The single surgeon learning curve of laparoscopic liver resection : a continuous evolving process through stepwise difficulties

The aim of the study was to evaluate the single-surgeon learning curve (SSLC) in laparoscopic liver surgery over an 11-year period with risk-adjusted (RA) cumulative sum control chart analysis.Laparoscopic liver resection (LLR) is a challenging and highly demanding procedure. No specific data are available for defining the feasibility and reproducibility of the SSLC regarding a consistent and consecutive caseload volume over a specified time period.A total of 319 LLR performed by a single surgeon between June 2003 and May 2014 were retrospectively analyzed. A difficulty scale (DS) ranging from 1 to 10 was created to rate the technical difficulty of each LLR. The risk-adjusted cumulative sum control chart (RA-CUSUM) analysis evaluated conversion rate (CR), operative time (OT) and blood loss (BL). Perioperative morbidity and mortality were also analyzed.The RA-CUSUM analysis of the DS identified 3 different periods: P1 (n = 91 cases), with a mean DS of 3.8; P2 (cases 92-159), with a mean DS of 5.3; and P3 (cases 160-319), with a mean DS of 4.7. P2 presented the highest conversion and morbidity rates with a longer OT, whereas P3 showed the best results (P<0.001). Fifty cases were needed to achieve a significant decrease in BL. The overall morbidity rate was 13.8%; no perioperative mortality was observed.According to our analysis, at least 160 cases (P3) are needed to complete the SSLC performing safely different types of LLR. A minimum of 50 cases can provide a significant decrease in BL. Based on these findings, a longer learning curve should be anticipated to broaden the indications for LLR

Viagens e Viajantes Portugueses na Ásia Central (séculos XVI-XVII)

A história das viagens terrestres portuguesas pela Ásia Central era, e continua a ser, esparsa, quer como elemento no processo da Expansão Portuguesa, quer como objeto específico de análise historiográfica. Para os indivíduos do Estado da Índia, a posição longínqua e interior da Ásia Central tornava-a incompatível com a natureza predominantemente marítima da Ásia portuguesa, fazendo da perspetiva de uma atividade ativa e duradoura uma impossibilidade geoestratégica. Consequentemente, houve um impacto diminuto da presença portuguesa naquela região, constituindo as viagens terrestres pelo interior asiático um episódio que recebe pouco mais que uma breve menção por parte da maioria dos historiadores. Contudo, a história das viagens portuguesas pelas Rotas da Seda terrestres e a historiografia que tem vindo a relatar e analisar tais iniciativas, revelam um rico potencial de informações interessantes para compreendermos inúmeros aspetos relativos à Ásia Central na época moderna e à Expansão Portuguesa. Por isso, a viagem terrestre transformou-se num nicho em ambos os tempos, passado e presente. Na época moderna, indivíduos oriundos da Ásia portuguesa demonstraram interesses e investiram esforços em espaços como a Pérsia Safávida, a Transoxiana e o Tibete. Tais interesses manifestaram-se sob a forma de viagens de procura de caminhos alternativos e de lendas com origem na medievalidade, bem como no estabelecimento de missões católicas na Pérsia e no Tibete. Desde a década de 1990, que se tem vindo a desenvolver uma historiografia sobre os viajantes, as viagens e as suas dinâmicas. O maior obstáculo para o desenvolvimento da área é a sua falta de visibilidade na academia, exacerbada pela ausência de uma história geral que aglomere diferentes tempos, espaços, viagens e viajantes, contrariando a tendência em especificar um só viajante ou grupo de viajantes que percorreram os mesmos caminhos. Este trabalho faz uma análise global da história da presença e atuação portuguesa na Ásia Central, incidindo sobre viagens realizadas pela Pérsia Safávida até o Reino de Portugal, sobre as viagens pelo Tibete e seus arredores, numa tentativa de busca pelo Cataio, e sobre as viagens dos jesuítas portugueses, inseridos na corte Qing, à Tartária.The history of Portuguese overland travel in Central Asia was, and to some extent still is, sparse, both as an element in the process of Portuguese Expansion and as a specific object of historiographical analysis. For the individuals from the State of India, the distant and inland position of Central Asia made it incompatible with the predominantly maritime nature of Portuguese Asia, turning the prospect of active and sustained activity into a geostrategic impossibility. Consequently, there was little impact on the Portuguese presence in that region, and overland voyages through the Asian interior are an episode that receives little more than brief mention by most historians. However, the history of Portuguese voyages along the terrestrial Silk Roads and the historiography that has been reporting and analyzing such initiatives, reveal a rich potential of interesting information to understand many aspects of Central Asia in modern times and the Portuguese Expansion. Therefore, overland travel has become a niche in both past and present times. In modern times, individuals from Portuguese Asia showed interest and invested efforts in spaces such as Safavid Persia, Transoxiana and Tibet. These interests manifested themselves in the form of journeys in search of alternative routes and legends originating in the Middle Ages, as well as in the establishment of Catholic missions in Persia and Tibet. Since the 1990s, a historiography on travelers, journeys and their dynamics has been developing. The biggest obstacle to the advancement of the area is its lack of visibility in academia, exacerbated by the absence of a general history that brings together different times, spaces, journeys and travelers, contrary to the tendency to specify a single traveler or group of travelers who journeyed through the same paths. This work makes a global analysis of the history of the Portuguese presence and action in Central Asia, focusing on the voyages made from Safavid Persia to the Kingdom of Portugal, on the voyages through Tibet and its surroundings, in an attempt to search for Cathay, and on the voyages of the Portuguese Jesuits, in the Qing court, to Tartary

The patient satisfaction in primary care consultation—Questionnaire (PiC): an instrument to assess the impact of patient-centred communication on patient satisfaction

BACKGROUND: Primary care consultation is significantly influenced by communication between the General Practitioner (GP) and their patients. Hypothesising that patient satisfaction can be tested based on an expectation-experience comparison, the aim of this article is to discuss the influence of communication on patient satisfaction. METHODS: A standardised questionnaire was developed striving for a universal primary care survey tool that focuses on patient satisfaction in the context of patient-centred-communication. The sample consisted of 14 German GPs with 80 patients each (n = 1120). Due to the inclusion in an overarching cluster-randomised-study (CRT), the medical practices to be examined were divided into intervention and control groups. The intervention was developed as a reflective training on patient-centred communication. RESULTS: The results in the present sample show no correlation between patient-centred-communication and patient satisfaction. There are also no significant differences between the intervention and control group. DISCUSSION: The results raise the question to what extent patient satisfaction can be shaped significantly through patient-centred-communication. The presented project represents part of the basic research in general medical care research and contributes to the transparent processing of theoretical assumptions. With the results described here, communication models with a focus on patient centredness can be evaluated with regard to their practical relevance and transferability

Reasons for merging and collaborating in healthcare:Marriage or living apart together?

BackgroundAcross OECD countries, integration between healthcare organisations has become an indispensable part of contemporary healthcare provision. In recent years, inter-organisational collaboration has increasingly been encouraged in health and competition policy at the expense of mergers. Yet, understanding of whether healthcare organisations make an active choice between merging and collaborating is lacking. Hence, this study systematically examines (i) healthcare executives' motives for integration, (ii) their potential trade-offs between collaborating or merging, and (iii) the barriers to collaborating perceived by them.MethodsEarly 2019, an online questionnaire was conducted among a nationwide panel of 714 healthcare executives in the Netherlands. Because of their strategic position within healthcare organisations as end-responsible managers, healthcare executives are especially suited to provide broad and in-depth knowledge on the internal and external processes and decisions. Three hundred thirty-seven Dutch healthcare executives completed the questionnaire (response rate 47%). This study sample was representative of the largest healthcare sectors in the Netherlands. In total, 137 mergers and 235 inter-organisational collaborations were reported. Both closed questions and open-ended questions were systematically analysed.ResultsImproving or broadening healthcare provision is the foremost motive for mergers as well as inter-organisational collaborations. When considering both types, reducing governance complexity is one of the decisive reasons to opt for a merger, whereas aversion towards a full merger and lack of support base within the own organisation convinced healthcare executives to choose for a collaboration. When comparing specific healthcare sectors, the overlap in pursued motives and sub-motives indicates that inter-organisational collaborations and mergers are used for comparable objectives. Only a small minority of the responding executives switched between both types of integration. Institutional barriers, such as laws, regulations and financing regimes, appear to be the most restricting for healthcare executives to engage in inter-organisational collaborations.ConclusionsOur integral approach and systematic comparison across sectors could serve policymakers, regulators and healthcare providers in aligning organisational objectives and societal objectives in decision-making on collaborations and mergers. Future research is recommended to study multiple collaboration and merger cases qualitatively for a detailed examination of decision-making by healthcare executives, and develop an integral assessment framework for balancing collaborations and mergers based on their effects in the medium to long term

Competence-based curriculum development for general practice in Germany: a stepwise peer-based approach instead of reinventing the wheel

BACKGROUND: Improving postgraduate medical training is one important step to attract more medical students into general practice. Keeping pace with international developments moving to competence-based curricula for general practice training, the aim of this project was to develop and implement such a curriculum in Germany. METHODS: A five-step, peer-based method was used for the curriculum development process including panel testing and a “test version” of the curriculum for the pilot implementation phase. The CanMEDS framework served as a basis for a new German competence-based curriculum in general practice training. Four curricula from European countries and Canada were reviewed and, following required cultural adaptions, key strengths from these were integrated. For the CanMEDS “medical expertise” element of the curriculum, the WONCA ICPC-2 classification of patient’s “reason for encounters” was also integrated. RESULTS: Altogether, 37 participants were involved in the development process representing 12 different federal states in Germany, and including an expert advisor from Denmark. An official “test version” of the curriculum consisting of three parts: medical expertise, additional competencies and medical procedures was established. A system of self-assessment for trainees was integrated into the curriculum using a traffic light scale. Since March 2012, the curriculum has been made freely available online as a “test version”. In 2014, an evaluation is planned using feedback from users of the test model as a further stage of the implementation process. CONCLUSIONS: The first German competence-based curriculum for general practice training has been developed using a pragmatic peer controlled approach and implementation is being trialed with a “test version” of the curriculum. This model project and its peer-based methodology may support competence-based curriculum development for other medical specialties both inside and outside Germany

The "Seminartage Weiterbildung Allgemeinmedizin" (SemiWAM): development, implementation and evaluation of a five-year, competence-based postgraduate programme in Bavaria

Introduction: Starting in 2013, a five-year, competence-based postgraduate programme, the "Seminartage Weiterbildung Allgemeinmedizin" (SemiWAM®) for continuing education in general practice, was developed and offered in Bavaria. This evaluation reports on the experiences of SemiWAM® after a first cycle.Material and methods: Process reflection based on the cycle of Kern: In addition to qualitative findings, results of the evaluation forms (mean values with standard deviation) are presented. The evaluation form contained questions on organisational issues, content of presentation, didactic preparation of the supervisor, transfer to real life practice as well as demographic variables. All questions were voted on a six-point Likert scale from "1=very satisfied" to "6=very dissatisfied".Results: The reflection showed three crucial entry points: Choosing "reason for encounter" as a content precondition to ensure target audience needs, the close didactic supervision of supervisor, and the continuous growth of supervisor team with newly qualified GP. The evaluation results for the overall assessment (MW 1.11-1.60), the didactic concept (MW 1.30-1.87), as well as the transfer into daily life practice (MW 1.48-2.35) reflect the high quality of the SemiWAM®. Discussion: The SemiWAM® curriculum presented can be easily transferred to comparable structures in Germany that accompany specialty training, such as the competence centres for residency training in general practice. The process evaluation based on the core cycle also provides important support for the agile implementation of these or similar programmes.Einleitung: Beginnend im Jahr 2013 wurde in Bayern ein fünfjähriges, kompetenzbasiertes, weiterbildungsbegleitendes Seminarcurriclum, die "Seminartage Weiterbildung Allgemeinmedizin" (SemiWAM®) für die Weiterbildung in der Allgemeinmedizin entwickelt und angeboten. Mit diesem Evaluationsbericht werden die Erfahrungen der SemiWAM® nach einem ersten Durchlaufen berichtet.Material und Methoden: Prozessreflexion auf Basis des Kern-Zyklus: Neben qualitativen Befunden werden Ergebnisse der Evaluation der Teilnehmenden (Mittelwerte mit Standardabweichung) dargestellt. Der Evaluationsbogen enthielt Fragen, u.a. zur Bewertung der Organisation, Inhalten und Art der Präsentation der Referierenden, der didaktischen Aufbereitung, des Transfers in die Weiterbildungspraxis sowie demographische Variablen. Alle Fragen wurden auf einer sechststufigen Likertskala von "1=sehr zufrieden" bis "6=sehr unzufrieden" abgestimmt.Ergebnisse: In der Prozessreflexion zeigten sich drei Stellschrauben als zielführend: Die Ausrichtung der Inhalte an Beratungsanlässen nah am Bedarf der Zielgruppe, die enge didaktische Supervision von Referierendenteams und die stetige Erweiterung des Referierendenteams durch junge Fachärztinnen und Fachärzte für Allgemeinmedizin. Die Evaluationsergebnisse für die Gesamtbewertung (MW 1,11-1,60), die didaktische Konzeption und Aufbereitung (MW 1,30-1,87) sowie den Transfer in die Weiterbildungspraxis (MW 1,48-2,35) spiegeln die hohe Qualität der SemiWAM®. Diskussion: Das vorgestellte Curriculum der SemiWAM® lässt sich zwanglos auf vergleichbare weiterbildungsbegleitende Strukturen in Deutschland wie die Kompetenzzentren Weiterbildung Allgemeinmedizin übertragen. Die Prozessevaluation auf Basis des Kern-Zyklus gibt zudem wichtige Hilfestellung in der agilen Umsetzung dieser oder ähnlicher Programme

Does GPs' self-perception of their professional role correspond to their social self-image? - A qualitative study from Germany

Contains fulltext : 88851.pdf (publisher's version ) (Open Access)BACKGROUND: There is a decline in the relative numbers of general practitioners in Germany. Earlier research showed that the professional relationship between general practitioners and specialists is overshadowed by conflicts which could influence medical students not to choose a career in general practice. The aim of the study is to analyse potential discrepancies between general practitioners' self-perception of their professional role and their social self-image in relation to medical specialists and to identify potential barriers that might prevent medical students from becoming a general practitioner. METHODS: A qualitative study design consisting of 16 interviews with general practitioners was chosen. Data analysis was carried out using the qualitative content analysis by Philipp Mayring. RESULTS: There is a discrepancy between general practitioners' professional self-perception and how they perceive they are viewed by specialists. General practitioners communicate a positive self-perception of their professional role. While general practitioners think that specialists in outpatient care have a positive view on general practice, it is assessed to be negative by specialists working in hospitals and as medical teachers. CONCLUSION: The negatively influenced social self-image may originate particularly from "badmouthing" general practitioners at universities and in hospitals. "Badmouthing" demonstrates the importance of the consideration of psychological aspects in medical teachers and hospital specialists acting as role models. Negative comments should be considered as an important factor in influencing medical students and trainees' career choices. These aspects should be more integrated in future medical education curricula