Journal of Surgical Education

Editorial Board

2010-05-01

A Team Approach in Communication Instruction: A Qualitative Description

Edward P. Polack, Theodore A. Avtgis, Daniel C. Rossi, Linda Shaffer — 2010-05-14

Objective: To establish communication instructional goals and objectives (IGOs) adapted to a postgraduate surgical residency program.Design: The curriculum that was tested in the current study is predicated on the following concepts: Leadership is a communication skill, not a medical skill; perception and interpretation are individual events and always will be imperfect; team is a relational-based concept, not a medical one; the concept of a perfect world is unrealistic and should not be the focus of any communication skills training; and change cannot occur locally if it is not nurtured globally.Results: A communication curriculum designed to teach “affirming communication” as well as to focus on how acquiring the knowledge and skill associated with competent communication can result in positive organizational and clinical outcomes were tested using subjects from a rural trauma network. Statistically significant findings were observed regarding knowledge acquisition as well as perceptions and attitudes toward communication.Conclusion: Any communication curriculum designed to educate needs to be grounded theoretically in both communication and medicine. Personnel from both disciplines need to be consulted in efforts to design a curriculum based in the social sciences yet applicable to surgery.

Assuring the Research Competence of Orthopedic Graduates

Emmanuel K. Konstantakos, Richard T. Laughlin, Ronald J. Markert, Lynn A. Crosby — 2010-05-01

Objectives: To assure that orthopaedic residents have the knowledge needed to critically appraise the medical/surgical literature and the skills needed to design and conduct musculoskeletal and orthopaedic research.Setting: Residency program of the Department of Orthopaedic Surgery, Sports Medicine and Rehabilitation at Wright State University Boonshoft School of Medicine, Dayton, Ohio.Participants: Established in 2005, members of the residency program’s Research Team (RT) include orthopaedic faculty and residents, university faculty and graduate students, community scientists, and department staff.Methods: The membership and responsibilities of the Research Team are described. The goals of the three-month research rotation during the second year of residency and the activities of the assigned resident are reported. The work of the two research residents during the second year of their six-year program is explained. Helpful educational resources are noted, the role of the faculty research mentor defined, funding sources listed, and the financial support for RT members and research staff presented.Results: The scholarly activity of orthopaedic surgery residents increased substantially from the five-year period before the implementation of the Research Team (September 2000 through August 2005) to the four-year period after initiation of the RT (September 2005 through November 2009). For peer-reviewed scholarship activity, publications on which residents were authors increased from 1 to 10 per year, national presentations at professional meetings increased from 6 to 11 per year, and local and regional presentations increased from 2 to 4 per year.Conclusions: The Research Team is an effective strategy for assuring that orthopaedic residents have the knowledge and skills to evaluate clinical care evidence and to conduct musculoskeletal and orthopaedic research.

Educational Resources for the Orthopedic In-Training Examination

2010-05-01

Objective: Various educational tools are available for the Orthopedic In-Training Examination (OITE). However, many residents are unsure of which resources are the most useful. This study assessed what educational resources residents consider to be most useful and how the top performers prepare for the examination.Methods: A web-based survey was distributed to orthopedic residency programs. Residents indicated their program type, year in residency, and most recent OITE score. They also rated (0-4 points) the value of various educational resources. An χ2 analysis identified resources that were used more frequently by residents who scored in the top 20%. We compared the useful educational resources identified by the entire group, as well as by the top 20% of residents, with what has been the most commonly cited recommended references for the OITE during a 5-year period.Results: Three hundred and sixty residents completed the OITE questionnaire. The journal that was most commonly used by orthopedic residents to prepare for the OITE was the Journal of the American Academy of Orthopedic Surgeons (n = 257, 71%). However, this journal was the third most frequently cited reference for the OITE. Past OITE questions were the highest scored resource with 215 (60%) residents rating them as a 4 (“very useful”). The residents who scored in the top 20% participated in more surgical cases than the other residents (53% vs 35% with 350 or more cases in each group, respectively).Conclusions: The results of this study suggest that many residents, especially those who do well on the OITE, are using the American Academy of Orthopedic Surgeons self-assessment examinations. The results also support the educational importance of exposure to surgical cases in addition to reading and reviewing journals and/or textbooks.

Evaluation of the Orthopaedic In-Training Examination: Spine Questions

Payam Farjoodi, A. Jay Khanna, David R. Marker, Frank J. Frassica — 2010-05-01

Background: The annual Orthopaedic In-Training Examination (OITE) is an objective evaluation administered annually to all residents by the American Academy of Orthopaedic Surgeons. To our knowledge, there are no guidelines for the type of material included on the examination; therefore, it is difficult for many academic centers to develop education programs directed toward improving resident performance on the OITE. Our goals were to determine the most commonly tested subjects in the spine portion of the OITE and to help direct development of an associated teaching program.Methods: We analyzed the number, type, anatomic focus, subject matter, and visual diagnostic modalities of spine questions on the OITEs from 2002 through 2007 and identified the most commonly referenced journals.Results: The average annual number of spine questions was 23.1 (8.4% of the examination). The most common types of spine questions related to knowledge (44.5%), evaluation and decision making (29.1%), and diagnosis (26.3%); the most common subject matters were trauma (15.1%) and anatomy (13.7%). The most frequently examined anatomic locations were the cervical (30.9% of questions) and lumbar (17.4%) spines. General spine information (no anatomic focus) accounted for 31.6% of questions. The most commonly referenced journals were Spine and The Journal of Bone and Joint Surgery, American Volume.Conclusions: Developing a study plan focusing on these journals and the most commonly tested topics and question types will better prepare orthopedic residents for the spine questions on the OITE.

Global Surgery: Thoughts on an Emerging Surgical Subspecialty for Students and Residents

Jeffrey J. Leow, T. Peter Kingham, Kathleen M. Casey, Adam L. Kushner — 2010-06-01

Interest is growing in global health among surgical residents and medical students. This article explores the newly developing concept of “global surgery.” Providing surgical care to resource-limited populations, often found in low- and middle-income countries, has numerous professional and personal developmental benefits. A significant interest is found among most general surgical residents; however, it is necessary to formalize more exchange programs and fellowships like some institutions have done. Medical schools also should establish similar global clinical electives to channel the exuberance of students, develop properly their global health interests, and expose them early to the realities and health needs of the global population. Current opportunities for medical students and residents are reviewed along with the relevant literature.

How Important Are American Board of Surgery In-Training Examination Scores When Applying for Fellowships?

Aaron T. Miller, Gary William Swain, Maria Widmar, Celia M. Divino — 2010-04-22

Background: The American Board of Surgery In-Training examination (ABSITE) first was administered in 1975 to evaluate a resident's general knowledge as well as the deficiencies within the resident and surgical program. The added importance of this examination in recent years stems from a correlation between ABSITE performance and performance on the American Board of Surgery qualifying examination. However, data are lacking in regard to how fellowship programs view ABSITE scores when considering applicants. Thus, this study was initiated to determine the importance of the ABSITE for surgical residents applying to fellowships.Study Design: Program coordinators and directors of various surgical fellowships were sent a short survey in regard to the ABSITE. The data then were analyzed.Results: One hundred forty-eight surveys were completed, with 74.8% of the programs ranking the importance of ABSITE scores as 3 or 4 (on a scale of 1 through 5). Most programs (78.9%) reported no minimum percentile requirement. Those that did required a mean percentile of 54.4. Of the programs, 57.8% placed a greater emphasis on the senior examination versus the junior examination (p = 0.06). When compared with other application factors, the ABSITE score ranked 3rd behind letters of recommendation and a candidate's residency program. Colon and rectal surgery placed the highest importance on ABSITE scores, whereas transplant surgery placed the lowest importance.Conclusion: The ABSITE score is an important factor for residents applying to surgical fellowship; however, more weight is given to candidates' letters of recommendation and his or her residency program. Applicants should aim to score above the 50th percentile to be competitive for most fellowship programs.

Is Basic Emergency Ultrasound Training Feasible as Part of Standard Undergraduate Medical Education?

2010-05-21

Objective: Bedside ultrasonography is regularly used by surgeons and emergency physicians to perform focused assessment with sonography in trauma (FAST) in acutely-injured patients. Despite this, there is no formal ultrasound training in UK undergraduate curricula and postgraduate accreditation remains difficult to achieve. This study aims to assess the feasibility of teaching basic ultrasound skills to undergraduates using FAST scanning as a model module.Design/Setting: Students were enrolled in a 5-hour theoretical and practical FAST scanning course. Ultrasound scanning competencies were ascertained using a 1-hour formal objective structured clinical examination (OSCE) assessment consisting of case-based discussions, problem-solving exercises, a complete FAST scan on a human volunteer, and free fluid detection exercises in organic simulators. A questionnaire was used to ascertain students' opinion on ultrasonography in undergraduate training.Participants: Twenty-five volunteer medical students (years 3 and 5) from a London medical school.Results: Students did not have prior experience of formal ultrasound training. The mean score achieved in the summative assessment was 86%. Eighty-five percent of students completed a full FAST scan at an adequate level of performance in under 6 minutes. The feedback survey indicated that all students felt confident in operating the ultrasound apparatus and were able to obtain good quality images at the end of the 5-hour course. Eighty-eight percent of students thought ultrasonography was relevant to their training; all students intended to seek formal ultrasound accreditation; 92% believed ultrasound training should be a regular component of the curriculum; and 96% of students preferred using cart-based ultrasound machines rather than hand-held devices.Conclusions: Undergraduate ultrasound tuition is an achievable educational goal which is well received by medical students. Medical schools need to consider the formal introduction of ultrasound teaching in their curricula to equip future doctors with relevant skill sets. The role of handheld ultrasound machines requires further investigation.

“July Effect” and Appendicitis

Arezou Yaghoubian, Christian de Virgilio, Vicki Chiu, Steven L. Lee — 2010-05-01

Background: Patients at teaching hospitals often worry about the involvement of inexperienced surgical residents in their care. The most apparent time that physician inexperience would affect surgical outcomes would be in July, which is the start of residency training. The purpose of our study was to determine whether the morbidity related to the management of appendicitis was higher in the beginning of the academic year.Methods: A retrospective review of all appendicitis cases between 1998 and 2007 at 2 public teaching hospitals was conducted. An analysis was performed comparing all appendicitis cases in July/August versus all other months of the academic year. The outcome variables were wound infection rate, postoperative abscess drainage rate, and length of hospitalization (LOH).Results: A total of 4325 patients were included in the study. Patient demographics and appendiceal perforation rate were similar between July/August and the rest of the year. Wound infection rate, postoperative abscess drainage rate, and LOH were also similar between these 2 time periods.Conclusions: Appendicitis outcomes were similar in the beginning of the academic year in comparison with the remaining months. These findings suggest that patients with acute appendicitis can safely undergo emergency surgery early in the training year.

Laparoscopic Colectomy In Octogenarians and Nonagenarians: A Preferable Option to Open Surgery?

2010-05-14

Objectives: To determine if laparoscopic colectomy is safer and more effective than open colectomy in patients older than 80 years of age.Methods: An operating room database of all colectomies performed on patients ≥80 years, from January 2002 to September 2007, was analyzed retrospectively. Data reviewed included type of operation, type of resection, length of procedure, length of stay (LOS), estimated blood loss, American Society of Anesthesiologists (ASA) grade, diagnosis, complications, mortality rates, and discharge destination, with p-values <0.05 considered significant.Results: One hundred thirty-nine patients underwent open procedures (Open group) during the study period versus 150 patients who underwent laparoscopic procedures (Lap group). Of the Lap group, 15 patients were converted to open cases. Forty-four patients from the Open group were excluded from the analysis as they were treated emergently, leaving 95 patients in the Open group. The mortality for open procedures was significantly higher at 9/95 (9.4%), compared with 3/150 (2%) following laparoscopic procedures (p = 0.0132). LOS was significantly longer for open procedures (11.16 days) versus laparoscopic procedures (7.11 days), p = 0.0001. Open procedures were associated with an increased risk of postoperative ileus (p < 0.02). The Open group had a higher likelihood of discharge to a nursing facility (43/87) than the Lap group (33/147), p < 0.0001. There were no significant differences in the length of procedure, estimated blood loss and postoperative complications.Conclusions: Laparoscopic colectomy is a safer option that offers an improved outcome compared with open colectomy in elderly patients. Significant improvements in LOS, mortality rates, and discharge destination were observed.

Retrospective Evaluation of Residents' American Board of Surgery In-Service Training Examination (ABSITE) Scores as a Tool to Evaluate Changes Made in a Basic Science Curriculum

Matthew W. Lube, Karen R. Borman, Ava E. Fulbright, Mark L. Friedell — 2010-04-22

Objective: To evaluate the effectiveness of a new basic science curriculum at a university-affiliated general surgery residency program.Design: A retrospective evaluation of general surgery residents' American Board of Surgery (ABS) In-Training Examination (ABSITE) scores before and after the implementation of a new basic science curriculum.Setting: Not-for-profit tertiary referral center with a university-affiliated Accreditation Council for Graduate Medical Education (ACGME) accredited community general surgery residency program.Participants: Postgraduate year (PGY) 1 through 5 general surgical residents.Results: The total questions answered correctly (percent correct) in the main 3 categories improved after implementation of the new curriculum for PGY 1 (total test: 70 ± 7 vs 60 ± 9, p < 0.05; clinical science: 71 ± 10 vs 59 ± 9, p < 0.05; and basic science: 69 ± 7 vs 60 ± 10, p = 0.0003) and for PGY 2 residents (total test: 74 ± 5 vs 66 ± 7, p < 0.05; clinical science: 74 ± 7 vs 66 ± 8, p = 0.003; and basic science: 74 ± 5 vs 66 ± 8, p < 0.05). With the exception of the percentage of clinical questions answered correctly for the PGY 4 level, there was no statistically significant worsening of scores in any other subcategories for any other PGY levels (3 through 5) after implementation of the new program. Before the institution of the new curriculum, 24% (26/110) of residents scored below the 35th percentile, and after the institution of the new curriculum, this number decreased to 12% (12/98), p = 0.006. The first-time passage rate on the ABS Qualifying Examination was unchanged in the period before and after the implementation of the new curriculum (89% vs 86%; p = 0.08). When comparing the bimonthly quizzes with the ABSITE, the correlation coefficient was 0.34.Conclusion: After the implementation of a new basic science curriculum organized and directed by the faculty, there were statistically significant improvements of PGY 1 and 2 residents' ABSITE scores.

Synthesis Versus Imitation: Evaluation of a Medical Student Simulation Curriculum Via Objective Structured Assessment of Technical Skill

Robert D. Acton, Jeffrey G. Chipman, Julie Gilkeson, Connie C. Schmitz — 2010-04-22

Background: Given the investment that programs make to simulation training, it is important to evaluate its effects on student learning. Tasks (e.g., gowning and gloving, suturing) are typically taught in isolation over a series of linked sessions. This study assessed students' ability to integrate such tasks while executing an unrehearsed procedure before and after a new simulation curriculum was introduced.Methods: An Objective Structured Assessment of Technical Skill (OSATS) was administered to 26 students in the 2007 clerkship who received a 3-hour orientation to the operating room followed by a 3-hour animate laboratory, and to 167 students in the 2008 clerkship who received a 9-hour simulation skills curriculum. The OSATS task involved a live volunteer “patient” with an arm laceration. Students had 40 minutes to explain the procedure, start an intravenous line, administer a local anesthetic, prepare the wound (pig's foot), gown and glove, and suture the wound. The OSATS was scored by trained raters using a tool with 57 checklist and 7 global rating items. Its internal consistency reliability was 0.82. Independent sample t tests were used to analyze differences between “pre” and “post” groups.Results: Mean scores were significantly higher for the post group for the checklist score (83% vs 62%, p < 0.001), the average global item score (3.62 vs 3.07, p = 0.003) and the OSATS total score (79% correct vs 62%, p < 0.001). Students from both groups were weakest in maintaining a sterile field, motion, and flow. Although superior, post group students still struggled with organizing a plan of action when faced with an unrehearsed procedure.Conclusions: The revised curriculum had a positive impact on students' mastery of basic surgical skills, despite the loss of the animal laboratory. Implications for instruction include greater use of discovery-learning techniques to teach productive versus reproductive skills.

Variation in Faculty Evaluations of Clerkship Students Attributable to Surgical Service

2010-06-01

Objective: The purpose of this study was to determine whether students' performance evaluations by faculty were influenced by the clinical service on which the student was evaluated.Methods: Third-year medical students spent 8 weeks rotating on 3 (or 2) surgical services. Typically, students rotate on one 4-week general surgery service and two 2-week subspecialty services. Faculty members rated student performance on 5 characteristics and provided a numeric grade. Data were analyzed to determine whether any significant variations in evaluation patterns emerged.Results: A total of 1033 evaluations were included in the analyses. Based on an analysis of variance, the numeric grade varied significantly by service (p < 0.001). The partial eta squared statistic was large (0.21). Ratings of students' performance on specific performance characteristics also varied significantly by service (p < 0.001).Conclusions: The assessment of a surgical student's clinical performance is influenced by the specific services on which he/she has rotated and may be related to the length of the rotation. Research is needed to determine whether the differences among services should be considered as a source of error in grading or considered to reflect the particular challenge of the service.

Video Games and Surgical Ability: A Literature Review

Jeremy Lynch, Paul Aughwane, Toby M. Hammond — 2010-05-01

Objective: Surgical training is rapidly evolving because of reduced training hours and the reduction of training opportunities due to patient safety concerns. There is a popular conception that video game usage might be linked to improved operating ability especially those techniques involving endoscopic modalities. If true this might suggest future directions for training.Methods: A search was made of the MEDLINE databases for the MeSH term, “Video Games,” combined with the terms “Surgical Procedures, Operative,” “Endoscopy,” “Robotics,” “Education,” “Learning,” “Simulators,” “Computer Simulation,” “Psychomotor Performance,” and “Surgery, Computer-Assisted,”encompassing all journal articles before November 2009. References of articles were searched for further studies.Results: Twelve relevant journal articles were discovered. Video game usage has been studied in relationship to laparoscopic, gastrointestinal endoscopic, endovascular, and robotic surgery.Conclusions: Video game users acquire endoscopic but not robotic techniques quicker, and training on video games appears to improve performance.

Enhancing Resident Interest in a State Surgical Meeting

George M. Fuhrman, Jana MacLeod, Carole Ehleben, Keith Delman — 2010-04-22

Objectives: To stimulate increased interest in the annual American College of Surgery (ACS) chapter meeting, a state-wide mock oral examination for senior level surgical residents was organized. The purpose of this study was to evaluate the impact of and the results from our state's initial attempt to conduct a state-wide mock oral examination.Methods: The mock oral examination was structured as a 90-minute assessment in 9 content areas. Residents at or above the postgraduate year (PGY)-3 level were offered the examination and every attempt was made to ensure that examiners were from institutions different than the examinee's training program. Examinations were scored as satisfactory, marginal, or unsatisfactory. Each examinee received a written assessment of their performance.Results: Thirty-eight volunteer examiners committed to participate and 37 of the state's 82 senior-level residents appeared for the mock oral examination. The examiners included faculty from all 7 of the state's training programs and 10 private practice surgeons. The residents represented 6 of the 7 programs with 10 PGY-3, 12 PGY-4, and 15 PGY-5 residents completing the examination. The overall performance on the examination included 15 (40.5%) residents rated as satisfactory, 15 (40.5%) assessed as marginal, and 7 (18.9%) received a rating of unsatisfactory.Conclusions: With rare exception, faculty examiners and resident examinees indicated by survey that the mock oral examination was a useful educational experience and increased the level of interest in attending the state's annual ACS meeting.