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Background: Medical students are increasingly choosing nonsurgical specialties; observership programs can address factors influencing them toward surgical careers by allowing preclerkship exposure and mentorship, and correcting misconceptions. The aims of this study were to assess the influence of a peer-led observership program at the Université de Montréal on the career choices of preclinical medical students and to determine the factors associated with a positive observership experience.Methods: We used a quasi-experimental convergent mixed-methods questionnaire design. From Nov. 19 to Dec. 31, 2018, and Mar. 1 to Apr. 4, 2019, all medical students participating in the observership program were eligible for the study; there were no ineligibility criteria. Using a prospective purposive sampling method, we recruited students via the email sent to confirm their observership. In the week after their observership, we invited the students by email to complete a postintervention survey. We used nonparametric tests to evaluate the impact of the observership on participants' career choices and an inductive data-driven thematic analysis to analyze their responses.Results: Of the 204 students who participated, 157 provided consent, of whom 85 (54.1%) completed questionnaires both before and after the observership. The majority of participants were interested in a surgical specialty before (72 [85%]) and after (68 [84%]) the observership. There was no significant change in the students' choices of surgical specialties after the observership. However, most (68 [81%]) reported being more interested in a surgical career as a result of the observership, which allowed them to see that the type of practice they considered was congruent with a surgical career. Their perceptions of the field of surgery became positive, particularly regarding its pace and atmosphere and the humanistic patient-doctor relationship it required. The experience was influenced by surgeons' and teams' attitudes toward students, knowledge-sharing and quality of exposure. Participants mentioned that their willingness to participate was in part responsible for the success of their experience.Conclusion: This observership program allowed an early, positive introduction of students to surgery while challenging stereotypes. It provided a better understanding of surgery, enabling participants to consider this field and potentially influencing their residency application. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSI) pose significant morbidity after colorectal surgery. We sought to document current practices in colorectal surgery SSI prevention in British Columbia (BC). Reporting the current provincial landscape on SSI prevention helps to understand the foundation upon which improvements can take place. We surveyed all BC surgeons performing elective colon and rectal resections, and 97 surveys were completed (60% response rate). Eighty-six per cent of respondent hospitals tracked SSI rates. The reported superficial SSI was less than 5% and the anastomotic leak/organ space rate was less than 10%. All respondents gave preoperative prophylactic antibiotics, with 24% continuing antibiotics postoperatively; 62% are using oral antibiotics (OAB) and mechanical bowel preparation (MBP) and 29% use MBP without OAB. Areas for improvement include OAB with MBP and discontinuing prophylactic antibiotics postoperatively, as recommended by the World Health Organization. [ABSTRACT FROM AUTHOR]

Background: Use of videos of surgical and medical techniques for educational purposes has grown over the last years. To our knowledge, there is no validated tool to specifically assess the quality of these types of videos. Our goal was to create an evaluation tool and study its intrarater and interrater reliability and its acceptability. We named our tool UM-OSCAARS (Université de Montréal Objective and Structured Checklist for Assessment of Audiovisual Recordings of Surgeries/techniques).Methods: UM-OSCAARS is a grid containing 10 criteria, each of which is graded on an ordinal Likert-type scale of 1 to 5 points. We tested the grid with the help of 4 voluntary otolaryngology - head and neck surgery specialists who individually viewed 10 preselected videos. The evaluators graded each criterion for each video. To evaluate intrarater reliability, the evaluation took place in 2 different phases separated by 4 weeks. Interrater reliability was assessed by comparing the 4 topranked videos of each evaluator.Results: There was almost-perfect agreement among the evaluators regarding the 4 videos that received the highest scores from the evaluators, demonstrating that the tool has excellent interrater reliability. There was excellent test-retest correlation, demonstrating the tool's intrarater reliability.Conclusion: The UM-OSCAARS has proven to be reliable and acceptable to use, but its validity needs to be more thoroughly assessed. We hope this tool will lead to an improvement in the quality of technical videos used for educational purposes. [ABSTRACT FROM AUTHOR]

Background: The number of Canadian Residency Matching Service (CaRMS) applicants ranking surgical specialties as their first choice has declined over the past 20 years; concurrently, there has been a reduction in the number of hours spent teaching undergraduate medical education (UGME) anatomy, particularly with cadaveric dissection. The aim of this study was to determine the factors that most influence selection of a surgical specialty, with specific focus on the impact of UGME anatomy training.Methods: A 36-item cross-sectional survey was designed by experts in medical education and distributed to all current surgical residents in Canada in October 2018. Responses were recorded on a 5-point Likert scale or by means of list ranking. We analyzed univariable outcomes with a t test for continuous outcomes and the χ2 test for dichotomous outcomes.Results: Of 1493 surgical residents, 228 responded to the survey (response rate 15.3%). Respondents reported experiences on core rotations and elective rotations, and access to a mentor as the most important factors in deciding to pursue a surgical residency. Anatomy training with or without cadaveric dissection was moderately influential in respondents' first-choice CaRMS discipline (mean Likert scale score 2.97 [standard deviation (SD) 1.34] and 2.87 [SD 1.26], respectively). General surgery residents' CaRMS applications were more likely to have been influenced by UGME anatomy training than the applications by residents in other surgical specialties (p < 0.001). The impact of UGME anatomy training did not vary between postgraduate years or between male and female residents.Conclusion: Canadian surgical residents' decision to apply to a surgical specialty did not seem to be strongly influenced by their UGME anatomy training, with or without cadaveric dissection, but, rather, by factors such as clinical experience and surgical mentorship. Further evaluation of groups that were more positively affected by their UGME anatomy training is warranted. [ABSTRACT FROM AUTHOR]

Background: Academic productivity, as measured by number and impact of publications, is central to the career advancement and promotion of academic surgeons. We compared research productivity metrics among specialties and sought factors associated with increased productivity.Methods: Academic surgeons were identified through departmental webpages and their scholarly metrics were collected through Scopus in a standardized fashion. We collected total number of documents, h-index, and average number of publications per year in the preceding 5 years. We explored whether presence of a training program, graduate degree, academic rank and size of the clinical group affected productivity metrics. Linear regression was used for multivariable analysis.Results: We collected data on 2172 surgeons from 15 separate academic centres across Canada. Wide variability existed in metrics among specialties, with cardiac and neurosurgery being the most productive, and vascular surgery and plastic surgery being the least productive. The average number of publications was 71, and the average h-index was 18.7. The average h-index for cardiac surgery was 25.7 compared with 8.3 for vascular surgery (p < 0.001). Our multivariable model identified academic rank, surgical specialty, graduate degree, presence of a training program, and larger clinical group as being associated with increased academic productivity.Conclusion: There is variability in research productivity among Canadian surgical specialties. Cardiac surgery and neurosurgery are productive, whereas vascular surgery and plastic surgery are less productive than other surgical disciplines. Obtaining a research-oriented graduate degree, being part of a larger clinical group, and presence of a training program were all associated with higher productivity, even after adjusting for academic rank and specialty. [ABSTRACT FROM AUTHOR]

Summary: William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine. This paper dissects how his innovative multi-tier residency program helped him hide his addiction while simultaneously providing outstanding patient care and academic training. [ABSTRACT FROM AUTHOR]

Background: In Canada, access to subspecialty surgical services for children imposes inconvenience and financial hardship on geographically remote families. The purpose of this study was to evaluate a recently implemented pediatric surgical telehealth pilot program from the family and provider perspectives.Methods: Enabled by an existing telehealth infrastructure for pediatric subspecialty medicine and mental health, a pilot telehealth program for surgical consultation was established by a single surgeon in British Columbia. Following establishment of eligibility criteria, patients from remote communities requiring new consultation or clinical follow-up were offered a telehealth alternative. At the end of the encounter, both the parent and patient (if appropriate) provided feedback via a questionnaire. Provider satisfaction was also assessed via a questionnaire. We estimated costs avoided and analyzed data on pediatric surgery consultation wait time.Results: Between September 2014 and November 2017, 80 patients were seen in 19 remote telehealth centres, 23 as new referrals and 57 in follow-up consultation. Among new referrals, the commonest diagnosis was chest wall deformity. The average travel distance avoided was 705 km, with an estimated direct cost avoidance of $585. Sixty-four families (80%) completed the questionnaire. Almost all (63 [98%]) indicated high overall satisfaction with the telehealth experience. Provider satisfaction was similarly high, in terms of both the technology user interface and clinical effectiveness. Overall pediatric surgical consultation wait times were unaffected.Conclusion: Implementation of telehealth technology in a pediatric surgical practice offered high value to patients/families and, from the provider’s perspective, yielded an acceptable alternative to in-person assessment. [ABSTRACT FROM AUTHOR]

Background: Multimodal treatment of colorectal liver metastases (CRLMs) relies on precise upfront assessment of resectability. Variability in the definition of resectable disease and the importance of early consultation by a liver surgeon have been reported. In this pilot study we investigated the initial resectability assessment and patterns of referral of patients with CRLMs.Methods: Surgeons and medical oncologists involved in the management of colorectal cancer at 2 academic institutions and affiliated community hospitals were surveyed. Opinions were sought regarding resectability of CRLMs and the type of initial specialty referral (hepatobiliary surgery, medical oncology, palliative care or other) in 6 clinical cases derived from actual cases of successfully performed 1- or 2-stage resection/ablation of hepatic disease. Case scenarios were selected to illustrate critical aspects of assessment of resectability, best therapeutic approaches and specialty referral. Standard statistical analyses were performed.Results: Of the 75 surgeons contacted, 64 responded (response rate 85%; 372 resectability assessments completed). Hepatic metastases were more often considered resectable by hepatobiliary surgeons than all other respondents (92% v. 57%, p < 0.001). Upfront systemic therapy was most commonly prioritized by surgical oncologists (p = 0.01). Hepatobiliary referral was still considered in 73% of "unresectable" assessments by colorectal surgeons, 59% of those by general surgeons, 57% of those by medical oncologists and 33% of those by surgical oncologists (p = 0.1).Conclusion: Assessment of resectability varied significantly between specialties, and resectability was often underestimated by nonhepatobiliary surgeons. Hepatobiliary referral was not considered in a substantial proportion of cases erroneously deemed unresectable. These disparities result largely from an imprecise understanding of modern surgical indications for resection of CRLMs. [ABSTRACT FROM AUTHOR]

Background: Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). Methods: We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. Results: The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. Conclusion: We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD. [ABSTRACT FROM AUTHOR]

Background: Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era. Methods: We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS. Results: Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%,p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028). Conclusion: From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice. [ABSTRACT FROM AUTHOR]

Background: Recognition of tissue planes during surgery appears to be a skill acquired with experience. We conducted a pilot study to test this hypothesis using a novel method for evaluating this skill in a simulated environment. Methods: Twelve surgeons of varying levels of experience were shown 16 captured images from a mesorectal excision. For each image, they were asked to draw the ideal dissection plane with a stylus on a tablet computer. We used a novel metric for comparing agreement between lines to determine the level of precision observed between junior and senior trainees and consultant surgeons and measure the accuracy of junior and senior trainees compared with consultant surgeons. Results: We observed significant differences in precision for 9 of 16 images; 7 of these followed the predicted stepwise pattern associated with level of experience. Using consultant surgeons as the reference standard, we observed significant differences in accuracy between senior and junior trainees for 11 images, with senior trainees being more accurate in 10 of them. Only 2 images failed to contribute significant findings to our analysis. Conclusion: The findings of this pilot evaluation of a novel method for measuring a surgeon's ability to recognize tissue planes in a simulated model show that skill improves with experience. Further evaluation of this method will reveal its utility as an assessment tool and possibly as a training instrument. [ABSTRACT FROM AUTHOR]

Background: There is increased awareness that, to minimize variation in clinician practice and improve quality, performance reporting should be implemented at the provider level. This optimizes physician engagement and creates a sense of professional responsibility for quality and performance measurement at the individual and organizational levels. Methods: Individual provider level reporting was implemented within a provincial health region involving 56 clinicians (general surgeons, surgical oncologists, urologists and pathologists). The 2 surgical pathology indicators chosen were colorectal cancer (CRC) lymph node retrieval rate and pT2 prostate cancer margin positivity rate. Surgical resections for all prostate and colorectal cancer performed between Jan. 1, 2011, and Mar. 30, 2012, were included. We used a pre- and postsurvey design to obtain physician perceptions and focus groups with program leadership to determine organizational impact. Results: Survey results showed that respondents felt the data provided in the reports were valid (67%), consistent with expectations (70%), maintained confidentiality (80%) and were not used in a punitive manner (77%). During the study period the pT2 prostate margin positivity rate decreased from 57.1% to 27.5%. For the CRC lymph node retrieval rate indicator, high baseline performance was maintained. Conclusion: We developed a robust process for providing physicians with confidential, individualized surgical and pathology quality indicator reports. Our results reinforce the importance of individual physician feedback as a strategy for improving and sustaining quality in surgical and diagnostic oncology. [ABSTRACT FROM AUTHOR]

Background: Research has demonstrated equivalent patient safety outcomes for various cardiac procedures when the primary surgeon was a supervised trainee. However, cardiac surgery cases have become more complex, and the Canadian cardiac surgery education model has undergone some changes. We sought to compare patient safety and efficiency of aortic valve replacement (AVR) between Canadian patients treated by senior cardiac trainees and those treated by certified cardiac surgeons. Methods: We completed a single-centre, case-matched, prospectively collected and retrospectively analyzed study of AVR. Patients were matched between trainees and consultants for age, sex, New York Heart Association and Canadian Cardiovascular Society status, urgency of operation and diabetes status. Results:We analyzed 1102 procedures: 624 isolated AVRs and 478 AVRs with coron - ary artery bypass graft (CABG). For isolated AVR, there was no significant difference in 30-d mortality (p = 0.13) or in major adverse events (p = 0.38) between the groups. In the AVR+CABG group, there was no significant difference in 30-day mortality (p = 0.10) or in the rates of major adverse events (p = 0.37) between the groups. Secondary outcomes (hospital and intensive care unit lengths of stay, valve size and type) did not differ significantly between the groups for isolated AVR or AVR+CABG. Conclusion: Despite a higher-risk patient population and changes in the cardiac surgery training model, it appears that outcomes are not negatively affected when a senior trainee acts as the primary surgeon in cases of AVR. [ABSTRACT FROM AUTHOR]

Background: In the spring of 2008, St. Boniface General Hospital in Winnipeg, Man., created an acute care surgical service (ACSS) designed to improve care for emergent, nontrauma surgical patients. We sought to assess the effect of the ACSS on patient care timeliness Methods:We retrospectively examined the time intervals in care for patients admitted with acute appendicitis, acute cholecystitis and small bowel obstruction in 3 study periods: pre-ACSS, newly formed ACSS and established ACSS. Results: There was a 2-fold increase in patient volume after the ACSS was created. Patient characteristics were similar in all 3 groups. Time from triage to surgical consultation was also similar. The ACSS significantly reduced the duration of the surgical consultation (1 h 43 min in period 1 v. 62 min in period 2 and 49 min in period 3, p = 0.029). Time from admission to operation was similar despite a significant increase in patient load after the ACSS was created. Total length of hospital stay was similar except in the subgroup analysis (appendicitis + cholecystitis only), where the length of stay was reduced after creation of the ACSS (2 d 15 h pre- v. 1 d 19 h post-ACSS, p = 0.009). Most operations occurred between 4 pm and midnight. Conclusion: With the implementation of an ACSS, the number of surgical patients assessed and treated doubled. Despite the increased volume, consultations were completed significantly faster, there was no significant difference in time to operation, and on subgroup analysis length of hospital stay was significantly faster. [ABSTRACT FROM AUTHOR]

Background:We sought to study the impact of the change in gender balance and the shift in generational beliefs on the practice of surgery. Methods: We used in-depth, individual, semistructured interviews to explore the ideas, perceptions and experiences of recently recruited academic surgeons regarding the role of gender and the influence of the changing attitudes of this generation on the work environment. All the interviews were audiotaped and transcribed verbatim. The data analysis was both iterative and interpretative. Results: Nine women and 8 men participated in the study. All participants stated that departmental expectations regarding their performance as clinicians and as academics were not influenced by gender. However, further exploration revealed how gender did influence the way they sought to balance their personal and professional lives. Women in particular struggled with attaining this balance. While maternity leave was endorsed by both men and women, the challenging logistics associated with such leave were noted. Our data also revealed a generational shift among men and women in terms of the importance of the balance between their personal and professional lives. Participants saw this priority as radically different from that of their senior colleagues. Conclusion: Gender and the shift in generational attitudes are changing the culture of academic surgery, often described as the prototypical male-dominated medical environment. These changes may reflect the changing face of medicine. Contexte : Les changements générationnels observés sur le plan de la répartition hommes:femmes et sur le plan des attitudes exercent un impact sur la pratique de la chirurgie et nous avons voulu mesurer cet impact. Méthodes : Nous avons utilisé des entrevues de fond individuelles semi-structurées pour explorer les opinions, les perceptions et les expériences de chirurgiens frais émoulus des universités quant à l'influence exercée sur le monde du travail par les changements qui touchent la répartition hommes:femmes et les attitudes de la présente génération. Toutes les entrevues ont été enregistrées et transcrites textuellement. L'analyse des données s'est faite de manière itérative et interprétative. Résultats : Neuf femmes et 8 hommes ont participé à l'étude. Tous les participants ont affirmé que les attentes départementales à l'endroit de leur rendement en tant que médecins et en tant qu'universitaires n'ont subi aucune influence de leur appartenance à un sexe ou à l'autre. Toutefois, une analyse plus approfondie a révélé en quoi l'appartenance à l'un ou l'autre sexe exerçait une influence sur la recherche de la conciliation entre vie personnelle et professionnelle : les femmes luttaient plus particulièrement pour atteindre cet équilibre. Le congé de maternité recevait l'aval des hommes autant que des femmes, mais les répondants ont mentionné les défis logistiques qui lui sont associés. Nos données ont aussi révélé une distinction générationnelle entre les hommes et les femmes pour ce qui est de l'importance de l'équilibre entre les dimensions personnelles et professionnelles de leur vie. Les participants ont accordé à cette priorité une importance radicalement différente comparativement à leurs collègues plus âgés. Conclusion : Les changements générationnels de la répartition hommes:femmes et les changements d'attitudes modifient la culture de la chirurgie dans les établissements universitaires, souvent décrits comme un environnement médical surtout dominé par les hommes. Ces changements pourraient modifier le visage de la médecine. [ABSTRACT FROM AUTHOR]

Background: Today's acute care surgery (ACS) service model requires multiple hand - overs to incoming attending surgeons and residents. Our objectives were to investigate current handover practices in Canadian hospitals that have an ACS service and assess the quality of handover practices in place. Methods:We administered an electronic survey among ACS residents in 6 Canadian general surgery programs. Results: Resident handover of patient care occurs frequently and often not under ideal circumstances. Most residents spend less than 5 minutes preparing handovers. Clinical uncertainty owing to inadequate handover is most likely to occur during overnight and weekend coverage. Almost one-third of surveyed residents rate the overall quality of the handovers they received as poor. Conclusion: Handover skills must be taught in a systematic fashion. Improved resident communication will likely decrease loss of patient information and therefore improve ACS patient safety. [ABSTRACT FROM AUTHOR]

Background: Surgeons and residents are at increased risk of exposure to blood-borne pathogens owing to percutaneous injury (PI) and contamination. One method known to reduce risk is double-gloving (DG) during surgery. Methods: All surgeons and residents affiliated with the University of Western Ontario (UWO) and McMaster University in 2005 were asked to participate in a Web-based survey. The survey asked respondents their specialty, the number of operations they participated in per week, their age and sex, the proportion of surgeries in which they double-gloved (DG in ± 75% surgeries was considered to be routine), and the average number of PIs they sustained per year and whether or not they reported them to an employee health service. Results: In total, 155 of 331 (47%) eligible surgeons and residents responded; response rates for UWO and McMaster surgeons were 50% and 39%, respectively, and for UWO and McMaster residents, they were 52% and 47%, respectively. A total of 43% of surgeons and residents reported routine DG; 50% from McMaster and 36% from UWO. Using logistic regression to simultaneously adjust for participant characteristics, we confirmed that DG was more frequent at McMaster than at UWO, with an odds ratio of 3.32 (95% confidence interval 1.35-8.17). Surgeons and residents reported an average of 3.3 surgical PIs per year (2.2 among McMaster participants and 4.5 among UWO participants). Of the 77% who reported at least 1 injury/year, 67% stated that they had not reported it to an employee health service. Conclusion: Percutaneous injuries occur frequently during surgery, yet routine DG, an effective means of reducing risk, was carried out by less than half of the surgeons and residents participating in this study. This highlights the need for a more concerted and broad-based approach to increase the use of a measure that is effective, inexpensive and easily carried out. [ABSTRACT FROM AUTHOR]

Background: We sought to assess the feasibility of applying Cancer Care Ontario's quality of care indicators to a single institution's colorectal cancer (CRC) database. We also sought to assess their utility in identifying areas that require improvement. Methods:We included patients who had surgery for CRC between 1997 and 2006 at Mount Sinai Hospital, Toronto, Ont. We excluded patients who had transanal excisions, carcinoma in situ or recurrences that required pelvic exenteration, as well as those whose information was incomplete. We obtained data from a prospective database and verified the data with hospital and office charts. We evaluated trends over a 10-year period using the Cochran-Armitage trend test. Results: During the study period there were 1005 surgical procedures performed in 987 patients with a mean age of 65.6 (standard deviation 15) years; the male:female ratio was 1:2. The most frequent tumour sites were the rectum and sigmoid colon (68%). Over the 10-year period, 9 indicators improved, including the proportion of patients with CRC identified by screening (p < 0.001), the proportion of patients who received preoperative liver imaging (p = 0.05), the proportion of rectal cancer patients who received preoperative pelvic imaging (p = 0.04), the proportion of patients with stage II or III rectal cancer who received radiotherapy (p = 0.03), the proportion of surgical specimens with more than 12 lymph nodes (p < 0.001), the proportion of pathology reports that included quantitative distal (p = 0.004) and radial (p < 0.001) margin measurements, the proportion of patients with an anastomotic leak (p = 0.03), the proportion of patients who received a colonoscopy 1 year after surgery (p < 0.001) and the proportion of operative reports that were complete (p < 0.001). Conclusion: The use of quality of care indicators to assess the quality of colorectal surgery is feasible. This study provides benchmarks that can be used to assess changes in the quality of CRC care at our institution. [ABSTRACT FROM AUTHOR]

Information about the 2008 Symposium of the Canadian Association of University Surgeons (CAUS) on September 6, 2008 in Halifax, Nova Scotia is presented. Topics include improvement of surgical outcomes, the indifference between the provision of care and regional Canadian patient needs and the importance of surgeon profession in the community. The symposium also featured several surgeons including John Birkmeyer, John Bohnen, and Bill Fitzgerald.

Background: Surgical educators have struggled with achieving an optimal balance between the service workload and education of surgical residents. In Ontario, a variety of factors during the past 12 years have had the net impact of reducing the clinical training experience of general surgery residents. We questioned what impact the reductions in trainee workload have had on general surgery graduates at the University of Toronto. Methods: We evaluated graduates from the University of Toronto general surgery training program from 1995 to 2006. We compared final-year In-Training Evaluation Reports (ITERs) of trainees during this interval. For purposes of comparison, we subdivided residents into 4 groups according to year of graduation (1995-1997, 1998-2000, 2001-2003 and 2004-2006). We evaluated postgraduate "performance" by categorizing residents into 1 of 4 groups: first, residents who entered directly into general surgery practice after graduation; second, residents who entered into a certification subspecialty program of the Royal College of Physicians and Surgeons of Canada (RCPSC); third, residents who entered into a noncertification program of the RCPSC; and fourth, residents who entered into a variety of nonregulated "clinical fellowships." Results: We assessed and evaluated 118 of 134 surgical trainees (88%) in this study. We included in the study graduates for whom completed ITER records were available and postgraduate training records were known and validated. The mean scores for each of the 5 evaluated residency training parameters included in the ITER (technical skills, professional attitudes, application of knowledge, teaching performance and overall performance) were not statistically different for each of the 4 graduating groups from 1995 to 2006. However, we determined that there were statistically fewer general surgery graduates (p < 0.05) who entered directly into general surgery practice in the 2004-2006 group compared with the 1998-2000 and 2001-2003 groups. The graduates from 2004 to 2006 who did not enter into general surgery practice appeared to choose a clinical fellowship. Conclusion: These observations may indicate that recent surgical graduates possess an acceptable skill set but may lack the clinical confidence and experience to enter directly into general surgery practice. Evidence seems to indicate that the clinical fellowship has become an unregulated surrogate extension of the training program whereby surgeons can gain additional clinical experience and surgical expertise. [ABSTRACT FROM AUTHOR]

Background: The practice of surgery had changed little over millennia when Abraham Groves and William Osler attended medical school together in Toronto, Ontario. The invention of anesthesia sparked such rapid development that by the time of Groves' and Osler's deaths, surgical practice resembled the current model. Several priority claims have been attributed to Groves' life in surgery, including aseptic surgery (1874), suprapubic lithotomy (1878), appendectomy (1883), surgical gloves (1885) and cancer radiotherapy (1903). These claims arise from an autobiography written by Groves at the age of 87 years in 1934. Methods: The purpose of this paper is to assess these priority claims from a modern surgical perspective. We did a systematic search of contemporary (1873-1934) and modern journals for articles by or about Groves. We searched relevant archives and museums. We reviewed the 1934 autobiography, notes held by descendants, reminiscences by contemporaries and collateral information. We assessed the information not only for priority but also for the development of organized surgical thought. Results: Groves published frequently throughout his career; thus far we have located 36 papers, almost all of which were published in Canadian journals. He spoke regularly at regional meetings in Ontario. Many medical students apprenticed with him (including his brother, son and grandson), he established a hospital and he founded a school of nursing. His contemporaries published complimentary reminiscences, but no correspondence with his classmate, William Osler, is known. Groves' priority claims for aseptic surgery, suprapubic lithotomy and radiotherapy are supported by contemporary publications. Groves independently developed an organized surgical system that remains valid today. Priority claims for appendectomy and the use of surgical gloves are entirely consistent with that system. Conclusion: Although Groves' impact was reduced by his location and the limited circulation of the journals in which he wrote, he demonstrated a systematic understanding of modern surgery well ahead of his contemporaries. [ABSTRACT FROM AUTHOR]

Background: This study investigates the feasibility of performing advanced minimally invasive surgery (MIS) in a nonspecialized practice environment. Methods: We conducted a cross-sectional survey of all community general surgeons currently practising in Ontario. Results: Few community surgeons perform a high volume (> 10 procedures per yr) of advanced MIS. Most (70%) believe it is important to acquire additional skills in advanced MIS. The most appropriate methods for learning advanced MIS are believed to be expert mentoring (79.7%), courses (77.2%) and a colleague mentor (63.9%). A total of 57.6% of respondents have attended a course in MIS while in practice, and most have access to a reasonable variety of instrumentation. Respondents believe that 57.6% of assistants, 54.8% of nurses and 43.4% of anaesthetists are relatively inexperienced with advanced MIS. Barriers to establishing advanced MIS include limited operating room access (50%), resources or equipment (45.2%) and limited expert mentoring (43.6%). Surgeons with less than 10 years of practice found lack of trained nursing staff (7.9% v. 4.2%, p = 0.01) and experienced assistants (12% v. 6.2%, p = 0.008) to be more important barriers than did those with over 10 years of practice, respectively. Conclusion: Most general surgeons working in Ontario are self-taught with respect to MIS skills, and few perform a high volume of advanced MIS. Only one-half of all respondents have access to skilled MIS operating room nurses, surgical assistants or anesthesiology. Despite this, general surgeons perceive the greatest barriers to introducing advanced MIS procedures to be limited access to operating rooms, resources or equipment and limited mentoring. This study has shown that the role of the surgical team in advanced MIS may be underestimated by many general surgeons. These data have important implications in training general surgeons and in incorporating additional advanced MIS procedures into the armamentarium of general surgeons. [ABSTRACT FROM AUTHOR]

Introduction: Practising surgeons need an effective means for learning new skills and procedures in advanced minimal access surgery (MASA). Currently, available educational methods include traditional continuing medical education symposia (1-day courses), instructional videos, mentoring, or comprehensive courses that combine lectures, skills laboratories and live surgery. The impact of comprehensive courses in advanced MASA on surgeons' knowledge, skills and practice has not been clearly established. Methods: We completed a survey of all physicians who attended comprehensive courses in advanced gastrointestinal MASA held at the Centre for Minimal Access Surgery (CMAS) in Hamilton, Ont. Results: Of 158 course attendees, we received 65 responses (response rate 41%). Fifty-sex men and 9 women responded, with a mean age of 44.9 years and a mean practice duration of 12.3 years. Eighty-seven percent of respondents were community-based surgeons. As a result of attending CMAS courses, respondents felt they experienced a substantial improvement in the knowledge and skills required to complete MASA. After a comprehensive course at CMAS, most respondents reported that they had introduced MASA procedures into their practice. The mean overall impact of a course on a surgeonÆs practice (with respect to patient referrals, procedural armamentarium and personal satisfaction) was rated by respondents at 3.92 (standard deviation [SD] 0.71; Likert scale 1û5, 1= negative, 5= positive). Conclusion: A comprehensive course in advanced MASA has a positive impact on attendeesÆ knowledge and skills. Ultimately, surgeons attending MASA courses will begin to introduce new MASA procedures into surgical practice. These courses have a distinct role in the teaching of MASA to surgeons in practice.ô [ABSTRACT FROM AUTHOR]

The article presents information on self-audit and practice appraisal for surgeons. It reports that in January 2001, the Royal College of Physicians and Surgeons (RCPSC) established the first 5-year cycle of the Maintenance of Certification program (MainCert). MainCert certification is now required for admission to the RCPSC and to renew Fellowship privileges. For practicing surgeons, involvement in MainCert implies that continuing professional development activities must be completed and documented by all surgeons wishing to maintain active Fellowship status.

This article is dedicated to the Canadian international surgeon, Norman Bethune (1890-1939). International surgery is defined as a humanitarian branch of medicine concerned with the treatment of bodily injuries or disorders by incision or manipulations, emphasizing cooperation and understanding among nations and involving education, research, development and advocacy. In this article I review the colonial past, the dark ages following the Declaration of Alma-Ata, the progress made and the present challenges in international surgery. I present a definition of international surgery that recognizes the current era of surgical humanitarianism, validates a global understanding of surgical issues and promotes cooperation among nations. Included are the principles of international surgery: education, research, infrastructure development and advocacy. International surgical projects are classified according to type (clinical, relief, developmental) and integration strategy (vertical or horizontal). Also reviewed are the Canadian practice of international surgery by nongovernmental, professional and academic organizations and the requirements of international and Canadian funding agencies, the development concepts basic to all projects, including results-based management and the cross-cutting themes of gender equity, environmental protection and human safety. I recommend formalizing international surgery into a discipline as a means of promoting surgical care in low-income countries. If international surgery is to be sustained in Canada, infrastructure and support from Canadian surgeons is particularly important. An understanding of the history, definition and classification of international surgery should promote surgical care in low-income countries. [ABSTRACT FROM AUTHOR]

The pioneering surgical training partnership between the Canadian Association of General Surgeons (CAGS) and the University of Guyana has successfully graduated 14 surgeons since 2006. The association has recruited 29 surgeons who have made 75 teaching visits to Guyana, and CAGS involvement has been critical to providing local credibility to the program, organizing the curriculum structure and developing rigorous examinations. The program is now locally sustained, with graduates leading a number of clinical hospital programs. The initial diploma qualification is being reassessed, as other specialties have introduced postgraduate Master of Medicine degree programs. Many graduates are pursuing additional training opportunities overseas, and almost all of those remaining in Guyana have returned to the tertiary centre from the regional hospitals. The program has succeeded in training surgeons and raising the standards of surgical care in Guyana, but broader health system efforts are necessary to retain surgeons in outlying regional hospitals. [ABSTRACT FROM AUTHOR]

Reports on the Canadian Association of General Surgeons' (CAGS) advocacy positions in the practice of general surgery in Canada. Results of the committee activities of the CAGS; Use of the `Canadian Journal of Surgery' periodical by the CAGS in publishing surgical news; Involvement in developing practice guidelines and advocating better workplace conditions for surgeons; Future activities of the association.

Highlights results of a survey on practice patterns of the repair of inguinal hernia by Canadian surgeons. Bassini; Mesh plug; Lichtenstein; Laparoscopic; Shouldice; McVay; Increased preference for laparoscopic repair for recurrent hernias and bilateral hernias; Practice variations between provinces.

The author discusses the effects of high perioperative oxygen fraction on surgical site infection based on the evidence-based reviews (EBR) in Canada. The EBR of the Canadian Association of General Surgeons (CAGS) and the American College of Surgeons (ACS) intends to improve the skills in general surgery. It also states that the EBR intends to assess the capability of the oxygen to reduce the frequency of surgical site infections (SSIs) without developing the risk for pulmonary complications.

The author reflects on the summary of D. W. Birch and colleagues on a consensus conference for the creation of practice and training standards in advanced minimally invasive surgery (MIS). The author cites that the conference remains relevant although it happened about two years ago due to the creation of newer technologies like single incision laparoscopic surgery (SILS). The author talks about the mentoring program for surgeons and stresses responsible dissemination of advanced MIS technology.

The article provides information on the Evidence-Based Reviews in Surgery (EBRS), a program that aims to improve practising surgeons' critical appraisal skills. It cites a multicentre randomized trial which compares patient outcomes, healthcare use and costs of on-demand and planned relaparotomy in patients with severe secondary peritonitis, conducted in two academic and 5 regional teaching hospitals in The Netherlands. It also provides the research's outcome along with a commentary about it.

Discusses the enhancement of the quality of medical care. Safety from iatrogenic harm as an element of quality patient care; Publications on improvement science and health care cited and discussed; Discussion on the quantification of the incidence of medical error; Recommendation of education in error science, reflection, data collection and discussion and communication among surgical team members as critical strategy; Comparison with safety norms in aviation industry; Promotion of research in error science and patient safety as means to accomplish goal.

In this editorial the author discusses the importance of mentoring new graduates entering surgery. Topics discussed include contribution of Gaspare Tagliacozzi, a surgeon, in medical science; work of several surgeons including Jean Couture, Don Wilson, and Tom McLarty for overcoming barriers to new treatments for patients; and mentions about training programs for promoting mentoring more effectively.

The author reflects on proposed curriculum by The Royal College of Physicians and Surgeons of Canada to provide surgical training to family physicians. Topics discussed include enhancing the surgical skills of family physicians that they could provide surgical care for patients in remote locations, course modules elements which include prerequisites, a learning phase, testing and maintenance of competence and perceived need for surgery in under serviced areas of Canada.

The author focuses on the efforts aimed at expanding future practitioners' understanding, interest and participation in global surgery. He mentions that despite the increasing popularity of global health among medical students possibilities of exposure to global surgery has been limited. He mentions that global health conferences serve as important adjuncts to undergraduate medical education.

The author reflects on the problems posed by restricted sources for surgical services in Canada. He presents the models that were developed to increase surgical volumes with minimal disruption, proven by high volumes of hip-and-knee replacement surgeries. He also discusses the models' common features such as increased in-hospital efficiency. The result of a review conducted by the Ministry of Health and Long-Term Care in Ontario, Canada is also presented.

The article describes the investigation on the interpersonal competencies of cardiac surgery teams in Canada. The investigation will focus on the attitude of team members toward teamwork. It also tackles the causes of medical errors in surgery. Respondents claimed that the most frequent types of error included miscommunication, performing actions at the incorrect time and the failure to follow established procedures.

An introduction is presented in which the editor discusses a report within the issue on the influence of the medicine industry on evidenced-based surgery studies.

Discusses the implications of an electronic data collection at source by surgeons for a joint replacement registry in Canada. Operation of a reward-based system for the services of surgeons; Factors related to the analysis of joint revisions; Efficiency of tracking patients who move or who have further surgery elsewhere.

Cites the indications for surgery in the global communities. Similarity of needs but different availability of resources of interdependent communities; Response of Canadian health personnel to the growing need of the public; Need of partnership among health professionals.