Examining the Growing Demand for Surgical Care in Rural Communities and Novel Approaches to Achieving a Sustainable Surgical Workforce: A Narrative Review

Surgery continues to be an increasingly vital component of public health and aspect of patient care in rural communities. An anticipated shortage of surgeons within the next decade in the United States prompts a growing concern for increasing the delivery of essential surgical care to these populations. When considering the existing barriers to surgical healthcare in rural communities, there is a sense of urgency to identify innovative approaches that will promote a sustainable surgeon workforce. A narrative review was conducted to investigate the current state of access to essential surgical care in rural communities. Qualitative and quantitative data were collected to better understand the key issues in rural healthcare and to provide statistical data related to the status of the surgical workforce. With the anticipated shortage of surgeons in both rural and urban areas, this review highlights the importance of enacting immediate measures to address the concern. This review has accomplished the initial objectives of gaining a better understanding of the current state of access to surgical care in rural communities and utilizing this knowledge to provide recommendations to readily attain a sustainable number of rural surgeons. With each approach addressing ways to address the contributory issues to the surgeon shortage, this review reveals a new avenue of integrating valuable aspects from each approach, rather than relying on a single approach. In particular, enhancing the overall pipeline of medical training to attending status may prove to be more beneficial for achieving this goal. Ultimately, this may be accomplished by introducing additional rural surgical mentorship opportunities for medical students, developing a rural surgery fellowship, and incorporating a market-based response that will correspond to attractive incentives that help to retain a sustainable number of surgeons working in rural areas.

Hand Motion Analysis Illustrates Differences When Drilling Cadaveric and Printed Temporal Bone

OBJECTIVE

Temporal bone simulation is now commonly used to augment cadaveric education. Assessment of these tools is ongoing, with haptic modeling illustrating dissimilar motion patterns compared to cadaveric opportunities. This has the potential to result in maladaptive skill development. It is hypothesized that trainee drill motion patterns during printed model dissection may likewise demonstrate dissimilar hand motion patterns.

METHODS

Resident surgeons dissected 3D-printed temporal bones generated from microCT data and cadaveric simulations. A magnetic position tracking system (TrakSTAR Ascension, Yarraville, Australia) captured drill position and orientation. Skill assessment included cortical mastoidectomy, thinning procedures (sigmoid sinus, dural plate, posterior canal wall) and facial recess development. Dissection was performed by 8 trainees (n = 5 < PGY3 > n = 3) using k-cos metrics to analyze drill strokes within position recordings. K-cos metrics define strokes by change in direction, providing metrics for stroke duration, curvature, and length.

RESULTS

T-tests between models showed no significant difference in drill stroke frequency (cadaveric = 1.36/s, printed = 1.50/s, P < .40) but demonstrate significantly shorter duration (cadaveric = 0.37 s, printed = 0.16 s, P < .01) and a higher percentage of curved strokes (cadaveric = 31, printed = 67, P < .01) employed in printed bone dissection. Junior staff used a higher number of short strokes (junior = 0.54, senior = 0.38, P < .01) and higher percentage of curved strokes (junior = 35%, senior = 21%, P < .01).

CONCLUSIONS

Significant differences in hand motions were present between simulations, however the significance is unclear. This may indicate that printed bone is not best positioned to be the principal training schema.

General surgery in Canada: current scope of practice and future needs

BACKGROUND

The scope of practice of general surgeons in Canada is highly variable. The objective of this study was to examine the demographic characteristics of general surgeons in Canada and compare surgical procedures performed across community sizes and specialties.

METHODS

Data from the Canadian Institute for Health Information's National Physician Database were used to analyze fee-for-service (FFS) care provided by general surgeons and other providers across Canada in 2015/16.

RESULTS

Across 8 Canadian provinces, 1669 general surgeons provided FFS care. The majority of the surgeons worked in communities with more than 100 000 residents (71%), were male (78%), were aged 35-54 years (56%) and were Canadian medical graduates (76%). Only 7% of general surgeons practised in rural areas and 14% in communities with between 10 000 and 50 000 residents. Rural communities were significantly more likely to have surgeons who were international medical graduates or who were older than 65 years. The surgical procedures most commonly performed by general surgeons were hernia repairs, gallbladder and biliary tree surgery, excision of skin tumours, colon and intestine resections and breast surgery. Many general surgeons performed procedures not listed in their Royal College of Physicians and Surgeons of Canada training objectives.

CONCLUSION

Canadian general surgeons provide a wide array of surgical services, and practice patterns vary by community size. Surgeons practising in rural and small communities require proficiency in skills not routinely taught in general surgery residency. Opportunities to acquire these skills should be available in training to prepare surgeons to meet the care needs of Canadians.

A systematic review and meta-analysis of valued obstetric and gynecologic (OB/GYN) procedures in resource-poor areas

Background

Obstetric and gynecologic procedures are valuable in rural settings. Data identifying common procedures may better prepare surgeons to meet patient needs in remote settings.

Materials and methods

A literature review using key MeSH terms was performed according to methods described by the Cochrane Collaboration and PRISMA on studies that described obstetric and gynecologic surgery in rural high-income countries or any setting in middle- to low-income countries. Meta-analysis was performed using random effects modeling for odds ratios of cesarean delivery and hysterectomy as proportions of total surgical volume.

Results

A total of 195 studies were included for qualitative synthesis and 22 for quantitative analysis. Obstetric and gynecologic procedures made up a 19% of all surgical cases. As compared to other obstetric and gynecologic surgical procedures, cesarean delivery was the most common procedure with odds ratio of 2.39 (95% confidence interval 1.48–3.86), and hysterectomy was the second most common procedure with odds ratio of 1.60 (1.57–1.64). However, heterogeneity between the studies was extremely high and risk of bias was high, limiting quality of findings.

Conclusion

Greater provision of surgical care can be enhanced by defining which procedures are most needed, which include many obstetric and gynecologic procedures, most commonly cesarean delivery and hysterectomy.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

Confidence Crisis Among General Surgery Residents: A Systematic Review and Qualitative Discourse Analysis

Importance

In the surgical community, there is concern that general surgery residents are choosing subspecialty training in large numbers because of a crisis in confidence at the end of training. Confidence is an essential quality of surgeons, and recent studies have attempted to quantify and measure it in graduating general surgery residents.

Objectives

To systematically review the quality of evidence provided and to critically analyze the language used to describe the findings using quantitative methods.

Evidence Review

A systematic review of the PubMed indexed literature on general surgery resident confidence was performed in March 2015. A summative table of each study's hypothesis, definition of confidence, quality using the Medical Education Research Study Quality Instrument, influence using Web of Science citations, results, and conclusions was created, and qualitative coding was applied to identify emerging themes. No date restrictions were used in the search.

Findings

Fifteen survey studies have been performed that measure confidence or readiness to practice. Although 5 studies had neutral or positive conclusions, most studies reported low confidence in general surgery graduates. There are conflicting data about definitions of confidence. The relationships between confidence, autonomy, and competence are varied and complex. Comparisons with the past are frequent.

Conclusions and Relevance

Confidence is difficult to define and measure. Despite limitations, survey studies are used to shape discourse and influence policies. Social and cultural factors influence self-efficacy, and focusing on operative volume and autonomy alone may not address all of the reasons that some residents express concerns about readiness to practice.

Are self-identified "disadvantaged" students less likely to enter surgical residencies? A single-institution study

BACKGROUND

Given more emphasis on training primary care physicians for underserved areas, we hypothesized that students self-identifying as "disadvantaged" would be less likely to pursue surgical training.

METHODS

We retrospectively reviewed medical school data on students graduating 2005-2014. Students were stratified into "disadvantaged" and "nondisadvantaged". Data were recorded on age, grade point average, Medical College Admission Test (MCAT), gender, surgery grade, United States Medical Licensing Examination step 1 score, and residency match into a surgical field. A comparison of the proportion of students matching into a surgical field was assessed with chi-square test. Multivariate logistic regression was performed to assess the factors that predict the choice of general surgery versus another surgical field.

RESULTS

Of the 1140 students who graduated during the study period, 219 (19.2%) students self-identified as "disadvantaged". Of all students, 158 (13.9%) chose a surgical field. The disadvantaged group was older at entry and had lower grade point average and total MCAT scores. Twenty-seven (12.3%) disadvantaged students chose a surgical residency versus 130 (14.1%) nondisadvantaged students (P = 0.56). On multivariate logistic regression, female gender (odds ratio [OR] = 3.9; 95% confidence interval = [1.9-8.3], P < 0.01), disadvantaged status (OR = 2.8 [1.1-7.1], P = 0.03), and United States Medical Licensing Examination step 1 score ≥ 227 (OR = 0.43 [0.21-0.88], P = 0.02) were significantly associated with matching into general surgery versus another surgical specialty.

DISCUSSION

Although the disadvantaged cohort was older and had lower undergraduate GPAs and MCAT scores, the proportion of disadvantaged students matching into a surgical residency was not statistically different. To address the future shortage of general surgeons in underserved areas, increasing enrollment of "disadvantaged" students may alleviate the "surgical desert".

Resident Preparation for Careers in General Surgery: A Survey of Program Directors

OBJECTIVE

The number of general surgery (GS) residency graduates who choose GS practice has diminished as the popularity of postresidency fellowships has dramatically increased over the past several decades. This study was designed to document current methods of GS preparation during surgery residency and to determine characteristics of programs that produce more graduates who pursue GS practice.

DESIGN

An email survey was sent by the American Board of Surgery General Surgery Advisory Committee to program directors of all GS residencies. Program demographic information was procured from the American Board of Surgery database and linked to survey results. Multiple regression was used to predict postresidency choices of graduates.

SETTING

Totally, 252 US allopathic surgical residencies.

PARTICIPANTS

Totally, 171 residency program directors (68% response rate).

RESULTS

The proportion of programs using an emergency/acute care surgery rotation at the main teaching hospital to teach GS increased from 63% in 2003 to 83% in 2014. An autonomous GS outpatient experience was offered in 38% of programs. Practice management curricula were offered in 28% of programs. Institutions with fewer postresidency fellowships (p < 0.003) and fewer surgical specialty residencies (p < 0.036) had a greater percentage of graduates who pursued GS practice. The addition of each fellowship at an institution was associated with a 2% decrease in the number of graduates pursuing GS practice. Residency size was not associated with predilection for fellowship selection and there was no difference between university and independent residencies vis-a-vis the proportion selecting fellowship vs GS practice.

CONCLUSIONS

Practice management principles and autonomous GS outpatient clinic experiences are offered in a minority of programs. Graduates of programs in institutions with fewer surgery fellowships and residencies are more likely to pursue GS practice. Increased number of postresidency fellowships and specialty residencies may be associated with fewer GS rotations and fewer GS mentors. Further study of these relationships seems warranted.

Simulation-based rhomboid flap skills training during medical education: comparing low- and high-fidelity bench models

OBJECTIVE

To assess if the bench model fidelity interferes in the acquisition of rhomboid flap skills by medical students.

METHODS

Sixty novice medical students were randomly assigned to 5 practice conditions with instructor-directed Limberg rhomboid flap skills training: didactic materials (control group 1), low-fidelity rubberized line (group 2) or ethylene-vinyl acetate (group 3) bench models; high-fidelity chicken leg skin (group 4) or pig foot skin (group 5) bench models. Pretests and posttests were applied, and Global Rating Scale, effect size, and self-perceived confidence were used to evaluate all flap performances.

RESULTS

Medical students from groups 2 to 5 showed better flap performances based on the Global Rating Scale (all P < 0.05) and felt more confident to perform rhomboid flaps (all P < 0.05) compared to their peers from control group 1, regardless of bench model fidelity (all P > 0.05). The magnitude of the effect was considered large (>0.80) in all measurements.

CONCLUSION

There was acquisition of rhomboid flap skills regardless of bench model fidelity.

Evaluation of advanced laparoscopic skills tasks for validity evidence

BACKGROUND

Since fundamentals of laparoscopic surgery (FLS) represents a minimum proficiency standard for laparoscopic surgery, more advanced proficiency standards are required to address the needs of current surgical training. We wanted to evaluate the acceptance and discriminative ability of a novel set of skills building on the FLS model that could represent a more advanced proficiency standard-advanced laparoscopic surgery (ALS).

METHODS

Qualitative and quantitative analyses were employed. Quantitative analysis involved comparison of expert (PGY 5+), intermediate (PGY 3-4) and novice (PGY 1-2) surgeons on FLS and ALS tasks. Composite scores included time and errors. Standard FLS errors were added to task time to create the composite score. Qualitative analysis involved thematic review of open-ended questions provided to experts participating in the study.

RESULTS

Out of 48 participants, there were 15 (31 %) attendings, 3 (6 %) fellows and 30 (63 %) residents. By specialty, 54 % were general/MIS/bariatric/colorectal (GMBC) and 46 % were other (urology and gynecology). There was no difference between experience level and performance on FLS and ALS tasks for the entire cohort. However, looking at the GMBC subgroup, experts performed better than novices (p = 0.012) and intermediates performed better than novices (p = 0.057) on ALS tasks. There was no difference for the same group in FLS performance. Also, GMBC subgroup performed significantly better on FLS (p = 0.0035) and ALS (p = 0.0027) than the other subgroup. Thematic analysis revealed that the majority of experts felt that ALS was more realistic, challenging and clinically relevant for specific situations compared to FLS.

CONCLUSION

For GMBC surgeons, we were able to show evidence of validity for a series of advanced laparoscopic tasks and their relationship to surgeon skill level. This study may represent the first step in the development of an advanced laparoscopic skills curriculum. Given the high degree of specialization in surgery, different advanced skills curricula will need to be developed for each specialty.

Will there be a good general surgeon when you need one? (Part II) Solutions and taking back general surgery

INTRODUCTION

Multiple reports have cited the looming shortage of physicians over the next decades related to increasing demand, an aging of the population, and a stagnant level in the production of new physicians. General surgery shares in this problem, and the specialty is "stressed" by a declining workforce related to increasing specialization that leaves gaps in emergency, trauma, and rural surgical care.

SUMMARY

The Society of Surgery of the Alimentary Tract (SSAT) Public Policy and Advocacy Committee sponsored panel discussions regarding the general surgery workforce shortage at the Digestive Disease Week 2012 and 2013 meetings. The 2012 panel focused on defining the problem. This is the summation of the series with the solutions to the general surgery workforce shortage as offered by the 2013 panel.

Low-fidelity bench models for basic surgical skills training during undergraduate medical education

It is remarkable the reduction in the number of medical students choosing general surgery as a career. In this context, new possibilities in the field of surgical education should be developed to combat this lack of interest. In this study, a program of surgical training based on learning with models of low-fidelity bench is designed as a complementary alternative to the various methodologies in the teaching of basic surgical skills during medical education, and to develop personal interests in career choice.