult↗
PubMed2005

A 25-year single institution analysis of health, practice, and fate of general surgeons.

OBJECTIVE: The objective of this study was to analyze nearly 3 decades of surgical residents from an established training program to carefully define individual outcomes on personal and professional health and practice satisfaction. SUMMARY BACKGROUND DATA: A paucity of data exists regarding the health and related practice issues of surgeons post-residency training. Despite several studies examining surgeon burnout and alcohol dependency problems, there have been no detailed reports defining health problems in practicing surgeons or preventive health patterns in this physician population. Important practice factors, including family and practice stress, that may impact on surgical career longevity and satisfaction have similarly received minimal focused examination. METHODS: All former surgery residents at the University of Wisconsin from 1978 to 2002 were contacted. Detailed direct interview or phone contact was made to ensure confidentiality and to obtain reliable data. Interviews concentrated on serious health and practice issues since residency completion. RESULTS: One hundred ten of 114 (97%) former residents were contacted. There were 100 males and 14 females with 2 deaths (accident, suicide). Including deaths and those lost to follow up, 15 (13.2%) were non-practicing; 5 voluntarily (3 planned, 1 accident, 1 arthritis) and 4 involuntarily (alcohol/substance dependency). Eighty-nine percent were married or remarried with a 21.4% divorce rate post-residency. Major health issues occurred in 32% of all surveyed and in 50% of those ages > or =50. Only 10% reported complete lack of weekly exercise activity with 62% exercising at least 3 times per week. Body mass index increased from 23.9 +/- 1.5 kg/m (age <40) to 26.6 +/- 3.0 kg/m (P = 0.009) by age > or =50. Alcohol dependency was confirmed in 7.3%. Overall, 75% of surgeons surveyed were satisfied with their practice/career. CONCLUSION: Despite a high job satisfaction rate, surgeon health may be compromised in up to 50% by age > or =50, with a 20% voluntary or involuntary retirement rate. Alcohol dependency occurred in up to 7.3% of surgeons, which contributed to the practice attrition rate. The success and length of a career in surgery is defined by post-residency factors rarely examined during training and include major and minor health issues, preventive health patterns/exercise, alcohol use or dependency, family life, and practice satisfaction. Surgeons mentoring during the course of surgical training should be improved to inform of important health and practice issues and consequences.

Adult↗
PubMed2006

The impact of the 80-hour resident workweek on surgical residents and attending surgeons.

OBJECTIVE: To assess the impact of the 80-hour resident workweek restrictions on surgical residents and attending surgeons. SUMMARY BACKGROUND DATA: The ACGME mandated resident duty hour restrictions have required a major workforce restructuring. The impact of these changes needs to be critically evaluated for both the resident and attending surgeons, specifically with regards to the impact on motivation, job satisfaction, the quality of surgeon training, the quality of the surgeon's life, and the quality of patient care. METHODS: Four prospective studies were performed at a single academic surgical program with data collected both before the necessary workforce restructuring and 1 year after, including: 1) time cards to assess changes in components of daily activity; 2) Web-based surveys using validated instruments to assess burnout and motivation to work; 3) structured, taped, one-on-one interviews with an external PhD investigator; and 4) statistical analyses of objective, quantitative data. RESULTS: After the work-hour changes, surgical residents have decreased "burnout" scores, with significantly less "emotional exhaustion" (Maslach Burnout Inventory: 29.1 "high" vs. 23.1 "medium," P = 0.02). Residents have better quality of life both in and out of the hospital. They felt they got more sleep, have a lighter workload, and have increased motivation to work (Herzberg Motivation Dimensions). We found no measurable, statistically significant difference in the quality of patient care (NSQIP data). Resident training and education objectively were not statistically diminished (ACGME case logs, ABSITE scores). Attending surgeons perceived that their quality of their life inside and outside of the hospital was "somewhat worse" because of the work-hour changes, as they had anticipated. Many concerns were identified with regards to the professional development of future surgeons, including a change toward a shift-worker mentality that is not patient-focused, less continuity of care with a loss of critical information with each handoff, and a decrease in the patient/doctor relationship. CONCLUSION: Although the mandated restriction of resident duty hours has had no measurable impact on the quality of patient care and has led to improvements for the current quality of life of residents, there are many concerns with regards to the training of professional, responsible surgeons for the future.

Burnout, Professional↗
PubMed1995

Inguinal hernia repair by laparoscopic surgeons: early experience and attitudes.

The introduction of laparoscopic inguinal hernia repair (LIHR) has been controversial. A questionnaire was sent to all general surgeons in New Zealand to document the early experience with LIHR and attitudes towards it. Of the 118 replies (response rate 55%), 74 were from laparoscopic surgeons, 26 of whom had performed 564 (201 public, 363 private) LIHR (23 bilateral) until January 1994. Only nine (35%) of these surgeons had assisted an experienced surgeon before performing an LIHR, and only four (15%) were supervised by an experienced surgeon during their first case. The transabdominal preperitoneal technique of LIHR was used by 14 (54%) surgeons, the extraperitoneal technique by eight (31%), and the transabdominal onlay technique by four (15%). There were 29 (5%) recurrences, 17 (3%) neuropathies, seven (1.2%) conversions, four (0.7%) major perforations, and one (0.17%) death. Of the 26 surgeons who performed LIHR, 20 (77%) were concerned about the absence of long-term results, 14 (54%) considered that the optimal technique had not been established, 13 (50%) were concerned about the unique complications associated with LIHR, 11 (42%) were less enthusiastic about performing LIHR than previously, 10 (38%) were doubtful about its advantages, and six (23%) were uncertain about its future and considered that it should only be performed within the context of a controlled trial. This study highlights a number of issues that need to be addressed before the role of LIHR can be determined.

Attitude to Health↗
PubMed1991

Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival.

OBJECTIVE: To assess the differences among surgeons in postoperative complications, postoperative mortality, and survival in patients undergoing surgery for colorectal cancer. DESIGN: Prospective study of patients with colorectal cancer managed by one of 13 consultant surgeons, none of whom had a special interest in colorectal surgery. SETTING: Royal Infirmary, Glasgow. PATIENTS: 645 sequential patients with colorectal cancer presenting over the six years from 1974 to 1979. MAIN OUTCOME MEASURES: Postoperative complications, postoperative mortality (within 30 days), and survival (up to 10 years); predictive factors for postoperative mortality and survival; and relative hazard rate ratios for individual surgeons. RESULTS: The proportion of patients undergoing apparently curative resection varied among surgeons from 40% to 76%; overall postoperative mortality varied from 8% to 30%. After curative resection postoperative mortality varied from 0% to 20%, local recurrence from 0% to 21%, and the rate of anastomotic leak from 0% to 25%. Survival at 10 years in patients who underwent curative resection varied from 20% to 63%, two year survival in those who underwent palliative resection varied from 7% to 32%, and median survival in those who underwent palliative diversion varied from one to eight months. The hazard rate ratios among individual surgeons, taking into account the identified risk factors, varied from 0.56 to 2.03, from 0.17 to 1.92, and from 0.57 to 1.50 for curative resection, palliative resection, and palliative diversion, respectively. CONCLUSION: There were significant variations in patient outcome among surgeons after surgery for colorectal cancer; such differences compromise survival. A considerable improvement in overall survival might be achieved if such surgery were undertaken by surgeons with a special interest in colorectal surgery or surgical oncology.

Clinical Competence↗