Academic Advancement in Global Surgery: Appointment, Promotion, and Tenure: Recommendations From the American Surgical Association Working Group on Global Surgery.

: There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).

Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery.

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

Global Surgery: Effective Involvement of US Academic Surgery: Report of the American Surgical Association Working Group on Global Surgery.

: There is an unacceptably high burden of death and disability from conditions that are treatable by surgery, worldwide and especially in low- and middle-income countries (LMICs). The major actions to improve this situation need to be taken by the surgical communities, institutions, and governments of the LMICs. The US surgical community, including the US academic surgical community, has, however, important roles to play in addressing this problem. The American Surgical Association convened a Working Group to address how US academic surgery can most effectively decrease the burden from surgically treatable conditions in LMICs. The Working Group believes that the task will be most successful (1) if the epidemiologic pattern in a given country is taken into account by focusing on those surgically treatable conditions with the highest burdens; (2) if emphasis is placed on those surgical services that are most cost-effective and most feasible to scale up; and (3) if efforts are harmonized with local priorities and with existing global initiatives, such as the World Health Assembly with its 2015 resolution on essential surgery. This consensus statement gives recommendations on how to achieve those goals through the tools of academic surgery: clinical care, training and capacity building, research, and advocacy. Through all of these, the ethical principles of maximally and transparently engaging with and deferring to the interests and needs of local surgeons and their patients are of paramount importance. Notable benefits accrue to US surgeons, trainees, and institutions that engage in global surgical activities.

Ensuring Equity, Diversity, and Inclusion in Academic Surgery: An American Surgical Association White Paper.

OBJECTIVE: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery. SUMMARY OF BACKGROUND DATA: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion. METHODS: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper. RESULTS: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. CONCLUSION: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition-doing good for our patients.

Global opportunities on 239 general surgery residency Web sites.

BACKGROUND: Many general surgical residency programs lack a formal international component. We hypothesized that most surgery programs do not have international training or do not provide the information to prospective applicants regarding electives or programs in an easily accessible manner via Web-based resources. MATERIALS AND METHODS: Individual general surgery program Web sites and the American College of Surgeons residency tool were used to identify 239 residencies. The homepages were examined for specific mention of international or global health programs. Ease of access was also considered. Global surgery specific pages or centers were noted. Programs were assessed for length of rotation, presence of research component, and mention of benefits to residents and respective institution. RESULTS: Of 239 programs, 24 (10%) mentioned international experiences on their home page and 42 (18%) contained information about global surgery. Of those with information available, 69% were easily accessible. Academic programs were more likely than independent programs to have information about international opportunities on their home page (13.7% versus 4.0%, P = 0.006) and more likely to have a dedicated program or pathway Web site (18.8% versus 2.0%, P < 0.0001). Half of the residencies with global surgery information did not have length of rotation available. Research was only mentioned by 29% of the Web sites. Benefits to high-income country residents were discussed more than benefits to low- and middle-income country residents (57% versus 17%). CONCLUSIONS: General surgery residency programs do not effectively communicate international opportunities for prospective residents through Web-based resources and should seriously consider integrating international options into their curriculum and better present them on department Web sites.

Global surgery opportunities for U.S. surgical residents: an interim report.

INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery developed guidelines that allowed time spent and cases performed outside of the United States by surgical residents from ACGME-accredited training programs to be applied toward program completion. We hypothesized that the number of programs with global surgical rotations would have increased after that important development. We also sought to determine the characteristics that led to sustainment of such programs. METHODS: An Institutional Review Board-approved electronic survey was sent to all 253 program directors of ACGME-approved general surgery residencies requesting information on international rotations available to residents. Responses were requested from program directors with extant rotations. Survey questions focused on locations, funding, nature of the rotations, faculty involvement, keys to success, and the barriers to overcome during program development and sustainment. RESULTS: The survey reported 34 surgery residency programs offering global surgery rotations, up from 23 just 5 years previously. Of these reporting programs, 25 have been approved by the ACGME. Most rotations occur in the postgraduate year 3 or 4 and are primarily clinical rotations. Africa is the main destination. Resident supervision is provided by a mixture of host and home surgeons. A dedicated faculty is considered to be the most important element for success while funding remains a major impediment. CONCLUSIONS: The interest in global surgery continues to increase, and general surgical programs will strive to meet the expectations of residents looking for international exposure. Collaboration could facilitate resident opportunities and potentially be more cost-effective.

The attitude and perceptions of work-life balance: a comparison among women surgeons in Japan, USA, and Hong Kong China.

BACKGROUND: The objective of the present study was to explore how women surgeons manage their work-life balance in three environmental and cultural settings. METHOD: Members of the Japan Association of Women Surgeons (JAWS), the United States of America (US) based Association of Women Surgeons (AWS), and the Women's Chapter of the College of Surgeons of Hong Kong (WCHK) were surveyed. RESULTS: Among 822 women surgeons contacted, 252 responded (response rate 31.8 %; 55.5 % JAWS, 28.2 % AWS, and 25.3 % WCHK). Japanese women surgeons think that work is the number one priority, whereas US and Hong Kong China (HK) respondents think the number one priority is home life. Work satisfaction level was generally high among women surgeons in all countries; however, 19 % of US surgeons are somewhat dissatisfied with their work and 76.1 % think that men are treated more favorably than women at work. Whereas 51.6 % of Japanese women surgeons think that men are treated more favorably than women at home, at the same time they placed more importance on the role of women in the family. More than half of Japanese women surgeons are "uncertain" about their career path in the future, whereas 55.2/87.1 % of US/HK respondents are optimistic. All surgeons recommended expanding support for child rearing or nursing care during work hours, promoting a flexible work schedule and changing some of the older conventional ideas about gender role. CONCLUSIONS: It is essential to address women surgeons' concerns to enable them to have a clearer vision and a challenging career, and to be more certain about their personal and professional goals.

Reactions of surgical program directors to a web-based interactive educational program focusing on cognitive skills.

OBJECTIVE: To assess reactions by program directors (PDs) to a preview of a scenario from the Fundamentals of Surgery Curriculum (FSC), which is a case-based interactive curriculum developed by the American College of Surgeons's (ACS) Division of Education and designed to be delivered online to first-year (PGY-1) surgical residents. DESIGN: After previewing a scenario, each PD completed a questionnaire requesting age and ratings of comfort using computers, the scenario's utility in addressing 9 educational goals (eg, provides a solid foundation for future learning), and 6 separate features of the scenario (eg, ease of use and feasibility). All ratings were based on a 1-9 scale. For items related to educational goals, ratings were anchored: 1-3 = poor/needs revision; 4-6 = adequate/as good as current methods; 7-9 = excellent/superior to current methods. Informal discussions were also conducted and comments were collected. SETTING: October 2007 ACS Clinical Congress. PARTICIPANTS: In all, 31 PDs participated in the study. RESULTS: Most PDs perceived that the scenario addressed 8 of the 9 educational goals in a manner superior to current methods [eg, provides a solid foundation for future learning (97%), challenges residents (90%), and delivers content consistent with current practices and/or evidence (90%)]. The mean ratings of all scenario features were 7 or greater on the 9-point scale. CONCLUSION: Most PDs reacted very positively to a preview of FSC perceiving that it can address several important educational goals in a manner superior to existing methods. Comments from PDs suggest a high level of interest in incorporating FSC into their residency programs as well as participating in a coordinated multi-institutional evaluation project. The results provide baseline data concerning PD expectations of the utility of FSC that will help to guide and evaluate further developments and applications of this curriculum.

Comparison of palpation-guided versus ultrasound-guided fine-needle aspiration biopsies of thyroid nodules in an outpatient endocrinology practice.

OBJECTIVE: To investigate the role of thyroid ultrasonography in our outpatient endocrine practice. METHODS: We compared the efficacy of ultrasound-guided fine-needle aspiration biopsy (US-FNAB) of thyroid nodules with that of palpation-guided aspiration (P-FNAB) and determined the malignancy rates of palpable and nonpalpable nodules. All patients referred for assessment of thyroid nodular disease from October 1997 through August 2001 were included in the study. Fine-needle aspirations were performed by palpation guidance until October 1999, after which US-FNAB was exclusively performed. All thyroid examinations, ultrasound imaging, and aspiration biopsies were performed by the same endocrinologist in an office-based setting. Histopathologic and cytologic diagnoses were compared for patients who underwent thyroidectomy. RESULTS: A total of 376 nodules in 276 patients were aspirated during a 47-month period. P-FNAB was used on 157 nodules, and US-FNAB was performed on 219 nodules (both procedures were done on 21 nodules). For palpable thyroid nodules that were resected, the cytologic diagnostic accuracy rate was 60.9% and 80% for P-FNAB and US-FNAB, respectively. With use of ultrasound guidance, the sensitivity, positive predictive value, and negative predictive value increased significantly. In addition, the inadequate specimen rate decreased from 11.2% in the P-FNAB group to 7.1% in the US-FNAB group. Among the nodules that were not palpable, the malignancy rate was similar to that for the palpable thyroid nodules (5.1% versus 6.8%). CONCLUSION: US-FNAB improved the cytologic diagnostic accuracy, sensitivity, and positive predictive value and reduced the false-negative rate in comparison with P-FNAB. The malignancy rate for nonpalpable thyroid nodules was similar to that for palpable nodules.

Intraoperative needle localization during neck reexploration.

BACKGROUND: Recurrent cervical adenopathy can be difficult to identify intraoperatively during a neck reexploration. Although local preoperative imaging techniques are available, these are not useful in the operative theater. METHODS: We introduce an intraoperative technique of ultrasound-guided needle localization to identify and guide the resection of suspicious cervical lymphadenopathy. CONCLUSIONS: This intraoperative approach to localizing the suspicious lymph node under ultrasound-guided needle localization makes surgical extirpation of lymph node metastasis easy.