Thesis (Ph. D.)--University of Toronto, 2005. / Includes bibliographical references (leaves 227-237).

A contentious area of clinical practice in the discipline of surgery, with ethical implications, relates to disclosure of clinician HIV status to patients, specifically where exposure prone procedures, performed in a confined body space using sharp instruments without full vision of the operative area, carrying a technical risk of blood borne pathogen transmission are being performed by HIV positive surgeons. Within the context of patient informed consent, it has been proposed that surgeons who are HIV positive make their status known to patients on whom they would perform such procedures. Failing which it is proposed that surgeons who are HIV positive should refrain from such procedures. It has been counterargued that such disclosure is an infringement on clinician privacy and that curtailing the scope of practice is prejudicial to both surgeon and patient. The former in terms of employment prospects and the latter based on the lack of data supporting a significant risk of clinician to patient transmission with a resultant unnecessary loss of surgical skills. Existing recommendations appear to be informed more by sentiment than science and are thus potentially unsatisfactory, more so in that they do not seem to confer benefit to either patients or clinicians. Further, whilst such policies emanate from developed countries they may not address the clinical realities or sentiment of the South African situation. Where such policies do exist, it is not clear to what extent the recommendations accord with clinician views. Against this background the current study surveyed views of practicing South African surgeons regarding aspects of this issue i.e. HIV and surgeons. Some of the salient findings included the view that a patient centred approach requiring HIV status disclosure to patients would be discriminatory to surgeons whilst not clearly of benefit to patients. Further that HIV positive surgeons should determine their own scope of practice. Certainly it appears that patient centered approaches and restrictive policies, related to this issue, do not appear to accord with clinician sentiment. In the absence of any comparable data either locally or internationally, the current study provides a preliminary indication of clinician views with implications for the development of locally relevant guidelines.

Title from PDF of title page (University of Missouri--Columbia, viewed on Feb. 19, 2008). The entire thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file; a non-technical public abstract appears in the public.pdf file. Dr. Luis Occeña, Thesis Supervisor. Includes bibliographical references.

The operating room (OR) is an area of particularly high risk for patients, due to technical and non-technical issues. Research in other high-risk industries has shown that leadership can impact safety and performance of work teams. As the leader of the surgical team, surgeons must demonstrate leadership along with technical excellence, to optimize performance and maximize patient safety in the OR. This thesis investigated surgeons’ leadership in the intraoperative period. A review of the surgical literature revealed ten empirical articles examining surgeon leadership. Of these, two articles linked leadership was an outcome measure. A preliminary taxonomy that included seven elements of leadership was developed based on definitions of leadership from the literature. To further investigate intraoperative leadership, observations (<i>n</i>=29) were conducted in three hospitals in Scotland across different types of surgery. Leadership was described in detail according to the leadership elements. Surgeons engaged in significantly more leadership during more complex operations. Ten focus groups with different members of the OR team were conducted to finalize the taxonomy. The final taxonomy, the Surgeons’ Leadership Inventory (SLI), was revised to include eight elements: maintaining standards making decisions, managing resources, directing, training, communicating, supporting others, and coping with pressure. The SLI was used with adequate reliability to code videos (<i>n</i>=29) of live operations. Elements of surgeons’ leadership differed before and after the surgical point of no return. Analysis revealed differences in training and supporting others behaviours in cases with an unexpected event. The element coping with pressure was significantly related to intraoperative blood loss. Surgeons’ intraoperative leadership was found to be reactive, situation based, and often transactional in nature. This thesis provides a first step in identifying the important behaviours and a basis on which improving surgeons’ intraoperative leadership may be made.

Objectives: The thesis seeks to provide an analysis of surgical work and decision making, to identify the basis of the widely observed variation in surgical practice and to indicate what surgeons see as the source(s) of that variation. Against this background, it examines the strengths and limitations of the approach promoted by the evidence-based medicine movement to surgical work. Methods: A qualitative study of surgical practice by urological and gynaecological surgeons in England and the USA involved in the treatment of female urinary stress incontinence. Depth interviews with 29 English surgeons and five American surgeons. Interviews were recorded and transcribed. Observation of 23 operations and additional ethnographic data collection at the hospitals and clinics where these surgeons worked. The observational data consist of near verbatim notes. All these data were analysed using the constant comparative approach described by Glaser and Strauss (1967). A variant of the split-half technique was used to test emerging themes. Results: Surgical practice is contingent: it is dependent on a range of variables, and, it is serendipitous. Three categories of contingency are identified (case, surgeon and external contingency). It is argued that surgical practice entails the complex interplay of these conditional factors and chance happenings. In order to learn to deal with contingency, surgeons learn or acquire practice skills through first hand experience. The thesis explores the role of the surgical apprenticeship and models of learning used by surgeons. Conclusion: The nature of surgical practice presents some fundamental challenges to EBM. The contingent and experiential features of surgical work raise serious doubts about the applicability of EBM to surgery.

The goal of this research was to establish a methodology for quantifying performance of surgeons and distinguishing skill levels during live surgeries. We integrated three physical measures (kinematics, time and movement transitions) into a modeling technique for quantifying performance of surgical trainees. We first defined a new hierarchical representation called Motor and Cognitive Modeling Diagram for laparoscopic procedures, which: (1) decomposes ‘tasks’ into ‘subtasks’ and at the very detailed level into individual movements ‘actions’; and (2) includes an explicit cognitive/motor diagrammatic representation that enables to take account of the operative variability as most intraoperative assessments are conducted at the ‘whole procedure’ level and do not distinguish between performance of trivial and complicated aspects of the procedure. Then, at each level of surgical complexity, we implemented specific mathematical techniques for providing a quantitative sense of how far a performance is located from a reference level: (1) The Kolgomorov-Smirnov statistic to describe the similarity between two empirical cumulative distribution functions (e.g., speed profiles) (2) The symmetric normalized Jensen-Shannon Divergence to compare transition probability matrices (3) The Principal Component Analysis to identify the directions of greatest variability in a multidimensional space and to reduce the dimensionality of the data using a weight space. Two experimental studies were completed in order to show feasibility of our proposed assessment methodology by monitoring movements of surgical tools while: (1) dissecting mandarin oranges, and (2) performing laparoscopic cholecystectomy procedures at the operating room to compare residents and expert surgeons when executing two surgical tasks: exposing Calot’s Triangle and dissecting the cystic duct and artery. Results demonstrated the ability of our methodology to represent selected tasks using the Motor and Cognitive Modeling Diagram and to differentiate skill levels. We aim to use our approach in future studies to establish correspondences between specific surgical tasks and the corresponding simulations of these tasks, which may ultimately enable us to do validated assessments in a simulated setting, and to test its reliability in differentiating skill levels at the operating room as the number of subjects and procedures increase.

The goal of this research was to establish a methodology for quantifying performance of surgeons and distinguishing skill levels during live surgeries. We integrated three physical measures (kinematics, time and movement transitions) into a modeling technique for quantifying performance of surgical trainees. We first defined a new hierarchical representation called Motor and Cognitive Modeling Diagram for laparoscopic procedures, which: (1) decomposes ‘tasks’ into ‘subtasks’ and at the very detailed level into individual movements ‘actions’; and (2) includes an explicit cognitive/motor diagrammatic representation that enables to take account of the operative variability as most intraoperative assessments are conducted at the ‘whole procedure’ level and do not distinguish between performance of trivial and complicated aspects of the procedure. Then, at each level of surgical complexity, we implemented specific mathematical techniques for providing a quantitative sense of how far a performance is located from a reference level: (1) The Kolgomorov-Smirnov statistic to describe the similarity between two empirical cumulative distribution functions (e.g., speed profiles) (2) The symmetric normalized Jensen-Shannon Divergence to compare transition probability matrices (3) The Principal Component Analysis to identify the directions of greatest variability in a multidimensional space and to reduce the dimensionality of the data using a weight space. Two experimental studies were completed in order to show feasibility of our proposed assessment methodology by monitoring movements of surgical tools while: (1) dissecting mandarin oranges, and (2) performing laparoscopic cholecystectomy procedures at the operating room to compare residents and expert surgeons when executing two surgical tasks: exposing Calot’s Triangle and dissecting the cystic duct and artery. Results demonstrated the ability of our methodology to represent selected tasks using the Motor and Cognitive Modeling Diagram and to differentiate skill levels. We aim to use our approach in future studies to establish correspondences between specific surgical tasks and the corresponding simulations of these tasks, which may ultimately enable us to do validated assessments in a simulated setting, and to test its reliability in differentiating skill levels at the operating room as the number of subjects and procedures increase.

Thesis (M.D.S.) -- University of Adelaide, Dept. of Oral Pathology and Oral Surgery, 1977.

Thèse : Droit : Rennes : 1940.

Dedicated to Samuel Borrowe, M.D. and Dr. Ely Burritt. / Caption title: Dissertation on permanent stricture of the urethra. "Appendix. The following cases are subjoined ... for the purpose of illustration ..."--p. [33]-46. Includes bibliographical references. Microform version available in the Readex Early American Imprints series.