Gender Disparity in Surgical Society Leadership and Annual Meeting Programs.

INTRODUCTION: Prior work suggests women surgical role models attract more female medical students into surgical training. We investigate recent trends of women in surgical society leadership and national conference moderator and plenary speaker roles. METHODS: Gender distribution was surveyed at 15 major surgical societies and 14 conferences from 2014 to 2018 using publicly reported data. Roles were categorized as leadership (executive council), moderator, or plenary speaker. Data were cross-checked from online profiles and by contacting societies. Logistic regression with Huber-White clustering by society was utilized to evaluate proportions of women in each role over time and determine associations between the proportion of women in executive leadership, and scientific session moderators and plenary speakers. RESULTS: The proportion of leadership positions held by women increased slightly from 2014 to 2018 (20.6%-26.6%, P = 0.23), as did the proportion of moderators (26.2%-30.6%, P = 0.027) and plenary speakers (26.2%-30.9%, P = 0.058). The proportion of women in each role varied significantly across societies (all P < 0.001): leaders (range 0.0%-52.0%), moderators (12.5%-58.8%), and plenary speakers (11.3%-60.0%). Three patterns of change were observed: eight societies (53.3%) demonstrated increases in representation of women over time, four societies (26.6%) showed stable moderate-to-good gender balance, and three societies (20.0%) had consistent underrepresentation of women. CONCLUSION: There is significant variability in the representation of women at the leadership level of national surgical societies and participating at national surgical conferences as moderators and plenary speakers. Over the past 5 years some societies have achieved advances in gender equity, but many societies still have substantial room for improvement.

The evolution of surgical virtual education and telementoring: One surgeon's journey.

The first era of the global proliferation of surgical advancements involved surgical infection rate and technique breakthroughs by Lister, Halsted, and others. This was propagated by letters, academic papers, and international visits. While success was achieved, it was at a suboptimal pace. In the current era of minimally invasive surgical approaches, these methods are inadequate. This paper chronicles the development and application of virtual learning and telementoring as force multipliers to speed procedural adoption and proliferation.

Paediatric surgical response to an 'adult' COVID-19 pandemic.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) has dramatically affected global healthcare systems. We aimed to determine the response of our paediatric surgical fraternity to a disease that overwhelmingly affects adults. MATERIALS AND METHODS: We conducted a cross-sectional questionnaire-based study over 6 weeks during a federally mandated lockdown. Using snowball sampling, we recruited paediatric surgeons, trainees and medical officers from paediatric surgical units in Malaysia. The anonymous online questionnaire covered sociodemographic information, changes in patient care, redeployment, concerns regarding family members, and impact on training. Mental well-being was assessed using the Depression, Anxiety and Stress Scale (DASS-21). Kruskal-Wallis, ANOVA and multiple regression analysis was used, with significance level 0.05. RESULTS: Of the 129 eligible participants, 100(77%) responded. Junior doctors had clinically higher levels of depression, anxiety, and stress. Age <30 years was significantly associated with anxiety. Junior doctors believed that redeployment led to loss of surgical skills (p<0.001) and trainees felt that clinical application of knowledge had reduced (p<0.020). CONCLUSION: Specific to our paediatric surgical community, this study highlights areas of concern, particularly among junior doctors. It is likely that recurrent cycles of the pandemic will occur soon. These issues must be addressed to preserve the mental and emotional well-being of all health care workers.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

The Sunshine Act and Surgeons: A Nation-Wide Analysis of Industry Payments to Physicians.

BACKGROUND: The Physician Payments Sunshine Act mandates the submission of payment records between medical providers and industry. We used the Open Payments Program database to compare industry payments to surgeons and nonsurgeons, as well as among surgical specialties, and to identify geographic distribution of payments. MATERIALS AND METHODS: We included all reported industry payments in the Centers for Medicare and Medicaid Services' Open Payments Program in the United States, 2014-2015. Multivariable regression fixed effects panel analysis of total payments was conducted among surgeons, adjusting for surgeon specialty, payor type, payment category, and state. A geographic heat map was created. RESULTS: Of 2,097,150 subjects meeting criteria, 1,957,528 (45.66%) were physicians. The mean standard deviation (SD) payment overall was $232.64 ($6262.00), and the state with the highest mean (SD) payment was Vermont at $2691.61 ($11,508.40). Surgeons numbered 153,916 (7.86%). The specialty with the highest mean (SD) payment was orthopedic surgery at $2811.50 ($33,632.71, P < 0.001). Among 2,097,150 subjects meeting criteria, in multivariable regression fixed effects panel analysis, orthopedic compared to general surgeons were significantly likely to receive more industry payments (beta $1065.34 [95% CI $279.00-1851.00, P = 0.008), even controlling for payor, payment type, and state. Significant geographic disparities in payment were noted as 12 states received the top mean ($24.52-$500,000.00), leaving seven states with the lowest ($0.00-$12.56). CONCLUSIONS: There are significant differences in industry payments to surgeons versus nonsurgeons and among surgical specialties, as well geographic distribution of payments. These data may prompt further investigation into trends and their causality and effects on research and practice.

Minimally invasive surgical exposure among US and Canadian pediatric surgery trainees, 2004-2016.

BACKGROUND: Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, with little data on minimally invasive surgery (MIS) training in US and Canadian pediatric surgery fellowship programs. METHODS: We performed a time series analysis of Accreditation Council for Graduate Medical Education pediatric surgery fellow case logs from 2003 to 2016. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time. RESULTS: There was a 30.9% increase in average number of MIS cases per fellow over the study time period. Twenty-three recorded procedures included MIS and open options (17 abdominal, three thoracic, and three genitourinary). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for each of these categories, respectively. Significant variability was observed in specific cases such as laparoscopic and open inguinal hernias, ranging from 0 to 85 and nine to 152 per trainee, respectively, in the final year of data collection. When examining pyloromyotomy, a high-volume procedure with a known increase in the MIS approach, the proportion of cases performed MIS increased by 83.3%. The minimum and maximum number of cases per fellow recorded ranged from 0 to 114 during the eight years in which MIS pyloromyotomy was recorded. CONCLUSIONS: MIS case exposure among graduating US and Canadian pediatric survey fellows increased substantially during the study period. More granular data, however, are needed to better define the current operative experience and criteria for determination of competency in advanced MIS.

The Brain Drain Myth: Retention of Specialist Surgical Graduates in East, Central and Southern Africa, 1974-2013.

BACKGROUND: This study assesses the retention of specialist surgical graduates from training programmes across eight countries in East, Central and Southern Africa from 1974 to 2013. It addresses the gap in existing data by analysing retention rates of surgical graduates by comparing graduating institution to current location. Data were assessed by country, region, specialty and gender with a view to informing national and regional healthcare and education strategies. METHODS: Twenty-five institutions train surgeons in the ten countries covered by the College of Surgeons of East, Central and Southern Africa (COSECSA)-24 Universities and the College itself. These institutions were requested in November 2014 to supply details of graduates from their postgraduate surgical training programmes. Complete graduate lists were returned by the College and 14 universities by March 2016. These surgical graduates were compared against the database of current practising surgeons in the region held by COSECSA. Data were cross-checked against medical council registers, surgical society records, and with members and fellows of COSECSA. RESULTS: Data were incomplete for 126 surgical graduates. Of the remaining 1038 surgical graduates, 85.1% were retained in the country they trained in, while 88.3% were retained within the COSECSA region. Ninety-three per cent (93.4%) were retained within Africa. Of the eight countries, Malawi had the highest retention rate with 100% of surgical graduates remaining in country, while Zimbabwe had the lowest rate with 65.5% remaining. CONCLUSION: High surgical graduate retention rates across the region indicate that the expansion of national surgical training initiatives is an effective solution to addressing the surgical workforce shortage in East, Central and Southern Africa and counters long-held arguments regarding brain drain in this region.

The Future of Emergency Surgery.

Introduction: Over the past three decades, there has been a recognised need for emergency surgery (ES). Studies of ES have demonstrated variation in patient outcomes depending on admission time or day. ES as a subspecialty is still under consideration in Europe despite being recognised as such in the US. This article reviews this need and addresses the issues required to develop ES as a separate surgical subspecialty in Europe. METHOD: A survey on ES was developed by the Educational Committee of the European Society for Trauma and Emergency Surgery (ESTES) and sent to all ESTES members with 102 responses received. Results: Of the responses, 93.1% had completed training. 75.3% of respondents report that ES should be a recognised subspecialty and 79% report that ES is capable of offering a rewarding career. 90% report that ES should have dedicated post-graduate training programme with 69.8% in agreement that dedicated emergency surgeons have improved outcomes following ES. CONCLUSION: Developing ES as a subspecialty in Europe would improve patient outcomes and facilitate resource allocation. This advancement is, however, still in its infancy and its evolution would require overhaul of our current European system, training methods and understanding of the role of emergency surgeons in ES.

Humanitarian skill set acquisition trends among graduating US surgical residents, 2004-2014.

BACKGROUND: Although interest in practicing surgery in resource-constrained settings is on the rise among graduating US surgical residents, there is ongoing debate about an optimal humanitarian skill set for surgeons who chose to work in such settings. In addition, increased emphasis on general surgery case exposure at the cost of specialty surgery case exposure has been documented and may have a negative impact on the breadth of resident training. Review of general surgery resident case logs to gauge experience in specialty surgery may provide insight into residents' readiness for work in resource-limited settings. METHODS: We compared Accreditation Council for Graduate Medical Education general surgery resident case logs from 2004 to 2014 for operations thought to be essential for working in resource-constrained settings. These operations were chosen from published literature on this topic and authors' personal experience. Case numbers for specialty operations were compared by unpaired t-test analysis between the two periods. RESULTS: Case averages in pediatric, genitourinary, and gynecologic surgery decreased significantly from 2004 to 2014 (range, 27%-46%). Orthopedic surgery case averages were unchanged, and plastic and general abdominal surgery case averages increased (range, 47%-50%). CONCLUSIONS: Case mix among graduating US surgical residents has narrowed over the past 10 y. Resident experience in a variety of specialty fields, thought to be essential in resource-constrained settings, decreased markedly over the study period. Residents who intend to work in resource-constrained settings may need to craft individualized residency experiences or pursue postgraduate training in specialty surgery courses to best prepare for such work.

Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children's hospitals.

PURPOSE: Widespread adoption of minimally invasive surgery (MIS) techniques in pediatric surgery has progressed slowly, and the shift in practice patterns has been variable among surgeons. We hypothesized that a pediatric surgeon committed to MIS could effectively change surgical practice by creating an emphasis on MIS. METHODS: Annual case volumes from 2000 to 2009 at two tertiary care pediatric hospitals, one with a dedicated minimally invasive pediatric surgeon, were evaluated for trends in MIS for ten different operations. Univariate analyses of the differences between hospitals in the use of the open versus laparoscopic approach were performed. The Breslow-Day test was used to examine differences in use of laparoscopic procedures across hospitals in early versus middle and middle versus late time periods. RESULTS: Between the two hospitals, for 9 of the 10 types of surgery, the number of laparoscopic and open procedures differed significantly (p values ranged from <0.0001 to 0.003). Over the 10-year period, the hospital with a dedicated MIS surgeon had a larger proportion of procedures done laparoscopically for all years. This difference reached statistical significance for appendectomy (p < 0.0001), congenital diaphragmatic hernia (p < 0.0002), chest wall reconstruction (p < 0.0001), cholecystectomy (p = <0.0001), gastrostomy (p < 0.0001), nissen fundoplication (p < 0.0001) oophorectomy (p < 0.0001), pyloromyotomy (p < 0.0001) and splenectomy (p = 0.0006). After grouping the years into early (2000-2003), middle (2004-2006) and late (2007-2009) categories, the hospital with a dedicated MIS surgeon had a significantly higher rate of increase in use of laparoscopic surgery between the early and middle years for four procedures: diaphragmatic hernia repair (p = 0.003), chest wall reconstruction (p = 0.0086), cholecystectomy (0.0083) and endorectal pull-through (p = 0.025). CONCLUSION: The presence of a dedicated minimally invasive pediatric surgeon led to a significant change in surgical practice with an overall trend of increasing MIS several years in advance of a hospital that did not have a dedicated MIS surgeon. This has implications for resident training in academic medical centers and potential patient care outcomes.

"Is general surgery still relevant to the subspecialised trainee?" A 10 year comparison of general versus specialty surgical practice.

BACKGROUND: The splintering of general surgery into subspecialties in the past decade has brought into question the relevance of a continued emphasis on traditional general surgical training. With the majority of trainees now expressing a preference to subspecialise early, this study sought to identify if the requirement for proficiency in managing general surgical conditions has reduced over the past decade through comparison of general and specialty surgical admissions at a tertiary referral center. METHODS: A cross-sectional review of all surgical admissions at Cork University Hospital was performed at three individual time points: 2002, 2007 & 2012. Basic demographic details of both elective & emergency admissions were tabulated & analysed. Categorisation of admissions into specialty relevant or general surgery was made using International guidelines. RESULTS: 11,288 surgical admissions were recorded (2002:2773, 2007:3498 & 2012:5017), showing an increase of 81 % over the 10-year period. While growth in overall service provision was seen, the practice of general versus specialty relevant emergency surgery showed no statistically significant change in practice from 2002 to 2012 (p = 0.87). General surgery was mostly practiced in the emergency setting (84 % of all emergency admissions in 2012) with only 28 % elective admissions for general surgery. A reduction in length of stay was seen in both elective (3.62-2.58 bed days, p = 0.342) & emergency admissions (7.36-5.65, p = 0.026). CONCLUSIONS: General surgical emergency work continues to constitute a major part of the specialists practice. These results emphasize the importance of general surgical training even for those trainees committed to sub-specialisation.

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure.

Practice patterns of carotid endarterectomy as performed by different surgical specialties at a single institution and the effect on perioperative stroke and cost of preoperative imaging.

BACKGROUND: Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost. METHODS: This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS). RESULTS: VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P < .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P < .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P = .0001) and protamine was used in 0.2%, 19%, and 8% (P < .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P < .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P < .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P = .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P < .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P = .009); and were 0.9% vs 3% for asymptomatic patients (P = .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series. CONCLUSIONS: CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate.

Academic productivity of directors of ACGME-accredited residency programs in surgery and anesthesiology.

BACKGROUND: Scholarly activity is expected of program directors of Accreditation Council for Graduate Medical Education (ACGME)-accredited residency training programs. Anesthesiology residency programs are cited more often than surgical programs for deficiencies in academic productivity. We hypothesized that this may in part reflect differences in scholarly activity between program directors of anesthesiology and surgical trainings programs. To test the hypothesis, we examined the career track record of current program directors of ACGME-accredited anesthesiology and surgical residency programs at the same institutions using PubMed citations and funding from the National Institutes of Health (NIH) as metrics of scholarly activity. METHODS: Between November 1, 2011 and December 31, 2011, we obtained data from publicly available Web sites on program directors at 127 institutions that had ACGME-accredited programs in both anesthesiology and surgery. Information gathered on each individual included year of board certification, year first appointed program director, academic rank, history of NIH grant funding, and number of PubMed citations. We also calculated the h-index for a randomly selected subset of 25 institution-matched program directors. RESULTS: There were no differences between the groups in number of years since board certification (P = 0.42), academic rank (P = 0.38), or years as a program director (P = 0.22). However, program directors in anesthesiology had less prior or current NIH funding (P = 0.002), fewer total and education-related PubMed citations (both P < 0.001), and a lower h-index (P = 0.001) than surgery program directors. Multivariate analysis revealed that the publication rate for anesthesiology program directors was 43% (95% confidence interval, 0.31-0.58) that of the corresponding program directors of surgical residency programs, holding other variables constant. CONCLUSIONS: Program directors of anesthesiology residency programs have considerably less scholarly activity in terms of peer-reviewed publications and federal research funding than directors of surgical residency programs. As such, this study provides further evidence for a systemic weakness in the scholarly fabric of academic anesthesiology.

Future and training of craniofacial surgery in India.

Craniofacial surgery, in the strictest sense, is the surgery of structures above and behind the maxilla. Craniofacial surgery is not new to India and has been around for more than 4 decades now since the 1970s. Keeping in mind the promotion of the specialty in India, an Indian Craniofacial Foundation was launched in the year 2012 at the Annual Meeting of the Association of Plastic Surgeons of India. To develop a craniofacial center in India, the primary requirement is a source of funding. Several craniofacial centers, which are already running successfully in India, have amply demonstrated that this can be done in several ways. We would like to discuss here the 2 models of craniofacial service delivery and training that the authors have seen and experienced firsthand.

[What's new in instrumental dermatology?]. / Quoi de neuf en dermatologie instrumentale?

This "What's new in instrumental dermatology" focuses on cutaneous oncologic surgery, base on a review of the 2012-2014 literature. First, the ability of dermatologists to make a good "oncologic reading of tumors" is the key of radical surgical treatment. Advantages and disadvantages of the biopsy are discussed. Then, the second message is the management of anticoagulants, that should not be interrupted for skin surgery. Despite recommendations, this practice is not followed in 40% of cases; this point is critical because bleeding complications are minor compared to potential morbidity of thrombotic events when stopping these medications. Regarding infection, nasal carriage of Staphylococcus aureus is identified as a risk factor for wound infection. A preoperative shower with chlorhexidine and mupirocin topical decolonization of nostril reduces this risk. Surgical techniques are trying to reach minimalism, by reducing undermining and scarring. On the trunk, using deep slow resorbable sutures improve scarring. In addition using adhesive sutures (strip) reduce the wideness of scar. On the face, the lower third of the nose is the most challenging because of the free edges, which are deformable. In this location bilobed or trilobed transposition flap offer the advantage of remaining in the nasal aesthetic unit and not disturbing the free edges of the nasal orifices. Regarding scarring, early hypertrophic scar is now well defined and linked with transposition flaps of the nasal region. An early treatment with intralesional corticosteroid injection appears to be effective. Finally, the biological mechanism of the effectiveness of compression in the prevention and treatment of dystrophic scar is now clear. The mechanotransduction explain how a mechanical stress of the skin activates biological cell pathways, which regulate the quality of collagen synthesis and the arrangement of skin fibrosis.

[Literature of so-called "clinical research": structure and trends, 1991-2010]. / A klinikainak nevezett kutatások szakirodalmának szerkezete és irányai, 1991-2010.

The authors studied trends and patterns in the literature of research labeled as clinical (i.e., having the word "clinical" in their title) in the period between 1991 and 2010. The main findings are: 1. The growth of the literature under study was somewhat stronger than that of the overall medical literature. 2. The dominance of the USA is strong but is challenged by some of the most rapidly developing countries (particularly in the Far-East region: China, Korea) in total production, and by the developed European countries in highly cited publications. The eminence of Italy is remarkable. 3. In comparing the medical fields, the most striking tendencies are the increase of oncology and the attenuation of internal medicine. Surgery is steadily growing in size but decreasing in its citation influence. 4. Word frequency studies support the ever growing weight of oncology and also of genetics. 5. Beyond the thematic changes, word frequency studies also reveal a substantial change in attitude: in the period under study more and more effort was made on emphasizing the usefulness, efficiency and risks of the results in contrast with the more descriptive, investigative approach of the past. The role of therapy is growing, the role of diagnostics is decreasing. The knowledge of these trends and patterns may orient health and science policy makers to cope appropriately with the ever changing world of clinical research.