RESISTING RESISTANCE TO CHANGE: A CRITICAL ANALYSIS OF THE STRUCTURE OF SURGICAL RESIDENCY TRAINING PROGRAMS

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) issued regulations affecting the structure of surgical residency training programs. These regulations placed work hour restrictions on residents. There has been significant resistance by the surgical leadership, including program directors and officers in academic organizations, to the adoption of the changes required by these regulations. The need for these changes to the structure of the resident’s work environment, and the resistance to the incorporation of these changes, provide an opportunity to examine the ethos and culture of surgical residency for a potential source of this conflict. This thesis claims that a significant element of this resistance is the recognition that the required changes will not only affect the structure of surgical residency training, but also the culture of residency training and the adoption of a traditional surgical identity by the trainees immersed in that culture. There is increasing evidence of significant ethical problems resulting from the traditional structure of surgical residency training. The norms perpetuated by the traditional approach to surgical training are antithetical to the current ethical norms expected regarding patient care and the surgeon’s personal and professional development. Critical ethical issues addressed in this thesis include those raised by both the apparent generational break between surgeons trained before and after work hour reform, and the conflict in balancing visions of surgical identity and concerns of patient and personal safety. The thesis argues that there is no well grounded reason for the resistance to incorporating the changes required by the ACGME. Instead, the development of the structure and culture of the surgical residency may have evolved in response to dysfunctional influences, rather than being built on sound pedagogical theory. The resulting surgical identity molded by this culture may then be appreciated as a potentially flawed, dysfunctional social construct. Changes prompted by the ACGME may result in both a healthier surgical work force and the ability to attract a greater diversity of applicants to the field of surgery. The reframing of what is essential to the surgical identity may allow the creation of new models of surgical training

Guidelines for the Development of Comprehensive Care Centers for Congenital Adrenal Hyperplasia: Guidance from the CARES Foundation Initiative

Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH) often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA), New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC), and National Newborn Screening and Genetics Resource Center (NNSGRC) also participated. Thus, this document should serve as a “roadmap” for the development phases of comprehensive care centers (CCC) for individuals and families affected by CAH

Guidelines for the Development of Comprehensive Care Centers for Congenital Adrenal Hyperplasia: Guidance from the CARES Foundation Initiative

Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH) often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA), New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC), and National Newborn Screening and Genetics Resource Center (NNSGRC) also participated. Thus, this document should serve as a “roadmap” for the development phases of comprehensive care centers (CCC) for individuals and families affected by CAH

Guidelines for the Development of Comprehensive Care Centers for Congenital Adrenal Hyperplasia: Guidance from the CARES Foundation Initiative

Abstract Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH) often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA), New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC), and National Newborn Screening and Genetics Resource Center (NNSGRC) also participated. Thus, this document should serve as a "roadmap" for the development phases of comprehensive care centers (CCC) for individuals and families affected by CAH

Endoscopically guided thoracoscopic esophagectomy for stricture in a child

Purpose: Caustic ingestion is a common cause for acquired esophageal strictures in children. Thoracoscopic esophagectomy can be very useful in this setting, particularly for short segments of disease [1-4]. Thus far, the use of endoscopy to guide resection margins has not been described. Methods: A 6-year-old boy developed a tight, short esophageal stricture from a lye ingestion injury at the age of 4 years. He had a gastrostomy tube placed at the time for supplemental feedings and subsequently failed attempts at antegrade and retrograde esophageal dilatation. This video demonstrates an endoscopically guided (endoscopes simultaneously passed retrograde via the gastrostomy and antegrade through the oropharynx) thoracoscopic esophagectomy and primary anastomosis management of the stricture. Methods: In the left lateral decubitus position, four 5-mm ports were placed in the right chest in the fifth intercostal space, anterior-axillary line; sixth intercostal space, midaxillary line; fourth intercostal space, midaxillary line; and seventh intercostal space, posterior axillary line. A 5-mm 30° Storz® telescope and 4.9-mm and 9.6-mm Olympus® endoscopes were used. The area of esophageal stricture was identified using the endoscopes and thoracoscopically dissected circumferentially. The vagus nerves were identified and circumferentially freed from the strictured esophageal segment. Primary resection and anastomosis was performed using intracorporeal sutures and then tested for leak using the endoscope via the gastrostomy site. Results: Esophagram on postoperative day (POD) 7 revealed no leak and a widely patent anastomosis. He was discharged home on a soft diet on POD 8 and continues to feed orally over 1 year following his operation. Conclusion: As demonstrated by our video, endoscopy is a useful adjunct in the performance of a thoracoscopic esophagectomy for short esophageal stricture. It is particularly helpful because it provides direct visualization of the compromised lumen and allows for a more precise resection. © 2009 Springer Science+Business Media, LLC

Spatiotemporal normalized ratio methodology to evaluate the impact of field-scale variable rate application

Project Co-ordinators: Dr. Jose Alfonso Gómez Calero (Instituto de Agricultura Sostenible (IAS-CISC), Dr. Weifeng Xu (Fujian Agriculture and Forest University, FAFU). -- Trabajo desarrollado bajo la financiación del proyecto “Soil Hydrology research platform underpinning innovation to manage water scarcity in European and Chinese cropping Systems” (773903), coordinado por José Alfonso Gómez Calero, investigador del Instituto de Agricultura Sostenible (IAS).Wide assimilation of precision agriculture among farmers is currently dependent on the ability to demonstrate its efficiency at the field-scale. Yet, most experiments that compare variable-rate vs uniform application (VRA and UA) are performed in strips, concentrated in a small portion of the field with limited extrapolation to the field scale. A spatiotemporal normalized ratio (STNR) methodology is proposed to evaluate the impact of VRA compared with UA for on-farm trials at the field scale. It incorporates a base year in which the whole plot is managed with UA and consecutive years in which half of the plot is managed with UA and the other half is managed with VRA. Additionally, a novel normalized relative comparison index (NRCI) is presented where the ratios of VRA/UA sub-plots are compared between a base year and a consecutive year, for any measured parameter. The NRCI determines the impact of VRA on variability using statistical measures of dispersion (variability measures) and on performance with statistical measures of central tendency (performance measures). Variability measures with NRCI values lower or higher than 1 indicate VRA management decreased or increased variability. Performance measures with NRCI lower or higher than 1 indicate subplot impairment or improvement, respectively due to VRA management. The methodology was demonstrated on a commercial drip irrigated peach orchard and a wine grape vineyard. NRCI results showed that VRA drip irrigation reduced water status in-field variability but did not necessarily increase yield. The benefits and limitations of the proposed design are discussed.This research is a part of The “Eugene Kendel” Project for Development of Precision Drip Irrigation funded via the Ministry of Agriculture and Rural Development in Israel (Grant No. 20–12-0030). The project has also received funding from the European Union’s Horizon 2020 research and innovation programme under Project SHui, Grant Agreement No. 773903.Peer reviewe