Surgical Education and Training in the US: a Collaborative Effort to Deliver the Next Generation of Surgeons.

The foundational principles of surgical training in the USA are based on didactic education, structured skill training, and experiential learning in surgical patient care with the supervision of surgical faculty. A consortium of professional organizations, academic institutions, and teaching hospitals with surgical faculty provide the structural framework, policies, and curriculum to train and evaluate surgeons capable of independent practice. This manuscript describes the roles of the organizations responsible for surgical training in the USA and highlights areas in evolution in the modern surgical education landscape.

Surgical leadership in changing times: the American College of Surgeons perspective.

Surgeons around the globe are challenged by the rapid evolution of the environment in which they practice their profession. Changes in surgical technologies, the complexity of surgical patient care, and the regulatory and financial environment of surgical care delivery demand that surgeons be supported in their work with access to superb educational offerings and engagement to foster satisfaction and efficacy in their professional activities. The American College of Surgeons (ACS), the largest international surgical professional organization, is committed to supporting surgeons as leaders in the healthcare system to build programs to create the optimal environment for delivery of quality surgical care to our patients. A selected portfolio of the programs of the ACS is presented.

Surrounded by quality metrics: what do surgeons think of ACS-NSQIP?

BACKGROUND: In an era of proliferating systems of quality assessment, surgeon confidence in metric tools is essential for successful initiatives in quality improvement. We evaluated surgeons' awareness and attitudes about ACS-NSQIP, which is the only national, surgeon-developed, risk-adjusted, system of surgical outcome assessment. METHODS: A 33-item survey instrument was constructed and content validity established through content expert review; test-retest reliability was assessed (weighted-kappa = 0.72). Survey administration occurred in three institutions with varying ACS-NSQIP experience. Summary statistics were generated and subgroup analyses performed (Fisher's exact test). RESULTS: One-hundred and eight surgeons participated. Practice experience varied (27% residents, 33% < 10, 12% 10-20, and 28% > 20 years). Seventy-two percent had fellowship training. Surgeons were familiar with ACS-NSQIP structure, including prospective data collection (70%), case-sampling (63%), and reporting as observed/expected ratios (83%). Surgeons knew some collected data-points but misidentified EKG-findings of MI (67%), surgeon case-experience (41%), and anastomotic dehiscence (79%). Most felt ACS-NSQIP would improve quality of care (79%) and identify areas for improvement (92%). Surgeons were less confident regarding utility at an individual level, with only 46% believing surgeon-specific outcomes should be reported. Few thought ACS-NSQIP data should be available publicly (45%), used for marketing (26%), or direct pay-for-performance (24%). Reservations were most pronounced among surgeons with institutional ACS-NSQIP experience. CONCLUSION: While surgeons accept ACS-NSQIP at an institutional level, skepticism remains surrounding measurement of individual outcomes and public reporting. Surgeons at institutions with a longer duration of experience with ACS-NSQIP tended to be more cynical about potential data applications. Ongoing education and assessment of surgeons' perceptions of quality improvement initiatives is necessary to ensure surgeons remain engaged actively in determining how quality of care data is measured and utilized.

Pheochromocytoma crisis induced by glucocorticoids: a report of four cases and review of the literature.

CONTEXT: Pheochromocytoma crisis (PC) is a rare life-threatening endocrine emergency that may present spontaneously or can be unmasked by 'triggers', including certain medications that provoke the release of catecholamines by tumors. Several isolated cases of PC have been reported after administration of exogenous glucocorticoids; evidence that these drugs cause adverse events in patients with pheochromocytoma is mainly anecdotal. PATIENTS: We report four cases of PC most likely induced by glucocorticoids and review seven previous reports in the literature linking steroid administration to the development of PC. RESULTS: In four new cases reported here, glucocorticoid administration was associated with a fatal outcome in one case, a pheochromocytoma multisystem crisis in another, and serious hypertensive crises in two others. Two patients had incidental adrenal masses and were undergoing high-dose dexamethasone suppression tests (DST). CONCLUSIONS: Exogenous glucocorticoids may unpredictably trigger PC. Pheochromocytoma should be included in the differential diagnosis of any patient who develops a hypertensive crisis, cardiac failure, tachycardia, headache, and abdominal or chest pain after receiving exogenous glucocorticoids. Glucocorticoid induced PC is frequently associated with hemorrhagic pheochromocytoma. Although exogenous glucocorticoids cause serious complications unpredictably, they should be avoided or administered only if necessary and with caution in patients with known or suspected pheochromocytoma. During the investigation of incidental adrenal masses, pheochromocytoma should ideally be ruled out before administering glucocorticoids. However, no cases have been reported with 1 mg of dexamethasone when given as a DST in patients with pheochromocytoma; larger doses, as low as 2 mg of dexamethasone, may trigger a PC. A patient with pheochromocytoma presenting as an adrenal incidentaloma may also be at risk if exposed to glucocorticoids given as pre-treatment in case of allergy to contrast media.

Early specialization in surgical training: an old concept whose time has come?

The complexity of surgical science and surgical patient care is increasing at an accelerating pace. As a consequence, many areas of surgical practice once within the scope of general surgery have evolved into distinct specialties with unique advanced training requirements. Given this evolution in surgical specialization, many have considered that our current model of surgical training--a 5-year residency in general surgery, followed by any of a wide variety of fellowships to acquire refined, advanced training--is due for major restructuring. The current debate focuses on the benefits and potential disadvantages of earlier differentiation of surgeons into specialty training pathways. The structure of surgical training, including the definition of core surgical training and the optimal structure to introduce advanced specialty training tracks, is the central issue in this debate. This article reviews the question and current deliberations of the stakeholders in graduate surgical education and training.