Tag Archives: surgical training

Hysterectomy Disconnect

At least two-thirds of hysterectomies in the United States are still performed through an abdominal incision, despite the availability of minimally invasive approaches that are associated with less pain, shorter hospital stay, more rapid recovery, and better cosmesis. In an attempt to change that, the AAGL  Advancing Minimally Invasive Gynecology Worldwide has just issued a position statement calling for nearly all hysterectomies that are done for benign uterine disease to be performed vaginally or laparoscopically, rather than abdominally.

"TAH" stands for Total Abdominal Hysterectomy. Image courtesy of Intuitive Surgical Inc.

According to the AAGL, the few contraindications to laparoscopic hysterectomy (LH) include conditions in which the risks of general anesthesia or intraperitoneal pressure are deemed unacceptable or where uterine malignancy is suspected. For both LH and vaginal hysterectomy (VH), exceptions include situations where trained surgeons or required facilities are unavailable, or in certain cases of distorted anatomy.

Otherwise, AAGL said, “When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice.” 

So why aren’t they?  After all, in some European countries the rate of abdominal hysterectomy (AH) is less than 25%.  Interesting insight can be found in the results of a recently published online/paper survey sent to a random sample of 1,500 practicing U.S. obstetrician-gynecologists.

Among the 376 who responded, the most commonly performed hysterectomy procedure in the previous year was AH (by 84% of respondents), followed by VH (76%).  But when asked to rank which hysterectomy approach they would prefer for themselves or their partner, 56% ranked VH as their first choice and 41% ranked LH as their first choice, with only 8% opting for AH. 

When asked about barriers to performing minimally invasive procedures, the most common ones reported for VH included technical difficulty, potential for complications, and personal caseload. For LH, respondents cited lack of training during residency, technical difficulty, personal surgical experience, and operating time as barriers. 

Nonetheless, when asked about their ideal goal for mode of access, the respondents felt on average that minimally invasive techniques should comprise 79% of all hysterectomy procedures. 

According to the AAGL’s position statement, “Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do, or should refer patients requiring hysterectomy to such individuals for their surgical care.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Anesthesia and Analgesia, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology, Plastic Surgery, Practice Trends, Surgery, Uncategorized

And a Woman Will Show Them the Way

Henry VIII and the Barber Surgeons image from Wikimedia Commons

From the annual meeting of the American Surgical Association

 Lifestyle and generational priorities are often cited as fostering the high attrition rate for both male and female surgical trainees.

 According to the first prospective, national survey, one in five general surgery residents resigns before completing their training, Yale University surgical resident Dr. Heather Yeo reported at the ASA’s annual meeting. That number is based on 2007-2008 data in 6,303 general surgery residents, but is fairly constant despite earlier implementation of the ACGME work rules limiting residents to an 80-hour work week, which many at the meeting said they hoped would help reduce attrition.

Slightly more women than men resigned (2.1% vs. 1.9%). Singles  were also more likely than married residents to resign (2.1% vs. 2%).

In multivariate analysis however, only postgraduate year level was a significant predictor of resignation, with most resignations occurring in PGY-1.

These data are both disturbing and strangely reassuring given the brain drain in general surgery and the well-known paucity of women in the field. Indeed, only a dozen or so women were in the audience, except for when the wives were allowed in for special sessions. And of the 39 new ASA fellows inducted at the meeting, only three were women.

Dr. Rachel Kelz stood out, both as one of the few women in that room and for her efforts to stop the bleeding.

Dr. Kelz and her surgical colleagues at the University of Pennsylvania modified the resident selection process to make it more extended, personalized and structured.

Their intervention, which required among other things that candidates write a 500-word essay related to stress management, organizational skills and future aspirations, dramatically decreased the overall 5-year attrition rate from 27% to 3% and attrition among women from 50% to 9%.

A smashing start considering that 63% of residents who left the program were women, 75% of exiting residents cited lifestyle issues as a reason for departing, and 38% of residents were flagged as having organizational/time management problems.

Other suggestions from the audience were for surgical programs to intentionally match additional residents to factor in attrition, and for medical schools to offer a more “robust” exposure to surgery so wannabe surgeons would have a better understanding of their residency and a surgeon’s lifestyle.

A quick peek at the old boy’s club could also motivate surgical residents to set their sights on  the ASA, “the nation’s oldest and most prestigious surgical organization.”

— Patrice Wendling (on Twitter @pwendl)

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Filed under IMNG, Practice Trends, Surgery, Thoracic Surgery, Transplant Medicine and Surgery, Uncategorized