Income, productivity, and satisfaction of breast surgeons

Background

The purpose of this study was to assess how the practice patterns of breast surgeons affect their income and job satisfaction.

Methods

A 19-question survey regarding practice patterns and income and job satisfaction was mailed to all active US members of the American Society of Breast Surgeons.

Results

There were 772 responses. An increasing percentage of breast care was associated with lower incomes (P = .0001) and similar income satisfaction (P = .4517) but higher job satisfaction (P = .0001). The increasing proportion of breast care was also associated with fewer hours worked per week (P = .0001). Although incomes were lower in surgeons with a higher proportion of their practice in breast care, income satisfaction was not affected.

Conclusions

Although cause and effect relationships between income and breast surgery are difficult to establish, several trends do emerge. Most significantly, we found that dedicated breast surgeons have higher job satisfaction ratings and similar income satisfaction despite lower incomes.     

Practice variation in common fracture presentations: a survey of orthopaedic surgeons

Background

Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation.

Materials and methods

A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored.

Results

358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures).

Conclusions

Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.     

State of the practice for pediatric surgery--career satisfaction and concerns. A report from the American Pediatric Surgical Association Task Force on Family Issues

Background

There has been increasing interest and concern raised in the surgical literature regarding changes in the culture of surgical training and practice, and the impact these changes may have on surgeon stress and the appeal of a career in surgery. We surveyed pediatric surgeons and their partners to collect information on career satisfaction and work-family balance.

Methods

The American Pediatric Surgical Association Task Force on Family Issues developed separate survey instruments for both pediatric surgeons and their partners that requested demographic data and information regarding the impact of surgical training and practice on the surgeon's opportunity to be involved with his/her family.

Results

We found that 96% of pediatric surgeons were satisfied with their career choice. Of concern was the lack of balance, with little time available for family, noted by both pediatric surgeons and their partners.

Conclusion

The issues of work-family balance and its impact on surgeon stress and burnout should be addressed in both pediatric surgery training and practice. The American Pediatric Surgical Association is positioned to play a leading role in this effort.     

Cardiac injury and troponin testing after orthopaedic surgery

Background

Cardiac injury after orthopaedic surgery is an increasing problem particularly in an ageing population. The detection of cardiac injury has been aided by the use of cardiac troponins which has also raised questions about the utility of this enzyme in the post-operative setting.

Objective

This review evaluates the diagnosis and pathophysiology of myocardial infarction after orthopaedic surgery and examines how myocardial injury is detected, with particular emphasis on the role of troponin testing.

Subjects

Eight recent orthopaedic trials evaluating the use of troponin were identified in the literature and included in this review.

Results

This review found that the diagnosis of myocardial infarction is more difficult after surgery since classic symptoms may be atypical or absent. Therefore, there is more reliance on the typical rise and fall in troponin to diagnose cardiac injury especially because electrocardiograph changes may be hard to detect. The pathophysiology of ischaemia after orthopaedic surgery may be different to ischaemia in the non-surgical setting. The incidence of troponin elevation is between 22 and 52.9% after emergency orthopaedic operations. Of note, patients sustaining a troponin elevation are often asymptomatic. Small studies have found troponin to be a prognostic marker of in-hospital cardiac complications, increased length of stay, increased likelihood of discharge to residential care and death at 1 year. No interventional studies have been published to date.

Conclusion

Cardiac injury is an important complication after orthopaedic surgery. Studies have found that troponin testing can detect asymptomatic cardiac injury. These patients are at risk of poorer outcomes and future research should be directed towards treatment of these patients.     

Practice patterns and career satisfaction of Canadian female general surgeons

Background

We wanted to study how female general surgeons in Canada manage lifestyle and career demands.

Methods

All female Canadian general surgeons registered with the Royal College of Physicians and Surgeons of Canada were asked to complete a survey evaluating their practice patterns, personal lives, and levels of satisfaction related to these factors.

Results

Eighty-five surveys (66%) were returned. Most respondents work in full-time clinical practices. While it was rare to find women in part-time or shared practices, 35% of women reported interest in these alternative models. Respondents described the necessary factors for a transition into alternative models. Job satisfaction was high (3.8 out of 5), with personal and parenting satisfaction being less highly rated (3.3 and 3.2, respectively).

Conclusions

Canadian female general surgeons have active and satisfying careers, although many would like to work in alternative practice models that better conform to their lifestyle demands. This pressure will have a significant impact on the future surgical workforce.     

Pediatric trauma nurse practitioners provide excellent care with superior patient satisfaction for injured children

Purpose

Work hour restrictions for house staff have forced a reevaluation of the traditional roles of all health care providers. In 2001, our level I pediatric trauma center augmented the role of our trauma pediatric nurse practitioners (PNPs) to include in-patient management. We hypothesized that a PNP can provide injured children a level of care commensurate with a resident (RES).

Methods

All children between 2 months and 17 years old admitted to the Trauma Service were considered for the study. Patients were randomized to PNP or RES care groups. Types of injuries, injury severity score, missed injuries, readmissions, hospital length of stay (LOS), and cost were recorded. Satisfaction surveys were administered to all families.

Results

A total of 76 children were enrolled. During the study period, there were no missed injuries or readmissions. The PNP group had a significantly shorter LOS and received significantly higher satisfaction survey scores with regard to information on injuries, tests and treatment, and frequency of visits provided to the patient/family.

Conclusions

PNPs provide equivalent care for injured children with significantly shorter LOS and higher patient satisfaction than RESs. In-patient trauma nurse practitioners provide added value to the care of the injured child in the era of reduced RES work hours.     

Minimally-invasive pediatric surgery in 2004: a survey including 50 German institutions

Background

A survey on the practice of laparoscopic and thoracoscopic surgery in pediatric surgical departments in Germany is presented.

Materials and methods

A questionnaire was sent to all 71 pediatric surgical departments in Germany (population 82 million). Fifty institutions (70%) took part in the survey that mainly included data for the year 2004: spectrum of minimally invasive operations, quantity of procedures, conversions, major complications, number of performing surgeons and residents.

Results

Laparoscopic techniques were used in 48 departments (96%) and thoracoscopic techniques in 37 (74%). The annual frequency of laparoscopies was less than 100 in 30 departments (62%) and more than 100 in 15 (31%). The number of thoracoscopies was less than 50 in 35 departments (73%) and more than 50 in 2 (4%). Appendectomy was offered in 45 (90%), varicocelectomy in 32 (64%), and Fowler-Stephens operation in 33 (66%). Twenty-one departments (42%) covered more advanced procedures such as laparoscopically assisted pull-through for Hirschsprung disease. Most demanding procedures such as laparoscopic choledochal cyst resection, duodeno-duodenostomy, heminephrectomy, or pyeloplasty were offered by 10 departments (20%). Minimally invasive surgery was performed by 1 surgeon (12%) in 6 institutions and by more than 5 surgeons (14%) in 7 institutions.

Conclusion

Minimally invasive techniques are increasingly accepted in most German pediatric surgical institutions for a wide range of indications. However, the number of departments offering major minimally invasive procedures remains limited.     

What makes a competent surgeon?: Experts' and trainees' perceptions of the roles of a surgeon

Background

Assessment of surgical competence is a priority; however little is known about surgeons' perceptions of competence. We investigated components of competence and adequacy of training in achieving them.

Methods

Using questionnaires, Surgical Attendings and trainees rated the importance of 7 CanMEDS roles that define a competent surgeon (Medical Expert; Communicator; Collaborator; Manager; Health Advocate; Scholar; Professional) and whether training enabled them to achieve competency in each role.

Results

Ninety-two of 125 questionnaires (74%) were completed. Junior trainees attributed lower importance to the roles of Manager, Communicator, Collaborator, and Professional than senior trainees or Attendings. No surgeon stated that they had achieved competency in every role.

Conclusion

Trainee surgeons do not appreciate the importance of all the roles required of a competent surgeon and current training does not ensure competence in all roles. These gaps must be addressed to develop surgeons able to provide the highest quality of care.     

Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation)

Aims and objectives

To measure long-term functional outcome and health-related quality of life following tibial fracture in association with the full spectrum of soft tissue injury.

Methods

One hundred and thirty patients with different types of tibial injury were selected from our trauma database. This included 33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures and 22 requiring below knee amputation. Mean time to final follow-up was 37.4 months. The EQ-5D (EuroQol) questionnaire was used to assess these patients at this point. Patients had been treated according to standard unit protocols. Open fractures were jointly managed under the care of local plastic and orthopaedic surgeons using a policy of obtaining early soft tissue cover.

Results

Patients with reconstructed IIIB fractures reported problems with pain and carrying out their normal activities more frequently than amputees whilst still reporting problems with mobility just as frequently. Anxiety and depression were more common in the patients with open fractures and amputees as were problems with self-care, though the latter were unusual overall. Stepwise logistic regression revealed that tibial injury type was significantly predictive of all measured outcomes except self-care (p < 0.0001). Age, ISS, sex and time to follow-up were not significant predictors of response.

Conclusions

These results show that patients with these injuries still report long-term problems with their health-related quality of life, though to varying degrees. This information is useful when determining the treatment options for these patients and it is important that it is shared with the patient prior to surgery where possible.     

Thoracoscopic repair for congenital diaphragmatic hernia: lessons from 45 cases

Purpose

To describe the surgical technique, initial results, and overview indications of thoracoscopic repair of congenital diaphragmatic hernia (CDH).

Materials and Methods

A retrospective review was undertaken of patients with CDH who underwent thoracoscopic repair by the same surgeon from January 2001 to January 2005. Patients underwent surgery under general anesthesia. Reduction of the hernia contents was carried out using 1 optical trocar and 2 operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots.

Results

There were 45 patients, including 29 boys and 16 girls. Among 19 newborn patients, there were 13 patients younger than 7 days. The other 26 patients were infants and elders. The hernia was located in the left side in 37 patients and in the right side in 8 patients. The mean operative time was 54 minutes. Conversion was required in 4 patients. There were no complications. However, there were 2 postoperative deaths.

Conclusions

Thoracoscopic repair is feasible and safe for children with CDH, including selective newborn. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.     

Skills coaches as part of the educational team: A randomized controlled trial of teaching of a basic surgical skill in the laboratory setting

Background

The aim of this study was to compare the laboratory teaching of a basic technical skill by a nonphysician skills coach and a faculty surgeon.

Methods

Medical students were randomized to instruction of skin suturing in the skills laboratory by a faculty surgeon or by a nonphysician skills coach. Testing of performance occurred at 3 time points. Other faculty surgeons, blinded to identities and training groups, rated performance.

Results

Forty-nine students participated. Baseline fourth-year student mean scores showed no significant difference between training groups. Third-year and fourth-year student performance showed no difference between training groups on postintervention testing. Delayed testing also showed no difference in third-year student scores.

Conclusions

Training by either a nonsurgeon skills coach or a faculty surgeon resulted in no difference in performance on a basic surgical skill. This was true for students with and without prior experience and was also true after subsequent clinical experiences. Nonphysician coaches may ease the teaching burden of surgical faculty members while providing similar quality of instruction for trainees.     

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study

Background/Purpose

A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery.

Method

A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications.

Results

114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths.

Conclusion

Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.     

Young surgeons' attitudes regarding surgery and professional organizations

Background

Attitudes of young surgeons regarding professional organizations are unclear. We surveyed young surgeons to assess their opinions regarding the role of The American College of Surgeons in the future of surgery.

Methods

A 21-question on-line survey was distributed to all young (age <45 years) ACS members. Questions were related to demographics, membership, educational, and health policy initiatives.

Results

Among 2689 respondents, reimbursement and malpractice were the most important issues to surgeons at all levels of training. Organizational attributes of importance to young surgeons included leadership, educational tools, mentorship, and avenues to participate in organized medicine. They value programs to address patient safety, surgical quality, reimbursement, and health policy.

Conclusions

Methods to recruit and retain young surgeons into medical organizations should include educational efforts, mentorship programs, practice-management courses, health policy reform, and opportunities for involvement in organizational activities.     

Efficacy of cognitive feedback in improving operative risk estimation

Background

Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships.

Methods

Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons'/medical students' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set.

Results

Post-feedback, both groups' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further.

Conclusions

Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making.     

Was the real Sherlock Holmes a pediatric surgeon?

Purpose

This article reviews the pioneering efforts of Joseph Bell, the model for Sherlock Holmes, in the surgical care of children during the antiseptic era.

Methods

I reviewed biographies of Sir Arthur Conan Doyle; the biography of Joseph Bell; his surgical textbook, Edinburgh Medical Journals; and the history of the Royal Edinburgh Hospital for Sick Children.

Results

Dr Bell was a colleague of Joseph Lister and one of the first surgeons to apply antiseptic methods to operations involving children. He was the surgeon appointed to the first surgical ward of the Royal Edinburgh Hospital for Sick Children; in that role, he cared for many children with surgical diseases.

Conclusions

Dr Joseph Bell, by his compassion for children and his surgical skill, was indeed a pioneer pediatric surgeon.     

Effect of subspecialty training and volume on outcome after pediatric inguinal hernia repair

Background/Purpose

Inguinal hernia repair is the most common operation performed in children. The aim of this study was to determine if there are any differences in outcome when this procedure is performed by subspecialist pediatric surgeons when compared with general surgeons.

Methods

All pediatric inguinal hernias repaired in the province of Ontario between 1993 and 2000 were reviewed using a population-based database. Children with complex medical conditions or prematurity were excluded. Cases done by general surgeons were compared with those done by pediatric surgeons. The χ² test was used for nominal data and the Student's t test was used for continuous variables. Probabilities were calculated based on a logistic regression model.

Results

Of 20,545 eligible hernia repairs, 50.3% were performed by pediatric surgeons and 49.7% were performed by general surgeons. Pediatric surgeons operated on 62.4% of children younger than 2 years, 51.8% of children aged 26 years, and 37% of children older than 7 years. Duration of operation, length of hospital stay, and incidence of early postoperative complications were similar among pediatric and general surgeons. The rate of recurrent inguinal hernia was higher in the general surgeon group compared with pediatric surgeons (1.10% vs 0.45%, P < .001). Among pediatric surgeons, the estimated risk of hernia recurrence was independent of surgical volume. There was a significant inverse correlation between surgeon volume and recurrence risk among general surgeons, with the highest volume general surgeons achieving recurrence rates similar to pediatric surgeons.

Conclusions

Pediatric surgeons have a lower rate of recurrence after inguinal hernia repair in children. General surgeons with high volumes have similar outcomes to pediatric surgeons.     

Unusual appearances following intracapsular neck of femur fractures

Purpose

The aim of the study was to investigate the possible outcomes of intracapsular femoral neck fractures managed non-operatively or with a simple form of internal fixation.

Methods

We reviewed 30 fractures and their post mortem reports from the Galler collection, a modern pathology reference series.

Results

Our investigation revealed unusual appearances of the hip following femoral neck fractures that are not usually seen in modern orthopaedic practice, including previously undescribed acetabularisation of the femur and ankyloses of ununited femoral heads.

Conclusion

Appreciation of these appearances and an understanding of how these fractures may progress are important in the current diagnosis and management of delayed presentations, neglected or inadequately fixed subcapital fractures of the femoral neck.     

Challenges of training and delivery of pediatric surgical services in Africa

Background

The practice of pediatric surgery in Africa presents multiple challenges. This report presents an overview of problems encountered in the training of pediatric surgeons as well as the delivery of pediatric surgical services in Africa.

Methods

A returned structured self-administered questionnaire sent to pediatric surgeons practicing in Africa was reviewed and analyzed using SPSS version 11.5 (SPSS, Chicago, IL).

Results

Forty-nine (57%) of 86 questionnaires were returned from 8 countries. Great variability in the requirements and training of pediatric surgeons, even within the same country, was found. Many surgical colleges are responsible for standardization and board certification of pediatric surgeons across Africa. There were 6 (12%) centers that train middle level manpower. Twenty-six (53%) participants have 1 to 2 trainees, whereas 22 (45%) have irregular or no trainee. A pediatric surgical trainee needs 2 to 4 (median, 2) years of training in general surgery to be accepted for training in pediatric surgery, and it takes a trainee between 2 to 4 (median, 3) years to complete training as a pediatric surgeon in the countries surveyed. The number of pediatric surgeons per million populations is lowest in Malawi (0.06) and highest in Egypt (1.5). Problems facing adequate delivery of pediatric surgical services enumerated by participants included poor facilities, lack of support laboratory facilities, shortage of manpower, late presentation, and poverty.

Conclusion

The training of pediatric surgical manpower in some African countries revealed great variability in training with multiple challenges. Delivery of pediatric surgical services in Africa presents problems like severe manpower shortage, high pediatric surgeon workload, and poor facilities. Standardization of pediatric surgery training across the continent is advocated, and the problems of delivery of pediatric surgical services need to be addressed urgently, not only by health care planners in Africa but by the international community and donor agencies, if the African child is to have access to essential pediatric surgical services like his or her counterpart in other developed parts of the world.     

Post-operative numbness and patient satisfaction following plate fixation of clavicular fractures

Introduction and aim

Numbness across the shoulder and upper chest wall is a frequent complication following plate fixation of clavicular shaft fractures. This is usually attributed to damage to branches of the supraclavicular nerve caused by the surgical approach. We investigate whether the use of an incision perpendicular to the long axis of the clavicle (vertical incision) rather than one parallel to it (horizontal incision) is associated with reduced post-operative numbness and improved patient satisfaction.

Methods

We retrospectively assessed a group of patients who underwent plate fixation of a fractured clavicle at our institution. Using a patient-completed questionnaire, we compared differences in numbness, scar satisfaction, pain, and overall satisfaction with the operation, between those who received a horizontal incision (n = 21) versus those treated using a vertical incision (n = 14).

Results

The likelihood of experiencing post-operative numbness was less in the vertical incision group. Those who had undergone vertical incisions also reported a significantly reduced degree of numbness and significantly less awareness of the numbness with clothing and shoulder straps. There was no statistically significant difference between the groups in terms of pain and scar satisfaction. Patients who reported being most bothered by their numbness also tended to report the highest dissatisfaction with the operation.

Conclusion

Vertical incisions for plate fixation of clavicular shaft fractures may be associated with reduced post-operative numbness and avoid some cases of patient dissatisfaction. Surgeons should consider using this approach in plate fixation of clavicle fractures.     

Motorcycle spoke injuries of the heel

Introduction

The spoke injuries of the lower extremity seems never stop haunting the surgeons since its first report 62 years ago. A prospective study of motorcycle spoke injuries in the heel was undertaken to study the injury mechanism, the treatment protocols, and the outcomes.

Patients and methods

From 2001 to 2010, 89 cases of motorcycle spoke injuries of the heel were examined. The various injury mechanisms were analysed. Flaps and other reconstruction surgeries were used to manage the involved extremity.

Results

The mechanisms of the motorcycle spoke injuries of the heel had some unique features. A grading system was developed for the injuries according to the tissues involved. The surgery protocols primarily consisted of flap transfers, Achilles tendon reconstruction, and calcaneus management.

Conclusions

The eradication of the motorcycle spoke injuries is a difficult task, but the treatment outcomes have been greatly improved due to the advancement of surgical techniques.