Surgical autonomy: A resident perspective and the balance of teacher development with operative independence.

BACKGROUND: This study aims to understand the perspectives of operative autonomy of surgical residents at various postgraduate levels. METHODS: Categorical general surgery residents at a single academic residency were invited to participate in focus groups to discuss their opinions and definitions of operative autonomy. Employing constructivist thematic analysis, focus groups were audio recorded, transcribed, and inductively analyzed using a constant comparative technique. RESULTS: Twenty clinical surgical residents participated in 6 focus groups. Overarching themes identified include autonomy as a dynamic, progressive path to operative independence and the complex interaction of resident-as-teacher development and operative autonomy. Four within operative case themes were intrinsic factors, extrinsic factors, autonomy promoting or inhibiting behaviors, and the relationship between residents and attendings. CONCLUSION: Residents define operative autonomy as a progressive and dynamic pathway to operative independence. Teacher development is viewed as both an extension beyond operative independence and potentially in conflict with their colleagues' development.

Early Outcomes in an Emerging Facial Nerve Center: The Oregon Health and Science University (OHSU) Experience.

OBJECTIVES: Nerve transfer (NT) and free gracilis muscle transfer (FGMT) are procedures for reanimation of the paralyzed face. Assessing the surgical outcomes of these procedures is imperative when evaluating the effectiveness of these interventions, especially when establishing a new center focused on the treatment of patients with facial paralysis. We desired to discuss the factors to consider when implementing a facial nerve center and the means by which the specialist can assess and analyze outcomes. METHODS: Patients with facial palsy secondary to multiple etiologies, including cerebellopontine angle tumors, head and neck carcinoma, and trauma, who underwent NT or FGMT between 2014 and 2019 were included. Primary outcomes were facial symmetry and smile excursion, calculated using FACE-gram and Emotrics software. Subjective quality of life outcomes, including the Facial Clinimetric Evaluation (FaCE) Scale and Synkinesis Assessment Questionnaire (SAQ), were also assessed. RESULTS: 14/22 NT and 6/6 FGMT patients met inclusion criteria having both pre-and postoperative photo documentation. NT increased oral commissure excursion from 0.4 mm (SD 5.3) to 2.9 mm (SD 6.8) (P = 0.05), and improved symmetry of excursion (P < 0.001) and angle (P < 0.001). FGMT increased oral commissure excursion from -1.4 mm (SD 3.9) to 2.1 mm (SD 3.7), (P = 0.02), and improved symmetry of excursion (P < 0.001). FaCE scores improved in NT patients postoperatively (P < 0.001). CONCLUSIONS: Measuring outcomes, critical analyses, and a multidisciplinary approach are necessary components when building a facial nerve center. At our emerging facial nerve center, we found NT and FGMT procedures improved smile excursion and symmetry, and improved QOL following NT in patients with facial palsy secondary to multiple etiologies.

Overcoming a Hostile Work and Learning Environment in Academic Surgery-Tools for Change at Every Level.

Mistreatment has been documented as a negative factor in the learning environment for the past 30 y but little progress has been made to determine an effective way to significantly improve these interactions. Faculty may also be victims of a hostile work environment as well, although frequency has not been well-measured or reported. In fact, it may be difficult to identify and address mistreatment and hostility in the work place within the commonly established surgical culture. Thus, efforts to define, identify, and address workplace mistreatment or hostility are crucial to the success of the academic surgical environment. This article summarizes presentations and panel discussion that took place at the 2019 Academic Surgical Congress organized by the Association for Academic Surgery and the Society of University Surgeons. Definitions of mistreatment and hostility were provided, as well as information regarding occurrence. Tools for addressing mistreatment in the work environment and tips for creating a positive environment were presented and discussed.

The 1951 Harvard student uprising against the intern match.

In the fall of 1951, a group of Harvard medical students led by W. Hardy Hendren, III organized a national movement against the newly instituted match that would assign graduating seniors to hospital internship programs. Before then, hospitals with intern positions to fill rushed to secure commitments from students, who in turn accepted the first decent offer that came their way. Knowing that students could not risk waiting for a better offer, hospitals pushed them into making early commitments. When some students began getting offers in their junior and sophomore years, medical schools, professional groups, and hospitals organized the National Inter-association Committee on Internships to deal with the issue. The intern match was thus organized and scheduled to take place in 1952. When the plan was announced in mid-October 1951, Hendren recognized that the proposed algorithm placed students at a disadvantage if they did not get their first choice of hospitals. Facing resistance at every step from the National Inter-association Committee on Internships and putting his standing at Harvard Medical School at risk, Hendren led a nationwide movement of medical students to change the procedure to one that favored students' choices. Their success <1 month later established in the inaugural match the fundamental ethic of today's National Resident Matching Program to favor students' preferences at every step of the process.

The ethics of insurance limiting institutional medical care: It's all about the money.

Dr F. Inest practices surgery at a renowned medical center but is concerned because increasing numbers of medical insurers are excluding his institution from coverage. Many of his former referring physicians are beginning to send their patients elsewhere for this reason. The marketing people have been busy increasing their advertising buys and exploring new business models. There is even talk about reducing expensive clinical trials. However, regardless of his affiliation, he has little control over these and other organizational decisions that directly impact his practice clinically and fiscally. What should he do?

Assessing Awareness and Implementation of a Recommendation for Surgical Innovation Committees: A Survey of Academic Institutions.

OBJECTIVE: In 2008, a Position Statement of the Society of University Surgeons (SUS) recommended the creation of institutional surgical innovation committees (SICs) to ensure appropriate oversight of surgical innovations. The purpose of this study was to determine the level of awareness of the position statement, and how innovations are handled in academic departments of surgery. METHODS: An electronic survey was designed to determine the level of awareness of the SUS recommendations among members of the Society of Surgical Chairs; the existence and characteristics of SICs; and alternative means of oversight of surgical innovations. RESULTS: The survey was distributed to 150 persons, and 65 (43%) surveys were returned; 84% reported their institution promoted innovative surgery as a strength, but 55% were unaware of the SUS recommendations; 23% reported that their institution has an SIC, and 20% said their institution has discussed or plans an SIC. Existing SICs have a median of 7 members; 57% reviewed 3 or fewer procedures in the prior year; and only 7% reviewed 10 or more. The majority of respondents reported alternative mechanisms of oversight, including morbidity/mortality conferences (88%), peer review (77%), and outcomes registries (51%). CONCLUSIONS: A minority of Surgery Department Chairs is aware of the SUS Position Statement. Although most reported surgical innovation was an institutional strength, only 23% had an SIC and most rely on other mechanisms of oversight. It is unclear whether academic surgical departments are committed to providing education and awareness of the appropriate development and implementation of surgical innovations.

[Bioethics in medical institutions--new custom or help? The example of clinical ethics consultation at a University Medical Center]. / Bioethik in medizinischen Institutionen--Mode oder Hilfe? Das Beispiel der klinischen Ethikberatung eines Universitätsklinikums.

Although ethics committees are well established in the medical sciences for human clinical trials, animal research and scientific integrity, the development of clinical ethics in German hospitals started much later during the first decade of the twenty-first century. Clinical ethics consultation should be pragmatic and problem-centered and can be defined as an ethically qualified and informed conflict management within a given legal framework to deal with and resolve value-driven, normative problems in the care of patients. Clinical ethics consultations enable shared clinical decision-making of all parties (e.g. clinicians, patients, family and surrogates) involved in a particular patient's care. The clinical ethicist does not act as an ethics expert by making independent recommendations or decisions; therefore, the focus is different from other medical consultants. Ethics consultation was first established by healthcare ethics committees (HEC) or clinical ethics consultation (CEC) groups which were called in to respond to an ethically problematic situation. To avoid ethical dilemmas or crises and to act preventively with regard to ethical issues in individual patients, an ethics liaison service is an additional option to ethics case consultations which take place on a regular basis by scheduled ethics rounds during the normal ward rounds. The presence of the ethicist offers some unique advantages: it allows early recognition of even minor ethical problems and accommodates the dynamics of ethical and clinical goal-setting in the course of patient care. Most importantly, regular and non-authoritative participation of the ethicist in normal ward rounds allows continuous ethical education of the staff within the everyday clinical routine. By facilitating clinical ethical decision-making, the ethicist seeks to empower physicians and medical staff to deal appropriately with ethical problems by themselves. Because of this proactive approach, the ethics liaison service can make a significant contribution to preventative ethics in reducing the number of emerging ethical problems to the satisfaction of all parties involved.

[Application for academic multicenter studies at German ethical review boards]. / Beantragung der Bewilligung von akademischen Multicenterstudien bei deutschen Ethikkommissionen.

Before the start of a clinical trial, approval by the responsible institutional ethical review board (IRB) is required. In Germany, nearly 50 independent IRBs may be responsible for the different participating sites of a multicenter study. In trials for rare diseases, the participation of many centers is required. Therefore, the application procedure for academic multicenter trials in malignant hematologic diseases is often a bureaucratic nightmare. Different aspects of IRB application and possible approaches for improvement are presented.

Medicine versus religion in the surgical intensive care unit: who is in charge?

The chief of surgery at a large academic medical center is approached by a vascular surgical faculty member. After a repair of an aortic dissection, an elderly man has remained comatose and has worsened over several weeks, developing multiple system organ failure. Statistically, his chance of leaving the hospital alive is <1%. The family is deeply religious, and the minister and various elders, deacons, and members of their church have been vigilant in constant prayerful attendance. The attending's tactful suggestions that the time is coming when nature should be allowed to take its course was not well received. The family and their support group are convinced that their fervor will summon a miracle. A large group complained to patient affairs and was taken to the medical center director's office. Today, the director told the attending that the hospital would absorb the overall cost until the patient dies and that the unfavorable press from stopping care is unacceptable. The chief of surgery should:

Duty to speak up in the health care setting a professionalism and ethics analysis.

Staff and students working in health care settings are sometimes reluctant to speak up when they perceive patients to be at risk for harm. In this article, we describe four incidents that occurred at our institution (Mayo Clinic). In two of them, health care professionals failed to speak up, which resulted in harm; in the other two, they did speak up, which prevented harm and improved patient care. We analyzed each scenario using the Physician's Charter on Medical Professionalism and prima facie ethics principles to determine whether principles were violated or upheld. We conclude that anyone who works in a health care setting has a duty to speak up when a patient faces harm. We also provide guidance for health care institutions on promoting a culture in which speaking up is encouraged and integrated into routine practice.

Academic medical centers write their own rules.

The interaction between pharmaceutical and device companies and hospitals and physicians has undergone significant transformation in the past few years due to the public's perception that bias may result when such relationships are not disclosed and monitored. Policies need to be written by medical centers and hospitals to preserve and retain the trust of the public. The policy written by Johns Hopkins Medical Institutions is outlined and its implications discussed in this article. The importance of such policies in guiding young faculty and staff as they begin their careers cannot be overemphasized.

Evaluation of academic scientists' responses to situations that pose a conflict of interest.

The industry-academy relationship has many benefits, but it also has potential drawbacks, including potential conflicts of interest (e.g., when the profit motives of a private company unduly influence academic responsibilities). To date, policies intended to regulate or manage financial conflicts of interest appear to be unsatisfying and inadequate. The present study examined predictors of the responses of academic scientists and clinicians to hypothetical situations in which financial and other conflicts of interest may arise. Academic scientists and clinicians at five medical schools completed an anonymous survey that included vignettes that posed a potential conflict of interest. Participants indicated the likelihood that they would engage in specific actions to avoid conflicts of interest. Findings indicated that junior faculty and those whose departments received more federal grant money were more likely to respond in ways that could create conflicts of interest (ps < .05). These results suggest that various sub-groups of faculty may require different approaches to appropriately avoid or manage financial conflicts of interest. These findings may contribute to the development of new policies that deal more effectively with conflicts of interest.

A perspective on commercial relationships between ophthalmology and industry.

Relationships between physicians and industry including pharmaceutical companies and device manufacturers are being closely scrutinized by the public and the media. These companies can contribute beneficially to patient outcomes by supporting research that improves eye care. However, ethical issues may arise that affect practicing ophthalmologists, researchers, academic faculty, and ophthalmologic organizations. These topics were discussed at a symposium sponsored by the American Ophthalmological Society in May 2008. After this meeting, the council of the society developed this perspective to clarify some of the issues at the interface of industry and ophthalmology. The perspective is intended to provide some guidance to physicians, researchers, and professional societies and to enhance further dialogue.

Report of 255 clinical ethics consultations and review of the literature.

OBJECTIVE: To review clinical ethics consultations at a tertiary care academic medical center. METHODS: We retrospectively reviewed all ethics consultations (and associated patient medical records) conducted at the Mayo Clinic in Rochester, Minn, between April 6, 1995, and December 31, 2005. RESULTS: Of the 255 consultations, 101 (40%) reviewed intensive care unit care, 103 (40%) involved patients who died during hospitalization, and 174 (68%) were requested by physicians. The most common primary diagnoses of the patients involved were malignancy (18%, n=47), neurologic disease (18%, n=47), and cardiovascular disease (17%, n=43). Most cases involved multiple issues: patient competency and decision-making capacity (82%, n=208), staff member disagreement with care plans (76%, n=195), end-of-life and quality-of-life issues (60%, n=154), and goals of care and futility (54%, n=138). Withholding or withdrawing measures was the focus of 132 (52%) of the consultations. We also identified previously published reports of ethics consultations and compared the findings of those reports with ours. CONCLUSIONS: Despite advances in medicine, the nature of ethical dilemmas remains relatively unchanged. Issues of communication, family conflict, and futility continue to give rise to ethical quandaries.

Reflexiones éticas sobre la investigación científica en Biomedicina desde el prisma de la Universidad Médica / Ethical reflections on scientific biomedical research from the point of view of the Medical University

Se realizó una reflexión teórica, sobre la evolución histórica del desarrollo de la ciencia y la investigación científica y el planteamiento de los principales problemas actuales relacionados con ese quehacer en el ámbito de las ciencias biomédicas del nivel mundial, desde el prisma de la universidad médica y vistos a la luz de los valores morales. Se reflexionó acerca de los aspectos éticos relacionados con la aplicación del método científico, especialmente en lo concerniente a los principios que deben regir la metodología de la investigación científica en general y, en particular, en el campo de la biomedicina. Se llamó la atención sobre los principales problemas de la investigación y publicación científicas y se alerta sobre numerosas formas de violaciones éticas practicadas por un número nada despreciable de profesionales de las ciencias en general y las ciencias médicas en particular, a lo largo de la historia. Se concluyó con el énfasis puesto en 3 principios fundamentales que no deben ser soslayados en ninguna investigación científica: valorar éticamente la finalidad que la investigación persigue, los medios utilizados para conseguir la finalidad propuesta, y las consecuencias próximas y lejanas de esa investigación