Gender-Based Microaggressions in Surgery: A Scoping Review of the Global Literature.

BACKGROUND: In addition to systemic gender disparities, women in surgery encounter interpersonal microaggressions. The objective of this study is to describe the most common forms of microaggressions reported by women in surgery. METHODS: We conducted a scoping review using PubMed/MEDLINE, Ovid, and Web of Science to describe the international, indexed English-language literature on gender-based microaggressions experienced by female surgeons, surgical trainees, and medical students in surgery. After screening by title, abstract, and full-text, 37 articles were retained for data extraction and analysis. Microaggressions were analyzed using the Sexist Microaggression Experience and Stress Scale (MESS) framework and stratified by country of origin. RESULTS: Gender-based microaggression publications most commonly originated from the United States (n = 27 articles), Canada (n = 3), and India (n = 2). Gender-based microaggressions were classified into environmental invalidations (n = 20), being treated like a second-class citizen (n = 18), assumptions of traditional gender roles (n = 12), sexual objectification (n = 11), assumptions of inferiority (n = 10), being forced to leave gender at the door (n = 8), and experiencing sexist language (n = 6). Additionally, attendings were more frequently reported to experience microaggressions than surgical trainees and medical students, but more articles reported data on attendings (n = 16) than surgical trainees (n = 10) or students (n = 4). CONCLUSION: While recent advancements have opened the field of surgery to women, there is still a lack of female representation, and persistent microaggressions may perpetuate this gender disparity. Addressing microaggressions against female surgeons is essential to achieving gender equity in surgical practice.

The Impact of Increasing Surgical Capacity at a Tertiary Hospital in Southern Haiti.

BACKGROUND: St. Boniface Hospital (SBH) plays a critical role in providing safe, accessible surgery in rural southern Haiti. We examine the impact of SBH increasing surgical capacity on case volume, patient complexity, and inpatient mortality across three phases. MATERIALS AND METHODS: A retrospective review and geospatial analysis of all surgical cases performed at SBH between 2015 and 2017 were performed. Inpatient mortality was defined by in-hospital deaths divided by the number of procedures performed. RESULTS: Between February 2015 and August 2017, over 2000 procedures were performed. The average number of surgeries per week was 3.1 with visiting surgical teams in phase 1 (P1), 10.4 with a single general surgeon in phase 2 (P2), and 20.1 with two surgeons and a resident in phase 3 (P3). There was a six-fold increase in surgical volume between P1 and P3 and a significant increase in case complexity. The distribution of American Society of Anesthesiologists scores of 1, 2, 3, and 4 during P2 was 81.05%, 14.74%, 3.42%, and 0.79%, respectively, whereas in P3, the distribution was 68.91%, 22.55%, 7.70%, and 0.84%. Surgical mortality was 0%, 1.2%, and 1.67% across phases. CONCLUSIONS: Increasing resources and surgical staff at SBH allowed for greater delivery of safe surgical care. This study highlights that investing in surgery has a significant impact in regions of great surgical need.

Correction to: Global surgery and the World Health Organization: indispensable partners to achieve triple billion goals.

The legend of the Figure currently reads: "A formula for advancing surgical system strengthening and World Health Assembly resolution 68.15 through the World Health Organization's thirteenth General Programme of Work (GPW-13). This graphic depicts the three strategic shifts outlined in GPW-13 and ties them to specific avenues for surgical system strengthening to achieve overarching goals. GPW-13 = Thirteenth General Programme of Work; NSOAPs = National Surgical, Obstetric, and Anesthesia Plans; PHC = primary healthcare; SDG 3 = Sustainable Development Goal 3; UHC = universal health coverage; WHA 68.18 = World Health Assembly resolution 68.15. " The corrected Figure legend should read: A formula for advancing surgical system strengthening and World Health Assembly resolution 68.15 through the World Health Organization's thirteenth General Programme of Work (GPW-13). This graphic depicts the three strategic shifts outlined in GPW-13 and ties them to specific avenues for surgical system strengthening to achieve overarching goals. GPW-13 = Thirteenth General Programme of Work; NSOAPs = National Surgical, Obstetric, and Anesthesia Plans; PHC = primary healthcare; SDG 3 = Sustainable Development Goal 3; UHC = universal health coverage; WHA 68.15 = World Health Assembly resolution 68.15.

Preventing pediatric accidental decannulation events: A quality improvement initiative.

OBJECTIVE: To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3. METHODS: A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases. RESULTS: Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases). CONCLUSION: This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

A Comparative Analysis of Otolaryngology Journal Characteristics and Metrics Across World Bank Income Groups.

Study Background and Aims: There are marked barriers to research and publishing for low- and middle- income country (LMIC) ENT researchers. This could be reflected in LMIC journal characteristics and research, which has never been investigated. We aim to characterize differences in the number, geographic distribution, publishing costs, reach, number of articles, citations, and impact factors of high-income country (HIC) journals compared to LMIC journals. Methods: We included journals listed under the category "Otorhinolaryngology' in three major journal databases. From journal websites, we collected data related to financial model, waiver policy, access, and distribution. Additionally, from the Clarivate Journal Citation Reports 2022, we collected the following journal metrics: total articles, total citations, journal citation indicator, journal impact factor (JIF), 5-year JIF, and JIF without self cites. Results: 79.7% HIC journals offered English editing services, compared with 25.0% of LMIC journals. Additionally, 40.0% of HIC journals are solely open access compared with 92.0% in LMICs. Lower journal metrics were seen in LMIC journals, including 2022 mean total articles (107 HICs vs. 60 LMICs), total citations (4296 vs. 751), journal citation indicator (0.88 vs. 0.35), and journal impact factor (12.68 vs. 0.82). Conclusion: We have identified substantial differences in the distribution, English editing services, and journal metrics of HIC journals compared to LMIC journals. These may point to potential barriers to publishing and research access for those in LMICs. To support LMIC research, future work should evaluate opportunities to increase the number of ENT journals in LMICs, expand open access publishing, improve access to language services, and increase LMIC research impact.

Towards universal access: A review of global efforts in ear and hearing care.

Hearing loss affects 1.6 billion people worldwide and disproportionately affects those in low- and middle-income countries. Despite being largely preventable or treatable, ear and hearing conditions result in significant and lifelong morbidity such as delayed language development, reduced educational attainment, and diminished social well-being. There is a need to augment prevention, early identification, treatment, and rehabilitation for these conditions. Expanded access to hearing screening, growth of the hearing health workforce, and innovations in ear and hearing care delivery systems are among the changes that are needed. To that end, the World Health Organization has prioritized ear and hearing care as a component of Universal Health Coverage, and recent publications have advanced the priority for ear and hearing care. Efforts are underway at the national levels around the world, as evidenced by countries like Zambia and Nigeria that have integrated ear and hearing care within national health strategies. While significant strides have been made in improving access, a critical need remains for additional research, advocacy, and intervention to ensure that no one is left behind in the goal to achieve universal access to ear and hearing care.

Essential equipment and services for otolaryngology care: a proposal by the Global Otolaryngology-Head and Neck Surgery Initiative.

PURPOSE OF REVIEW: To highlight the need for comprehensive resource lists to provide baseline care of otolaryngologic conditions; to present a proposed list of essential equipment and services that may be applied toward surgical systems research, policymaking, and charitable efforts in global otolaryngology-head and neck surgery. RECENT FINDINGS: To provide effective and high-quality surgical care across care settings, there must be a global standard for equipment and ancillary services necessary to provide baseline care. Though there have been efforts to devise resource standards via equipment lists and appraisal tools, these have been limited in scope to general surgery, emergency care, and a few other subspecialty surgical contexts. Recent efforts have brought attention to the significant burden imposed by otolaryngologic conditions such as hearing loss, otitis media, head and neck cancer, head and neck trauma, and upper airway foreign bodies. Yet, there has not been a comprehensive list of resources necessary to provide baseline care for common otolaryngologic conditions. SUMMARY: Through an internal survey of its members, the Global Otolaryngology-Head and Neck Surgery Initiative has compiled a list of essential equipment and services to provide baseline care of otolaryngologic conditions. Our efforts aimed to address common otolaryngologic conditions that have been previously identified as high-priority with respect to prevalence and burden of disease. This expert-driven list of essential resources functions as an initial framework to be adapted for internal quality assessment, implementation research, health policy development, and economic priority-setting.

The Global Otolaryngology-Head and Neck Surgery Workforce.

Importance: A core component of delivering care of head and neck diseases is an adequate workforce. The World Health Organization report, Multi-Country Assessment of National Capacity to Provide Hearing Care, captured primary workforce estimates from 68 member states in 2012, noting that response rates were a limitation and that updated more comprehensive data are needed. Objective: To establish comprehensive workforce metrics for global otolaryngology-head and neck surgery (OHNS) with updated data from more countries/territories. Design, Setting, and Participants: A cross-sectional electronic survey characterizing the OHNS workforce was disseminated from February 10 to June 22, 2022, to professional society leaders, medical licensing boards, public health officials, and practicing OHNS clinicians. Main Outcome: The OHNS workforce per capita, stratified by income and region. Results: Responses were collected from 121 of 195 countries/territories (62%). Survey responses specifically reported on OHNS workforce from 114 countries/territories representing 84% of the world's population. The global OHNS clinician density was 2.19 (range, 0-61.7) OHNS clinicians per 100 000 population. The OHNS clinician density varied by World Bank income group with higher-income countries associated with a higher density of clinicians. Regionally, Europe had the highest clinician density (5.70 clinicians per 100 000 population) whereas Africa (0.18 clinicians per 100 000 population) and Southeast Asia (1.12 clinicians per 100 000 population) had the lowest. The OHNS clinicians deliver most of the surgical management of ear diseases and hearing care, rhinologic and sinus diseases, laryngeal disorders, and upper aerodigestive mucosal cancer globally. Conclusion and Relevance: This cross-sectional survey study provides a comprehensive assessment of the global OHNS workforce. These results can guide focused investment in training and policy development to address disparities in the availability of OHNS clinicians.

Delphi Method Consensus on Priority Global Otolaryngology-Head and Neck Surgery Conditions and Procedures.

OBJECTIVE: The objective of this study was to develop an international expert consensus on priority otolaryngology-head and neck surgery conditions and procedures globally for which national health systems should be capable of caring. STUDY DESIGN: The Delphi method was employed via a multiround online survey administered to attending otolaryngologists in an international research collaborative of >180 otolaryngologists in >40 countries. SETTING: International online survey. METHODS: In round 1, participants listed the top 15 otolaryngologic conditions and top 15 otolaryngology procedures for their World Bank regions. In round 2, participants ranked round 1 responses in order of global importance on a 5-point Likert scale. In round 3, participants reranked conditions and procedures that did not achieve consensus, defined as 50% of the round 2 Likert responses being ranked as "important" or "very important." Descriptive statistics were calculated for each round. RESULTS: The survey was distributed to 53 experts globally, with a response rate of 38% (n = 20). Fifty percent (n = 10) of participants were from low- and middle-income countries, with at least 1 participant from each World Bank region. Ten consensus surgical procedures and 10 consensus conditions were identified. CONCLUSION: This study identified a list of priority otolaryngology-head and neck surgery conditions and surgical procedures for which all national health systems around the world should be capable of managing. Acute and infectious conditions with preventative and emergent procedures were highlighted. These findings can direct future research and guide international collaborations.

Impact of out-of-pocket expenses for surgical care on households in rural Haiti: a mixed-methods study.

OBJECTIVES: This study aimed to report household catastrophic spending on surgery and the experiences of patients and families seeking surgical care in rural Haiti. DESIGN: The study used an explanatory, sequential mixed-methods approach. We collected both quantitative and qualitative data from the participants through interviews. SETTING: A rural tertiary hospital (St. Boniface Hospital) in southern Haiti. PARTICIPANTS: There were 200 adult Haitian surgical patients who entered the study. Of these, 41 were excluded due to missing variables or health expenditure outliers. The final sample included 159 participants. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were (1) direct and indirect payments for surgical care; (2) the rate of catastrophic health expenditure (CHE) (as defined by the Sustainable Development Goals (10% of total household expenditure) and WHO (10%, 20%, 30% and 40% of household capacity to pay)) due to surgical care; and (3) common themes across the lived experiences of households of surgical patients seeking care. RESULTS: The median household expenditure on surgery-related expenses was US$385.6, slightly more than half of per capita gross domestic product in Haiti (US$729.3). Up to 86% of households experienced CHE, as defined by the Sustainable Development Goals, due to receiving surgical care. Patients commonly paid for surgical costs through loans and donations (69.8%). The qualitative analysis revealed prominent themes related to barriers to care including the burden of initiating care-seeking, care-seeking journeys and social suffering. CONCLUSIONS: CHE is common for Haitian surgical patients, and the associated care-seeking experiences are often arduous. These findings suggest that low, flat fees in non-profit hospital settings may not be sufficient to mitigate the costs of surgical care or the resulting challenges that patients experience.

Medical students' knowledge of HPV, HPV vaccine, and HPV-associated head and neck cancer.

On the basis of their training, medical students are considered "the best case scenario" among university students in knowledge of the human papillomavirus (HPV). We evaluated differences in knowledge of HPV, HPV vaccine, and head and neck cancer (HNC) among medical students. A previously validated questionnaire was completed by 247 medical students at a Midwestern university. Outcomes of interest were knowledge score for HPV and HPV vaccine, and HNC, derived from combining questionnaire items to form HPV knowledge and HNC scores, and analyzed using multivariate linear regression. Mean scores for HPV knowledge were 19.4 out of 26, and 7.2 out of 12 for HNC knowledge. In the final multivariate linear regression model, sex, race, and year of study were independently associated with HPV and HPV vaccine knowledge. Males had significantly lower HPV vaccine knowledge than females (ß = -1.53; 95% CI: -2.53, -0.52), as did nonwhite students (ß = -1.05; 95% CI: -2.07, -0.03). There was a gradient in HPV vaccine knowledge based on the year of study, highest among fourth year students (ß = 6.75; 95% CI: 5.17, 8.33). Results were similar for factors associated with HNC knowledge, except for sex. HNC knowledge similarly increased based on year of study, highest for fourth year students (ß = 2.50; 95% CI: 1.72, 3.29). Among medical students, gaps remain in knowledge of HPV, HPV vaccine, and HPV-linked HNC. Male medical students have significantly lower knowledge of HPV. This highlights the need to increase medical student knowledge of HPV and HPV-linked HNC.

Oral and Maxillofacial Surgery: An Opportunity to Improve Surgical Care and Advance Sustainable Development Globally.

Global health has evolved to focus on reducing health inequity and obtaining the highest attainable standard of health for all people. To do this, a range of actors now pursue interventions and policy with an eye toward global targets that place strong emphasis on improving health systems. Within global health, global surgery has sought to delineate the burden of surgical disease and propose policy to improve access to surgery. Oral and maxillofacial surgery has been underrepresented in global health but has a vital role in reducing the global health inequity attributable to the impact of oral and craniofacial conditions.

Global Burden of Head and Neck Cancer: Economic Consequences, Health, and the Role of Surgery.

OBJECTIVE: We aimed to describe the mortality burden and macroeconomic effects of head and neck cancer as well as delineate the role of surgical workforce in improving head and neck cancer outcomes. STUDY DESIGN: Statistical and economic analysis. SETTING: Research group. SUBJECTS AND METHODS: We conducted a statistical analysis on data from the World Development Indicators and the 2016 Global Burden of Disease study to describe the relationship between surgical workforce and global head and neck cancer mortality-to-incidence ratios. A value of lost output model was used to project the global macroeconomic effects of head and neck cancer. RESULTS: Significant differences in mortality-to-incidence ratios existed between Global Burden of Disease study superregions. An increase of surgical, anesthetic, and obstetric provider density by 10% significantly correlated with a reduction of 0.76% in mortality-to-incidence ratio (P < .0001; adjusted R2 = 0.84). There will be a projected global cumulative loss of $535 billion US dollars (USD) in economic output due to head and neck cancer between 2018 and 2030. Southeast Asia, East Asia, and Oceania will suffer the greatest gross domestic product (GDP) losses at $180 billion USD, and South Asia will lose $133 billion USD. CONCLUSION: The mortality burden of head and neck cancer is increasing and disproportionately affects those in low- and middle-income countries and regions with limited surgical workforces. This imbalance results in large and growing economic losses in countries that already face significant resource constraints. Urgent investment in the surgical workforce is necessary to ensure access to timely surgical services and reverse these negative trends.

Towards resilient health systems: opportunities to align surgical and disaster planning.

Natural disasters significantly contribute to human death and suffering. Moreover, they exacerbate pre-existing health inequalities by imposing an additional burden on the most vulnerable populations. Robust local health systems can greatly mitigate this burden by absorbing the extraordinary patient volume and case complexity immediately after a disaster. This resilience is largely determined by the predisaster local surgical capacity, with trauma, neurosurgical, obstetrical and anaesthesia care of particular importance. Nevertheless, the disaster management and global surgery communities have not coordinated the development of surgical systems in low/middle-income countries (LMIC) with disaster resilience in mind. Herein, we argue that an appropriate peridisaster response requires coordinated surgical and disaster policy, as only local surgical systems can provide adequate disaster care in LMICs. We highlight three opportunities to help guide this policy collaboration. First, the Lancet Commission on Global Surgery and the Sendai Framework for Disaster Risk Reduction set forth independent roadmaps for global surgical care and disaster risk reduction; however, ultimately both advocate for health system strengthening in LMICs. Second, the integration of surgical and disaster planning is necessary. Disaster risk reduction plans could recognise the role of surgical systems in disaster preparedness more explicitly and pre-emptively identify deficiencies in surgical systems. Based on these insights, National Surgical, Obstetric, and Anesthesia Plans, in turn, can better address deficiencies in systems and ensure increased disaster resilience. Lastly, the recent momentum for national surgical planning in LMICs represents a political window for the integration of surgical policy and disaster risk reduction strategies.