Layton F. "Bing" Rikkers, MD, FACS

Peer review is the filter that determines what is published in the scientific literature and what is not allowed to see the light of day. It has been considered "the gatekeeper of science." In modern times, peer review has consisted of a journal editor sending a submitted article to a limited number of experts in the field who then judge its worth for publication. Many specialists see reviewing manuscripts as a service to their profession, put considerable effort into their analysis, and provide extensive comments on revisions needed to strengthen papers.

However, the value of this venerable process as it is presently constituted has been questioned by numerous critics. Because manuscripts are reviewed by a limited number of often rival scientists in a highly specialized field, the practice is prone to bias. Innovation may be stifled when reviewers reject outlier concepts that may be correct but that do not fit into the mainstream of thought. Critiques are often superficial as they are performed by otherwise busy individuals who receive no compensation for their efforts. Finally, journal editors are given undue power in the process. Not only do they make the final decision to publish or reject a manuscript, they are also responsible for selecting reviewers and are then free to ignore or accept their recommendations.

These criticisms of this time-honored system have led to a strong impetus for change. Coincident with the motivation for modifying this essential component of the publication process have been technological advancements that are facilitating new approaches. The Internet has provided a mechanism for making peer review a more open, inclusive process with any member of the scientific community who so desires having the opportunity to contribute to the evaluation of published work. A recent incident highlights how uninvited, but valuable, input from the wider scientific community can rapidly and effectively improve the accuracy of the literature.

On July 2, 2014, National Public Radio’s Morning Edition broadcast "Easy method for making stem cells was too good to be true" and a New York Times headline proclaimed "Stem cell research papers are retracted." In January 2014, Haruko Obokata of the RIKEN Centre for Developmental Biology in Japan published an innovative and considerably simpler method of producing stem cells than extracting them from embryos or making them from skin cells in a complicated and prolonged process (Nature 2014;505: 641-7). At the time of publication, the work was viewed by many to be potentially Nobel Prize-worthy research—that is, until the stem cell research community chimed in with its extensive and detailed post-publication peer review.

A number of research groups questioned Obokata’s conclusions. Some even attempted to replicate the experiments, but with no success. Soon the critics’ findings and opinions appeared on a variety of websites and blogs, including the Nature website. The RIKEN Centre took notice and appointed a committee to investigate the research. The committee found that Obokata had manipulated her data on at least two occasions and concluded that she had participated in research misconduct. Pressure mounted, which led to the recent voluntary retraction of the article by its authors.

This case represents an extreme outcome resulting from a failure of pre-publication vetting followed by a successful post-hoc peer review. But it demonstrates how the emerging and more comprehensive means of evaluating published research is rapidly working its way into the fabric of how science and the reporting of it operate. It would be ideal if this extensive vetting of potentially important research could be done prior to rather than after its release to the general public. Physics academicians have accomplished this by posting their research papers as pre-prints on-line for their colleagues to evaluate. Only after a successful conclusion of this process is a work deemed acceptable for entry into the physics literature. Submission of biomedical research to a similar process has a significant downside in that new, possibly harmful therapies, not yet peer-reviewed, could be adopted by practitioners and/or patients before their time. However, some modification of it will likely evolve and lead to a more accurate assessment of submitted work than the present process allows.

How publications are valued is also being modified thanks to the omnibus means of rapid communication allowed by an ever-expanding Internet. Bibliometrics, most notably the number of times an article is subsequently cited in print, has been the mainstay in determining the value of individual articles. The journal impact factor, which has historically been the main measure of a journal\'s standing compared to that of others in its field, is derived from the aggregate of citations for all articles over a period of time. With the advent of the Internet, a new set of alternative metrics (altmetrics) is now contributing to the evaluation of published work. While print citations take years to accumulate, article downloads, mentions on Facebook, number of tweets on Twitter, and numerous other altmetrics have the considerable advantage of immediacy and can be logged by any reader, not only those authors who decide to subsequently cite certain publications. Although these new metrics are unlikely to replace traditional citations in assigning value to individual articles, along with them, they will be helpful in determining what must be read to maintain currency in one’s specialty.

So, readers of the surgical literature feel your newly found power and exert it. You along with your colleagues around the globe can, and in fact have an obligation to, play a role in determining what is worth reading from an ever-expanding volume of new information. Many eyes will almost certainly be better than relying solely on the opinions of a chosen few.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Peer review is the filter that determines what is published in the scientific literature and what is not allowed to see the light of day. It has been considered "the gatekeeper of science." In modern times, peer review has consisted of a journal editor sending a submitted article to a limited number of experts in the field who then judge its worth for publication. Many specialists see reviewing manuscripts as a service to their profession, put considerable effort into their analysis, and provide extensive comments on revisions needed to strengthen papers.

However, the value of this venerable process as it is presently constituted has been questioned by numerous critics. Because manuscripts are reviewed by a limited number of often rival scientists in a highly specialized field, the practice is prone to bias. Innovation may be stifled when reviewers reject outlier concepts that may be correct but that do not fit into the mainstream of thought. Critiques are often superficial as they are performed by otherwise busy individuals who receive no compensation for their efforts. Finally, journal editors are given undue power in the process. Not only do they make the final decision to publish or reject a manuscript, they are also responsible for selecting reviewers and are then free to ignore or accept their recommendations.

These criticisms of this time-honored system have led to a strong impetus for change. Coincident with the motivation for modifying this essential component of the publication process have been technological advancements that are facilitating new approaches. The Internet has provided a mechanism for making peer review a more open, inclusive process with any member of the scientific community who so desires having the opportunity to contribute to the evaluation of published work. A recent incident highlights how uninvited, but valuable, input from the wider scientific community can rapidly and effectively improve the accuracy of the literature.

On July 2, 2014, National Public Radio’s Morning Edition broadcast "Easy method for making stem cells was too good to be true" and a New York Times headline proclaimed "Stem cell research papers are retracted." In January 2014, Haruko Obokata of the RIKEN Centre for Developmental Biology in Japan published an innovative and considerably simpler method of producing stem cells than extracting them from embryos or making them from skin cells in a complicated and prolonged process (Nature 2014;505: 641-7). At the time of publication, the work was viewed by many to be potentially Nobel Prize-worthy research—that is, until the stem cell research community chimed in with its extensive and detailed post-publication peer review.

A number of research groups questioned Obokata’s conclusions. Some even attempted to replicate the experiments, but with no success. Soon the critics’ findings and opinions appeared on a variety of websites and blogs, including the Nature website. The RIKEN Centre took notice and appointed a committee to investigate the research. The committee found that Obokata had manipulated her data on at least two occasions and concluded that she had participated in research misconduct. Pressure mounted, which led to the recent voluntary retraction of the article by its authors.

This case represents an extreme outcome resulting from a failure of pre-publication vetting followed by a successful post-hoc peer review. But it demonstrates how the emerging and more comprehensive means of evaluating published research is rapidly working its way into the fabric of how science and the reporting of it operate. It would be ideal if this extensive vetting of potentially important research could be done prior to rather than after its release to the general public. Physics academicians have accomplished this by posting their research papers as pre-prints on-line for their colleagues to evaluate. Only after a successful conclusion of this process is a work deemed acceptable for entry into the physics literature. Submission of biomedical research to a similar process has a significant downside in that new, possibly harmful therapies, not yet peer-reviewed, could be adopted by practitioners and/or patients before their time. However, some modification of it will likely evolve and lead to a more accurate assessment of submitted work than the present process allows.

How publications are valued is also being modified thanks to the omnibus means of rapid communication allowed by an ever-expanding Internet. Bibliometrics, most notably the number of times an article is subsequently cited in print, has been the mainstay in determining the value of individual articles. The journal impact factor, which has historically been the main measure of a journal\'s standing compared to that of others in its field, is derived from the aggregate of citations for all articles over a period of time. With the advent of the Internet, a new set of alternative metrics (altmetrics) is now contributing to the evaluation of published work. While print citations take years to accumulate, article downloads, mentions on Facebook, number of tweets on Twitter, and numerous other altmetrics have the considerable advantage of immediacy and can be logged by any reader, not only those authors who decide to subsequently cite certain publications. Although these new metrics are unlikely to replace traditional citations in assigning value to individual articles, along with them, they will be helpful in determining what must be read to maintain currency in one’s specialty.

So, readers of the surgical literature feel your newly found power and exert it. You along with your colleagues around the globe can, and in fact have an obligation to, play a role in determining what is worth reading from an ever-expanding volume of new information. Many eyes will almost certainly be better than relying solely on the opinions of a chosen few.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Peer review is the filter that determines what is published in the scientific literature and what is not allowed to see the light of day. It has been considered "the gatekeeper of science." In modern times, peer review has consisted of a journal editor sending a submitted article to a limited number of experts in the field who then judge its worth for publication. Many specialists see reviewing manuscripts as a service to their profession, put considerable effort into their analysis, and provide extensive comments on revisions needed to strengthen papers.

However, the value of this venerable process as it is presently constituted has been questioned by numerous critics. Because manuscripts are reviewed by a limited number of often rival scientists in a highly specialized field, the practice is prone to bias. Innovation may be stifled when reviewers reject outlier concepts that may be correct but that do not fit into the mainstream of thought. Critiques are often superficial as they are performed by otherwise busy individuals who receive no compensation for their efforts. Finally, journal editors are given undue power in the process. Not only do they make the final decision to publish or reject a manuscript, they are also responsible for selecting reviewers and are then free to ignore or accept their recommendations.

These criticisms of this time-honored system have led to a strong impetus for change. Coincident with the motivation for modifying this essential component of the publication process have been technological advancements that are facilitating new approaches. The Internet has provided a mechanism for making peer review a more open, inclusive process with any member of the scientific community who so desires having the opportunity to contribute to the evaluation of published work. A recent incident highlights how uninvited, but valuable, input from the wider scientific community can rapidly and effectively improve the accuracy of the literature.

On July 2, 2014, National Public Radio’s Morning Edition broadcast "Easy method for making stem cells was too good to be true" and a New York Times headline proclaimed "Stem cell research papers are retracted." In January 2014, Haruko Obokata of the RIKEN Centre for Developmental Biology in Japan published an innovative and considerably simpler method of producing stem cells than extracting them from embryos or making them from skin cells in a complicated and prolonged process (Nature 2014;505: 641-7). At the time of publication, the work was viewed by many to be potentially Nobel Prize-worthy research—that is, until the stem cell research community chimed in with its extensive and detailed post-publication peer review.

A number of research groups questioned Obokata’s conclusions. Some even attempted to replicate the experiments, but with no success. Soon the critics’ findings and opinions appeared on a variety of websites and blogs, including the Nature website. The RIKEN Centre took notice and appointed a committee to investigate the research. The committee found that Obokata had manipulated her data on at least two occasions and concluded that she had participated in research misconduct. Pressure mounted, which led to the recent voluntary retraction of the article by its authors.

This case represents an extreme outcome resulting from a failure of pre-publication vetting followed by a successful post-hoc peer review. But it demonstrates how the emerging and more comprehensive means of evaluating published research is rapidly working its way into the fabric of how science and the reporting of it operate. It would be ideal if this extensive vetting of potentially important research could be done prior to rather than after its release to the general public. Physics academicians have accomplished this by posting their research papers as pre-prints on-line for their colleagues to evaluate. Only after a successful conclusion of this process is a work deemed acceptable for entry into the physics literature. Submission of biomedical research to a similar process has a significant downside in that new, possibly harmful therapies, not yet peer-reviewed, could be adopted by practitioners and/or patients before their time. However, some modification of it will likely evolve and lead to a more accurate assessment of submitted work than the present process allows.

How publications are valued is also being modified thanks to the omnibus means of rapid communication allowed by an ever-expanding Internet. Bibliometrics, most notably the number of times an article is subsequently cited in print, has been the mainstay in determining the value of individual articles. The journal impact factor, which has historically been the main measure of a journal\'s standing compared to that of others in its field, is derived from the aggregate of citations for all articles over a period of time. With the advent of the Internet, a new set of alternative metrics (altmetrics) is now contributing to the evaluation of published work. While print citations take years to accumulate, article downloads, mentions on Facebook, number of tweets on Twitter, and numerous other altmetrics have the considerable advantage of immediacy and can be logged by any reader, not only those authors who decide to subsequently cite certain publications. Although these new metrics are unlikely to replace traditional citations in assigning value to individual articles, along with them, they will be helpful in determining what must be read to maintain currency in one’s specialty.

So, readers of the surgical literature feel your newly found power and exert it. You along with your colleagues around the globe can, and in fact have an obligation to, play a role in determining what is worth reading from an ever-expanding volume of new information. Many eyes will almost certainly be better than relying solely on the opinions of a chosen few.

Dr. Rikkers is Editor in Chief of ACS Surgery News.

Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

The trial will be conducted over 1 year, with residents’ opinions being surveyed at its midpoint. If patient outcomes are similar in the two arms or superior in the arm with more flexible rules and resident opinion is favorable, this would lend strong support for more flexibility in all general surgery residencies. As of this date, more than 100 general surgery programs have agreed to randomization.

The sponsoring agencies are to be congratulated for designing a trial that for the first time will objectively evaluate just how restrictive work rules need to be. Their efforts may effectively preserve a value that is at the core of our profession – the continuous care of our surgical patients.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

The trial will be conducted over 1 year, with residents’ opinions being surveyed at its midpoint. If patient outcomes are similar in the two arms or superior in the arm with more flexible rules and resident opinion is favorable, this would lend strong support for more flexibility in all general surgery residencies. As of this date, more than 100 general surgery programs have agreed to randomization.

The sponsoring agencies are to be congratulated for designing a trial that for the first time will objectively evaluate just how restrictive work rules need to be. Their efforts may effectively preserve a value that is at the core of our profession – the continuous care of our surgical patients.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Along with many others who are rapidly fading from the American surgical scene, I was born as a baby boomer. Most of us from that generation who embraced surgery as a career held fast to the values of the era. First and foremost among these was a high premium put on hard work, long hours, and an unwavering dedication to our profession and to our patients. We were particularly proud of the continuity of care that we provided to our patients.

During my early years as a surgeon, it was a 24/7 job. Saturday mornings were consumed by Surgery Grand Rounds followed by usually prolonged and detailed patient rounds. Most of us visited our hospitalized patients 7 days a week. When one of my patients developed a complication, I, rather than the surgeon on call, managed it. I missed soccer matches, baseball games, dance recitals, and even some family birthdays because etched into my conscience was the concept that duty to my patients trumped duty to my family. Although there is much to admire in this singular focus on patient care, it took its toll on the other aspects of what should be a more balanced professional life.

Two factors, one of them cultural and the other regulatory, have altered this all-consuming aspect of a surgeon’s life, with implications for the ideal of continuity of care. First was the arrival of freshly minted surgeons from generations X and Y who had a different set of priorities than their predecessors. They insisted on a more even balance between professional and family obligations. In part this resulted from the need for them to be more involved in child rearing since many of their spouses were engaged in time-intensive careers of their own. As they gravitated onto academic surgical faculties and joined private practice groups, they insisted on moving educational programs such as Surgery Grand Rounds to weekdays so they could participate in family activities. They entrusted the care of their patients to their partners, freeing them for entire weekends that could be devoted to family events.

The healthier balance they have brought to a career in surgery is to be admired. Much to the benefit of their senior colleagues, it has become their way of life as well. The trade-off has been some decay of the ideals of patient ownership and continuity of care.

The next and potentially more serious challenge to the cherished concept of continuous care of our patients was the mandate of an 80-hour work week by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. As to its effects on graduate surgical education, I believe the 80-hour work week has been a double-edged sword. On the positive side, at a time when interest in general surgery was waning, institution of duty hours restrictions along with the advent of minimally invasive surgery made our specialty more attractive to medical school graduates, including women, who now constitute 50% of most medical school classes. Another plus was that teaching hospitals were forced to hire physician extenders and other personnel to perform some of the noneducational tasks previously carried out by residents.

On the negative side, since many of the lost hours were in the evenings and weekends, residents’ exposure to urgent and emergency cases was diminished. More significantly, surgery residents began to work in shifts to accommodate increasingly inflexible rules. Ownership of their patients could no longer be held as a high priority in surgical education. Several classes of surgery residents who were educated under these fairly restrictive guidelines have now graduated and have brought a "shift mentality" with them to their positions in private practice groups and on academic faculties.

Since work hour restrictions are highly unlikely to disappear from our training programs and may in fact be applied in the future to all working physicians and surgeons, what can be done to preserve the time-honored value of continuous care of our patients? The answer probably lies in seeking reasonable flexibility within the rules rather than elimination of them. A bright light in this regard is an upcoming randomized controlled trial to assess the feasibility of more flexible work hours rules for general surgery residents. This trial is sponsored by the American Board of Surgery and the American College of Surgeons, and has the support of the ACGME. It will be conducted in hospitals that have instituted the National Surgical Quality Improvement Program (NSQIP) and also sponsor general surgery residencies. Beginning in July 2014, these residencies will be randomized to one of two arms – one using the extensive and rigid present duty hour standards and the second utilizing more flexible standards limited to an 80-hour work week, one night in three on call, and one day in seven free of clinical responsibilities, all averaged over a month. Patient outcomes in each arm will be determined from NSQIP data.

The trial will be conducted over 1 year, with residents’ opinions being surveyed at its midpoint. If patient outcomes are similar in the two arms or superior in the arm with more flexible rules and resident opinion is favorable, this would lend strong support for more flexibility in all general surgery residencies. As of this date, more than 100 general surgery programs have agreed to randomization.

The sponsoring agencies are to be congratulated for designing a trial that for the first time will objectively evaluate just how restrictive work rules need to be. Their efforts may effectively preserve a value that is at the core of our profession – the continuous care of our surgical patients.

Dr. Rikkers is the Editor in Chief of ACS Surgery News.

Although unraveling the human genome has been exciting and potentially beneficial, I was a bit dismayed to discover that our genes barely outnumber those of the chimpanzee and, in fact, are only 50% greater in number than those of the fruit fly. If they were able to communicate, even the most discriminating chimpanzee – and especially the humble fruit fly – would likely admit that they are several rungs below us on the animal kingdom ladder. Fortunately, it turns out that this is not the whole story.

The human microbiome project (HMP), close on the heels of the genome undertaking, has found that we have many more genes working for us than those located on the strands of our DNA. The HMP analysis reveals that each of us has more than 100 trillion microorganisms living in the many nooks and crannies of our bodies, with the highest concentration in the gastrointestinal tract. This population of microbes is incredibly diverse, and its exact composition is unique to each of us. Thus, in addition to the individuality granted to us by the genes we receive from our parents, each of us is also a distinctive and rather complex ecosystem.

Not only do these creatures live in and on us peacefully most of the time, they also add to our genetic complement. Whereas our DNA contains only 23,000 genes, these microorganisms in aggregate account for 100 times more genes, several of which transcribe proteins that are essential for our normal daily functioning. For example, they manufacture enzymes that allow digestion of complex carbohydrates that account for more than 10% of our daily calories and that would be indigestible if it were not for the contributions of this microscopic workforce. They also make a variety of vitamins (for example, folic acid, B₂, and B₁₂), and they have the capability of gearing production to one’s needs depending on diet and other circumstances. Furthermore, the microbiome likely plays a significant role in the development of our immune system.

When this large population of indigenous bacteria is in appropriate balance, all is well. However, when the equilibrium among species is disrupted by antibiotic therapy or other environmental influences, one or more of a long list of maladies may result. Alterations in the microbiome have been implicated as being a factor in diseases as diverse as colon and pancreatic cancer, diabetes, autism, multiple sclerosis, irritable bowel syndrome, and Clostridium difficile colitis. The latter, usually caused by antibiotic therapy, has even been treated successfully by restoring the microbiome to its normal state by means of a stool transplant from a normal donor. The relationship between the composition of the microbiome and the other disorders is less well understood but is fertile ground for further studies. Such investigations may open doors to future therapies for heretofore untreatable diseases.

Particularly fascinating is the association between the microbiome and the nutritional state. Since microbiomes play an important role in processing what we eat, it makes sense that these microscopic travelers might in part determine our body habitus. Dr. Jeffrey Gordon and his associates at Washington University, St. Louis, have investigated this intriguing prospect (Nature 2006;44:1022-3). They have shown in both animal and human studies that the composition of the microbiome is closely related to the degree of obesity or leanness of the subjects. Of the 100 or so known phyla of bacteria, only two, Bacteroidetes and Firmicutes, account for more than 90% of the microbes in our gastrointestinal tract. Obese mice and humans have a higher ratio of firmicutes to bacteroidetes than do their lean counterparts. Moreover, transplanting the microbiome from obese mice to germ-free animals results in an increase in the body fat of the latter group. Additionally, obese individuals who effectively diet over time increase their intestinal Bacteroidetes-to-Firmicutes ratio.

A common topic of discussion in Surgery News is the worldwide epidemic of obesity and its treatment with a variety of surgical procedures. It is within the realm of possibility that simply altering the microbiome of obese patients might help to resolve this affliction, which impairs the quality of life of so many.

So what is the gift that keeps on giving? It is our microbiome. For more than a century, bacteria have been considered one of the scourges of mankind. It is appropriate as the holiday season approaches that we finally acknowledge the contributions that these usually despised organisms make to our daily welfare. In turn and in the spirit of giving back, we can take some pride in the fact that we provide a warm and hospitable home for these friendly symbionts.

Dr. Rikkers is editor in chief of Surgery News.

Although unraveling the human genome has been exciting and potentially beneficial, I was a bit dismayed to discover that our genes barely outnumber those of the chimpanzee and, in fact, are only 50% greater in number than those of the fruit fly. If they were able to communicate, even the most discriminating chimpanzee – and especially the humble fruit fly – would likely admit that they are several rungs below us on the animal kingdom ladder. Fortunately, it turns out that this is not the whole story.

The human microbiome project (HMP), close on the heels of the genome undertaking, has found that we have many more genes working for us than those located on the strands of our DNA. The HMP analysis reveals that each of us has more than 100 trillion microorganisms living in the many nooks and crannies of our bodies, with the highest concentration in the gastrointestinal tract. This population of microbes is incredibly diverse, and its exact composition is unique to each of us. Thus, in addition to the individuality granted to us by the genes we receive from our parents, each of us is also a distinctive and rather complex ecosystem.

Not only do these creatures live in and on us peacefully most of the time, they also add to our genetic complement. Whereas our DNA contains only 23,000 genes, these microorganisms in aggregate account for 100 times more genes, several of which transcribe proteins that are essential for our normal daily functioning. For example, they manufacture enzymes that allow digestion of complex carbohydrates that account for more than 10% of our daily calories and that would be indigestible if it were not for the contributions of this microscopic workforce. They also make a variety of vitamins (for example, folic acid, B₂, and B₁₂), and they have the capability of gearing production to one’s needs depending on diet and other circumstances. Furthermore, the microbiome likely plays a significant role in the development of our immune system.

When this large population of indigenous bacteria is in appropriate balance, all is well. However, when the equilibrium among species is disrupted by antibiotic therapy or other environmental influences, one or more of a long list of maladies may result. Alterations in the microbiome have been implicated as being a factor in diseases as diverse as colon and pancreatic cancer, diabetes, autism, multiple sclerosis, irritable bowel syndrome, and Clostridium difficile colitis. The latter, usually caused by antibiotic therapy, has even been treated successfully by restoring the microbiome to its normal state by means of a stool transplant from a normal donor. The relationship between the composition of the microbiome and the other disorders is less well understood but is fertile ground for further studies. Such investigations may open doors to future therapies for heretofore untreatable diseases.

Particularly fascinating is the association between the microbiome and the nutritional state. Since microbiomes play an important role in processing what we eat, it makes sense that these microscopic travelers might in part determine our body habitus. Dr. Jeffrey Gordon and his associates at Washington University, St. Louis, have investigated this intriguing prospect (Nature 2006;44:1022-3). They have shown in both animal and human studies that the composition of the microbiome is closely related to the degree of obesity or leanness of the subjects. Of the 100 or so known phyla of bacteria, only two, Bacteroidetes and Firmicutes, account for more than 90% of the microbes in our gastrointestinal tract. Obese mice and humans have a higher ratio of firmicutes to bacteroidetes than do their lean counterparts. Moreover, transplanting the microbiome from obese mice to germ-free animals results in an increase in the body fat of the latter group. Additionally, obese individuals who effectively diet over time increase their intestinal Bacteroidetes-to-Firmicutes ratio.

A common topic of discussion in Surgery News is the worldwide epidemic of obesity and its treatment with a variety of surgical procedures. It is within the realm of possibility that simply altering the microbiome of obese patients might help to resolve this affliction, which impairs the quality of life of so many.

So what is the gift that keeps on giving? It is our microbiome. For more than a century, bacteria have been considered one of the scourges of mankind. It is appropriate as the holiday season approaches that we finally acknowledge the contributions that these usually despised organisms make to our daily welfare. In turn and in the spirit of giving back, we can take some pride in the fact that we provide a warm and hospitable home for these friendly symbionts.

Dr. Rikkers is editor in chief of Surgery News.

Although unraveling the human genome has been exciting and potentially beneficial, I was a bit dismayed to discover that our genes barely outnumber those of the chimpanzee and, in fact, are only 50% greater in number than those of the fruit fly. If they were able to communicate, even the most discriminating chimpanzee – and especially the humble fruit fly – would likely admit that they are several rungs below us on the animal kingdom ladder. Fortunately, it turns out that this is not the whole story.

The human microbiome project (HMP), close on the heels of the genome undertaking, has found that we have many more genes working for us than those located on the strands of our DNA. The HMP analysis reveals that each of us has more than 100 trillion microorganisms living in the many nooks and crannies of our bodies, with the highest concentration in the gastrointestinal tract. This population of microbes is incredibly diverse, and its exact composition is unique to each of us. Thus, in addition to the individuality granted to us by the genes we receive from our parents, each of us is also a distinctive and rather complex ecosystem.

Not only do these creatures live in and on us peacefully most of the time, they also add to our genetic complement. Whereas our DNA contains only 23,000 genes, these microorganisms in aggregate account for 100 times more genes, several of which transcribe proteins that are essential for our normal daily functioning. For example, they manufacture enzymes that allow digestion of complex carbohydrates that account for more than 10% of our daily calories and that would be indigestible if it were not for the contributions of this microscopic workforce. They also make a variety of vitamins (for example, folic acid, B₂, and B₁₂), and they have the capability of gearing production to one’s needs depending on diet and other circumstances. Furthermore, the microbiome likely plays a significant role in the development of our immune system.

When this large population of indigenous bacteria is in appropriate balance, all is well. However, when the equilibrium among species is disrupted by antibiotic therapy or other environmental influences, one or more of a long list of maladies may result. Alterations in the microbiome have been implicated as being a factor in diseases as diverse as colon and pancreatic cancer, diabetes, autism, multiple sclerosis, irritable bowel syndrome, and Clostridium difficile colitis. The latter, usually caused by antibiotic therapy, has even been treated successfully by restoring the microbiome to its normal state by means of a stool transplant from a normal donor. The relationship between the composition of the microbiome and the other disorders is less well understood but is fertile ground for further studies. Such investigations may open doors to future therapies for heretofore untreatable diseases.

Particularly fascinating is the association between the microbiome and the nutritional state. Since microbiomes play an important role in processing what we eat, it makes sense that these microscopic travelers might in part determine our body habitus. Dr. Jeffrey Gordon and his associates at Washington University, St. Louis, have investigated this intriguing prospect (Nature 2006;44:1022-3). They have shown in both animal and human studies that the composition of the microbiome is closely related to the degree of obesity or leanness of the subjects. Of the 100 or so known phyla of bacteria, only two, Bacteroidetes and Firmicutes, account for more than 90% of the microbes in our gastrointestinal tract. Obese mice and humans have a higher ratio of firmicutes to bacteroidetes than do their lean counterparts. Moreover, transplanting the microbiome from obese mice to germ-free animals results in an increase in the body fat of the latter group. Additionally, obese individuals who effectively diet over time increase their intestinal Bacteroidetes-to-Firmicutes ratio.

A common topic of discussion in Surgery News is the worldwide epidemic of obesity and its treatment with a variety of surgical procedures. It is within the realm of possibility that simply altering the microbiome of obese patients might help to resolve this affliction, which impairs the quality of life of so many.

So what is the gift that keeps on giving? It is our microbiome. For more than a century, bacteria have been considered one of the scourges of mankind. It is appropriate as the holiday season approaches that we finally acknowledge the contributions that these usually despised organisms make to our daily welfare. In turn and in the spirit of giving back, we can take some pride in the fact that we provide a warm and hospitable home for these friendly symbionts.

Dr. Rikkers is editor in chief of Surgery News.

Following several tragic aviation disasters in the 1970s, the airline industry adopted a training method called Crew Resource Management (CRM) to enhance safety of commercial flights. The essentials of this new concept included checklists, briefings, and a flattening of the hierarchy in the cockpit that encouraged all crew members to express their opinions, even when in conflict with those of the captain.

The results of CRM training have been astonishing. There were no deaths secondary to airline crashes during 2007 and 2008, a period in which commercial airliners transported 1.5 billion passengers. And according to Arnold Barnett, Ph.D., a professor at Massachusetts Institute of Technology, Cambridge, who has written extensively about airline fatality risks, it’s more likely for a young child to be elected president than to die in an airline accident in the United States or similar industrial nations (USA Today, Jan. 11, 2009).

Considering the similarities between the cockpit and the operating room – intense environment, dependence on elaborate equipment, multidisciplinary team dynamics, a historically rigid hierarchy, and the potential for catastrophic results – there has been considerable interest in using CRM training to improve safety in the OR. In fact, a mini-industry of CRM training consultants has arisen and made themselves readily available to those hospitals desirous of pursuing this course. Early results suggest that such an approach improves communication among OR team members, enhances efficiency, and decreases the incidence of complications.

Practices such as checklists and briefings are relatively easy to transfer to the operating room. But what about flattening the rigid hierarchy that has long been a central component of surgical culture? As soon as a surgeon enters the OR, a steep power differential develops between that surgeon and all other members of the team. This power differential can inhibit team members who are often hesitant to express their opinions. Unfortunately, many surgeons enjoy their exalted positions. In a survey of airline pilots and surgeons, 97% of pilots, but only 55% of surgeons, rejected hierarchies (BMJ 2000;320:745-9).

Leveling the playing field within the OR can occur only if the surgeon exhibits strong, inclusive leadership. After the time-out (briefing), during which the surgeon must be present and OR team members are introduced to the anesthesia and nursing staff, the need for open communication in the name of safety should be stressed. The surgeon should share examples of times in the past when observations by junior members of the team helped resolve difficult situations. While not relinquishing the team leader role, the surgeon should emphasize that thoughtful input by all team members is highly valued and is likely to enhance the safety and the outcome of the procedure.

To further encourage those who may be timid about sharing their observations, the surgeon should directly solicit input from team members as the operation proceeds. If their opinions are off the mark, the surgeon should avoid public criticism and instead offer feedback constructively and in private after the operation is concluded. Harsh public criticism is an effective way to permanently silence a nurse or junior colleague.

Actions often speak louder than words. Calling or inviting a colleague into the OR for his or her opinion during a procedure is a powerful statement that the surgeon is willing to be guided by the advice of others. Even when it was not necessary, I sometimes did this to emphasize to my residents that inviting advice or assistance can be a wise choice rather than a sign of weakness.

To replicate the impressive record of safety achieved by the airline industry, surgeons must move away from an authoritative and commanding style of leadership, and instead adopt an inclusive style that encourages and values input from everyone – even those on the lowest rungs of the surgical hierarchy. The result will be enhanced communication, better efficiency, a safer environment, a more congenial atmosphere and, most importantly, improved outcomes for our patients.

Dr. Rikkers is editor in chief of Surgery News, a publication of Elsevier.

Following several tragic aviation disasters in the 1970s, the airline industry adopted a training method called Crew Resource Management (CRM) to enhance safety of commercial flights. The essentials of this new concept included checklists, briefings, and a flattening of the hierarchy in the cockpit that encouraged all crew members to express their opinions, even when in conflict with those of the captain.

The results of CRM training have been astonishing. There were no deaths secondary to airline crashes during 2007 and 2008, a period in which commercial airliners transported 1.5 billion passengers. And according to Arnold Barnett, Ph.D., a professor at Massachusetts Institute of Technology, Cambridge, who has written extensively about airline fatality risks, it’s more likely for a young child to be elected president than to die in an airline accident in the United States or similar industrial nations (USA Today, Jan. 11, 2009).

Considering the similarities between the cockpit and the operating room – intense environment, dependence on elaborate equipment, multidisciplinary team dynamics, a historically rigid hierarchy, and the potential for catastrophic results – there has been considerable interest in using CRM training to improve safety in the OR. In fact, a mini-industry of CRM training consultants has arisen and made themselves readily available to those hospitals desirous of pursuing this course. Early results suggest that such an approach improves communication among OR team members, enhances efficiency, and decreases the incidence of complications.

Practices such as checklists and briefings are relatively easy to transfer to the operating room. But what about flattening the rigid hierarchy that has long been a central component of surgical culture? As soon as a surgeon enters the OR, a steep power differential develops between that surgeon and all other members of the team. This power differential can inhibit team members who are often hesitant to express their opinions. Unfortunately, many surgeons enjoy their exalted positions. In a survey of airline pilots and surgeons, 97% of pilots, but only 55% of surgeons, rejected hierarchies (BMJ 2000;320:745-9).

Leveling the playing field within the OR can occur only if the surgeon exhibits strong, inclusive leadership. After the time-out (briefing), during which the surgeon must be present and OR team members are introduced to the anesthesia and nursing staff, the need for open communication in the name of safety should be stressed. The surgeon should share examples of times in the past when observations by junior members of the team helped resolve difficult situations. While not relinquishing the team leader role, the surgeon should emphasize that thoughtful input by all team members is highly valued and is likely to enhance the safety and the outcome of the procedure.

To further encourage those who may be timid about sharing their observations, the surgeon should directly solicit input from team members as the operation proceeds. If their opinions are off the mark, the surgeon should avoid public criticism and instead offer feedback constructively and in private after the operation is concluded. Harsh public criticism is an effective way to permanently silence a nurse or junior colleague.

Actions often speak louder than words. Calling or inviting a colleague into the OR for his or her opinion during a procedure is a powerful statement that the surgeon is willing to be guided by the advice of others. Even when it was not necessary, I sometimes did this to emphasize to my residents that inviting advice or assistance can be a wise choice rather than a sign of weakness.

To replicate the impressive record of safety achieved by the airline industry, surgeons must move away from an authoritative and commanding style of leadership, and instead adopt an inclusive style that encourages and values input from everyone – even those on the lowest rungs of the surgical hierarchy. The result will be enhanced communication, better efficiency, a safer environment, a more congenial atmosphere and, most importantly, improved outcomes for our patients.

Dr. Rikkers is editor in chief of Surgery News, a publication of Elsevier.

Following several tragic aviation disasters in the 1970s, the airline industry adopted a training method called Crew Resource Management (CRM) to enhance safety of commercial flights. The essentials of this new concept included checklists, briefings, and a flattening of the hierarchy in the cockpit that encouraged all crew members to express their opinions, even when in conflict with those of the captain.

The results of CRM training have been astonishing. There were no deaths secondary to airline crashes during 2007 and 2008, a period in which commercial airliners transported 1.5 billion passengers. And according to Arnold Barnett, Ph.D., a professor at Massachusetts Institute of Technology, Cambridge, who has written extensively about airline fatality risks, it’s more likely for a young child to be elected president than to die in an airline accident in the United States or similar industrial nations (USA Today, Jan. 11, 2009).

Considering the similarities between the cockpit and the operating room – intense environment, dependence on elaborate equipment, multidisciplinary team dynamics, a historically rigid hierarchy, and the potential for catastrophic results – there has been considerable interest in using CRM training to improve safety in the OR. In fact, a mini-industry of CRM training consultants has arisen and made themselves readily available to those hospitals desirous of pursuing this course. Early results suggest that such an approach improves communication among OR team members, enhances efficiency, and decreases the incidence of complications.

Practices such as checklists and briefings are relatively easy to transfer to the operating room. But what about flattening the rigid hierarchy that has long been a central component of surgical culture? As soon as a surgeon enters the OR, a steep power differential develops between that surgeon and all other members of the team. This power differential can inhibit team members who are often hesitant to express their opinions. Unfortunately, many surgeons enjoy their exalted positions. In a survey of airline pilots and surgeons, 97% of pilots, but only 55% of surgeons, rejected hierarchies (BMJ 2000;320:745-9).

Leveling the playing field within the OR can occur only if the surgeon exhibits strong, inclusive leadership. After the time-out (briefing), during which the surgeon must be present and OR team members are introduced to the anesthesia and nursing staff, the need for open communication in the name of safety should be stressed. The surgeon should share examples of times in the past when observations by junior members of the team helped resolve difficult situations. While not relinquishing the team leader role, the surgeon should emphasize that thoughtful input by all team members is highly valued and is likely to enhance the safety and the outcome of the procedure.

To further encourage those who may be timid about sharing their observations, the surgeon should directly solicit input from team members as the operation proceeds. If their opinions are off the mark, the surgeon should avoid public criticism and instead offer feedback constructively and in private after the operation is concluded. Harsh public criticism is an effective way to permanently silence a nurse or junior colleague.

Actions often speak louder than words. Calling or inviting a colleague into the OR for his or her opinion during a procedure is a powerful statement that the surgeon is willing to be guided by the advice of others. Even when it was not necessary, I sometimes did this to emphasize to my residents that inviting advice or assistance can be a wise choice rather than a sign of weakness.

To replicate the impressive record of safety achieved by the airline industry, surgeons must move away from an authoritative and commanding style of leadership, and instead adopt an inclusive style that encourages and values input from everyone – even those on the lowest rungs of the surgical hierarchy. The result will be enhanced communication, better efficiency, a safer environment, a more congenial atmosphere and, most importantly, improved outcomes for our patients.

Dr. Rikkers is editor in chief of Surgery News, a publication of Elsevier.