Addressing the new competencies for residents' surgical training.

In July 2001 the Accreditation Council for Graduate Medical Education (ACGME) charged U.S. residency training programs to implement a curriculum and evaluation plan covering six competencies. The authors describe the curriculum and evaluation strategy of the first surgical training program developed to meet the competencies, and list each competency and the teaching method and measurement instruments used. Implementation began July 1, 2001, and the program was fully operational on July 1, 2002. Meeting the curriculum challenges required modification of the existing curriculum and the addition of new instructional units. Nine additional evaluation instruments were needed. The largest investment was in planning and implementation, a one-time development cost. Staff workload increased by 252 hours; this is expected to be a continuing annual requirement. Faculty workload increased by two hours per resident and each resident's workload increased by 112 hours per year (2.3 hours per week). The transition was smoother than expected. Faculty and residents' buy-in was crucial. Faculty and residents were alerted to upcoming changes at the beginning of the year in a grand rounds presentation on the ACGME competencies and the approach to meeting requirements. Updates were presented periodically. The authors recommend that residency programs engaged in similar efforts make effective use of instruments developed elsewhere and collaborate with other programs rather than develop everything locally. The program's benefits include time savings and the availability of validity data and norms to inform decision making on residents' and program progress.     

Immunocompetence and resistance to marble spleen disease of broiler- and layer-type pure lines of chickens

The intent of this study was to evaluate, under concurrent conditions, certain responses that may be important in chicken breeding and growing. Three commercial broiler pure lines (A, B, and C) and two experimental White Leghorn lines selected for high (HAS) and low (LAS) antibody response to sheep red blood cells were evaluated concurrently for humoral and cell-mediated immunocompetence, resistance to marble spleen disease virus (MSDV), relative asymmetry (RA), and comb weight. Chicks were injected with 0.1 ml of 0.25% SRBC at 21 days of age. Antibody response 6 days after injection was highest in line HAS. Titres for the commercial lines were similar to those in line LAS. The cutaneous basophil hypersensitivity test, an in vivo cell-mediated immune response, was measured as the increase in toe-web thickness 24 h after an injection with T-cell mitogen phytohaemagglutinin (PHA)-P or -M into a sample of chicks at 9 days of age and a different sample of chicks at 20 days of age. PHA-P elicited greater responses than PHA-M at both ages. The pattern among stocks, however, differed depending upon age. Responses at 9 days were greater for the Leghorn than broiler lines, while at 20 days, responses were greater in lines A and LAS than in lines B, C, and HAS. Resistance to MSDV challenge differed among stocks, with the ranking for resistance being C>(A=B=LAS)>HAS. Rankings of RA for normal thickness of the toe web between the third and fourth digits at 9 days of age were (HAS=LAS)>(A=B=C). There were no differences in RA among stocks at 20 days of age. There was a significant line by sex interaction for relative comb weight, due to differences between lines for males but not females. Data from this study suggest that competence in one arm of the immune system is not a reliable measure of general immunocompetence, nor is it a measure of resistance in general.     

A Novel BMPR2 Mutation Associated with Pulmonary Arterial Hypertension in an Octogenarian

We describe the case of an 83-year-old man with a family history of pulmonary hypertension (PH) who presented with severe pulmonary arterial hypertension (PAH) and later tested positive for a novel bone morphogenetic protein receptor 2 (BMPR2) gene mutation. To our knowledge, this may be the oldest reported patient with PAH in whom a BMPR2 mutation was initially identified.     

Health-related information gathering practices in breast and colorectal specialty clinics: the end of the electronic divide?

Background

Health-related information can help patients understand their disease process and make informed decisions. We hypothesize that with the increased availability of Web-based resources, sociodemographic factors no longer impact Internet use among patients.

Methods

Study-specific surveys were administered to a convenience cohort of patients seen in the breast and colorectal specialty clinics at a single academic institution between August 2008 and February 2009.

Results

One hundred ninety-four surveys were returned (response rate 80%). Median age was 53 years (range 19-88) with 131 (75%) females. Twenty-six percent of patients were college graduates and 59% reported an annual income greater than $50,000. There was no association between Internet use and age, gender, income, or educational level.

Conclusion

Web-based information is being increasingly used by patients irrespective of their demographic characteristics. These resources can therefore be used to educate patients about their disease, treatment options, and health maintenance.     

Changing surgical education strategies in an environment of changing health care delivery systems

Emerging changes in health care delivery will have a significant impact on the structure of surgical education in academic departments of surgery. Based on some assumptions as to the probable nature of the final product of this reform, this article encourages a proactive stance by surgical educators to anticipate changes and move toward restructuring in areas of curricular content, the teaching process, performance evaluation strategies, and faculty infrastructure of the academic department. Curriculum changes must bridge the gap between public health and medicine and continue the aggressive trend toward teaching in the outpatient setting. Surgical educators must adapt to evolving computer and instructional technology that will make multimedia presentations, distance education, teleconferencing, hypermedia, and virtual reality commonplace in the teaching setting. Increased emphasis on accountability and accreditation will require stringent criteria in performance and program evaluation methodology. The academic infrastructure will need to adapt to the changing goal of training more general surgeons and fewer specialists and yet maintain the fundamental responsibility of an academic surgeon for mentoring the medical student and surgical resident.

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Resumen Los emergentes cambios en los sistemas de atención de la salud han tenido un significativo impacto sobre la estructura de la educación quirúrgica en los departamentos académicos de cirugía. Con base en algunas suposiciones en lo referente a la probable naturaleza final del producto de esta reforma, el presente artículo estimula a los educadores quirúrgicos a tomar una posición activa con miras a definir los cambios por venir y a iniciar la reestructuración de diversos aspectos del contenido curricular, del proceso de enseñanza, de las metodologías de evaluación del rendimiento y de la infraestructura académica de los departamentos ruirúrgicos. Los cambios curriculares deben eliminar la brecha entre la salud pública y la medicina y mantener una decidida tendencia hacia la enseñanza en los escenarios de consulta externa. Los educadores quirúrgicos deben adaptarse para asumir las teconologías de computación y los nuevos métodos de instrucción que comprenden sistemas multimedia, educación a distancia, teleconferencias, hipermedia y realidad virtual, en tal forma que se conviertan en lo usual en el contexto educativo. El mayor énfasis sobre responsabilidad auditada y acreditación demanda estrictos criterios en las metodologías de ejecución y de evaluación de programas. La infraestructura académica deberá adaptarse a los cambiantes objectivos de adiestrar un mayor número de cirujanos generales y menos especialistas, y, sin embargo, preservando la responsabilidad fundamental del cirujano académico en cuanto a la tutoría del estudiante de medicina y del residente quirúrgico.

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Résumé Les changements actuels dans l'administration des soins vont avoir un impact important sur l'enseignement de la chirurgie dans les services de Chirurgie Universitaire. Basé sur quelques présomptions sur la forme finale de la réforme en cours, cet article encourage les enseignants futurs à anticiper ces changements et à commencer dès à présent une restructuration du programme, de l'enseignement, des stratégies d'évaluation et de l'infrastructure des services Universitaires. Le programme doit combler l'écart actuel entre les services de Santé publique et de Médecine et continue d'enseigner la prise en charge des patients dès la consultation. Les enseignants doivent s'adapter à la technologie informatique qui permet entre outre de réaliser les présentations multimédiatiques, le télé-enseignement, la téléconférence, l'hypermédiatique et la réalité virtuelle. On insiste aussi sur l'accréditation qui demande une méthodologie stricte d'évaluation et de contrôle de réalisation. L'infrastructure académique a besoin d'orienter ces objectifs vers la formation de moins de spécialistes et de plus de chirurgiens généraux. Elle doit avoir maintenir le principe fondamental d'un chirurgien académique responsable de la formation des étudiants et des résidents en chirurgie.

     

Surgeon communication behaviors that lead patients to not recommend the surgeon to family members or friends: Analysis and impact

BACKGROUND: This study analyzes specific elements of physician communication that lead patients to not recommend surgeons to family members or friends (FMoFs). METHODS: Patients completed questionnaires after surgery clinic encounters. Questionnaires addressed whether surgeons used optimal communication behaviors and whether patients would recommend the surgeon. RESULTS: A total of 1,514 questionnaires were completed for 39 surgeons. Patients reported the following communication lapses: failure to ask whether the patient had questions (6.9% of occasions), failure to sit down (6.5%), use of words patients could not understand (5%), failure to educate patients about their condition (4.3%), failure to introduce themselves (4%), lack of interest in patients as persons (2.4%), and inadequacies in answering questions (2%). Surgeons omitted at least one of these optimal behaviors in 16.3% of encounters. Surgeons were not recommended in 1.7% of encounters. Twelve surgeons (31%) were not recommended on at least 1 occasion. Behaviors omitted most commonly in encounters where patients wouldn't recommend surgeons included failure to show interest in the patient (52%), explain their medical condition (52%), invite questions (40%), and answer questions (36%). CONCLUSIONS: Extrapolating these results to 1,618 patient visits/surgeon/year, results in the following number of patients annually who do not recommend their surgeons: 15 for failure to adequately explain their medical condition, 15 for failure to show interest in them, 11 for failure to ask if the patient had questions, and 10 for failure to answer questions. Considering the ripple effect due to the number of a patient's FMoFs, surgeons should be aware of the significant impact of even occasional lapses in optimal communication behaviors.     

Structured single-observer methods of evaluation for the assessment of ward performance on the surgical clerkship

This study compares the traditional method (TM) of evaluating ward performance on the surgical clerkship with four structured, single-observer methods (SSOM) of evaluating the clinical skills demonstrated in patient workups, progress notes, physical examination, and technical performance. SSOM differed from TM in preciseness of evaluation criteria, training of evaluator, and amount of direct observation of clinical performance. SSOM appeared to be a more precise measurement instrument than TM and far more sensitive to the detection of clinical improvement. The study documents the significant contribution of a nurse-educator to the evaluation process, as this contribution correlates well with TM yet provides a unique and independent perspective. Finally, SSOM of evaluation correlated significantly with oral examination and the National Board of Medical Examiners (NBME) test results. Addition of SSOM to TM is recommended for clerkship evaluation of ward performance.