National Medical Expenditures Associated With Surgical Care Among Individuals in the United States

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

Reflections of a Cardiac Surgeon Turned Global Health Educator

The coronavirus disease 2019 (COVID-19) pandemic initiated a series of events halting elective surgery across the United States. The American College of Surgeons and Centers for Disease Control and Prevention guidelines recommended indefinite postponement of elective procedures in all subspecialties of surgical care, including colorectal surgery, to redirect resources to the frontlines of COVID-19.1,2 In this restructuring of medical care,3 many surgeons have ground to a halt, whereas other professionals have been deployed beyond their usual scope of practice. While analysis of the financial impact on health care systems and the nation emerge, we also are learning of the firsthand accounts and needs of those serving on the frontlines as they battle a public health crisis.4–6 Missing from this picture are the narratives of surgeons who have been unable to perform the vast majority of their scheduled procedures. Surgeries deemed "nonessential" by health care centers across the United States are not necessarily surgeries that do not need to be done. The focus of medical care in the country has acutely narrowed to a single focus fighting a novel virus while creating an unprecedented triage situation sidelining surgical patient care needs. The focus of storytelling thus far has rightfully focused on patients sick with COVID-19 and frontline workers. Those not on the frontlines, however, are also affected. We have very little understanding of how nonfrontline surgeons not on the frontlines are thinking through professional, patient, and personal concerns as they navigate the uncertainty of a changed profession. This Viewpoint reflects the narratives of 58 colorectal surgeons who engaged in an in-depth qualitative interview during the COVID-19 shutdown of elective surgeries. Our goal for reporting these findings is to offer a "snapshot" of surgeon perspectives on the delays of elective surgeries and give voice to surgeons who were unable to perform most or all of their duties as a surgeon. In so doing, we hope that this descriptive thematic analysis will offer a perspective into how surgeons are impacted and how they are thinking about patient care while leadership moves forward and attempts to triage the backlog of care in the United States. METHODS The data for this article are the result of in-depth qualitative interviews with n = 58 colorectal surgeons about continuous professional development, surgical coaching, and sociocultural issues around colorectal surgery. As part of our larger comprehensive study design, we intended to interview 100 colorectal surgeons outside Michigan (nonparticipants) over 3 years who did not have access to formal surgical coaching to better inform our practices, to understand national challenges to coaching, and to gather in-depth social and cultural narratives about colorectal surgeons. Our goal was to complete the first 30 interviews at the American Society of Colon and Rectal Surgeons conference in June 2020. We paused all activities related to this research on March 13, 2020. After meeting as a virtual research group on March 20, 2020, we recognized that most national academic meetings would be postponed. We reprioritized nonparticipant interviews by pivoting to telephone interviews. Although our interview guide in regard to coaching, technical improvements, and continuous professional development did not change, we shifted our broad social and cultural questions to focus specifically on how colorectal surgeons were coping through COVID-19. We recruited surgeons from the American Society of Colon and Rectal Surgeons mailing list via email (our original institutional review board-approved recruitment strategy) and 127 surgeons responded within 3 hours of which we interviewed 58. Two interviewers (M.E.B. and J.C.B.) interviewed surgeons between April 2, 2020, and April 27, 2020. This study was approved by the institutional review board IRBMED (HUM00080599). Design and Procedure The overall objective of in-depth interviews was to understand experiences of technical improvement, attitudes toward surgical coaching and formative feedback, and experiences around continuous professional development. Our COVID-19 questions were posed at the end of the interview and focused on 3 questions related to department handling, concerns, and personal impact. Although we created a semistructured interview guide, we used an interviewing technique known as an "active" interview style so that surgeons could expand on the ideas that were important to them.7 Participants were monetarily compensated for their time. Interviews lasted from 35 to 75 minutes; they were audio-recorded and transcribed verbatim by an outside transcriptionist who returned transcripts redacted of identifying personal and geographic information. Data Analysis Coding of transcripts was approached through focused coding by 1 coder (M.E.B). Focused coding is an appropriate coding technique when exploring for broad categories of participant knowledge in a thematic analysis.8,9 Because our research is ongoing, we chose to only code for COVID-19 responses for which responses fell under 6 main codes: department handling, personal response, patients, other concerns, telemedicine, and prioritization. As a team, we analyzed coded data to identify "issues around which codes cluster."9 RESULTS Surgeons disclosed 4 key ways in which they thought about the impact of the shutdown of elective surgery in the United States. Concerns for the profession of surgery, concerns about patients, issues around telemedicine, and personal concerns are reported in Table 1. TABLE 1. - Code, definitions, and exemplary quotes Code Definition Exemplary quotes Professional concern Concerns expressed by surgeons that referenced their role or institution "Well, that the practice will collapse, actually. If this goes over six months, then we might have to shut our doors completely. And that would be a problem, because I am more than midway in my career, so trying to find and establish a new practice would be extremely difficult." —Surgeon 31 "I always kind of understood that we were slaves to the accounts receivable, a little bit, as a private group. It's just surprising how fast, you know, when no money is coming in and it's going out the door at a pretty brisk clip. There's going to be a point where we run out of money, coming sooner than we would like, I think. And so that's the biggest thing is whether we're going to have a group when we get done with this." —Surgeon 53 Telemedicine Expressions about the use of virtual visits with patients "It's hard kind of, because...there's a lot of questions that I have to ask that are a little uncomfortable, that, normally, I feel like visually I can tell...Like, I wish I could just say are you overweight or are you thin? Because I need to, you know, know some of those things. Also another tough situation, and it's easier for me to tell in person is, sometimes people have problems with their bottom, and they maybe would have anal intercourse, so over the phone like trying to tell if they, you know, and so I just have to just plain out ask, you know, do you, you know, do you participate or, you know, are you currently having anal intercourse? Because, I need, if you're having problems there, you need to stop doing that. Right? So that's been like, being a, I didn't realize the factor that you miss by being able to look at people." —Surgeon 25 "It doesn't really work in colorectal. So that has been brought up, but that doesn't, it doesn't really work. If someone is in a lot of pain and I think they have an abscess or something else that needs to be addressed, then we open up the office and see them and try to address the issue . . . stop-gap better, drain the abscess. You know, the fistula can wait. Just take care of the things that need to be done." —Surgeon 49 Patient concerns Concerns expressed that referenced patients and/or patient care "I worry that these patients, their cancer worsens while we're just sitting here, you know, sitting on our hands. It worries me...We've got to, in the near future, we've got to start taking care of other people's health problems. It just has to happen." —Surgeon 45 "It really makes me wonder what is going on like in [city] where, clearly, these people aren't going to a hospital, but like what the hell is happening with them? I have no idea." —Surgeon 36 Concern for self Concerns expressed that referenced self, family, or home life "I hate to say it. I really hate to say this since it may come out the wrong way, but it's sort of relaxing. It's sort of peaceful. Like I was just commenting to my neighbor...I haven't had this time, so to speak. I'm still seeing patients, right, I mean, or on the phone, I'm still following up on stuff. I'm still managing my office. I'm still going into my office, you know, and we're still manning the phones, because you never know... But I was letting him know, I'm like, I don't think I've had this much time away or even to myself since fourth year of medical school after I knew where I was going to match for residency." —Surgeon 19 "It's very difficult to just be idled as a surgeon, to not be operating at full tilt, and it's hard to concentrate on other stuff. Like I have to get a book chapter done. Okay. Gee, anal cancer. Do you know what the last thing in the world I want to be sitting and writing about right now? Anal cancer, yeah. But I've got to, you know, get this done. So instead, I'm out here in the garden. I've got a, I'm a gardener, so I'm out here doing spring cleanup. That's what I'm doing while I'm talking to you." —Surgeon 27 Professional Concern Participants in this study discussed concerns for the profession of surgery or their role as a surgeon because of the COVID-19 pandemic (Table 1). Participants were frustrated because of new and rapidly changing restrictions, changed practice patterns, and surgical slowdown or complete shutdown. Seemingly overnight, the entirety of surgical care and practice was revolutionized into a profession that was unrecognizable to surgeons in this study. Moreover, colorectal surgeons, many of whom wanted to work through the pandemic, found themselves in the new reality of sitting on the sidelines. In this respect, surgeons spoke to the core fix-it identity of a surgeon (https://links.lww.com/DCR/B381). Surgeon 50 explains: … it's been very frustrating to not be able to do more to participate…everybody wants to be out there doing something…I mean, there is no surge. The hospital is completely empty, and we're not doing anything…I mean, we recognize the seriousness of the illness, but we're also sitting around saying, 'we should be doing more, and we're not.' In the detailed narrative, this surgeon explains the "frustration" of not being able to "participate" and "do[ing] something" to contribute during the pandemic. Telemedicine One way surgeons were able to connect with their physically distanced patients was through telemedicine (Table 1). Although most participants had opinions about telemedicine whether they used it or not, surgeons' experiences were mixed. In many instances, surgeons described detailed scenarios where telemedicine proved challenging because of the nature of the anatomy in colorectal surgery (https://links.lww.com/DCR/B381). Surgeon 30 explains: …doable, obviously, not ideal…most of my colon cancer patients don't really need to do a physical exam. Diverticulitis…when it comes to benign anal/rectal disease, when it comes to rectal cancer…I think it would be important to do an exam. But there's a fair amount of colorectal surgery that you don't necessarily need to do that hands-on physical exam for. Concerns for Patients Surgeons in our study discussed the impact of delayed elective procedures on colorectal patient care and patient well-being (Table 1). For our sample, concerns about patient care were the priority, as Surgeon 27 concisely states, "Obviously, I'm worried for my patients and their families." In the words of Surgeon 50, his patient concerns were in the "unintended consequences" of the elimination of elective surgeries on population health: So for every day that we're not doing something…another day that somebody who has a cancer is not being diagnosed…there will be other unintended consequences for everybody…And we may have X number of deaths from COVID, but we're also going to have X number of percentage of increase of morbidity and mortality for people who are sitting at home waiting…this weekend I had a guy that came in with ruptured appendicitis, and he sat at home for five days because he didn't want to come in and get sick in the hospital. So by the time he finally came in, he had peritonitis. Concern for Self Not surprisingly, almost all surgeons in our sample shared the general societal fear of contracting the novel coronavirus. Surgeons also recognized that the period under physical distance brought on emotional impacts to surgeons (https://links.lww.com/DCR/B381). DISCUSSION Much of the current and future qualitative work regarding surgical care during the COVID-19 pandemic will focus on the vital narratives of frontline workers. However, our research demonstrates important narratives for surgeons who have had their surgical practice truncated by the need to reallocate resources and fight the pandemic. Surgeons in our study found themselves in unprecedented, rapid occupational change that upended surgical care and had a profound effect on the ways surgeons were able to attend to their patients and perform surgical care. The surgeons interviewed found themselves without clear strategies to combat the unknown future of surgery. The narratives around COVID-19 spoke to general frustrations of change and uncertainty about current and future surgical practices and the impact of this uncertain future on patients. Our snapshot helps inform what decision making for surgical departments might look like as elective surgery slowly resumes in much of the country, insofar as what matters to surgeon stakeholders, as hospitals ramp back up their operating capacity. Our descriptive thematic analysis reports on an early understanding and primary analysis of how 1 sample of colorectal surgeons across the United States thought about the occupation and future of surgical care in the COVID-19 pandemic and beyond. We found that, ultimately, surgeons wanted to do more for their patients who were suffering, or feared for their suffering, because of delayed elective procedures. Telemedicine, while helpful in some cases, could not meet the needs of colorectal surgeons, most of whom described physical examination as a priority in their specialty. Surgeons also described, in rich detail, their concern for the future of surgery and the onslaught of the backlog of cases without any knowledge or understanding of how they will proceed through this backlog. Finally, despite the challenges to the subspecialty that the pandemic caused, surgeons found clarity and respite in time, an occupational moment so rarely afforded to the profession.

Demand for Surgical Procedures Following COVID-19: The Need for Operational Strategies That Optimize Resource Utilization and Value.

Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association

Principles and Core Competencies of Surgical Palliative Care: an Overview

Perioperative Medicine: What the Future Can Hold for Anesthesiology.

Sepsis and Sex: Can We Look Beyond Our Hormones?

Research Probes Surgery on Elders in Their Last Years of Life

Thus, any of these specialties could take the lead in provid-ing perioperative care.However, the 2014 Institute of Medicine report on gradu-ate medical education in the United States noted that there is “a gap between new physicians’ knowledge and skills and the competencies required for current medical practice.”

Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care.

With current changes in training requirements, it is important to understand the venues in the United States for a general surgery (GS) and plastic surgery (PS) resident interested in pursuing a burn surgery career. The study aims to evaluate the pathways to a career in burn surgery and the current state of leadership. A cross-sectional study was conducted between August and September 2017. A 12-question survey was sent to all burn unit directors in the United States, asking about their background, who manages various aspects of burn care and the hiring requirements. Responses were received from 55 burn unit directors (47% response rate). Burn units are lead most commonly by physicians who received GS training (69%), but the majority either did not undergo fellowship training (31%) or completed a burn surgery fellowship (29%). While surgical care (GS = 51%, PS = 42%) and wound care (GS = 51%, PS = 42%) were predominantly managed by GS- or PS-trained burn teams, management of other aspects of burn care varied depending on the institution, demonstrating that a shift in burn care management. The desired hiring characteristics, including GS (67%) or PS residency (44%) and a burn surgery (55%), trauma surgery (15%), or critical care (44%) fellowship. Directors' training significantly influenced their preferences for hiring requirements. While leadership in burn surgery is dominated by GS-trained physicians, the surgical and wound care responsibilities are shared among PS and GS. Although one third of current directors did not undergo fellowship training, aspiring surgeons are advised to obtain a burn surgery and/or critical care fellowship.

According to the GLOBOCAN 2012 data released by the International Agency for Research on Cancer, an estimated 14.1 million new cancer cases and 8.2 million cancer deaths occurred worldwide in 2012. This is an immense increase compared with 2008 statistics, which reported 12.7 and 7.6 million new cases and deaths, respectively. Lowand low-middle–income countries accounted for more than half of the new cancer cases and nearly two thirds of all cancerrelated deaths. The social and economic disparities in cancer prevention and treatment present a disproportionate burden in these low-resource settings. Honduras is a low-middle–income country with a total population of 8.3 million. Cancer accounts for 13% of deaths each year. The most common cancers reported are prostate, gastric, cervix, liver, and breast. The mortality rates from cervix and gastric cancers are among the highest globally, at 18.5 and 8.8%, respectively. There are 24 surgical, eight gynecologic, 13 medical, and four radiation oncologists in Honduras. Hospital General San Felipe (HGSF) is the only public cancer hospital in Honduras that treats underserved patients. Currently, there is only one surgical oncology training program in Honduras. During the 4-year curriculum, residents are taught to provide surgical care for men and women with a wide spectrum of malignancies. Efforts to improve the education and training of residents in surgery and oncology in countries with limited specialists have been growing in the last decade. Medical volunteerism in such countries has become an area of interest for medical students, residents, fellows, and attending physicians from outside of the affected countries, and there are a number of models for providing this assistance. Barriers to successful exchanges between volunteers and in-country physicians include time constraints of the volunteers and infrastructure deficits in low-resource settings that prohibit optimal learning environments. Increasingly, a combination of short-term, hands-on teaching sessions coupled with ongoing Internet-based instruction by volunteers at a distance has emerged as a successful model for supporting incountry physicians to provide increasingly sophisticated medical and surgical care within the limits of available resources. For example, a successful program of surgical training to perform radical hysterectomies in patients with cervical cancer has been implemented in Kenya through collaboration with the Society of Gynaecologic Oncology of Canada. The 2-week intensive program, which is staffed by one expert Canadian surgeon, included seven video didactics, a preand post-test, and seven live surgical sessions with oral and written feedback after each patient case. Short-term follow-up revealed four successful radical hysterectomies by the Kenyan surgeons after the Canadian trainer had left. Similarly, the Central America Gynecologic Oncology Education Program, an initiative that is focused on the education and training of obstetrics and gynecology residents in the prevention and treatment of gynecologic cancers, is a collaboration between the American College of Obstetrics and Gynecology and six Central American countries and includes in-country training trips with US gynecologic oncologists with ongoing distance learning and support. Another option for training physicians from low-resource settings is for these individuals to travel to high-resource settings for training. However, this approach has drawbacks. A recent report suggests that the numbers of physicians emigrating from Sub-Saharan Africa to the US is increasing and will negatively affect low-resource countries, where there is a great need for health care providers. Training of physicians in their respective countries offers the advantage of hands-on training, given that direct patient contact is not allowed during an observership in the United States. In addition, the context of care and the resources available for treatment are different in settings such as Honduras compared with the United States. Despite increasing numbers of medical missions to assist underserved countries, there is still a lack of formalized educational curricula and supervised training in these countries. In this article, we describe the Health Volunteers Overseas (HVO) Oncology Training Program in Honduras, which focuses on providing education, surgical training, and research mentorship to surgical oncology residents, nurses, and other health care providers in Tegucigalpa, Honduras.

Racial and ethnic inequities in surgical care in the United States are well documented. Less is understood about evidence-based interventions that improve surgical care and reduce or eliminate inequities. In this review, we discuss effective patient, surgeon, community, health care system, policy, and multi-level interventions to reduce inequities and identifying gaps in intervention-based research. Evidenced-based interventions to reduce racial and ethnic inequities in surgical care are key to achieving surgical equity. Surgeons, surgical trainees, researchers, and policy makers should be aware of the evidence-based interventions known to reduce racial and ethnic disparities in surgical care for prioritization of resource allocation and implementation. Future research is needed to assess interventions effectiveness in the reduction of disparities and patient-reported measures. We searched PubMed database for English-language studies published from January 2012 through June 2022 to assess interventions to reduce or eliminate racial and ethnic disparities in surgical care. A narrative review of existing literature was performed identifying interventions that have been associated with reduction in racial and ethnic disparities in surgical care. Achieving surgical equity will require implementing evidenced-based interventions to improve quality for racial and ethnic minorities. Moving beyond description toward elimination of racial and ethnic inequities in surgical care will require prioritizing funding of intervention-based research, utilization of implementation science and community based-participatory research methodology, and principles of learning health systems.

Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients