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PubMed1990

Integration of the medical degree in oral and maxillofacial surgery training: a survey of the American Association of Oral and Maxillofacial Surgeons membership.

Fifty percent of the American Association of Oral and Maxillofacial Surgeons membership in the United States was polled in an effort to evaluate the influence a medical degree might have on privileges and referral patterns, and its role in the office, hospital, and academic settings. Biographical data were collected and responses evaluated for the following groups: 1) the nation as a whole, 2) geographic regions of practice, 3) population, 4) number of years in practice, and 5) involvement in academic programs. Questions concerning the spectrum of privileges as well as referrals and desire to possess a medical degree were asked. Substantially different responses were seen between the MD/non-MD oral and maxillofacial (OMF) surgeons as well as differences between geographic locations, years in practice, and academic involvement. In general, MD and academic OMF surgeons possessed a broader spectrum of privileges than their colleagues. No consistent patterns were seen between the various geographic regions. No significant differences existed in privileges based on the size of a community in which a surgeon practices. A greater or equal percentage of privileges was possessed by more recently trained OMF surgeons than their more experienced colleagues. The results presented may aid future graduates in making a more informed decision when considering obtaining a medical degree.

Attitude of Health Personnel↗
PubMed2006

Impact of hospital and surgeon volumes on outcomes following pelvic reconstructive surgery in the United States.

OBJECTIVE: The purpose of this study was to estimate the effect of hospital and surgeon volumes on outcomes following urogynecologic surgery. STUDY DESIGN: This was a retrospective cohort study of women who underwent urogynecologic procedures between 1998 and 2003 from the Nationwide Inpatient Sample. Hospitals and surgeons were categorized as low, medium, or high volume based on average number of cases per year. Outcomes included in-hospital mortality, complications, and nonroutine discharges. Multivariable analyses were performed using generalized estimation equations to estimate relative risks. RESULTS: There were 310,759 women and 2986 hospitals. Women who had procedures at low-volume hospitals were 2.75 (95% CI 2.33-3.16) times more likely to die and 1.63 (95% CI 1.44-1.83) times more likely to have a nonroutine discharge, compared to those at high-volume hospitals. Women who had procedures by low-volume surgeons were also more likely to suffer complications and have nonroutine discharges compared to those with high-volume surgeons. CONCLUSION: Differences in hospital and surgeon volumes of urogynecologic procedures may contribute to variations in mortality and morbidity risks.

Aged↗
PubMed2005

A cumulative analysis of an individual surgeon's early experience with elective open abdominal aortic aneurysm repair.

BACKGROUND: Several studies have reviewed the role of hospital and surgeon case volumes in determining early mortality after elective open abdominal aortic aneurysm (AAA) repair. Few, however, have analyzed this relationship at the individual surgeon level. The purpose of this study was to display the usefulness of a unique statistical tool as a form of an ongoing practice audit. METHODS: All patients who underwent an elective open AAA repair by an individual surgeon at a university-affiliated medical center over a 5-year period were analyzed. The cumulative sum failure method was used to analyze the results over time. Failure was defined as the presence of early mortality, myocardial infarction, or a complication resulting in another surgical procedure or prolonged hospitalization. A target failure rate of 10% was chosen, and 80% alert and 95% alarm boundary lines were established. RESULTS: One hundred thirty-eight patients underwent elective AAA repair by this surgeon over a 5-year period (1998-2003). There were 5 early mortalities (3.6%), 15 myocardial infarctions (10.9%), and 3 major morbidities (2.2%). These results were plotted on a cumulative sum curve as an example of an ongoing practice audit. CONCLUSIONS: The cumulative sum failure method provides a tool whereby a surgeon can prospectively audit his practice and recognize trends in performance before their recognition by standard statistical tools.

Academic Medical Centers↗
PubMed2005

Gender differences among spouses of surgeons.

BACKGROUND: The goal of this study was to identify whether gender differences exist regarding the degree of spousal support for, satisfaction with, and perception of surgeons' careers. METHODS: A survey was performed of spouses of academic surgeons in the United States and Canada. RESULTS: Female respondents were significantly less likely to work outside of the home and were significantly more likely to be the major decision-makers at home. They were less likely to credit their surgeon spouses with contributing to household duties and childcare. If both spouses worked outside of the home, the female spouse was still more likely to be the major decision maker. Overall, male and female respondents rated their role in and their satisfaction with their spouses' career choices similarly. CONCLUSIONS: Male and female spouses contribute equally to the career choices of their surgeon spouses. However, female spouses, both surgeon and nonsurgeon, are more likely to make the majority of the decisions at home and contributions to household care.

Adult↗
PubMed2005

Surgeon and community factors affecting breast cancer sentinel lymph node biopsy.

BACKGROUND: We sought to determine whether the results of sentinel lymph node (SLN) biopsy are related to practice and community factors. METHODS: This prospective study included more than 300 surgeons from a variety of practice environments. Most surgeons had minimal experience with SLN biopsy prior to this study. Patients underwent attempted SLN biopsy, followed by completion axillary dissection. Univariate and multivariate analyses were performed to assess factors related to the SLN identification rate and the false negative rate. RESULTS: A total of 4131 patients were enrolled. SLN identification rate was 93%; the false negative (FN) rate was 7.9%. The only factor that was significantly associated with improved SLN identification rate (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.12 to 2.36, P = .0126) and FN rate (OR 2.39, 95% CI 1.32 to 4.79, P = .0073) was surgeon experience (>20 SLN cases). CONCLUSIONS: Surgeon experience is the major factor that contributes to improved SLN biopsy results. SLN biopsy can be performed equally well by community and academic surgeons.

Adult↗
PubMed2006

Do the American College of Surgeons' "major resuscitation" trauma triage criteria predict emergency operative management?

STUDY OBJECTIVE: We wish to assess whether individual or collective American College of Surgeons' "major resuscitation" criteria accurately identify injured patients who receive emergency operative treatment. METHODS: In this observational secondary registry analysis of 8,289 consecutive trauma team activations during a 7.5-year period, we evaluated the test performance of 5 American College of Surgeons' major criteria in predicting emergency (within 1 hour) operative management by general (for adults) or pediatric (for children) surgeons. RESULTS: In adults, the individual major resuscitation criteria each predicted emergency operative management as follows (sorted from highest to lowest test performance): gunshot wounds to the neck or torso (likelihood ratio positive [LR+] 7.5; 95% confidence interval [CI] 6.2 to 9.1); confirmed hypotension (LR+ 5.3; 95% CI 4.0 to 7.1); interhospital transfers requiring blood transfusions (LR+ 4.6; 95% CI 2.6 to 8.2); respiratory compromise (LR+ 2.9; 95% CI 2.2 to 3.7), and Glasgow Coma Scale score less than 8 (LR+ 2.1; 95% CI 1.6 to 2.7). The collective strategy of using any of these 5 criteria exhibited a LR+ of 3.5 (95% CI 3.2 to 3.8), sensitivity 82% (95% CI 75% to 87%), and specificity 76% (95% CI 75% to 77%). Our findings in children were similar, but their precision was limited by the low baseline prevalence of emergency operative intervention. CONCLUSION: These 5 American College of Surgeons-mandated major resuscitation criteria vary several-fold in their individual ability to predict emergency operative management and collectively exhibit modest test characteristics for this purpose. Selective use of these criteria or revisions thereof could result in more efficient secondary trauma triage. Our results do not support the existing obligatory use of these criteria to maintain American College of Surgeons trauma center certification.

Adult↗
PubMed2006

Racial and ethnic disparities in care: the perspectives of cardiovascular surgeons.

BACKGROUND: Although racial/ethnic disparities in care are well documented, particularly for cardiac care, we know little about what cardiac surgeons think about them. For educational efforts to be effective in helping physicians address disparities, they must consider providers' knowledge and beliefs about the underlying causes of the disparities. METHODS: We conducted a survey in 2004 to assess cardiologists' and cardiac surgeons' knowledge of racial/ethnic disparities in cardiovascular care and their perceptions about the underlying causes. Respondents were recruited from the membership of four cardiovascular professional associations. This paper focuses on cardiovascular surgeons' responses (n = 208). RESULTS: Forty-four percent of cardiovascular surgeons thought that, among patients with cardiac risk factors, black patients were not as likely as white patients to receive cardiac diagnostic tests and procedures. Additionally, 30% thought that black patients were not as likely as white patients to receive therapeutic tests and procedures. However, only 13% agreed that cardiac care disparities occur "often" or "somewhat often" based on patients' race/ethnicity, independent of their insurance and education. Only 3% thought disparities were likely to occur in their clinical setting. Respondents appeared more likely to endorse patient factors (eg, health behaviors or treatment adherence) than system or provider (eg, miscommunication or continuity of care) factors as reasons for disparities. CONCLUSIONS: Although some surgeons acknowledge that racial/ethnic disparities in cardiac care occur, very few agree that they occur often, independent of patients' characteristics. Educational efforts tailored to local care settings, such as reviewing quality of care data on patients of different races/ethnicities within a clinic/hospital, may effectively inform all physicians of these disparities.

Attitude of Health Personnel↗
PubMed2005

Outcome following TVT sling procedure: a comparison of outcome recorded by surgeons to that reported by their patients at a London district general hospital.

OBJECTIVE: Retrospective study to assess patient satisfaction rates after TVT sling procedure for stress urinary incontinence (SUI), and comparison of these results to the post-operative progress documented by the surgeons in the clinical notes. METHODS: All TVT sling cases at our institution during February 1999 to December 2002 were included. Data was collected from clinical notes on post-operative outcome as recorded by the surgeons, and a patient satisfaction questionnaire was used to assess patients' perception of their progress. RESULTS: The response rate to the patient satisfaction questionnaire was 72%. Overall 94% of the patients were satisfied with the procedure. However, they reported cure rates of only 44%. This is comparable to the 46% cure rates documented by the surgeons. CONCLUSION: The surgeons' and the patients' perceptions regarding outcome and change in symptoms after TVT sling for SUI at our hospital, correlate well. Hence, the documentation in the clinical notes by the surgeons can be relied upon as an accurate representation of post-operative patient progress. Despite the relatively low cure rates (44-46%) for SUI with TVT sling procedure, the patient satisfaction rates with the outcome are high (94%), reiterating that there is a poor correlation between quality of life impairment and the concept of cure.

Adult↗
PubMed2005

Resuming driving after a fracture of the lower extremity: a survey among Dutch (orthopaedic) surgeons.

BACKGROUND: Patients with a fracture of the lower extremity often ask their physician during their rehabilitation when they can resume driving. Since no guidelines exist and only scarce literature is available with varying advices the physician has to rely on his own clinical experience and judgment. The Dutch legislation also fails to provide rules when driving can be resumed after a temporary invalidity, it relies on the physician to judge when driving can be assumed to be safe. With this study, we investigated the need for specific guidelines concerning driving after fractures of the lower extremity among Dutch (orthopaedic) surgeons. METHODS: A survey was conducted among Dutch (orthopaedic) surgeons consisting of four parts; the first part contains questions about how the physician handles with patients who suffered from a lower extremity fracture. The second part of the survey is about which criteria are used to judge whether driving can be resumed. The third part contains true/false/do not know questions about the legal context on participation in motorized traffic with a (temporary) disability. The fourth and last part is a series of examples of fractures with a description of how the fracture was treated in which we asked how long it should normally take before a patient can resume driving again safely per case. A final question is about the need for specific guidelines on this topic. RESULTS: One third of the surgeons do not advise their patients regarding driving. A wide range of criteria is used to consider whether driving is safe, however the possibility of full weight bearing is considered the most important. The legal knowledge of the surgeons on this subject is poor; up to 10% believe that driving with a plaster on the right leg is allowed. Seventy-nine percent of the questioned surgeons believe that guidelines concerning driving after a fracture should be developed. CONCLUSIONS: Our study shows that there is a great demand for guidelines concerning car driving after a fracture of the lower extremity.

Attitude of Health Personnel↗
PubMed2004

Surgeon workhours in the era of limited resident workhours.

BACKGROUND: Resident workhours have received much attention, yet there is little information concerning faculty workhours. In addition, the perspectives of surgical faculty on the anticipated effects of reducing resident hours have not been studied. STUDY DESIGN: An anonymous survey was distributed to all clinical faculty in the Departments of Surgery, Neurosurgery, Orthopaedics, and Otolaryngology at a single, large academic institution. Surgeons completed a detailed retrospective report of hours worked during a 1-week period. Opinions regarding resident workhour restrictions were also elicited. Chi-square or Student's t-tests were used to determine p values as appropriate, with p </= 0.05 considered significant. RESULTS: Of 120 surveys distributed, 102 (85%) were returned. Subspecialty departments comprised 51% of respondents with 49% from general surgeons. The mean number of hours worked per week by faculty was 70.4 +/- 12.5 (SD) (73.8 +/- 14.1 for general surgeons versus 67.1 +/- 9.9 for subspecialists, p = 0.006), with only 44.1% having at least 1 day per week free from clinical duties. Up to 95% of general surgeons are paged overnight at least once per week (mean 13.6 +/- 11.2 calls/week), with 73% returning from home at least once during the week (mean 1.8 +/- 1.1 returns/week). Importantly, 84% of general surgeons believe reducing resident workhours will increase faculty hours, compared with 57% of subspecialists (p = 0.004). In addition, 87% predict that reducing resident hours will compromise surgical education, with only 11% believing the benefits of hour reduction will outweigh the negatives. CONCLUSIONS: The recommended limit for resident workhours closely approximates the average number of hours worked by surgical faculty in an academic center. Despite this, significant concern exists among the majority of surgical faculty regarding the impact of resident workhour restriction, both on faculty workhours and on resident education.

Attitude of Health Personnel↗
PubMed2005

Physical examination of the carpal bones by orthopaedic and accident and emergency surgeons.

Our aim was to test knowledge of carpal bone surface anatomy among orthopaedic and accident and emergency surgeons. A survey of 58 surgeons was conducted. Each was asked to palpate seven points on five commonly injured carpal bones. Eight surgeons declined to participate. Five of the remaining 50 correctly palpated all surface markings. Six failed to accurately palpate even a single point. The scaphoid waist and trapezial ridge were accurately palpated by 47 surgeons. The median score for all participants was 3 correctly identified points. The majority of orthopaedic and accident and emergency surgeons do not perform an accurate physical examination of the carpal bones. The ancient art of history taking, precise physical examination and elucidation of a confident diagnosis is at risk of being replaced with tentative diagnoses and imaging techniques that are expensive and time consuming. We believe that basic anatomical teaching is inadequate.

Carpal Bones↗
PubMedDate not supplied

Surgeon accuracy in the selection of the flexion-extension axis of the elbow: an in vitro study.

The incorrect determination of the flexion-extension axis of the elbow may result in poor clinical outcomes for patients undergoing ligament repairs, joint arthroplasties, and procedures requiring articulated external fixators. The variability in the selection of the flexion-extension axis based on a visual approximation of bony landmarks on the distal humerus was studied within a group of surgeons. Three surgeons of different experience levels independently selected points through which they believed the flexion-extension axis passed on the medial and lateral surfaces of 23 distal humeri. One surgeon repeated the point selection on three separate occasions. These surgeon points were compared with an axis calculated by use of a computer-assisted method that relied on the centers of the trochlear sulcus and capitellum via digitization of these structures. Relative to the computer-generated flexion-extension axis, the error in the surgeons' selections resulted in a mean frontal plane angle of 1.5 degrees +/- 3.0 degrees valgus (range, 6.3 degrees varus to 9.6 degrees valgus) and a coronal plane angle of 1.6 degrees +/- 3.3 degrees external rotation (range, 8.3 degrees internal rotation to 10.2 degrees external rotation). These results suggest that the use of a computer-assisted surgical technique will allow a more accurate determination of the flexion-extension axis of the elbow, which may lead to improved clinical outcomes in patients treated with ligament repairs or reconstructions, elbow arthroplasties, or articulated external fixators.

Adult↗
PubMed2004

Preclinical students: who are surgeons?

BACKGROUND: The purpose of the present study was to determine how preclinical medical students formulate their career choice and to determine the origin of negative perceptions regarding surgery as a career. MATERIALS AND METHODS: A qualitative study was performed with second-year medical students voluntarily participating in focus group study. Students with and without an interest in surgery attended. Topics discussed included factors influencing career choice, priorities, perceptions, exposure, and interactions with surgeons. Three investigators conducted independent content analysis. RESULTS: Career choices for students interested in surgery originated primarily from premedical school experiences/interactions with surgeons. In contrast, students not interested in surgery made career choices during medical school and choices were shaped primarily by second-year preceptors. The main priority for students interested in surgery was personal happiness that was perceived as being significantly dependent upon career satisfaction. Students not interested in surgery tended to separate happiness derived from career versus family. Negative perceptions toward surgery were developed and reinforced by media, preceptors, and classmates. All students had minimal exposure to surgeons during preclinical years and generally agreed that increased involvement with surgeons would be beneficial, particularly through preclinical preceptorships. CONCLUSIONS: Career choices of preclinical students interested in surgery were made prior to entering medical school, suggesting that outreach programs to high schools and colleges may beneficial. Negative perceptions about surgery develop through a variety of sources, including fellow classmates, preceptors, and the media. Surgeons need to take responsibility for these perceptions.

Career Choice↗
PubMed2006

Exploring quality of life for patients undergoing major surgery: the perspectives of surgeons, other healthcare professionals, and patients.

BACKGROUND: Surgeons, other healthcare professionals, and patients may identify different health-related concerns related to the quality of life of patients undergoing major surgery. METHODS: Semistructured interviews were conducted with surgeons (n =14), other healthcare professionals (n =19), and patients undergoing major elective surgery (n = 52). Themes were extracted by content analysis and organized into major domains. The frequencies with which specific themes were mentioned were compared among groups. RESULTS: A total of 85 themes were extracted from the interviews, 15 of which were mentioned by 50% or more of participants in each group, representing 5 of the 6 domains. The greatest differences were observed in the domains of social well-being, wherein 5 themes were mentioned less often by surgeons than other groups, and spiritual well-being, wherein 2 themes were mentioned more often by patients than other groups. Differences in the physical, emotional, cognitive preparation, and concern about quality of care domains were minimal. CONCLUSIONS: Surgeons, other healthcare professionals, and patients identified many similar concerns related to the well-being of patients undergoing major surgery. However, the importance of social and spiritual themes to patients may be underestimated by surgeons.

General Surgery↗
PubMed2005

Conflicts in the surgeon's duties to the patient and society.

Surgeons may face a dilemma in which their obligations to their patients and their obligations to others or society may conflict. One way of examining these conflicts is through a model as depicted in Fig. 1. When both the patient and society are benefited (eg, in cases of routine surgical care), the surgeon may proceed with the planned treatment. In situations where it is agreed that both the patient and society will be harmed (eg, surgeon involvement in capital punishment or in many cases of deception), the surgeon should avoid acting in a manner against that of the patient. Many situations, however, involve the need to weigh the benefits and burdens of both the patient and society. In these cases, surgeons need to analyze carefully all of the ethical and legal issues involved, and make a decision based on their own set of values.

Biomedical Research↗
PubMed2001

Time as a catalyst for tension in nurse-surgeon communication.

Carefully studying communication patterns between nurses and surgeons questions popular stereotypes about OR discourse and expands educators' understanding of the factors that motivate team communication, patterns that are habitual among team members, and issues that act as catalysts for tension. This study examines the nature of communication between perioperative nurses and surgeons and identifies patterns and sites of tension. Researchers observed 128 hours of interaction between nurses and surgeons in four surgical divisions at one teaching hospital in Ontario, Canada. Field notes were read, coded, and analyzed independently. Results showed that higher tension in nurse-surgeon communication clusters around particular themes, the most dominant of which is time. Analysis of this theme reveals communication strategies that allow surgeons and nurses to achieve individual goals and support social cohesion among team members.

Anesthesiology↗
PubMed2001

The performance of master surgeons on standard aptitude testing.

BACKGROUND: Identification of the desired psychomotor abilities of optimal surgical performance, if possible, would be useful in the selection of surgical trainees. The aim of this study was to determine the level of these abilities among endoscopic consultant surgeons held in high regard by their peers. METHODS: Twenty endoscopic consultant "master" surgeons were tested on three aptitude tests: the Gibson Spiral Maze Test (error score measures eye-hand coordination), the Crawford Small Parts Dexterity Test (execution time indicates manual dexterity), and the Space Relations Test (correct scores reflect visuo-spatial ability). Their performance was compared with that of 20 medical students and the reference norm as provided by the tests' manuals. RESULTS: The median scores of master surgeons fell in the 20th, 24th, and 30th percentiles, whereas the scores of medical students fell in the 50th, 20th, and 65th percentile of norm reference for the Gibson Spiral Maze, Crawford Small Parts Dexterity, and Space Relations tests, respectively. The master surgeons enacted significantly fewer errors (Gibson Spiral Maze), had similar execution times (Crawford Small Parts Dexterity), and lower visuo-spatial scores (Space Relations) than medical students. CONCLUSION: The level of eye-hand coordination and manual dexterity of master surgeons was found to be higher than that of the average norm including medical students, while their visuo-spatial ability was lower.

Aptitude Tests↗
PubMed2002

Valid peer review for surgeons working in small hospitals.

BACKGROUND: Hospitals with one or only a few practicing surgeons need a valid way to analyze the quality of their work. Head-to-head comparisons, especially in a competitive small environment, are not likely to be fruitful. METHODS: We compared the quality of surgical care delivered by a single surgeon whose practice was located in rural Kentucky with that of a group of peers in the same region. A surgical data sheet was completed by each of the participating surgeons from July 1, 1998, to September 1, 2001. The cases were entered into a database maintained by a professional limited liability corporation, which was founded to enhance the quality of surgical care. We measured quality of care based on complication rate, patient education, resource utilization, use of diagnostic testing, and number of days the patient returned to work. RESULTS: A total of 11,761 cases were entered into the database during the 38 months recorded. Of those, 256 cases were performed by the studied surgeon. The cases included skin and subcutaneous biopsies (n = 145), colonoscopies (n = 80), upper endoscopies (n = 25), and inguinal hernia repair (n = 6). The studied surgeon performed better than the peer group in the categories of patient education, complication rates, and use of diagnostics. Resource utilization, as measured by length of stay, was identified as an area that could be improved. CONCLUSIONS: By using this organization and its methods, a good way to identify strengths and weaknesses of delivered surgical care is enabled.

Benchmarking↗