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At least 1,423 records · Page 79Linked to original sources
PubMed2003

How many cases are enough for accreditation in sentinel lymph node biopsy in breast cancer?

BACKGROUND: There is considerable argument concerning the number of sentinel node biopsy cases with axillary dissection that surgeons should perform before they are eligible on abandoning axillary dissection in negative sentinel node patients. DATA SOURCES: Papers that (1) address directly or indirectly the subject of credentialing or of learning curve, (2) report on a surgeon's performance, (3) are reported as feasibility or learning curve studies, or both, (4) discuss the learning curve issue, and (5) express an expert's opinion on the learning curve. CONCLUSIONS: The number of procedures of the learning curve can not be fixed for all surgeons. Only surgeons in specialized breast cancer centers can succeed in meeting current recommendations with 20 to 30 cases. Surgeons from affiliated community hospitals will need more than 30 cases, whereas broad-based surgeons might need as many as 60 cases with their current caseload. Not all surgeons will be able to offer the procedure to their patients by the current recommendations.

Accreditation↗
PubMed1993

Spectrum and management of major complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the most prevalent method of treating uncomplicated, symptomatic cholelithiasis in the United States and elsewhere. As experience with this procedure grows, certain pitfalls are becoming apparent. Since October 1990, we have treated 22 patients for major injuries incurred during laparoscopic cholecystectomy, including 15 women and 7 men (range: 23 to 85 years). One patient had previous upper abdominal surgery; no other patient had any relative contraindication to laparoscopic surgery. The most frequent site of injury (19 patients) was the extrahepatic biliary tract. There was one fatal duodenal perforation. All but two patients whose injuries went unrecognized at laparoscopy were symptomatic during the immediate postoperative period. The biliary injuries included complete transection of the common hepatic or common bile duct in 10 patients, complete ductal occlusion in 3, a cystic duct stump leak in 2, and a partially retained gallbladder with a contained intraperitoneal bile leak in 2. The site and extent of biliary injuries were delineated with transhepatic or endoscopic retrograde cholangiography. Reconstruction or repair of the biliary tract was accomplished with Roux-en-Y hepaticojejunostomy or cholangiojejunostomy in 11 and 1 patients, respectively, completion cholecystectomy in 2, and temporary transhepatic stenting, primary choledochocholedochostomy, and primary choledochorrhaphy over a T-tube in 1 patient each. One patient with a cystic duct stump leak was managed successfully with endoscopic sphincterotomy, whereas another required operative ligation. Laparoscopic injuries during cholecystectomy can lead to serious morbidity and mortality, thus emphasizing the need for adequate training and credentialing for surgeons and for a heightened clinical awareness of the potential complications, their long-term sequelae, and how to avoid them.

Adult↗
PubMed1997

The relationship between criteria used to select residents and performance during residency.

PURPOSE: Can data available at time of interview and evaluation predict level of performance during residency? METHODS: General surgery residents were studied. Applicant information available prior to admission was used to predict performance during residency as measured by faculty judgment of residents' knowledge, technical skill, maturity and judgment, and overall ability. RESULTS: No relationship was found between admission data and final evaluation (using Spearman's coefficient r(s) = 0.27; p = 0.13). We could not distinguish between the top 10 and the bottom 10 ranked residents on admission variables. Nine of the top 10 and 3 of the bottom 10 residents remained in general surgery. Performance on the American Board of Surgery In-Training Examination accounted for 37% of the variance in faculty grading (F(5,28;.05) = 3.26; P = 0.02). CONCLUSIONS: Residents' interpersonal and technical skills and qualities of character may have a significant role in faculty perception of success during surgical residency. These qualities are not well reflected in candidates' credentials at admission.

Career Choice↗
PubMed1998

The nature and fate of categorical surgical residents who "drop out".

BACKGROUND: Little is known about the fate of categorical surgical residents who leave a program or if they differ from those who successfully complete a program. METHODS: Matching into separate categorical and preliminary categories with elimination of the pyramid began in 1982. The files of all categorical residents matched between 1982 and 1995 were reviewed for demographic and scholastic data. Drop-outs were compared with the residents who completed the program and with the current house staff. All residents have been followed up to the present. RESULTS: Between 1982 and 1996, 19 of 88 (22%) categorical residents who matched into the program left voluntarily. Eleven of 63 (17%) were male and 8 of 25 (32%) female (P = 0.12; test of proportions-Z = -1.55). They entered both surgical and nonsurgical fields. The major reasons for leaving were related to life-style issues. Their academic credentials are very similar to those who remained. CONCLUSIONS: The drop-out rate of categorical surgical residents is significant, and replacing them is not easy. We have not identified any characteristics that might predict attrition.

Adult↗
PubMed1999

Emergent management of multisystem injuries by a general trauma surgeon.

OBJECTIVE: To determine the requisite education and scope of practice for a general surgeon trained to deliver emergent trauma care without the need for specialty consultation. DESIGN: Retrospective case review. SETTING: Private Level I trauma center. PATIENTS: 4097 trauma patients admitted between 1/1/92 and 30/6/97. MAIN OUTCOME MEASURES: Mechanisms of injury; operations (total within the first 24 h) by mechanism and by surgical specialty. RESULTS: Of 4097 trauma patients, 1086 (27%) underwent 1772 operative procedures within 24 h of admission, and 246 (6%) underwent 484 later operations. Orthopaedic and general surgical procedures were most common (51% of early operations). Early operations were most commonly orthopaedic for blunt trauma and general surgical for penetrating trauma. Although 685 patients (16.7%) received neurosurgical evaluation, only 150 early operations were performed (8% of the total early operations). At least 1244 procedures (55%) fell within the scope of current trauma general surgical practice advocated by some authorities. CONCLUSIONS: The contribution of the various specialties to early operative trauma management is a function of the injury mechanism. As orthopaedics and neurosurgery together comprise 34% of emergency practice, a fully credentialed general surgeon with additional training in these disciplines could perform up to 90% of early operations.

Adolescent↗
PubMedDate not supplied

Molding the future of advanced practice nursing.

During this time when the walls that divide inpatient, outpatient, primary, tertiary, and community care are coming down, society should expect that the nursing profession will prepare and regulate advanced nursing practice for the good of patient care and society as a whole. To do so, schools with clinical practice graduate programs must create a consistent product; professional credentialing bodies must use consistent criteria to acknowledge advanced practice knowledge and expertise; and state boards of nursing must give legal recognition for advanced practice to these same nurses. Within this environment, advanced practice nurses will be prepared to serve society, even if their skills are applied in a variety of roles.

American Nurses' Association↗
PubMed2001

Internet availability of contraceptives.

OBJECTIVE: To measure the accessibility of contraceptive supplies over the Internet. METHODS: We performed an Internet search with the use of search engines and key words. We posed as consumers purchasing both prescription and over-the-counter contraceptive supplies. The number of clicks or web pages accessed, costs, shipping time, barriers to access, and prescription requirements were compared for selected birth control supplies. RESULTS: More than 200 web sites were visited to locate at least one site where we could purchase each selected product. Contraceptive supplies, including male and female condoms, spermicides, vaginal sponges, intrauterine devices (IUDs), diaphragms, and cervical caps, were easily obtained without a prescription from foreign web sites. Oral contraceptive pills (OCs) were readily available online in November 1999; some sites had discontinued sales by February 2000, but OCs could still be purchased with no prescription in August 2000. None of the four prescription sites supplied physician or prescriber credentials. The contraceptive costs varied by vendor and product. A type of copper IUD could be purchased for less than $50.00, whereas a single package of emergency contraceptive pills cost $141.00 from one vendor because of prescription and shipping fees. Some emergency contraceptive pills ordered arrived after 72 hours or did not arrive and the purchase was not refunded. A levonorgestrel IUD was shipped without difficulty in December 1999, but a second device, ordered in February 2000, was temporarily impounded by United States Customs. CONCLUSION: This method of contraceptive purchase is accessible, expensive, erratically regulated, and rapidly changing.

Contraceptive Agents↗
PubMed2000

Sentinel lymphadenectomy in breast cancer: university research tool or community practice?

There is considerable controversy regarding the introduction and granting of credentials for sentinel lymphadenectomy in breast cancer. Given the workload of the average general surgeon and current procedural guidelines, two to three years would be required to demonstrate competence before a surgeon might perform sentinel lymphadenectomy without an immediate completion axillary node dissection. This article reviews issues related to the introduction of sentinel lymphadenectomy in the general surgeon's armamentarium.

Breast Neoplasms↗
PubMed1998

The surgeon's use of transesophageal echocardiography.

Transesophageal echocardiography has become an instrumental diagnostic modality for the accurate evaluation of cardiac and aortic anatomy and function. Multiplanar technology has facilitated improved visualization of structures and enhanced TEE over TTE in many situations. Care of the trauma patient and critically ill patient is improved with the appropriate and timely performance of TEE. Education, certification, credentialing, and determination of competency are areas that need to be addressed continually in the future.

Aortic Dissection↗
PubMed1991

Quality assurance in the surgical intensive care unit. Where it came from and where it's going.

The early history of QA is one of stunning achievements. Men and women led by a vision of what hospital health care should be brought about fundamental changes in the structure of hospitals and medical schools. These successes required lifetimes of work and enormous capital (Flexner's war chest would have amounted to billions of 1990 dollars). A second wave of reform included the creation of credentialing committees, tissue committees, and infection control efforts. Although less dramatic in their impact, these efforts have had measurable influence on the outcome of health care and, under the joint administration of local hospitals and the JCAHO, continue to guarantee excellence in health care. The most recent attempts at quality assurance, driven at least in part by a federal mandate to control costs, have been much more modest in their success. Committed groups working within a sound theoretical framework have had great difficulty monitoring and evaluating centrally a process as decentralized as health care. The regularity with which new fashions in QA have appeared underscores the frustration felt with this approach. If the quality of health care is to be monitored centrally, reliable measures of quality will be required. No one knows if such measures actually exist. The absence of objective evidence that quality has been improved by these efforts suggests that little has been accomplished, perhaps because all easily attainable improvements had already been implemented. The basic concept of a centrally monitored hospital structure within which provision is made for ongoing observation and innovation by those actually involved in the care of patients retains the advantages of central monitoring and local invention. It is a model that will be hard to improve on. We should persist in our efforts, but fundamental advances are unlikely. In the end, quality is only doing everything the best it can be done. The best quality assurance requires an excellent hospital in which a well-trained and committed staff has a central mandate and local purview to do the best possible job. Two thousand years after Hammurabi's minions busied themselves determining the appropriate punishment for various medical misadventures, the Greek Hippocrates advocated a less complex approach to the same problem. He suggested that the quality of health care could be best guaranteed by administering an oath to physicians, exhorting them simply to do what was best for their fellow men. This approach has seen us through two millennia and, however variable its results, may not be easily improved on.

Cost-Benefit Analysis↗
PubMed1991

Laparoscopy and the general surgeon.

Laparoscopic cholecystectomy has belatedly awakened the general surgical community to the concept of closed abdominal surgery. Current techniques have largely been developed by our colleagues in gynecology. The unanticipated demand by the public has placed unprecedented pressure on our systems for training, credentialing, developing, supplying, and evaluating changes in surgical technique. The diagnostic value of laparoscopy has been documented by a handful of general surgeons over the past several decades and is likely to become a more widely accepted technique. The potential of future developments in video-controlled operations is immense.

History, 19th Century↗
PubMed1992

Political issues in endovascular surgery.

"Political issues" may determine the relative progress if not the ultimate success and acceptance of endovascular surgery as much as its intrinsic merits. These issues include turf battles, commercialization of newly developing technologies, unethical advertising, and self-serving reporting practices in presenting clinical results. Acceptable indications, methods of evaluating results, standardized reporting practices, appropriate "gold standards" for comparison, and controlled trials (without premature release) are recommended, as well as an emphasis on the future need for proper training and credentialing and quality assurance programs.

Cost-Benefit Analysis↗
PubMed1992

Evolving uses of laparoscopy in children.

As the technology evolves, the number of procedures that can be performed laparoscopically will continue to expand (Table 3). The impact on the field of pediatric surgery, which encompasses surgical oncology, gastrointestinal surgery, trauma, and gynecologic surgery, will be significant. There are several hurdles for the pediatric surgeon to overcome before beginning operative laparoscopy. The acquisition of the initial instrumentation is expensive, and the credentialing process may be time-consuming. And there remains a healthy suspicion on the part of many pediatric surgeons that these techniques represent a fad. We believe that operative laparoscopy has advantages and disadvantages. Some of the procedures require more time and are frequently tedious, thus trying the patience of the surgeon. It is difficult for experienced surgeons to subject themselves electively to the learning curve associated with a new procedure. While the benefits are mostly in the postoperative period, we believe exposure is vastly improved in obese patients. Patients appear to have less pain and postoperative ileus, and they may return to unrestricted activity sooner. We are still discovering which laparoscopic procedures can be done safely to the patient's advantage. Solving the dilemma of what procedures should be performed using laparoscopic techniques will require extensive experience and study, and minimally invasive surgery will be a subject of controversy and debate for many years. It is difficult to imagine that open cholecystectomy would once again become the standard. We predict that we will see a continued expansion in the types of procedures to be performed using minimal-access techniques. And in the future, we may have to justify our opening of a patient's abdomen when the procedure could have been performed laparoscopically, as is now the case for cholecystectomy in some areas of the country.

Appendectomy↗
PubMed1995

Abdominal ultrasonography in trauma.

The use of ultrasonography for the investigation of urgent diagnostic dilemmas is by no means new. Although it has been widely used for almost 40 years, during the past two decades ultrasonography has achieved a primary role in Europe and Asia in the investigation of emergent conditions such as trauma. The use of this bedside diagnostic modality is expanding rapidly and will continue to do so. Emergency physicians have developed a fellowship program in emergency ultrasonography, have set forth a model curriculum for physician training in emergency ultrasonography, and have begun to conduct hands-on courses for academic emergency physicians. Because diagnostic ultrasonography has proven to be of value in the diagnosis and management of a variety of emergent conditions, ultrasound examination, interpretation, and clinical correlation should be immediately available around the clock in resuscitation areas. It is hoped that (1) ultrasound training will be incorporated into general surgical residency programs, (2) ultrasound curriculum and credentialing processes will be established, and (3) more surgeons will have this modality available to them as part of their diagnostic armamentarium in the evaluation of injured patients.

Abdominal Injuries↗
PubMedDate not supplied

A master's degree for entry-level ACNM-certified midwives. An option or necessity?

The health care industry is a massive system that is changing so rapidly that it is reinventing itself. With these changes, added demands have been placed on the knowledge base and practice of nurse-midwifery with emphasis on primary care, administration, and research as well as traditionally accepted nurse-midwifery practice. The American College of Nurse-Midwives (ACNM) has a history of being alert to consumer demands, sociopolitical forces, and the health care industry itself as stimuli for change after full dialogue with the membership and appropriate study. Because the ACNM Division of Accreditation will be requiring a baccalaureate degree upon entrance or completion of each midwifery education program by June 1999, dialogue should begin now about the benefits of requiring a masters degree as the entry-level credential.

Certification↗
PubMed1991

Quality of care in a chain of walk-in centers.

Several aspects of quality of care at one chain of freestanding ambulatory health care walk-in centers were evaluated. Those areas for which data were available--medical record review, physician credentials, and patient satisfaction--suggest that for primary acute episodic care, HSMMI walk-in centers provided care comparable to that which would have been received in traditional health care settings. In fact, HSMMI offices were found to be similar in organizational structure and appeared very much like private physicians' offices in management, staffing, patient flow, and physician performance. The corporation's QA program evolved from a series of informal managers' meetings (in 1986), to a detailed and structured program involving a CEO and regional medical directors by the end of 1990. The exact way in which HSMMI's new emphasis on formal quality-of-care assessment and assurance will affect patient care will be seen as the program fully matures. The issue of the proper relationship between money and medicine remains a problem. As health services organizations are increasingly influenced by market forces and consumers have ever-higher expectations, patients and physicians alike want to be sure that high-quality health care remains the first priority. Although this is an issue for all providers, it is much more visible in proprietary offices, making physicians as well as the public uneasy. For this reason, HSMMI's burden of proof regarding quality may be higher--particularly within the medical community--than the burden on traditional private practice physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

The utility of PRO data on surgical volume: the example of carotid endarterectomy.

As part of a small-area analysis of carotid endarterectomy (CE) surgery, this review of Medicare claims data for a 26-month period addresses variations in surgical volume, mortality, readmissions, and charges. A surprisingly high percentage of surgeons performing CE did few procedures, and surgical volume appeared to be associated with higher mortality and charges. The implications of these data for both hospital credentialing committees and management and for purchasers and consumers of care, as well as the ways in which the Health Care Financing Organization's (HCFA) Health Care Quality Improvement Initiative (HCQII) will reorder their relationships with peer review organizations (PROs), are discussed. This study is useful in addressing the potential of efforts by PROs to increase the quality of care under the HCQII.

Data Collection↗
PubMed1989

Dr. William O. Coffee and his absorption cure for cataract.

Dr. William O. Coffee was an ophthalmologist who conducted an office and mail-order practice in the Midwest from the 1880s until 1927. His main stock in trade was a self-discovered absorption cure for a variety of ocular diseases, with particular emphasis on the medical cure of cataracts. Dr. Coffee's career was a checkered one, marked by dubious credentials, exuberant self-promotion, unlikely and exaggerated claims of medical successes, plagiarism, and rejection by the medical "establishment." Certain parallels may be drawn between his activities and some currently observed practices in ophthalmology.

Cataract↗