Surgery in the western Canadian Arctic: The relative impact of family physicians with enhanced surgical skills working collaboratively with specialist surgeons.

Introduction: Little is known about the surgical needs of rural, remote or circumpolar populations in Canada; these same regions are also home to half of all Indigenous people in the country. In the present study, we sought to understand the relative impact of family physicians with enhanced surgical skills (FP-ESS) and Specialist Surgeons in the surgical care of a mostly Indigenous rural and remote community in the western Canadian Arctic. Methods: A descriptive and retrospective quantitative study was conducted to determine the number and range of procedures performed for the defined catchment population of the Beaufort Delta Region of the Northwest Territories, as well as the type of surgical provider and location of that service, over the 5 years from 1 April, 2014, to 31 March, 2019. Results: FP-ESS physicians in Inuvik performed 79% of all endoscopic and 22% of all surgical procedures, which accounted for nearly half of the total procedures performed. Over 50% of all procedures were performed locally (47.7% by FP-ESS and 5.6% by visiting specialist surgeons). For surgical cases alone, nearly one-third were performed locally, one-third in Yellowknife and the remaining one-third out-of-territory. Conclusions: This networked model reduces the overall demand on surgical specialists, who can better focus their efforts on surgical care that is beyond the scope of FP-ESS. With nearly half of the procedural needs of this population being met locally by FP-ESS, there are decreased health-care costs, better access and more surgical care closer to home.

Résumé Introduction: On connaît peu les besoins en chirurgie des populations rurales, éloignées ou circumpolaires du Canada; ces mêmes régions abritent également la moitié de tous les peuples autochtones du pays. Dans la présente étude, nous avons cherché à comprendre l'impact relatif des médecins de famille ayant des compétences chirurgicales améliorées (FP-ESS) et des chirurgiens spécialistes dans les soins chirurgicaux d'une communauté rurale et éloignée principalement autochtone dans l'Arctique canadien occidental. Méthodes: Une étude quantitative descriptive et rétrospective a été menée pour déterminer le nombre et l'éventail des procédures effectuées pour la population desservie définie de la région du delta de Beaufort des Territoires du Nord-Ouest, ainsi que le type de fournisseur de services chirurgicaux et le lieu de ce service; sur une période de 5 ans allant du 1er avril 2014 au 31 mars 2019. Résultats: Les médecins de la FP-ESS à Inuvik ont effectué 79% de toutes les procédures endoscopiques et 22% de toutes les procédures chirurgicales, ce qui représente près de la moitié du total des procédures effectuées. Plus de 50% de toutes les procédures ont été effectuées localement (47,7% par la FP-ESS et 5,6% par des chirurgiens spécialistes en visite). Pour les cas chirurgicaux seulement, près d'un tiers ont été effectués localement, un tiers à Yellowknife et le dernier tiers à l'extérieur du territoire. Conclusions: Ce modèle en réseau réduit la demande globale de spécialistes en chirurgie, qui peuvent mieux concentrer leurs efforts sur les soins chirurgicaux qui ne relèvent pas de la compétence de la FP-ESS. Comme près de la moitié des besoins procéduraux de cette population sont satisfaits localement par la FP-ESS, les coûts des soins de santé diminuent, l'accès est amélioré et les soins chirurgicaux sont plus proches du domicile. Mots clés: Chirurgie, spécialistes ruraux, chirurgiens spécialisés, médecins de famille aux compétences chirurgicales renforcées, médecine rurale.

Consensus statement on networks for high-quality rural anesthesia, surgery, and obstetric care in Canada.

OBJECTIVE: To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible. COMPOSITION OF THE COMMITTEE: A volunteer Writers' Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia. METHODS: A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence. REPORT: Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition. CONCLUSION: The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program-Rural Surgical Obstetrical Networks-built on the principles and supporting evidence described in this consensus statement.

Surgical Task-Sharing in the Western Canadian Arctic: A Networked Model Between Family Physicians with Enhanced Surgical Skills and Specialist Surgeons.

BACKGROUND: With the loss of generalism in the surgical specialties, there has been a move in Canada to train family physicians in enhanced surgical skills (FP-ESS) to address the surgical needs of rural and remote populations. This research project sought to describe one network integrating FP-ESS and specialist surgeons, focusing on the role of FP-ESS and their relationship with specialist surgeons, in the surgical care of the Beaufort Delta Region of the Northwest Territories of Canada. METHODS: Using a participatory approach, semi-structured interviews were conducted with 22 stakeholders within the surgical system. Interviews were transcribed and reviewed, then imported into NVivo 12 for analysis. First-level coding was performed based on both deductive and inductive reasoning in an iterative fashion during interview collection to develop and refine the codebook. This was followed by second-level categorizing. RESULTS: The FP-ESS physicians provide cesarean section services to maintain a local obstetrics program, to provide gastrointestinal endoscopy, and to provide emergency on-call support, as described by one stakeholder. FP-ESS work together with specialist surgeons through an informal network keeping surgical care as close to home as possible. FP-ESS within this health regions were seen as "a really big gain to the system." CONCLUSIONS: This study deepens our understanding of rural surgical service delivery, in particular where FP-ESS and specialist surgeons function collaboratively. It also contributes to strengthening rural surgical systems in Canada and therefore to addressing the health gap between rural/remote/indigenous and urban populations.

Surgical Task-Sharing to Non-specialist Physicians in Low-Resource Settings Globally: A Systematic Review of the Literature.

BACKGROUND: As the global community increasingly recognizes the large and unmet burden of surgical disease, a new emphasis is being placed on strengthening the health system at the first-level hospital. The shortage of surgical care providers at this district and rural level can be met by surgical task-shifting/sharing to non-physician clinicians (NPCs) and non-specialist physicians (NSPs). While the role of NPCs in low-middle-income countries (LMICs), in particular in sub-Saharan Africa (SSA), has been well documented in the literature, there has been little focus on NSPs. In addition to providing essential surgical services, this physician cadre also practices generalist medicine, an advantage at the first-level hospital. The present study seeks to explore where, across all country income groups, NSPs are providing surgical services and what additional surgical training, if any, is available in each identified country. METHODS: A systematic review of the literature was performed, following PRISMA guidelines. Medline, EMBASE, EBM Reviews, and CINAHL were searched. Including hand-searching for further references, 53 publications met inclusion/exclusion criteria and were identified for data extraction purposes. Gray literature was also explored within the time limits for this study. RESULTS: Surgical task-shifting/sharing to NSPs occurs across all country income groups; some provide surgical obstetrics, while others also provide a broader scope of surgical services. Within LMIC countries, the majority are in SSA. In SSA, 16 of 54 countries were included in the reviewed articles, only 4 of which (Ethiopia, Niger, Nigeria, and Sierra Leone) have a formal surgical program beyond the regular medical officer/general practitioner training. Canada and Australia have established programs for both surgical obstetrics and the broader scope, while the USA has several programs for surgical obstetrics and is developing a new, broad-scope program. CONCLUSION: This study has demonstrated that NSPs are providing surgical services across all income groups, with varying degrees of additional training specific to the surgical needs of their district/rural location. To "close the gap" in needed surgical services at the first-level hospital, more task-sharing needs to occur to both NSPs (the focus of this study) and NPCs. Collaboration between practitioners and training programs, given the shared challenges and practice environments, would help support task-sharing at the first-level hospital and improve access to the 5 billion underserved people.

A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills.

SUMMARY: Rural western Canada relies heavily on family physicians with enhanced surgical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a "community of practice" section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the training and evaluation of the ESS skill set.

Optogenetic micro-electrocorticography for modulating and localizing cerebral cortex activity.

OBJECTIVE: Spatial localization of neural activity from within the brain with electrocorticography (ECoG) and electroencephalography remains a challenge in clinical and research settings, and while microfabricated ECoG (micro-ECoG) array technology continues to improve, complementary methods to simultaneously modulate cortical activity while recording are needed. APPROACH: We developed a neural interface utilizing optogenetics, cranial windowing, and micro-ECoG arrays fabricated on a transparent polymer. This approach enabled us to directly modulate neural activity at known locations around micro-ECoG arrays in mice expressing Channelrhodopsin-2. We applied photostimuli varying in time, space and frequency to the cortical surface, and we targeted multiple depths within the cortex using an optical fiber while recording micro-ECoG signals. MAIN RESULTS: Negative potentials of up to 1.5 mV were evoked by photostimuli applied to the entire cortical window, while focally applied photostimuli evoked spatially localized micro-ECoG potentials. Two simultaneously applied focal stimuli could be separated, depending on the distance between them. Photostimuli applied within the cortex with an optical fiber evoked more complex micro-ECoG potentials with multiple positive and negative peaks whose relative amplitudes depended on the depth of the fiber. SIGNIFICANCE: Optogenetic ECoG has potential applications in the study of epilepsy, cortical dynamics, and neuroprostheses.

Single optical fiber probe for fluorescence detection and optogenetic stimulation.

We have developed a fiber-optic-based probe for precise delivery of stimulation/excitation light pulses and detection of faint fluorescence signals for applications in neuroscience and optogenetics. In this design, a thin multimode fiber serves as the head of the probe to be inserted into the brain. This fiber is used to deliver light to the region of interest and guide a sample of the emission signal back to detectors. The major tradeoff in the design of such a system is to decrease the size of the fiber and intensity of input light to minimize physical damage and to avoid photobleaching/phototoxicity but to keep the signal-to-noise ratio (S/N) reasonably high. Here, the excitation light and the associated emission signal are frequency modulated. Then, the output of the detector is passed through a time lens which compresses the distributed energy of the emission signal and maximizes the instantaneous S/N. By measuring the statistics of the noise, the structure of the time lens is designed to achieve the global optimum of S/N. We have also designed side-firing fibers and a micromechanical assembly for distributed light delivery and fluorescence detection.