Priorities for professionalism: what do surgeons think?

OBJECTIVE: To gain an understanding of the relative importance of the nine surgical competencies and their 27 attributes defined by the Royal Australasian College of Surgeons (RACS), which together provide the curriculum framework for today's surgeons. DESIGN, SETTING AND PARTICIPANTS: Between 9 August and 30 September 2010, trainees and Fellows of the RACS across Australia and New Zealand actively involved in educational activities rated, via questionnaire, the importance of the RACS competencies (technical expertise, communication, professionalism, medical expertise, judgement and decision making, scholarship and teaching, collaboration and teamwork, management and leadership, and health advocacy) and associated attributes. MAIN OUTCOME MEASURES: Importance ranking of competencies and their attributes for surgical education and training. RESULTS: Of 3054 questionnaires distributed, 1834 (60%) were returned. We identified clear priorities in the perceived relative importance of the nine competencies and 27 attributes. The most important attributes were competence, insight, and recognising conditions amenable to surgery; least important were responding to community and cultural needs, supporting others, and maintaining personal health and wellbeing. Key differences were noted for the competency of collaboration and teamwork, which was ranked as more important by trainees than by Fellows. Female trainees and Fellows regarded all attributes as more important than did male trainees and Fellows. CONCLUSION: In a complex environment with multiple pressures, the priorities of the competencies are important. Trainees and Fellows had a very similar approach to the prioritisation of the attributes. Of concern is the lesser importance given to attributes beyond individual expertise.

Educating future leaders in patient safety.

Education of health care professionals has given little attention to patient safety, resulting in limited understanding of the nature of risk in health care and the importance of strengthening systems. The World Health Organization developed the Patient Safety Curriculum Guide: Multiprofessional Edition to accelerate the incorporation of patient safety teaching into higher educational curricula. The World Health Organization Curriculum Guide uses a health system-focused, team-dependent approach, which impacts all health care professionals and students learning in an integrated way about how to operate within a culture of safety. The guide is pertinent in the context of global educational reforms and growing recognition of the need to introduce patient safety into health care professionals' curricula. The guide helps to advance patient safety education worldwide in five ways. First, it addresses the variety of opportunities and contexts in which health care educators teach, and provides practical recommendations to learning. Second, it recommends shared learning by students of different professions, thus enhancing student capacity to work together effectively in multidisciplinary teams. Third, it provides guidance on a range of teaching methods and pedagogical activities to ensure that students understand that patient safety is a practical science teaching them to act in evidence-based ways to reduce patient risk. Fourth, it encourages supportive teaching and learning, emphasizing the need to establishing teaching environments in which students feel comfortable to learn and practice patient safety. Finally, it helps educators incorporate patient safety topics across all areas of clinical practice.

Educational and health impact of the Baume Report: 'A Cutting Edge: Australia's Surgical Workforce'.

OBJECTIVES: The Baume Report (1994) on Australia's surgical workforce had the potential to impact upon the health and educational sectors. This paper analyses the recommendations of this report and their impact at the time and 15 years later (2009). METHODS: A questionnaire-based study was performed with the 18 senior Fellows and the Royal Australasian College of Surgeons (RACS) solicitor who had been instrumental in facilitating responses to the review. RESULTS: The 19 respondents were asked to evaluate 22 areas from the Baume Report. The most highly ranked areas identified as being reasonable in 1994 were: additional funding being made available for more training positions, identifying workforce deficits, moving towards compulsory continuing professional development and having evidence of competence before introducing new technology. In 2009, the most highly ranked areas were: funding for more training positions; compulsory continuing professional development, involving the profession in improvements and broadening the training environment beyond public hospitals. Areas considered to be substantially addressed were: the selection process and encouragement of diversity, workforce numbers and deficits, confirming the educational merit of the training program and the role of professional colleges. CONCLUSIONS: The Baume Report highlighted many issues including workforce planning, the role of professional organisations in society and the complex interface between health and education. Issues of ongoing standards through a surgical career, access for patients to surgical services, funding for more training posts to provide the appropriate workforce level and distribution, and the assessment and introduction of technology remain priorities. Time has not diminished the relevance of these issues. WHAT IS KNOWN ABOUT THIS TOPIC?: The impact of key government reviews can always be substantial. The Baume Report was directed to postgraduate specialist medical training, particularly surgical training. There have been substantial changes in the health and educational sectors since the report, with significantly more regulation and transparency. WHAT DOES THIS PAPER ADD?: Analysis of the Baume Report after 15 years by the senior office bearers of the RACS who were actively involved in handling and implementing many of the recommendations provides an insight into the dynamics of specialist training. It outlines the significant changes that have occurred and the things that still need to be done. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Professional bodies have an influential presence across society. They are particularly focused on the standards required to become a practitioner of that profession and the ongoing maintenance of these standards. However, this comes with responsibility for and accountability to society and the community. External reviews, particularly with a political imperative, change both the dynamics and key relationships, issues that the professional bodies must commit to addressing in a positive manner.

Isotope ratios of H, C, and O in CO2 and H2O of the martian atmosphere.

Stable isotope ratios of H, C, and O are powerful indicators of a wide variety of planetary geophysical processes, and for Mars they reveal the record of loss of its atmosphere and subsequent interactions with its surface such as carbonate formation. We report in situ measurements of the isotopic ratios of D/H and (18)O/(16)O in water and (13)C/(12)C, (18)O/(16)O, (17)O/(16)O, and (13)C(18)O/(12)C(16)O in carbon dioxide, made in the martian atmosphere at Gale Crater from the Curiosity rover using the Sample Analysis at Mars (SAM)'s tunable laser spectrometer (TLS). Comparison between our measurements in the modern atmosphere and those of martian meteorites such as ALH 84001 implies that the martian reservoirs of CO2 and H2O were largely established ~4 billion years ago, but that atmospheric loss or surface interaction may be still ongoing.

Clinical supervisors: are they the key to making care safer?

The evidence shows that notwithstanding efforts by health professionals and hospital managers to improve the quality and safety of healthcare, adverse events remain prevalent. Clinical supervision is understandably dominated by transferring discipline knowledge and skills but the environment today requires equal attention to integrating patient safety concepts and principles into clinical supervision. Trainees learn from supervisors who themselves often have inadequate patient safety knowledge and skills. This conundrum may partly explain why there has been no visible reduction in adverse events. Patient safety literature has emphasised that clinical errors are rarely linked with incompetent doctors or trainees with inadequate knowledge but rather to failures in appreciating the context, complexity and uncertainty of clinical decisions made under the pressure of time. It is time to consider whether clinical supervisors themselves first need to demonstrate patient safety competencies before being responsible for supervising trainees.

Knowledge, skills, and attitudes of medical students to patient safety: a cross-sectional pilot investigation in China.

BACKGROUND: To reduce harm caused by health care is a global priority. Medical students should be able to recognize unsafe conditions, systematically report errors, and near misses, investigate and improve such systems with a thorough understanding of human fallibility, and disclose errors to patients. Therefore, incorporating knowledge about patient safety into medical school curriculums is an urgent necessity. OBJECTIVES: To describe the extent to which Chinese medical students have patient safety in their knowledge, skills, and attitudes so as to provide evidence for implementation of a patient safety curriculum in medical schools, and to assess the quality of this investigative questionnaire. METHODS: Our questionnaire of 31 items was developed based on a 2008 WHO pilot study for a patient safety curriculum guide. Our investigation was conducted in three university medical schools in China. Year 3 and year 4 medical students were asked to complete an anonymous questionnaire in their classroom settings. All items were scored from 1 to 5. Differences in responses among different universities, genders, and levels, as well as the validity and reliability of the questionnaire, were analyzed using SPSS 15.0. RESULTS: A total of 500 questionnaires were distributed, and 143 male and 262 female students completed the survey. An average of 0.96% of survey questions were not answered, of which the most frequently unanswered item was "what will happen when medical error occurs?" The students' attitudes to learning about patient safety were positive, although their knowledge of medical error and how to report error was poor. There were no statistical differences among different medical schools and levels in any item responses. The only gender difference appeared in the response to "I would like to discuss with others when I made a medical error." There was a good coherence of reliability in sections 2, 3, and 4 of the questionnaire (Cronbach's alpha > 0.8), while sections 5 and 6 scored as less reliable. The validity of the questionnaire was good. CONCLUSIONS: Although medical students' understanding of patient safety is very poor in China, the students have a positive attitudes to learning about the knowledge of patient safety in their future careers.

Patient safety education for undergraduate medical students: a systematic review.

BACKGROUND: To reduce harm caused by health care is a global priority. Medical students should be able to recognize unsafe conditions, systematically report errors and near misses, investigate and improve such systems with a thorough understanding of human fallibility, and disclose errors to patients. Incorporating the knowledge of how to do this into the medical student curriculum is an urgent necessity. This paper aims to systematically review the literature about patient safety education for undergraduate medical students in terms of its content, teaching strategies, faculty availability and resources provided so as to identify evidence on how to promote patient safety in the curriculum for medical schools. This paper includes a perspective from the faculty of a medical school, a major hospital and an Evidence Based Medicine Centre in Sichuan Province, China. METHODS: We searched MEDLINE, ERIC, Academic Source Premier(ASP), EMBASE and three Chinese Databases (Chinese Biomedical Literature Database, CBM; China National Knowledge Infrastructure, CNKI; Wangfang Data) from 1980 to Dec. 2009. The pre-specified form of inclusion and exclusion criteria were developed for literature screening. The quality of included studies was assessed using Darcy Reed and Gemma Flores-Mateo criteria. Two reviewers selected the studies, undertook quality assessment, and data extraction independently. Differing opinions were resolved by consensus or with help from the third person. RESULTS: This was a descriptive study of a total of seven studies that met the selection criteria. There were no relevant Chinese studies to be included. Only one study included patient safety education in the medical curriculum and the remaining studies integrated patient safety into clinical rotations or medical clerkships. Seven studies were of a pre and post study design, of which there was only one controlled study. There was considerable variation in relation to contents, teaching strategies, faculty knowledge and background in patient safety, other resources and outcome evaluation in these reports. The outcomes from including patient safety in the curriculum as measured by medical students' knowledge, skills, and attitudes varied between the studies. CONCLUSIONS: There are only a few relevant published studies on the inclusion of patient safety education into the undergraduate curriculum in medical schools either as a selective course, a lecture program, or by being integrated into the existing curriculum even in developed countries with advanced health and education systems. The integration of patient safety education into the existing curriculum in medical schools internationally, provides significant challenges.

The Australian e-Health Research Centre: enabling the health care information and communication technology revolution.

The CSIRO (Commonwealth Scientific and Industrial Research Organisation) and the Queensland Government have jointly established the Australian e-Health Research Centre (AEHRC) with the aim of developing innovative information and communication technologies (ICT) for a sustainable health care system. The AEHRC, as part of the CSIRO ICT Centre, has access to new technologies in information processing, wireless and networking technologies, and autonomous systems. The AEHRC's 50 researchers, software engineers and PhD students, in partnership with the CSIRO and clinicians, are developing and applying new technologies for improving patients' experience, building a more rewarding workplace for the health workforce, and improving the efficiency of delivering health care. The capabilities of the AEHRC fall into four broad areas: smart methods for using medical data; advanced medical imaging technologies; new models for clinical and health care interventions; and tools for medical skills development. Since its founding in 2004, new technology from the AEHRC has been adopted within Queensland (eg, a mobile phone-based cardiac rehabilitation program), around Australia (eg, medical imaging technologies) and internationally (eg, our clinical terminology tools).

Radical prostatectomy: a systematic review of the impact of hospital and surgeon volume on patient outcome.

BACKGROUND: To assess the impact of hospital and surgeon volume on mortality, morbidity, length of hospital stay and costs of radical prostatectomy (RP). METHODS: This systematic review identified relevant studies published between 1997 and June 2007. Inclusion of papers was established through application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. RESULTS: Compared with low volume hospitals, the included studies showed high volume hospitals demonstrated lower rates of mortality, postoperative complications and readmissions, and lower overall hospital costs. High volume surgeons similarly showed lower rates of postoperative complications and shorter length of stay compared with low volume surgeons, but no difference in mortality. CONCLUSIONS: From the literature obtained, patients undergoing RP performed by high volume providers may have better outcomes compared to low volume providers; however, any move to centralize RP must be further evaluated.

Centralization and the relationship between volume and outcome in knee arthroplasty procedures.

BACKGROUND: Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals. OBJECTIVES: This review assessed the efficacy of centralization for knee arthroplasty by examining the relationship between hospital and surgeon volume and patient outcomes. DATA SOURCES AND REVIEW METHODS: The systematic review identified studies using multiple databases, including Medline and Embase. Two independent researchers ensured studies met the inclusion criteria. Morbidity, mortality, length of stay, financial outcomes and statistical rigour were examined. Correlations between volume and outcome were reported. RESULTS: Twelve primary knee arthroplasty studies examined hospital volume, which was significantly associated with decreased morbidity (five of seven studies), mortality (two of five studies) and length of stay (two of three studies). Three primary knee arthroplasty studies examined surgeon volume, which was significantly associated with decreased morbidity (two of three studies), mortality (zero of two studies) and length of stay (one of one study). Two revision knee arthroplasty studies examined hospital volume. One study examined but did not test for significance between hospital volume and patient morbidity; both studies examined volume and patient mortality reporting inconclusive results; and one study reported no significant association between volume and length of stay. None of the revision knee arthroplasty studies examined surgeon volume. CONCLUSIONS: Significant associations between increased hospital and surgeon volume and improved patient outcomes were reported. However, when these results were separated by arthroplasty type, the association appeared tenuous. Judgements regarding centralization of knee arthroplasty should be made with caution until further evidence is published.

Systematic review of the impact of volume of oesophagectomy on patient outcome.

PURPOSE: This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume. METHODS: A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision. RESULTS: A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume. CONCLUSIONS: Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.

Defining research priorities for pancreatic cancer in Australia: results of a consensus development process.

INTRODUCTION: Pancreatic cancer (PC) is the sixth leading cause of cancer death in Australia and the fourth in the United States, yet research in PC is lagging behind that in other cancers associated with a high disease burden. In the absence of agreed processes to reliably identify research areas which can deliver significant advances in PC research, the Cancer Council NSW established a strategic partnership with the NSW Pancreatic Cancer Network to define critical research issues and opportunities that could accelerate progress in this field in Australia. MATERIALS AND METHODS: The process consisted of five distinct stages: a literature review on recent progress in PC research, semi-structured expert interviews, a Delphi process, consumer focus groups, and a nominal group process. Information collected at each step informed the development of subsequent stages. RESULTS: The results from these steps were refined by the nominal group into a set of seven specific pancreatic cancer research goals. The goals were disseminated and led to a new funding scheme for key PC research priorities. DISCUSSION: This prioritisation exercise provided a much needed "road map" for research prioritisation in PC and served as a checklist to researchers applying for PC research grants to confirm how their research can contribute towards accelerating progress in PC research in Australia.

The University of Sydney Endocrine Surgery Database: 50 years of data accrual.

Surgical databases are now a fundamental part of clinical practice and research but have only been commonplace in the past decade or so. The University of Sydney Endocrine Surgery Database has now been in existence for more than 50 years since it was started by Tom Reeve in 1957. It includes comprehensive documentation of every aspect of every thyroid, parathyroid and adrenal procedure carried out by its surgeons while they were active members of the unit. During those 50 years, 17,466 such procedures have been documented. In the first year of data collection, only 20 thyroid procedures carried out by one surgeon in one hospital were entered, whereas in the most recent year, 1092 major endocrine procedures carried out by three surgeons in 10 separate hospitals required entry. As well as providing for surgical audit, the database has been integral to the writing of 130 published articles and articles in press on the topic of thyroid, parathyroid and adrenal surgery. The database has been instrumental to significant changes in the practice of endocrine surgery, including introduction of total thyroidectomy for benign bilateral multinodular goitre by this unit two decades ago, leading to changed practice in most countries around the globe. Data acquisition has also allowed documentation of the safety and efficacy of new minimally invasive endocrine procedures such as minimally invasive parathyroidectomy and minimally invasive thyroid surgery. Audit-based research with accumulation of data based on surgical outcomes, that is, evidence-based surgery, remains the fundamental basis of sound surgical practice with the potential to lead important changes in clinical practice.

Complete axillary dissection: a technique that still has relevance in contemporary management of breast cancer.

Axillary lymph node status is an important prognostic indicator for women with breast cancer and axillary dissection provides accurate information regarding nodal status. In addition, local control of axillary disease and allocation of adjuvant systemic therapy are dependent on appropriate axillary surgery. The survival benefit of an axillary dissection remains controversial. We describe a technique of complete axillary clearance that includes levels I, II and III. In our experience this technique is associated with no additional morbidity to patients and incurs minimal prolongation of operative time compared with a level II dissection. Other operative descriptions of axillary surgery generally do not adequately describe a method that clearly and consistently identifies the boundaries, anatomical landmarks and neurovascular structures that traverse the axilla. This technique, with relative ease, allows the identification and preservation of these structures in their original anatomical planes and avoids the division of the pectoralis minor muscle. The assumption that routine level III axillary clearance, as opposed to level I or level II dissection, is associated with greater morbidity warrants further evaluation. No well-conducted randomized trials have addressed this issue.

Two hundred consecutive parathyroid ultrasound studies by a single clinician: the impact of experience.

OBJECTIVE: To assess the ability of ultrasound studies, performed by an experienced clinician, to predict surgical findings and provide precise anatomic localization of abnormal parathyroid glands. METHODS: We retrospectively examined 200 consecutive parathyroid ultrasound studies performed by a single experienced clinician in our unit. All patients subsequently underwent parathyroidectomy, with histopathologic confirmation of abnormal parathyroid tissue. The correlation between the ultrasound and surgical findings was assessed. RESULTS: Of the 200 study patients, 197 (98.5%) were cured of their disease at the initial operation. Ultrasound studies correctly predicted the surgical findings in 88% of patients, including 168 of 180 (93%) with single gland disease and 7 of 20 (35%) with multiple gland disease (MGD). In all cases in which a single adenoma was identified, precise information regarding its location relative to adjacent anatomic structures was provided. In 92% of these cases, anatomic details correlated closely with surgical findings. Ectopic and descended superior adenomas were most frequently missed. Patients with two nonlocalizing studies (scintigraphy and ultrasonography) had a >50% likelihood of having MGD. CONCLUSION: In experienced hands, parathyroid ultrasonography is a highly sensitive technique that provides both localization of enlarged parathyroid glands and precise anatomic detail. Thus, in this study, focused parathyroidectomy was possible in 76.5% of patients. MGD remains difficult to diagnose preoperatively. Nonlocalizing studies should alert the surgeon to a high probability of MGD and prompt the performance of 4-gland exploration.

The role of safety and quality councils in improving the quality of healthcare: an Australian perspective.

The Australian Council for Safety and Quality in Health Care (the Council) has made considerable advances in gaining acceptance of and commitment to the healthcare safety improvement agenda by all involved in healthcare in Australia. It has provided a focus for national efforts in safety and quality improvement, by raising awareness, building consensus and clarifying areas for priority action. While the Council has set the agenda for change and provides advice in relation to problems, initiatives and actions, it has limited operational capacity and lacks the statutory authority to embed a culture of safety at all levels of the healthcare system. Statutory and regulatory responsibility and accountability for implementation lies with the Australian, State and Territory Governments and organizations in the private sector. Progress depends on coordinating the activities of Departments of Health and Human Services of nine sovereign governments. The "levers for change" available to the Council were leadership, persuasion, advice and example, with the ability to develop strategies, frameworks, standards, tools and guidelines. With the end of the Council's term approaching, a recent review recommended the establishment of an Australian Commission on Safety & Quality in Health Care (the Commission).