Accuracy and content of medical student midclerkship self-evaluations

Background

Midclerkship self-evaluations (MCSEs) require students to reflect on their knowledge, skills, and behaviors. We hypothesized that MCSEs would be consistent with supervisor midpoint evaluations during a surgical clerkship.

Methods

MCSEs of 153 students who completed our surgery clerkship in 2 academic years were compared with supervisor midclerkship evaluations. The quantitative domains of the MCSE and supervisor evaluation were compared for accuracy. Identified areas of strengths and weakness were evaluated for thematic consistency.

Results

Student MCSE scoring was accurate across evaluated domains most of the time; when students were inaccurate, they tended to underrate themselves. Students and supervisors most often identified cognitive skills as areas for improvement and noncognitive skills predominated as student strengths.

Conclusions

Medical students can accurately identify their strengths and weaknesses in the context of an MCSE. Based on these findings, knowledge acquisition and application by medical students in the clinical setting should be emphasized in undergraduate medical education.     

Cutting too deep? Assessing the impact of a shorter surgery clerkship on students' clinical skills and knowledge

Background

The aim of this study was to compare the performance of students completing an 8-week versus a 6-week surgery clerkship on an objective structured clinical examination (OSCE) and the National Board of Medical Examiners (NBME) clinical science surgery examination.

Methods

One hundred fifteen students from the 8-week clerkship and 99 from the 6-week clerkship were included. Performance on a summative OSCE was assessed using behaviorally anchored checklists. NBME exams were graded using the NBME's standard scaled scores. Results were compared using 2-tailed, independent-samples, unequal-variance t tests.

Results

Mean OSCE scores for the 8-week and 6-week curricula were not statistically different. Mean NBME scores also did not statistically differ. Six-week students performed significantly better in the specific OSCE subdomains of blood pressure, orthostatic blood pressure, rectal exam, and fecal occult blood test.

Conclusions

Overall OSCE and NBME exam performance did not differ between 8-week and 6-week surgery clerkship students.     

American College of Surgeons/Association for Surgical Education medical student simulation-based surgical skills curriculum needs assessment

Background

Simulation can enhance learning effectiveness, efficiency, and patient safety and is engaging for learners.

Methods

A survey was conducted of surgical clerkship directors nationally and medical students at 5 medical schools to rank and stratify simulation-based educational topics. Students applying to surgery were compared with others using Wilcoxon's rank-sum tests.

Results

Seventy-three of 163 clerkship directors (45%) and 231 of 872 students (26.5%) completed the survey. Of students, 28.6% were applying for surgical residency training. Clerkship directors and students generally agreed on the importance and timing of specific educational topics. Clerkship directors tended to rank basic skills, such as examination skills, higher than medical students. Students ranked procedural skills, such as lumbar puncture, more highly than clerkship directors.

Conclusions

Surgery clerkship directors and 4th-year medical students agree substantially about the content of a simulation-based curriculum, although 4th-year medical students recommended that some topics be taught earlier than the clerkship directors recommended. Students planning to apply to surgical residencies did not differ significantly in their scoring from students pursuing nonsurgical specialties.     

Outcomes of thyroidectomy from a large California state database

Background

Thyroidectomy is an operation with infrequent but potentially significant complications. This study aimed to determine risk factors for complication after thyroidectomy in California.

Methods

The California Office of Statewide Health Planning and Development database was retrospectively analyzed from 1995 to 2010. Main outcome measures were complications including death. Logistic regression identified risk factors for complications.

Results

There were 106,773 patients; 61% were women and 44% Caucasian; 16,287 (15%) thyroidectomies were performed at high-volume centers. Complication rates included voice change (.5%), vocal cord dysfunction (1.1%), hypocalcemia (4.5%), tracheostomy (1.62%), hematoma (1.75%), and death (.3%). There was significantly increased risk of complications for patients older than 65 compared with those younger than 40 years (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.3; P < .01). High-volume hospitals were protective against complication (odds ratio, .8; 95% confidence interval, .6 to .97; P = .026).

Conclusions

Older age was a significant risk factor for complication after thyroidectomy. High-volume hospitals had lower risk. This information is useful in counseling patients about the risks of thyroid surgery.     

A booming economy means a bursting trauma system: association between hospital admission for major injury and indicators of economic activity in a large Canadian health region

Background

Injury epidemiology fluctuates with economic activity in many countries. These relationships remain unclear in Canada.

Methods

The annual risk of admission for major injury (Injury Severity Score ≥12) to a high-volume, level-1 Canadian trauma center was compared with indicators of economic activity over a 16-year period using linear regression.

Results

An increased risk of injured patient admissions was associated with rising mean gross domestic product (GDP [millions of chained 2002 dollars]) (.36 person increase per 100,000 population/$1,000 increase in GDP; P = .001) and annual gasoline prices (.47 person increase per 100,000 population/cent increase in gasoline price; P = .001). Recreation-related vehicle injuries were also associated with economic affluence. The risk of trauma patient mortality with increasing mean annual GDP (P = .72) and gasoline prices (P = .32) remained unchanged.

Conclusion

Hospital admissions for major injury, but not trauma patient mortality, were associated with economic activity in a large Canadian health care region.     

Palliative and end-of-life care training during the surgical clerkship

Background

In 2000, the Liaison Committee on Medical Education required that all medical schools provide experiential training in end-of-life care. To adhere to this mandate and advance the professional development of medical students, experiential training in communication skills at the end-of-life was introduced into the third-year surgical clerkship curriculum at Wright State University Boonshoft School of Medicine.

Materials and methods

In the 2007–08 academic year, 97 third-year medical students completed six standardized end-of-life care patient scenarios commonly encountered during the third-year surgical clerkship. Goals and objectives were outlined for each scenario, and attending surgeons graded student performances and provided formative feedback.

Results

All 97 students, 57.7% female and average age 25.6 ± 2.04 y, had passing scores on the scenarios: (1) Adult Hospice, (2) Pediatric Hospice, (3) Do Not Resuscitate, (4) Dyspnea Management/Informed Consent, (5) Treatment Goals and Prognosis, and (6) Family Conference. Scenario scores did not differ by gender or age, but students completing the clerkship in the first half of the year scored higher on total score for the six scenarios (92.8% ± 4.8% versus 90.5% ± 5.0%, P = 0.024).

Conclusions

Early training in end-of-life communication is feasible during the surgical clerkship in the third-year of medical school. Of all the scenarios, “Conducting a Family Conference” proved to be the most challenging.     

A retrospective analysis of the effectiveness of low molecular weight heparin for venous thromboembolism prophylaxis in trauma patients

Background

In trauma patients, Enoxaparin (a low molecular weight heparin, LMWH) prophylaxis for venous thromboembolism (VTE) risk reduction is unproven.

Methods

Cohort analysis conducted consisting of all trauma patients age >13 admitted to Level-I trauma center and hospitalized >48 hours. VTE risk determined by the Risk Assessment Profile. High risk patients received LMWH unless contraindicated, while low and moderate risk patients received LMWH at attending surgeon's discretion. Odds ratio for VTE by logistic regression. VTE incidence, relative risk (RR), and number needed to treat (NNT) to prevent deep vein thrombosis (DVT) or pulmonary embolism determined by risk category.

Results

Cohort consisted of 2,281 patients (1,211 low, 979 moderate, 91 high risks). VTE occured in 254 patients (11.1%). High-risk patients had significantly higher VTE incidence, odds ratio = 31.8 (P < .001). VTE was significantly reduced in high-risk patients receiving LMWH versus those who did not (.26 vs .53, P = .02). Among moderate and high risk, prophylactic LMWH reduced the incidence of pulmonary embolism (RR = .19, NNT = 40.4, P = .01), and trended toward reduced DVT incidence (RR = .81, NNT = 27.3, P = .15). LMWH lowered DVT incidence (RR = .52, NNT = 4.1, P = .03) in high risk patients.

Conclusion

Prophylactic LMWH is associated with reduction of VTE in trauma patients.     

Feedback activities of instructors during a trauma surgery course

Background

The aim of this study was to examine the quality and quantity of feedback and instruction from faculty members during an acute trauma surgery team training using a newly designed observational feedback instrument.

Methods

During the training, 11 operating teams, each consisting of 1 instructor coaching 2 trainees, were videotaped and audiotaped. Forty-five minutes of identical operating scenarios were reviewed and analyzed. Using a new observational feedback instrument, feedback and instruction, containing different levels of specific information related to technical and nontechnical skills, were noted.

Results

Instructors more often provided instruction (25.8 ± 10.6 times) than feedback (4.4 ± 3.5 times). Most feedback and instruction contained either nonspecific or less specific information and referred to technical skills. Instructors addressed communication skills more specifically.

Conclusions

Coaching by faculty members predominantly contained unspecific instructions regarding technical skills. The observational feedback instrument enabled scoring of the coaching activities.     

Treatment Options Available for Bacillus Calmette-Guérin Failure in Non–muscle-invasive Bladder Cancer

Context

Intravesical bacillus Calmette-Guérin (BCG) is a standard conservative treatment for patients with high-risk non–muscle-invasive bladder cancer (NMIBC). Many patients will experience recurrence or progression following BCG and are termed BCG failures.

Objective

To summarise the current treatment options available for patients with high-risk NMIBC who experience BCG failure.

Evidence acquisition

We searched the Medline, Embase, and Cochrane Trials databases for studies of BCG failure using predetermined relevant Medical Subject Heading terms and free text terms.

Evidence synthesis

Radical cystectomy (RC) should be strongly recommended when a patient has been deemed to fail BCG, if the patient is fit and fully informed of the risks, benefits, and quality-of-life issues. RC achieves long-term survival in excess of 90% with ongoing improvements in morbidity. While other salvage intravesical therapies have to be considered oncologically inferior to RC, several options are now available if bladder preservation is the objective. The options can be categorised as immunotherapy, chemotherapy, device-assisted therapy, and sequential combinations of these newer modalities with conventional therapy. Some agents have shown specific promise in BCG-failure patients (eg, gemcitabine, thermochemotherapy, taxane chemotherapy), and some modalities have been shown to be effective only in non–BCG-failure cohorts (eg, electromotive mitomycin).

Conclusions

The definition, prediction, and treatment of BCG failure remain unclear secondary to inconsistent studies and the heterogeneous entity of patients with NMIBC. RC should be the default position upon failing BCG, but if bladder preservation is sought, then several promising intravesical salvage options are available. It will be necessary to individually tailor the management of such patients based on tumour risk and medical profiles. Currently data are still inadequate to formulate definitive recommendations, and larger studies of salvage intravesical agents are urgently required.     

Anxiété : facteur prédictif d’échec du bloc axillaire sous neurostimulation ?

Objective

To evaluate the impact of the anxiety level using Spielberger test on axillary block success.

Study design

Prospective double-blind study.

Patients and methods

An axillary brachial plexus block was performed with a nerve stimulator for all patients undergoing elective or emergency upper limb surgery. Spielberger test result was blinded for both patient and anaesthesiologist performing the block. Time to perform the block (minutes) was measured. Anxiety and pain scores were assessed, using a numeric scale (NS), at different time. Successful block was defined as complete sensory blockade combined with painless during surgical incision. Data were compared using Spearman test and multivariate logistical regression analysis.

Results

Patients (184) were included (elective surgery = 62%; emergency = 38%). Failure rate was 10%. On multivariate logistical regression analysis, time to perform the block and NS anxiety score before starting the block were associated with block failure. Spielberger score correlated with NS anxiety score before puncture (Rho = 0,586, p < 10⁻⁴). Anxiety level was increased in emergency context.

Conclusion

Patient's anxiety level before axillary brachial plexus block is a risk factor of failure, especially in emergency condition. We suggest anesthesiologists to evaluate patient anxiety prior to block performance. A specific anxiolytic treatment may be recommend in some cases.     

International surgical clerkship rotation: perceptions and academic performance

Background

Concerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship.

Methods

A 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers.

Results

Twenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions.Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement.Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant.

Conclusions

This study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.     

A “safe and effective” protocol for management of post-thyroidectomy hypocalcemia

Background

This study evaluates the outcomes of a protocol to manage hypocalcemia after thyroidectomy (TTX).

Methods

A review of prospectively collected data was performed in 130 patients who underwent TTX after the introduction of a specific protocol. These patients were compared with a control group of 195 patients who underwent TTX the year prior when routine calcium supplementation was utilized and no specific protocol was used.

Results

Of the 120 patients in whom the protocol was followed, 44 (37%) patients were classified as high risk, 15 (13%) intermediate risk, and 61 (51%) low risk. The protocol had a sensitivity of 85% and a negative predictive value of 92% for predicting subsequent hypocalcemia. With the implementation of the protocol, there was significant reduction in temporary hypocalcemia events (P = .008) and intravenous calcium drip (P = .49). Also, calcium supplementation was significantly lower in the protocol group (P ≤ .001).

Conclusions

This hypocalcemia protocol identifies patients who do not require additional supplementation and additional monitoring. At the same time, it identifies those who will benefit from supplementation after TTX.     

Simple frailty score predicts postoperative complications across surgical specialties

Background

Our purpose was to determine the relationship between preoperative frailty and the occurrence of postoperative complications after colorectal and cardiac operations.

Methods

Patients 65 years or older undergoing elective colorectal or cardiac surgery were enrolled. Seven baseline frailty traits were measured preoperatively: Katz score less than or equal to 5, Timed Up and Go test greater than or equal to 15 seconds, Charlson Index greater than or equal to 3, anemia less than 35%, Mini-Cog score less than or equal to 3, albumin less than 3.4 g/dL, and 1 or more falls within 6 months. Patients were categorized by the number of positive traits as follows: nonfrail: 0 to 1 traits, prefrail: 2 to 3 traits, and frail: 4 or more traits.

Results

Two hundred one subjects (age 74 ± 6 years) were studied. Preoperative frailty was associated with increased postoperative complications after colorectal (nonfrail: 21%, prefrail: 40%, frail: 58%; P = .016) and cardiac operations (nonfrail: 17%, prefrail: 28%, frail: 56%; P < .001). This finding in both groups was independent of advancing age. Frail individuals in both groups had longer hospital stays and higher 30-day readmission rates. Receiver operating characteristic curves examining frailty's ability to forecast complications were colorectal (.702, P = .004) and cardiac (.711, P < .001).

Conclusions

A simple preoperative frailty score defines older adults at higher risk for postoperative complications across surgical specialties.     

A Calculator for Prostate Cancer Risk 4 Years After an Initially Negative Screen: Findings from ERSPC Rotterdam

Background

Inconclusive test results often occur after prostate-specific antigen (PSA)–based screening for prostate cancer (PCa), leading to uncertainty on whether, how, and when to repeat testing.

Objective

To develop and validate a prediction tool for the risk of PCa 4 yr after an initially negative screen.

Design, setting, and participants

We analyzed data from 15 791 screen-negative men aged 55–70 yr at the initial screening round of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer.

Outcome measurements and statistical analysis

Follow-up and repeat screening at 4 yr showed either no PCa, low-risk PCa, or potentially high-risk PCa (defined as clinical stage >T2b and/or biopsy Gleason score ≥7 and/or PSA ≥10.0 ng/ml). A multinomial logistic regression analysis included initial screening data on age, PSA, digital rectal examination (DRE), family history, prostate volume, and having had a previous negative biopsy. The 4-yr risk predictions were validated with additional follow-up data up to 8 yr after initial screening.

Results and limitations

Positive family history and, especially, PSA level predicted PCa, whereas a previous negative biopsy or a large prostate volume reduced the likelihood of future PCa. The risk of having PCa 4 yr after an initially negative screen was 3.6% (interquartile range: 1.0–4.7%). Additional 8-yr follow-up data confirmed these predictions. Although data were based on sextant biopsies and a strict protocol-based biopsy indication, we suggest that men with a low predicted 4-yr risk (eg, ≤1.0%) could be rescreened at longer intervals or not at all, depending on competing risks, while men with an elevated 4-yr risk (eg, ≥5%) might benefit from immediate retesting. These findings need to be validated externally.

Conclusions

This 4-yr future risk calculator, based on age, PSA, DRE, family history, prostate volume, and previous biopsy status, may be a promising tool for reducing uncertainty, unnecessary testing, and overdiagnosis of PCa.     

Risk factors of liver failure after right-sided hepatectomy

Background

To prevent hepatic failure after major hepatectomy, it is important to assess preoperative factors related to liver failure.

Methods

We examined 80 patients who underwent right-sided hepatectomy. Hyperbilirubinemia, uncontrolled ascites, and prolonged postoperative hospital stay were defined as liver failure after hepatectomy, and these 3 factors were evaluated in relation to clinicopathological and surgical factors.

Results

In the 80 patients, hyperbilirubinemia was observed in 10 (12.7%) patients, uncontrolled ascites in 18 (22.5%) patients, and prolonged hospital stay after surgery in 39 (48.8%) patients. Multivariate analyses identified platelet count as a risk factor of hyperbilirubinemia, uncontrolled ascites, and prolonged postoperative hospital stay, and the ratio of remnant liver volume to body surface area (RLV/BSA ratio) as an additional risk factor of hyperbilirubinemia and prolonged postoperative hospital stay.

Conclusions

Platelet count and RLV/BSA ratio are useful risk factors for prediction of liver failure after right-sided hepatectomy.     

Development of a fresh cadaver model for instruction of ultrasound-guided breast biopsy during the surgery clerkship: pre-test and post-test results among third-year medical students

Background

The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions.

Methods

Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist.

Results

Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 (P < .001).

Conclusions

Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students.     

The risk factors and clinical significance of acute postoperative complications after unstented pediatric pyeloplasty: A single surgeon’s experience

Purpose

To analyze the risk factors and clinical significance of postoperative complications after unstented pediatric pyeloplasty.

Materials and Methods

We analyzed 285 kidney units (KUs) on which unstented pyeloplasty was performed between April 2002 and March 2010. Measures included preoperative factors, postoperative complications, change in postoperative differential renal function (DRF), and failure of pyeloplasty. Risk factors for acute complications requiring additional ureteral stenting and decreased DRF were analyzed.

Results

During a median follow-up period of 67.0 months, an additional ureteral stenting was required in 28 KUs (9.8%) due to the development of acute postoperative complications after unstented pyeloplasty. The incidence of complications increased significantly as preoperative DRF increased. DRF of more than 60% was the only independent risk factor for acute complications. Postoperative decrease in DRF was observed in 58 KUs (22.4%) among 259 KUs analyzed. Pyeloplasty failure was observed in 10 KUs (3.5%). The development of acute complications was not a risk factor for a decrease in DRF or pyeloplasty failure.

Conclusions

Urinary diversion during pyeloplasty is not related to a decrease in DRF or pyeloplasty failure. However, in patients with a preoperative DRF of greater than 60%, diversion could be considered due to the high prevalence of complications.     

Outcome Following Active Surveillance of Men with Screen-detected Prostate Cancer. Results from the Göteborg Randomised Population-based Prostate Cancer Screening Trial

Background

Active surveillance (AS) has emerged as a treatment strategy for reducing overtreatment of screen-detected, low-risk prostate cancer (PCa).

Objective

To assess outcomes following AS of men with screen-detected PCa.

Design, setting, and participants

Of the 968 men who were diagnosed with screen-detected PCa between 1995 and 2010 in the Göteborg randomised, population-based PCa screening trial, 439 were managed with AS and were included in this study. Median age at diagnosis was 65.4 yr of age, and median follow-up was 6.0 yr from diagnosis.

Intervention

The study participants were followed at intervals of 3–12 mo and were recommended to switch to deferred active treatment in case of a progression in prostate-specific antigen, grade, or stage.

Outcome measurements and statistical analysis

The end points—overall survival (OS), treatment-free survival, failure-free (no relapse after radical treatment) survival, and cancer-specific survival—were calculated for various risk groups (very low, low, intermediate, and high) with Kaplan-Meier estimates. A Cox proportional hazards model as well as a competing risk analysis were used to assess whether risk group or age at diagnosis was associated with failure after AS.

Results and limitations

Forty-five per cent of all screen-detected PCa were managed with AS, and very low-risk and low-risk PCa constituted 60% of all screen-detected PCa. Thirty-seven per cent (162 of 439) switched from surveillance to deferred active treatment, and 39 men failed AS. The 10-yr OS, treatment-free survival, and failure-free survival were 81.1%, 45.4%, and 86.4%, respectively (Kaplan-Meier estimates). Men with low-, intermediate-, and high-risk tumours had a hazard ratio for failure of 2.1 (p = 0.09), 3.6 (p = 0.002), and 4.6 (p = 0.15), respectively, compared to very low-risk tumours (Cox regression). Only one PCa death occurred, and one patient developed metastasis (both in the intermediate-risk group). The main limitation of this study is the relatively short follow-up.

Conclusions

A large proportion of men with screen-detected PCa can be managed with AS. AS appears safe for men with low-risk PCa.     

Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010

Background

The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality.

Methods

The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression.

Results

From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05).

Conclusions

The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.