Expanding Global Surgery Education in Brazil: Perspectives after the 35th Brazilian Surgical Congress.

The 35th Brazilian Congress of Surgery marked a turning point for surgical education in the country. For the first time, the Brazilian College of Surgeons included Global Surgery on the main congressional agenda, providing a unique opportunity to rethink how surgical skills are taught from a public health perspective. This discussion prompts us to consider why and how Global Surgery education should be expanded in Brazil. Although Brazilian researchers and institutions have contributed to the fields expansion since 2015, Global Surgery education initiatives are still incipient in our country. Relying on successful strategies can be a starting point to promote the area among national surgical practitioners. In this editorial, we discuss potential strategies to expand Global Surgery education opportunities and propose a series of recommendations at the national level.

Expanding Global Surgery Education in Brazil: Perspectives after the 35th Brazilian Surgical Congress / Expandindo o Ensino de Cirurgia Global no Brasil: Perspectivas após o 35º Congresso Brasileiro de Cirurgia

ABSTRACT The 35th Brazilian Congress of Surgery marked a turning point for surgical education in the country. For the first time, the Brazilian College of Surgeons included Global Surgery on the main congressional agenda, providing a unique opportunity to rethink how surgical skills are taught from a public health perspective. This discussion prompts us to consider why and how Global Surgery education should be expanded in Brazil. Although Brazilian researchers and institutions have contributed to the fields expansion since 2015, Global Surgery education initiatives are still incipient in our country. Relying on successful strategies can be a starting point to promote the area among national surgical practitioners. In this editorial, we discuss potential strategies to expand Global Surgery education opportunities and propose a series of recommendations at the national level.

RESUMO O 35º Congresso Brasileiro de Cirurgia foi marcado por discussões inovadoras para a educação cirúrgica no país. Pela primeira vez, o Colégio Brasileiro de Cirurgiões incluiu a Cirurgia Global na pauta principal do congresso, proporcionando uma oportunidade única de repensar como as habilidades cirúrgicas são ensinadas a partir de uma perspectiva de saúde pública. Essa discussão nos leva a considerar por que e como o ensino da Cirurgia Global deve ser expandido no Brasil. Embora pesquisadores e instituições brasileiras tenham contribuído para a expansão do campo desde 2015, as iniciativas de educação em Cirurgia Global ainda são incipientes em nosso país. Basear-se em estratégias bem-sucedidas pode ser um ponto de partida para promover a área entre os profissionais de cirurgia nacionais. Neste editorial, discutimos potenciais estratégias para expandir as oportunidades de educação em Cirurgia Global e propomos uma série de recomendações a nível nacional.

Geospatial mapping of surgical systems for earthquake emergency planning in Guerrero, Mexico: an ecological study.

Background: Accessibility to surgical services can impact earthquake preparedness and response. We aimed to estimate the population with timely access to surgical care in Guerrero, a Mexican state with high tectonic activity, and identify populations at risk in the event of an earthquake. Methods: We conducted an ecological study using open government data. We extracted data from Guerrero municipalities regarding their earthquake risk, social vulnerability, social inequality, marginalisation, and resilience indices. The latest combines municipalities' resistance to unexpected events and capacity to maintain optimal functionality without immediate federal or international support. Geographical coordinates of active public and private surgical facilities in Guerrero were combined with ancillary spatial data on roads and municipalities' population density to estimate population coverage within 30-min and 1-h driving time to surgical facilities in Redivis. We built an ordered beta regression model for each driving time estimate. Findings: We identified 25 public and 16 private facilities capable of providing surgical care in Guerrero. The population with access to facilities with surgical capacity within 30 min and 1-h driving times were 48.4% and 69.1%, respectively. We found that municipalities with very high levels of earthquake risk, social vulnerability, social inequality, and marginalisation, and very low levels of resilience had decreased coverage. In the multivariable analysis, the resilience index was statistically significant only for the 30-min model, with an effect size of 0.524 (95% CI 0.082, 1.089). Interpretation: Access to surgical care remains unequally distributed in Guerrero municipalities at the highest risk for earthquakes. Municipalities' resilience was the most significant predictor of higher surgical care coverage in 30-min driving time. Our study provides insights on how surgical system strengthening can enhance earthquake emergency disaster planning. Funding: No funding.

Correction: Academic global surgical competencies: A modified Delphi consensus study.

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis.

Background: Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors. Methods: By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach. Findings: We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model. Interpretation: Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico. Funding: None.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Online medical education: A student survey.

BACKGROUND: During COVID-19, medical schools transitioned to online learning as an emergency response to deliver their education programmes. This multi-country study compared the methods by which medical schools worldwide restructured the delivery of medical education during the pandemic. METHODS: This multi-country, cross-sectional study was performed using an internet-based survey distributed to medical students in multiple languages in November 2020. RESULTS: A total of 1,746 responses were received from 79 countries. Most respondents reported that their institution stopped in-person lectures, ranging from 74% in low-income countries (LICs) to 93% in upper-middle-income countries. While only 36% of respondents reported that their medical school used online learning before the pandemic, 93% reported using online learning after the pandemic started. Of students enrolled in clinical rotations, 89% reported that their rotations were paused during the pandemic. Online learning replaced in-person clinical rotations for 32% of respondents from LICs versus 55% from high-income countries (HICs). Forty-three per cent of students from LICs reported that their internet connection was insufficient for online learning, compared to 11% in HICs. CONCLUSIONS: The transition to online learning due to COVID-19 impacted medical education worldwide. However, this impact varied among countries of different income levels, with students from LICs and lower middle income countries facing greater challenges in accessing online medical education opportunities while in-person learning was halted. Specific policies and resources are needed to ensure equitable access to online learning for medical students in all countries, regardless of socioeconomic status.

Women Representation on Editorial Boards in Latin America Journals: Promoting Gender Equity in Academic Surgery, Anesthesia, and Obstetrics.

BACKGROUND: Inequitable representation in journal editorial boards may impact women's career progression across surgical, anesthesia, and obstetric (SAO) specialties. However, data from Latin America are lacking. We evaluated women's representation on editorial boards of Latin America SAO journals in 2021. METHODS: We conducted a cross-sectional analysis, retrieving journals through Scimago Journal and Country Rank 2020. Journals were included if active, focused on SAO topics, and publicly provided information on editorial board staff. Editorial board member names and positions were extracted from journals' websites. Members were classified into senior (e.g., editor-in-chief), academic (e.g., reviewer), and non-academic roles (e.g., administrative office). Women's representation was predicted from first names using Genderize.io. The number of women SAO physicians per country was obtained from articles and governmental reports. RESULTS: We included 19 of 25 identified journals and analyzed 1,318 names. Three anesthesiology, seven obstetric, and nine surgical journals represented five Latin American countries. Women held 17% (224/1,318) of board positions [p < 0.0001; 95% CI(0.14, 0.19)]. Women held fewer academic roles (14.3%, 155/1,084) compared to senior [28.9%, 64/221 (p < 0.001)] and non-academic roles [38.4%, 5/13 (p = 0.042)]. Surgical journals had fewer women (7.7%, 58/752) compared to anesthesia [25.5%, 52/204 (p = 0.006)] and obstetrics [31.5%, 114/362 (p < 0.001)]. Women's proportion on editorial boards increased according to the number of women SAO physicians per country (p < 0.001). CONCLUSIONS: Our study assessed the composition of editorial boards from Latin America SAO journals and demonstrated that women remain underrepresented. Our findings highlight the need for regional strategies to advance women's careers across SAO specialties.

Capacity Building in Peer-review: A Student-Led Journal Report.

Peer-review optimizes the quality of research articles; however, new strategies need to be implemented to enhance peer-review capacity. This report comprises the peer-review process of a medical student-led journal editorial board, detailing its challenges and the students' role. The peer education approach conducted a capacity-building activity, developing guidelines, and practicing critical appraisal and constructive feedback in manners that classroom research training cannot. Understandings of an effective peer-review brought to discussion from standardization and blinding to ethical and scientific competencies essential in researchers. All parties, including students, should be allowed to extend their capabilities to enhance scholarly publishing.

Global Surgery at the National Landscape: Perspectives after the XXXIV Brazilian Congress of Surgery.

The XXXIV Brazilian Congress of Surgery included Global Surgery for the first time in its scientific program. Global Surgery is any action in research, clinical practice, and policy-making that aims to improve access and quality of care in surgical specialties. In 2015, The Lancet Commission on Global Surgery highlighted that five billion people lack safe, timely, and affordable surgical care. Even more critical, nine of ten people cannot access essential surgical care in low and middle-income countries, where a third of the worldwide population resides, and only 6% of global surgical procedures are performed. Although Brazilian researchers and institutions have been contributing to lay the movement's foundations since 2014, Global Surgery remains a barely debated subject in the country. It is urgent to expand the field and break paradigms regarding the surgeons' role in public health in Brazil. Accomplishing these standards requires a joint effort to strategically allocate resources and identify collaboration opportunities, including those from medical societies and regulatory bodies. As members of the International Student Surgical Network of Brazil - a nonprofit organization by and for students, residents, and young physicians focused on Global Surgery - we review why investing in surgery is cost-effective to strengthen health systems, reduce morbimortality, and lead to economic development. Additionally, we highlight and propose key recommendations to foster the field at the national level.

Women Representation in Surgical Specialties: Reflections about Gender Equity after the 34th Brazilian Surgical Conference.

In September 2021, the 34th Brazilian Surgical Conference hosted the "Panel: Women in Surgery" - the only session in the event solely composed of female speakers. Although gender inequities in surgery are well recognized in the international literature, the panel portrayed how distant we are from the desired equity in our country. In addition, the session emphasized the need to broaden the debate and identify the mechanisms for greater inclusion and maintenance of women in the surgical career. In this editorial, we provide a historical overview of gender disparities in the Brazilian surgical ecosystem, highlight the contributing factors to a reduced number of female surgeons, and how the structure of medical societies may influence the rise of women to leadership positions. Accordingly, we discuss the benefits of gender diversity for surgeons, patients, and institutions. Furthermore, we analyze the representation of women in the Brazilian College of Surgeons since its foundation and in the scientific sessions at the conference, demonstrating that more initiatives are required to encourage female representation in the college. Finally, we propose a series of recommendations to foster engagement and contribute to the prosperity of women surgeons in Brazil.

Global Surgery at the National Landscape: Perspectives after the XXXIV Brazilian Congress of Surgery / Cirurgia Global no Cenário Nacional: Perspectivas após o 34º Congresso Brasileiro de Cirurgia

ABSTRACT The XXXIV Brazilian Congress of Surgery included Global Surgery for the first time in its scientific program. Global Surgery is any action in research, clinical practice, and policy-making that aims to improve access and quality of care in surgical specialties. In 2015, The Lancet Commission on Global Surgery highlighted that five billion people lack safe, timely, and affordable surgical care. Even more critical, nine of ten people cannot access essential surgical care in low and middle-income countries, where a third of the worldwide population resides, and only 6% of global surgical procedures are performed. Although Brazilian researchers and institutions have been contributing to lay the movement's foundations since 2014, Global Surgery remains a barely debated subject in the country. It is urgent to expand the field and break paradigms regarding the surgeons' role in public health in Brazil. Accomplishing these standards requires a joint effort to strategically allocate resources and identify collaboration opportunities, including those from medical societies and regulatory bodies. As members of the International Student Surgical Network of Brazil - a nonprofit organization by and for students, residents, and young physicians focused on Global Surgery - we review why investing in surgery is cost-effective to strengthen health systems, reduce morbimortality, and lead to economic development. Additionally, we highlight and propose key recommendations to foster the field at the national level.

RESUMO O 34° Congresso Brasileiro de Cirurgia incluiu Cirurgia Global pela primeira vez em seu programa científico. Cirurgia Global é qualquer ação em pesquisa, prática clínica e políticas em saúde que visa melhorar o acesso e a qualidade do atendimento em especialidades cirúrgicas. Em 2015, a Comissão da The Lancet em Cirurgia Global destacou que cinco bilhões de pessoas carecem de assistência cirúrgica segura, oportuna e acessível. Ainda mais crítico, nove em cada dez pessoas não têm acesso a cuidados cirúrgicos essenciais em países de baixa e média renda, onde um terço da população mundial reside e apenas 6% dos procedimentos cirúrgicos globais são realizados. Embora pesquisadores e instituições brasileiras tenham contribuído para lançar as bases internacionais e nacionais do movimento desde 2014, a Cirurgia Global ainda é um assunto pouco debatido no país. Assim, faz-se urgente expandir essa área de conhecimento e quebrar paradigmas quanto ao papel do cirurgião na saúde pública no Brasil. Isso requer um esforço conjunto para alocar recursos de forma estratégica bem como para identificar oportunidades de colaboração, incluindo as sociedades médicas e os órgãos reguladores. Como membros da International Student Surgical Network of Brazil - organização sem fins lucrativos feita por e para estudantes, residentes e jovens médicos com foco na Cirurgia Global - revisamos por que investir em Cirurgia é uma medida custo-efetiva para fortalecer os sistemas de saúde, reduzir a morbimortalidade e promover o desenvolvimento econômico. Além disso, destacamos e propomos recomendações-chave para fomentar a Cirurgia Global a nível nacional.

Women Representation in Surgical Specialties: Reflections about Gender Equity after the 34th Brazilian Surgical Conference / Representatividade das Mulheres nas Especialidades Cirúrgicas: Reflexões sobre Equidade de Gênero após o 34º Congresso Brasileiro de Cirurgia

ABSTRACT In September 2021, the 34th Brazilian Surgical Conference hosted the "Panel: Women in Surgery" - the only session in the event solely composed of female speakers. Although gender inequities in surgery are well recognized in the international literature, the panel portrayed how distant we are from the desired equity in our country. In addition, the session emphasized the need to broaden the debate and identify the mechanisms for greater inclusion and maintenance of women in the surgical career. In this editorial, we provide a historical overview of gender disparities in the Brazilian surgical ecosystem, highlight the contributing factors to a reduced number of female surgeons, and how the structure of medical societies may influence the rise of women to leadership positions. Accordingly, we discuss the benefits of gender diversity for surgeons, patients, and institutions. Furthermore, we analyze the representation of women in the Brazilian College of Surgeons since its foundation and in the scientific sessions at the conference, demonstrating that more initiatives are required to encourage female representation in the college. Finally, we propose a series of recommendations to foster engagement and contribute to the prosperity of women surgeons in Brazil.

RESUMO Em setembro de 2021, o 34º Congresso Brasileiro de Cirurgia sediou o "Painel de debates: Mulheres na Cirurgia" - o único espaço do evento composto somente por mulheres. Embora a existência de iniquidades de gênero na cirurgia seja bem reconhecida na literatura internacional, esse painel retratou como estamos distantes da almejada equidade em nosso país. Além disso, a sessão enfatizou a necessidade de ampliar o debate e identificar os mecanismos para maior inclusão e retenção das mulheres na carreira cirúrgica. Neste editorial, apresentamos panorama histórico e atual das disparidades de gênero no ecossistema cirúrgico brasileiro; destacamos os fatores que contribuem para o número reduzido de cirurgiãs e, como a estrutura das sociedades médicas influencia na ascensão de mulheres para cargos de liderança. Em seguida, discutimos os benefícios da diversidade de gênero para cirurgiões, pacientes e instituições. Ademais, analisamos a representatividade feminina no Colégio Brasileiro de Cirurgiões desde a fundação e nos espaços científicos do congresso, demonstrando que mais medidas serão necessárias para incentivar maior protagonismo feminino no colégio. Finalmente, propomos uma série de recomendações para fomentar o engajamento e contribuir para a prosperidade das cirurgiãs no Brasil.

Desenvolvimento de Líderes em Pesquisa e Extensão: o Papel de uma Associação de Representatividade Estudantil / Developing Leaders in Research and Extension: The Role of a Student Representative Association

A essência da extensão universitária se pauta na emancipação da sociedade, culminando na indissociabilidade entre ensino, pesquisa e extensão, aspecto de interesse das instituições de ensino superior e dos discentes, visando o exercício da cidadania. Assim, iniciativas que destaquem a relação entre pesquisa e extensão são de extrema relevância. Nesse contexto, a International Federation of Medical Students Associations of Brazil (IFMSA Brazil) é uma organização que trabalha com intuito de fortalecer o tripé universitário e engajar novas lideranças nessas áreas. O principal objetivo deste estudo é discorrer sobre a atuação do time nacional de publicação, pesquisa e extensão da IFMSA Brazil da gestão 2019 ­ 2020 como recurso humano para formação de líderes em pesquisa e extensão, analisando o impacto deste trabalho no âmbito estudantil e universitário, da saúde pública e da comunidade. Este estudo observacional descritivo e retrospectivo tem como objeto de análise as atividades realizadas por este time, no período entre dezembro de 2019 a junho de 2020, em prol da formação de lideranças estudantil no cenário da pesquisa e extensão. Com isso, este trabalho demonstra como esse time não apenas enaltece o acesso à educação em pesquisa e em extensão, através de capacitações, divulgação de oportunidades, materiais, entre outras estratégias, mas também fomenta a liderança estudantil em 220 escolas médicas com o propósito de consolidar a saúde pública, a tradução do conhecimento, a responsabilidade social e o letramento em saúde.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study.

BACKGROUND: The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. METHODS: Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state. FINDINGS: Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663-1,523,995) total operations, 161,321 (95%CI 37,468-395,478) emergent operations, and 928,758 (95%CI 675,202-1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. INTERPRETATION: Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Promovendo equidade de gênero nas especialidades cirúrgicas: experiência de programa de mentoria na América Latina / Promoting gender equity in surgical specialties: experience from a mentorship program in Latin America

Resumo: Introdução: Cirurgia global é uma área que advoga por melhores desfechos e equidade para todos que demandam assistência cirúrgica, anestésica e obstétrica. No Brasil, embora as mulheres componham 46,6% da demografia médica em 2020, inequidades de gênero persistem nas especialidades cirúrgicas. O objetivo deste artigo é relatar a experiência do programa de mentoria do Gender Equity Initiative in Global Surgery como mecanismo de promoção de equidade de gênero. Relato de experiência: O programa almeja capacitar, empoderar e amplificar vozes de minorias de gênero, sendo voluntário e sem fins lucrativos. Baseia-se na criação de pequenos grupos heterogêneos, com diferentes graus de experiência acadêmica e pessoal. As inscrições ocorrem por formulário on-line, com perguntas relacionadas à identidade, a interesses e expectativas dos aplicantes, sendo os grupos organizados de acordo com essas informações. Os mentores são selecionados com base em: nível de treinamento, especialidade, identidade de gênero e expectativas. Realizam-se três acompanhamentos por preenchimento de questionário pelos participantes. Discussão: A necessidade de programas como este durante a pandemia é evidente, mostrando-se como uma iniciativa positiva para desenvolver estratégias de enfrentamento dos desafios vivenciados. Este relato fornece uma visão geral de como um programa de mentoria pode contribuir para que mais estudantes de Medicina sejam incentivados a seguir carreiras em cirurgia, anestesia e obstetrícia, de modo a promover equidade de gênero para além da perspectiva binária, e discute as principais dificuldades em se estabelecerem programas como esse na América Latina. Conclusão: É preciso reforçar que não basta apenas dar suporte a mulheres (cis e trans) e pessoas de gênero não binário, mas também educar a sociedade para compreender identidades de gênero além da perspectiva binária, reconhecendo os impactos nas relações de trabalho e perspectivas de carreira, especialmente dentro do campo cirúrgico.

Abstract: Introduction: Global surgery is an area that advocates for better outcomes and equity for everyone who requires surgical, anesthetic, and obstetric assistance. In Brazil, although women represent 46.6% of medical demographics in 2020, gender equity disparities persist in surgical specialties. The objective of this article is to report the experience of the mentoring program from the Gender Equity Initiative in Global Surgery as a mechanism for promoting gender equity. Experience report: The voluntary and non-profit program aims to train, empower, and amplify voices of gender minorities. It is based on the creation of small heterogeneous groups, with different degrees of academic and professional experience. Applications are made via an online form, with questions related to the identity, interests, and expectations of applicants, and the groups are organized according to this information. Mentors are selected based on the level of training, specialty, gender identity, and expectations. The participants then have three follow-up sessions conducted by completing questionnaires. Discussion: The need for programs like this during the pandemic is evident, proving to be a positive initiative to develop strategies to tackle the challenges experienced. This report provides an overview of how a mentoring program can contribute to greater adherence for medical students to pursue careers in surgery, anesthesia, and obstetrics, promoting gender equity beyond the binary perspective and discussing the main difficulties in establishing similar programs in Latin America. Conclusion: It is necessary to reinforce that educating and supporting women (cisgender and transgender) and non-binary gendered people are not enough, but to educate society to understand gender identities beyond the binary perspective, recognizing the impacts on work relationships and career perspectives, especially within the surgical field.