The importance of young surgeons in surgical health policy advocacy engagement.

Gaps in Practice Management Skills After Training: A Qualitative Needs Assessment of Early Career Surgeons

Introducing the American Journal of Surgery Virtual Research Mentor: A primer for aspiring surgeon-scientists

In this short commentary article, the complex association between journalism, health policy, and political campaigning in Indonesia is explained, in need of more scholarly expansion. Within those limitations, the paper does alert to the necessary function journalism serves intrinsic to the public discourse that drives health policy recommendations, as well as noting how this has been perverted by misinformation and dwindling faith in the media. The article examines how journalism (including digital and social media) has shaped health policy advocacy and public opinion and highlights the role of the media in health communication campaigns and policy reform. Through scrutiny of its role in health policy advocacy, with a broader look at how journalism roles have shifted over time. In this article, the author demonstrated that journalism is a bridge between health policy experts and the public, enabling a more informed democratic engagement with health policy. These conclusions highlight the need to build a nexus between democratic journalism and health policy advocacy for public health priorities in Indonesia. Keywords: health policy, journalism, political campaign

Professional and social changes have resulted in decreased involvement in organizations. Little is currently known about young plastic surgeons' attitudes toward the Plastic Surgery Foundation and its sponsored activities. The authors gathered opinions of young plastic surgeons to determine factors related to participation. A 21-question online survey was e-mailed to all 2155 members of the Young Plastic Surgeons Forum. Questions were related to demographics, current involvement, and initiatives in education, research, funding, and health policy. Of 2155 forum members, 397 responded (19 percent response rate). Most had not contributed to the Plastic Surgery Foundation. The primary reason cited was financial hardship, and respondents noted this would change with increased practice revenue. Involvement in American Society of Plastic Surgeons committees correlated with contribution to Plastic Surgery Foundation. The main educational initiatives favored by Young Plastic Surgeons included critical analysis of literature/evidence-based medicine, statistical analysis, and compensation issues. According to respondents, primary areas for organizational focus should be clinical research, increased representation of young surgeons, and leadership development. Respondents would be more willing to donate if they could earmark their contributions for specific purposes, including leadership training, clinical research, and medical missions. Methods to recruit and retain young surgeons into the American Society of Plastic Surgeons and in contributing to the Plastic Surgery Foundation should include opportunities to participate at a decreased cost, focus on compensation issues, clinical research, leadership development, and increased young surgeon representation. These data should be used to guide efforts to increase young member involvement.

BackgroundStarting the first job as a young physician is a demanding challenge. Certain skills are important to master this transformation that go beyond the theoretical knowledge and practical skills taught in medical school. Competencies such as communication, leadership and career management skills are important to develop as a young physician but are usually not sufficiently taught in medical school in a structured and comprehensive way.MethodsWe performed an online survey among final year medical students regarding how they perceive their current competency level in communication, leadership and career management skills. We also assessed how they rate the importance to acquire these competencies and the current emphasis during their medical school education regarding these topics.ResultsOf 450 final year medical students 80 took part in the voluntary survey and 75 complete datasets were returned (16.7%). The majority of respondents rated different communication skills, leadership skills and career management skills as important or very important for their later clinical work. However, most students felt to be poorly or very poorly prepared by the current medical school curriculum, especially for certain leadership and career management skills. Overall, 90.7% of participants expressed interest in an additional educational course that covers subjects of communication, leadership and career management skills during the later stage of medical school, preferably as a hybrid in-person session that also offers synchronous online participation.ConclusionsThe results of the survey express the need to address communication, leadership and career management skills in the medical curriculum to be better prepare students for the demands of residency and their further course as physicians. An educational format during the final year of medical school may be suitable to address mentioned topics in the framework of clinical practical exposure.

Working as a physician in the 21st century is clearly a different endeavor compared to 50 or 100 years ago. Automation and digitalization in every part of modern work have fundamentally changed the medical sciences and clinical environments. The rise of artificial intelligence (AI) and deep machine learning will likely transform patient care and medical research in the near future. A recent study published in Nature Medicine showed that AI was as effective as junior pediatricians in detecting common pediatric diseases.1 In surgery, it is still unclear how far AI will be able to refine, accelerate, or even replace surgeons in their specialized fields. Albert Einstein once said: “Imagination is more important than knowledge. For knowledge is limited […]”. In the context of this modern technological revolution, imagination, and constant reinvention as surgeons seem more important than before. To proactively design the future of surgery, it is essential that surgeons become key players in novel and high-quality research. Historically, surgeons have been combining both clinical and research activities since the 1800s, as suggested by the term “surgeon-scientist.” Unfortunately, the quality of surgical research seems to be declining. In the New England Journal of Medicine, the proportion of surgical papers on the overall number of publications in the journal has been dropping dramatically since 1952.2 Even more concerning is the apparent shortage of young surgeons to design and conduct original research.3 A recent Nature editorial urged more surgeons to perform basic science as a response to a report that indicated that the number of surgeon-scientists has dramatically been decreasing.4,5 These negative developments in surgical research seem hazardous and conflicting with the upcoming drastic changes and innovations required to maintain a high level of performance in modern academic surgery. Woldu et al, consequently asked whether the surgeon-scientist is a dying breed.6 In this context, it is particularly unfortunate that the interest in research seems to decrease among young surgeons, resulting in the “extinction of surgeon-scientists.”7 Recently, the Basic Science Committee of the Society of University Surgeons published a roadmap to encourage and guide the next generation of surgeon-scientists towards their academic career.8 Doing a research fellowship can be an essential step on this roadmap for aspiring surgeon-scientists. Here we aimed to highlight the benefits of a research fellowship and the advantages it holds for an academic surgical career. Whether the aim of the trainee is to become a surgeon-scientist or not, performing a research fellowship will impact and strengthen the 3 pillars of a modern academic surgeon: clinical practice, research, and teaching. Individual outcomes of formal research training among general surgeons show a strong association of research time during residency and objective markers of long-term academic success.9 Surgeons that performed 1 year of research training had higher h-indices and were more likely to obtain National Institutes of Health funding later in their careers.9 Bobian et al reported that otolaryngology surgeons who had research training were more likely to achieve higher academic ranks, whereas clinical fellowships did not show this association.10 It seems intuitive that surgeons who perform research training are more likely to thrive in academic environments. Dedicated research training promotes research productivity and output. Surgeons that performed a 1-year research training had more first-author publications during residency, which objectifies their commitment to research and their ability to lead a project to completion.9 Being “extracted” from a clinical setting and put into a scientific environment might be an initially stressful and frustrating experience for a trainee but can eventually promote a unique and precious “out-of-the-box” thinking attitude. Research fellowships are often the trainee's first interaction with research, especially in Europe where medical students do not usually perform an undergraduate degree before entering medical school. Such research experiences prepare young surgeons for their work in academic centers. Given the worldwide ongoing centralization into large academic centers, young surgeons will benefit from such preparation. Research training will teach young surgeons how to distinguish low-quality from high-quality scientific work, how to read, evaluate, and criticize the scientific literature and how to put different scientific methodologies into perspective. Moreover, this experience will teach surgeons how to plan and manage projects and to understand what it takes to complete a project within a certain timeframe. Some academic centers offer opportunities to enroll into programs leading to a secondary degree such as the Doctorate, Master of Science, Master of Public Health, Master of Science in Public Health, or Master of Business Administration. Residents involved in such programs with coursework would receive formal research training on various aspects of research, such as methodology, ethics, and grant writing The impact of a research fellowship on the clinical mindset and performance – although difficult to objectify – can be significant. Dedicated time for research is the ideal ground for boosting creativity that can later be applied to both scientific and clinical practice. The time and freedom required for creativity will render visionary and innovative strategic thinking. This time and freedom are not always available in a busy clinical environment. A more inquisitive mindset will help to shift one's perspective from the diagnosis and management of a disease towards questioning the underlying pathogenesis, facilitating bedside to bench research, as a first essential step to translate results from bench to bedside. Moreover, the extra time during training without calls and night shifts allows for new information to be processed and stored properly. To memorize knowledge and recall when necessary we need time. The opportunity to do exactly this and the freedom to take some time to reflect will likely enhance quality of life during those years.11 Throughout a research fellowship, trainees will be interacting with scientists, biologists, and students with different backgrounds. Whereas it is well-known that physicians, and even more so surgeons, tend to evolve in a tight community of similar personalities with similar backgrounds and training, a diverse research experience provides an ideal environment to improve communication skills. Clear communication is crucial in medicine. Patient outcomes depend on exact communication between physicians, nurses, patients, and caregivers. Also, good interaction can enhance work satisfaction among the involved professionals. It is essential for effective communication to express thoughts precisely and clearly. During research training, residents learn how to express their thoughts clearly and communicate complex data in an understandable way. For instance, scientific abstract and manuscript writing requires precise and concise summarizing of research findings. The preparation of a scientific presentation will train the resident to introduce their topic in a structured and logical way. Furthermore, learning how to present results from fundamental research will clearly enhance teaching skills. A scientific discussion educates trainees to defend their opinion but also to consider other valuable aspects. This enhances critical thinking skills which are important to acquire during research time. The constant interaction with other researchers fosters scientific thinking, that can be used for research design and hypothesis. The underlying scientific motto postulated by Karl Popper in his “Logic of Scientific Discovery” was the attempt to falsify one's own hypothesis. This constant reflection on hypothesis, results, and their interpretation will practice critical thinking, that in turn enables young surgeons to question dogmas in the clinical arena and position them to develop innovative strategies to challenge these dogmas. Another positive effect of formal research training is access to the international surgical community. Meetings at scientific conferences not only provide young academic surgeons with the state-of-the-art knowledge in their field, but also nourishes relationships with other academic surgeons worldwide. Once introduced to the international scientific community, young surgeons will become part of this community which can boost their intrinsic motivation. This can broaden their horizon as a surgeon and a person and put opinions into perspective. These benefits do not apply only to the trainee, but also to the institutions and training programs. The reputation of an academic center with high quality research will help attract future students, residents, and fellows, but also maintain a certain level of expertise and expectation, resulting in further expansion of the academic mission. These institutions should aim to develop a culture where scientific activity is the “gold-standard” and not the exception. Therefore, dedicated and protected research time is essential and young academics who undergo research training are more likely to support this approach. Lifelong personal relations with mentors within academic institutions can foster ongoing scientific and personal mentorship. It is widely accepted that one requirement for a successful career in medicine is mentorship.8 During a research fellowship it is likely that, one will find a lifelong mentor with substantial experience to support and guide the resident's trajectory in a surgical career. Moreover, extra time for personal development under directly mentored supervision will not only help to become a better researcher, but also enhance skills like public speaking, writing, innovative thinking, and networking. In line with this, Mansukhani et al argue that the years spent in the laboratory should be rebranded as personal development time.12 Whereas most countries are aiming towards standardized surgical training programs, a research fellowship is the ideal time for a resident to enjoy some freedom in training and self-management. This may lead to discover a new interest for yet unexplored domains during the often rigid and standardized clinical training. Although in the US and Canada research fellowships are often undertaken before or during general surgical residency, this is still rather an exception for trainees in other countries. In the US and Canada, research fellowships help applicants to obtain a position for residency or clinical fellowship which is likely why there is more request to do research during their training. In most European countries, where surgeons often times start a subspecialty without prior training in general surgery, there is no such incentive to conduct research training. Another aspect concerns the costs of a formal research training program for residents and their absence in clinical training during that time. Who will pay or compensate for it? We believe that if we want to strengthen and improve academic surgery, we have to advocate for funding for young academic surgeons to participate in established research programs. As academic surgeons, we have to participate in the decision making on the allocation of research funds and be present in the respective review committees. Also, access to dedicated research time has to be without barriers for all academic surgeons. Equity, diversity, and inclusion need to be promoted in terms of opportunities to collaborate or issues in balancing family and work life. If we want to enhance surgical research performance, we have to guarantee equal opportunity to recruit the best possible faculty into academic surgery. Now that the benefits of performing a research fellowship have been well established, another crucial question is the timing of such an experience. We believe that early research exposure is essential to develop the abovementioned skills necessary for high quality research. A formal training early during residency will not only enhance the interest for the specialty but will allow the establishment of a critical and scientific mindset that the resident will be able to benefit from during his/her residency. More than ever, it is now undeniable that surgeons should invest more in (basic) science – a formal research training such as a research fellowship is the best starting point to do exactly this.

The paper investigates the critical role that the arts play in health policy advocacy, focusing on how artistic expression improves communication, encourages emotional engagement, and boosts public health programs. Health policy advocates can use artistic disciplines such as visual arts, theatre, and dance to engage with various audiences, highlight serious health challenges, and catalyse societal change. The arts provide a unique platform for marginalised people to express their health experiences, bridging the divide between public health data and community awareness. This paper examines successful case studies and discusses the obstacles to incorporating artists into health policy advocacy, specifically issues about tokenism and budget restrictions. Finally, this interdisciplinary approach shows how art can influence health policy and public perception. Keywords: Arts in health, Health policy advocacy, Creative expression, Public health communication, Marginalized voices.

Pacific Northwest advanced practice registered nurse health policy and legislative advocacy participation.

Despite difficult challenges during responses to the terrorist attacks of September 11, 2001, Hurricane Katrina, and the 2009 Pandemic Influenza A/H1N1 and severe acute respiratory syndrome outbreaks, no North American emergency to date has overwhelmed intensive care unit (ICU) services on a widespread basis since the modern development of the field of critical care. However, planners have recognized that in a future public health emergency we may not be so fortunate. To deal with very large emergencies involving many patients whose survival depends on immediate access to intensive care, an international Task Force for Mass Critical Care proposed recommendations in January 2007 to extend critical care resources for the adult population, referred to as the Emergency Mass Critical Care (EMCC) approach (1–5). The EMCC approach triples critical care capabilities for a period of up to 10 days in a very large public health emergency by focusing on immediately life-saving interventions, while delaying or forgoing less urgent care. Crisis standards of care in a large public health emergency would attempt to optimize population outcomes, rather than use unlimited efforts to maximize survival of each individual. Available resources would be substituted or adapted for equivalent or nearly equivalent unavailable resources. Resources would be conserved, reused, and reallocated to those patients most likely to benefit from them. Modest increases in stockpiles and major changes in the organization of care would be essential. While planners in the field acknowledge that mass critical care is a reasonable concept, we lack evidence that such an approach is feasible. However, failure to begin operational planning for mass critical care guarantees a failed response. As public health emergency planners begin to consider the EMCC framework, it is urgent that pediatric implications be detailed for integration into these developing plans. This supplement represents the discussions of a multidisciplinary panel convened by the Oak Ridge Institute for Science and Education (supported financially by the Centers for Disease Control and Prevention), and provides guidance for pediatric EMCC (PEMCC). Work of the PEMCC Task Force was directed by a 17-member Steering Committee selected on the basis of their expertise and experience, and included representatives from the Task Force for Mass Critical Care, World Federation of Pediatric Intensive and Critical Care Societies, American Academy of Pediatrics, American College of Critical Care Medicine, American College of Emergency Medicine, Royal College of Physicians (Canada), and National Commission on Children and Disasters, as well as several unaffiliated disaster preparedness experts. This Steering Committee led development of all manuscripts and selected individuals for the PEMCC Task Force. The full PEMCC Task Force comprised 44 experts from fields including bioethics, pediatric critical care, pediatric trauma and surgery, neonatology, obstetrics, general pediatrics, emergency medicine, pediatric emergency medicine, disaster preparedness and response, emergency medical services (EMS), infectious diseases, toxicology, military medicine, nursing (including critical care nursing), pharmacy, veterinary medicine, information sciences, public health law, maternal and child public health, and local, state, and federal government emergency planning and response agencies. Priority topics were organized on the basis of MEDLINE and Ovid database literature searches, bibliographies, state and federal government planning documents, after-action reports of recent medical responses to catastrophes, and through participation in local, state, and federal government working groups on hospital and disaster preparedness. Where evidence was available, it was utilized in formulating recommendations. Where evidence was lacking, recommendations represent expert opinion. Wherever possible, recommendations are consistent with and easily integrated into prior recommendations of the adult Task Force for Mass Critical Care. The Steering Committee produced draft outlines by synthesizing information obtained in the evidence-gathering process and convened October 6–7, 2009, to review and revise each outline. Eight draft manuscripts were subsequently developed from the revised outlines. The full PEMCC Task Force convened March 29–30, 2010, to present and discuss the draft manuscripts. Feedback on each manuscript was compiled and the Steering Committee modified the draft documents to reflect this input, in addition to updating the manuscripts based on the most current medical literature. The Steering Committee revised the manuscripts from March to October, 2010, working primarily via email and conference calls. New versions were electronically transmitted to all Task Force members to obtain concurrence with manuscript revisions. All authors and reviewers completed disclosure statements; there were no conflicts of interest. The authors were given complete autonomy by the Oak Ridge Institute for Science. The views expressed in these summaries are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Based on the recognition of the special needs of children during disasters and extensive discussion, the following recommendations are made by the PEMCC Task Force. These recommendations are described in detail in nine subsequent articles. Readers should refer to individual articles for all recommendations rather than those highlighted in this executive summary. Treatment and Triage Recommendations for PEMCC (p. S109) PEMCC in Pediatric Hospitals. These recommendations provide the basis for hospitals to prepare for PEMCC: Every hospital with a pediatric ICU or neonatal ICU should plan and prepare to provide PEMCC, and should do so in coordination with regional health planning efforts. Hospitals with ICUs should plan and prepare to provide PEMCC every day of the response for a total critically ill patient census at least double the pediatric ICU bed capacity and at least triple usual ICU capability. Hospitals should prepare to deliver PEMCC for 10 days without sufficient external assistance. Care should be coordinated with the emergency department for triage and transfer of patients to/from ICUs. All communities should develop a graded response plan for events across the spectrum from multiple casualties to catastrophic critical care events. To optimize medication availability and safe administration, the Task Force suggests that modified processes of care should be considered before an event, such as the following: rules for medication substitutions and restrictions; safe dose and frequency reduction; conversions from parenteral to oral/enteral administration; shelf-life extension; and use of length-based weight estimations. PEMCC for pediatric patients ideally should occur in hospitals or similarly designed and equipped structures with experience in providing critical care to pediatric patients. Principles for staffing models should include the following: strategies to achieve and maintain adequate staffing levels; patient care assignments for the unit should be managed by the most experienced clinician available; and assignments should be based on staff abilities and experience, with delegation of some duties and efforts to reduce care variability and complications. PEMCC in Nonpediatric Hospitals All hospitals must plan to care for children in their proportion to the population or for those affected by the mass casualty event. To facilitate such planning, nonpediatric hospitals should include a pediatrician or pediatric medical liaison in those committees responsible for disaster planning, appeals, and determining when crisis standards of care should be implemented. During a disaster, it may be more efficient to transfer skilled pediatric critical care teams to nonpediatric centers to support those facilities in providing care to critically ill pediatric patients. Nonpediatric hospitals may not have the pediatric equipment needed to sustain critically ill patients; therefore, these teams may need to take their own equipment. Establish referral network for pediatrics consultation or transfers to support hospitals that do not normally receive pediatric patients. Nonpediatric hospitals should preidentify hospital staff with experience in care of pediatric patients and create key positions in which these individuals would serve. The Task Force was unable to recommend a protocol for allocating scarce pediatric critical care resources (tertiary triage) during PEMCC. However, they suggest that: Resources should be allocated on the basis of need, benefit, the conservation of resources, and finally lottery or queuing. Younger children should not be discriminated against based on age alone. While a validated pediatric scoring system is being developed, tertiary triage should be based on expert opinion and conducted by triage teams, including experienced trauma surgeons and/or intensivists, using their best medical judgment as is the current standard of practice. The Task Force recommends that the American Academy of Pediatrics and the Institute of Medicine, bodies with subject-matter expertise and necessary positioning, develop a set of research priorities for disaster pediatric medicine such that the evidence base can be established to facilitate the development of necessary tools (i.e., decision matrices). Supplies and Equipment for PEMCC (p. S120) This chapter focuses on strategies and paradigms for purchasing and stockpiling equipment that will be necessary in PEMCC. This includes specific equipment (not including personal protective equipment, which is beyond the scope of this chapter) and supply lists necessary to triple pediatric ICU capacity for up to 10 days for a scenario in which the surge includes patients across all ages, and another scenario in which most patients are from a single age group. Recommendations include the deployment of mechanical ventilators including specifications (see p. 128 for further details), ventilation ancillary equipment (including equipment that could be disinfected or sterilized between patient uses in a pandemic situation), other options for assisted ventilation and nonconventional ventilation, suggestions for a ventilator inventory, equipment for hemodynamic management, and supplies for sedation, analgesic, antimicrobials, and nutrition. Additional equipment and supply recommendations necessary for various types of pediatric hospitals to prepare for disasters have been provided by the New York City Department of Health and Mental Hygiene's Pediatric Hospital Disaster Toolkit (http://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml); the toolkit has been positively viewed and is an additional resource that should be considered. Neonatal and Pediatric Regionalized Systems in PEMCC (p. S128) This chapter outlines the present system of care in the United States and Canada, and the systems likely to be available for providing mass critical care. Topics discussed in this manuscript include: gaps between anticipated needs and existing resources, changes in functioning of regional systems necessary for PEMCC, protocols for patient transfer, agreements with healthcare institutions that primarily provide adult care, just-in-time training of healthcare workers, transport systems for patients, and allocating staff to other healthcare facilities. Recommendations are provided for operational planning integrated across jurisdictions necessary to implement PEMCC. All preparations for mass critical care for the general population must include pediatric aspects. For this to occur, pediatric experts must be involved in all aspects of emergency and disaster planning. States and Regions. States and regions should: Facilitate PEMCC by providing legal protections for those involved in PEMCC. Reaffirm ethical norms in PEMCC. Ensure that all hospitals are prepared to provide care for children in a mass casualty scenario, including a level or scope of care beyond what they might ordinarily provide during normal operating conditions. Plan to share scarce resources with neighboring states and ensure effective public-private collaboration to meet the needs of a pediatric patient surge and optimize pediatric critical care capacity in a mass casualty event. Develop pediatric-specific performance criteria to hold regional systems accountable for PEMCC preparations and responses. Perform vulnerability analyses to estimate anticipated pediatric mass critical care needs, including especially vulnerable populations. Inventories of functional resources (space, equipment, supplies, and staff) for mass critical care must be performed at every hospital with an ICU. State information systems must be developed to track critical care needs and resources in real time during public health emergencies. Integrate operational plans for mass critical care and triage allocation (rationing) across all jurisdictional levels and all response agencies, and integrated with all aspects of emergency preparedness planning. Define regional mechanisms to direct the distribution of patients and resources in a public health emergency. Federal. Action at the federal level should include: Plans for federal involvement are consistent with state plans for mass critical care and triage allocation (rationing). Federal expertise and guidance to promote consistency in informing state laws and regulations regarding mass critical care and triage allocation (rationing) in public health emergencies. Federal incentives, specific readiness requirements, readiness, and performance measures germane to pediatric care capabilities and capacity to ensure that all states prepare sufficiently for mass critical care and triage allocation (rationing). Federal support for research on best practices ahead of time, as well as real-time surveillance, epidemiologic research, and clinical trials during a public health emergency, which will result in better evidence-based practices at the level of regional systems of care, and better clinical care. Education in a PEMCC setting (p. S135) Prospective and just-in-time training modules for pediatric critical care providers and the public are discussed within this article. Recommended topics for skilled clinicians, particularly those who do not typically treat pediatric patients, include: training in pediatric triage, administration of EMCC coordination and planning, and training in use of nonstandard equipment. As part of comprehensive emergency preparation, educational needs should be identified and addressed. Practitioners should work to maintain their basic pediatric care levels pertinent to their job, and contemplate whether additional training might benefit them in preparation for potential mass critical care events. If they are likely to be involved in a PEMCC response, they should seek out additional proactive training. Hospitals should: identify team leaders and pediatric care providers and encourage them to receive additional training and stay current in the management of critically ill children; identify just-in-time resources that could be used in times of need, and contemplate how they could best implement those resources, particularly if infrastructure, such as internet access, is compromised; and, if they do not have pediatric critical care capabilities, establish a relationship with a regional children's hospital to look for potential educational and training collaboration and offer these courses to their hospital staff. Regional pediatric critical care centers should: maintain an active educational role in both self-education in management of critically ill children and in regional education in their usual referral network; identify potential local hospitals that could help with surge capacity and ensure that those hospitals are receiving necessary training to manage potential surge patients; and work to develop just-in-time resources for remote assistance in training, such as telemedicine or telephone consultation. State/federal/professional societies should fund and develop additional training courses for pediatric mass critical care, both proactive courses and for development, evaluation, and distribution of just-in-time training modules. PEMCC: The role of community preparedness in conserving critical care resources (p. S141) This section of the supplement addresses the role of the wider community in preparing for disasters and PEMCC. Community preparedness reduces extraneous use of hospital resources and conserves scarce critical care resources by delivering population-based care in the community by utilizing the following: citizens, hotlines/healthlines, EMS/9-1-1, alternate care facilities, pediatric-specific agencies and organizations (i.e., schools, daycares, after-school programs), and integration with a health emergency operations center linked to community incident command systems. The Task Force recommends the following actions by pediatric leadership (those who represent, care for, and advocate for children): Actively promote programs to ensure, before and during a crisis, an informed citizenry and the education of children and families in the Centers for Disease Control and Prevention guidelines on community mitigation strategies. Advocate for a community level of preparedness that leads to empowered self-awareness, knowledge of the information that best prepares the public to provide basic lifesaving information and self-care, and builds physical and mental health resilience. Advocate for the establishment of permanent national- and state-level call systems and disease- and child-specific healthlines as crucial adjuncts during public health emergencies. Advocate for 9-1-1 telephone triage with pre-established criteria and protocols for the proper use and safety of EMS and EMS-sanctioned transportation during pandemics. Work with community planners to identify the logistic support necessary for establishing and operating alternate care facilities, and identify and create protocol-driven, patient management objectives based on assumptions about the types of patients that would be managed in such facilities. Advocate for creative operational concepts that provide guidance and protocols sensitive to the needs of the pediatric population. Legal Considerations during PEMCC events (p. S152) Liability is a significant concern for healthcare practitioners and facilities during PEMCC. While many of the legal issues associated with providing PEMCC are not unique within the context of disaster health care, the scope of parens patriae power of state, principles of informed consent, and security should be considered in PEMCC planning and response efforts since parents and legal guardians may be unavailable to participate in decision making during disasters. This article describes the legal considerations inherent in planning for and responding to catastrophic emergencies and makes recommendations for PEMCC legal preparedness. To address gaps in existing liability protections for public health and PEMCC emergency responses, the Task Force recommends strengthening several areas of legal preparedness. As outlined in the Institute of Medicine crisis standards of care guidance (6): Necessary legal protections must be provided for healthcare practitioners and institutions that implement crisis standards of care plans. Unless comprehensive, national liability protections are implemented, state governments must link existing health practitioner and entity liability protections to crisis standards of care. Courts and other adjudicators should consider whether adherence to the Institute of Medicine guidance provides evidence of meeting the standard of care and "the legal effect of changing standards of care during emergencies" in medical malpractice claims. In addition to the Institute of Medicine recommendations, the following suggestions should be considered for PEMCC preparedness: PEMCC disaster protocols should be properly vetted and accepted; when providing pediatric mass critical care, practitioners who follow such accepted and vetted protocols in good faith should be protected from civil liability (5–7). PEMCC protocols should be included in state disaster plans. Health facilities should ensure that their pediatric disaster plans are consistent with state plans and, to the extent possible, with neighboring health facilities. Facilities that care for pediatric patients should develop specific informed consent and security protocols to incorporate into their disaster plans. Facilities that do not normally care for pediatric patients or that do not routinely provide care for critically ill pediatric patients should also consider incorporating such planning or partnering with other facilities that provide such care in the event that pediatric patients arrive at their facilities during emergencies. PEMCC: Focus on family-centered care (p. S157) Family-centered care (FCC) is especially a concern and challenge in PEMCC. This article addresses the tension between offering FCC and effective disaster treatment/triage. It offers a list of practical suggestions for incorporating FCC principles into each of the following healthcare settings during a disaster, including a PEMCC event: EMS transport, emergency departments, pediatric ICUs, general pediatric wards, and alternative sites. Disaster and PEMCC responses must incorporate FCC principles to the extent possible in a variety of healthcare settings. Family-Centered Care in EMS Care of Children. Practical suggestions have been developed for EMS professionals planning for and responding to mass casualty/pandemic events that involve children. These include encouraging families, local pediatricians, and local groups (champions) to engage in every stage of planning and preparation for disasters. FCC in Emergency Departments and ICUs in a Mass Event. Overcrowding, panic, security concerns, staff stress, and separation of families during triage make practicing FCC an imperative and demanding task. The fundamental precepts of FCC, such as attention to the as a of and of the health of the critical to the of disaster The following are some recommendations for emergency department professionals as they plan and to the needs of children and their families in a mass event: possible, EMS and emergency should a to with the child during the triage and This may providing care for parents in addition to children. The local triage and tools should for a and should a of including at least date of and should be obtained as and as possible, and if necessary to the National for and Children an by the government to with families in a mass Mental health professionals in triage and emergency of children should be available on the In the pediatric and of a liaison such as a child or nursing to and general information of to families could reduce on the and skilled medical to the acute needs of critically or patients. FCC in should include a for children with families and proper for children. The Task Force also recommends planning for FCC during PEMCC at alternative and a medical strategies to establishing of when families are and and families, including those with and in PEMCC (p. The specific is ethical issues unique to children in disasters to their and It that children should be not in proportion to existing resources, to their proportion of the general population or those affected by the event. While the ethical principles of triage the for and the lack of a validated pediatric scoring system on expert opinion. The article the to individuals between and of capacity for children should be based on their proportion of the population, or in proportion to those or likely to be affected by the mass critical care event, rather than in proportion to existing standards are to be resources should be allocated on the basis of medical need, medical benefit, and the conservation of resources. the of a validated pediatric the recommends the use of expert opinion. lists are to the Resources should not be allocated based on the complete or on or to in this is essential. The of PEMCC in the developing (p. care in developing is as well as the that can be for offering mass critical care in developed during disasters. in scarce resource and routinely make difficult allocation This article and recommendations for providing the most good with resources through with existing healthcare and using available resources to The of pediatric critical care should include "the of the child with a or in without for the and including emergency, and intensive to disasters in developing have to take into the available resources and (i.e., to provide special needs care that as a of immediate lifesaving The response in these needs to be to the stage of development of the health services and resources. In the must be on care, and basic emergency care, in care should without care resources. in preparing for a pandemic in a developing from public health and and developing strategies for community and mitigation strategies. care strategies must on using the United Health guidelines and for of and of and assistance is provided to during through provided by the Health of 2007 and the Regional emergency response capabilities and their through the Regional with international such as for government (Canada), Department for and will the deployment of scarce resources. are many issues to PEMCC that are such as of triage and decision making and research priorities that need to be addressed. institutions need to make use of these recommendations as guidelines to their readiness and in preparation for PEMCC. The Pediatric Emergency Mass Critical Care Task Force the American Academy of Pediatrics and Disaster for their review and to this

COVID-19 The Great Disruptor

Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents' training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration ("the Collaborative") to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative's activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative's impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

Background: Physicians are increasingly recognized as key stakeholders in health policy reform due to their clinical insight and system-level experience. However, empirical evidence quantifying their advocacy involvement and evaluating determinants such as leadership training remains limited. Understanding these dynamics is essential for guiding professional development and institutional strategies aimed at enhancing physician-led policy engagement. Objective: To quantify the level of physician involvement in health policy advocacy, assess the impact of formal leadership training on advocacy engagement, and identify barriers and facilitators to such involvement across various healthcare settings. Methods: A cross-sectional survey was conducted between January and March 2025 among 210 licensed physicians engaged in leadership, academic, public health, or policy roles across Pakistan. Participants were recruited through purposive and snowball sampling methods. A structured, self-administered online questionnaire was developed using the Medical Leadership Competency Framework and PATH Advocacy Evaluation Framework. Data on leadership competencies, advocacy behaviors, and perceived policy impact were collected using 5-point Likert scales. Descriptive statistics, chi-square tests, independent t-tests, and multivariate logistic regression were used for data analysis. Results: Among 210 participants, 59.0% were male, and 79.0% had over 10 years of professional experience. The most represented work settings were hospital leadership (34.3%) and academia (27.6%). High leadership scores were observed in personal qualities (Mean = 4.21) and working with others (Mean = 4.15), while improving services scored lowest (Mean = 3.88). Frequently reported advocacy activities included public speaking (46.7%) and contacting policymakers (40.0%), while legislative testimony (20.0%) and international engagement (8.7%) were less common. Leadership training (OR = 2.45, p = 0.002) and high policy competency (OR = 3.21, p < 0.001) significantly predicted advocacy engagement. Institutional support remained low (Mean = 3.52), despite high confidence in policy influence (Mean = 4.01). Conclusion: Leadership training and strong policy competencies significantly enhance physician engagement in health policy advocacy. However, limited institutional support may hinder sustained advocacy efforts. Strengthening advocacy curricula and supportive organizational environments is critical to empowering physicians as leaders in health reform.

To identify and address areas for improvement within the current surgical training model in Australia and New Zealand relating to family planning and inflexible training as top barriers to gender equity in surgery. A cross-sectional study of accredited surgical trainees and early career surgeons in Australia and New Zealand was conducted between September and October 2023. Participants were recruited by the RACS Fax Mentis, the Urological Society of Australia and New Zealand (USANZ) e-newsletter, and medical social media networks. Qualitative and quantitative data were collated by the electronic survey and thematically analyzed. There was a total of 146 participants. Approximately two-thirds of respondents identified as mothers and one-third as fathers, with representation from all surgical specialties. We identified four key themes including the disruptive impact of poor work-life balance on family planning, an absence of workplace systemic supports, a need for structured support program upon return-to-work from parental leave, and challenges in balancing professional and parental identities and responsibilities. To promote a culture of equity, inclusivity, and acceptance, restructuring of surgical training programs are necessary to support trainees as they navigate family planning and parenthood. Promotion of flexible training options and recruitment of additional clinical supports around parental leave period may reduce negative biases toward trainees simultaneously balancing family and work. Systemic change is required to lower barriers to entry and achieve gender equality in surgery.

Many nurses work largely as policy implementers rather than policy developers. The literature posits several multifaceted reasons for this lack of policy acumen including interprofessional power dynamics, marginalization of nurses in policy making, and lack of formal training in public policy advocacy. To evaluate the impact of a targeted teaching strategy on increasing political astuteness, perceived skill, and comfort in health policy advocacy among a cohort of acute care pediatric nurse practitioner students. Curriculum assessment data were collected using the Political Astuteness Inventory, pre- and postclass discussions, and written reflections. Results: This curriculum evaluation suggests that specific policy and advocacy training coupled with civic-based experiential learning increased graduate nursing students' political astuteness as well as increased their perceived skill and comfort with health policy advocacy. Targeted training is an important step in giving nurses the needed tools to work for equitable health care policies.

This study sought to explore the relationship of bariatric surgeon age and patient outcomes. Regulators, policy makers, and patient advocacy groups have recently been pushing to establish clear guidelines for physician retirement in the United States. Although it is often assumed that increasing physician age leads to worse patient outcomes, the relationship is lacking robust evidence, and is still unclear. We conducted a study analyzing all bariatric surgeons in Michigan who participated in a statewide collaborative quality improvement program (n = 71) who performed primary laparoscopic Roux-en-Y Gastric Bypass, or sleeve gastrectomy operations, and data on their patients (n = 60430) over the past 10 years. Our primary outcomes were 30-day postoperative complications. Odds ratios for overall complications and serious complications were calculated for each age group, and surgery type. Late career surgeons had more bariatric surgery experience and had a higher average annual case volume than early career surgeons. Considering all cases in the past 10 years, older surgeons performed more Roux-en-Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons (34.7% and 51.5%). When adjusting for patient and surgeon characteristics, there were no statistically significant differences in overall or serious complication rates for either procedure among surgeon age groups. When evaluating bariatric surgeons in the State of Michigan, we found no statistically significant association between surgeon age and patient outcomes. Our findings do not provide evidence for age-specific retirement cut-offs, but support the development of guidelines which are holistic, and focus on evaluating and improving physician outcomes at all career levels.