Bruce P. Waxman

SURGEONS’ ATTITUDES TOWARDS AND USAGE OF EVIDENCE‐BASED MEDICINE IN SURGICAL PRACTICE: A PILOT STUDY

Background:  Within surgery the debate about the place of evidence‐based medicine (EBM) has focused on the nature and compatibility of EBM with surgical practice with an inevitable polarization of opinion. However, EBM techniques are being embedded into undergraduate medical curricula and surgical training programs across Australia. The Monash University Department of Surgery at Monash Medical Centre implemented a pilot study to explore current knowledge, attitudes and behaviours of practising surgeons towards EBM techniques.

ADHERENCE TO GUIDELINES FOR PREVENTION OF POSTSPLENECTOMY SEPSIS. AGE AND SEX ARE RISK FACTORS: A FIVE-YEAR RETROSPECTIVE REVIEW

Background:  Vaccination, education and use of long‐term antibiotics are recommended in expert guidelines for the prevention of infectious complications after splenectomy. However, studies outside Australia have shown poor adherence to the guidelines. The aim of this study was to determine overall adherence to the guidelines and to ascertain any independent risk factors for poor compliance with the guidelines.

Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy.

Background:  To document the technical aspects, outcome and lessons learnt during the learning curve phase of implementing laparoscopic splenectomy, by comparing the results before and after the introduction of a standardized technique.

Adaptive ageing surgeons

The surgical workforce is ageing. This will impact on future workforce supply and planning, as well as the professional performance and welfare of surgeons themselves. This paper is a ‘call to arms’ to surgeons to consider the complex problem of advancing years and surgical performance. We aim to promote discussion about the issue of ageing as it relates to surgeons, while exploring ways in which successful ageing in surgeons may be promoted. The task‐specific aspects of surgical practice suggest that it is a physically and cognitively demanding task, reliant on a range of fine motor, sensory, visuospatial, reasoning, memory and processing skills. Many of these skills potentially decline with age, although there is great inter‐individual variation, particularly in cognitive performance. Nevertheless, there is some consensus in the literature that age‐related cognitive changes exist in a proportion of surgeons, and there is an increase in operative mortality rates for certain surgical procedures performed by older and more experienced surgeons. In the absence of mandatory retirement, guidance is needed in regard to individualizing the timing of retirement and encouraging reflective and adaptive practice based on insight into how ones skills and performance may change with age. This may be best facilitated by some form of informed and guided self‐monitoring or ‘self‐screening’. It should be emphasized that self‐screening is not a form of self‐treatment but aims to enhance insight, using a tool kit of resources to promote adaptive ageing. Moreover, self‐screening should not be restricted to cognition, which is only part of the picture of ageing, but extended to emphasize the maintenance of mental and physical wellness, and the acceptance of independent professional treatment and support when required.

Patient perceptions of the surgical ward round

than one, error-producing condition. Most errors occurred during after-hours shifts when the staff were treating an unfamiliar patient, often shortly after handover from another team. Many were associated with reports of tiredness or when the staff were busy and distracted by other demands. It is not difficult to understand how these conditions increase the risk of medication error, but the findings also suggest potential defensive strategies. Staff can be taught the importance of latent error-producing conditions when there is a need to be especially vigilant to the possibility of committing an error. The problem of distraction during drug prescribing and administration needs particular attention. The danger inherent in conducting seemingly routine tasks, including re-writing drug charts, needs to be acknowledged. A strategy akin to surgery ‘time out’ seems appropriate so that staff can complete all medication-related tasks and check for accuracy free from other distractions. The knowledge-based mistakes that were committed by doctors during the prescription of a new medication were also associated with latent conditions. Fatigue and distraction may explain why they failed to fill gaps in their knowledge during the prescribing process, but there were additional identifiable factors. The prescribing doctors were junior and quite often reported that they lacked guidance from experienced colleagues. Sometimes, low expectations of a helpful response lead to a reluctance to ask. Sometimes, they were too busy to check available drug information on the hospital computer system, and sometimes there were queues for the ward computer terminals. The main implication of these disturbing findings is that these doctors failed to recognize the dangers inherent in prescribing unfamiliar medications. Other studies have found that doctors often underestimate the dangers in prescribing. Another implication is that more education in clinical pharmacology or therapeutics will not necessarily improve the situation. Access to appropriate drug information at the time of prescribing is crucial, and prescribing doctors need strong encouragement to adhere to the rules of safe prescribing. We also found distinct differences in how ADEs were dealt with at our hospital. All the nurses and pharmacists had discussed the incident with supervisors, which had been reported to the Australian Incident Monitoring System. In contrast, no ADE committed by medical staff had been formally reported, and two-thirds of the doctors we interviewed had not known that their actions had lead to an ADE. They had received no feedback until being approached by the research team because the errors had been committed after hours on patients belonging to other teams. We interpreted this as a lost opportunity to learn from mistakes and also, possibly, a reluctance to acknowledge the ADE by the treating team. What lessons can be drawn to guide surgical practice? First, this is an important topic for surgeons. Errors and error-prone conditions are ubiquitous, and ADEs are likely to be a significant additional problem for surgical patients. Possibly the most important step would be for a surgeon to accept this reality and to consider how to improve the situation in their own practice. My personal recommendation would be to arrange for an audit of existing patients, and I would be very surprised if errors, potential ADEs and actual ADEs were not detected in quite a small sample. The hospital pharmacy service is generally happy to assist with drug audits. The second most important step would be to carry out some sensible action to attempt to improve the system of drug management. Possible strategies include insisting that safe prescribing habits are adopted by junior staff and advocacy for automated prescribing in your hospital. The clinical pharmacy service is an often under-utilized resource, and there is evidence that pharmacists can pick up potentially harmful prescribing errors before they occur. Senior surgeons have the capacity to take the lead and engender a change of culture surrounding the problem of suboptimal drug management.

A qualitative evaluation of the Care of the Critically Ill Surgical Patient course

Background:  The Care of the Critically Ill Surgical Patient (CCrISP) course was adapted by the Royal Australasian College of Surgeons, being made compulsory for all Basic Surgical Trainees in 2001. The aim of this study was to evaluate whether the course objectives were achieved and identify strengths and weaknesses.

Adhesives and adhesions: intestinal surgery on a sticky wicket!

In the healing of incised wounds, specifically in the peritoneal cavity, there is a delicate balance between adherence of the wound edges and adhesions between peritoneal surfaces. For bowel anastomosis, adherence of the wound edges is vital to allow apposition and wound healing and avoid leakage of intraluminal content. The traditional use of sutures and staples has now been augmented by tissue adhesives in an attempt to obtain a more favourable outcome, yet avoid excessive adhesion formation. A tissue adhesive may be defined as a substance that by polymerization will hold tissues together and provide a barrier to leakage. 1 Ideally, the adhesive must maintain approximation long enough for wound healing to occur, then dissolve or be absorbed without hindering the healing process. Safety of the product is vital to minimize adverse events particularly toxic, inflammatory or infectious sequelae. Tissue adhesives in clinical use include: fibrin sealants, albumin-based compounds (glutaraldehyde glues), cyanoacrylates (super glue), hydrogels (polyethylene glycol polymers) and collagen-based adhesives (collagen combined with fibrin). Of these, the fibrin sealants have had by far the widest application in almost all surgical procedures, and in bowel surgery have demonstrated good results in wound healing and reducing adhesions. 2

A balance of fellowship and science: a model for RACS Regional Committee Annual Scientific Meetings

dents. New patient cases relevant to someone’s projects are alerted to the person concerned by colleagues or students (e.g. a student sending a short message to a supervisor, providing a new patient’s name and admission number); a digital camera or a smart phone is used to shoot images whenever appropriate and feasible; and research ideas that cross one’s mind are recorded in a smart phone, a small notebook, or a slip of paper at any time, including during the short breaks between operations and at each section’s monthly/biweekly research meetings. This cadre of diligent orthopaedic surgeons working in a Level 3-Grade A hospital in East China resembles clinician researchers/ scientists, to use Anglo-American terminology. Yet the time for research is not officially counted into these hard-pressed Chinese surgeons’ workload. It is likely the most research-active doctors in the more reputable specialty departments in other major hospitals in the country are in a similar situation of juggling between the hardship of being responsible doctors and productive researchers at the same time. As a possible contrast to the situation in the Anglo-American context where the workforce of clinicians conducting research has been reportedly dwindling, clinician researchers in China may be growing in number.

Postgraduate surgical education and training in Canada and Australia: each may benefit from the other's experiences.

Canada and Australia share similar cultural origins and current multicultural societies and demographics but there are differences in climate and sporting pursuits. Surgeons and surgeon teachers similarly share many of the same challenges, but the health care and health‐care education systems differ in significant ways. The objective of this review is to detail the different postgraduate surgical training programs with a focus on general surgery and how the programs of each country may benefit from appreciating the experiences of the other. The major differences relate to entry requirements, the role of universities in governance of training, mandatory skills courses in early training, the accreditation process, remuneration for surgical teachers and the impact of private practice. Many of the differences are culturally entrenched in their respective medical systems and unlikely to change substantially. Direct entry into specialty training without an internship per se is now firmly established in Canada just as delayed entry after internship is mandated by the Australian Medical Board. Both recognize the importance of establishing goals and objectives, modular curricular and the emerging role of online educational resources and how these may impact on assessments. The Royal Australasian College of Surgeons is unlikely to cede much responsibility to the universities but alternative academic models are emerging. Private health care in the two countries differs, but there are increasing opportunities for training in the private sector in Australia. In spite of the differences, both provide excellent health care and surgical training opportunities in an environment with significant fiscal, technological and societal challenges.

MEDICINE IN SMALL DOSES

The guardians of the Declaration, the World Medical Association (WMA), is calling for submissions to undertake another revision of the document. The Declaration of Helsinki was first developed in 1964, indirectly from the Nuremberg Code of 1947, and has already weathered five revisions and two clarifications. The objectives of this revision are to identify any gaps in the content, but more importantly to use this process to promote the declaration and maintain its relevance. The current (2004) version is the only official one and all previous versions have been replaced and should not be used or cited except for historical purposes (www.wma.net/e/ethicsunit/helsinki.htm). Goodyear et al. (BMJ 2007; 335: 624–5) who question how effective the declaration has become, with frequent violations and without monitoring or enforcement, however, are very supportive of its value as an ‘external imposed morality’, overriding any values of an individual researcher. Moreover, its strength lies in its basic principles and procedural rules that promote high ethical standards and protect the vulnerable. He points out, however, that the World Medical Association must be open and transparent in this revision and maintain the basic principles that should apply all aspects of the conduct and presentation of the results of the research. The WMA will provide the final amendments of the revision for the adoption by the General Assembly in October 2008. The Royal Australasian College of Surgeons (RACS) endorses the Declaration within the College’s Code of Conduct (www.surgeons.org and search ‘Code of Conduct’).