Survey of surgical training and experience of associate clinicians compared with medical officers to understand task-shifting in a low-income country.

Background: A workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania. Methods: All surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences. Results: A total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice. Conclusions: ACs report similar training and operative experience compared with their physician colleagues in Tanzania.

Antecedentes: La falta de cirujanos en determinadas áreas geográficas es flagrante. Una posible solución es el intercambio de tareas, es decir, la delegación de tareas quirúrgicas en personal sanitario no médico o en clínicos asociados (associate clinicians, AC). Si bien varios estudios han demostrado que los AC obtienen resultados postoperatorios similares a los de los médicos, hay poco información acerca de su entrenamiento quirúrgico. Este estudio tuvo como objetivo caracterizar la capacitación quirúrgica y la experiencia de los AC en comparación con los médicos titulados (medical officer, MO) en Tanzania. Métodos: En este estudio, se encuestaron todos los proveedores de atención quirúrgica de la Región de Pwani, Tanzania. Los participantes proporcionaron datos demográficos, años de entrenamiento y número y tipo de procedimientos realizados y a los que se había asistido durante el periodo de capacitación. Además, respondieron a preguntas abiertas sobre el entrenamiento y su experiencia quirúrgica posterior al entrenamiento. Se comparó la mediana del número de procedimientos más realizados por cada grupo mediante la suma de rangos de Wilcoxon y la prueba de la t de Student. Los investigadores realizaron un análisis del contenido de las respuestas a las preguntas abiertas sobre las necesidades y la experiencia durante la etapa de entrenamiento. Resultados: En el estudio participaron 21 ACs y 12 MOs. Los CA estuvieron expuestos a un mayor número procedimientos del mismo tipo antes de efectuar su primera operación de forma independiente en comparación con los OM (40 versus 17 casos, P = 0,031). No hubo diferencias en el volumen operatorio total de los procedimientos comunes entre los AC y los MO (150 versus 171 casos, P = 0,995). Las opiniones de los dos grupos sobre el entrenamiento fueron similares. Los dos grupos se dieron soporte entre ellos, pero quedó patente que la supervisión por parte de un especialista durante el entrenamiento y la práctica independiente era insuficiente. Conclusiones: En Tanzania, los asociados clínicos tienen entrenamientos y experiencias quirúrgicas similares a las de sus colegas médicos.

An estimation of inguinal hernia epidemiology adjusted for population age structure in Tanzania.

PURPOSE: Surgical conditions represent a significant source of global disease burden. Little is known about the epidemiology of inguinal hernia in resource-poor settings. We present a method to estimate inguinal hernia disease burden in Tanzania. METHODS: Using data from the United States National Health and Nutrition Examination Survey (NHANES) prospective cohort study and Tanzanian demographic figures, we calculated inguinal hernia incidence and prevalence in Tanzanian adults under three surgical rate scenarios. Gender-specific incidence figures from NHANES data were adjusted according to Tanzanian population age structure. Hernia duration was adjusted for Tanzanian life expectancy within each age group. RESULTS: The prevalence of inguinal hernia in Tanzanian adults is 5.36% while an estimated 12.09% of men had hernias. Today, 683,904 adults suffer from symptomatic inguinal hernia in Tanzania. The annual incidence of symptomatic hernias in Tanzanian adults is 163 per 100,000 population. At Tanzania's current hernia repair rate, a backlog of 995,874 hernias in need of repair will develop over 10 years. 4.4 million disability-adjusted life-years would be averted with repair of prevalent symptomatic hernias in Tanzania. CONCLUSIONS: Our data indicate the extent of inguinal hernia disease burden in Tanzania. By adjusting our figures for the age structure of Tanzania, we have demonstrated that while the incidence of symptomatic cases may be lower than previously thought, prevalence of inguinal hernia in Tanzania remains high. This approach provides an update to our previously described methodology for calculation of inguinal hernia epidemiology in resource-poor settings that may be used in multiple country contexts.

Peer assisted learning in surgical skills laboratory training: a pilot study.

BACKGROUND: Peer assisted learning (PAL) has been rarely investigated in surgical skills training. AIMS: Describe feedback residents give peers on surgical skills with and without guidelines, determine the association between feedback and actual performance, evaluate resident satisfaction with PAL. METHOD: Participants evaluated peers using a validated knot-tying checklist and provided feedback on suturing without a guideline. Feedback comments were coded by type and an expert scored performance of each participant. Residents completed a satisfaction questionnaire. RESULTS: Comments were generally specific. Feedback was twice as likely with the use of a guideline. Specific feedback correlated significantly with expert knot-tying score but not suturing score. Most participants felt peer feedback was helpful and were motivated to practice surgical skills after PAL sessions. CONCLUSIONS: Surgical residents can provide high quality specific feedback to peers on surgical skills using performance guidelines. Further exploration of effective PAL methodology in surgical skills laboratory training is needed.

Mode of delivery decisions among HIV-infected mothers at an urban maternity hospital in Kenya.

OBJECTIVES: To quantify the use of elective Caesarean section (ECS) for prevention of mother-to-child transmission of HIV (PMTCT) at an urban Kenyan maternity hospital, to describe mode of delivery decision making among HIV positive women, and to understand patient knowledge and attitudes regarding ECS for PMTCT. DESIGN: Descriptive cross-sectional study. SETTING: Pumwani Maternity Hospital, Nairobi, Kenya. SUBJECTS: Two hundred and fifty postpartum HIV-infected women. MAIN OUTCOME MEASURES: ECS delivery rate, correlates of mode of delivery decisions and ECS for PMTCT knowledge and attitudes RESULTS: The rate of delivery by ECS for PMTCT was 4.0% (10/250), though 13.6% (34/250) planned this mode of delivery. Patient education regarding ECS for PMTCT was limited, and 64% (160/250) of participants had never heard of ECS. Planning ECS for PMTCT was positively correlated with attending clinic at PMH (OR=9.12, 95% CI: 2.94-28.28, p<0.001), knowledge of ECS (OR=27.22, 95% CI: 5.04-148.20, p<0.001) and having a history of abdominal surgery (OR=30.96, 95% CI: 6.32-205.02, p<0.001). Delivering by ECS was associated with planning this mode of delivery (OR=19.52, 95% CI: 3.69-103.23, p<0.001). Planning but not delivering by ECS was mostly due to labour before scheduled ECS (55.6%, 15/27) or poor patient understanding of the intervention (29.6%,8/27). After education on ECS for PMTCT, 48.0% (120/250) of participants would consider elective Caesarean section if offered, though cost represented a significant barrier to acceptability. CONCLUSIONS: Knowledge and utilisation of ECS for PMTCT are limited and varied in this patient population. ECS may be an acceptable mode of delivery for some Kenyan women, especially if the burden of cost is removed. A clear policy on ECS counselling and utilisation is urgently needed to ensure consistent and appropriate use of this PMTCT intervention in Kenya.

Prostate cancer detection in a clinical urological practice by ultrasonography, digital rectal examination and prostate specific antigen.

The prostate cancer detection rate from screening by digital rectal examination and tactilely guided prostate biopsy is approximately 1.7%. Among 1,807 men a detection rate of 14.6% was achieved in a clinical urological practice by physician-conducted prostate ultrasonography, digital rectal examination and determination of serum prostate specific antigen. Results are presented in 5-year increments as well as for the group as a whole. The possible benefit to be derived from an improved detection rate is undetermined. Recommendations are made regarding the clinical use of these diagnostic modalities.

Clinical application of transrectal ultrasonography and prostate specific antigen in the search for prostate cancer.

We reviewed 225 men who were followed for 2 to 21 years by periodic rectal examination in an effort to detect prostatic cancer without the glands having been sufficiently suspicious for biopsy to have been recommended. These patients underwent further evaluation with transrectal prostatic ultrasonography and serum prostate specific antigen determinations. When appropriate, ultrasonically guided transrectal needle biopsy of the prostate was performed without analgesia, anesthesia or prophylactic antibiotics. This is a simple, safe and effective means to obtain tissue for diagnosis. Recommendations for the current applicability of these diagnostic modalities by the practicing urologist are given.

Percutaneous ultrasonic lithotripsy in the community hospital.

A total of 38 patients underwent attempted percutaneous extraction of upper tract calculi with the Wolf nephroscope. A 1-day interval between radiological insertion of the guide wire and extraction of the stone with the patient under general anesthesia was used. Of the stones 87 per cent were removed successfully. Average operating and hospitalization times were 62 minutes and 9.9 days, respectively. Reduced morbidity and a shorter interval to return to work make this the procedure of choice in selected cases.

Psychiatric rehabilitation and long-term rehospitalization rates: the findings of two research studies.

Two controlled studies at Fountain House examined the influence of psychiatric rehabilitation services on rehospitalization. Study I, initiated in 1959, followed 252 experimental and 81 control subjects for 9 years. Study II, initiated in 1964, followed 40 experimental and 34 control subjects for 5 years. Experimental subjects had Fountain House services available, while controls did not. Additionally, experimental subgroups received systematic reaching-out services: home visits, telephone or letter contact. Study II findings essentially replicated study I. Followup was 96--97 percent complete. Three quarters of controls were rehospitalized within 5 years. Experimental subjects receiving reaching-out services for 2 years had significantly lower rehospitalization rates for the first 5 years in study I and the first 2 years in study II. Rehospitalizations were delayed, not prevented. Study I experimentals receiving 2 years of reaching-out services spent twice as long in the community before rehospitalization and 40 percent fewer days in the hospital than controls. Study II experimental subjects were in the community almost three times longer than controls before rehospitalization. Half of study I experimental subjects attended less than 10 times. Experimental subjects receiving reaching-out services attended twice as often as those not receiving reaching-out services. Low or nonattending experimentals had almost identical relapse rates (77 percent) as controls (74 percent), while, of experimentals having 100 or more visits, 37 percent were rehospitalized.