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Ewies AAA. Gynaecological surgery between generalists and high-volume specialists. J OBSTET GYNAECOL 2023; 43:2286743. [PMID: 38070125 DOI: 10.1080/01443615.2023.2286743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Ayman A A Ewies
- Pan Birmingham Gynaecological Cancer Centre, Birmingham City Hospital, Birmingham, UK
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Temkin SM, Terplan M. Levels of Gynecologic Care: A Task Force Consensus Statement. Obstet Gynecol 2023; 142:993-994. [PMID: 37734102 DOI: 10.1097/aog.0000000000005363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
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Gender Equity in Gynecologic Surgery: Lessons from History, Strengthening the Future. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00307-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tummers FHMP, Hoebink J, Driessen SRC, Jansen FW, Twijnstra ARH. Decline in surgeon volume after successful implementation of advanced laparoscopic surgery in gynecology: An undesired side effect? Acta Obstet Gynecol Scand 2021; 100:2082-2090. [PMID: 34490608 DOI: 10.1111/aogs.14242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/13/2021] [Accepted: 08/08/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The implementation of advanced minimally invasive surgical (MIS) techniques has broadened. An extensive body of literature shows that high hospital and surgeon volumes lead to better patient outcomes. However, no information is available regarding volume trends in the post-implementation phase of MIS. This study investigated these trends and poses suggestions to adjust these developments. This knowledge can provide guidance to optimize patient safe performance of new surgical techniques. MATERIAL AND METHODS A national retrospective cohort study in the Netherlands. The number of advanced laparoscopic (level 3 and 4) and robotic procedures and the number of gynecologists performing them were collected through a web-based questionnaire to determine hospital and gynecological surgeon volume. These volumes were compared with our previously collected data from 2012. RESULTS The response rate was 85%. Hospitals produced larger volumes for advanced laparoscopic and robotic procedures. However, still 63% of the hospitals perform low-volume level 4 laparoscopic procedures. Additionally, gynecological surgeon volumes appeared to decrease for level 3 procedures, as the group of gynecologists performing fewer than 20 procedures expanded (64% vs. 44% in 2012), with 15% of the gynecologists performing fewer than ten procedures. Despite an increase in surgeon volumes for level 4 laparoscopy and robotic surgery, volumes continued to be low, as still 49% of gynecologists performed fewer than 10 level 4 procedures per year and 41% performed fewer than 20 robotic procedures per year. CONCLUSIONS The broad implementation of advanced MIS procedures resulted in an increasing number of these procedures with increasing hospital volumes. However, as a side-effect, a disproportionate rise in number of gynecologists performing these procedures was observed. Therefore, surgeon volumes remain low and even decreased for some procedures. Centralization of complex procedures and training of specialized MIS gynecologists could improve surgeon volumes and therefore consequently enhance patient safety.
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Affiliation(s)
| | - Jasmin Hoebink
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sara R C Driessen
- Department of Gynecology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Frank Willem Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Bio Mechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Comparing Surgical Experience and Skill Using a High-Fidelity, Total Laparoscopic Hysterectomy Model. Obstet Gynecol 2020; 136:97-108. [DOI: 10.1097/aog.0000000000003897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Meltzer C, Hull M, Sundang A, Adams JL. Association Between Annual Surgeon Total Thyroidectomy Volume and Transient and Permanent Complications. JAMA Otolaryngol Head Neck Surg 2019; 145:830-837. [PMID: 31343681 DOI: 10.1001/jamaoto.2019.1752] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although the association between annual surgeon total thyroidectomy volume and clinical outcomes is well established, published methods typically group surgeons into volume categories. The volume-outcomes association is likely continuous, but little is known about the point at which the annual surgeon procedure volumes begin to be associated with a decrease in complication rates. Objective To model the volume-outcomes association as a continuous function and identify the point at which increasing surgeon volume begins yielding better outcomes. Design, Setting, and Participants A retrospective cohort study was conducted in 2018 to 2019 on 10 546 patients from 2 Kaiser Permanente regions (Northern and Southern California), who underwent total thyroidectomy from January 1, 2008, through December 31, 2015, and were followed up through December 31, 2017. The association between annual surgeon procedure volume and outcomes was modeled with analyses that accounted for an association of unknown form and surgeon-specific effects, after adjusting for sociodemographics, prior-year utilization, and multiple comorbidities. Data were analyzed from October 2018 to April 2019. Exposure Total thyroidectomy. Main Outcomes and Measures Presence or absence of transient and permanent hypoparathyroidism and vocal cord paralysis (VCP) in relation to surgeon volume of total thyroidectomies. Results Of 10 546 patients in this study, 8500 (81.0%) were male and 4877 (46.2%) aged 45 to 64 years. Surgeons with annual volumes of 1 to 9 total thyroidectomies operated on 2912 patients (27.7%), those with an annual volume of 10 to 19 operated on 3404 (32.6%), and those with an annual volume of 20 or more operated on the remaining 4232 (40.6%). During 2008-2015, a mean of 53.5 (range, 46-198) thyroidectomies were performed each year by surgeons with an annual volume of 40 or more procedures. A generalized additive model showed that the occurrence rates of VCP and hypoparathyroidism began to decrease at annual surgeon procedure volumes of 18.2 (95% CI, 15.0-21.5) and 18.1 (95% CI, 13.8-21.3) procedures per year, respectively. The model revealed a subsequent increase in complication rates for transient VCP. With the use of a refined model, statistically significant decreases were noted in the occurrence rates of complications as annual surgeon volumes increased. Among all 10 546 patients who underwent total thyroidectomy, 632 (6.0%) experienced transient hypoparathyroidism and 170 (1.6%) experienced permanent hypoparathyroidism, whereas 440 (4.2%) experienced transient VCP and 182 (1.7%) experienced permanent VCP. Absolute decreases in complication rates when all surgeons had modeled minimum annual procedure volumes greater than 40 were low, ranging from 0.6% for permanent VCP and hypoparathyroidism to 1.5% for transient hypoparathyroidism. Conclusions and Relevance In this study, occurrence rates of transient and permanent hypoparathyroidism and VCP appeared to decrease as the annual surgeon procedure volume increased, but the absolute decrease may be modest if the affected health system already has low complication rates. Shifting patients to higher-volume surgeons to realize these reductions may be of variable attractiveness in systems with low baseline complication rates.
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Affiliation(s)
| | - Michaela Hull
- Kaiser Permanente Center for Effectiveness & Safety Research, Pasadena, California
| | | | - John L Adams
- Kaiser Permanente Center for Effectiveness & Safety Research, Pasadena, California
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Surgeon Volume in Benign Gynecologic Surgery: Review of Outcomes, Impact on Training, and Ethical Contexts. J Minim Invasive Gynecol 2019; 26:279-287. [DOI: 10.1016/j.jmig.2018.09.775] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/08/2018] [Accepted: 09/17/2018] [Indexed: 11/20/2022]
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Chervenak FA, McCullough LB, Grünebaum A. Preventing incremental drift away from professionalism in graduate medical education. Am J Obstet Gynecol 2018; 219:589.e1-589.e3. [PMID: 30240658 DOI: 10.1016/j.ajog.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
Abstract
Professionalism is a core competency of graduate medical education programs, stipulated by the Accreditation Council for Graduate Medical Education. We identify an underappreciated challenge to professionalism in residency training, the risk of incremental drift from professionalism, and a preventive ethics response, which can occur in residency programs in countries with oversight similar to that of the Accreditation Council for Graduate Medical Education. Two major, welcome changes in graduate medical education-required duty hours and increased attending supervision-create incentives for drift from professionalism. This article analyzes these incentives based on the ethical concept of medicine as a profession, introduced into the history of medical ethics in late 18th century Britain. This concept calls for physicians to make 3 commitments: to scientific and clinical competence; to the protection and promotion of the patient's health-related interests; and to keeping individual and group self-interest systematically secondary. Some responses of programs and residents to these incentives can undermine professionalism, creating a subtle and therefore hard-to-detect drift away from professionalism that in its worst form results in infantilization of residents. Program directors and educators should prevent this drift from professionalism by implementing practices that promote professionally responsible responses to the incentives created by required duty hours and increased attending supervision.
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Vargas MV, Milad MP. Matching Trends for the Fellowship in Minimally Invasive Gynecologic Surgery Since Participation in the National Residency Match Program. J Minim Invasive Gynecol 2018; 25:1060-1064. [DOI: 10.1016/j.jmig.2018.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 11/26/2022]
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Kumar A, Wallace SA, Cliby WA, Glaser GE, Mariani A, Leitao MM, Frumovitz M, Langstraat CL. Impact of Sentinel Node Approach in Gynecologic Cancer on Training Needs. J Minim Invasive Gynecol 2018; 26:727-732. [PMID: 30138740 DOI: 10.1016/j.jmig.2018.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/12/2018] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We sought to estimate the impact of sentinel nodes in gynecologic oncology on fellowship training and discuss potential solutions. DESIGN Retrospective multi-institution cohort (Canadian Task Force classification II-2). SETTING Three tertiary cancer referral cancer centers. PATIENTS Patients with endometrial and vulvar cancer undergoing lymph node evaluation. INTERVENTIONS Patient history and fellow case volumes were evaluated retrospectively for type of lymph node assessment. MEASUREMENTS AND MAIN RESULTS Minimally invasive endometrial cancer and vulvar cancer fellow case volumes in 3 large institutions were reviewed and average annual volumes calculated for each clinical gynecologic oncology fellow. For vulvar cancer, probabilities of sentinel lymph node mapping and laterality of lesions were estimated from the literature. For endometrial cancer, estimates of lymphadenectomy rates were determined using probabilities calculated from our historic database and from review of the literature. Modeling the approaches to lymphadenectomy in endometrial cancer (full, selective, and sentinel), 100% versus 68% versus 24%, respectively, of patients would require complete pelvic lymphadenectomy and 100% versus 34% versus 12% would require para-aortic lymphadenectomy. In vulvar cancer, rates of inguinal femoral lymphadenectomy are expected to drop from 81% of unilateral groins to only 12% of groins. CONCLUSIONS Sentinel lymph node biopsy for endometrial and vulvar cancer will play an increasing role in practice, and coincident with this will be a dramatic decrease in pelvic, para-aortic, and inguinal femoral lymphadenectomies. The declining numbers will require new strategies to maintain competency in our specialty. New approaches to surgical training and continued medical education will be necessary to ensure adequate training for fellows and young faculty across gynecologic surgery.
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Affiliation(s)
- Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota.
| | - Sumer A Wallace
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Gretchen E Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
| | - Mario M Leitao
- Department of Gynecologic Oncology (Dr. Leitao), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Frumovitz
- Department of Gynecologic Oncology (Dr. Frumovitz), MD Anderson Cancer Center, Houston, Texas
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery (Drs. Kumar, Wallace, Cliby, Glaser, Mariani, and Langstraat), Mayo Clinic, Rochester, Minnesota
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Khaliq OP, Konoshita T, Moodley J, Naicker T. The Role of Uric Acid in Preeclampsia: Is Uric Acid a Causative Factor or a Sign of Preeclampsia? Curr Hypertens Rep 2018; 20:80. [PMID: 29992361 DOI: 10.1007/s11906-018-0878-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Because of the significant discrepancies on this topic, this review will focus on the role of uric acid in PE, uric acid as a predictor of preeclampsia and fetal growth retardation. We considered eligible review and original articles relevant to the research question. RECENT FINDINGS Hypertensive disorders of pregnancy such as preeclampsia (PE) are a major cause of both maternal and fetal morbidity and mortality worldwide. Uric acid has been reported as a key factor contributing to the pathogenesis of PE. Some studies have indicated that serum uric acid levels increase with the severity of PE, while several studies have shown contradictory results. Some studies suggested high uric acid levels lead to PE, while others state that PE causes an increase in uric acid levels. Despite the strong association of uric acid in the pathogenesis of preeclampsia, current data is still contradictory hence genetic and high-end laboratory investigations may clarify this enigma.
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Affiliation(s)
- Olive P Khaliq
- Optics and Imaging Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Tadashi Konoshita
- Third Department of Internal Medicine, University of Fukui Faculty of Medicine Sciences, Fukui, Japan
| | - Jagidesa Moodley
- Department of Obstetrics and Gynaecology and Women's Health and HIV Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Thajasvarie Naicker
- Optics and Imaging Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
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Moawad G, Tyan P, Corpodean F, Robinson J. Ethical Considerations Arising From Surgeon Caseload Volume in Benign Gynecologic Surgery. J Minim Invasive Gynecol 2018; 25:749-751. [DOI: 10.1016/j.jmig.2018.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/13/2018] [Indexed: 11/16/2022]
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Using Concentration Curves to Assess Organization-Specific Relationships between Surgeon Volumes and Outcomes. Jt Comm J Qual Patient Saf 2018; 44:321-327. [DOI: 10.1016/j.jcjq.2017.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/10/2017] [Indexed: 11/22/2022]
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The role of simulation and warm-up in minimally invasive gynecologic surgery. Curr Opin Obstet Gynecol 2018; 29:212-217. [PMID: 28520585 DOI: 10.1097/gco.0000000000000368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills. RECENT FINDINGS Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes. SUMMARY Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.
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Finding the Value of Minimally Invasive Gynecologic Surgery. Clin Obstet Gynecol 2018; 60:223-230. [PMID: 28121645 DOI: 10.1097/grf.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Minimally invasive surgery is indistinctly defined and some cases possess clinical outcomes that are similarly indistinct or excessively costly. Seeking to clarify these issues will offer organized medicine an opportunity to deliver value-based health care. Context (patient, society, and clinician) is critical to finding that clarity, although the clinician context likely offers the best insights into how the ideal of high-value care may be incorporated into minimally invasive gynecologic surgery.
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Kho RM. Prophylactic bilateral salpingectomy at vaginal hysterectomy: time for a "policy"? Am J Obstet Gynecol 2017; 217:503-504. [PMID: 29110812 DOI: 10.1016/j.ajog.2017.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/25/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Rosanne M Kho
- Section of Benign Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH.
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Gutman RE, Morgan D, Levy B, Kho RM, Walter AJ, Mansuria S. How Can We Increase the Percentage and Quality of Minimally Invasive Hysterectomy for Benign Disease Among Low/Intermediate-Volume Gynecologic Surgeons? A Perspective Piece From an Expert Panel Session at the 2017 Society of Gynecologic Surgeons Annual Meeting. J Minim Invasive Gynecol 2017; 24:1055-1059. [PMID: 28576694 DOI: 10.1016/j.jmig.2017.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Robert E Gutman
- MedStar Washington Hospital Center, Georgetown University, Washington, DC.
| | | | - Barbara Levy
- American Congress of Obstetricians and Gynecologists, Washington, DC
| | | | | | - Suketu Mansuria
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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