Comparison of Medical Research Abstracts Written by Surgical Trainees and Senior Surgeons or Generated by Large Language Models.

Importance: Artificial intelligence (AI) has permeated academia, especially OpenAI Chat Generative Pretrained Transformer (ChatGPT), a large language model. However, little has been reported on its use in medical research. Objective: To assess a chatbot's capability to generate and grade medical research abstracts. Design, Setting, and Participants: In this cross-sectional study, ChatGPT versions 3.5 and 4.0 (referred to as chatbot 1 and chatbot 2) were coached to generate 10 abstracts by providing background literature, prompts, analyzed data for each topic, and 10 previously presented, unassociated abstracts to serve as models. The study was conducted between August 2023 and February 2024 (including data analysis). Exposure: Abstract versions utilizing the same topic and data were written by a surgical trainee or a senior physician or generated by chatbot 1 and chatbot 2 for comparison. The 10 training abstracts were written by 8 surgical residents or fellows, edited by the same senior surgeon, at a high-volume hospital in the Southeastern US with an emphasis on outcomes-based research. Abstract comparison was then based on 10 abstracts written by 5 surgical trainees within the first 6 months of their research year, edited by the same senior author. Main Outcomes and Measures: The primary outcome measurements were the abstract grades using 10- and 20-point scales and ranks (first to fourth). Abstract versions by chatbot 1, chatbot 2, junior residents, and the senior author were compared and judged by blinded surgeon-reviewers as well as both chatbot models. Five academic attending surgeons from Denmark, the UK, and the US, with extensive experience in surgical organizations, research, and abstract evaluation served as reviewers. Results: Surgeon-reviewers were unable to differentiate between abstract versions. Each reviewer ranked an AI-generated version first at least once. Abstracts demonstrated no difference in their median (IQR) 10-point scores (resident, 7.0 [6.0-8.0]; senior author, 7.0 [6.0-8.0]; chatbot 1, 7.0 [6.0-8.0]; chatbot 2, 7.0 [6.0-8.0]; P = .61), 20-point scores (resident, 14.0 [12.0-7.0]; senior author, 15.0 [13.0-17.0]; chatbot 1, 14.0 [12.0-16.0]; chatbot 2, 14.0 [13.0-16.0]; P = .50), or rank (resident, 3.0 [1.0-4.0]; senior author, 2.0 [1.0-4.0]; chatbot 1, 3.0 [2.0-4.0]; chatbot 2, 2.0 [1.0-3.0]; P = .14). The abstract grades given by chatbot 1 were comparable to the surgeon-reviewers' grades. However, chatbot 2 graded more favorably than the surgeon-reviewers and chatbot 1. Median (IQR) chatbot 2-reviewer grades were higher than surgeon-reviewer grades of all 4 abstract versions (resident, 14.0 [12.0-17.0] vs 16.9 [16.0-17.5]; P = .02; senior author, 15.0 [13.0-17.0] vs 17.0 [16.5-18.0]; P = .03; chatbot 1, 14.0 [12.0-16.0] vs 17.8 [17.5-18.5]; P = .002; chatbot 2, 14.0 [13.0-16.0] vs 16.8 [14.5-18.0]; P = .04). When comparing the grades of the 2 chatbots, chatbot 2 gave higher median (IQR) grades for abstracts than chatbot 1 (resident, 14.0 [13.0-15.0] vs 16.9 [16.0-17.5]; P = .003; senior author, 13.5 [13.0-15.5] vs 17.0 [16.5-18.0]; P = .004; chatbot 1, 14.5 [13.0-15.0] vs 17.8 [17.5-18.5]; P = .003; chatbot 2, 14.0 [13.0-15.0] vs 16.8 [14.5-18.0]; P = .01). Conclusions and Relevance: In this cross-sectional study, trained chatbots generated convincing medical abstracts, undifferentiable from resident or senior author drafts. Chatbot 1 graded abstracts similarly to surgeon-reviewers, while chatbot 2 was less stringent. These findings may assist surgeon-scientists in successfully implementing AI in medical research.

Preventing Surgeon Work-Related Musculoskeletal Disorders: A Pilot Study of the Comprehensive Operating Room Ergonomics (CORE) Program.

IMPORTANCE: Work-related musculoskeletal disorders (WMSDs) among surgeons are markedly increasing. Several proposed interventions to reduce WMSDs among surgeons have been studied, but few follow an occupational therapy-oriented approach addressing biomechanical, psychophysical, and psychosocial risk factors. OBJECTIVE: To design, implement, and assess the potential of the Comprehensive Operating Room Ergonomics (CORE) program for surgeons, a holistic evidence-based ergonomics and wellness intervention grounded in occupational therapy principles. DESIGN: Mixed-methods pilot study with the quantitative strand embedded in the qualitative strand. SETTING: University-affiliated hospital. PARTICIPANTS: Six laparoscopic surgeons. OUTCOMES AND MEASURES: CORE program outcomes were assessed using qualitative and quantitative data to indicate changes in posture, physical discomfort, sense of wellness, and operating room (OR) ergonomic performance. The Rapid Upper Limb Assessment (RULA) was used to quantify surgeons' WMSD risk level before and after intervention. RESULTS: There were 12 baseline observations (two for each participant), and two or three post-CORE implementation observations. A statistically significant difference, F(1, 6) = 8.57, p = .03, was found between pre- and post-occupational therapy intervention RULA scores. Thematic analysis of surgeon feedback, which was overwhelmingly positive, identified five themes: postural alignment, areas of commonly reported physical pain or discomfort, setup of the OR environment, surgical ergonomics training, and ergonomics in everyday life. CONCLUSIONS AND RELEVANCE: The CORE program effectively decreased ergonomic risk factors to optimize surgeons' occupational performance in the OR. This study demonstrates a potential solution to how occupational therapists can holistically support surgeons and health care providers who are at risk for WMSDs. Plain-Language Summary: By 2025, a surgeon shortage is expected, partly because of the increase in surgeons' work-related musculoskeletal disorders, which affect their health and job continuity. This pilot study shows that the Comprehensive Operating Room Ergonomics program effectively addresses these problems. The study also serves as a framework for occupational therapy professionals to work with health care providers on ergonomics, benefiting population health. Results suggest that this approach could enhance surgeons' work conditions, supporting the American Occupational Therapy Association's Vision 2025 to improve health and quality of life.

Clinical and surgical physician's perception of nutrition knowledge.

BACKGROUND: Due to the significant increase in the prevalence of food-related diseases, the value that physicians place on nutritional advice may have implications for patient treatment. The objective of this study was to evaluate the perception of the importance of nutritional intervention among physicians in the Universidad San Francisco de Quito's (USFQ) healthcare system. METHODS: This cross-sectional study employed a telephone survey administered to a subset of all medical doctors (MDs) working in the healthcare system clinics of USFQ between 2021 and 2022. Study participants were recruited through voluntary response sample from a complete list of 253 MD. The single time questionnaire consisted of a 22-item validated survey in which attitudes, self-perceived capacity, and knowledge about nutrition ofmedical doctors were evaluated. Data was analyzed using descriptive statistics, two-sided t test, bivariate associations and linear and logistic regressions. RESULTS: 136 MDs completed the survey yielding a response rate of 54%. Our analysis grouped participants into clinical (CE) and non-clinical specialties, hereafter referred to as surgical MDs. While a higher percentage of physicians in CE are confident in their ability to provide examples of recommended food portions based on national or international guidelines, 1 in 10 do not know how to use and interpret BMI or waist circumference, and around 1 in 3 do not know how many calories there are in one gram of fat, protein, or carbohydrates, and their basic metabolic functions. Almost all survey participants believe MDs can have an impact on the eating behavior of a patient if time is used to discuss the problem, however, almost half of survey participants believe nutrition counseling is not an effective use of time. CONCLUSION: It is important to explore the perceptions and self-confidence of physicians around nutrition related issues. Our results demonstrated that nearly 1 in 4 surgical MDs do not feel capable of recognizing nutritional risk in patients, which highlights the essentiality of physicians having an updated understanding of basic nutrition principles. Future research should examine how commonly MDs refer patients to nutritionists/dietitians, as well as strategies for improving physician knowledge on basic nutrition concepts.

Podiatric surgery: a canary in the coalmine for professional monopolies.

What is known about the topic?  The health workforce and health tasks are highly contested and largely controlled by regulation. Since the introduction of medical regulation in the mid-19th century, the practice of surgery has been largely dominated by medically trained surgeons. A small group of Australian podiatrists have defied these historic boundaries by creating their own colleges of training and convincing government and regulators of their safety and efficacy in surgical practice. The Podiatry Board of Australia commissioned an independent review of the regulation and regulatory practices of podiatric surgeons in Australia. What does this paper add? This paper discusses the implications of a regulatory review of the role of podiatric surgeons for professional role boundaries. What are the implications for practitioners? Despite historic role boundaries and definitions, with appropriate training, regulation, and financing, the health workforce can be mobilised in different ways to meet population needs, overcoming a professional monopoly over roles.

Ergonomics appraisals in operating rooms.

This document presents the ergonomic assessments carried out by Spanish surgeons on the materials used within an operating room. With the objective of disseminating and raising awareness of the importance of ergonomics, this working group has compiled information from a previously conducted survey on musculoskeletal disorders associated with surgical work from the year 2022, obtaining feedback from 131 surgeons from 17 distinct specialties. A noteworthy 80.2 % of surveyed surgeons reported having experienced forced postures during surgery, and 96.9 % believe that their physical discomfort is a result of the posture adopted during operations. Such postures can result in the development of pathologies and may have a direct impact on work performance and even in extreme cases, it can lead to sick leave or early retirement. By providing their insights on electronic devices, surgical furniture, and instrumentation, surgeons can help identify areas for improvement in the practice of their profession.

Intraoperative workload of the surgeon in robot-assisted radical prostatectomy: a systematic review.

In the present study, we aimed to systematically evaluate the current evidence regarding the intraoperative workload of surgeons performing robot-assisted radical prostatectomy (RARP) for prostate cancer. A systematic search was carried out in the PubMed-MEDLINE and Web of Science databases through April 2024 using the following search terms: "workload AND robot assisted radical prostatectomy", "workload AND robotic radical prostatectomy", "task load AND robotic radical prostatectomy", "task load AND robot assisted radical prostatectomy" and "NASA-TLX AND robot assisted radical prostatectomy" by combining population, intervention, comparison, and outcome (PICO) terms, following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We therefore selected studies that included patients with prostate cancer (P) who underwent robotic radical prostatectomy (I) and reported a workload/task load questionnaire (C) to assess the intraoperative workload/task load of the surgeon performing robot-assisted radical prostatectomy (O). A total of 11 studies were identified. The surgeon's workload during RARP was assessed using the National Aeronautics and Space Administration task load index (NASA-TLX) and/or the surgery task load index (SURG-TLX) in the studies. Total NASA-TLX scores of the studies ranged from 22.7 ± 3.2 to 62.0 ± 6.4. Mental and physical demands, flow interruptions, surgeon experience, the use of single or multiple ports, and the relationship between the surgeon and other staff in the operating theater may play a role in the intraoperative workload of the console surgeon. The studies we reviewed suggest that RARP offers an acceptable workload for the console surgeon despite its mental demands.

Gender Differences in Electronic Health Record Usage Among Surgeons.

Importance: Understanding gender differences in electronic health record (EHR) use among surgeons is crucial for addressing potential disparities in workload, compensation, and physician well-being. Objective: To investigate gender differences in EHR usage patterns. Design, Setting, and Participants: This cross-sectional study examined data from an EHR system (Epic Signal) at a single academic hospital from January to December 2022. Participants included 224 attending surgeons with patient encounters in the outpatient setting. Statistical analysis was performed from May 2023 to April 2024. Exposures: Surgeon's gender. Main Outcomes and Measures: The primary outcome variables were progress note length, documentation length, time spent in medical records, and time spent documenting patient encounters. Continuous variables were summarized with median and IQR and assessed via the Kruskal-Wallis test. Categorical variables were summarized using proportion and frequency and compared using the χ2 test. Multivariate linear regression was used with primary EHR usage variables as dependent variables and surgeon characteristics as independent variables. Results: This study included 222 529 patient encounters by 224 attending surgeons, of whom 68 (30%) were female and 156 (70%) were male. The median (IQR) time in practice was 14.0 (7.8-24.3) years. Male surgeons had more median (IQR) appointments per month (78.3 [39.2-130.6] vs 57.8 [25.7-89.8]; P = .005) and completed more medical records per month compared with female surgeons (43.0 [21.8-103.9] vs 29.1 [15.9-48.1]; P = .006). While there was no difference in median (IQR) time spent in the EHR system per month (664.1 [301.0-1299.1] vs 635.0 [315.6-1192.0] minutes; P = .89), female surgeons spent more time logged into the system both outside of 7am to 7pm (36.4 [7.8-67.6] vs 14.1 [5.4-52.2] min/mo; P = .05) and outside of scheduled clinic hours (134.8 [58.9-310.1] vs 105.2 [40.8-214.3] min/mo; P = .05). Female surgeons spent more median (IQR) time per note (4.8 [2.6-7.1] vs 2.5 [0.9-4.2] minutes; P < .001) compared with male surgeons. Male surgeons had a higher number of median (IQR) days logged in per month (17.7 [13.8-21.3] vs 15.7 [10.7-19.7] days; P = .03). Female surgeons wrote longer median (IQR) inpatient progress notes (6025.1 [3692.1-7786.7] vs 4307.7 [2808.9-5868.4] characters/note; P = .001) and had increased outpatient document length (6321.1 [4079.9-7825.0] vs 4445.3 [2934.7-6176.7] characters/note; P < .001). Additionally, female surgeons wrote a higher fraction of the notes manually (17% vs 12%; P = .006). After using multivariable linear regression models, male gender was associated with reduced character length for both documentations (regression coefficient, -1106.9 [95% CI, -1981.5 to -232.3]; P = .01) and progress notes (regression coefficient, -1119.0 [95% CI, -1974.1 to -263.9]; P = .01). Male gender was positively associated with total hospital medical records completed (regression coefficient, 47.3 [95% CI, 28.3-66.3]; P < .001). There was no difference associated with gender for time spent in each note, time spent outside of 7 am to 7 pm, or time spent outside scheduled clinic hours. Conclusions and Relevance: This cross-sectional study of EHR data found that female surgeons spent more time documenting patient encounters, wrote longer notes, and spent more time in the EHR system compared with male surgeons. These findings have important implications for understanding the differential burdens faced by female surgeons, including potential contributions to burnout and payment disparities.

Assessing extremely negative online patient reviews and complaints of musculoskeletal oncology surgeons in the United States: a retrospective analysis.

INTRODUCTION: Physician-review websites (PRWs) are commonly used by patients while searching for a surgeon. There is no current literature investigating the factors that contribute to online one-star reviews of musculoskeletal oncology surgeons. This retrospective study aims to identify these factors to determine areas of care affecting patient's subjective reviews. METHODS: Patient ratings and comments regarding musculoskeletal oncology surgeons from the Musculoskeletal Tumor Society (MSTS) were collected from Vitals.com. One-star reviews with comments were then classified as either operative or nonoperative. These complaints were then further classified based on content including wait time, uncontrolled pain, time spent with the physician, surgical outcomes, medical staff/institutional complaints, and bedside manner. RESULTS: A total of 169 reviews (375 complaints) from 181 physicians were included. Of these complaints, 198 were from patients in the operative category while 177 were from patients in the nonoperative category. Bedside manner was the most common complaint. Operative patients reported higher instances of uncontrolled pain in their reviews, whereas nonoperative patients more frequently cited wait time. No significant difference in the complaints that mentioned the amount of time spent with the physician, bedside manner, a disagreement with the plan, or the medical staff or institution was found. CONCLUSION: Online one-star reviews of musculoskeletal oncology surgeons on Vitals.com referenced both surgical and non-surgical aspects of patient encounters, with bedside manner being the most popular complaint overall. Surgical patients were more likely to complain of uncontrolled pain whereas non-operative patients were more likely to complain of wait time. TYPE OF STUDY: Outcomes 2c.

Implementing a no-drain policy for extraperitoneal colorectal anastomosis in a real-life setting: analysis of outcomes and surgeons' adherence.

AIM: Recent evidence has questioned the usefulness of anastomotic drain (AD) after low anterior resection (LAR). However, the implementation and adoption of a no-drain policy are still poor. This study aims to assess the clinical outcomes of the implementation of a no-drain policy for rectal cancer surgery into a real-life setting and the adherence of the surgeons to such policy. METHOD: A retrospective analysis was conducted on patients who underwent elective minimally invasive LAR between January 2015 and December 2019 at two tertiary referral centers. In 2017, both centers implemented a policy aimed at reducing the use of AD. Patients were retrospectively categorized into two groups: the drain policy (DP) group, comprising patients treated before 2017, and the no-drain policy (NDP) group, consisting of patients treated from 2017 onwards. The endpoints were the rate of anastomotic leak (AL) and of related interventions. RESULTS: Among the 272 patients included, 188 (69.1%) were in the NDP group, and 84 (30.9%) were in the DP group. Baseline characteristics were similar between the two groups. AL rate was 11.2% in the NDP group compared to 10.7% in the DP group (p = 1.000), and the AL grade distribution (grade A, 19.1% (4/21) vs 28.6% (2/9); grade B, 28.6% (6/21) vs 11.1% (1/9); grade C, 52.4% (11/21) vs 66.7% (6/9), p = 0.759) did not significantly differ between the groups. All patients with symptomatic AL and AD underwent surgical treatment for the leak, while those with symptomatic AL in the NPD group were managed with surgery (66.7%), endoscopic (19.0%), or percutaneous (14.3%) interventions. Postoperative outcomes were similar between the groups. Three years after implementing the no-drain policy, AD was utilized in only 16.5% of cases, compared to 76.2% at the study's outset. CONCLUSION: The introduction of a no-drain policy received a good adoption rate and did not affect negatively the surgical outcomes.

Surgeon Skill and Perioperative Outcomes in Robot-Assisted Partial Nephrectomy.

Importance: Technical skill in complex surgical procedures may affect clinical outcomes, and there is growing interest in understanding the clinical implications of surgeon proficiency levels. Objectives: To determine whether surgeon scores representing technical skills of robot-assisted kidney surgery are associated with patient outcomes. Design, Setting, and Participants: This quality improvement study included 10 urological surgeons participating in a surgical collaborative in Michigan from July 2021 to September 2022. Each surgeon submitted up to 7 videos of themselves performing robot-assisted partial nephrectomy. Videos were segmented into 6 key steps, yielding 127 video clips for analysis. Each video clip was deidentified and distributed to at least 3 of the 24 blinded peer surgeons from the collaborative who also perform robot-assisted partial nephrectomy. Reviewers rated technical skill and provided written feedback. Statistical analysis was performed from May 2023 to January 2024. Main Outcomes and Measures: Reviewers scored each video clip using a validated instrument to assess technical skill for partial nephrectomy on a scale of 1 to 5 (higher scores indicating greater skill). For all submitting surgeons, outcomes from a clinical registry were assessed for length of stay (LOS) greater than 3 days, estimated blood loss (EBL) greater than 500 mL, warm ischemia time (WIT) greater than 30 minutes, positive surgical margin (PSM), 30-day emergency department (ED) visits, and 30-day readmission. Results: Among the 27 unique surgeons who participated in this study as reviewers and/or individuals performing the procedures, 3 (11%) were female, and the median age was 47 (IQR, 39-52) years. Risk-adjusted outcomes were associated with scores representing surgeon skills. The overall performance score ranged from 3.5 to 4.7 points with a mean (SD) of 4.1 (0.4) points. Greater skill was correlated with significantly lower rates of LOS greater than 3 days (-6.8% [95% CI, -8.3% to -5.2%]), EBL greater than 500 mL (-2.6% [95% CI, -3.0% to -2.1%]), PSM (-8.2% [95% CI, -9.2% to -7.2%]), ED visits (-3.9% [95% CI, -5.0% to -2.8%]), and readmissions (-5.7% [95% CI, -6.9% to -4.6%]) (P < .001 for all). Higher overall score was also associated with higher partial nephrectomy volume (ß coefficient, 11.4 [95% CI, 10.0-12.7]; P < .001). Conclusions and Relevance: In this quality improvement study on video-based evaluation of robot-assisted partial nephrectomy, higher technical skill was associated with lower rates of adverse clinical outcomes. These findings suggest that video-based evaluation plays a role in assessing surgical skill and can be used in quality improvement initiatives to improve patient care.

Comparative analysis of carotid artery stenting practice and outcomes across operator specialties: insights from a prespecified subanalysis of a large real-world patient cohort (ROADSAVER Study).

BACKGROUND: In contemporary clinical practice, carotid artery stenting (CAS) is increasingly becoming a multispecialty field, joining operators of various training backgrounds, which bring forth their unique expertise, patient management philosophies, and procedural preferences. The best practices and approaches, however, are still debated. Therefore, real-world insights on different operator preferences and related outcomes are of utmost value, yet still rather scarce in the available literature. METHODS: Using the data collected in the ROADSAVER observational, European multicenter CAS study, a prespecified comparative analysis evaluating the impact of the operator's specialization was performed. We used major adverse event (MAE) rate at 30-day follow-up, defined as the cumulative incidence of any death or stroke, and its components as outcome measures. RESULTS: A total of 1965 procedures were analyzed; almost half 878 (44.7%) were performed by radiologists (interventional/neuro), 717 (36.5%) by cardiologists or angiologists, and 370 (18.8%) by surgeons (vascular/neuro). Patients treated by surgeons were the oldest (72.9±8.5), while radiologists treated most symptomatic patients (58.1%) and more often used radial access (37.2%). The 30-day MAE incidence achieved by cardiologists/angiologists was 2.0%, radiologists 2.5%, and surgeons 1.9%; the observed differences in rates were statistically not-significant (P=0.7027), even when adjusted for baseline patient/lesion and procedural disparities across groups. The corresponding incidence rates for death from any cause were 1.0%, 0.8%, and 0.3%, P=0.4880, and for any stroke: 1.4%, 2.3%, and 1.9%, P=0.4477, respectively. CONCLUSIONS: Despite the disparities in patient selection and procedural preferences, the outcomes achieved by different specialties in real-world, contemporary CAS practice remain similar when using modern devices and techniques.

Trends in using intraoperative parathyroid hormone monitoring during parathyroidectomy: Protocol and rationale for a cross-sectional survey study of North American surgeons.

Hyperparathyroidism is a common endocrine disorder that occurs secondary to abnormal parathyroid gland functioning. Depending on the type of hyperparathyroidism, surgical extirpation of hyperfunctioning parathyroid glands can be considered for disease cure. Intraoperative parathyroid hormone (IOPTH) monitoring improves outcomes in patients undergoing surgery for primary hyperparathyroidism, but studies are needed to characterize its institutional adoption and its role in surgery for secondary and tertiary hyperparathyroidism, as these entities can be difficult to cure. Hence, we will perform a cross-sectional survey study of surgeon rationale, operational details, and barriers associated with IOPTH monitoring adoption across North America. We will utilize a convenience sampling technique to distribute an online survey to head and neck surgeons and endocrine surgeons across North America. This survey will be distributed via email to three North American professional societies (i.e., Canadian Society for Otolaryngologists-Head and Neck Surgeons, American Head and Neck Society, and American Association of Endocrine Surgeons). The survey will consist of 30 multiple choice questions that are divided into three concepts: (1) participant demographics and training details, (2) details of surgical adjuncts during parathyroidectomy, and (3) barriers to adoption of IOPTH. Descriptive analyses and multiple logistic regression will be used to evaluate the impact of demographic, institutional, and training variables on the use of IOPTH monitoring in surgery for all types of hyperparathyroidism and barriers to IOPTH monitoring adoption. Ethics approval was obtained by the Hamilton Integrated Research Ethics Board (2024-17173-GRA). These findings will characterize surgeon and institutional practices with regards to IOPTH monitoring during parathyroid surgery and will inform future trials aimed to optimize the use of IOPTH monitoring in secondary and tertiary hyperparathyroidism.

Knowledge and attitude towards the use of pain medications according to WHO cancer pain analgesic ladder in tertiary care hospitals of Pakistan.

To assess the knowledge and attitude of practicing physicians and surgeons towards the use of pain medication according to the World Health Organisation cancer pain analgesic ladder, the current study was conducted at tertiary care hospitals of the four provinces of Pakistan. Professionals having experience of treating cancer patients for >2 years were included. Data was collected using a self-administered questionnaire sent to each participant using Google Forms. Of the 630 physicians approached, 133(21%) responded. Of them, 74(55.64%) participants were familiar with the World Health Organisation analgesic ladder. There was a significant difference in the frequency of using the ladder based on age (p<0.05). Most participants 31(23%) reported the nonavailability of the recommended drugs as the reason for not following the analgesic ladder. There is a strong need to educate physicians and surgeons about the World Health Organisation analgesic ladder, and to make strategies to improve opioid availability in Pakistan.