By Gustavo Stringel, MD, MBA

In recent years, medical and surgical resident have been working fewer hours per week, in contrast to the 80+ hour-workweeks that were common in the past. Fortunately, we have options available to deal with the problem of the reduced workweek. In sum, we must enhance those hours our residents do spend on the job.

First, we must recognize that though all doctors have received training, not all have the same levels of cognition and psychomotor skills, and so we must tailor their training accordingly. Secondly, we can improve our ability to give feedback to the interns and residents under our supervision and provide honest, constructive critiques to help them learn. A key weapon in our training arsenal is the simulator. As medicine has become more sophisticated, so has our ability to train through simulations. While it is true that our simulators are not as sophisticated as flight simulators, for instance, certain skills can be acquired through repeated training in simulated surgeries.

Next, we can develop a system of meaningful rewards to motivate interns and residents to work harder during their reduced workweeks. Research has shown that people will work harder if they believe that their efforts will lead to rewards. Most residents are motivated, but they may become discouraged in the face of the constraints placed upon them by the hospital work environment and the relative loss of autonomy they experience as trainees. We must encourage residents to work around these obstacles.

Finally, we must never forget the circumstances that brought us to this point and strive to make the best use of whatever hours are available to us. Since we typically measure experience in terms of time, if we must reduce the time available to gain experience, we must make that time more meaningful.

This article is a brief synopsis of points raised by Dr. Gustavo Stringel in his President’s Address to the Society of Laparoendoscopic Surgeons, which was published in the Society’s Journal in 2010. Dr. Stringel currently holds the posts of Surgeon in Chief and Director of Pediatric Surgery and Minimally Invasive Surgery at the Westchester Medical Center’s Maria Fareri Children’s Hospital.

Based in Valhalla, New York, renowned pediatric surgeon Dr. Gustavo Stringel is surgeon in chief of Maria Fareri Children’s Hospital. For over two decades, Dr. Gustavo Stringel has been at the forefront of the field of laparoscopic surgery for young patients.

Laparoscopic techniques are frequently used for a wide range of common pediatric procedures, typically with outcomes that are superior to those of more invasive open operations. Modern pediatric laparoscopic surgeries include appendectomies, various tumor and organ biopsies, and hernia exploration and repair, among many others.

Laparoscopic surgery wasn’t always available for children. In the early 1990s, laparoscopy was a fairly well-developed field in adult and gynecological medicine. The world of pediatric medicine, however, lagged behind for a couple of reasons. First, existing equipment was not ideally sized for children’s bodies. Secondly, a number of doctors resistant to pediatric laparoscopy suggested that the natural resilience of children to surgery made laparoscopy an unnecessary replacement for more traditional open surgery.

Fortunately, a few insightful pediatricians like Dr. Stringel identified the advantages of laparoscopy in the early 1990s, and worked hard toward establishing the necessary knowledge and expertise to safely operate laparoscopically on young patients. The less invasive nature of laparoscopy was found to be advantageous to children, as well, with quicker recovery times, fewer infections, and less postoperative pain. With the advent of smaller instruments better suited to children’s procedures, the results only improved.

Thanks to the persistence of those pioneering pediatric surgeons, today pediatric laparoscopic procedures are routine and produce positive outcomes for thousands of young patients every year.

Chief of pediatric surgery at Maria Fareri Children’s Hospital in Valhalla, New York, Dr. Gustavo Stringel is an accomplished surgeon with over 30 years of experience. Especially renowned for his innovation and skill in laparoscopic procedures, Dr. Gustavo Stringel also teaches medicine in his position as a professor of surgery and pediatrics at New York Medical College.

A relatively common infant ailment requiring surgery is pyloric stenosis, which consists of an irregularly large growth of muscle around the pylorus, the connection between the stomach to the small intestine. The result of this extra tissue is that food is restricted from passing through into the intestine. The condition is usually quickly identified, as it causes projectile vomiting. Pyloric stenosis most often occurs in infant males around a month old.

Fortunately, pyloric stenosis is easily corrected with surgery. The operation involves cutting the muscle tissue constricting the pylorus, which does not damage the stomach itself. This procedure can be done laparoscopically. In this case, the resulting tiny incisions not only leave practically no scarring later in life, but also greatly reduce the incidence of infection immediately following the surgery.

Dr. Gustavo Stringel, the Surgeon-in-Chief at Maria Fareri Children’s Hospital in Valhalla, New York, specializes in minimally invasive surgeries. Dr. Stringel has performed many pediatric endoscopies to diagnose and treat diseases of the digestive tract. Like many in his field, Dr. Gustavo Stringel must frequently explain to parents how he decides when an endoscopy is justified and when it is not.


The North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) has issued a set of guidelines for pediatric endoscopies. These procedures require anesthesia and can be very expensive. Like all procedures, they carry risk. Therefore, the NASPGN recommends that doctors perform pediatric endoscopies only when they will provide diagnostic or therapeutic value to the patient.

For instance, these procedures, which involve inserting a small flexible tube with a light and a camera into a patient’s digestive tract, can locate the source of gastrointestinal bleeds and determine the source of poor weight gain and stooling issues. On the other hand, they should not be used in patients whose gastrointestinal issues are well controlled. For example, a patient with simple reflux who responds well to medication does not need an endoscopy. If a child has issues with constipation but laxatives resolve them, there is no need for this procedure. The NASPGN recommends that endoscopy be used only in cases in which it will increase quality of life and the potential benefits outweigh potential risks.

 

For nearly 130 years, the Hospital for Sick Children in Toronto has aided children in need of medical care. Affiliated with the University of Toronto, the Hospital for Sick Children is recognized across the globe as one of world’s best pediatric hospitals, due to its staff’s dedication, state-of-the-art equipment and laboratories, and innovative research programs.

While the Hospital for Sick Children treats a variety of illnesses, it specializes in several key areas such as attention-deficit/hyperactivity disorder, asthma, and juvenile diabetes. Additionally, it connects patients and their families with psychologists and social workers. Parents can remain in contact with their children, as each room contains a telephone, and computers are available free of charge.

People interested in learning more about this facility can log onto http://www.sickkids.ca. The site also contains links for individuals who want to donate money, toys, games, and other equipment to the institution.

About the Author:

A pediatric and laparoscopic surgeon, Dr. Gustavo Stringel trained at the Hospital for Sick Children. He also obtained experience in general surgery at the University of Toronto’s prestigious Gallie Program.

When the appendix becomes inflamed and infected, doctors perform an appendectomy to prevent a rupture and systemic infection. As a Pediatric Surgeon at Maria Fareri Children’s Hospital in Valhalla, New York, Dr. Gustavo Stringel frequently performs this type of surgery in children.

An untreated appendix can rupture quite quickly, which can be fatal. Dr. Gustavo Stringel cautions that appendicitis (inflammation of the appendix) is a medical emergency that requires immediate medical care. Parents should be alert for early signs of appendicitis in their children, including sharp pain around the belly button or in the right lower quadrant of the abdomen. Vomiting, dry heaves, loss of appetite, fever, and frequent painful urination may also be present.

Once doctors diagnose appendicitis, they move quickly. The child will be admitted to the hospital, and his or her physician will remove the appendix using a laparoscope or by open incision. The child will likely remain in the hospital for one to three days following the surgery, although laparoscopic removal often results in quicker recovery time than open surgery.

For more than 150 years, Westchester-based New York Medical College has educated students in a variety of health science-related matters. Affiliated with the Touro College and University System, New York Medical College holds certification from the Middle States Association of Colleges and Secondary Schools, the Liaison Committee on Medical Education, and other groups. A national leader in graduating primary care physicians, the College boasts a student and resident population of approximately 2,500.

New York Medical College features three schools: the School of Health Sciences and Practice, the School of Medicine, and the Graduate School of Basic Medical Sciences. Those who attend these institutions can receive training at numerous medical clinics, including Metropolitan Hospital Center, Lenox Hill Hospital, Terence Cardinal Cook Health Care Center, and Norwalk Hospital. To learn more about the facilities and options available at New York Medical College, visit NYMC.edu.

About the Author: A medical professional trained in laparoscopic surgery, Dr. Gustavo Stringel tends to patients at Maria Fareri Children’s Hospital. In addition, Dr. Stringel teaches academic surgery at New York Medical College and has earned tenure there as a Professor of Surgery and Pediatrics.

In 2003, the Accreditation Council for Graduate Medical Education limited the number of hours resident surgeons could spend working to 80 per week. Before those limits were established, surgeons in training commonly worked more than 100 hours per week, which left many exhausted and, in some cases, caused fatigue-related mistakes that might otherwise have been avoided.

As new research shows, however, those 100-plus-hour weeks also allowed surgeons to complete 520 more surgical procedures per year of training than 80-hour weeks do. The new restrictions mean that surgeons are entering practice with less experience than they once had, and of course, this lack of experience can also lead to serious mistakes.

The debate over how to balance the need for extensive experience with the need for sleep and rest rages on in the medical field, but as long as the current restrictions remain, surgeons in training must maximize the benefits they can from the hours they are allowed to work.

About Dr. Gustavo Stringel:

A surgeon with more than 30 years of experience, Dr. Gustavo Stringel has studied the changes that surgeons’ training schedules have undergone in recent years. Dr. Stringel published an article on this issue, “Making the Most of the Hours We Have Left,” which he delivered as President of the Society of Laparoendoscopic Surgeons in 2010.

Established in 1980, the Association for Surgical Education (ASE) was founded to support surgical education research and training. The organization comprises roughly 850 members hailing from more than 190 medical institutions across the continent. In addition to providing teaching awards, educational materials, and grants for clinicians and educators, ASE also offers several programs for qualified surgical trainees.

 

The Surgical Education Research Fellowship, or SERF, is one of the better-known educational initiatives at ASE. Emphasizing knowledge and the advancement of surgical education studies, the year-long SERF program is completed through the home institution of accepted fellows.

 

The SERF program, available to ASE members interested in surgical education research, accepts no more than 16 candidates each year. Program faculty members pair each fellow with an experienced researcher who mentors, advises, and consults with the fellow throughout the duration of the course. SERF program curricula include educational research design protocol, literature review strategies, research project management, presentation and article preparation, and networking opportunities with other surgical education researchers. The SERF program is funded by the ASE, the ASE Foundation, and tuition fees.

 

Other initiatives at the ASE include educational intervention strategies, the creation of new teaching aids and modules, and the maintenance of the ASE’s Educational Clearinghouse. Housed at the Southern Illinois University School of Medicine, the clearinghouse collects surgical education materials for the benefit of students and instructors. The Educational Clearinghouse also distributes surgery clerkship curriculum, evaluation materials, and faculty development aids, along with other resources.

 

 

About the Author: Dr. Gustavo Stringel serves as Surgeon in Chief and Director of Pediatric Surgery and Minimally Invasive Surgery at the Maria Fareri Children’s Hospital in Valhalla, New York. A member of the Association for Surgical Education, Dr. Gustavo Stringel maintains the title of Fellow with the American Academy of Pediatrics, the American College of Surgeons, and the Royal College of Physicians and Surgeons of Canada.

Dr. Gustavo Stringel is the Surgeon in Chief and Director of Pediatric Surgery and also Minimally Invasive Surgery (MIS) for the Maria Fareri Children’s Hospital at Westchester Medical Center in Valhalla, New York. In his position, Dr. Stringel fulfills a number of functions including hiring specialists in a variety of fields, treating patients, and managing the day-to-day operations. As head of MIS, Dr. Gustavo Stringel obtained several pieces of state-of-the-art technology, including da Vinci robotic surgical equipment, to assist practitioners engaged in laparoscopic surgery. Furthermore, he has engaged in research into laparoscopy in children and infants.

Laparoscopic Surgery oublic domain

Also known as minimally invasive surgery, laparoscopic surgery utilizes video cameras and tiny instruments to diagnose and treat certain conditions. Doctors start by making a small incision in the patient just large enough to insert the laparoscopy equipment and other instruments through the opening. The camera relays images to a monitor visible to the surgeons. These professionals can then mechanically control the other devices without needing to increase the size of the incision.

Laparoscopic techniques offer several benefits when compared to traditional forms of surgery, including smaller scars, quicker recovery time, shorter hospital stays, and less potential for complications.