Gynecologic pathology services in low- and middle-income countries

ObjectiveThe International Gynecologic Cancer Society (IGCS) offers multidisciplinary conferences to underserved communities. Mentor pathologists have become an integral part of these tumor boards, as pathology services in low-to-middle-income countries are often inadequate and disjointed. The IGCS Pathology Working Group conducted a survey to assess barriers to quality pathology services in low-to-middle-income countries and identified potential solutions.MethodsA 69-question cross-sectional survey assessing different aspects of pathology services was sent to 15 IGCS Extension for Community Healthcare Outcomes (ECHO) training sites in Africa, Asia, Central America, and the Caribbean. Local gynecologic oncologists distributed the survey to their pathology departments for review. The responses were tabulated in Microsoft Excel.ResultsResponses were received from nine training sites: five sites in Africa, two in Asia, one in Central America, and one in the Caribbean. There were no pathologists with subspecialty training in gynecologic pathology. Most (7/9, 78%) surveyed sites indicated that they have limited access to online education and knowledge transfer resources. Of the eight sites that responded to the questions, 50% had an electronic medical system and 75% had a cancer registry. Synoptic reporting was used in 75% of the sites and paper-based reporting was predominant (75%). Most (6/7, 86%) laboratories performed limited immunohistochemical stains on site. None of the sites had access to molecular testing.ConclusionsInitial goals for collaboration with local pathologists to improve diagnostic pathology in low- and middle-income countries could be defining minimal gross, microscopic, and reporting pathology requirements, as well as wisely designed educational programs intended to mentor local leaders in pathology. Larger studies are warranted to confirm these observations.

Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program

Background Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists. Methods The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3–7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics. Results According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that “UMPH made me more likely to practice primary care” and 59% agreed “UMPH should target residents pursuing subpecialty careers.” Conclusions A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers.

Cosmetic Surgery: A Subspecialty That Needs Specialized Training and Recognition

Introduction: This study was performed to provide a comprehensive review of the breadth and depth of fellowship training provided by the American Academy of Cosmetic Surgery (AACS), with direct comparison with other current aesthetic surgery training programs available in the United States. We hypothesized that this subspecialty training provides essential experience and confidence to perform aesthetic procedures, which are likely not adequately imparted during traditional residency training. We also address the notion that Cosmetic Surgery is not under the sole ownership of one specialty, but rather a subspecialty that flourishes by collaboration between multidisciplinary surgical backgrounds. Materials and Methods: We performed a cross-sectional study of survey data from 2 distinct groups—current fellows in a 1-year AACS program and surgeons who completed an AACS fellowship between July 2008 and June 2017, who have been in active cosmetic surgery practice ranging from 6 months to over 6 years. A survey was administered via email and distributed by the AACS central office. The responses were compared with data published in the Annals of Plastic Surgery concerning Recent Trends in Resident Career Choices after Plastic Surgery Training. Results: The Accreditation Council for Graduate Medical Education (ACGME) requirements for aesthetic surgical cases in a 6-year Plastic Surgery program are 150 cases, but 50% of graduating seniors feel inadequately prepared to transition straight into aesthetic surgery practice, whereas among AACS graduating fellows, 100% feel very prepared to go on the aesthetic surgery practice, having completed an average of 687 cases within the yearlong training program. We note that the survey response rate was 81% among current fellows versus 35% among practicing surgeons. Discussion: We believe that focused subspecialty training in cosmetic surgery after completion of a primary surgical residency in a form of a structured fellowship through AACS, American Society of Plastic Surgery, American Academy of Facial Plastic and Reconstructive Surgery, Commission on Dental Accreditation, and American Society of Ophthalmic Plastic and Reconstructive Surgery (Oculoplastic) is the ideal preparation for the future. As we learn from each other through fellowship training, academic conferences, and research, this will further advance the subspecialty and ultimately improve patient care and outcomes. There is no evidence that these training programs provide less adequate preparation, although they are not accredited by the ACGME. To the contrary, the additional experience and knowledge gained during these fellowship training programs result in better outcomes and more competent practitioners. Conclusions: The development of subspecialty training and board certification for surgeons committed to cosmetic surgery yields the highest level of qualified providers. The diverse backgrounds of these providers continue to allow us to expand and innovate in this field. This study is aimed at moving this conversation forward in a positive direction.

An Online Survey on Job Satisfaction among Indian Radiologists - Under-Studied Journey from Promised Land to Paradise Lost

BACKGROUND Globally, radiodiagnosis is considered as one of the most sought after specialty in the field of medicine, based on the perceived notion that it is a high income, risk-averse, white-collared job. Radiologists are touted as being one of the highest paid specialists with defined work-hours; however, the ground reality appears to be in contradiction, particularly in the Indian context. The purpose of this study was to objectively assess the current day situation amongst the Indian radiologists. This gender-neutral survey not only dispels many of the prevailing assumptions but also brings to clear light the issues that assail the radiologist on a day to day basis. METHODS A cross-sectional descriptive study was performed with Google survey forms and collected data was obtained from 370 radiologists regarding various parameters, such as the workplace, years of experience, work hours per day, monthly income, peer, and work-related pressures, and their overall perceived happiness quotient. Issues concerning threats to radiology, the need for super or subspecialty training were also addressed. RESULTS Most of the young radiologists opted to work in either diagnostic centers or corporate hospitals as salary drawn was considerably higher than their counterparts in medical colleges. Nearly half the radiologists working at medical colleges augmented their income by working in diagnostic centers. Nearly 2/3rds of the young radiologists work for an average of 10 hours per day, six days a week with a take home salary of approximately 1 – 2 lakhs per month. Only 5 % of the radiologists stated that they were most happy with their work environment, nearly 57 % of them had some kind of occupational hazard and this was directly related to the years of work. Burn out predominated amongst the upcoming radiologists with less than 5 years of work experience and this was found to be compounded by work hours, work pressure and inadequate compensation. CONCLUSIONS Today, young radiologist is caught in a whirlpool of change that has not only threatened the “concept of a settled, satisfied, specialist”, furtherance to this, commoditization of radiology has led to increase in work hours, work pressure, leading to dissatisfaction and early burn out. KEY WORDS Radiologist, Psychosocial Aspects, Burn Out, Artificial Intelligence.

Positive experiences of healthcare professionals with a mainstreaming approach of germline genetic testing for women with ovarian cancer

According to current guidelines, all women with epithelial ovarian cancer are eligible for genetic testing for BRCA germline pathogenic variants. Unfortunately, not all affected women are tested. We evaluated the acceptability and feasibility for non-genetic healthcare professionals to incorporate germline genetic testing into their daily practice. We developed and implemented a mainstreaming pathway, including a training module, in collaboration with various healthcare professionals and patient organizations. Healthcare professionals from 4 different hospitals were invited to participate. After completing the training module, gynecologic oncologists, gynecologists with a subspecialty training in oncology, and nurse specialists discussed and ordered genetic testing themselves. They received a questionnaire before completing the training module and 6 months after working according to the new pathway. We assessed healthcare professionals’ attitudes, perceived knowledge, and self-efficacy, along with the feasibility of this new mainstream workflow in clinical practice, and evaluated the use and content of the training module. The participation rate for completing the training module was 90% (N = 19/21). At baseline and after 6 months, healthcare professionals had a positive attitude, high perceived knowledge and high self-efficacy toward discussing and ordering genetic testing. Knowledge had increased significantly after 6 months. The training module was rated with an average of 8.1 out of 10 and was considered useful. The majority of healthcare professionals (9/15) was able to discuss a genetic test in five to 10 min. After completion of a training module, non-genetic healthcare professionals feel motivated and competent to discuss and order genetic testing themselves.

Sub-Specialization Among Nigerian Ophthalmologists: Status, Disposition and Barriers.

Purpose: To determine the status of sub-specialization among Nigerian ophthalmologists as well as their dispositions and barriers against sub-specialization with a view to providing valuable information for the purpose of human resources for eye care planning thereby providing useful insight into the future of ophthalmic practice in Nigeria. Methods: This was a web-based, cross-sectional study conducted among Ophthalmologists in Nigeria. An online questionnaire was distributed through e-mails using Qualtrics software (Qualtrics, Provo, UT, USA). Information concerning socio-demographic characteristics, type of practice, location of practice, years of practice, status and disposition to sub-specialization as well as barriers to sub-specialization were obtained through the questionnaire.Results: two hundred and four Nigerian Ophthalmologists participated in the study out of which 118 (57.8%) were females. One hundred and ten (54.0%) respondents had undergone sub-specialty training. The sub-specialties with the highest number of patronage was Paediatric Ophthalmology and Strabismus (14.2%). Respondents older than 46 years were three times more likely to have undergone subspecialty training compared to respondents who were aged 46 years and below [odds ratio (OR) = 3.01, 95% Confidence interval (CI) = 1.33 – 6.83, p = 0.01]. The main barriers to the availability and uptake of sub-specialty services as well as the challenges of sub-specialty services at the centres with established sub-specialty practice were non-availability/inadequate trained specialist and inadequate equipment. Conclusion: Nigerian Ophthalmologists are well disposed to sub-specialization although the extent of sub-specialization among them was a little above average. The main barriers to the availability and uptake of sub-specialty services as well as the challenges of sub-specialty services at the centres with established sub-specialty practice in this study were non-availability/inadequate trained specialist and inadequate equipment.

Board Certification Is Associated With a Reduced Risk of Endophthalmitis After Intravitreal Injections

Purpose: This work investigates associations between physician qualifications and the risk of postintravitreal injection endophthalmitis. Methods: This retrospective analysis of data from medical claims studied Medicare beneficiaries undergoing 1 or more intravitreal injections between January 1, 2013, and December 31, 2017. Logistic regression analysis was performed to assess whether board certification status or retina subspecialty training was associated with lower risk of postinjection endophthalmitis, controlling for patient's age, race, and sex, type of agent injected, diagnosis, and year of injection. The main outcome measure was odds ratio (OR) of receiving a diagnosis of endophthalmitis in the 14 days after intravitreal injection. Clinical outcome and quality of care were not evaluated in this study. Results: A total of 2 907 324 intravitreal injections were performed on 219 640 patients by 4315 ophthalmologists, 3196 (74%) of whom were retina specialists and 4021 (92%) of whom were certified by the American Board of Ophthalmology (ABO). Overall, there were 1088 (0.037%) cases of postinjection endophthalmitis, of which 1024 (0.037%) were injected by ABO-certified ophthalmologists and 64 (0.050%) by non–board-certified ophthalmologists. Injections by ABO-certified ophthalmologist had 28% reduced odds of endophthalmitis (OR = 0.72; 95% CI, 0.523-0.996, P = .05). Higher odds of endophthalmitis were observed for corticosteroid injections (OR = 3.91; 95% CI, 2.75-5.56, P < .001) and aflibercept injections (OR = 1.47; 95% CI, 1.19-1.80, P < .001). Patients' sex and race, the diagnosis associated with the injection, and providers' retina subspeciality training were not associated with the rate of endophthalmitis ( P < .20 for all comparisons). Conclusions: We found evidence that endophthalmitis may be reduced when ABO-certified physicians perform an intravitreal injection.