Surgical leadership

Does the Implementation of Clinical Pathways Affect Hierarchical Structures Within a Surgical Department? A Qualitative Study

Objective:

To explore effects of the implementation of clinical pathways (CPs) on hierarchical structures within a surgical department.

Summary of background data:

CPs are care plans stipulating diagnostic and therapeutic measures along a time axis for a given condition or procedure. They are widely used in surgery. There is limited evidence to what extent CP implementation has an effect on hierarchical structures within surgical departments.

Methods:

Semistructured individual interviews were conducted with key members of a CP project team in a large academic surgery department. Interviews were carried out by an external researcher to increase the likelihood of obtaining unbiased opinions. Using an interview guide, it was ensured that respondents provided opinions on various issues related to CP implementation, including hierarchical relationships within the department, but also between caregivers and patients. The transcribed text was independently content analyzed by 2 researchers who converged their findings.

Results:

Clinical pathway implementation changed perceived surgical hierarchy from a top-down to a participatory approach. However, it was acknowledged that some form of hierarchy is required to ensure successful clinical pathway implementation. Respondents felt that clinical pathways changed surgical culture from a largely eminence-based to more evidence-based medicine.

Conclusions:

The implementation of CPs potentially affects several dimensions of surgical hierarchy. It changes “traditional” surgical hierarchy and is associated with perception of increased autonomy and competency in junior staff. The clinical approach appears to shift from eminence- to evidence-based medicine. The knowledge about these changes is important for carrying out CP projects in surgery.

Being a surgeon--the myth and the reality: a meta-synthesis of surgeons' perspectives about factors affecting their practice and well-being

OBJECTIVES

Synthesize the findings from individual qualitative studies about surgeons' account of their practice.

BACKGROUND

Social and contextual factors of practice influence doctors' well-being and therapeutic relationships. Little is known about surgery, but it is generally assumed that surgeons are not affected by them.

METHODS

We searched international publications (2000-2012) to identify relevant qualitative research exploring how surgeons talk about their practice. Meta-ethnography (a systematic analysis of qualitative literature that compensates for the potential lack of generalizability of the primary studies and provides new insight by their conjoint interpretation) was used to identify key themes and synthesize them.

RESULTS

We identified 51 articles (>1000 surgeons) from different specialties and countries. Two main themes emerged. (i) The patient-surgeon relationship, described surgeons' characterizations of their relationships with patients. We identified factors influencing surgical decision making, communication, and personal involvement in the process of care; these were surgeon-related, patient-related, and contextual. (ii) Group relations and culture described perceived issues related to surgical culture (image and education, teamwork, rules, and guidelines); it highlighted the influence of a social dimension on surgical practice. In both themes, we uncovered an emotional dimension of surgeons' practice.

CONCLUSIONS

Surgeons' emphasis on technical aspects, individuality, and performance seems to impede a modern patient-centered approach to care and to act as a barrier to well-being. Our findings suggest that taking into account the relational and emotional dimensions of surgical practice (both with patients and within the institution) might improve surgical innovation, surgeons' well-being, and the attractiveness of this specialty.

Innovation in e-learning: learning for all

Online learning is not a new concept for most in the medical profession. However, surgical oncology is poorly represented, and in a world of ever-changing research evidence, relying on published texts may not be efficient learning or an accurate representation of current practice for many trainees. This article demonstrates how our educational collaborative, ePOSSOM, approaches the problem. It outlines the development process of the whole project between ecancer and the Severn School of Surgery, UK, and provides links to the pilot completed modules on pancreatic cancer and its treatment for the reader to experience.