Game theory: applications for surgeons and the operating room environment.

BACKGROUND: Game theory is an economic system of strategic behavior, often referred to as the "theory of social situations." Very little has been written in the medical literature about game theory or its applications, yet the practice of surgery and the operating room environment clearly involves multiple social situations with both cooperative and non-cooperative behaviors. METHODS: A comprehensive review was performed of the medical literature on game theory and its medical applications. Definitive resources on the subject were also examined and applied to surgery and the operating room whenever possible. RESULTS: Applications of game theory and its proposed dilemmas abound in the practicing surgeon's world, especially in the operating room environment. CONCLUSION: The surgeon with a basic understanding of game theory principles is better prepared for understanding and navigating the complex Operating Room system and optimizing cooperative behaviors for the benefit all stakeholders.

The being of leadership.

The ethical foundation of the medical profession, which values service above reward and holds the doctor-patient relationship as inviolable, continues to be challenged by the commercialization of health care. This article contends that a realigned leadership framework - one that distinguishes being a leader as the ontological basis for what leaders know, have, and do - is central to safeguarding medicine's ethical foundation. Four ontological pillars of leadership - awareness, commitment, integrity, and authenticity - are proposed as fundamental elements that anchor this foundation and the basic tenets of professionalism. Ontological leadership is shaped by and accessible through language; what health care leaders create in language "uses" them by providing a point of view (a context) within and from which they orient their conversations, decisions, and conduct such that they are ethically aligned and grounded. This contextual leadership framework exposes for us the limitations imposed by our mental maps, creating new opportunity sets for being and action (previously unavailable) that embody medicine's charter on professionalism. While this leadership methodology contrasts with the conventional results-oriented model where leading is generally equated with a successful clinical practice, a distinguished research program, or a promotion, it is not a replacement for it; indeed, results are essential for performance. Rather, being and action are interrelated and their correlated nature equips leaders with a framework for tackling health care's most complex problems in a manner that preserves medicine's venerable ethical heritage.

The 3 essential responsibilities: a leadership story.

The 3 fundamental and essential responsibilities of leadership--setting a compelling and appealing direction (vision), selecting the right people (talent), and creating and embracing the right set of guiding core values (culture)--are reviewed in the context of the many contributions and leadership legacy of Dr Stanley J. Dudrick, one of the giants of American surgery. Critical success factors which enable the development of leadership as an organizational capacity in any department or unit are emphasized. They include building a team of faculty and residents who are aligned on mission, vision, and values; forging a climate where people are willing to have difficult conversations rather than avoiding complex problems; and the establishment of an esprit d'corps where people experience that they are contributing to a purpose larger than themselves.

MicroRNA-29a regulates intestinal membrane permeability in patients with irritable bowel syndrome.

BACKGROUND: The molecular mechanisms underlying the pathophysiology of irritable bowel syndrome (IBS) are poorly understood. One mechanism may involve increased intestinal permeability that is reversed with glutamine supplementation. Our goal was to evaluate the expression of glutamine synthetase and its complementary miRNA in blood microvesicles and gut tissues of IBS patients with increased intestinal membrane permeability. METHODS: We evaluated 19 diarrhoea-predominant IBS patients and 10 controls for intestinal membrane permeability using the lactulose/mannitol method. miRNA expression was evaluated in blood microvesicles and gut tissue. To further confirm the relationship between miRNA and glutamine synthetase expression, cell culture experiments were conducted. Glutamine synthetase was also evaluated in the gut tissues of patients. RESULTS: A subset of patients with IBS (8/19, 42%) had increased intestinal membrane permeability and decreased glutamine synthetase expression compared to patients with IBS normal membrane permeability, and to controls. Expression of miR-29a was increased in blood microvesicles, small bowel and colon tissues of IBS patients with increased intestinal membrane permeability. Increased intestinal permeability was modulated by miR-29a which has a complementary site in the 3'-UTR of the GLUL gene. CONCLUSIONS: The results support the conclusion that GLUL regulates intestinal membrane permeability and miR-29a regulates both GLUL and intestinal membrane permeability. The data suggests that miR-29a effects on intestinal membrane permeability may be due to its regulation of GLUL. Targeting this signalling pathway could lead to a new therapeutic approach to the treatment of patients with IBS, especially because small molecules that mimic or inhibit miRNA-based mechanisms are readily available.

Does agreement on institutional values and leadership issues between deans and surgery chairs predict their institutions' performance?

PURPOSE: To gain a better understanding of the values that medical school deans and surgery chairs consider most essential for effective leadership, to assess their perceptions of the values and leadership climate in their institutions, and to test the premise that agreement on leadership values and climate predict greater organizational effectiveness and performance. METHOD: From June 2005 through March 2006, questionnaires designed to assess leadership core values and organizational leadership climate were mailed to medical school deans and surgery chairs of the 125 U.S. academic health centers. Institutional performance measures used were the National Institutes of Health (NIH) standing and U.S. News and World Report ranking of each institution. RESULTS: Sixty-eight surgery chairs (54%) and 60 deans (48%) returned surveys. Q-sort results on 38 positive leadership values indicated that integrity, trust, and vision were considered the most important core values for effective leadership by both chairs and deans. Both groups ranked business acumen, authority, and institutional reputation as least important. Deans consistently ranked the leadership climate as being healthier (more positive) than did their surgery chairs on multiple scale items: leadership is widely shared (P = .005), information is widely shared (P = .002), missions are aligned (P = .003), open communication is the norm (P = .009), good performance is rewarded (P = .01), teamwork is widely practiced (P = .01), and leaders are held accountable (P = 002). Tighter alignment between chairs and deans on core values and on the leadership climate scale correlated with higher school and department NIH standing and higher U.S. News and World Report medical school and hospital ranking (P < .05). CONCLUSIONS: Although surgery chairs and deans espouse similar core leadership values, deans believe that a healthier leadership climate exists in their institutions than their surgery chairs do. The study findings suggest that tighter leadership alignment between deans and surgery chairs may predict a higher level of institutional performance in the clinical and academic arenas.

Glucocorticoids have a role in renal cortical expression of the SNAT3 glutamine transporter during chronic metabolic acidosis.

Glucocorticoids are involved in many aspects of regulation of acid-base homeostasis, including the stimulation of renal ammoniagenesis during chronic metabolic acidosis. Plasma glutamine is the principal substrate for ammoniagenesis under these conditions. Expression of the System N glutamine transporter SNAT3 is increased in the renal proximal tubules during acidosis. In vivo studies in rats using 1) sham and adrenalectomized rats, 2) the glucocorticoid receptor antagonist RU486, and 3) dexamethasone treatment demonstrated involvement of glucocorticoids in regulation of SNAT3 expression. Adrenalectomy attenuated the acidosis-induced increase in renal cortical SNAT3 mRNA approximately 40%, and treatment with dexamethasone (1 mg x kg(-1) x day(-1) sc) partially reversed this effect. RU486 also blunted the acidosis-induced increase in SNAT3 expression approximately 50%. Chronic dexamethasone treatment (0.1 mg x kg(-1) x day(-1) sc, 6 days) of normal rats slightly increased SNAT3 expression. In all cases, renal glutamine arteriovenous difference mirrored SNAT3 expression and activity in the proximal tubules, suggesting that SNAT3 regulates glutamine uptake during acidosis. These studies indicate that glucocorticoids regulate acid-base homeostasis during metabolic acidosis in part by regulating expression of the System N transporter SNAT3.

Stimulation of expression of the intestinal glutamine transporter ATB0 in tumor-bearing rats.

BACKGROUND: Glutamine supplementation ameliorates host catabolic response in tumor bearing states. The purpose of this in vivo study was to investigate intestinal glutamine transport and expression of glutamine transporter ATB(0) in methyl-cholanthrene (MCA)-sarcoma bearing rats. METHODS: Fisher-344 rats underwent subcutaneous flank implantation of MCA-sarcoma cells (saline as control) and were pair-fed an equal quantity of chow as controls, to account for tumor-induced anorexia, until tumors reached 10 or 20% body weight. Intestinal mucosal brush border membrane [3H]-Glutamine transport was measured. Glutamine transporter ATB(0) mRNA and protein levels were measured by real-time PCR and western blot techniques, respectively. RESULTS: Glutamine transport activity across the intestinal brush border membrane (BBM) was 3.7-fold higher in tumor-bearing rats (TBR) than in controls (TBR 153 +/- 22.6 vs. Control 41.9 +/- 9.7 pmol/mg protein/10s, P < .01). Transporter ATB(0) mRNA levels were 1.4-fold higher in tumor-bearing rats (Relative value TBR .61 +/- .12 vs. Control .43 +/- .1, P < .05). A 1.4-fold increase in transporter ATB(0) protein levels was observed in the tumor-bearing rats (Relative value TBR .52 +/- .07 vs. Control .37 +/- .04, P < .05). Circulating aortic plasma glutamine levels were 1.3-fold higher in tumor bearing rats ([Glutamine] = .63 +/- .02 Control vs. [Glutamine] = .74 +/- .01 mmol/l TBR, P < .0001). Portal venous plasma glutamine levels were also higher in tumor bearing rats ([Glutamine] = .47 +/- .01 Control vs. [Glutamine] = .60 +/- .02 mmol/l TBR, P < .0001). CONCLUSION: Intestinal brush border membrane glutamine transport activity, transporter ATB(0) mRNA and protein levels are up-regulate in tumor-bearing rats.

Challenges confronting female surgical leaders: overcoming the barriers.

BACKGROUND: The number of women reaching top ranks in academic surgery is remarkably low. The purpose of this study was to identify: 1) barriers to becoming a female surgical leader; 2) key attributes that enable advancement and success; and 3) current leadership challenges faced as senior leaders. METHODS: Semi-structured interviews of ten female surgical leaders queried the following dimensions: attributes for success, lessons learned, mistakes, key career steps, the role of mentoring, gender advantages/disadvantages, and challenges. RESULTS: Perseverance (60%) and drive (50%) were identified as critical success factors, as were good communication skills, a passion for scholarship, a stable home life and a positive outlook. Eighty percent identified discrimination or gender prejudice as a major obstacle in their careers. While 90% percent had mentors, 50% acknowledged that they had not been effectively mentored. Career advice included: develop broad career goals (50%); select a conducive environment (30%); find a mentor (60%); take personal responsibility (40%); organize time and achieve balance (40%); network (30%); create a niche (30%); pursue research (30%); publish (50%); speak in public (30%); and enjoy the process (30%). Being in a minority, being highly visible and being collaborative were identified as advantages. Obtaining buy-in and achieving consensus was the greatest leadership challenge reported. CONCLUSIONS: Female academic surgeons face challenges to career advancement. While these barriers are real, they can be overcome by resolve, commitment, and developing strong communication skills. These elements should be taken into consideration in designing career development programs for junior female surgical faculty.