Challenges of Congenital Heart Surgery in Brazil: It is Time to Designate Pediatric Congenital Heart Surgery Subspecialty.

Congenital heart disease (CHD) affects eight to ten out of every 1,000 births, resulting in approximately 23,057 new cases in Brazil in 2022. About one in four children with CHD requires surgery or other procedures in the first year of life, and it is expected that approximately 81% of these children with CHD will survive until at least 35 years of age. Professionals choosing to specialize in CHD surgery face numerous challenges, not only related to mastering surgical techniques and the complexity of the diseases but also to the lack of recognition by medical societies as a separate subspecialty. Furthermore, families face difficulties when access to services capable of providing treatment for these children. To address these challenges, it is essential to have specialized hospitals, qualified professionals, updated technologies, sustainable industry, appropriate financing, quality assessment systems, and knowledge generation. The path to excellence involves specialization across all involved parties. As we reflect on the importance of Pediatric Cardiovascular Surgery and Congenital Heart Diseases establishing themselves as a subspecialty of Cardiovascular Surgery, it is essential to look beyond our borders to countries like the United States of America and United Kingdom, where this evolution is already a reality. This autonomy has led to significant advancements in research, education, and patient care outcomes, establishing a care model. By following this path in Brazil, we not only align our practice with the highest international standards but also demonstrate our maturity and the ability to meet the specific needs of patients with CHD and those with acquired childhood heart disease.

Building a gender-affirming surgery service: The fundamentals.

BACKGROUND: As the healthcare needs of transgender patients become increasingly recognized and supported, gender-affirming surgery services are in increasing demand. However, establishing a gender-affirming surgery service is unlike many other surgical specialties and requires unique expertise and administrative support. The aim of this article is to outline the considerations for starting a gender-affirming surgery service and identify pearls for success. METHODS: In this article, we describe the critical components of building and maintaining a successful gender-affirming surgery service. We intersperse findings from our own experiences developing a gender-affirming surgery service. RESULTS: A successful gender-affirming surgery service starts by developing a clear vision of the patient population within your hospital system's area, as well as the design of your center. Establishing a center relies on early engagement of hospital administration and its continued support. A multidisciplinary team with intensive interpersonal and operative training offers the best patient experience and surgical outcomes. By following these steps, our service has been able to provide gender-affirming surgery to more than 200 patients since its inception. Future goals entail partnerships with other institutions and continued outcomes evaluation to ensure sustained success of all gender-affirming surgery services. CONCLUSION: Although there are unique challenges and considerations for establishing a gender-affirming surgery service, careful planning and stakeholder engagement allow providers to deliver high-quality care. We hope that our experience can serve as a model for future much needed gender-affirming surgery services.

"I need to have a fulfilling job": A qualitative study of surgeon well-being and professional fulfillment.

BACKGROUND: Burnout, often regarded as an individual failing, rather than a systemic one, negatively impacts quality of care, patient safety and healthcare costs. Focusing on improving well-being can help mitigate burnout. This study examined protective factors that promote well-being and professional fulfillment in surgeons. METHODS: Using a purposive sample, 32 semi-structured 30-60-min interviews were conducted with surgeons of varying sub-specialties and rank. Abductive exploratory analysis was used to code and interpret interview transcripts and to build a conceptual model of surgeon well-being. RESULTS: Emergent protective factors were placed into one of three levels of implementation: individual, team-level, and institutional (figure). Individual factors for well-being included autonomy and adequate time to pursue non-clinical endeavors. Team-level factors consisted of adaptability, boundaries, and cohesion. Institutional factors related to diversifying performance evaluations and celebrating and recognizing individual value and contributions. CONCLUSIONS: The conceptual model developed from the results of this study highlights factors important to surgeons' professional well-being. This model can be used to guide quality improvement efforts.

A contemporary reassessment of the US surgical workforce through 2050 predicts continued shortages and increased productivity demands.

BACKGROUND: We aimed to predict practicing surgeon workforce size across ten specialties to provide an up-to-date, national perspective on future surgical workforce shortages or surpluses. METHODS: Twenty-one years of AMA Masterfile data (1997-2017) were used to predict surgeons practicing from 2030 to 2050. Published ratios of surgeons/100,000 population were used to estimate the number of surgeons needed. MGMA median wRVU/surgeon by specialty (2017) was used to determine wRVU demand and capacity based on projected and needed number of surgeons. RESULTS: By 2030, surgeon shortages across nine specialties: Cardiothoracic, Otolaryngology, General Surgery, Obstetrics-Gynecology, Ophthalmology, Orthopedics, Plastics, Urology, and Vascular, are estimated to increase clinical workload by 10-50% additional wRVU. By 2050, shortages in eight specialties are estimated to increase clinical workload by 7-61% additional wRVU. CONCLUSIONS: If historical trends continue, a majority of surgical specialties are estimated to experience workforce deficits, increasing clinical demands substantially.

Gender trends of authors presenting at a regional vascular surgery meeting.

OBJECTIVE: We hypothesized a potential gender disparity within a regional society like the Southern Association of Vascular Surgery (SAVS) when compared with vascular surgery demographics in the region. To assess this, we analyzed meeting and membership participation at the SAVS compared with regional data from the Society of Vascular Surgery as well as board certification in vascular surgery published by the American Board of Surgery (ABS). METHODS: The published programs from the SAVS Annual Meeting from 2012 to 2019 were analyzed for membership, presenter gender, type, topic, discussant gender, moderator gender, postgraduate course presenter gender, and manuscript publication demographics. The ABS was petitioned and yearly Vascular Surgery diplomate (ABS-VS) gender from member states of the SAVS was examined for the same period. Fisher's exact Student's t-test and analysis of covariance were used. RESULTS: There were 257 total presentations (184 podium, 71.6%; 73 poster, 28.4%). A total of 61.4% (n = 43) of presentations by females were podium presentations, compared with 75.4% (n = 141) by males (P = .03). Females were less likely to be published when compared with their male counterparts (41.8% vs 58.7%, P = .02). The percentage of female gendered presenters statistically increased over the time period examined compared with a decrease in male presenters (R2 = 0.61, m = 1.27 vs R2 = 0.08, m = -0.35, P = .02). Female presenters had a female discussant 10.5% of the time compared with male presenters who had a male discussant 95.1% of the time (P < .0001). Females comprised 3.8% ± 1.1% of SAVS yearly membership compared with 12.0% ± 4.6% ABS-VS diplomates among SAVS member states (P < .0001). SAVS female membership significantly lagged behind the increase in ABS-VS female diplomate rate (P = .001). Only 39.1% of SAVS members were cross-listed in Society of Vascular Surgery membership rolls, with a total of 464 potential SAVS members, 11.2% or 52 of whom are female. CONCLUSIONS: We found that female presenters at the SAVS Annual Meeting were less likely to be podium presenters, interface with other female discussants, and publish manuscripts when compared with their male counterparts. Statistically, female members were underrepresented within the SAVS membership rolls when compared with known boarded female vascular surgeons among southern member states. This gender gap highlights a unique opportunity to enhance and potentially increase mentorship opportunities for female trainees who are presenting and/or attending this regional vascular surgery meeting.

"Diversity in Surgery-How Do We Change the Narrative: Pipeline to Professor?"

The goal of our paper is to provide our perspectives on why there is a need to change the narrative in academic surgery to improve health equity by increasing the pipeline of pre-med students to professors. It is well documented that Health disparities hurt many different people, but they especially hurt Black, Indigenous, and People of color. Black men and women have a decreased life expectancy. Differences in care are associated with greater mortality among minority patients and that care provided to black patients by black physicians can lead to improved compliance with medications and care plans. The lack of black diversity in the medical profession proportional to the societal ethnic distribution is alarming. We have opportunities for improvement for recruitment, retention and promotion within the field of surgery.

Crisis Containment: Tools for Harm Mitigation in Surgery.

BACKGROUND: Surgical crises represent unrecognized opportunities for improving patient safety and adding value in healthcare. The first step in a crisis response is to contain and mitigate harm. While the principles of damage control are well established in surgery, methods of containing harm on broader clinical and organizational levels are not clearly defined. STUDY DESIGN: A multimethods qualitative study identified crisis containment strategies and tools in commercial aviation. These were translated and clinically adapted in 3 stages: semi-structured observational fieldwork with commercial airlines, interviews with senior pilots, and focus groups with both healthcare and aviation safety experts. Thematic analysis and expert consensus methods were used to derive a framework for crisis containment. RESULTS: Fieldwork with 2 commercial airlines identified 2 crisis containment concepts: the detrimental impact of surprising or startling events on operator performance; and the use of prioritization tools to take basic but critical actions (Aviate, Navigate and Communicate model). Twenty-two experts in aviation and healthcare practice informed the topic of crisis containment in 17 interviews and 3 focus groups. Three strategies were identified and used to form a crisis containment algorithm: 1. Manage the operators' startle response to facilitate meaningful mitigating actions (STOP tool); 2. Take priority actions to secure core functions. These included managing patients' physiologic shock, optimizing environmental risks, and mobilizing resources (Perfuse, Move and Communicate tool); 3. Deploy well-rehearsed drills targeting case-specific harms or errors (Memory Actions). This model requires validation in clinical practice. CONCLUSIONS: Crisis containment can be achieved by controlling operators' startle response, applying prioritization tools, and deploying drills against specific failures. The application of this model may extend to healthcare areas outside surgery.

Avoid, Trap, and Mitigate: Development of an Evidence-Based Crisis Management Framework in Surgery.

BACKGROUND: Increasingly, surgeons are adopting broader roles in emergency response, on both clinical and executive levels. These have highlighted the need to develop healthcare-specific crisis management systems. Cross-professional research between safety-critical industries is a valuable method for learning crisis control. Commercial aviation, in particular, has been used to drive innovation in surgical safety. This study aimed to identify, adapt, and operationalize a surgical crisis management framework based on current practice in commercial aviation. STUDY DESIGN: A multimethod qualitative study interrogated safety experts in commercial aviation and healthcare. Stage I used immersive observational fieldwork in commercial aviation practice. Stage II performed semi-structured interviews with senior airline pilots. "Snowball" sampling targeted professional networks, recruiting 17 pilots from 4 airlines. Thematic analysis was used to derive a model of crisis management. Stage III undertook 3 focus groups with 5 pilots and 5 healthcare safety specialists. Expert consensus methods were used to adapt the model to clinical practice. RESULTS: Interview data provided 2,698 verbatim quotes on crisis management from aviation experts with a combined flying experience of 188,000 hours. Aviation crisis management was structured in 3 phases: avoid, trap, and mitigate. Adapted to clinical practice, these translated to crisis preparedness, recovery, and containment interventions. Additionally, the study identified 7 types of implementation tools and 9 crisis management skills that could be used to operationalize this framework in surgical practice. CONCLUSIONS: Surgical crisis management can follow the avoid, trap, and mitigate framework used in commercial aviation. Implementation relies on the combined use of crisis skills and performance tools. Crisis management should be delivered as part of a systems-based approach that relies on well-integrated failure management models. Simulation and in-situ validation of this framework is needed.

Trends in Number of Women Speakers at the American Head and Neck Society Meetings, 2007-2019.

Importance: The number of female speakers at American Head and Neck Society (AHNS) conferences should ideally be consistent with the number of women entering head and neck surgery fellowships to ensure gender equity in the field. Yet the presence of women speakers at the annual AHNS meetings, which is specific to the field of head and neck cancer, endocrine and microvascular reconstructive surgery, has yet to be studied. Objective: To determine whether the proportion of female speakers at the AHNS has increased in a manner consistent with the numbers of women entering fellowships since 2007. Design, Setting, and Participants: This qualitative study assessed 13 final meeting programs from AHNS national/international conferences from 2007 to 2019. The number of male and female participants in different roles throughout the meeting were retrospectively tracked. Participants were male and female speakers at AHNS national/international conferences who took part in the roles of scientific session presenter, scientific session moderator, expert panelist, miscellaneous moderator, and named lecturers/keynote speaker. Gender of the speaker was determined by searching names on the internet and using available published pronouns. Main Outcomes and Measures: Number of speaking opportunities for men and women in different roles from 2007 to 2019 as well as number of men and women entering AHNS fellowships since 2007 and new active AHNS members since 2012. Results: In this qualitative study, from 2007 to 2019, 4059 speakers were identified. Of these speakers, 902 (22%) were women and 3157 (78%) were men. Overall, there was a strong correlation between increasing years and number of women speakers from 2007 to 2019 (ρ = 0.75; 95% CI, 0.72-0.78). There were 2096 invited speaking roles that excluded research presentations, of which 400 were offered to female participants (19.1%) across the study period. There were 131 different women that made up all 400 of the opportunities that were offered to women in the years surveyed. There was a strong correlation in the proportion of women as presenters for oral abstracts, expert panelists, and miscellaneous moderators between the years but no correlation in scientific session moderators and named lecturers/keynote speakers. Of the 45 named lecturers/keynote speakers in the programs tracked, only 2 were women. Conclusions and Relevance: In this study, from 2007 to 2019, the presence of women at ANHS has increased overall, reflecting the changing demographic characteristics of those entering in head and neck oncology and microvascular surgery fellowships. However, a strong disparity continues to exist for preeminent speaking opportunities.

Surgical Perspectives for Pediatric Theater Teams during the SARS-CoV-2 Pandemic and Beyond: Narrative Review and Mandatory Tasks Guidelines.

This is a narrative review during the ongoing coronavirus disease 2019 (COVID-19) pandemic to streamline workflow of pediatric surgical patients in operating theaters and for theater teams involved in their management. Pediatric patient anxiety in theaters, aspects of communication, and optimizing vision during surgery during the pandemic have also been addressed. The COVID-19 pandemic has led to the creation of pathways in the surgical management of patients. As the pandemic progressed, hospitals developed pathways to offer increased protection to staff during procedures. This narrative review provides a clear perspective in the management of pediatric patients in operating theaters. Guidelines received from National Health Authorities and Societies affiliated with surgery, endoscopic surgery, anesthesiology, and endoscopy were carefully reviewed regarding their recommendations and data emerging from reports on COVID-19 were selected to compile the pathways specific for pediatric patients and staff. The workflow pathways have been successfully implemented during the pandemic and include a section on patients for endoscopy as well as approach to endoscopic surgery and open procedures. Theater room ergonomics that were successful during the pandemic have been outlined along with identification of areas specific to the pediatric patient anxiety, interteam communication/identification, and visor-related vision. The guidelines used successfully during the pandemic for pediatric theater teams can be used or adapted for formulating local hospital guidelines in other centers that could be valuable in patient management beyond the pandemic.

Surgical subspecialists in West Africa: Workforce size, training opportunities, and contributing factors.

BACKGROUND: The global burden of disease treatable by surgical subspecialists remains an outstanding area of need, and yet little is known about the subspecialist workforce worldwide, especially in sub-Saharan Africa. This study aims to quantify the subspecialty surgical workforce and number of subspecialty training programs in West Africa and to identify socioeconomic factors predicting the number of subspecialists in West African countries. METHODS: West African subspecialists and accredited fellowship training programs in 17 West African countries were quantified using membership data from the West African College of Surgeons and compared with publicly available workforce data from the United States, the United Kingdom, and East, Central, and Southern Africa. Spearman's coefficients were calculated to identify socioeconomic predictors of subspecialist surgical workforce. RESULTS: Of 2,181 surgeons, 712 (32.6%) were surgical subspecialists. Three (18%) of 17 West African countries had greater than 11 subspecialists. There were 174 subspecialty training programs in the region, though 13 countries (76%) had no programs. The number of subspecialists correlated most strongly with the number of subspecialty training programs (rS = 0.68, P = .003) but also correlated significantly with gross population and number of medical schools (rS = 0.50-0.52, P ≤ .05). CONCLUSION: Subspecialist surgeons represent one third of surgeons in West Africa, though most countries have fewer than 12 providers. The number of subspecialists is significantly correlated with the number of subspecialty training programs, and yet many West African countries lack accredited programs. These results suggest that investing in training programs is the most valuable potential strategy to address the shortage of surgical subspecialists in West Africa.

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.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches.

OBJECTIVE: Integrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process. METHODS: An anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists. RESULTS: Seventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance. CONCLUSIONS: Successfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.