Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence.

PURPOSE: Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries. METHOD: Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries. RESULTS: From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified. CONCLUSIONS: This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Future and training of craniofacial surgery in India.

Craniofacial surgery, in the strictest sense, is the surgery of structures above and behind the maxilla. Craniofacial surgery is not new to India and has been around for more than 4 decades now since the 1970s. Keeping in mind the promotion of the specialty in India, an Indian Craniofacial Foundation was launched in the year 2012 at the Annual Meeting of the Association of Plastic Surgeons of India. To develop a craniofacial center in India, the primary requirement is a source of funding. Several craniofacial centers, which are already running successfully in India, have amply demonstrated that this can be done in several ways. We would like to discuss here the 2 models of craniofacial service delivery and training that the authors have seen and experienced firsthand.

[Formation of centers in general and abdominal surgery -- necessity or trend?]. / Zentrenbildung in der Allgemein- und Viszeralchirurgie - Notwendigkeit oder Trend?

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.

[Development of pediatric surgery in the next 20 years]. / Entwicklung der Kinderchirurgie in den nächsten 20 Jahren.

Pediatric surgery focuses not on an anatomic region or organ system, but on the development of a growing human being according to age. Recently, a tendency to reduce and to downgrade pediatric surgery could be observed which is due to economic reasons and an alarming lack of trained surgeons. Just as 60 years ago, general surgeons continue to operate on infants and children. However, this is a step backwards and an anachronism. Children are not small adults and pediatric surgery can be distinguished from adult surgery in many aspects, such as the spectrum of surgical diseases, the congenital malformations and frequently the indications and techniques of surgery. Pediatric surgeons, however, by themselves should specialize in centers which are focused on rare and complex diseases. Pediatric surgery should not be separated in the hospital, but integrated in a network with general surgery, traumatology, pediatrics, neonatology and specialists of the other surgical disciplines. Strict patient age limitations are not compatible with the individuality of adolescents and should be avoided. A well-equipped clinic for pediatric surgery is expensive, but a mandatory investment in the future!

[Development of trauma surgery in the next 20 years]. / Entwicklung der Unfallchirurgie in den nächsten 20 Jahren.

During the last century trauma surgery became established as an independent and academically accepted surgical specialty and significant progress was achieved. A high international reputation was also gained. Nowadays health care in Germany is under increased economical pressure mostly caused by a loss of resources as a sign of decreased public appreciation of excellent trauma care. Thus it becomes more and more necessary to find new structures for delivery of trauma care as well as for development of staff, especially in times of feminization in medicine. It is beyond any doubt that the demand for musculoskeletal surgery will rise during the next 20 years especially for the elder generation but it is uncertain how excellent trauma care should be delivered without massive spending and financing of health care including research and innovative forms of trauma treatment.

Surgical practice in the UK.

Throughout the working lifetime of any surgeon, major changes take place often stimulated by matters outwith the practitioner's control. This has certainly been true over the last forty years. The holistic care of a patient is now well established, with surgeons being seen as doctors who can add technical skills to their therapeutic armamentarium rather than being speedy technicians. Many of the changes have been for the good of patient care and developments in other areas such as anaesthesia, intensive care and radiology have had a significant influence on surgical practice. Not all change has been for the better. Some of the Government pressures and concerns with financing of the Health Service have had an adverse affect by deviating attention away from the patient.

Breast surgery as a specialized practice.

The interest in breast surgery as a specialized practice has expanded over the last decade as technology advances and medicine became more complex and specialized overall. There is evidence that breast cancers treated in high-volume centers and by specialists result in improved survival and that the demand for breast surgical oncologists will increase with the aging population. Breast specialists of the future are more likely to be trained in oncoplastic techniques, thereby providing more comprehensive care.

Breast cancer services--a population-based study of service reorganization.

BACKGROUND: The Calman-Hine Report in England and Wales and the Campbell Report in Northern Ireland initiated a major reorganization of cancer services with the aim of improving the provision and delivery of care to cancer patients. In this paper, breast cancer patients diagnosed in 1996 and those diagnosed in 2001 are compared in order to examine the extent of service change in Northern Ireland. METHODS: Patients living in Northern Ireland with invasive breast cancer diagnosed in either 1996 or 2001 were identified from the Northern Ireland Cancer Registry database. Information relating to the delivery of cancer care to these patients was collected by retrospective review of their case notes. RESULTS: Breast cancer surgery was performed in fewer hospitals (13 versus 21) by fewer surgeons (19 versus 40) with 98 percent of patients operated on by designated breast surgeons in 2001. Clinically relevant axillary node excision increased with 765 (87 percent) patients having six or more nodes excised in 2001 compared to 515 (67 percent) in 1996 (p < 0.001). Recording of oestrogen receptor (ER) status improved from 23 percent in 1996 to 91 percent in 2001 (p < 0.001) and 81 percent of patients received hormone therapy appropriate to their ER status in 2001 compared with 6 percent in 1996 (p < 0.001). Communication between hospitals and patients and their GPs also improved. CONCLUSION: A significant change in service provision and delivery has occurred in Northern Ireland in line with the recommendations of the Campbell report. Further work is underway to ascertain the extent to which these changes may have impacted on patient outcomes.

[Bariatric surgery -- stereotypes and paradigms]. / Adipositaschirurgie im interdisziplinären und rechtlichen Spannungsfeld.

Many physicians regard obesity as a sin and treat fat patients with disdain befitting a moral leper. Non-bariatric physicians, being a product of our culture, seem more likely to have an obesity paradigm close to that of the public. Many members of the public regard obesity surgery as dangerous. Many insurers reject morbid obese patients from bariatric surgical treatment with the paradigmal statement that obesity is totally the fault of a fat person. These medical experts do not accept obesity as a disease (which WHO does) and therefore social courts also reject applications of patients who want to undergo bariatric surgery. Morbid obesity is a multifactorial problem with genetic, biochemical, hormonal, environmental, behavioral and cultural elements. It is recognized as an extreme health hazard which is rarely the result of an aberrant moral problem or true addictive behavior. We need to change effectively the negative paradigms towards obesity and its surgery from some of our colleagues, hospital administration, medical insurers and the public. The existing prejudices are not acceptable.

Medicina alternativa o no convencional en ortopedia / Alternative or non-conventional Medicine in Orthopaedics

Se incluyeron en la investigación 100 pacientes, tanto de los hospitalizados como los de sola consulta externa. En su mayoría se trataba de gente de escasos recursos, hombres y mujeres, con actividades muy diversas. Algunos de ellos, habían nacido ya en la ciudad, pero otros habían emigrado del campo a la capital. Se recabaron los datos personales y familiares del paciente, la enfermedad que padecía, sus causas, terapéuticas y consecuencias de esta situación. Se obtuvieron entre otros los siguientes resultados: 1) concepto de enfermedad, 2) frecuencia en que acude al médico y al practicante, 3) condiciones socioeconómicas de los pacientes, 4) terapéuticas empleadas en la curación de esta enfermedad, 5) edades promedio y duración de estas enfermedades, 6) razón por la cual acuden al Hospital General de México y a la alternativa terapéutica, 7) costo, 8) para qué entidades patológicas se utilizó la alternativa terapéutica más frecuentemente, 9) grado de mejoría obtenida, y 10) complicaciones. En este trabajo se presentan los resultados que pudimos obtener