Ashton Barnett-Vanes

The impact of feedback of intraoperative technical performance in surgery: a systematic review

Objectives Increasing patient demands, costs and emphasis on safety, coupled with reductions in the length of time surgical trainees spend in the operating theatre, necessitate means to improve the efficiency of surgical training. In this respect, feedback based on intraoperative surgical performance may be beneficial. Our aim was to systematically review the impact of intraoperative feedback based on surgical performance. Setting MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews were searched. Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. 32 data-points per study were extracted. Participants The search strategy yielded 1531 citations. Three studies were eligible, which comprised a total of 280 procedures by 62 surgeons. Results Overall, feedback based on intraoperative surgical performance was found to be a powerful method for improving performance. In cholecystectomy, feedback led to a reduction in procedure time (p=0.022) and an improvement in economy of movement (p<0.001). In simulated laparoscopic colectomy, feedback led to improvements in instrument path length (p=0.001) and instrument smoothness (p=0.045). Feedback also reduced error scores in cholecystectomy (p=0.003), simulated laparoscopic colectomy (p<0.001) and simulated renal artery angioplasty (p=0.004). In addition, feedback improved balloon placement accuracy (p=0.041), and resulted in a smoother learning curve and earlier plateau in performance in simulated renal artery angioplasty. Conclusions Intraoperative feedback appears to be associated with an improvement in performance, however, there is a paucity of research in this area. Further work is needed in order to establish the long-term benefits of feedback and the optimum means and circumstances of feedback delivery.

Prevalence of undiagnosed asymptomatic bacteriuria and associated risk factors during pregnancy: a cross-sectional study at two tertiary centres in Cairo, Egypt

Background The prevalence of asymptomatic bacteriuria (ASB) during pregnancy is poorly understood in Egypt—a country with a high birth rate. Objectives To determine the prevalence of ASB among pregnant women booking at El Hussein and Sayed Galal Hospitals in Al-Azhar University in Egypt; and to observe the relationship between ASB prevalence and risk factors such as socioeconomic level and personal hygiene. Setting Obstetrics and gynaecology clinics of 2 university hospitals in the capital of Egypt. Both hospitals are teaching and referral hospitals receiving referrals from across over the country. They operate specialist antenatal clinics 6 days per week. Participants A cross-sectional study combining the use of questionnaires and laboratory analysis was conducted in 171 pregnant women with no signs or symptoms of urinary tract infection (1 case was excluded). Samples of clean catch midstream urine were collected and cultured using quantitative urine culture and antibiotic sensitivity tests were performed. Results Of 171 pregnant women, 1 case was excluded; 17 cases (10%, 95% CI 5.93% to 15.53%) were positive for ASB. There was a statistically significant relation between the direction of washing genitals and sexual activity per week—and ASB. Escherichia coli was the most commonly isolated bacteria followed by Klebsiella. Nitrofurantoin showed 100% sensitivity, while 88% of the isolates were resistant to cephalexin. Conclusions The prevalence of ASB seen in pregnant women in 2 tertiary hospitals in Egypt was 10%. E. coli and Klebsiella are the common organisms isolated. The direction of washing genitals and sexual activity significantly influences the risk of ASB. Pregnant women should be screened early for ASB during pregnancy; appropriate treatment should be given for positive cases according to antibiotic sensitivity screening. Cephalexin is likely to be of limited use in this management.

MB/PhD training in the UK: towards embracement

Editor – The MD/PhD training model in use for over 30 years in the USA is accredited with assisting ‘the emergence of US leadership in clinical science’. Calls to strengthen translational research in the UK have highlighted the increasing demand for clinician-scientists. Recent articles describing outcomes of MB/PhD graduates at the University of Cambridge and University College London have demonstrated the potential of such programmes to nurture aspiring clinician-scientists in academic research and to contribute to translational medicine. Yet limited development of the UK MB/PhD system leaves much of this medical cohort’s potential untouched.

Clinician-scientist MB/PhD training in the UK: a nationwide survey of medical school policy

Objective This study surveyed all UK medical schools regarding their Bachelor of Medicine (MB), Doctor of Philosophy (PhD) (MB/PhD) training policy in order to map the current training landscape and to provide evidence for further research and policy development. Setting Deans of all UK medical schools registered with the Medical Schools Council were invited to participate in this survey electronically. Primary The number of medical schools that operate institutional MB/PhD programmes or permit self-directed student PhD intercalation. Secondary Medical school recruitment procedures and attitudes to policy guidance. Findings 27 of 33 (81%) registered UK medical schools responded. Four (14%) offer an institutional MB/PhD programme. However, of those without institutional programmes, 17 (73%) permit study interruption and PhD intercalation: two do not (one of whom had discontinued their programme in 2013), three were unsure and one failed to answer the question. Regarding student eligibility, respondents cited high academic achievement in medical studies and a bachelors or masters degree. Of the Medical schools without institutional MB/PhD programmes, 5 (21%) have intentions to establish a programme, 8 (34%) do not and 3 were unsure, seven did not answer. 19 medical schools (70%) considered national guidelines are needed for future MB/PhD programme development. Conclusions We report the first national survey of MB/PhD training in the UK. Four medical schools have operational institutional MB/PhD programmes, with a further five intending to establish one. Most medical schools permit study interruption and PhD intercalation. The total number MB/PhD students yet to graduate from medical school could exceed 150, with 30 graduating per year. A majority of medical school respondents to this survey believe national guidelines are required for MB/PhD programme development and implementation. Further research should focus on the MB/PhD student experience. Discussion regarding local and national MB/PhD policies between medical schools and academic stakeholders are needed.

Disaster curricula in medical and health care education: Adopting an interprofessional approach

Correspondence: Ashton Barnett-Vanes Sir Alexander Fleming Building Imperial College London South Kensington Campus London SW7 2AZ E-mail: ashton.barnett-vanes11@imperial.ac.uk Disasters continue to pose substantial threats to human health worldwide. Knowledge in the principles of disaster medicine and of the wider function of the health system is therefore essential for health care teams who must respond effectively in dynamic environments with strained resources. Developed in 2005 by the United Nations International Strategy for Disaster Reduction, the Hyogo Framework for Action acknowledged the importance of ‘‘knowledge, innovation and education’’ to help build disaster resilience, emphasizing the need for individuals to be ‘‘well prepared and ready to act.’’ Strengthening the preparedness of health systems to support disaster-affected communities could start in university, with educational strategies aimed at medical and health care students. Despite increasing international attention, current disaster curricula coverage levels during undergraduate pre-license training appear alarmingly low. Moreover, little consideration has been given to collaborative learning among medical and other health care students, which is vital if we are to ‘‘successfully mitigate the effects of disasters.’’ Interprofessional collaboration is the foundation of effective health care teams. Barriers to this, such as difficulties over leadership, uncertainty, negotiation, and conflict resolution, are exacerbated in the disaster setting. Interprofessional disaster education could therefore strengthen non-technical skills needed to overcome these barriers early, and prevent imbalances in the educational experiences and competencies of different medical and health care students in disaster medicine. Thus far, educational efforts ‘‘have been limited primarily to individual specialties’’; defragmentation of these programs could enable a holistic interprofessional approach. Furthermore, disasters demand unique interprofessional collaboration between health care professionals and other services in these settings, particularly among specialist units such as Disaster Medical Assistance Teams. The importance of preparing future health care practitioners for disasters, together with the interprofessional challenges disaster situations pose, suggests that research on interprofessional disaster education programs is warranted. Despite the existence of small-scale pilot initiatives, which demonstrate the potential to establish strong interprofessional skills among health care students in the context of disasters, the evidence base on this subject remains limited and must be strengthened. This could be achieved by expanding on previous initiatives, towards large-scale, multi-institute pilot programs, with standardized curricula and outcome measures. Student representative organizations have expressed their desire to enhance disaster education for medical and health care students. For example, the International Federation of Medical Students, an international body representing over 1 million medical students worldwide, produced a policy statement in 2012 calling on medical schools to ‘‘incorporate disaster medicine and health emergency management into the medical curricula’’ and the health sector to ‘‘provide training of medical students and other health care professionals in disaster medicine and health emergency management.’’ Furthermore, another organization, Asian Medical Students’ Association-International, chose disaster medicine as the theme of its 2012 conference. Further progress will need agreement among educationalists on disaster curricula content and strategies for implementation. Dialogue among these stakeholders also should involve disaster organizations and student representatives. Together with input from national and international interprofessional organizations, appropriate development and integration of interprofessional disaster education into mainstream medical and health care curricula could be achieved. Interprofessional organizations could ensure Received: May 18, 2013 Accepted: July 2, 2013

Towards an equitable internship programme at WHO: is reform nigh?

### Summary Box The global health workforce is under immense strain.1 For example, Africa—a continent with one-third of the worlds disease burden has only ∼3% of global health personnel.2 This year WHO launched its Global Strategy on Human Resources for Health 3 (GSHRH)—calling for a redoubling of efforts to better train and equip the global health workforce in order to strengthen public health capacity; echoing the 2006 World Health Assembly (WHA) resolution ‘Rapid scaling up of health workforce production’ passed in 2006.4 In pursuit of these aims, WHO runs a range of external programmes to train public health professionals, including the WHO Fellowship Programme; and through partnership with over 700 collaborating centres—often at universities—in more than 80 countries. In addition to these external programmes, WHO also runs what should be an internal training programme for future public health …

Redefining global health-care delivery

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded signifi cantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-eff ectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering eff orts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of eff ective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

Confronting the Global Burden of Surgical Disease: The Research Tools for the Job

To the Editor, Mock aptly highlights in the May 2013 issue of the World Journal of Surgery, the core components required of public health initiatives to achieve global reductions in morbidity and mortality from surgical disease. Data collection, provision of essential services, and political support, as illustrated in the case of maternal health, have contributed to a 30 % reduction in deaths over the last two decades [1]. While we agree that ‘‘more needs to be done to define the overall burden of death and disability avertable by improved surgical care,’’ little attention has been given to developing capacity in lowand middle-income countries (LMICs) to collect, monitor, and disseminate the data required to achieve this goal, thereby informing health initiatives at both the national and international level. For example, a landmark study in 2008 that sought to estimate the global volume of surgery could only access full country-wide surgical data for 25 % of WHO member states [2]. Though helpful, estimates cannot replace detailed in-country statistics. Given that such estimates influence international decision making and subsequent resource allocation, global health stakeholders should place greater focus on supporting LMICs in developing rigorous and scientific frameworks for disease monitoring and data collection. These must be low-cost to implement, reproducible, and encourage the development of future generations of researchers, a priority for tackling major challenges facing humanity [3]. A number of approaches could help in achieving this goal. First, surgical research collaborators and funders in high-income settings should seek to invest in local LMIC research settings. By transferring skills and expertise to personnel on-the-ground, sustained local research activity could continue long after the completion of time-scaled projects. Second, there is a need for innovative methods to cost-effectively enhance surgical disease monitoring. Training and expansion of community-based surveillance volunteers has been proposed as a strategy to supplement existing surveillance efforts [4]. Other strategies include the use of mobile health technology (mHealth) to rapidly communicate surveillance data, empowering patients and circumventing logistical barriers such as transportation. Finally, provision of funding (including development aid) is needed to establish and maintain research infrastructure in LMICs, and to support coordinated research. The launch of the online platform ‘World RePORT’, through collaboration between nine major funding organizations is a significant step toward mapping where research drives are most needed [5]. For example, searching this database using the keywords ‘‘surgical’’ and ‘‘surgery’’ returns a total of 12 projects in sub-Saharan Africa, compared to over 200 for ‘‘malaria.’’ Such tools offer new opportunities to triangulate areas in need, potential synergies between projects, and areas where duplication or other inefficiencies may exist. Adequate research initiatives in LMICs are required to better confront the global burden of surgical disease. However, without the provision of essential surgical services that are accessible to all, and the political will to enable this, progress will falter. Yet, if the scale of unmet global surgical need is to be accurately defined, the global health community must equip health and research personnel in affected regions with the tools necessary to achieve it. In turn, this will enable a coordinated and well-resourced A. Barnett-Vanes (&) J. Shalhoub Imperial College London, London SW7 2AZ, UK e-mail: ashton.barnett-vanes11@imperial.ac.uk

Improving health in humanitarian crises: from reactive to proactive.

www.thelancet.com Vol 382 August 24, 2013 679 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ Chinese ethnic-minority communities in disaster-prone areas while gathering crucial information, hold the potential to foster sustained community preparedness. The humanitarian health response to crises is shaped by the preparedness of affected communities and the resilience of their health systems. Reflecting this interdependence through a trans-phase humanitarian research framework might seize the opportunity for an integrated and proactive approach from future humanitarian and development health initiatives. Such an approach will aid continuity and improve efficacy by addressing the disaster-development continuum as a whole.