Awori J. Hayanga

Results of a national survey of surgical resident interest in international experience, electives, and volunteerism.

BACKGROUND Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. STUDY DESIGN A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. RESULTS Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried >or=

Residual Treatment Disparities After Oncology Referral for Rectal Cancer

100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). CONCLUSIONS American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

Implementing Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center

BACKGROUND Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists. METHODS We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided. RESULTS There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy. CONCLUSION Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Residential Segregation and Access to Surgical Care by Minority Populations in US Counties

BACKGROUND Effective communication and teamwork are critical in many health care settings, particularly the operating room (OR). Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR. METHODS In a prospective cohort study at a high-volume teaching, research, and tertiary care referral hospital, a standardized one-page briefing and debriefing tool was developed and implemented in October 2006 to improve interdisciplinary communication and teamwork in the OR. The briefing portion of the tool was completed by the surgical team after the patients final positioning and before incision; the debriefing portion was initiated and completed by the circulating nurse after the first counts were conducted. Compliance was calculated as the number of cases where the briefing and debriefing tool was completed divided by the total number of eligible cases. Surveys (n=40) were conducted to elicit caregiver perceptions of interdisciplinary communication and teamwork in the OR and the burden and average time taken to complete the briefing and debriefing tool. RESULTS Between October 2006 and March 2008, 37,133 briefings and debriefings were conducted. Average compliance varied over time since implementation, with overall compliance ranging from 76% to 95%. The majority of caregivers perceived that the briefing and debriefing tool improved interdisciplinary communication and teamwork. On average, it took 2.9 minutes (range, 1-5 minutes) to complete the briefing portion of the tool and 2.5 minutes (range, 1-5 minutes) to complete the debriefing portion. DISCUSSION Implementation of a standardized briefing and debriefing tool in a large regional medical center was a, practical and feasible strategy to improve perceptions of interdisciplinary communication and teamwork in the OR.

The impact of high body mass index on postoperative complications and resource utilization in minority patients.

BACKGROUND Minority groups in the US have comparatively poorer access to a range of health care services. Access can be considered a function of opportunity and use and can vary with the level of segregation within a county. We hypothesized that with varying levels of segregation, increasing the proportion of the minority population within a county was accompanied by decreasing levels of access to surgical care. STUDY DESIGN A cross-sectional analysis was performed on data from the 2004 Area Resource File. Each county in the US was categorized into one of three levels: most, moderately, or least segregated, using the Isolation Index. Multivariable linear regression analysis was performed to examine the association between access to surgical services and proportion of minority population with varying levels of segregation adjusting for socioeconomic and health characteristics. RESULTS In the most segregated counties, each percentage point increase in Hispanic or African-American population was associated with a statistically significant decrease in outpatient surgery volume (p < 0.0001), ambulatory surgical facilities (p < 0.0001), and number of general surgeons (p < 0.0001). In the least segregated counties, these associations showed no statistical significance. A significant increase (p < 0.0001) in the volume of emergency medical visits was associated with increasing proportions of African-American and Hispanic populations within the most segregated counties. CONCLUSIONS In the most segregated counties, an increase in the African-American or Hispanic population was associated with a decrease in the availability and use of surgical services and an increase in emergency visits after adjustment for socioeconomic and health characteristics.

Paraneoplastic Pemphigus in a Burn Intensive Care Unit: Case Report and Review of the Literature

BACKGROUND Obesity is disproportionately prevalent among minority patients, yet very little has been written about its effect on surgical outcome in this group. OBJECTIVE We investigated the association of body mass index (BMI) category with perioperative complications and resource utilization. METHODS Data from the American College of Surgeons National Surgical Quality improvement Program Participant Use Data File was used to calculate the BMI (kg/m2) of all minority patients undergoing inpatient surgery from 2005 to 2008. Patients were stratified into 4 BMI classes, ranging from normal weight to severely obese. Postoperative length of stay (LOS) was used as the main proxy for resource utilization. Stepwise logistic regression was used to calculate odds ratios for prolonged LOS after controlling for clinically relevant cofactors. RESULTS Among 73978 patients, 28% were in the normal BMI category, 28.9% were overweight, 28.2% were obese, and 14.9% were severely obese. Morbidity and mortality distribution varied significantly by BMI category, with the highest proportion of cases occurring in the normal-BMI group and the lowest in the severely obese patients. Postoperative LOS was longer for patients in the normal-BMI group than for severely obese patients. Other markers of resource utilization also followed the same pattern with progressive decrease from normal-BMI patients to the severely obese group. CONCLUSION Postoperative morbidity and mortality and markers of hospital resource consumption were highest in the normal-BMI patients and decreased progressively to the severely obese group. This group appears to enjoy a paradoxical protection from perioperative complications and so utilize fewer hospital resources.

A contaminated source of drinking water in Kenya : who will take the blame?

Paraneoplastic pemphigus is a rare cause of acute diffuse blistering in the adult patient. It commonly presents with subepidermal blistering, epidermal necrosis, and symptoms of mucosal irritation, such as conjunctivitis and vaginal ulceration. Because of its rarity, it is frequently misdiagnosed as Stevens-Johnson syndrome or toxic epidermal necrolysis. In this study, the authors will describe clinical and histologic manifestations of paraneoplastic pemphigus. This case report describes a 45-year-old woman with paraneoplastic pemphigus who was admitted and treated in a burn intensive care unit. Although initially diagnosed with Stevens-Johnson syndrome, the patient had progression of desquamation when potentially offending medications were discontinued. Diffuse adenopathy was noted on examination, and biopsy confirmed a low-grade lymphoma. Paraneoplastic pemphigus is a rare but important cause of acute diffuse blistering in adults. This disorder should be considered in the differential diagnosis of patients with diffuse blistering.

Wangari Mathai: an African woman’s environmental and geopolitical landscape

A recent contamination of the water supply in a rural district in Kenya is used as a point of discussion. Many canine carcasses were dumped in a major water source. This highlighted one of the shortcomings of the privatization of water supply and sanitation under the Water Act of Kenya in 2002. In the absence of strict governmental regulation, there may be little reliability in the provision of safe water. Contaminated water sources may ultimately have significant deleterious public health effects where appropriate sanitation and purification standards are not met and once again the lowest socio‐economic groups may fare the worst. Water supply problems and poverty go together.

Legislating change in surgical residency

In 2004, Wangari Mathai became the first African woman ever to receive the Nobel Peace prize. The award was bestowed on her for her contribution to reforestation efforts in Kenya through her non‐governmental organization, The Green Belt Movement. She is responsible for having planted 35 million trees and simultaneously carving out a geopolitical agenda that she has used as a vehicle to challenge governmental policy, lead her parliamentary constituents and elevate an environmental conservationist manifesto to a global level. Her struggle highlights gender inequalities in education, economics and leadership that remain a common denominator in many parts of sub‐Saharan Africa. Her achievements, however, offer an alternative and inspiring blueprint for the contemporary African woman and strengthen the principle that increasing female education and financial independence may serve to improve societal health, political freedom and economic prosperity as a whole.

The End of Poverty: Economic Possibilities for Our Time

The Patient Protection and Affordable Care Act, also known as the House of Representatives Bill HR 3590, was created to improve the quality of patient care and access to health care for American citizens. Provisions of this bill are likely to have both intended and unintended consequences on surgical education. The purpose of this article is to explore the ways in which HR 3590 may affect the educational experience of surgical house officers at teaching hospitals.