Surgical Subspecialist Research Articles

The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda

I read the article by Ozgediz et al. entitled ‘‘The Neglect of the Global Surgical Workforce: Experience and Evidence from Uganda’’ [1]. I want to share my experience and contribute my thoughts on this serious problem facing rural populations in sub-Saharan Africa. I had conducted a similar health facility assessment and survey for the government of Cross River State (CRS) in Nigeria in 2000 (unpublished report). I have also worked in Mozambique and witnessed the surgical skill and volume of surgical services rendered by nonphysician surgical technicians called ‘‘tecnicos de cirurgia’’ in Portuguese. I have undergone surgical training as part of my residency training in General Practice/Family Medicine (GP/FM)-original Nigerian Model, and served in peripheral/rural hospitals in Nigeria and Mozambique at the level of Principal Medical Officer/Medical Director for more than 10 years before going into public health medicine. I am therefore not writing as a specialist surgeon but as someone who has served the rural population as a generalist physician with surgical and obstetric training and skills. My review had the same findings as Ozgediz et al. had in Uganda. There were two specialist surgeons for the 18 general hospitals (district hospitals) serving a population of more than 3 million people, 90% living in rural areas. The teaching hospital in the capital city is home to 95% of all the medical doctors in the State (province). This is because most of the doctors at the teaching hospital in the postgraduate residency in various surgical specialties (and other specialties) stay in training an average of 8 years (some stay up to 10 years). In their study in Mozambique Kruk et al. [2] have shown that training more midlevel health workers in surgery is a good investment and a way to respond to the shortage in the surgical workforce. In Nigeria, the surgical and obstetric and gynecologic training component in GP/FM residency (12 months), if maintained as the originally intended, is an equally good investment and way to increase surgical services in rural populations. It is obvious that one way of improving the surgical workforce in Africa is to promote short postgraduate (PG) training programs and intensive rural clerkship at the undergraduate level. A PG training program of 18 months in general surgery, 18 months in OG-GYN, and 18 months in anesthesia, all leading to government and medical council licentiates as specialists and designed for peripheral hospital career development, will go a long way to attract and retain trained specialists in rural and peripheral hospitals. One reason why the Mozambique program has worked is because of the recognition and respect given to these ‘‘tecnicos de cirurgia’’ by the government, medical council, and medical doctors (MD), both generalist physicians and specialists. In fact, the generalist MDs who spend two compulsory years in rural hospitals after graduation in Mozambique refer surgical cases to the ‘‘tecnicos’’ and some of the MDs even get surgical tutoring from the ‘‘tecnicos.’’ Finally, the above proposals of shortening surgical training for MDs or the use of nonphysicians are not substitutes for long surgical training and subspecialist programs. They are intended to produce more hands for basic and life-threatening surgical services until such a time when all the development indices have spread to engulf the rural population. The short training programs will then be adjusted accordingly. The UK recently E. Monjok (&) Institute of Community Health, University of Houston, Texas Medical Center, 1441 Moursund St. Suite 119, Houston, TX 77030, USA e-mail: emonjok@uh.edu

Pediatric surgical oncology

Pediatric surgical oncology is a relatively new and rapidly evolving field. This textbook, edited by Dr. Richard Andrassy, endeavors to provide a single source for current practice trends. It is aimed at those physicians involved in the care of children with cancer but specifically the family practitioner, general pediatrician, general surgeon, pediatric surgeon, and pediatric surgical sub-specialist. Many of the authors have contributed expert opinions on subjects for which they are surgical representatives for the Children’s Cancer Group. This is the second book entitled Pediatric Surgical Oncology (the first was edited by Dr. Dan Hays). It is therefore appropriate that he begin the current text with an overview of the interesting history of the development of the field. Dr. Andrassy manages to add charming anecdotes of the important figures in the field. He then continues to the “General Principles” chapter, which serves as an introduction to the rest of the text. The book has been divided into two main parts, with the first being general management issues in children with cancer and the second with chapters devoted to each of the main pediatric oncology topics. The initial chapters include an overview of anesthetic concerns, chemotherapy, radiotherapy, molecular biology, minimally invasive surgery, and vascular access as it pertains to care. It then focuses on specific important points in care for pediatric oncology patients. In general, the initial chapters are a good review of each topic. The molecular biology chapter was extremely well written, and provides the reader with an excellent foundation for understanding future developments in research and treatment. The chapters that address specific tumors are perhaps the best portion of this book. They are up-to-date, well written, and explain to the reader the current approaches to management of each topic. These chapters review important management issues and provide insightful interpretations of important studies that have gone into establishing the current protocols. The reader gains and appreciates the evolving field of pediatric surgical oncology. Overall, the aim of the editor was not to provide an all-inclusive summary of present treatment modalities but as a single source for current practice trends. In general, the book achieves this goal. Some topics could have included further information of current active areas of investigations and research. However, in an age of rapidly evolving technology where areas of interest may change over a matter of months, we realize this is likely impossible. Therefore, we would highly recommend this book as a prerequisite for all surgeons looking after children with cancer and be available in all children’s hospital libraries as an important reference to current pediatric surgical oncology management.

Has the trauma surgeon become house staff for the surgical subspecialist?

Background The role of the trauma surgeon is perceived to be mostly supportive of other procedure-oriented specialties. We designed this study to characterize the surgical and nonsurgical responsibilities of the contemporary trauma surgeon. Methods Trauma patients admitted to an urban academic level I trauma center were studied using trauma registry data for 2004. Results The large majority of patients admitted to trauma service has mild single-system injuries to 1 or 2 anatomic regions. Most (57%) did not have injuries to the neck, chest, or abdomen. Head and extremity injuries were present in 45% and 46% of patients, respectively. Surgeries were performed by orthopedists in 28%, trauma surgeons in 11%, and neurosurgeons in 6% of patients. Conclusions The contemporary trauma surgeon has little surgical opportunity and provides a disproportionate amount of nonsurgical care in support of consultant specialists. This is a major deterrent to general surgeon interest in trauma care and must be addressed as the acute-care surgeon evolves.

What is a “fair salary” for a surgical subspecialist?

The author presents a net present model by which a "fair salary" for surgical subspecialists is justified. Neurosurgical practitioners are used as an example, based on assumed fair salary for family physicians.

Pediatric Surgical Oncology

Pediatric surgical oncology is a relatively new and rapidly evolving field. This textbook, edited by Dr. Richard Andrassy, endeavors to provide a single source for current practice trends. It is aimed at those physicians involved in the care of children with cancer but specifically the family practitioner, general pediatrician, general surgeon, pediatric surgeon, and pediatric surgical sub-specialist. Many of the authors have contributed expert opinions on subjects for which they are surgical representatives for the Children’s Cancer Group. This is the second book entitled Pediatric Surgical Oncology (the first was edited by Dr. Dan Hays). It is therefore appropriate that he begin the current text with an overview of the interesting history of the development of the field. Dr. Andrassy manages to add charming anecdotes of the important figures in the field. He then continues to the “General Principles” chapter, which serves as an introduction to the rest of the text. The book has been divided into two main parts, with the first being general management issues in children with cancer and the second with chapters devoted to each of the main pediatric oncology topics. The initial chapters include an overview of anesthetic concerns, chemotherapy, radiotherapy, molecular biology, minimally invasive surgery, and vascular access as it pertains to care. It then focuses on specific important points in care for pediatric oncology patients. In general, the initial chapters are a good review of each topic. The molecular biology chapter was extremely well written, and provides the reader with an excellent foundation for understanding future developments in research and treatment. The chapters that address specific tumors are perhaps the best portion of this book. They are up-to-date, well written, and explain to the reader the current approaches to management of each topic. These chapters review important management issues and provide insightful interpretations of important studies that have gone into establishing the current protocols. The reader gains and appreciates the evolving field of pediatric surgical oncology. Overall, the aim of the editor was not to provide an all-inclusive summary of present treatment modalities but as a single source for current practice trends. In general, the book achieves this goal. Some topics could have included further information of current active areas of investigations and research. However, in an age of rapidly evolving technology where areas of interest may change over a matter of months, we realize this is likely impossible. Therefore, we would highly recommend this book as a prerequisite for all surgeons looking after children with cancer and be available in all children’s hospital libraries as an important reference to current pediatric surgical oncology management.

A surgical subspecialist enhances general surgical operative experience.

To examine the impact of a surgical subspecialist on residents' operative experience in a mature general surgery training program. American Board of Surgery operative experience records were used to examine the impact of a surgical subspecialist on surgical training in a stable residency program. Operations performed as surgeon by residents in their chief and junior years were analyzed 4 years before and 4 years after the addition of this subspecialist to the faculty. Hospital admissions for Crohn's disease and ulcerative colitis during these periods were analyzed as well. There was a statistically significant increase in the number of ileal pouch anal anastomoses, ileostomies, small-bowel resections, partial colectomies, and coloanal anastomoses performed by surgical residents after the addition of a colorectal surgical subspecialist. Subspecialty faculty may favorably influence general surgical training by increasing resident operative experience and patient management skills with procedures characteristic of the subspecialty.

Status of Surgical Training in the German Military

This article describes the current career path that must be followed when an individual wishes to pursue a career as a surgeon or surgical subspecialist in the German military. After graduating from high school, the young soldier has to sign a 16-year commitment and start medical studies at a civilian university. Having finished medical school, the officer is educated in general medicine for 2 years at one of the military hospitals. Several years as a battalion's doctor complete his or her general training. Basic surgical education of 5 years precedes specialization as trauma/orthopedic, abdominal, vascular, or thoracic surgeon within 3 years. Based on the experiences of the first German attempts in United Nations missions, the education of surgical officers needs to be concentrated on clinical practice. Otherwise, surgical skills cannot be attained and maintained.

The organ donor's doctor: a new role for the neurosurgeon.

IN cities where organ transplantation flourishes, the neurosurgeon is currently enjoying a new kind of attention from some of his colleagues. In addition to his customary role as that unique surgical subspecialist who elects to work in small, deep crannies with sucker and cautery, he now finds himself very much in demand when he is acting as the temporary custodian of young, vigorous patients neurologically destroyed beyond repair, but otherwise physiologically and anatomically intact. As such, the neurosurgeon can be counted on to have patients who are potential sources of many donor organs. Here, then, is a new problem. It . . .