Maryland's surgical workforce-2007: an in-depth analysis and implications for the future.

BACKGROUND: Critical decisions about the future supply of surgeons must be based on an accurate assessment of current surgical manpower. This study examined the demographics and clinical activities of seven surgical subspecialty groups on the frontlines of health care in Maryland. These data are compared with those customarily quoted in the literature, and the implications of these findings are discussed. STUDY DESIGN: Clinical activity of surgeons versus administrative, teaching, research, and other obligations was determined after interviews with medical directors in all of Maryland's 52 acute care hospitals. Additional information was obtained from residency program directors, chairmen, and others, if necessary. Data were stratified by specialty, location of practice, and age of surgeon. RESULTS: Data were analyzed for general, orthopaedic, ENT, vascular, and noncardiac thoracic surgeons, neurosurgeons, and urologists. Surgeons in rural western, eastern, and southern regions spent 86.3% of their time in care of patients compared with 70.3% for surgeons in urban, suburban, or teaching settings. Across the state, the number of surgeons providing care to patients per 100,000 residents was below reported requirements in general surgery, vascular, and noncardiac surgery. Overall, 40.3% of surgeons were 55 years or older in 2007. CONCLUSIONS: Critical shortages of qualified surgeons currently exist in many regions of Maryland, especially in rural regions. Administrative, teaching, and research activities significantly reduce the amount of time surgeons are able to devote to patient care, particularly in academic and suburban settings. Fewer surgeons are available to care for patients in Maryland, and they are significantly older than assumed in manpower databases. Access to surgical care in Maryland will be jeopardized if these issues are not considered in future health care workforce discussions.

Violations of behavioral practices revealed in closed claims reviews.

OBJECTIVE: Closed claims against general surgeons were reviewed, seeking insights into the effects of surgeons' deficient behavioral practices on outcomes. Research and educational strategies based on findings may reduce errors and improve care. SUMMARY BACKGROUND DATA: Adverse events occur in 2.9% to 3.7% of hospital admissions in the United States. Of these adverse events, 27.4% to 32.6% are the result of errors. Failures at the point-of-service can undermine the other elements of systems of care designed to reduce preventable adverse outcomes. In this regard, the relative importance of surgeons' behavior is poorly defined. METHODS: Fellows of the American College of Surgeons (ACS) reviewed 460 malpractice claims against general surgeons. The relationship between detrimental behavioral practice patterns--deficiencies in care that reflected a lack of diligence, vigilance, and/or commitment of time more than a lack of knowledge and/or skill--and the preventability of adverse events was assessed. RESULTS: Failures in practice patterns of behavior occurred in 78% of cases and were frequently associated with preventable injuries. When both behavioral practice violations and technical misadventures occurred, the complications were more likely to be preventable than if only a technical misadventure had occurred. Among several deficient behavioral practices, the failure to communicate was most pervasive, accounting for 22% of complications in the study. CONCLUSIONS: Stakeholders in health care policy should focus on the issue of physician behavior in crafting shifts in institutional cultures and in targeting new CME toward evidenced-based behavioral practices.

The American College of Surgeons' closed claims study: new insights for improving care.

BACKGROUND: All physicians must be vigilant in the pursuit of safe care for patients. While problems in care are identified, education that provides an understanding of these problems and guidelines for improvement can enhance patient safety. Our objective was to determine problematic aspects of surgical care, including care provided by surgeons before, during, after, and instead of surgery, that negatively affect patient safety. STUDY DESIGN: Four hundred sixty malpractice claims against general surgeons were reviewed by surgeons (FACS). All claims were closed in 2003 or 2004. The data collection was completed at five medical liability companies representing a nationwide distribution of surgeons. Surgeons also dictated or wrote narratives for each case. The quantitative data and narratives were later analyzed to determine events responsible for unsafe care. RESULTS: Surgeon-reviewers identified deficiencies in care that fell below accepted standards more often before and after operations than during them. These deficiencies were often the result of a failure to recognize surgical injuries, and many of these deficiencies were preventable. The quality of surgical care was satisfactorily met in 36% of cases. The most common procedures involving patient safety concerns were those involving the biliary tract, intestines, hernias, vascular system, esophagus, and stomach. The most frequent events leading to claims included delayed diagnosis, failure to diagnose, failure to order diagnostic tests, technical misadventure, delayed treatment, and failure to treat. Complications occurring most frequently were organ injuries, adult respiratory distress syndrome, and infection. CONCLUSIONS: Closed claims reviews provide valuable data that may enhance provider performance through heightened awareness of common unsafe practices. Specifically, opportunities exist to improve surgical care provided during the preoperative and postoperative phases of treatment through continuing medical education to improve patient safety.