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Powell, et. al. 2010

Created By: Carolina Jaime
http://degreedirectory.org/articles/Surgeon_Career_Definition_Employment_Outlook_and_Education_Requirements.html

Surgeon Career Definition,

Employment Outlook, and Education Requirements

Would you like to perform operations as a surgical doctor? Your efforts could relieve the suffering of patients, and potentially save lives. As a surgeon, you could specialize in areas such as orthopedic surgery, cardiovascular surgery or plastic surgery. If you'd like to know the career definition of a surgeon, as well as the employment outlook and education requirements for these professionals, read further. Schools offering Surgical Technology degrees can also be found in these popular choices.


What Is the Career Definition of a Surgeon?

As a surgeon, you are a medical doctor who uses sterile surgical instruments and invasive techniques to operate on anesthetized patients. In doing so, you can correct anomalies and treat injuries or diseases. You must collect and study information regarding a patient's medical background, perform physical examinations, and diagnose patients' medical conditions. When it has been established that an operation is needed, you must ensure your patients receive the necessary preoperative and postoperative care. Your work takes place primarily in operating rooms, hospital wards and in some clinics.

What Is the Employment Outlook?

[1]The U.S. Bureau of Labor Statistics (BLS) reported that surgical careers were expected to expand by 22% from 2008-2018, which was more rapid growth than average compared to other occupations (www.bls.gov). The job outlook for surgeons was favorable, especially in under-served low-income and rural communities. Prospects were also believed to be good for surgeons who specialized in radiology or cardiology.

Possible job growth was attributed to increases in health care businesses and in the numbers of elderly individuals who relied on quality health care. Job openings were expected due to many surgeons retiring during the decade. Surgeons who worked in medical and surgical hospitals earned average annual salaries of about $225,390 as of May 2010.


What Education Requirements Must I Fulfill?

Like all physicians, surgeons must hold a bachelor's degree in addition to a Medical Doctorate degree. As you begin working towards your goal of becoming a surgeon, enroll in an undergraduate premedical program, which includes courses in mathematics, biology, microbiology, health economics, chemistry and physics. Next, apply to medical schools that are approved by the Liaison Committee on Medical Education (LCME).

The medical school admissions process is very selective, so it will be necessary for you to have earned superior grades and have impressive Medical College Admission Test (MCAT) scores. You will also need letters of recommendation from your prior educational institution. Medical school will consist of classroom and laboratory instruction in the first two years. Your curriculum should include courses such as clinical anatomy, neurological science, biomedical informatics and infectious disease.

Your final two years of medical school might include classes such as ethics, clinical epidemiology, and clinical reasoning. Also included in your program will be internships or clerkships, where you'll have opportunities to provide direct care to patients while being supervised by medical doctors. When you have graduated from medical school, you'll begin a hospital residency where you can choose a medical specialty. In essence, residencies provide on-the-job paid training, and they can last between two and six years.

After completing your residency, apply to the American Osteopathic Association or the American Board of Medical Specialists to become certified in your specialty. Be aware that any aspiring surgeon who has successfully completed medical school must pass the Comprehensive Osteopathic Medical Licensing Examination or the United States Medical Licensing Examination to practice in all states.
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Anonymous, 2011

Created By: Carolina Jaime
http://www.forbes.com/top-colleges/list/

[1]Princeton University

At a Glance
Student Population: 7,813
Undergraduate Population: 5,203
Student to Faculty Ratioa: 6:01
Total Annual Costc: $53,934
In-State Tuitionc: $37,865
Out-of-State Tuitionc: $37,865
Percent on Financial Aidd: 60.0%
Percent Admittede: 8.0%
SAT Composite Rangef: 1410


Forbes Lists

#1 Overall
#1 in Private Colleges
#1 in Research Universities
 
 

Profile

Princeton University is a four-year, coeducational, private research university located in Princeton, New Jersey. It was established in 1746 and currently has 5,203 undergraduate students with an additional 2,610 graduate students. Of those who were immediately employed, 46% of the class of 2006 took jobs on Wall Street and four years later, only 36% did. In 1783, the Continental Congress met at Nassau Hall in Princeton, which served as the capital of the United States for approximately five months. Princeton University competes in Division I-AA athletics, and the school mascot is the Tiger. The current president of the university is Shirley M. Tilghman.Charles “Pete” Conrad ‘53 was the third person to walk on the moon and planted a Princeton Tiger flag there on November 19, 1969. Forbes editor-in-chief Steve Forbes graduated from Princeton in 1970. 



[2]University of California, Riverside 

At a Glance
Student Population: 20,900
Undergraduate Population: 18,522
Student to Faculty Ratioa: 19:01
Total Annual Costc: $53,213
In-State Tuitionc: $12,924
Out-of-State Tuitionc: $35,802
Percent on Financial Aidd: 86.0%
Percent Admittede: 76.0%
SAT Composite Rangef: 930


Forbes Lists

#296 Overall
#111 in Research Universities 


Profile

The University of California, Riverside is a four-year, coeducational, public research university located in Riverside, California. It was established in 1954 and currently has 18,522 undergraduate students with an additional 2,378 graduate students. The University of California, Riverside competes in NCAA Division I-AAA athletics and the school mascot is Scotty Highlander. The current chancellor of the university is Timothy P. White. The University of California, Riverside is home to the Eaton Collection – the largest publicly-accessible collection of science fiction and fantasy in the world. 




[3]University of Oregon

At a Glance
Student Population: 24,396
Undergraduate Population
: 20,623
Student to Faculty Ratioa: 24:01
Total Annual Costc: $40,916
In-State Tuitionc: $8,789
Out-of-State Tuitionc: $27,653
Percent on Financial Aidd: 72.0%
Percent Admittede: 79.0%
SAT Composite Rangef: 991 
 

#210 Overall
#84 in Research Universities
 
 
Profile

The University of Oregon is a four-year, coeducational, public research university located in Eugene, Oregon. It was established in 1872. Michael R. Gottfredson is the current president of the university. In order to open the university, local residents raised about $500,000 dollars through various efforts such as festivals and socials in order to build Deady Hall, the university’s first official building. Currently, the school has 20,623 undergraduate students with an additional 3,773 graduate students. The University of Oregon competes in NCAA Division I-A athletics and is home to 16 national team championships. Oregon was the only collegiate or professional team to have a duck as its mascot until 1993, when the Anaheim Mighty Ducks entered the National Hockey League. The movie Animal House was filmed on campus.


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Wenrich, et. al. 2002

Created By: Carolina Jaime
http://www.jpsmjournal.com/article/S0885-3924(02)00694-2/fulltext

Introduction

[1]As the medical community focuses on the need to improve the quality of care at the end of life,1, 2 it becomes increasingly important to identify those areas of care that are most important to dying patients and their families. Addressing patient and family perceptions of their needs may help to reverse the lack of progress to date implementing interventions effective in improving end-of-life care.3, 4 Although the emotional needs of the terminally ill patient have been part of the dialogue on improving end-of-life care, these needs have traditionally been approached by primarily addressing depression and anxiety.5, 6, 7 Yet the dying patient has emotional and personal needs other than anxiety and depression. Recent work has examined the issues that define “a good death” and high-quality care at the end of life from the perspectives of dying patients, their families, and health care professionals who work in end-of-life care.8, 9, 10, 11 Studies have highlighted the importance of providing emotional support to dying patients and attention to the “whole person,” rather than simply the disease processes.9, 10, 11

These studies set the stage to elucidate specific aspects of emotional support and attention to the “whole person” that are important to patients and their families and to give physicians direction in providing this support. Few studies have addressed exactly what dying patients' emotional needs are or how physicians may address these needs in the medical care setting. Further, because medical schools are not currently teaching students the affective skills necessary for addressing these needs,12 it is important to identify specific areas of emotional support that can be highlighted in the medical education arena.

[2]This article describes a study using focus groups to understand the important aspects of physician skills at providing end-of-life care. We conducted focus groups of patients with chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), or cancer, as well as family members and health-care providers. Two of the twelve domains of important physician skills at end-of-life care identified through this study were grouped, in the conceptual model, under “affective skills.” These two domains were emotional support and personalization.1 The current report addresses those domains identified as affective skills with the intent of elucidating how physicians can offer emotional support and personalized attention to dying patients.

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Methods

Study Design and Recruitment

Focus groups, a qualitative research method,13, 14 were used to examine physician skills at end-of-life care. Results from this study published previously describe a conceptual framework for understanding physician skills at providing end-of-life care;11 the specific components of communication about end-of-life care that are important to patients, families, and health care workers;15 physicians' interactions with health care teams and systems in the care of dying patients;16 and differences in the perspectives of patients by disease type concerning end-of-life care.17 The methods were described in detail previously.11 In brief, we identified individuals from four distinct categories: patients with a terminal diagnosis, family members who had a loved one die of a chronic illness, nurses and social workers with experience in end-of-life care, and physicians identified as experts at end-of-life care. Inclusion criteria for patients included C3 AIDS as defined by the Centers for Disease Control and Prevention,18 oxygen-dependent COPD, or metastatic cancer or non-operable lung cancer. Participants were recruited through purposive sampling designed to identify individuals with experience at end-of-life care. To recruit patients, flyers were posted and distributed in physicians' offices throughout Seattle, and researchers contacted leaders of AIDS, cancer, and COPD support groups in the area. The study was described to potential participants as a research project designed to develop questionnaires to evaluate how well doctors care for patients who have very serious illnesses that may be terminal. During focus groups, patients were told that investigators were interested in improving the care that doctors provide for patients with a serious illness and who are thinking about end-of-life issues. Although inclusion criteria defined these patients as terminally ill, patients were not specifically asked if they thought their illness was terminal.

The inclusion criterion for family members was having participated in or observed the medical care of a loved one who died 2–12 months previously from any chronic illness. Family members were recruited through grief support groups, flyers in clinics, and key informants in hospice programs. The inclusion criterion for health care workers (nurses and social workers) was working closely with dying patients in a health care setting. Health care workers were recruited through key informants in hospitals and hospice programs. To recruit physicians, nurses who participated in focus groups were asked to identify physicians who were outstanding at end-of-life care. Inclusion criteria for physicians included practicing a specialty in which end-of-life care for chronic conditions is commonly provided and being nominated by at least one nurse from a focus group. Specialties of physicians identified included primary care, infectious diseases, gerontology, pulmonary and critical care medicine, oncology, and neurology. The University of Washington Human Subjects Committee approved all procedures.

Focus Groups

Investigators developed a series of moderator guides for the different focus group categories, with similar structures and open-ended questions.11 (Moderator guides are available by request from investigators.) Patients, family members, and health care workers were asked to think about physicians who were especially skilled at end-of-life care and then describe what was good or helpful about their care and what aspects of care could have been improved. They were then asked to think about and describe care from physicians that was poor. Participants were also asked to describe what are the most important qualities that doctors should possess in order to deliver excellent end-of-life care.

A trained focus group facilitator (DMA) conducted the focus groups. All groups, except for physician groups, were 90 minutes in length; physician groups were 60 minutes. The facilitator also used scripted probes to continue discussion, refocus the participants on issues relevant to end-of-life care, and encourage all participants to share their views while discouraging anyone from monopolizing the discussion. Participants were paid US$ 30, and all groups were audiotaped and transcribed verbatim.

Twenty focus groups were held with a total of 137 participants between 29 October 1997 and 1 July 1998. Three groups were held with patients with COPD (n = 24), four groups were held with patients with AIDS (n = 36), and four groups were held with patients with cancer (n = 19). Among the four AIDS groups, one group consisted of Caucasian men, one of African-Americans, one of women of mixed ethnicities, and one of men and women of mixed ethnicities. Three focus groups were held with family members (n = 20). Four focus groups were held with health care workers (n = 27). Finally, two groups were held with physicians from both academic and community settings (n = 11).

Transcript Analyses

Transcripts were analyzed using principles of grounded theory.19, 20 The unit of analysis for text was an entire passage of speech from an individual until the speaker changed. Domains of physicians' skills at providing end-of-life care were identified using open coding. Specific components within each domain were then identified using selective coding. Investigators used previously published domains of quality end-of-life care to draft a preliminary framework for the domains.21, 22 We then used the transcripts to revise and modify this framework to reflect participants' views of physician skill at providing high quality end-of-life care.11 After the framework was developed, investigators coded all relevant passages of speech from the focus groups into the domains. We used a qualitative software program (ATLAS/ti) to identify all passages coded for each domain.

After all transcripts were coded, teams of investigators reviewed all passages within each domain to identify the major themes or “components” within each domain (selective coding). All investigators then met to review and agree on all the components and representative passages. To assess the reliability of domain coding, each investigator-pair reviewed and coded the same three transcripts using the methods described above. We compared coding across the three investigator-pairs and found 63% agreement across all three pairs and 89% agreement for two of the three pairs.

For the current study focusing specifically on the domains of emotional support and personalization, subsequent analyses were performed to determine the frequency with which each specific component of these two domains occurred in each focus group category. One investigator (MDW) reviewed the transcripts and coded all passages previously identified as falling within the domains representing emotional support and personalization into components. A research assistant independently reviewed and coded the same passages. Initial agreement between coders was found on 82% of codes for categories in personalization and 86% of codes for categories in emotional support. All discrepancies in coding were discussed and complete resolution was achieved.
Results

Demographic characteristics of focus group participants are shown in Table 1. From transcript analyses, 12 domains were identified related to physician competence at end-of-life care.11 These domains were: communication with patients, patient education, inclusion and recognition of family, medical competence, pain and symptom management, emotional support, personalization, attention to patient values, respect and humility, support of patient decision making, accessibility and continuity, and team coordination. Findings concerning the two domains emotional support and personalization are described below. The numbers of passages for components in each domain are shown in Table 2.

Table 1. Demographic Characteristics of Focus Group Participants

Table 2. Number of Passages of Focus Group Participant Speech in the Domains of Emotional Support and Personalization




Domain and Component

Patients with AIDs (n = 36)

Patients with Cancer (n = 19)

Patients with COPD (n = 24)

Family Members (n = 20)

Health Care Workers (n = 27)

Physicians (n = 11)

Total Count of Codes




Emotional Support





Compassion

21

34

23

23

23

4

128



Responsive to emotional needs

23

18

12

17

20

15

105



Maintains hope and a positive attitude

12

39

9

8

9

0

77



Provides comfort through touch

8

9

4

2

6

2

31



Total count of codes

64

100

48

50

58

21

341



Personalization




Treats the whole person, not just the disease

21

21

5

8

6

3

64



Makes the patient feel unique and special

18

15

3

6

3

2

47



Considers the person's social situation

1

4

2

4

14

2

27



Total count of codes

40

40

10

18

23

7

138


Emotional Support

[3]Among the 12 domains identified in this study, emotional support ranked second overall after communication in number of comments from all focus groups participants, and first among all three patient groups. Four components emerged as central to emotional support for patients: compassion, maintaining hope and a positive attitude, providing comfort through touch, and being responsive to patients' emotional needs. Each of these components and subcomponents is described below.
Compassion
The need for compassion from physicians received the largest number of comments from focus group participants and appeared to be the most basic and necessary form of emotional support. It was the component raised most frequently by patients with COPD, family members, and health care workers. Words that participants used frequently to describe compassion include warmth, caring, empathy, kindness, sensitivity, and sympathy. A family member described the elements of compassion:

They simply communicated their care. They came across warmer, they spent a little more time, they explained things more, their compassion came through, a sense of understanding, of caring.


Comments that showed a lack of compassion focused on poor bedside manner, acting cold, rude, inhuman, distant, and giving a sense of abandoning the patient. For example, a patient with cancer said:

I tried to explain to him why it was important to me that he was there, and I said to him, “When you think you're dying and it's like your doctor's the only thing that stands between you and death, it's kind of a bonding, it's very important.” He got really exasperated, he goes, “I know! I know!” But it's like distant, distant, distant.

Responsiveness to Emotional Needs
Responsiveness to emotional needs was the category raised second most frequently overall, including first among patients with AIDS and among physicians. Comments from focus group participants suggest responsiveness to emotional needs occurs at two levels. One focuses on being supportive, making the patient comfortable, and seeming concerned. This level of emotional support consists of acknowledging that what the patient is going through is significant, responding to issues raised by the patients, and/or actively addressing or eliciting the patient's emotional needs. A patient with cancer described the manner in which emotional support can be offered by asking one simple question beyond the usual:

My doctor says, “How are you feeling?” And I say, “Well, you've got the charts.” And he says, “No, how are you feeling?”


Some physicians responded poorly when patients raised their emotional needs and concerns. A patient with cancer said:

Only twice in my course of treatment did I ever express emotional issues. One time I said, “You know, I feel really frightened,” and he got really irritable and he goes, “Well, we're doing the best we can.” And you know? It wasn't meant as a criticism of him, but he did not know how to respond.


In a different focus group, a patient with COPD offered a simple tool for physicians to use in such instances:

If a patient says, “I'm frightened,” all they have to do is acknowledge what you're saying and maybe say something like, “Well, other patients feel that way, too.”


A second, less common level of responding to emotional needs was defined by exceptionally strong emotional support. In some cases, this involved participating in the patient's life. In other cases, it involved offering support within the context of the medical setting. One form was being willing to cry with the patient or family. A health care worker said, “He stayed with the family, and when she died, cried with them.” A patient with AIDS offered an example of an act of strong emotional support:

The doctor I had at the time knew that I was afraid of being in the hospital and doctors and all of that. He came to the hospital, and he climbed up on my bed with me and we sat there and we watched Oprah. And I felt so good that he took time out of his schedule and we sat there and chitchatted and he calmed me down.

Hope and a Positive Attitude
The need for physicians to maintain hope and a positive attitude was raised third most frequently among comments about emotional support. It was the most frequently raised emotional support topic by patients with cancer, with half of the comments in this category from patients with cancer. Key words used to describe this quality of emotional support include encouraging the patient, helping the patient to fight, smiling, and using humor. Especially for patients with cancer, offering hope and a positive attitude had several facets. A patient with cancer described the way the provision of hope encourages the patient to fight: “Even when you know they're sugar-coating and even when you know that they're trying to be a cheerleader, emotionally it still feels good.” Another patient with cancer described her reaction to a physician who offered palliation rather than hope:

He made the comment that he was going to make me comfortable several times. And I wanted to smack him! I did not want to be comfortable. I asked my oncologist if I could get a third, a different surgeon … unfortunately, it seems the second one was right, and there is nothing that they can really do at this point, but at least each time I see [my surgeon], we're exploring the possibility that there might be something…


A family member stated that it was possible for a physician to be both positive and realistic: “She … always seemed to leave a positive note. Even though something dreadful was happening, [she] remained optimistic, but not unrealistic.”

Emphasizing the negative was perceived as reducing the patient's will to fight, as described by a patient with cancer:

“They give you the negative and they scare the beejeezus out of you and then they expect you to go home and fight. I see people sitting in the [chemo] room and they look sad and so depressed and so defeated and I just want to say, “Wait! You don't have to listen to all this negativity.”

Provides Comfort through Touch
Another form of emotional support raised by focus group participants was providing comfort through touch. The largest number of comments was from patients with cancer and AIDS. A patient with AIDS described the benefit of touch:

What we started to do at the end of each appointment is to hug each other. And it kind of puts a closure to the situation … And I walk out of there feeling much better, even if I'm physically the same. Emotionally, I'm up there.


Others described the manner in which a simple touch could make a difference for the patient, as described by this patient with COPD:

Just as I was getting ready to leave, he just touched my shoulder. And there was something about that touch that I felt, “Gee, this is a caring person.”


Personalization

Among the 12 domains of physician skill providing end-of-life care identified in this study, personalization was eighth in the number of comments from focus group participants. Three components were identified within the domain: treats the whole person, not just the disease; makes the patient feel unique and special; and considers the patient's social situation when making treatment plans. Each of these components and subcomponents is described below.
Treats the Whole Person, Not Just the Disease
A basic need described by focus group participants was that physicians treat the whole person, not just the disease. This was the most frequently raised category of personalization among all focus group categories except health care workers, and manifested itself in several ways.

Being treated like a person and not a disease, case, or number involved making the patient aware that the physician knows who the patient is and is familiar with his/her medical history. A patient with COPD pointed out the manner in which being told that the physician was preparing for the visit personalized it:

It's like the doctors think of you as a person and not as a subject, not a file. One thing that impressed me a great deal. Dr. X is usually very punctual. His nurse was taking my vitals and she said, “Dr. X will be right in, he's reviewing your blood work.” … He was actually taking the time to go through my papers and educate himself before he saw me.


Negative comments focused on the dehumanization associated with not knowing the individual patient. A patient with cancer said: “They don't even see you. And if they do see you, half the time they don't even know your name.” A health care worker described observing a physician's interaction with a patient who felt dehumanized:

The doctor walked in and looked at the chart and she [the patient] grabbed the chart and said, “What is my name? Tell me—I've been coming to you for two years and [do you know] my name? My life is in your hands. The least you can do is know my name.”


A second facet of this component involved paying attention to the emotional and social aspects of the patient in addition to the physical. A patient with AIDS said:

The doctor [should] treat the entire patient and not the disease only, and that means dealing with the emotional baggage that goes along with having an illness and being sympathetic to how the person is responding to medication, how they are responding socially, and everything else.


A third way was looking at the patient's entire body rather than treating only the organ system associated with the physician's specialty. A patient with cancer said: “He wasn't willing to talk about the condition of my liver, he was only interested in talking about the 8 centimeters of my colon.”
Makes the Patient Feel Unique and Special
Making the patient feel unique and special involved focusing on the individual patient and his/her unique interests or personality. This category was raised second most frequently by all groups except health care workers. It appeared to operate at two levels. The basic level involved paying individual attention to and finding out about the patient in a way that personalizes the visit. A patient with COPD felt that even a simple question at each visit personalized the visit: “She always asks me, ‘How are your pets?’ That puts it more on a personal basis.” A patient with AIDS described feeling demoralized at not being treated as an individual with a unique background:

At that particular time, I was isolated from my family because of drugs. So here I was, and they never asked about my family.


A second level focused on an exceptional level of personalization. This involved the physician being a friend to the patient, showing an exceptional amount of consideration, sharing details of his/her own life, and/or knowing the patient's personal life well. A patient with AIDS said, “I always felt like I was his only patient. He made me feel extremely special.” For many patients, this level of personalization still displayed an element that kept the relationship a professional one rather than a personal one. A patient with AIDS said:

I like that he calls me at home, and I like that there's closeness, and I love him to death. I mean, he's a great guy, but I still call him Doctor So-and-So, because I need him as my doctor—I don't need another pal, you know? And I don't want to blur those lines.

Considers the Patient's Social Situation
Taking into consideration the patient's social situation in treatment decisions was raised most often by health care workers. One described a physician's skill at considering the patient's experience:

I've observed him over time weighing the person's experiences in the course of treatment, and what they're telling him when they come to the office, and what he's presenting in terms of options at that point, against those original statements about what's important, or who is important to this person.


Another health care worker described the lack of congruence seen between treatments and the patient's social situation:

The ability to realize what they're offering a patient in a technical way, how that's going to impact their life in a real way. You know, they have an 80-something-year-old guy who doesn't drive, whose wife doesn't drive, and you're saying, “Let's go for daily radiation for 5 weeks.” And what that means for him to get going, get out of the house.


Defining a Minimum Level of Emotional Support and Personalization

Table 3 shows a grouping of the components and subcomponents of emotional support and personalization in a hierarchy of skills, from basic skills to those that represent an extraordinary level of support. All the components represent skills or qualities that patients, families, health care workers, and physicians felt were important in the care of patients at or near the end-of-life. The three levels of skills, developed through ordering of transcript passages, suggest increasing personal involvement with the patient. Based on comments from the transcripts, the basic skills appear to represent a minimum level that provides sufficient personal support for patients near the end of life. Intermediate skills represent a more active involvement in providing emotional support or more individualized attention to the patient. The extraordinary skills entail an unusual act or approach on the part of some physicians. The two quotes below from health care workers are examples of the comments that support this hierarchy from basic to extraordinary. In the first quote, a health care worker describes the basic level of support:

I think the [good] physicians recognize that for them, it's just another patient in a long series, but for this family, this is something that they're going to remember for the rest of their lives. And these little kindnesses go a long way.
Table 3. Levels of Emotional Support and Personalization from Physicians Important to Dying Patients and Their Families


Emotional Support

Personalization


Basic

Compassion

Warm Caring Empathetic Kind Sympathetic

Treats whole person, not just disease

Treats me like a person, not a case or disease; Knows who I am/knows my medical history/body; Looks at my whole body, not just parts; Doesn't stick just to own specialty; Talks about the big picture



Intermediate

Supportive of emotional needs

Makes me comfortable; Sits with me to offer emotional support; Lets me cry

Gives individual attention/consideration

Asks about my family; Sees the human being; Seems interested in me as a unique individual


Hope and positive attitude

Encourages me; Helps me to fight; Uses humor; Smiles

Considers the patient's social situation when making treatment plans

Understands impact of treatment; Helps me manage my life



Extraordinary

Provides strong emotional support

Cries over me; Does something that feels exceptional

Takes a strong personal interest

Is my friend; Calls me at home; Knows details of my personal life; Shares his/her personal life


Provides comfort through touch

Hold my hand; Hugs; Offers a hand

a Key words or examples from transcripts.

In the second quote, a health care worker describes the extraordinary level of support:

Very few people could probably do this or be this way and that's okay, because it's above and beyond, but I had the privilege of working with a physician … [who] had a patient that had, as a result of the treatment, some skin problems, and there was a certain lotion that he desperately wanted this person to have. And we couldn't find it, it was not available within our own institution. He personally made a trip to a drugstore where he could find it, purchased it, brought it back the next morning for the patient. It's not required of everyone, but what a wonderful physician.


Back to Article Outline

Discussion

Prior studies have discussed and documented how to assess and manage depression and anxiety in the dying patient5, 6, 7 and the need to consider the dying patient's emotional needs.8, 9, 10, 11 Because physicians are key providers of medical care for patients at and after terminal diagnosis, it is important to elucidate exactly how physicians can support the emotional and personal well-being of patients who have received a terminal diagnosis and are undergoing medical care. There are no empiric investigations of the specific components of emotional support and personalization that patients and families find most helpful. We undertook a study to determine what domains and components of physician skills are most important at the end of life. This article focuses on the specific skills of the two domains most directly relevant to patients' emotional well-being: emotional support and personalization.

The fact that emotional support was the second most frequently discussed domain and first among all three patient groups highlights the importance of this area for physicians who work with dying patients. Our data suggest that emotional support can be provided at a number of different levels, from basic to extraordinary. The level of support offered can be individualized, depending on both provider and patient preferences. Some physicians may feel most comfortable offering only basic support to their patients. Other physicians may offer different levels of support for different patients. Just as the single question “Are you depressed?” provides a sensitive and specific assessment of depression among dying patients,23 our data highlight the extent to which some basic tools, such as asking one or two simple questions about the patient's experience or acknowledging a patient's fear, can provide important emotional support.

Many patients talked about the need to maintain hope and a positive attitude as a form of emotional support. There is a strong ethic that patients need to know the truth about their terminal illnesses; in fact, our work concerning communication confirms that patients say they want honest and straightforward information about their illness.15 On the other hand, hope improves emotional outlook. Lynn and colleagues have pointed out how patients may look at their disease realistically and yet still remain hopeful, and that hopeless people, on the other hand, have no desire to continue living.24 As noted by Christakis, physicians may be able to alleviate their fear of robbing patients of hope with a terminal prognosis by broadening their definition of hope.25

Comments concerning hope and a positive attitude were most prevalent in our study among patients with cancer. Cancer remains the disease for which the most research has been performed regarding hope as well as truth-telling. The disease is complex; because there are both curable and incurable cancers, it may be easy for patients with metastatic disease to believe that there is hope for cure of their own cancer.26 Patients with metastatic cancer are often offered, and often choose, to complete chemotherapy, even if the chances of symptom relief are small.27, 28 Besides the preference of patients for continued treatment, physicians may offer treatment because they may find it difficult to tell patients that they cannot effectively fight their cancer.26 These factors may influence the patient's approach to hope.

It is striking that, in addition to the prevalence of comments among patients with cancer, hope and a positive attitude was raised less often by family members and health care workers and was not raised at all by physicians. The number of physician comments concerning the need for compassion was also small in comparison with patients, family members, and health care workers. Our data suggest that physicians and other health care professionals should pay close attention to patients' need for hope, especially among patients with cancer. This is a complex area, however. Our data suggest that patients appreciate and look for hope in spite of, or perhaps sometimes because, it appears not to represent a full picture. It is important to ensure that patients do not use hope as denial, but rather understand the full import of their disease while still maintaining a positive outlook. Fighting a terminal illness and accepting the terminal nature of that illness are not mutually exclusive. Rather, for some patients, fighting may be important as a coping mechanism and a way of improving one's emotional outlook, so long as the likely course of illness has not been misrepresented or misunderstood. The comments of patients and family members also suggest that part of maintaining a hopeful attitude involves the provider being cheerful or positive, using humor, and smiling. While these may be difficult skills for physicians to achieve with patients whom they know are going to die, patients, families and health care professionals in this study attest to their importance.

Personalization, which is related to emotional support, was not a domain originally envisioned by investigators in our preliminary work reviewing the literature and talking with experts in end-of-life care.11 Rather, the domain emerged from the perspectives of individuals who are dying and those who care for them. Personalization describes the need for physicians to treat the whole person rather than the disease and to treat each patient as a unique individual. As Epstein pointed out, caring requires an interest in the patient as a person rather than as an abstraction of disease.29 This domain of medical care was raised as important by focus group participants in our study,11 as well as in a recent study of individuals cared for in the VA medical system.9, 10 Data presented in this report suggest that personalization, similar to emotional support, may take place at several levels, from being treated as a person rather than a case to receiving strong personal attention. The extent of personalization may be individualized, depending on physician and patient preferences. It appears, however, that a basic level of personalization is an important component of good quality care.

Our data illuminate specific aspects of emotional support and personalization in the medical care setting that are important to patients nearing the end of life. Although many of the physician skills identified in this study may also be important for high quality general medical care, they were identified by patients with terminal illness and their families and by health care workers in response to specific questions about high quality skill at providing end-of-life care. These data also highlight the extent to which offering a basic level of emotional support and personalization is important. Some physicians may fear that provision of emotional support may “open the floodgates” and complicate an already busy clinical schedule through the need for ad hoc psychotherapy. Comments from focus group participants suggest, in contrast, that patients receive and appreciate emotional support in the clinical setting through simple comments and gestures that demonstrate respect and compassion from their physician. When possible and appropriate, further individual attention in small but meaningful ways can stay with patients and families and appears to have a profound effect on their lives. Physicians must decide for themselves what level of support and personalization they are able to offer each individual patient; for some patients, the level of support may change over time. Physicians should, however, strive to achieve at least basic levels at all times with all patients. It is also important that physicians look for and attend to the psychological disorders commonly associated with dying, including depression and anxiety, that may call for specific treatment or referral.5, 7

This study has several limitations. All focus groups were held in one geographic region, and the racial and ethnic composition of the groups reflected the population in the Pacific Northwest. There may be geographic or cultural differences across the United States that are important to understanding physicians' skills in providing end-of-life care. Patients in this study had one of three diseases; differences may be found in patients with other diseases. The number of utterances does not necessarily equal the importance of a domain or component in focus groups, because a few participants could dominate the group. However, study methods were designed to avoid letting one or a few participants dominate discussions. Finally, because of the small number of participants, it was not possible to determine with any certainty differences within or across groups by participants' demographic characteristics.

[4]This study highlights the need for physicians who work with dying patients to address emotional needs and personalize care as much as possible. At a time when patient-centered care is frequently invoked as an ideal for health care, emotional support and personalization represent basic areas in which, one-on-one, physicians can achieve a genuinely patient-centered focus. Doing so appears to be of great importance to dying patients and their families, and may contribute to maximizing their well-being and satisfaction with care during a critical period in their lives. Further work is needed to determine how and to what extent emotional support and personalization in the medical care setting influence patient satisfaction and improve the dying experience.



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Katz, et. al. January 20, 2007

Created By: Carolina Jaime
http://jco.ascopubs.org/content/25/3/271.full?maxtoshow=&HITS=10&hits=50&RESULTFORMAT=1&title=surgeon&andorexacttitle=and&andorexacttitleabs=and&fulltext=surgeon&andorexactfulltext=and&searchid=1&FIRSTINDEX=100&sortspec=match&fdate=1/1/2005&resourcetype=HWCIT

Patterns and Correlates of Patient Referral to Surgeons for Treatment of Breast Cancer

Steven J. Katz,
Timothy P. Hofer,
Sarah Hawley,
Paula M. Lantz,
Nancy K. Janz,
Kendra Schwartz,
Lihua Liu,
Dennis Deapen and
Monica Morrow

+ Author Affiliations

From the Division of General Medicine, Department of Internal Medicine, Department of Health Management and Policy, Department of Health Behavior and Health Education, University of Michigan; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor; Department of Family Medicine and Karmanos Cancer Institute, Wayne State University, Detroit, MI; Department of Preventive Medicine, University of Southern California, Los Angeles, CA; and the Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA

Address reprint requests to Steven J. Katz, MD, MPH, Departments of Medicine and Health Management and Policy, University of Michigan, 300 N Ingalls; Suite 7E12, Box 0429, Ann Arbor, MI 48109-0429; e-mail: skatz@umich.edu




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Abstract


[1]Purpose Characteristics of surgeons and their hospitals have been associated with cancer treatments and outcomes. However, little is known about factors that are associated with referral pathways.


Methods We analyzed tumor registry and survey data from women with breast cancer diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries (n = 1,844; response rate, 77.4%) and their attending surgeons (n = 365; response rate 80.0%).


Results About half of the patients (54.3%) reported that they were referred to the surgeon by another provider or health plan; 20.3% reported that they selected the surgeon; and 21.9% reported that they both were referred and were involved in selecting the surgeon. Patients who selected the surgeon based on reputation were more likely to have received treatment from a high-volume surgeon (adjusted odds ratio [OR], 2.2; 95% CI, 1.5 to 3.4) and more likely to have been treated in an American College of Surgeons–approved cancer program or a National Cancer Institute (NCI) –designated cancer center (adjusted OR, 2.0; 95% CI, 1.3 to 3.1; adjusted OR, 3.4; 95% CI, 1.9 to 6.2, respectively). Patients who were referred to the surgeon were less likely to be treated in an NCI-designated cancer center (adjusted OR, 0.5; 95% CI, 0.3 to 0.9).


Conclusion Women with breast cancer who actively participate in the surgeon selection process are more likely to be treated by more experienced surgeons and in hospitals with cancer programs. Patients should be aware that provider or health plan–based referral may not connect them with the most experienced surgeon or comprehensive practice setting in their community.



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INTRODUCTION

Characteristics of surgeons and their institutions have been associated with processes and outcomes of cancer care.1 Surgeon procedure volume and subspecialty training have been associated with treatment patterns, morbidity, and mortality.2-6 Hospital procedure volume and cancer center designation have been associated with patterns of treatment and health outcomes.5,7,8 Relationships between clinician and hospital characteristics and patterns of treatment have been examined for women with breast cancer. Surgeon volume has been associated with patterns of local therapy such as definitive surgery, radiation after breast-conserving therapy, and breast reconstruction after mastectomy.9-15 Thus, breast cancer patients with similar clinical characteristics may receive different treatment depending on the type of surgeon who provides their care and the institution where they receive treatment.

These observations have motivated recommendations to concentrate the initial care of cancer to providers with the most experience.5 One strategy that has been evoked is to guide patients to surgeons and centers with the best quality record.7 This strategy would provide information about practice-related attributes of clinicians or institutions to encourage referral to the highest quality providers. There are, however, challenges to this strategy. First, knowledge about the link between the structure of cancer care delivery and patient outcomes is not sufficient to distinguish accurately between clinical practices based on quality of care. Second, profiling individual clinicians is limited by statistical challenges, and the logistics and cost of data collection and dissemination. Finally, it may not be feasible or desirable to reshape referral relationships among the large number of specialists who evaluate and treat patients with breast cancer. However, there is little information about patterns and correlates of patient referral to providers and their institutions. To address this issue we used survey data from a large population-based sample of patients recently diagnosed with breast cancer and their attending surgeons to answer the following research questions. First, how are surgeons who treat newly diagnosed patients with breast cancer selected? Second, what is the association between how surgeons are selected and characteristics of the surgeon (breast cancer surgery volume) and hospital (cancer program status)?


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METHODS


Sampling and Data Collection

Details of the sampling and data collection procedures for the patient and surgeon surveys have been published elsewhere.9,15 We surveyed women age 79 years and younger diagnosed with ductal carcinoma in situ (DCIS) and invasive breast cancer, identified by the Surveillance, Epidemiology, and End Results (SEER) registries of the greater metropolitan areas of Detroit and Los Angeles between December 2001 and January 2003. We selected all patients with DCIS and a random sample of invasive cases (oversampling African American women) each month into the preliminary study sample (N = 2,647). The survey was completed by 77.4% of eligible women (n = 1,844). SEER data were merged with survey data for 98.2% of patients. Pathology reports were used to identify surgeons (n = 456) for 98.5% of the patient sample. Surgeons subsequently were mailed a questionnaire and cash gift. The surgeon response rate was 80.0% (n = 365).

The patient and surgeon data were merged using primarily information from pathology reports. Most respondent patients (94.6%) had exactly one surgeon identified from the pathology reports. Patient report of the name of their attending surgeon compared with the surgeon identified from their pathology reports showed high agreement in a convenience sample of 908 respondent patients (99% in Detroit and 90% in Los Angeles). Patient report was used to merge patient and surgeon respondents in cases where pathology information either failed to identify a respondent surgeon (2.8%) or identified two respondent surgeons (2.6%). The final merged data set contained complete patient-surgeon dyad information for 64.6% of accrued and eligible patients (n = 1,539) and 69.7% of accrued surgeons (n = 318). Patients excluded from the final study sample were less likely to be white (62.2% v 72.6%; P < .001) and were more likely to have received a mastectomy (34.7% v 30.0%; P = .021). Surgeons who were excluded from the study sample were less likely to be a high-volume surgeon (20.6% v 32.0%; P = .011) but there were no differences in age, sex, or years in practice.


Measures

The dependent variables were measures of surgeon procedure volume and hospital cancer program status. Surgeon breast cancer procedure volume was based on surgeon report of the percentage of their total practice devoted to breast cancer–related procedures. Responses were collapsed into three categories: less than 25%, 25% to 50%, more than 50%. These variable categories were highly associated with the number of cases of breast cancer reported to the two SEER registries for each respondent surgeon in 2002 (mean, 44, 67, and 124, respectively). Hospital cancer program status was determined using information from the Cancer Program of the American College of Surgeons (ACoS).16 ACoS cancer program approval is based on a periodic onsite evaluation that considers the comprehensiveness of services, care coordination, patient support programs, and monitoring and improvement of care. Information was gathered for the 114 hospitals where one or more patients in the study sample were treated: National Cancer Institute (NCI) –designated comprehensive cancer center (n = 4), other ACoS approved cancer program (n = 35), and no ACoS-approved cancer program (n = 75).

The primary independent variable was patient self-report of how the surgeon was selected. Patients were asked: “Which of the following statements describe how the surgeon who performed your breast surgery was selected?” Patients could select all that applied from the following items: (1) The surgeon was one of the only surgeons available through my health care plan; (2) I was referred to the surgeon by another doctor; (3) I chose this surgeon because of his/her reputation; (4) This surgeon was recommended to me by a relative or friend; (5) I chose this surgeon because I wanted to be treated at the medical institution where he/she worked; (6) I wanted a surgeon who practiced near my home; or (7) I chose this surgeon because of some other reason. We created three variables based on these responses. Patients were categorized as referred to their surgeon if they endorsed either item (1) or (2); selected their surgeon based on reputation if they endorsed any of the items (3), (4), or (5); and selected based on proximity if they chose item (6).

Additional patient variables included tumor behavior, patient age, race/ethnicity, education, income, the number of surgeons consulted before surgery, and geographic site. Additional surgeon variables included sex and the number of years in practice since completing training. Hospital breast cancer surgery volume was defined as the number of breast cancer surgeries performed in 2002 in each treating hospital and reported to the registries.


Analysis

We examined the distribution of how surgeons were selected by patient characteristics. We then used logistic regression to examine the independent association of covariates (tumor behavior, patient age, race, income, education, geographic site, whether the patient was referred to the surgeon, and whether the patient selected the surgeon) with surgeon volume specified as a dichotomous variable (1 > 50%; 0 = 50% or less). Variables indicating surgeon sex, years in practice, and hospital cancer program status were also included in this model.

We then used multinomial logistic regression to examine the association of independent variables with hospital cancer program status (NCI-designated center, other ACoS cancer program, and no cancer program as the baseline category). Surgeon volume and hospital breast cancer surgery volume were included in this model. Wald tests were used to test for differences for group variables. All second-order interactions were evaluated and none were statistically significant. Data were weighted to account for the sampling design and nonresponse. Coefficient SEs were calculated to account for patient clustering within surgeons.17,18


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RESULTS

Table 1 shows the characteristics of the study population. About one fifth of patients had DCIS on initial pathology reports. The mean age was 59.7 years. Two thirds were white, whereas 18.7% were African American. Almost two thirds of the patients had at least some college education and 18.2% reported incomes below $20,000. Patients were about equally divided between the two geographic sites. About one third of patients reported that they consulted two or more surgeons before surgery. About one third of patients were treated by a high-volume surgeon, defined as having more than 50% of total practice devoted to breast cancer surgery. About one third of patients were treated by a female surgeon. On average, patients were treated by attending surgeons who reported that they had been in practice 16 years after completing training. About one third of patients were treated in a hospital without an ACoS-approved cancer program or NCI-designated cancer center. The median number of definitive breast cancer surgeries performed in the treating hospitals was 166.



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Table 1.
Population Characteristics (N = 1,539)


Figure 1 shows the distribution of patient responses regarding how the attending surgeon was selected. Percentages sum to greater than 100% because respondents could select more than one category. Nearly two thirds of patients reported that they were referred to their surgeon by another doctor; 14.9% reported that they were referred by their health plan; about one fourth reported that they chose the surgeon based on reputation; 15.3% selected their surgeon based on the institution; 12.9% chose the surgeon based on the recommendation of family or friends, and 8.7% chose a surgeon based on proximity. When we combined responses we found that 54.3% reported that they were referred but did not select their surgeon; one fifth (21.9%) reported that they were referred and they selected their surgeon; one fifth (20.3%) reported that they selected their surgeon but were not referred by a provider or plan. The remaining patients (4.9%) reported that they had a prior relationship with their surgeon primarily through a previous surgery. Selection of their surgeon based on reputation was more frequently reported by white patients (36.5% v 26.5%; P < .001), more highly educated patients (40.0%, 38.7%, 24.4%, 21.6%, respectively, for highest to lowest education categories; P < .001), patients with higher incomes (54.4%, 43.8%, 35.4%, and 35.4%, respectively, for highest to lowest income categories; P < .001), and patients who consulted with two or more surgeons before surgery (43.5% v 28.5%; P < .001). There was no association with age, tumor behavior, and geographic site. Patient report of selecting the surgeon based on proximity or of being referred to the surgeon was not associated with patient clinical or demographic factors.



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Fig 1.
Patient responses by categories to the question about how the surgeon who performed the breast surgery was selected. Percentages sum to greater than 100% because patients could select all items that applied.


Table 2 lists adjusted odds ratios (aORs) for receipt of surgical treatment by a high-volume surgeon controlling for other factors. Patients who selected their surgeon based on reputation were more likely to have received treatment from a high-volume surgeon (aOR, 2.2; 95% CI, 1.5 to 3.4). There was no independent association between being treated by a high-volume surgeon and the other selection categories. The aOR for being treated by a high volume surgeon was 0.4 (95% CI, 0.2 to 0.8) and 1.0 (95% CI, 0.6 to 1.7) for patients who selected their surgeon based on proximity and those who were referred by a doctor or health plan, respectively. The positive association between patients who selected their surgeon by reputation and treatment by high-volume surgeons was observed after controlling for patient factors and hospital factors (breast cancer surgery volume and cancer program status), and there were no significant interactions.



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Table 2.
Adjusted Odds Ratios for Receiving Treatment From a High-Volume Surgeon


Table 3 shows adjusted relative rate ratios for receiving surgical treatment in hospitals with different cancer programs, controlling for other factors including surgeon procedure volume and hospital surgery volume. The second column shows adjusted relative rate ratios for receipt of surgical treatment in NCI-designated comprehensive cancer centers versus hospitals without an NCI-designated cancer center or ACoS-approved cancer program. The third column shows relative rate ratios for receipt of surgical treatment in hospitals with an ACoS-approved cancer program versus hospitals without NCI-designated cancer center or ACoS-approved cancer program. Patients who selected their surgeon based on reputation were more likely to receive treatment in NCI-designated cancer centers (aOR, 3.4; 95% CI, 1.9 to 6.2) or other ACoS-approved programs (aOR, 2.0; 95% CI, 1.3 to 3.1) than in hospitals without approved cancer programs. Patients who were referred to their surgeon were less likely to be treated in a hospital with an NCI-designated cancer center (aOR, 0.5; 95% CI, 0.3 to 0.9) versus hospitals without approved cancer programs.



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Table 3.
Adjusted Multinomial Odds Ratios for Receipt of Treatment in a Cancer Program–Affiliated Hospital



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DISCUSSION

In this population-based study, we found that about one third of patients were treated by surgeons who devoted more than 50% of their practice to breast cancer, and approximately two thirds of patients were treated in an NCI-designated cancer center or ACoS-approved cancer program. About three fourths of patients reported that they were referred to their surgeon by a provider or health plan, whereas 42% reported that they selected their surgeon. There was considerable overlap between these categories: about one fifth of patients reported that they were both referred to and selected their surgeon.

[2]Patients who reported that they selected their surgeon based on reputation were more likely to be treated by a high-volume breast surgeon after controlling for other factors including cancer program status and hospital breast cancer surgery volume. These findings suggest that patients select high-volume breast surgeons independent of the practice setting.

Patients who selected their surgeon based on reputation were more likely to have seen two or more surgeons before surgery. This likely reflects one pathway to high-volume surgeons: patients seeking a second opinion. Patients who selected their surgeon based on reputation were also more likely to be treated in a hospital with an NCI-designated cancer center or ACoS-approved cancer program after controlling for other factors including individual surgeon procedure volume and hospital surgery volume. This suggests that some patients select their surgeons based on the reputation of their clinician's institution.

Patient report of being referred to the surgeon by other providers or health plans was not associated with whether a patient was treated by a high-volume surgeon. However, patients who reported provider or health plan–based referral were less likely to be treated in an NCI-designated cancer center after controlling for other factors. This was consistent across geographic sites.


Several limitations of the study merit comment. Breast surgery volume was determined by surgeon self-report of the percentage of their total practice devoted to breast cancer. This variable was highly associated with the number of breast surgeries performed by individual respondent surgeons and reported to the two participating SEER registries in 2002. However, it may lack some accuracy. Lack of detail about health insurance may have introduced unmeasured confounding because some health plans limit patient referral to contracted provider networks. However, the option “the surgeon was one of the only surgeons available through my health care plan” was listed among reasons why the treating surgeon was selected and was endorsed by 14.9% of respondents. Finally, although the sample size was large and patient and surgeon response rates were high, differences in respondent characteristics between those included versus excluded from the analyses may limit generalizability.

[3]Our results have important implications for patient care and policy. Physician experience and hospital cancer program status have been associated with different treatment experiences for patients with breast cancer.1-15,19,20 These findings have motivated recommendations to concentrate the first course of treatment for cancer by guiding patients to the providers with the best quality record. Our findings suggest that women who were more actively involved in selecting their surgeon were more likely to be treated by surgeons more experienced in breast surgery and in more comprehensive treatment settings. In contrast, the provider-based referral pathway was not associated with surgeon volume.

We can only speculate about why patients who reported being referred to their surgeon were less likely to receive surgery in NCI-designated cancer centers. Virtually all patients with newly diagnosed breast cancer consult with a surgeon after a problem is identified through an abnormal mammogram or detection of a breast mass suggestive of cancer. The referral patterns of surgeons may be based largely on organizational and provider relationship factors. Organizational factors such as restricted provider networks within health maintenance organizations or preferred provider organizations may play an important role. Informal professional and social network factors may also play an important role. Most surgeons who perform breast surgery are general surgeons with diverse clinical practices. Patient referral to these surgeons may reflect provider relationships built on general surgical practice availability and performance rather than surgeon's specific expertise in treatment of breast cancer. Given the limited literature linking the structure of cancer care delivery to patient outcomes, community physicians may not be convinced that targeting referral to high-volume surgeons or hospitals with cancer programs would add clinically important value for most newly diagnosed patients with breast cancer seen in their practice.

Additional referral barriers may partly explain the inverse association observed in this study between provider-based referral and treatment in an NCI-designated cancer center. Community clinicians may perceive disadvantages of referral to NCI-designated cancer centers because of concerns about losing patients, concerns about continuity and coordination between themselves and other providers, or concerns that their patients may face difficulties when navigating different systems of care. Given the large number of surgeons who care for patients with breast cancer and the myriad of potential factors shaping current patient referral patterns, it may be difficult to concentrate breast cancer surgical care by influencing referral practices.

More research is needed to address the quality implication of the referral patterns identified in this study. This research should address the relationship between provider characteristics and key delivery system factors such as patient-provider communication, provider-provider communication, patient decision and care support, and practice management initiatives. Ultimately, these factors should be linked to outcomes such as use of effective treatments, patient satisfaction, and quality of life. In the meantime, women with breast cancer should be aware that provider-based referral might not connect them with the most experienced surgeons or the most comprehensive practice setting in their community. Patients might consider a second opinion, especially if they are advised to undergo a particular procedure without a full discussion of treatment options or a clear medical rationale for the recommendation.


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AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.


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AUTHOR CONTRIBUTIONS

Conception and design: Steven J. Katz, Timothy P. Hofer, Monica Morrow

Financial support: Steven J. Katz

Administrative support: Steven J. Katz, Kendra Schwartz, Lihua Liu, Dennis Deapen

Provision of study materials or patients: Steven J. Katz, Kendra Schwartz, Lihua Liu, Dennis Deapen

Collection and assembly of data: Steven J. Katz, Paula M. Lantz, Nancy K. Janz, Kendra Schwartz, Lihua Liu, Dennis Deapen

Data analysis and interpretation: Steven J. Katz, Timothy P. Hofer, Sarah Hawley, Paula M. Lantz, Nancy K. Janz, Monica Morrow

Manuscript writing: Steven J. Katz, Timothy P. Hofer, Sarah Hawley, Paula M. Lantz, Nancy K. Janz, Monica Morrow

Final approval of manuscript: Steven J. Katz, Timothy P. Hofer, Sarah Hawley, Paula M. Lantz, Nancy K. Janz, Kendra Schwartz, Lihua Liu, Dennis Deapen, Monica Morrow


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Acknowledgments

We thank the American College of Surgeons Cancer Department (Connie Bura and David Winchester, MD) for their support for the surgeon study.


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Footnotes

Supported by the National Cancer Institute (Grant No. RO1 CA8837-A1) to the University of Michigan. Supported in part with federal funds from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, under Contracts No. N01-PC-35139 and NO1-PC-65064. The collection of cancer incidence data used in this publication was supported by the California Department of Health Services as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885.

The ideas and opinions expressed herein are those of the authors, and no endorsement by the State of California, Department of Health Services is intended or should be inferred.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

Received February 15, 2006.
Accepted August 18, 2006.


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Benson, Friday, January 21, 2011

Created By: Carolina Jaime
http://www.naturalnews.com/031074_surgeons_suicide.html

Many surgeons struggle with thoughts of suicide, study finds 

(NaturalNews) [1] High stress levels, burnout and even past surgical mistakes are among the top reasons why one in 16 surgeons has considered suicide, according to a new study published in the journal Archives of Surgery. Tait Shanafelt from the Mayo Clinic and his colleagues found that within the past year, six percent of surgeons contemplated suicide. And surgeons between the ages of 55 and 64 are three times more likely than the national average for that age group to consider taking their own lives.

"What we are seeing through this work is that there is a high amount of burnout and stress among America's physicians, with potentially serious consequences for both physicians and their patients," said Shanafelt. "It isn't necessarily that having thoughts of suicide endangers patient health, but some of the same root causes, particularly burnout, do appear to have a strong relationship with quality of care."

The team surveyed more than 7,900 physicians and found that between six and seven percent of those over the age of 45 had considered suicide, while seven percent of those between the ages of 55 and 64 had considered it. In general, "emotional exhaustion" was also linked to an overall increase in patient medical errors.

Strikingly, only 25 percent of those who indicated suicidal thoughts said they sought any sort of professional help for their problems. Many expressed fear that they would lose their medical licenses if they came forward, so they instead self-prescribed or had someone else prescribe them antidepressant drugs.

A 2009 report published in the Daily Mirror found that U.K. physicians committed 4,000 medical errors in 2008 that could have been avoided. Such errors, which included improper diagnoses, wrong prescriptions, and surgical errors, some of which resulted in patient deaths, likely occurred as a result of fatigue and doctors being overworked 

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Huff, Saturday, April 07, 2012

Created By: Carolina Jaime
http://www.naturalnews.com/035496_surgeons_alcoholics_addiction.html 


[1]Surgeons twice as likely as general population to be alcoholics, survey finds 

(NaturalNews) A survey sent out to 25,000 surgeons has revealed that the prevalence of alcoholism within this particular medical category is disproportionally high compared to that of the general population. At least 15 percent of surgeon respondents showed signs of alcohol abuse or dependency problems, while only about nine percent of the general population struggles with alcohol problems.

Published in the journal Archives of Surgery, the results of the survey also revealed that female surgeons are nearly twice as likely as male surgeons to have alcohol issues, with 14 percent of male surgeons and 26 percent of female surgeons indicating alcohol problems. And among all surgeons, both male and female, with alcohol dependency or addiction, nearly half of them admitted to causing a "major medical error" within the previous three months.

"The nature of the beast is that the percent of emergencies, the percent of after hours work, and actual scheduled work itself all require an energy and concentration that is really different than a lot of the other specialties," said study author Dr. Michael Oreskovich from the University of Washington, who added that depression and burnout symptoms, which are common in the surgical profession, were directly linked to alcohol issues in many cases.

The survey itself, which was specifically designed to screen for indicators of alcohol abuse, was only completed by 7,200 of the 25,000 surgeons to whom it was sent. According to Dr. Edward Livingston, a professor of surgery at the University of Texas Southwestern Medical Center in Dallas who wrote an accompanying editorial on the study, this low response rate could be indicative of an even more problematic alcoholism problem than the findings indicate.

Dr. Oreskovich agrees, having said that "folks who are less likely to respond may have shame and guilt and fear associated with their alcohol abuse and dependence that they don't want to report on the survey." In other words, alcoholism among surgeons could be even higher than the figures suggest, which is particularly concerning for the thousands of patients who undergo serious surgical procedures on a daily basis.

Last year, another study published in the Archives of Surgery found that one in 16, or about six percent, of surgeons has actually considered committing suicide. And in the upper age category of 55 to 64, that percentage was even higher, teetering at around seven percent 
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