The First Generation of Asian American Pediatric Surgical Trainees in North America.

INTRODUCTION: Pediatric surgical trainees come from diverse races and ethnicities. However, Asian-Americans (AAs) including West, South, and East Asians may represent a unique group of individuals. We sought to identify any unique challenges and experiences. METHODS: Pediatric surgical trainees were identified from, "The Genealogy of North American Pediatric Surgery: From Ladd to Now" and "Celebrating 50 Years: Canadian Association of Paediatric Surgeons/Association Canadienne de Chirurgie Pediatrique". A database was compiled, and AAs identified who completed their pediatric surgical training on or before 1980. Personal interviews and online sources provided further information. RESULTS: Of 635 pediatric surgical trainees in North America (NA) there were 49 AA trainees (7.7%). There was insufficient information for seven, thus leaving 42 (41 male, one female) for review. The region of Asia of origin included 16 East, 16 West, and 10 South. Thirty-seven (88.0%) had moved to NA for training. The most frequent training programs included seven from Toronto and four each at Buffalo, Detroit, Pittsburgh, and Chicago (Children's Memorial). Thirty-five (83%) trainees spent most of their careers in NA while 7 (17%) practiced in their home country. CONCLUSIONS: The first AA pediatric surgical trainees voiced few examples of discrimination but indicated needs to adjust to the NA culture and often confusion over non-Western names. Mentorship was valued and gratitude expressed over the opportunity offered to train in NA. While some had intended to return to their home countries, plans changed due to meeting spouses or political turmoil. Many of those reviewed sought each other out at national meetings.

Evaluating the scope of rural general surgery in British Columbia.

BACKGROUND: Rural general surgeons perform many procedures outside the conventional scope of the specialty. Unique to British Columbia, the Rural Practice Subsidiary Agreement (RSA) formally defines rurality in the province. Our goal is to understand the scope of practice for BC's rural general surgeons and whether it has been affected over time by changing privileging guidelines. METHODS: Medical Services Plan (MSP) data were collected from 2011 to 2021 for procedures billed by general surgeons in communities defined by the RSA as rural. We categorized codes from the MSP based on surgical specialty. For each community, we calculated the totals for these categories considering what other surgical specialties were present as well as changes over time. RESULTS: From 2011 to 2021, 222 905 procedures were performed in 23 rural communities in BC. Colonoscopies were the most frequently performed procedure (n = 80 114, 35.9%), followed by colorectal (n = 23 891, 10.7%) and hernia procedures (n = 20 911, 9.4%). The most common unconventional procedures were plastic surgeries (n = 8077, 3.6%). Classification within the RSA did not significantly influence the percentage of unconventional general surgery procedures performed (p = 0.4). When another surgical specialty was present, there was often a decrease in the number of that specialty's procedures performed by general surgeons. Over the past decade, rural general surgeons performed fewer unconventional general surgery procedures (p < 0.001). CONCLUSION: General surgeons working in rural communities perform a variety of procedures based on resources, community need, and access to other specialists. Over the last decade, this appears to have been influenced by new privileging guidelines. Understanding the scope of rural general surgery can inform training opportunities and, as there is a migration away from rural surgeons performing as many unconventional procedures, can elucidate the implications on patients and communities.

Establishing the predictive validity of the intercollegiate membership of the Royal Colleges of surgeons written examination: MRCS Part A.

Successful completion of the Intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination is mandatory for surgical trainees entering higher specialist training in the United Kingdom. Despite its international reputation, and the value placed on the examination in surgical training, there has been little evidence of its predictive validity until recently. In this review, we present a summary of findings of four recent Intercollegiate studies assessing the predictive validity of the MRCS Part A (written) examination. Data from all four studies showed statistically significant positive correlations between the MRCS Part A and other written examinations taken by surgical trainees over the course of their education. The studies summarised in this review provide compelling evidence for the predictive validity of this gatekeeping examination. This review will be of interest to trainees, training institutions and the Royal Colleges given the value placed on the examination by surgical training programmes.

BEST of Surgical Training: the pan-London Core Surgical Training induction programme: "There's no I in team, but there is a me."

BACKGROUND: In the UK, Core Surgical Training (CST) marks the start of a surgical career, but previous experience and skills vary widely. Whilst Individual hospital Trusts offer local inductions, these are generally of a generic, administrative nature rather than advising trainees on how best to harness training opportunities. We designed a regional induction programme, 'Building Excellence in Surgical Training' (BEST) to address this, develop essential technical and non-technical skills, and engender support networks. METHODS: All incoming London Core Surgical Trainees (annual cohort size 90) were invited to participate, during the week prior to commencement of training. Trainees undertook 3 modules (portfolio, surgical skills and human factors-based simulation) and a research paper presentation day. We collected qualitative and quantitative data through a structured evaluation form, pre and post course Likert-scale scores and self-assessment utilising the non-technical skills for surgeons (NOTSS) framework. RESULTS: 972 CSTs have completed BEST over the past 12 years. In 2019, significant improvements were seen in: confidence for starting CST, 45% (n = 22/49)-83% (n = 33/40,p = 0.00045); feeling the core programme cared about them, 55% (n = 27/49)-98% (n = 41/42, p =< 0.00001); getting to know peers 16% (n = 8/49)-88% (n = 35/40, p =< 0.00001); understanding human factors 82% (n = 40/49)-95% (n = 36/38, p = 0.00427); gaining confidence of trainers, 49% (n = 23/47)-86% (n = 31/36, p = 0.00114), and ability to speak out over patient safety concerns, 78% (n = 38/49)-97% (n = 37/38,p = 0.00019). NOTSS assessments showed significant improvement across all 4 criteria (n = 142, p =< 0.00001). CONCLUSION: BEST equips trainees with the fundamental skills and confidence to safely embark on surgical training and provides tools to navigate the challenges training presents. The ethos of collaboration and support will aid the development of more resilient and empowered surgeons, vital in this era.

Results of the FUSE Evaluation Project in France.

BACKGROUND: The Federation of Visceral and Digestive Surgery (FCVD) is in charge in France of the continuing medical education of digestive surgeons. Since 2016 and in collaboration with SAGES, it has offered the Fundamental Use of Surgical Energy (FUSE) program as part of the continuing education for surgeons including eLearning and hands-on workshops. METHODS: The aim of this study was to evaluate the impact of the FUSE program on the participants by participating in a knowledge test and completing a survey. RESULTS: 485 participants fully completed the knowledge test of 18 questions. Post-test assessment showed an increase in the mean score with respect to pre-test assessment, and the surgeons who have participated to the hands-on workshops had a better score. 304 participants filled the survey of 6 questions. The majority were satisfied by the FUSE program and felt that the objectives were achieved. CONCLUSIONS: The FUSE program developed by SAGES and adopted by the FCVD in France was very much appreciated by the participants and achieved its educational objectives. Our goal is to spread it as widely as possible to all members of the operating room team.

An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group.

BACKGROUND: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training. METHODS: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries. RESULTS: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country's need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries. CONCLUSIONS: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Surgical training programmes in the South Pacific, Papua New Guinea and Timor Leste.

BACKGROUND: There is a surgical workforce shortage in Papua New Guinea (PNG), the Pacific and Timor Leste. Previously, Pacific Island specialists who trained overseas tended to migrate. METHODS: A narrative review was undertaken of the training programmes delivered through the University of Papua New Guinea and Fiji National University's Fiji School of Medicine, and support provided through Australian Aid and the Royal Australasian College of Surgeons (RACS), including scholarships and visiting medical teams. RESULTS: The Fiji School of Medicine MMed programme, which commenced in 1998, has 39 surgical graduates. Sixteen of 22 Fijians, nine of ten Solomon Islanders and four of five in Vanuatu currently reside and/or work in-country. Surgical training in PNG began in 1975, and now has 104 general surgical graduates, 11 of whom originate from the Pacific Islands or Timor Leste. The PNG retention rate of local graduates is 97 per cent, with 80 per cent working in the public sector. Twenty-two surgeons have also undertaken subspecialty training. Timor Leste has trained eight surgical specialists in PNG, Fiji, Indonesia or Malaysia. All have returned to work in-country. The RACS has managed Australian Aid programmes, providing pro bono visiting medical teams to support service delivery and, increasingly, capacity building in the region. The RACS has funded scholarships and international travel grants to further train or sustain the surgical specialists. CONCLUSION: The local MMed programmes have been highly successful in retaining specialists in the region. Partnerships with Australian Aid and RACS have been effective in ensuring localization of the faculty and ongoing professional development.

Training and accrediting international surgeons.

BACKGROUND: Formal international medical programmes (IMPs) represent an evolution away from traditional medical volunteerism, and are based on the foundation of bidirectional exchange of knowledge, experience and organizational expertise. The intent is to develop multidirectional collaborations and local capacity that is resilient in the face of limited resources. Training and accreditation of surgeons continues to be a challenge to IMPs, including the need for mutual recognition of competencies and professional certification. METHODS: MEDLINE, Embase and Google Scholar™ were searched using the following terms, alone and in combination: 'credentialing', 'education', 'global surgery', 'international medicine', 'international surgery' and 'training'. Secondary references cited by original sources were also included. The authors, all members of the American College of Academic International Medicine group, agreed advice on training and accreditation of international surgeons. RESULTS AND CONCLUSION: The following are key elements of training and accrediting international surgeons: basic framework built upon a bidirectional approach; consideration of both high-income and low- and middle-income country perspectives; sourcing funding from current sources based on existing IMPs and networks of IMPs; emphasis on predetermined cultural competencies and a common set of core surgical skills; a decentralized global system for verification and mutual recognition of medical training and certification. The global medical system of the future will require the assurance of high standards for surgical education, training and accreditation.

In-Country Training by the Ghana College of Physicians and Surgeons: An Initiative that has Aided Surgeon Retention and Distribution in Ghana.

BACKGROUND: Prior to 2003, production of new surgeons in Ghana was limited. In 2003, the Ghana College of Physicians and Surgeons (GCPS) initiated the first wholly in-country training and credentialing of surgeons. The purpose of this study was to assess the impact of in-country training of surgeons in Ghana. METHODS: We interviewed 117 (80%) of the 146 surgeons trained through the GCPS from inception through 2016. We gathered data on type of training, practice location, clinical workload, and administrative and teaching roles. Operations were categorized into those deemed essential (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities project versus other. RESULTS: In-country retention was 87-97%. A little more than half (56%) were working in the two largest cities and 44% were working in higher need areas. Twenty-two (19%) were the first surgeon to have worked at their current hospital. The surgeons performed a mean of 13 operations per week (seven electives, six emergencies). 35% of elective and 77% of emergency operations were in the essential category. Most (79%) surgeons were engaged in training/teaching; 46% were engaged in research; and 33% held an administrative office. CONCLUSIONS: In-country surgical training has led to high retention and wide geographic distribution, including high need areas. The in-country trained surgeons are playing key roles in clinical practice, training, and administration. These data provide support for investments in similar efforts in other low- and middle-income countries.

Challenges of training and delivery of pediatric surgical services in developing economies: a perspective from Pakistan.

BACKGROUND: As the pediatric population requiring health services rises globally, developing countries are struggling to cater to the growing burden of non-communicable diseases - particularly those requiring specialized surgical care. MAIN BODY: Despite the literature supporting specialized pediatric surgical care, the developing world is far from meeting the American Pediatric Surgical Association (APSA) Manpower taskforce recommendation of at least 1 qualified pediatric surgeon per 100,000 patients (0-15 years-old). In Pakistan, there is an unmet surgical need in the pediatric population due to a multitude of short shortcomings, notably in quality and quantity of the training programs on offer, and urgent short- and long-term steps are needed to improve this dire situation. CONCLUSION: It is crucial for the global surgical community to take steps, especially with regards to pediatric surgical training, to ensure delivery of accessible and quality surgical care to the world's children.

Which factors predict success in the mandatory UK postgraduate surgical exam: The Intercollegiate Membership of the Royal College of Surgeons (MRCS)?

BACKGROUND: The Membership of the Royal College of Surgeons examination (MRCS, Parts A and B) is one of the largest postgraduate surgical exams in the world, but little is known about the factors that affect candidate performance. We describe the relationship between both parts of MRCS and several independent predictors of MRCS success. METHODS: Pearson correlation coefficients were used to examine the linear relationship between MRCS Part A and B and logistic regression analysis to identify potential independent predictors of MRCS success. We included all UK medical graduates who attempted either part of MRCS between 2007 and 2016. RESULTS: 7896 candidates made 11,867 attempts at Part A and 4310 made 5738 attempts at Part B. A positive correlation was found between Part A and B first attempt score (r = 0.41, P < 0.001). Gender (male vs. female, odds ratio (OR) 2.78, 95% confidence interval (CI) 1.83-4.19), ethnicity (white vs. Black Minority and Ethnic, OR 1.70, 95% CI 1.52-1.89), stage of training (e.g. Core Surgical Year 2 trainees vs. Foundation Year 1 doctors, OR 0.50, 95% CI 0.32-0.77) and maturity (young vs. mature graduates, OR 2.60, 95% CI 1.81-3.63) were all found to be independent predictors of Part A success. In addition to ethnicity and stage of training, Part A performance (number of attempts and score) was also identified as an independent predictor for Part B. The odds of passing each part of the MRCS decreased by 14% (OR 0.86, 95% CI 0.80-0.92) for Part A and 30% for Part B (OR 0.70, 95% CI 0.61-0.81) with each additional attempt that was made. CONCLUSIONS: Several independent predictors of MRCS success were identified, but only ethnicity and stage of training were found to be common predictors of both Part A and B.

The Education of American Surgeons and the Rise of Surgical Residencies, 1930-1960.

In the first half of the twentieth century, the training of American surgeons changed from an idiosyncratic, often isolated venture to a standardized, regulated, and mandated regimen in the form of the surgical residency. Over the three critical decades between 1930 and 1960, these residencies developed from an extraordinary, unique opportunity for a few leading practitioners to a widespread, uniform requirement. This article explores the transformation of surgical education in the United States, focusing on the standardization and dissemination of residencies during this key period. Utilizing the archives of professional organizations, it shows how surgical societies initiated and forced reform in the 1930s. It demonstrates the seminal and early role taken by the federal government in the expansion of surgical residencies through incentivized policies and, especially, the growth of the Veterans Administration health system after World War II. Finally, an examination of intra-professional debates over this process illustrates both the deeper struggles to control the nature of surgical training and the importance of residency education in defining the midcentury American surgeon.

Non-technical skills of surgical trainees and experienced surgeons.

BACKGROUND: In addition to technical expertise, surgical competence requires effective non-technical skills to ensure patient safety and maintenance of standards. Recently the Royal Australasian College of Surgeons implemented a new Surgical Education and Training (SET) curriculum that incorporated non-technical skills considered essential for a competent surgeon. This study sought to compare the non-technical skills of experienced surgeons who completed their training before the introduction of SET with the non-technical skills of more recent trainees. METHODS: Surgical trainees and experienced surgeons undertook a simulated scenario designed to challenge their non-technical skills. Scenarios were video recorded and participants were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring system. Participants were divided into subgroups according to years of experience and their NOTSS scores were compared. RESULTS: For most NOTSS elements, mean scores increased initially, peaking around the time of Fellowship, before decreasing roughly linearly over time. There was a significant downward trend in score with increasing years since being awarded Fellowship for six of the 12 NOTSS elements: considering options (score -0·015 units per year), implementing and reviewing decisions (-0·020 per year), establishing a shared understanding (-0·014 per year), setting and maintaining standards (-0·024 per year), supporting others (-0·031 per year) and coping with pressure (-0·015 per year). CONCLUSION: The drop in NOTSS score was unexpected and highlights that even experienced surgeons are not immune to deficiencies in non-technical skills. Consideration should be given to continuing professional development programmes focusing on non-technical skills, regardless of the level of professional experience.

Landmark lecture on surgery: paediatric cardiothoracic surgery - training the next generation of congenital heart surgeons.

Introduction Recent changes in surgical education have had an impact on our congenital training programmes. The mandate of the 8-hour workweek, a rapidly expanding knowledge base, and a host of other mandates has had an impact on the readiness of the fellows who are entering congenital programmes. To understand these issues completely, we interviewed the top congenital experts in the United States of America. The purpose of this paper is to share their insight and offer suggestions to address these challenges. METHODS: We used a qualitative thematic analysis approach and performed phone interviews with the top five congenital experts in the United States of America. RESULTS: Experts unanimously felt that duty-hour restrictions have negatively affected congenital training programmes in the following ways: current fellows do not seem as conditioned as fellows in the past, patient handoffs are not consistent with excellent performance, the mentor-mentee relationship has been affected by duty-hour restrictions, and fellows may be less prepared for real-world practice. Three positive themes emerged in response to duty-hour restrictions: fellows appear to be doing less menial task work, fellows are now better rested for learning, and we are attracting more individuals into the speciality. Experts agreed that congenital fellowships should be increased to 2 years. There was support for both the traditional and integrated residency pathways. Discussion We are in a new era of education and must work together to overcome the challenges that have arisen in recent years.

Palliative Medicine-Becoming a Subspecialty of the Royal College of Physicians and Surgeons of Canada.

The discipline of palliative medicine in Canada started in 1975 with the coining of the term "palliative care." Shortly thereafter, the provision of clinical palliative medicine services started, although the education of the discipline lagged behind. In 1993, the Canadian Society of Palliative Care Physicians (CSPCP) started to explore the option of creating an accredited training program in palliative medicine. This article outlines the process by which, over the course of 20 years, palliative medicine training in Canada went from a mission statement of the CSPCP, to a 1 year of added competence jointly accredited by both the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada, to a 2-year subspecialty of the Royal College with access from multiple entry routes and a formalized accrediting examination.

New Paradigms in Post-Graduate Surgical Education.

With a growing focus on patient safety and trainee education, the Accreditation Council for Graduate Medical Education implemented changes including work hour restrictions, focused clinical competencies, and the Next Accreditation System (NAS). The NAS poses initial challenges on residencies with the implementation of surgical simulation programs and defining resident competency. It is the hope that innovative training methods will allow for improved advancement of knowledge and surgical skills given the current direction of post-graduate surgical training.

The surgical workforce shortage and successes in retaining surgical trainees in Ethiopia: a professional survey.

BACKGROUND: Medical workforce shortages represent a major challenge in low- and middle-income countries, including those in Africa. Despite this, there is a dearth of information regarding the location and practice of African surgeons following completion of their training. In response to the call by the WHO Global Code of Practice on the International Recruitment of Health Personnel for a sound evidence base regarding patterns of practice and migration of the health workforce, this study describes the current place of residence, practice and setting of Ethiopian surgical residency graduates since commencement of their surgical training in Ethiopia or in Cuba. METHODS: This study presents data from a survey of all Ethiopian surgical residency training graduates since the programme's inception in 1985. RESULTS: A total of 348 Ethiopians had undergone surgical training in Ethiopia or Cuba since 1985; data for 327 (94.0 %) of these surgeons were collected and included in the study. The findings indicated that 75.8 % of graduates continued to practice in Ethiopia, with 80.9 % of these practicing in the public sector. Additionally, recent graduates were more likely to remain in Ethiopia and work within the public sector. The average total number of surgeons per million inhabitants in Ethiopia was approximately three and 48.0 % of Ethiopian surgeons practiced in Addis Ababa. CONCLUSIONS: Ethiopian surgeons are increasingly likely to remain in Ethiopia and to practice in the public sector. Nevertheless, Ethiopia continues to suffer from a drastic surgical workforce shortage that must be addressed through increased training capacity and strategies to combat emigration and attrition.

["Let's become the surgeon" the present status of the medical course beside teaching in Department of surgery, Daisan Hospital the Jikei University School of medicine: based on the experience OF clinical Clark ship for 5 years].

In Department of Surgery, Daisan Hospital, The Jikei University School of Medicine, Clinical Clark ship (C.C.) is positively taken in the bedside teaching of the medical course fifth and sixth grader from April, 2010. We think that the C.C. is a good opportunity to tell the charm of the surgeon to the students. We introduce a bedside teaching going in our Department, based on the experience of the C.C. for 5 years. In the bedside teaching of our department, there are many tasks not to advance before when students do not have discussion with preceptors, about participation in surgery, presentation of the preoperative conference, visiting of outpatient care and night practice. Moreover, students decide the theme about submitting report and research presentation. For our department which built a bedside teaching with on the job training as a concept from 2010, "students in the C.C." is welcome and beneficial for the doctors, the students itself and the patients. When C.C. will be introduced into all Department of our university in earnest from 2016, we have to examine the merits and demerits in future so that C.C. functions going well.