Judging surgical research: how should we evaluate performance and measure value?
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OBJECTIVE: To establish criteria to evaluate performance in surgical research, and to suggest strategies to optimize research in the future. SUMMARY BACKGROUND DATA: Research is an integral component of the academic mission, focusing on important clinical problems, accounting for surgical advances, and providing training and mentoring for young surgeons. With constraints on healthcare resources, there is increasing pressure to generate clinical revenues at the expense of the time and effort devoted to surgical research. An approach that would assess the value of research would allow prioritization of projects. Further, alignment of high-priority research projects with clinical goals would optimize research gains and maximize the clinical enterprise. METHODS: The authors reviewed performance criteria applied to industrial research and modified these criteria to apply to surgical research. They reviewed several programs that align research objectives with clinical goals. RESULTS: Performance criteria were categorized along several dimensions: internal measures (quality, productivity, innovation, learning, and development), customer satisfaction, market share, and financial indices (cost and profitability). A "report card" was proposed to allow the assessment of research in an individual department or division. CONCLUSIONS: The department's business strategy can no longer be divorced from its research strategy. Alignment between research and clinical goals will maximize the department's objectives but will create the need to modify existing hierarchical structures and reward systems. Such alignment appears to be the best way to ensure the success of surgical research in the future. (+info)
Likely variations in perioperative mortality associated with cardiac surgery: when does high mortality reflect bad practice?
(50/965)
OBJECTIVE: Several methods exist for estimating the risk of perioperative mortality based on preoperative risk factors; graphical methods such as the variable life adjusted display (VLAD) can be used to examine how an individual surgeon's performance for a series of operations fares against what would be expected, given the case mix. This study aimed to devise a method for assessing the natural variation in outcome in order to assist with making judgements about individual performance, in particular whether seemingly poor performance could have occurred by chance. METHOD: The risk scoring system has been derived and validated locally for cardiac surgery. A method is described for calculating the probability that an observed number of deaths occurs within a sequence of operations if perioperative mortality is regarded as a chance event with an expected value derived from the risk score. To illustrate this method, nested prediction intervals are superimposed onto VLAD plots for a series of 393 isolated coronary artery bypass and isolated valve operations performed by a single surgeon. RESULTS: Using the locally derived risk score, the VLAD plot for the individual surgeon shows a net life gain of about 6 over the predicted number of survivors, which is observed to be within the 90% prediction interval. If the Parsonnet scoring system is used instead of the locally derived risk score, the net life gain is considerably overestimated. CONCLUSIONS: The nested prediction intervals are straightforward to generate and can be integrated into a visually informative display. As an indication of the inherent variability in outcome, they have a valuable role in the monitoring of surgical performance. (+info)
Procedural skills training. Canadian family practice residency programs.
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OBJECTIVE: To survey Canadian family practice residency programs to discover which procedural skills residents are expected to learn. DESIGN: Cross-sectional eight-item questionnaire. SETTING AND PARTICIPANTS: The survey was sent to all 92 program directors and site or unit directors of family practice residency programs across Canada. MAIN OUTCOME MEASURES: Information on procedural skills lists was solicited. We sought date of creation, date of most recent revision, and who was involved in creating the list. A copy of the most recent list available was requested. RESULTS: We received 65 responses, for a 71% return rate. Surveys were received from all provinces and from all Canadian universities offering family practice residency programs. We received 24 unique lists of procedural skills: the shortest listed only 10 procedural skills; the longest, 75 skills; and the average, 36 skills. Only five procedural skills were found on more than 80% of the lists; 30 skills were listed on half or more of the lists. CONCLUSIONS: Canadian family practice residency programs have widely varying expectations of procedural skills for their residents. This survey is a first step in examining the whole issue of procedural skills training in Canadian family medicine programs. (+info)
A needs assessment of surgical residents as teachers.
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OBJECTIVE: To determine the needs of surgical residents as teachers of clinical clerks. DESIGN: A needs assessment survey. SETTING: Department of Surgery, University of Toronto. PARTICIPANTS: Clinical clerks and surgical residents and staff surgeons. METHODS: Three stakeholder groups were defined: staff surgeons, surgical residents and clinical clerks. Focus-group sessions using the nominal group technique identified key issues from the perspectives of clerks and residents. Resulting information was used to develop needs assessment surveys, which were administered to 170 clinical clerks and 190 surgical residents. Faculty viewpoints were assessed with semi-structured interviews. Triangulation of these 3 data sources provided a balanced approach to identifying the needs of surgical residents as teachers. RESULTS: Response rates were 64% for clinical clerks and 66% for surgical residents. Five staff surgeons were interviewed. Consensus was noted among the stakeholder groups regarding the importance of staff surgeon role modelling and feedback, resident attitude, time management, knowledge of clerks' formal learning objectives, and appropriate times and locations for teaching. Discrepancies included a significant difference in opinion regarding the residents' capacity to address clerks' individual learning needs and to foster good team relationships. Residents indicated that they did not receive regular feedback regarding their teaching and that staff did not place an emphasis on their teaching role. CONCLUSIONS: This study has, from a multi-source perspective, assessed the needs of surgical residents as teachers. These needs include enhancing residents' education regarding how and what to teach medical students on a surgical rotation, and a need for staff surgeons to increase feedback to residents regarding their teaching. (+info)
A longitudinal analysis of the pediatric surgeon workforce.
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OBJECTIVE: To describe the trends in the pediatric surgeon workforce during the last 25 years and to provide objective data useful for planning graduate medical education requirements. SUMMARY BACKGROUND DATA: In 1975, the Study on U.S. Surgical Services (SOSSUS) was published, including a model to survey staffing. A pediatric surgeon workforce study was initiated in conjunction with SOSSUS as a population, supply, and need-based study. The study has been updated every 5 years using the same study model, with the goals of determining the number and distribution of pediatric surgeons in the United States, the number needed and where, and the number of training programs and trainee output required to fill estimated staffing needs. This is the only such longitudinal workforce analysis of a surgical specialty. METHODS: Questionnaires were sent to 100 pediatric surgeons representing the 62 standard metropolitan statistical areas (SMSAs) in the United States with a population of 200,000 or more to verify the names and locations of all active pediatric surgeons and to gain information about the 5-year need for new pediatric surgeons by region. A program was developed to predict the number of pediatric surgeons relative to the total population and the 0-to-17-year-old population in the subsequent 30 years using updated data on the present number and ages of pediatric surgeons, age-specific death and retirement rates, projections of U.S. population by age group, and varying numbers of trainees graduated per year. As each 5-year update was done, previous projections were compared with actual numbers of pediatric surgeons found. The trends during the last 25 years were analyzed and compared and additional information regarding the demographics of practice, trends in reimbursement, and volume and scope of surgery was obtained. RESULTS: The birth rate has been stable since 1994. The 0-to-17-year-old population has been increasing at 0.65% per year; a 0.64% annual rate is projected to 2040. At present, 661 pediatric surgeons are distributed in every SMSA of 200,000 or more population, with an average age of 45 and an average age of retirement 65. The actual number of pediatric surgeons in each 5-year survey has consistently validated previous projections. Trainee output has increased markedly in the past 10 years. The rate of growth of the pediatric surgeon workforce at present is 50% greater than the forecasted rate of increase in the pediatric age group, and during the past 25 years the rate of growth of the pediatric surgeon workforce has been double that of the pediatric population growth. Nationally, significant changes in reimbursement, volume of surgery, and demographics of practice have occurred. (+info)
Does the endovascular repair of aortoiliac aneurysms pose a radiation safety hazard to vascular surgeons?
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OBJECTIVES: Endovascular aortoiliac aneurysm (EAIA) repair uses substantial fluoroscopic guidance that requires considerable radiation exposure. Doses were determined for a team of three vascular surgeons performing 47 consecutive EAIA repairs over a 1-year period to determine whether this exposure constitutes a radiation hazard. METHODS: Twenty-nine surgeon-made aortounifemoral devices and 18 bifurcated devices were used. Three surgeons wore dosimeters (1) on the waist, under a lead apron; (2) on the waist, outside a lead apron; (3) on the collar; and (4) on the left ring finger. Dosimeters were also placed around the operating table and room to evaluate the patient, other personnel, and ambient doses. Exposures were compared with standards of the International Commission on Radiological Protection (ICRP). RESULTS: Total fluoroscopy time was 30.9 hours (1852 minutes; mean, 39.4 minutes per case). Yearly total effective body doses for all surgeons (under lead) were below the 20 mSv/y occupational exposure limit of the ICRP. Outside lead doses for two surgeons approximated recommended limits. Lead aprons attenuated 85% to 91% of the dose. Ring doses and calculated eye doses were within the ICRP exposure limits. Patient skin doses averaged 360 mSv per case (range, 120-860 mSv). The ambient (> 3 m from the source) operating room dose was 1.06 mSv/y. CONCLUSIONS: Although the total effective body doses under lead fell within established ICRP occupational exposure limits, they are not negligible. Because radiation exposure is cumulative and endovascular procedures are becoming more common, individuals performing these procedures must carefully monitor their exposure. Our results indicate that a team of surgeons can perform 386 hours of fluoroscopy per year or 587 EAIA repairs per year and remain within occupational exposure limits. Individuals who perform these procedures should actively monitor their effective doses and educate personnel in methods for reducing exposure. (+info)
A study of clinical opinion and practice regarding circumcision.
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AIM: To establish clinical opinion regarding appropriate indications for circumcision and to examine actual clinical practice. METHODS: A questionnaire was sent to all NHS hospital consultants in the Yorkshire region of the UK identified as having a role to play in the management of boys (under 16 years of age) requiring circumcision. Retrospective data on actual clinical practice during a three month study period were also collected via a simple proforma. RESULTS: Of 153 questionnaires sent, 64 were returned. Responses revealed varying opinions regarding appropriate indications for circumcision within each consultant group, and between paediatricians and surgeons. Surgeons were generally more inclined to recommend circumcision for each of the indications listed in the questionnaire. Analysis of clinical practice revealed that almost two thirds of procedures were carried out for phimosis, and nearly half of these children were under the age of 5 years. CONCLUSION: There are differences in the clinical opinions of surgeons and paediatricians on what constitutes an appropriate indication for circumcision. Paediatricians' opinions are generally more in line with current evidence than those of surgeons, possibly resulting in many unnecessary circumcisions. (+info)
The influence of experience and specialisation on the reliability of a common clinical sign.
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OBJECTIVES: To explore the influence of experience and specialisation on clinical judgement by comparing accuracy in diagnosing anaemia between a consultant general surgeon, a consultant ophthalmologist and their registrars. PATIENTS AND METHODS: Conjunctival inspection of 101 patients, subsequent correlation with haemoglobin concentration. MAIN OUTCOME MEASURES: Number of correct and incorrect diagnoses of anaemia. RESULTS: 54 patients were anaemic and 47 were not. Overall accuracy in diagnosing anaemia ranged from 0.61-0.69, sensitivity 0.52-0.65 and specificity 0.62-0.83. Agreements between pairs of examiners were 0.68-0.81, with kappa values of 0.36-0.60 when adjusted for chance agreement. CONCLUSIONS: Neither experience nor specialisation significantly influenced our ability to diagnose anaemia, based on conjunctival inspection. Without critical analysis of clinical signs, we are unaware of their diagnostic limitations. (+info)