Dr. Gustavo Stringel is an experienced surgeon currently serving as the chief of pediatric surgery at the Maria Fareri Children's Hospital in Valhalla, New York. Gustavo Stringel holds memberships to several medical organizations, including the Society of Laparoendoscopic Surgeons (SLS).

The SLS is a nonprofit organization that works to improve the practice of laparoscopic and endoscopic surgery through education and the dissemination of new and established ideas, techniques, and therapies. The largest society of its kind in North America, the SLS has a membership of over 6,000 individuals who are primarily physicians from various specialties, but SLS membership also includes nurses, technicians, midlevel providers, and other health professionals.

In fulfilling its mission, the SLS conducts several activities each year, including conferences, postgraduate courses, and workshops that help advance laparoscopic and endoscopic techniques and procedures, and assist in fostering the productive exchange of ideas. These events and activities also work to improve physicians' skills and ultimately promote better patient care. In addition, the SLS publishes a scholarly, peer-reviewed journal that has further served the organization's mission since 1997 by helping spread the newest ideas in the field of minimally invasive surgery.

A distinguished health care leader and an accomplished physician, Dr. Gustavo Stringel serves as surgeon-in-chief and director of pediatric and minimally-invasive surgery at the Maria Fareri Children’s Hospital in Valhalla, New York. Gustavo Stringel holds a master of business administration and has earned the prestigious Certified Physician Executive designation from the American College of Physician Executives. 

Established in 1975, the American College of Physician Executives (ACPE) is the world’s most prominent association for physicians who fulfill leadership and management roles. The ACPE has more than 10,000 members in 46 countries. The group’s membership includes allopathic and osteopathic physicians, podiatrists, and dentists. The ACPE provides opportunities for its members to develop and enhance their supervisory and administrative skills through continuing education and training, career counseling, and networking. Through its chartered corporation, the Certifying Commission in Medical Management, the ACPE also offers the Certified Physician Executive (CPE) distinction to physician executives who have consistently displayed excellence in their professional life.

To attain the CPE status, a licensed medical doctor or doctor of osteopathy must hold board certification and one year of management experience. In addition, they must possess three years of clinical experience following residency and fellowship as well as a management degree or 150 hours of verified management education. Physicians are also required to complete a rigorous four-day certification program. In a competitive health care marketplace, the Certified Physician Executive credential shows a strong commitment to innovative and knowledgeable leadership.

One of the most common ways that we measure experience is time spent performing a job or task. The measurement is especially true of individuals in the health care profession, where the first question a patient often asks is how long a doctor or surgeon has been practicing.

However, instead of the long 100-hour work week, many hospitals are mandating shorter work week hours for their residents and surgeons. The trend is not merely limited to the United States: England, Sweden, and other countries are also experimenting with shorter work weeks.

Experts propose several arguments in favor of shortening the work weeks, including a desire to reduce preventable and non-preventable errors. However, the fact remains that less time spent in the hospital means less time for a surgeon or resident to perfect his or her skills.

In an article published in the Journal of the Society of Laparoendoscopic Surgeons, Dr. Gustavo Stringel proposed five integrated approaches to make the most of a surgeon’s remaining work hours. They include reorganizing the educational system to account for an individual surgeon’s cognitive abilities and psychomotor skills, integrating effective feedback into a surgeon’s professional career, and making the use of simulators a bigger part of the surgeon’s training experience. Dr. Stringel also proposed taking a new look at how surgical residents are motivated, perhaps even borrowing from the business world, where motivation is a key issue.

Most of all, Dr. Stringel stressed the ongoing importance of being aware of the challenges inherent in a new system in which surgeons and residents are spending less time in the hospital, and in surgery, than their predecessors. The number of hours worked is an excellent way to measure a surgeon’s expertise, but it may not be the only way.

As Surgeon in Chief as well as Chief of Pediatric Surgery at Maria Fareri Children’s Hospital in Valhalla, New York, Dr. Gustavo Stringel treats a number of common childhood conditions. One illness that causes many parents to seek care for their children is gastroenteritis.

According to Dr. Gustavo Stringel, while gastroenteritis is commonly referred to as stomach flu, it isn’t a form of influenza. Instead, the condition arises as the result of an inflammation and irritation of the gastrointestinal tract. Children with this condition may present with abdominal pain and cramping, nausea, diarrhea, vomiting, and fever.

No single cause exists for gastroenteritis. Rather, it can arise from viral, parasitical, or bacterial infection. In the case of bacterial infection, the condition may come from either infectious or food-borne types of bacteria.

One of the primary dangers of gastroenteritis, especially in children, is dehydration, brought about by prolonged nausea and vomiting. Parents should frequently offer small amounts of clear liquids to replenish lost fluids. Parents concerned about dehydration should seek advice from their doctor. Likewise, if the child is vomiting blood or expressing black or bloody stool, seek emergency medical care immediately.

Dr. Gustavo Stringel, a widely respected laparoscopic surgeon, is the Chief of Pediatric Surgery and Surgeon in Chief at Maria Fareri Children's Hospital in Valhalla, New York, as well as a Professor of Surgery and Pediatrics. In his short paper, “How To Make the Most of the Hours We Have Left,” Dr. Stringel argues that recent limits set throughout the Western world on the number of hours that surgical residents are allowed to work each week has led to a different type of residency education than he and his peers were subjected to in decades past.

He points out that previously, before limits had been set, surgeons in residence often worked for 100 or more hours per week, which had numerous benefits. The sheer amount of experience a surgeon could expect to accrue over a five-year residency was far in excess of author Malcolm Gladwell's “10,000 hour rule,” which posits that 10,000 is the minimum number of hours required to gain working proficiency in any skilled endeavor.

Additionally, being able to stay on shift as long as was deemed necessary allowed surgical residents to provide continuous, knowledgeable care and support to their patients, whereas a resident forced to leave at an arbitrary time might be handing the care of patients off to others without giving them all the information they need to continue providing adequate care. He also notes that most experienced surgeons agree that during residency, a great learning opportunity may present itself at nearly any time. Working extremely long shifts allowed residents in previous years to increase the chances that they would be on hand for any such opportunity.

Dr. Stringel avoids the contentious question of whether or not the new work week limitations are having an adverse effect on new surgical residents, but he firmly maintains that such limitations have changed the face of the residency process. Therefore, to ensure continued effectiveness, surgeons must be open to changes in the way residencies are conducted.

Appendicitis, the most common condition among children that requires emergency abdominal surgery, presents in as many as 8 percent of pediatric patients who visit the emergency room for acute abdominal pain. Most pediatric appendectomies can be performed as a laparoscopic, or minimally invasive, surgery. A laparoscopic appendectomy generally involves three very small (5-12 mm) incisions to admit a camera, surgical instruments, and a tube for injecting air into the abdomen. The inflation provides higher visibility for the surgeon. Uncomplicated appendicitis is often treated with a single-access laparoscopy, which requires only one incision. Patients undergo laparoscopic appendectomy under general anesthesia.

Laparoscopic surgery offers some potential advantages over open surgery, including an opportunity to examine the entire abdomen, which is useful in cases of uncertain diagnosis. For example, some gynecological conditions in adolescent female patients cause symptoms similar to appendicitis. Laparoscopic appendectomy also provides a useful alternative to open surgery for patients suffering from obesity.

A detailed article on pediatric laparoscopic surgery is available at laparoscopy.blogs.com/prevention_management_3/2010/11/laparoscopic-pediatric-surgery.html

About the Author: 

Dr. Gustavo Stringel, a surgeon with extensive experience in pediatric surgery and laparoscopy, currently serves as Surgeon in Chief at the Maria Fareri Children's Hospital in Valhalla, New York. Since accepting the position in 1994, Dr. Gustavo Stringel has taken a leading role in developing the hospital's minimally invasive and laparoscopic surgery capabilities.

Thoracoscopy, historically known as pleuroscopy, refers to a diagnostic or surgical procedure that facilitates the direct visual examination of structures inside the thoracic and pleural cavities of the chest. Thoracoscopy is performed using a specialized instrument with an external light source and a lens for imaging on an external monitor. Video-assisted thoracoscopic surgery, or VATS, comprises a variety of techniques and procedures involving one or more small incisions. VATS typically requires either general anesthesia or local anesthesia combined with sedation. 

Thoracoscopy, a minimally invasive diagnostic and therapeutic procedure, allows clinicians to collect precise tissue samples from the pleura with the aid of sophisticated viewing equipment. Thoracoscopy enables surgeons to make reliable diagnoses when investigating abnormal pleural fluid or pleural thickening. Several diagnostic tests, such as computed axial tomography or transbronchial biopsy, also exist for diagnosing pleural pathology, but thoracoscopy exhibits a higher success rate in detecting pleural disease. 

About Dr. Gustavo Stringel: Gustavo Stringel, M.D., has presented and published research on several medical pulmonary topics, including video-assisted thoracoscopy. Currently holding the position of Surgeon in Chief at the Maria Fareri Children’s Hospital in Valhalla, New York, Dr. Stringel has performed a wide variety of laparoscopic procedures over the course of his career, including laparoscopic appendectomies, laparoscopic cholecystectomies, and diagnostic laparotomies.

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.

• Time is of the Essence – Part I