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Objective: To evaluate whether the rate of surgical complications is higher during the first semester of the General Surgery residency in the largest hospital complex in Latin America. During this period, students are expected to have less experience in carrying out procedures., Methods: During a period of two years, all General Surgery resident doctors at the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo, made a notification of all the procedures they performed (n = 14.063), containing information such as name of the procedure, date, who participated, complications, among others. These data were analyzed with the purpose of evaluating the variation in the rate of complications throughout the year., Results: There was a 52 % increase in the rate of complications in the first academic semester when compared to the second semester. This phenomenon was observed in resident doctors in the first and second years of residency. Furthermore, it was observed that second-year residents remain with high rates of complications, in some procedures, for a longer time than first-year residents. Furthermore, the first three months (March, April and May) seem to have the highest complication rates of the entire year., Conclusion: The impact of these complications can affect several health services and the increase in surgical complications in the first half of the year must be monitored by institutions, in order to control this phenomenon., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

The review considers the approach placing famous French surgeon A. Paré into more general European context of European Renaissance of XVI century and into local context of intellectual life of Paris of this period. The refutation of widespread in history of medicine opinion about strict separation of university medicine from artisan surgery in Medieval Europe is discussed.

Background: While the number of women entering medicine has steadily increased since the 1970s in Canada, the gender composition along each stage of the medical training pathway has not been comprehensively reported. We therefore sought to systematically examine the gender composition of students, residents, and practicing physicians over the past 30 years in Canada., Results: In this cross-sectional analysis of Canadian medical trainees including MD applicants (137,096 male, 169,099 female), MD students (126,422 male, 152, 967 female), MD graduates (29,413 male, 34,173 female), residents by the decade (24,425 male, 28,506 female) and practicing surgeons (total 7,457 male, 3,457 female), we find that increased female representation in medicine is not matched by representation in surgery, with the key being the specialty choice process. The likelihood of female applicants matriculating to medical school was less than male applicants in the 90s (OR 0.92, 95% CI 0.92-0.93), greater in the early 2000s (OR 1.03, 95% CI 1.03-1.04), and has since balanced out (OR 1.00, 95% CI 1.00-1.01), with medical school classes being nearly 60% female for the past two decades. Despite this, females have remained underrepresented in most surgical residency programs, with odds of female medical students entering surgical residency other than Ob/Gyn being about half that of male students (OR 0.56, 95% CI 0.44-0.71), resulting in a slow increase in practicing female surgeons of less than 0.5% per year in many surgical disciplines and projected parity decades or centuries in the future., Conclusions: While undergraduate medical education has been majority female in Canada for nearly three decades, females remain greatly underrepresented in the physician workforce within surgical specialties. To build a representative medical workforce equipped to care for diverse patient populations, factors influencing the specialty choices of early career physicians will need to be examined and addressed., (© 2024. The Author(s).)

Despite increased attention devoted to diversity, equity, and inclusion (DEI) within academic medicine, representation, lack of workforce and leadership diversity, and bias within medicine remain persistent problems. The purpose of the current study was to understand the current efforts and attention to DEI within academic departments of surgery in the United States. 251 department of surgery websites were reviewed, using a standardized data collection form and scoring procedure, accompanied by a 10 percent fidelity check by an independent reviewer. Only 16% of departments of surgery included DEI-specific information, such as a DEI mission statement or initiatives on their departmental sites, with less than seven percent of departments reporting a DEI committee. Such public information may have implications for recruitment and retention of diverse faculty and trainees, downstream effects for patient care, and could be critical to public accountability to improve diversity and create a culture of equity and inclusion., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Core Surgical Training (CST) is a 2-year UK training programme, designed to provide junior doctors interested in surgery with formal training and to introduce them to various surgical specialties. The selection process is divided into two stages. In the portfolio stage, applicants submit a score based on a published self-assessment guidance. Only candidates whose scores remain higher than the cut-off after verification will proceed to the interview stage. Finally, jobs are allocated according to the overall performance of both stages. Despite the rising number of applicants, the number of job vacancies remains largely similar. Hence, the intensity of competition has increased over the past few years. The competitive ratio increased from 2.8:1 in 2019 to 4.6:1 in 2021. Hence, several changes have been implemented in the CST application process, with the aim to combat this trend. The recurring changes in the CST application process have sparked considerable discussions among applicants. The effect of the changes on the current and prospective applicants is yet to be explored. This letter aims to highlight the changes and discuss the potential impacts. The CST application from 2020 to 2022 has been compared to identify the changes implemented throughout the years. Specific changes have been highlighted. The impact of changes in the CST application process on applicants has been divided into 'pros' and 'cons' sections. Recently, many specialties have shifted from portfolio-based assessment to Multiple Specialty Recruitment Assessments. In contrast, CST application preserves its emphasis on holistic assessment and academic excellence. However, the application process could be further refined for more impartial recruitment. This would ultimately help alleviate the challenging situation of staff shortage, increase the number of specialist doctors, reduce waiting time for elective surgeries and most importantly, provide better care for our patients in the NHS., (© The Author(s) 2022. Published by Oxford University Press on behalf of Postgraduate Medical Journal. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Surgical palliative care, palliative care interventions, and palliative surgery all reference a blend of these 2 sub-specialty fields. Despite prior published definitions, use of these phrases both clinically and in the literature is varied and can lead to confusion and misunderstanding. Herein, we proposed the adoption of standardized nomenclature to guide the consistent use of these phrases.

In the second half of the nineteenth century, scientific and technological developments in surgery permitted safer procedures to be carried out. Theoretically, therefore, children whose lives would otherwise have been blighted by disease could be saved by timely operative interference. The reality was more complicated, however, as this article shows. Through an exploration of British and American surgical textbooks and an in-depth analysis of the child surgical patient base at one London general hospital, the tensions between the possibilities and the actualities of surgery on children can be examined for the first time. Hearing the child's voice through case notes allows both a restoration of these complex patients to the history of medicine and a questioning of the wider application of science and technology to working-class bodies, situations, and environments which resist such treatment., (© The Author(s) 2023. Published by Oxford University Press.)

Background: Surgery has deep historical roots. Rhazes (865-925 CE), a Persian physician, made a significant contribution to the development of medical sciences in the medieval era. Liber Almansoris is one of his significant works on medicine. This book is a medical textbook for medical students. It covers every aspect of the medical sciences. This article discusses Rhazes' contribution to surgery, based on Liber Almansoris ., Method: This study examines Rhazes' contribution to surgery, based on his book, Liber Almansoris ., Results: Rhazes's Liber Almansoris contains a chapter (seventh chapter) on orthopedics, which includes surgical approaches. This chapter also describes surgical procedures for traumas and skull fractures. In other chapters, he also recommends surgical options for treating certain complications when discussing different treatment methods., Discussion: Although Rhazes mentioned surgical procedures as a medical treatment method, he did not include a separate chapter on surgery. This strategy can be found in his other medical works, such as Liber Continens or Al-Hawi . It appears that Rhazes adheres to the Galenic (Greek) perspective on surgery. In this context, surgery is not an independent major but a method that a physician can employ as needed. It differs from an alternative approach in that era that adheres to ancient Persian perspectives, which identified surgery as a major like other medical sciences disciplines.

Historians and physicians have struggled to incorporate history into American medical education for over a century. Most efforts focus on local initiatives targeting a narrow audience. We describe a novel method involving the American College of Surgeons, a national organization with tens of thousands of members. Capitalizing on its infrastructure and influence over the field, we have implemented a variety of ventures that include panel sessions at meetings, poster competitions, travel grants, themed breakfasts, online communities, and other such projects. This programming has reached thousands of participants, ranging from pre-medical students to retired physicians, and it has increased both the exposure to and production of surgical history. Our article describes the process of establishing this nationally coordinated enterprise in the hopes that other medical specialties can emulate it and further the study of and appreciation for medical history., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Women remain underrepresented in Surgery in Aotearoa New Zealand (AoNZ). This study described interest in surgical careers by gender in the early postgraduate period and associated influencing factors., Methods: AoNZ medical graduates between 2012 and 2016 responding to an Exit Questionnaire (EQ) at graduation and 3 years later (PGY3) as part of the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) were included. Analyses of specialty preferences and influences by gender were performed., Results: Of 992 participants, 58% were women. At EQ, 158 participants (16%) had a surgical preference: 21% of men and 14% of women (P < 0.01). By PGY3, this was 20% of men and 10% of women (P < 0.01). A logistic regression found women were half as likely as men to have a surgical preference at PGY3. Those with a surgical preference at EQ were over 23 times more likely to have a surgical preference at PGY3, irrespective of gender. There were significant differences in self-reported career influencing factors between women and men at EQ and PGY3, as well as between PGY3 women with a surgical and those with a non-surgical preference. These included nature of the specialty, training requirements, lifestyle, family and personal factors., Conclusions: Increasing the proportion of women in Surgery requires a multifaceted approach starting during medical school and continuing through early postgraduate years. More needs to be done to make surgical experiences as an undergraduate and junior doctor appealing to women., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Deep learning (DL) is a subset of machine learning that is rapidly gaining traction in surgical fields. Its tremendous capacity for powerful data-driven problem-solving has generated computational breakthroughs in many realms, with the fields of medicine and surgery becoming increasingly prominent avenues. Through its multi-layer architecture of interconnected neural networks, DL enables feature extraction and pattern recognition of highly complex and large-volume data. Across various surgical specialties, DL is being applied to optimize both preoperative planning and intraoperative performance in new and innovative ways. Surgeons are now able to integrate deep learning tools into their practice to improve patient safety and outcomes. Through this review, we explore the applications of deep learning in surgery and related subspecialties with an aim to shed light on the practical utilization of this technology in the present and near future.

Historically, largely due to the good prognosis for survival, there has been little attention paid to the possible impact of meningiomas and their treatment on health-related quality of life (HRQoL). However, in the last decade there has been increasing evidence that patients with intracranial meningiomas suffer from long-term decreases in their HRQoL. Compared with controls and normative data, meningioma patients have worse HRQoL scores both before and after intervention and continuing long term (even after >4 years of follow-up). Overall, surgery results in improvements in many aspects of HRQoL. The limited available studies investigating the impact of radiotherapy suggest that this type of treatment decreases HRQoL scores, especially in the long term. There is however only limited evidence on additional determinants of HRQoL. Patients with anatomically complex skull base meningiomas and severe comorbidities, including epilepsy, report the lowest HRQoL scores. Other tumor and sociodemographic characteristics have shown weak associations with HRQoL. Furthermore, about one-third of caregivers of meningioma patients report caregiver burden, warranting interventions to improve caregiver HRQoL. As antitumor interventions may not improve HRQoL scores to be comparable to those of the general population, more attention should be paid to the development of integrative rehabilitation and supportive care programs for meningioma patients., (© 2023. Springer Nature Switzerland AG.)

The historiography of medicine has shifted from narratives of inevitable progress, authored mainly by the medical profession, to a more complex, analytical approach in which historians place medicine in its social context. However, the history of surgery has lagged behind somewhat; Christopher Lawrence suggests this is because the recent focus on the construction of medical knowledge does not incorporate the practical aspects of surgery, which are difficult to extract from their previous linear narrative. Thomas Schlich likewise recognises that surgery is both knowledge and skill-therefore more of a 'craft' than medicine. A possible solution is aligning the history of surgery with the history of technology: analysing the interplay of instruments and human activity.This case study uses the history of endoscopic endonasal pituitary surgery to explore the historiography of surgical innovation, in the context of its heavy reliance on both technology and interdisciplinary divisions of labour. Re-enactment, evolutionary frameworks and using Social Construction of Technology methods all require close collaboration between historian and surgeon to bridge the gap between scholarship and tacit knowledge., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Perceptions are important and can affect efficacy of trainer-trainee interactions. Inherent bias toward other specialties may influence the perceived benefit of a multi-specialty learning environment. The aim of this work was to determine surgical resident perceptions regarding the utility of learning from faculty and with learners from other surgical specialties., Design: We measured surgical residents' perceptions before and after a multi-specialty robotic simulation event. Pre- and post-activity surveys were administered electronically to all residents determining previous experience with robotic surgery, perceptions of learning from faculty in different surgical sub-specialties, and of learning from and with residents in other surgical specialties., Setting: Robotic simulation laboratory., Participants: General surgery (GS), Obstetrics and gynecology (OBG), and Urology (URO) residents in one academic healthcare program., Results: Prior to the simulation, OBG and URO residents perceived highest utility in learning from faculty within their own specialty. While OBG residents reported high pre-activity agreement that learning from other faculty was useful, more than 50% of GS and URO residents were neutral or disagreed that learning from OBG faculty was useful. Pre-activity, all specialties perceived highest value in learning from and about residents of their own specialty. Following the educational event, all specialties reported increased agreement that learning from faculty of different specialties had utility. Following the simulation, the cohort reported the multi-specialty learning environment improved their knowledge and confidence in robotic surgery., Conclusions: Participation in a multi-specialty educational event can improve perceptions of surgical residents regarding the utility of being taught by faculty in different specialties. Resident opinion of the benefits of learning with and about learners from other specialties can also be improved. Multi-specialty learning environments are important in developing communities of practice to allow socialization and promotion of positive identity development in our surgical residents, which may ultimately benefit efficacy of learning and patient care., Competing Interests: Disclosures The authors report no conflict of interest, (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about gender disparity in the surgery specialty in Lebanon., Aims: To assess the status of female surgeons and possible gender gaps in surgery specialty in Lebanon., Methods: The study was conducted in May 2021. Data were retrieved from the Lebanese Order of Physicians website, indicating the number of physicians in the different specialties, their gender, hospitals, and locations. The c2 test of homogeneity was used to establish whether the gender distribution was equal., Results: Women only accounted for 21.84% (3,370) of physicians in Lebanon, with surgery having the lowest number of female physicians in (n = 65; 2.30%). Women accounted for 1.63% of all surgeons in Lebanese hospitals, there were more female plastic and reconstructive surgeons (n = 12; 7.14%), while neurosurgery, oncological surgery and vascular surgery had no females. There was no significant difference in gender between academic and non-academic institutions (χ 2 = 2.164, P = 0.149), or between public and private hospitals (χ 2 = 1.277, P = 0.234)., Conclusion: The surgical specialty had the widest gender gap among all the medical fields in Lebanon. Therefore, the healthcare systems, including public and private hospitals, have a long and difficult road in narrowing the gender gap. Different strategies to incorporate women into surgery should be explored to assure equitable opportunities for all physicians, based on competency rather than gender., (Copyright © Authors 2022; licensee World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Background: Representation of specialist international medical graduates (SIMGs) in specific specialties such as surgery can be expected to grow as doctor shortages are predicted in the context of additional care provision for aging populations and limited local supply. Many national medical boards and colleges provide pathways for medical registration and fellowship of SIMGs that may include examinations and short-term training. There is currently very little understanding of how SIMGs are perceived by colleagues and whether their performance is perceived to be comparable to locally trained medical specialists. It is also not known how SIMGs perceive their own capabilities in comparison to local specialists. The aim of this study is to explore the relationships between colleague feedback and self-evaluation in the specialist area of surgery to identify possible methods for enhancing registration and follow-up training within the jurisdiction of Australia and New Zealand., Methods: Feedback from 1728 colleagues to 96 SIMG surgeons and 406 colleagues to 25 locally trained Fellow surgeons was collected, resulting in 2134 responses to 121 surgeons in total. Additionally, 98 SIMGs and 25 Fellows provided self-evaluation scores (123 in total). Questionnaire and data reliability were calculated before analysis of variance, principal component analysis and network analysis were performed to identify differences between colleague evaluations and self-evaluations by surgeon type., Results: Colleagues rated SIMGs and Fellows in the 'very good' to 'excellent' range. Fellows received a small but statistically significant higher average score than SIMGs, especially in areas dealing with medical skills and expertise. However, SIMGs received higher scores where there was motivation to demonstrate working well with colleagues. Colleagues rated SIMGs using one dimension and Fellows using three, which can be identified as clinical management skills, inter-personal communication skills and self-management skills. On self-evaluation, both SIMGs and Fellows gave themselves a significant lower average score than their colleagues, with SIMGs giving themselves a statistically significant higher score than Fellows., Conclusions: Colleagues rate SIMGs and Fellows highly. The results of this study indicate that SIMGs tend to self-assess more highly, but according to colleagues do not display the same level of differentiation between clinical management, inter-personal and self-management skills. Further research is required to confirm these provisional findings and possible reasons for lack of differentiation if this exists. Depending on the outcome, possible support mechanisms can be explored that may lead to increased comparable performance with locally trained graduates of Australia and New Zealand in these three dimensions., (© 2022. The Author(s).)

Mesh brachytherapy is a special type of a permanent brachytherapy implant: it uses low-energy radioactive seeds in an absorbable mesh that is sutured onto the tumor bed immediately after a surgical resection. This treatment offers low additional risk to the patient as the implant procedure is carried out as part of the tumor resection surgery. Mesh brachytherapy utilizes identification of the tumor bed through direct visual evaluation during surgery or medical imaging following surgery through radiographic imaging of radio-opaque markers within the sources located on the tumor bed. Thus, mesh brachytherapy is customizable for individual patients. Mesh brachytherapy is an intraoperative procedure involving mesh implantation and potentially real-time treatment planning while the patient is under general anesthesia. The procedure is multidisciplinary and requires the complex coordination of multiple medical specialties. The preimplant dosimetry calculation can be performed days beforehand or expediently in the operating room with the use of lookup tables. In this report, the guidelines of American Association of Physicists in Medicine (AAPM) are presented on the physics aspects of mesh brachytherapy. It describes the selection of radioactive sources, design and preparation of the mesh, preimplant treatment planning using a Task Group (TG) 43-based lookup table, and postimplant dosimetric evaluation using the TG-43 formalism or advanced algorithms. It introduces quality metrics for the mesh implant and presents an example of a risk analysis based on the AAPM TG-100 report. Recommendations include that the preimplant treatment plan be based upon the TG-43 dose calculation formalism with the point source approximation, and the postimplant dosimetric evaluation be performed by using either the TG-43 approach, or preferably the newer model-based algorithms (viz., TG-186 report) if available to account for effects of material heterogeneities. To comply with the written directive and regulations governing the medical use of radionuclides, this report recommends that the prescription and written directive be based upon the implanted source strength, not target-volume dose coverage. The dose delivered by mesh implants can vary and depends upon multiple factors, such as postsurgery recovery and distortions in the implant shape over time. For the sake of consistency necessary for outcome analysis, prescriptions based on the lookup table (with selection of the intended dose, depth, and treatment area) are recommended, but the use of more advanced techniques that can account for real situations, such as material heterogeneities, implant geometric perturbations, and changes in source orientations, is encouraged in the dosimetric evaluation. The clinical workflow, logistics, and precautions are also presented., (© 2021 American Association of Physicists in Medicine.)

Background: High anal fistula (HAF) treatment is more complicated than low anal fistula treatment. Improper treatment can easily affect anal function. The main treatment of HAF is surgery; however, external medicine and systemic medicine may also be used as adjuvant treatments. This study used bibliometric methods to analyze the relevant literature and provide a rough outline of the current status of HAF research., Methods: A subject word-search strategy was used to retrieve HAF-related documents from the Science Citation Index Expanded (SCI-E) database. CiteSpace software was used to analyze the exported raw data files, and draw a visual map, and BUSRT was used to detect and analyze the usage of keywords., Results: A total of 1,020 documents were retrieved using "high anal fistula" as the search term, and the number of documents generally shows an increasing trend over time. These papers were mainly published in developed countries, such as Europe and the United States (US). The US is the country that has carried out the most relevant cooperative research; however, there is a lack of cooperation among a large number of authors. The keyword analysis showed that the current research focus is the treatment of HAF, while research on the prevention of HAF is largely lacking., Conclusions: More international multi-center clinical research studies on HAF should be conducted, and research on HAF prevention should also be strengthened.

This review essay discusses the debates on infant male circumcision and on paediatric cochlear implants, two instances of surgical interventions done on small children without there being any pressing life-threatening indication. Reviewing these two issues together-something that has not previously been done, although there is a vast scholarly debate on both issues separately-helps frame the medical humanities and the current turn in the field towards abandoning the nature/culture and science/humanities divides. The debates on these procedures are fraught with a distinction between medicine and culture which constructs a certain kind of body as 'natural' and seeks to defend that body against 'cultural' interventions while welcoming supposedly acultural 'medical' interventions on other bodies. In the scholarship in medical humanities and medical ethics on these topics, this implicit nature/culture divide and view on medicine as separate from culture is also evident. My contention is that the medical humanities have important work to do here, in particular regarding a critique of the notion of the 'whole' or 'intact' body., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Gender inequality within the medical field continues to be a prominent issue, particularly for surgical specialties. The purpose of this systematic review was to evaluate the factors that influence female medical students' decision to pursue a career in surgery, including general surgery and surgical subspecialties., Methods: A literature search was conducted by 2 independent researchers searching PubMed, Embase, Medline, Web of Science, and Science Direct databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included "female," "medical students," "surgery," "gender," "career," "surgical subspecialty," "plastic surgery," "otolaryngology," "neurosurgery," "orthopedics," and "urology." Studies evaluating factors that influenced female medical students' decision to pursuing surgical specialties were identified., Results: The initial search identified 2200 articles. Five hundred twenty-seven duplicates were removed, and 1993 studies were eliminated based on inclusion and exclusion criteria. Sixty-one articles underwent full-text review. Twenty-six additional studies were identified from references. A total of 14 articles were included in the review. Female medical students were positively influenced by mentorship, intellectual challenge, the rewarding nature of surgery, and specialty exposure. Gender discrimination, surgical lifestyle, and societal and cultural barriers were deterrents for female medical students. Compared to male, females minimized the importance of prestige and expected financial rewards., Conclusions: This systematic review identifies mentorship, specialty exposure, nature of the surgical field, gender discrimination, and personal factors to be major determinants in female medical students' decisions to pursue a career in surgery. While factors such as inherent interest in surgery may not be easily modified, improvements in gender discrimination, access to mentorship, and specialty exposure can attract more female trainees to surgical specialties. Specifically, improving parental leave policies, reducing pregnancy-related stigma, eliminating gender-discrimination, matching medical students with role models early, and implementing outreach programs designed for women may increase students' interest in a surgical career., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study aims to identify factors influencing female medical students' decision-making about specialties, specifically surgery and interventional radiology (IR), in an effort to inform future recruitment and professional development strategies., Design: An electronic survey was created to assess both qualitative and quantitative data., Setting: The survey was sent prior to a symposium for trainees interested in pursuing IR or surgery, held at University of Chicago (Chicago, IL) in February 2019., Participants: The 90 female trainees who registered were sent the survey, and 48 (53%) responded voluntarily., Results: All respondents were female, 46% planned to pursue surgery or IR. Students pursuing surgery/IR were less concerned about being valued by their colleagues (p = 0.0073), being in charge of patients' lives (p = 0.0017), radiation exposure (p = 0.0171), chemical exposure (p = 0.0223), emotional stress (p = 0.0244), or shift work (p = 0.0045), compared to the nonsurgery/IR students. No differences were found in ranking of motivating factors, personal strengths or weaknesses, deciding factors, areas for seeking mentorship, or gender diversity. Top motivations among all respondents were intellectual rigor of medicine and becoming a mentor, while concerns were personal physical health, managing a career, pay equity, and gender-based biases. Students most often sought mentors and clerkship experience for making specialty decisions. They reported greatest strengths in empathy and resilience, and weaknesses in negotiating and public speaking., Conclusions: Female medical students planning to pursue surgery/IR expressed greater confidence in their contributions to patient care and lower concerns about workplace hazards. Regardless of specialty intent, female students shared scholarship motivations for a career in medicine, valued the role of mentorship, and expressed persistent concerns about gender discrimination, personal health, and skills-based weaknesses. Identifying factors influential in career decision-making is important in order to recruit and retain a more gender-diverse physician workforce., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Dose titration with immediate-release opioids is currently recommended for acute pain. The Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine released a statement in March 2018 supporting their use in the treatment of opioid-naïve patients; however, the impact of this statement on clinical practice is currently unknown. This retrospective cohort study was conducted to compare opioid prescribing patterns before and after the release of the recommendations. Data were collected on 184 patients (2017, n  = 78; 2018, n  = 106) admitted to the Prince of Wales Hospital in November 2017 and 2018, which consisted of demographic data, opioid prescriptions and discharge opioid information. The main outcome is the number of prescriptions of slow-release opioids in 2017 versus 2018 after the recommendations were published. Confounding factors were accounted for using logistic and multiple regression as appropriate. There was a 29% decrease in slow-release opioid prescriptions during hospitalisation ( n  = 31, 40% versus n  = 12, 11%; P  < 0.001) and 17% decrease at discharge ( n  = 20, 26% versus n  = 9, 9%; P  = 0.02) post-publication. After adjusting for confounders, the odds of slow-release opioids being prescribed postoperatively and at discharge reduced by 86% and 88%, respectively (postoperative period: odds ratio 0.14, P  < 0.05; discharge: odds ratio 0.12, P  < 0.05). In addition, orthopaedic patients were more likely to receive slow-release opioids, consistent with existing literature. As the use of slow-release opioids has been associated with increased harm and protracted opioid use compared to immediate-release opioids, it is hoped that wider dissemination of these recommendations and a change in prescribing practice can be a step towards overcoming the opioid crisis.

Purpose: To summarize the available information from mythology, archeology, and classical literature aiming to compose the image of Asclepieia, Asclepius, and the Asclepiads, and to depict the atmosphere of medicine in its infancy., Method: A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the pharmacies and pain practices used for trauma in ancient Greece., Results: The antiquity of medicine is confirmed by the worship of God Apollo and Asclepius, who were the persons who possessed the knowledge of medicine and surgery, and delivered it to mortals. The available archaeological data, stone offerings, and inscriptions from Asclepieia were the first testimonies of divine and human knowledge and provide insights on individual cases of patients cured by the Asclepiads. Sparse descriptions offer a first glimpse of the methods and means used by the first priests-physicians for wound healing and diseases treatment., Conclusion: Asclepieia established the roots of medicine and the first step of human knowledge, and contributed to the field of surgery and pharmacology that gave birth to the rational medicine. With Hippocrates and his research, the circle of Asclepieia ended, and the era of the organized medical schools with theories and experiments on every aspect of medicine begun.

Introduction: Choosing a medical specialty is a complex decision comprised of a combination of intrinsic and extrinsic factors that can include economic status, personal interest, input from mentors, and personality traits. The fictional world of Harry Potter, a generational literary phenomenon, describes 4 distinct houses in the wizarding Hogwarts school; each valuing particular traits of mortality that correspond with personality types. As such, we hypothesized that with each medical specialty often attracting particular personalities, the percentage of residents who self-sorted into the different Hogwarts' houses would vary depending on their chosen specialty., Methods: A web survey was sent out nationwide to surgical coordinators and residents, collecting demographic information and responses regarding specialty type and Hogwarts' house self-sorting., Results: The survey was completed by 251 residents (49.4% from surgical specialties) with a 12.6% response rate of surgical coordinator dissemination and a 43.1% resident response rate at Carolinas Medical Center. Surgical specialties were found to have significantly fewer self-sorted Hufflepuffs (p = 0.002) and more Slytherins (p = 0.0061) than nonsurgical specialties. General surgery had significantly more Gryffindors (p = 0.04) and fewer Hufflepuffs (p = 0.0017) whereas orthopedic surgery had significantly more Slytherins (p = 0.0282). Pediatrics had significantly fewer Gryffindors (p = 0.0096) and more Hufflepuffs (p = 0.0006). Obstetrics and gynecology had significantly fewer Gryffindors (p = 0.0082) and the highest percentage of Ravenclaws when compared to all other specialties (35.3% vs 19.9%; p = 0.1344). Family medicine had no self-proclaimed Slytherins., Conclusions: The discrepancies between specialties in the ratios of residents per Hogwarts house highlights that certain attributes may be more essential, advantageous, or complementary to a specific specialty. This information may guide medical students in choosing a satisfying and successful career path., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The OSCE is regarded as the gold standard of competence assessment in many healthcare programs, however, there are numerous internal and external sources of variation contributing to checklist marks. There is concern amongst organisers that candidates may be unfairly disadvantaged if they follow an "excellent" preceding candidate. This study assessed if average checklist scores differed depending on who a candidate follows accounted for different sources of variation. Design/methodology/approach: This study examined assessment data from final year MBChB OSCEs at the University of Aberdeen and categorised candidates into three levels dependent on examiner awarded global scores of preceding candidates for each station. Data were modelled using a linear mixed model incorporating fixed and random effects. Findings: A total of 349 candidates sat the OSCEs. The predicted mean (95% CI) score for students following an "excellent" candidate was 21.6 (20.6, 22.6), followed "others" was 21.5 (20.5, 22.4) and followed an "unsatisfactory" student was 22.2 (21.1, 23.3). When accounted for individual, examiner and station levels variabilities, students following an "excellent" candidate did not have different mean scores compared to those who followed "other" (p = 0.829) or "unsatisfactory" candidates (p = 0.162), however, students who followed an "unsatisfactory" student scored slightly higher on average compared to those who followed "other" (p = 0.038). Originality/value: There was weak evidence that candidate's checklist variations could be attributed to who they followed, particularly those following unsatisfactory students; the difference in predicted mean scores may be of little practical relevance. Further studies with multiple centres may be warranted assuring perceived fairness of the OSCE to candidates and educators.

Clinical supervisors play key roles in facilitating trainee learning. Yet combining that role with patient care complicates both roles. So, we need to know how both roles can effectively co-occur. When facilitating their trainees' learning through practice, supervisors draw on their skills - clinical and supervisory - and available opportunities in their practice. This process can be conceptualised as supervisory knowing in practice (or contextual knowing) and offers ways to elaborate on how facilitating trainees' learning can be optimised. The practice-based study presented and discussed here examined clinical supervisors' knowing in practice related to facilitating trainee learning, across three medical specialities. Nineteen clinical supervisors from emergency medicine, internal medicine and surgery, were interviewed about their roles and engagement with trainees. Interview transcripts were analysed in two stages. Firstly, a framework analysis, informed by interdependent learning theory was conducted, focussing on affordances and individual engagement. Secondly, drawing on practice theory, a further layer of analysis was undertaken interrogating supervisors' knowing in practice. We identified two common domains of supervisor practice used to facilitate trainee learning: (1) orientating and assessing trainees' readiness (or capabilities), (2) sequencing and enriching pedagogic practices. Yet across the speciality groups the supervisors' knowing in practice differed and were shaped by a trio of: (i) disciplinary practices, (ii) situational requirements and (iii) clinician preference. Overall, we offer a new reading of clinical supervision as practice differences generated distinct supervisory knowing in practice. These findings emphasise clinical supervision as fundamentally entwined in the speciality's practice; and reinforce alignments with patient care.

The existing performance evaluation methods in robot-assisted surgery (RAS) are mainly subjective, costly, and affected by shortcomings such as the inconsistency of results and dependency on the raters' opinions. The aim of this study was to develop models for an objective evaluation of performance and rate of learning RAS skills while practicing surgical simulator tasks. The electroencephalogram (EEG) and eye-tracking data were recorded from 26 subjects while performing Tubes, Suture Sponge, and Dots and Needles tasks. Performance scores were generated by the simulator program. The functional brain networks were extracted using EEG data and coherence analysis. Then these networks, along with community detection analysis, facilitated the extraction of average search information and average temporal flexibility features at 21 Brodmann areas (BA) and four band frequencies. Twelve eye-tracking features were extracted and used to develop linear random intercept models for performance evaluation and multivariate linear regression models for the evaluation of the learning rate. Results showed that subject-wise standardization of features improved the R[superscript 2] of the models. Average pupil diameter and rate of saccade were associated with performance in the Tubes task (multivariate analysis; p-value = 0.01 and p-value = 0.04, respectively). Entropy of pupil diameter was associated with performance in Dots and Needles task (multivariate analysis; p-value = 0.01). Average temporal flexibility and search information in several BAs and band frequencies were associated with performance and rate of learning. The models may be used to objectify performance and learning rate evaluation in RAS once validated with a broader sample size and tasks.

Heath advocacy (HA) remains a difficult competency to train and assess, in part because practicing physicians and learners carry uncertainty about what HA means and we are missing patients' perspectives about the role HA plays in their care. Visual methods are useful tools for exploring nebulous topics in health professions education; using these participatory approaches with physicians and patients might counteract the identified training challenges around HA and more importantly, remedy the exclusion of patient perspectives. In this paper we share the verbal and visual reflections of patients and physicians regarding their conceptualizations of, and engagement in 'everyday' advocacy. In doing so, we reveal some of HA's hidden dimensions and what their images uncovered about the role of advocacy in patient care. Constructivist grounded theory guided data collection and analysis. Data was collected through semi-structured interviews and photo-elicitation, a visual research method that uses participant generated photographs to elicit participants knowledge and experiences around a particular topic. We invited patients living with chronic health conditions (n = 10) and physicians from diverse medical and surgical specialties (n = 14) to self-select photographs representing their experiences navigating HA in their personal and professional lives. Both groups found taking photographs useful for revealing the nuanced and circumstantial factors that either enabled or challenged their engagement in HA. While patients' photos highlighted their embodiment of HA, physicians' photos depicted HA as something quite elusive or as a complicated and daunting task. Photo-elicitation was a powerful tool in eliciting a diversity of perspectives that exist around the HA role and the work advocates perform; training programs might consider using visuals to augment teaching for this challenging competency.

Objective: Clinical management issues are contributory factors to mortality. The aim of this study was to use data from the Victorian Audit of Surgical Mortality (VASM), an educational peer-review process for surgeons, to discover differences in the incidence of these issues between surgical specialties in order to focus attention to areas of care that might be improved., Design: This study used retrospectively analysed observational data from VASM. Clinical management issues between eight specialties were assessed using χ(2) analysis., Data Sources: VASM data were reported by participating public and private health services, the Coroner and self-reporting surgeons across Victoria., Results: A total of 2946 specific clinical issues as deficiencies of care were reported. 15% of cases had significant issues of care. The most common clinical management issue was the delay in delivery of treatment. Other clinical issues included the quality of communication and documentation, preoperative and postoperative care, adverse events and protocol issues. There were significant differences in issues between specialties., Conclusions: The clinical management issues presented across surgical specialties were similar; however, five issues of clinical care differed significantly in frequency across surgical specialties. The three main issues varying among specialties were complications after operation, communication and postoperative care. Addressing these clinical management issues via the peer-review process may impact positively on patient care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Medical students' motivation and study strategies are crucial in determining academic performance. This study aimed to assess the motivation and learning strategies of medical students as well as their association with performance in anatomy examinations. The Motivated Strategies for Learning Questionnaire, two focus group discussions, and students' current anatomy cumulative grade point average (cGPA) were used. Generally, the medical students strongly felt that anatomy is fundamental to the practice of medicine and surgery. This result was consistent with high task value scores of 5.99 ± 1.25. They were also driven by extrinsic goal orientation (5.59 ± 1.42) and intrinsic goal orientation (5.08 ± 1.26). Most medical students typically relied on elaboration (5.35 ± 1.25) ahead of other cognitive strategies namely rehearsal (5.30 ± 1.11), organization (5.15 ± 1.34), and lowest-rated critical thinking (4.77 ± 1.19). The students also relied on resource management strategies, effort regulation (5.15 ± 1.20) and time and study environment regulation (5.03 ± 1.03) more than the moderately scored peer learning (4.95 ± 1.50) and help-seeking (4.95 ± 1.09). In the focus group discussions, students reported that they often narrate or explain to each other what they would have read and understood from anatomy lectures, tutorials, and textbooks. They also bemoaned the lack of institutional support for stress burdens. The motivation and learning strategies subscales were not correlated with anatomy cGPA. Males were driven by extrinsic goals and experienced significantly higher levels of test anxiety than females (P < 0.05). Knowing the motivation and learning strategies students employ early in the medical curriculum can be leveraged to promote self-directed learning and academic achievement.

Background: Pupillometry has been studied as a physiological marker for quantifying cognitive load since the early 1960s. It has been established that small changes in pupillary size can provide an index of the cognitive load of an individual as he/she performs a mental task. The utility of pupillometry as a measure of expertise is less well established, although recent research in the fields of education, medicine and psychology indicates that differences in pupillary size during domain-specific tasks allows differentiation between experts and novices in appropriately designed experiments. Purpose: The goal of this review is to explore the existing body of evidence for the use of pupillometry as a measure of expertise and to identify its strengths and constraints within the context of expertise research in the medical sciences. Results: Pupillometry is a robust metric that allows researchers to better understand cognitive load in medical practitioners with varying levels of expertise. In medical expertise research, it has been used to study surgeons, anesthetists and emergency physicians. Its strengths include its ability to provide quantitative and objective outputs, to be measured unobtrusively with new technology and to be precisely computed as cognitive load changes over the course of completion of a task. Constraints associated with this methodology include its potential inaccuracy with changes in ambient light and pupillary accommodation as well as the need for relatively expensive equipment. Conclusion: With recent technological advances, pupillometry has become a simple and robust method for quantifying physiological changes attributable to cognitive load and is increasingly being utilized in medical education. It can be used as a reliable marker of cognitive load and has been shown to differentiate levels of expertise in medical practitioners.

Clinical skills and medical knowledge enable physicians to overcome the uncertainty of emergent and rare clinical scenarios. Recently, a growing emphasis on evidence-based medicine (EBM) has flooded medical curricula of universities across the globe with guideline-based material, and while it has given teachers and students new tools to improve medical education, clinical reasoning must be reaffirmed in its capacity to provide physicians with the ability to solve unexpected clinical scenarios. Anatomical education in medical school should have two main objectives: to acquire anatomical knowledge and to develop the skill of applying that knowledge in clinical scenarios. The authors present a clinical scenario in which an unexpected and rare complication occurred during a routine elective hip replacement surgery. The general surgeon presiding over the case, also an anatomy professor, solved the problem using clinical reasoning and anatomical knowledge. It was a clear example of how clinical reasoning is key in approaching unprecedented, rare, or unknown complications. The intention of this scenario is to remind colleagues and medical schools that, although EBM is the standard, educators must uphold sound clinical reasoning to best prepare health care providers for their careers.