Assessment of the Non-Technical Skills for Surgeons (NOTSS) framework in the USA

Background

Surgeons' non-technical skills are important for patient safety. The Non-Technical Skills for Surgeons assessment tool was developed in the UK and recently adapted to the US surgical context (NOTSS-US). The aim of this study was to evaluate the reliability and distribution of non-technical skill ratings given by attending (consultant) surgeons who underwent brief online training.

Methods

Attending surgeons across six specialties at a large US academic medical centre underwent a 10-min online training, then rated 60-s standardized videos of simulated operations. Intraclass correlation coefficient (ICC), and mean(s.d.) values for NOTSS-US ratings were determined for each non-technical skill category (score range 1–5, where 1 indicates poor, 3 average and 5 excellent) and for total NOTSS-US score (range 4–20; sum of 4 category scores). Outcomes were adjusted for rater characteristics including sex, specialty and clinical experience.

Results

A total of 8889 ratings were submitted by 81 surgeon raters on 30 simulated intraoperative videos. The mean(s.d.) total NOTSS-US score for all videos was 9·5(4·8) of 20. The within-video ICC for total NOTSS-US score was 0·64 (95 per cent c.i. 0·57 to 0·70). For individual non-technical skill categories, the ICC was highest for social skills (communication/teamwork: 0·63, 95 per cent c.i. 0·56 to 0·71; leadership: 0·64, 0·55 to 0·72) and lowest for cognitive skills (situation awareness: 0·54, 0·45 to 0·62; decision-making: 0·50, 0·41 to 0·59). Women gave higher total NOTSS-US scores than men (adjusted mean difference 0·93, 95 per cent c.i. 0·44 to 1·43; P = 0·001).

Conclusion

After brief online training, the inter-rater reliability of the NOTSS-US assessment tool achieved moderate strength among trained surgeons rating simulated intraoperative videos.

Development and evaluation of the General Surgery Objective Structured Assessment of Technical Skill (GOSATS)

Background

Technical skill acquisition is important in surgery specialty training. Despite an emphasis on competency-based training, few tools are currently available for direct technical skills assessment at the completion of training. The aim of this study was to develop and validate a simulated technical skill examination for graduating (postgraduate year (PGY)5) general surgery trainees.

Methods

A simulated eight-station, procedure-based general surgery technical skills examination was developed. Board-certified general surgeons blinded to the level of training rated performance of PGY3 and PGY5 trainees by means of validated scoring. Cronbach's α was used to calculate reliability indices, and a conjunctive model to set a pass score with borderline regression methodology. Subkoviak methodology was employed to assess the reliability of the pass–fail decision. The relationship between passing the examination and PGY level was evaluated using χ2 analysis.

Results

Ten PGY3 and nine PGY5 trainees were included. Interstation reliability was 0·66, and inter-rater reliability for three stations was 0·92, 0·97 and 0·76. A pass score of 176·8 of 280 (63·1 per cent) was set. The pass rate for PGY5 trainees was 78 per cent (7 of 9), compared with 30 per cent (3 of 10) for PGY3 trainees. Reliability of the pass–fail decision had an agreement coefficient of 0·88. Graduating trainees were significantly more likely to pass the examination than PGY3 trainees (χ2 = 4·34, P = 0·037).

Conclusion

A summative general surgery technical skills examination was developed with reliability indices within the range needed for high-stakes assessments. Further evaluation is required before the examination can be used in decisions regarding certification.

Faculty development and support needed to integrate the learning of prevention in the curricula of medical schools

Comprehensive coverage of prevention-related topics in the curricula of medical schools is important for the training of future physicians; however, the changes needed in educational programs to include such topics are likely to challenge many institutions. Faculty members are central to the successful adoption of any new curricular paradigm, yet many of the impediments to change are also likely to be found within the faculty ranks. Achieving major curricular change requires institution leaders to define a new vision and allocate sufficient resources to support faculty efforts. Appropriate steps should be taken to actively involve the faculty early in the process of change and to recruit stakeholders from within the faculty ranks to play prominent roles. The educational models should be based on educationally and scientifically sound underpinnings that will facilitate acceptance of the models by the faculty, and faculty members must be offered appropriate opportunities to develop the skills to successfully implement the models. A school-wide faculty development program should address organizational development, instructional development, and personal development. The expertise needed to design and implement these activities may be secured from within or outside the institution. Individuals who have played key roles in the curricular change process must be rewarded and given appropriate recognition for their contributions. These steps will help in the successful integration of prevention-related topics into the curriculum, which will add a much-needed dimension, resulting in students' being better prepared to address the needs of their patients and the community.

Paraganglionoma of extrahepatic biliary tract causing obstructive jaundice

We report a young woman with paraganglionoma arising from the extrahepatic bile duct presenting with acute obstructive jaundice. The patient underwent excision of the gall bladder and extrahepatic bile duct with the tumor, and Roux-en-Y hepaticojejunostomy. She is asymptomatic 9 months later, with normal biochemical investigations and imaging.

A new model for recognizing and rewarding the educational accomplishments of surgery faculty

Faculty members' educational endeavors have generally not received adequate recognition. The Association for Surgical Education in 1993 established a task force to determine the magnitude of this problem and to create a model to address the challenges and opportunities identified. To obtain baseline information, the task force reviewed information from national sources and the literature on recognizing and rewarding faculty members for educational accomplishments. The group also developed and mailed to surgery departments at all U.S. and Canadian medical schools a questionnaire asking about the educational endeavors of the surgery faculty and their recognition for such activities. The response rate after two mailings was only 56%, but the responses reaffirmed the inadequacy of systems for rewarding and recognizing surgeon-teachers and surgeon-educators, and confirmed that the distinction between the roles of teacher and educator was rarely made. The task force created a four-tier hierarchical model based on the designations teacher, master teacher, educator, and master educator as a framework to offer appropriate recognition and rewards to the faculty, and endorsed a broad definition of educational scholarship. Criteria for various levels of achievement, ways to demonstrate and document educational contributions, appropriate support and recognition, and suggested faculty ranks were defined for these levels. The task force recommended that each surgery department have within its faculty ranks a cadre of trained teachers, a few master teachers, and at least one educator. Departments with a major commitment to education should consider supporting a master educator to serve as a resource not only for the department but also for the department's medical school and other medical schools. Although this model was created for surgery departments, it is generalizable to other disciplines.

A new educational role for plastic surgery in the fourth year of medical school

At most medical schools, students are offered limited or sporadic experiences in plastic surgery. This is unfortunate because all physicians need to possess the knowledge and skills to evaluate skin lesions and participate in wound management. Also, students who are considering a career in plastic surgery do not have adequate information to make informed decisions. With the restructuring of plastic surgery training programs, career decisions of individuals interested in plastic surgery are being made earlier than ever before in the education continuum, and the aforementioned problem assumes greater magnitude both for the students and the faculty. At MCP-Hahnemann School of Medicine, basic plastic surgery experiences have been integrated into the third-year surgery clerkship as a requirement for all students, and a Plastic Surgery Pathway has been designed in conjunction with the school's pathway system for fourth-year students. The Pathway provides a framework for the student to select a combination of rotations that will best provide an appropriate broad-based education in preparation for training in plastic surgery, and it provides extensive guidance by faculty members in the discipline to assist with career decisions, rotation selection, and preparations for the residency application process. Students in the Plastic Surgery Pathway are required to take rotations in medicine, neurology, and plastic surgery. The remaining rotations are selected from a list of options based on the student's individual learning needs, interests, and career aspirations. Early experience with the Plastic Surgery Pathway has shown that it has been well received by students and faculty, has assisted students with their career decisions, and has led to an increased student awareness of the importance and relevance of the specialty.

Redesigning the surgery clerkship at MCP Hahnemann School of Medicine to address the educational needs of generalists

This article describes how the surgery clerkship at MCP Hahnemann School of Medicine was redesigned to provide all students a well-rounded general professional education and to address the specific educational needs of generalists. During the 12-week clerkship, students spend eight weeks on two different general surgery rotations, which include significant experiences in outpatient settings. The evaluation and management of common general surgical problems, as well as the holistic approach to patient care, are emphasized. A nurse educator, recruited through funding obtained from The Robert Wood Johnson Foundation's Generalist Physician Initiative, provides formal instruction in holistic care and teaches bedside procedures. Two weeks are devoted to focused surgical subspecialty experiences addressing common conditions and are conducted primarily in outpatient settings. The remaining two weeks include an integrated musculoskeletal disease rotation, including orthopaedic surgery, rheumatology, physiatry, and radiology. Didactic teaching includes criteria for referral of patients from generalists to specialists. The new clerkship model has been well received by the students. Review of student logs for the first six months indicates the breadth of surgical experience has been maintained and appropriate balance achieved between simple and complex surgical cases. Further evaluation of the model will continue through longitudinal follow-up.

Use of a paper-cut as an adjunct to teaching the Whipple procedure by video

BACKGROUND

Medical students often experience difficulty comprehending anatomic relationships of complex operations to which they are exposed during surgical clerkship. Pancreaticoduodenectomy, the Whipple procedure, is one such operation. Although video recordings are available to facilitate the learning of the Whipple procedure, commercially available tapes are not self-explanatory to the uninitiated. Since we have previously demonstrated that third-year medical students could learn the operative steps of inguinal herniorraphy by a paper-cutting exercise, we set out to determine whether an exercise of similar design could enhance a student's comprehension of the Whipple procedure.

METHODS

Using Adobe Illustrator 5.5 for MacIntosh, an exercise was developed on a 8.5 x 11-inch paper that could be distributed to students for self-administration. The exercise was performed using a #15 scalpel or an iris scissors. Thirty-seven students were randomized into two groups. Each student received a pretest of questions focusing on the Whipple procedure. Group I was shown an 18-minute commercially available teaching video on the Whipple procedure. Group II was given the Whipple origami exercise, which required 20 minutes to complete. A first posttest was administered to each group. Next, the groups switched exercises, and a second posttest was administered.

RESULTS

There was no significant difference between the groups' pretest scores (two-tailed t test, P = 0.290). Group I improved its score from an average of 64.21 (SD 14.27) to 67.89 (SD 13.16) after watching the video, and further to 77.89 (SD 14.37) after completing the paper-cut exercise. Group II improved from 60.00 (SD 9.43) to 78.95 (SD 11.00) after performing the paper-cut, but derived no additional measurable benefit from watching the video, average score 74.74 (SD 18.37). After the first exercise, students who performed the paper-cut showed a significantly greater improvement in test scores compared with students who saw the video (P = 0.0035 by Mann-Whitney U). After both groups had completed the exercises, the mean changes from baseline were no longer significantly different (P = 0.58 by Mann-Whitney U).

CONCLUSION

As a single educational intervention, the paper-cut exercise was a more effective teaching device than the video in the given time frame. The origami model may be generalized to a variety of surgical procedures and appears to be a valuable adjunct to traditional teaching.

Teaching three-dimensional surgical concepts of inguinal hernia in a time-effective manner using a two-dimensional paper-cut

BACKGROUND

Because inguinal hernia repair is difficult for third-year students to comprehend, a 2-dimensional paper-cut was developed to teach the concepts of inguinal hernia in a time-effective manner before students' observation of herniorrhaphy in the operating room.

METHODS

Using Adobe Illustrator 5.5 for MacIntosh, a 2-dimensional inexpensively printed paper-cut was created to allow students to perform their own simulated hernia repair before observing surgery. The exercise was performed using a no.15 scalpel or an iris scissors and was evaluated by comparing 10-question pre-tests and post-tests.

RESULTS

Seventy-five students performed the exercise, most completing it within 15 minutes. The mean pre-test score was 7.4/10 and the mean post-test score was 9.1/10. Students performing the paper-cut reported better understanding when observing actual herniorrhaphy.

CONCLUSIONS

A 2-dimensional paper-cut ("surgical origami") may be a time-effective method to prepare students for the observation of hernia repair.

Impact of a standardized patient intervention to teach breast and abdominal examination skills to third-year medical students at two institutions

BACKGROUND

This study examined whether a single intervention with standardized patients (SPs) as a supplement to traditional teaching during the surgery clerkship would enhance the breast and abdominal examination skills of third-year medical students.

METHODS

During the academic year 1994-1995, 153 students from two institutions were assigned to control or experimental groups. At institution A, all students underwent pretests and posttests with SPs; at institution B, no pretest was conducted. All experimental students received group and one-to-one instruction with SPs during the intervention session.

RESULTS

At posttest, the experimental group performed better than the control group on breast examination (P = 0.002), professionalism during this examination (P <0.001), abdominal examination (P <0.001), and professionalism during the latter examination (P = 0.050). The improvement from pretest to posttest at institution A was significantly greater in the experimental group than the control group for the breast examination (P = 0.036) and the abdominal examination (P <0.001). Analyses on a variety of specific tasks within each examination were also performed.

CONCLUSION

A single intervention with SPs teaching breast and abdominal examinations resulted in significant enhancement of these clinical skills.

Who should teach medical students surgery?

BACKGROUND

Medical schools are undergoing major curricular reform, partly in attempts to increase the number of graduates pursuing careers in the generalist disciplines. These reforms have often resulted in a shortening of the surgery clerkship, decreasing students' experiences in several domains important to the generalist.

METHODS

A seven-question survey of clerkship directors of US medical schools was administered to measure the magnitude of curriculum change during the past 5 years affecting the surgery and family practice clerkships. The survey also addressed attitudes about the purpose of the surgery clerkship.

RESULTS

There was an 80% (103 of 129) response rate. Between 1989 and 1994, surgery clerkships decreased on average from 11 to 10.2 weeks (P <0.05) while family practice clerkships increased from 4.2 to 6.8 weeks (P <0.05). Ninety-one percent of clerkship directors felt the primary goal of the clerkship should be to train generalists.

CONCLUSIONS

The length of the surgery clerkship has decreased at several institutions. In order to ensure an appropriate educational experience for medical students, surgeons must participate actively in curriculum reform within medical schools and highlight their unique role in training generalists.

Description and evaluation of the Surgeons as Educators course

BACKGROUND

Since 1993, the American College of Surgeons has sponsored an annual 6-day course entitled the Surgeons as Educators. The course was designed to provide academic surgeons with the knowledge and skills necessary to enhance the surgical education curriculum, teaching strategies, educational program administration, and performance evaluation. This article describes the development, implementation, and effect of the course on the classes graduating in 1993 and 1994.

STUDY DESIGN

The effect of the course was studied by using a longitudinal survey approach. A survey was mailed to participants 3 to 6 months after they completed the course. Graduates were asked to describe any education-related actions taken attributable to attending the Surgeons as Educators course. The quality of course content and presentations were evaluated by using end-of-course evaluation forms and daily feedback forms and by an external reviewer.

RESULTS

Within 6 months of returning from the course, more than one half of the graduates initiated actions related to curriculum development, teaching strategies, or educational administration. One third or more of the graduates modified their performance and program evaluation systems. Using a five-point scale, ratings of the course content ranged from 3.78 to 4.64 for "value of topic" and from 3.77 to 4.76 for "quality of presentation." Items evaluated by the graduates on the end-of-course evaluation forms ranged from 7.8 to 8.7 on a nine-point scale.

CONCLUSIONS

The Surgeons as Educators course offered an opportunity for participants to interact among themselves and with course faculty about educational issues and to practice teaching skills. The course was highly rated for educational quality and value. The retreat environment and the length of the program helped attendees become immersed during this "protected time" to analyze strengths and weaknesses of their programs and devise achievable plans to improve their abilities as educators and the effectiveness of their programs.

von Hippel Lindau syndrome presenting as obstructive jaundice with involvement of pancreas in two siblings

Von Hippel Lindau disease is rare autosomal dominant disorder. In our patient's family, 4 out of 7 siblings had manifestations of the disease; 3 of those affected had pancreatic lesions with obstructive jaundice in 2 siblings caused by pancreatic cysts is reported for the first time.

Preserving the best of the art of teaching

Teachers often develop unique methods to help students learn, but these techniques may be lost when they retire from the profession. In the 15 years that they have conducted the Effective Teaching Workshop: Improving Your Skills, the authors of this paper have observed presentations of many innovative teaching methods. The article describes five methods recently presented at the annual workshop: the use of a flipchart with slides; the use of Polarmotion overhead transparencies; an asthma simulation; a breast-mass simulation; and teamwork and game-playing. The authors present these techniques in the hope of reaching a broader audience, and to stimulate other teachers to submit descriptions of innovative teaching methods for possible publication in the Ideas for Medical Education column.

Use of effective questioning to enhance the cognitive abilities of students

Skillful questioning can be very effective in enhancing the cognitive abilities of medical students, residents, fellows, and students from the various health professions. Teachers should be able to use one of the taxonomies of thinking skills described in the literature in order to pose a variety of questions corresponding to various levels of cognition. Bloom's taxonomy is very useful in this regard. It includes a hierarchy starting with knowledge as the lowest-level cognitive skill, advancing through comprehension, application, analysis, and synthesis to evaluation at the highest level. Teachers should be able to construct questions that require different levels of thinking and use them during interactive discussions. The process of effective questioning includes establishing an appropriate environment, creating a climate conducive to learning, using an appropriate mix of questions, phrasing questions accurately, interposing sufficient wait time, and using various probes in response to the answers given by students. Teachers should be trained to enhance their own questioning skills through workshops, peer observation and critique, videotaping and feedback, and use of self-study modules.

Use of effective feedback to facilitate adult learning

Effective feedback plays a critical role in helping adult learners achieve their educational goals and reach their maximum potential. It should be an integral part of every adult education program. Both formal and informal feedback should be provided by teachers, based on the underpinnings of effective feedback techniques. The feedback source, message, and recipient exert influences on the process and must be considered in this context. For maximum impact, the source of feedback must be considered credible and trustworthy by the recipient. The message should provide clear information about performance standards and the performance of the student, in order to elucidate any differences. Positive information should be shared before negative information, and the feedback should be specific, objective, consistent, and timely. The environment in which feedback is provided must be supportive, and should encourage an open dialog between the teacher and the student. Both parties should discuss various items in a spirit of collaboration, and clearly define the goals that need to be achieved. A plan for follow-up and ongoing reinforcement must be developed and implemented. In addition to oral and written feedback, other modes of providing feedback, such as computers, audiotapes, and videotapes, should be considered, and used as appropriate. Skills of faculty members in providing effective feedback may be enhanced through faculty-development programs, such as workshops and self-study modules.

An adult education model for training third-year medical students in use of the Physician Data Query (PDQ) System

BACKGROUND AND METHODS

An adult education model was developed to familiarize third-year medical students with the Physician Data Query (PDQ) system, a computerized, full-text database of state-of-the-art cancer information developed by the National Cancer Institute. The educational model was designed in collaboration with a medical librarian and was implemented within the context of a busy surgery clerkship using only modest resources that were readily available within the medical school.

RESULTS

During three years, 275 medical students participated in the exercise and evaluated both the PDQ system and the educational model. Overall, 87% of the students considered the PDQ system to be a valuable source of information, and 84% anticipated using PDQ after completing their surgical rotations. Ninety-six percent of the students agreed that the objectives of the exercise were met.

CONCLUSIONS

This article provides a description of the educational model and discusses the principles of adult education and andragogy on which it was developed. The importance of emphasizing the process of learning as well as the content is described relative to self-directed and life-long learning.

A beleaguered profession yearning for Lincolns: the need for visionary leadership in the health care profession

In the current milieu of monumental change in medicine and the health sciences, effective leadership is needed from within the health care profession to address various challenges. A leader needs to be visionary, and must possess the ability to share this vision with others through effective communication. The leader should be fair, trustworthy, sincere, truthful, honest, courageous, and compassionate. He or she should be strong and resolute and be able to lead through persuasion rather than coercion. The leader should possess the attributes and skills to mold organizational change in the desired direction and to deal with reactions of individuals going through the change process. The democratic style of leadership appears to be the most effective, although the autocratic style may be needed occasionally to accomplish a specific task. The noncentered, laissez-faire style of leadership is generally not effective and results in significant frustration among subordinates. The most desirable type of power a leader can exercise over subordinates results from deep trust and effective communication, which make people follow the leader willingly. The health care profession needs to solicit the help of experienced members who have shown leadership to help guide various activities and to serve as mentors for the less experienced individuals. Special courses should be designed and implemented to develop specific leadership skills, which are applicable to various health care disciplines. Practical teaching models, including individuals from various disciplines working together in teams, with opportunities for leadership, should be implemented. Also, an appropriate culture that recognizes and rewards effective leadership in academe needs to be established within academic institutions.

Teaching medical students by role playing: a model for integrating psychosocial issues with disease management

BACKGROUND

Medical students on third-year rotations seem to be focused more on the particulars of disease management than on patient management. They often pay too little attention to the psychological and social needs of the patient and to the importance of working in a multidisciplinary team. The authors postulated that a model for teaching breast cancer management that included role playing, self-study, and active student involvement would facilitate the integration of psychosocial and affective issues into scientific content and would demonstrate the importance of the team approach in managing patients with breast cancer.

METHODS

One month following a problem-oriented, case-based, interactive session focusing on clinical management of breast disease, each student was assigned the role of either "patient" or one of four "specialists"-1) a general surgeon, 2) a medical oncologist, 3) a radiation oncologist, or 4) a plastic surgeon. A packet of readings containing discipline-specific information was distributed to each "specialist" and a similar preparation packet was distributed to each "patient." One week later students from each specialty met in "multidisciplinary groups" and five "patients" with written scenarios of recently diagnosed primary breast cancer rotated among them. Important decision-making choices were discussed in each consultation. Following their consultations in the "multidisciplinary" groups, the "patients" met with the entire group of 20-25 students and with physician faculty to discuss differences in the information obtained. They compared "specialists'" styles of presentation and attitudes. Specific issues involving coordination of care among "specialists" were carefully highlighted.

RESULTS

All students participated and the teaching sessions were well received.

CONCLUSIONS

Role playing facilitates the discussion of psychosocial issues and aptly demonstrates to students the need for a multidisciplinary approach to breast cancer treatment. This model is applicable to other types of cancer and to other groups of cancer educators.

Preceptorship, mentorship, and the adult learner in medical and health sciences education

Preceptorship and mentorship are both based on principles of adult education and involve experiential, student-centered learning. Preceptorial relationships are especially useful in developing the practical skills of students. The preceptor works either with small groups of students or one-on-one with individual students, and serves as a teacher, role model, and evaluator. Preceptorial relationships between a teacher and a student are relatively short, and generally span the duration of a course or student rotation. Mentoring involves an intense, global, and long-term relationship between a mentor and a protégé/e, and-encompasses both professional and personal domains. It spans several years and may extend far beyond the period of the structured mentorship. The mentor serves as a teacher, role model, coach, and confidant for the protégé/e and works one-on-one with a protégé/e to achieve various outcomes. Both parties reap significant rewards as a result of the mentorship, and are transformed in the process. Preceptors and mentors must be appropriately selected and adequately trained. Comprehensive faculty development courses and workshops should be designed and implemented to enhance the requisite skills of both groups. The effectiveness of preceptorship and mentorship needs to be continually assessed and appropriate steps taken to further enhance these special educational options. Both options should be included in medical and health sciences education to train competent and well-rounded professionals for the future.

Variability in the clinical skills of residents entering training programs in surgery

BACKGROUND

Residents may have significant differences in clinical skills at the start of their surgical training. The purpose of this study was to investigate the variability in these skills by using an objective structured clinical examination.

METHODS

A needs assessment was performed, and an objective structured clinical examination composed of 10, two-part stations was developed. Standardized patients (SPs) were trained, validated, and used as both simulated patients and evaluators to assess history taking, physical examination, and interpersonal skills of 10 first-year surgical residents. Structured patient notes (PNs) written by residents after the SP encounters were used to assess history and physical examination documentation skills. Data from one station were not used because more than 25% of the SP ratings were missing.

RESULTS

The alpha-reliability was 0.78 for SP ratings, 0.91 for PN scores, and 0.91 for the combined scores. ANOVA revealed significant variation in individual residents' clinical skills as assessed by SPs (F = 4.56, p < 0.01), PNs (F = 11.09, p < 0.001), or both (F = 10.9, p < 0.001). Paired t tests showed that residents scored significantly higher on history taking than on physical examination and attained significantly lower scores on documentation as compared with performance of both history and physical examination (p < 0.001 for each comparison).

CONCLUSIONS

The results showed significant variability in clinical skills of the group of residents and yielded detailed information on the performance of each resident. The data were shared with individual residents and are being used to make changes in the educational activities of the program.

Course of severe ulcerative colitis in northern India

Thirty patients with severe ulcerative colitis were studied prospectively. Sixty percent (18/30) of severe ulcerative colitis were in remission after mean duration of 9.2 days (range 2-20 days) of intensive intravenous therapy without major side effects of steroids. Factors predicting poor response to medical therapy on admission are: stool frequency > or = 9 per day, pulse rate > or = 120/minute, temperature > or = 38 degrees C, Albumin < or = 2 gm, mucosal tags on plain x-ray abdomen and pancolitis.

Description and results of a needs assessment in preparation for the "Surgeons as educators" course

BACKGROUND

In August 1993 the American College of Surgeons sponsored a course entitled "Surgeons as Educators" (SAE) aimed at equipping academic surgeons with the knowledge and skills necessary to enhance surgical education administration, curriculum, teaching, and evaluation.

METHODS

The instructional design model used to construct the course called for a formal needs assessment to determine the importance, current skill level, and priority of what needed to be learned to be an effective educator. The needs assessment was accomplished using a job analysis and questionnaire approach. The 68-item questionnaire was mailed to 320 academic surgeons representing eight medical schools.

RESULTS

A 62% response rate was achieved. Results indicated the education-related tasks or activities that faculty felt were important to their careers, as well as their perceived level of development in each area. Descriptive statistics were used to summarize the responses that were critical to the SAE faculty in helping prioritize, sequence, and time ration course content. Collective results became the foundation for developing the SAE curriculum by the course's five faculty members.

CONCLUSIONS

A well-done needs assessment does not necessarily guarantee course success; however, it is the first and critical step to planning an educationally sound faculty development course or program designed for adult learners.

Evaluation of parallel pelvic/breast and male genital/rectal teaching programs

Pelvic/breast (PB) and male genital/rectal (GR) programs were evaluated to learn if male and female students differed in their reactions to the programs and if observations of the programs confirmed students' reactions. In-depth interviews were conducted with male and female teaching associates to uncover the need for program improvements beyond those suggested by observation and student reactions. Participating in the PB program were 74 men and 85 women; 79 men and 90 women took part in the GR program. Sex differences were found in the GR program: Female students admitted to greater anxiety about examining male genitalia prior to the program (p = .009) and expressed more dissatisfaction with the timing (too late in the curriculum p = .006). Male students were less likely than females to improve their ability to communicate as a result of the GR program (p = .009). Observations and interviews indicated that the programs were successful in teaching technical skills but that they needed further work in integrating technical and communication training, especially during GR examination training.

Surgical educators and the contemporary training of generalists

The national agenda calling for an increase in the number of generalists has resulted in several curricular recommendations, ones which might seriously compromise the training of medical students in surgery. Review of the curricular needs of family physicians reveals that substantial and broad education in surgery is necessary to achieve full competency. Currently, many such curricular objectives are met through special surgical courses and rotations during postgraduate training in family medicine. The argument suggesting that close student interaction with surgeons is unnecessary, and will discourage students from entering generalist disciplines, does not take into account a number of important factors. With appropriate modifications in the core third-year surgery clerkship and inclusion of an appropriately designed fourth-year surgery subinternship, it is possible for surgical educators to provide students with the experience in surgery that is essential for the training of generalists.

Redesigning the surgical teaching of fourth-year medical students to meet the training needs of generalists

The fourth year of the medical student curriculum remains of questionable educational value at most medical schools. The training needs of generalists include the acquisition of knowledge and skills in broad areas of general surgery and the surgical subspecialties. By appropriately tailoring the educational objectives to the learning needs of individual students and implementing teaching models based on principles of adult education, a special surgical experience may be provided to each fourth-year medical student, building on the previously acquired knowledge and skills. Rotations may be offered in a number of surgical disciplines, with heavy emphasis on teaching in the ambulatory setting. One such model was recently implemented at The Medical College of Pennsylvania. Advantages of this type of program include support of the training of generalists using contemporary teaching strategies and provision of a meaningful educational experience to medical students during the fourth year.

Technique of ultrasonic detection and mapping of abdominal wall adhesions

A technique for noninvasive ultrasound examination to detect and map abdominal wall adhesions is described. The examination is based on the demonstration of movement of abdominal viscera during real-time imaging. This movement is called viscera slide and either occurs spontaneously as a result of respiratory movement or may be induced by manual compression. Abdominal wall adhesions produce a restriction of viscera slide. Ultrasonic demonstration of restricted viscera slide has been used for the precise localization and mapping of abdominal wall adhesions prior to abdominal surgery. The technique may be particularly useful in providing safe initial access in patients undergoing laparoscopy who are at increased risk for trocar injury of viscera due to abdominal wall adhesions resulting from previous surgery or peritonitis.

Surgical treatment of peptic ulcer disease

Elective surgery for peptic ulcer disease has diminished significantly over the past 15 years. However, emergency surgery has not shown a decline. Some series have even reported an increase in hospitalizations and operations for hemorrhage. The appropriate surgical procedure for peptic ulcer disease must be tailored to the specific needs of the individual patient. During emergency operations for hemorrhage from duodenal ulcer, we recommend suture ligature of the bleeding vessel and vagotomy-pyloroplasty for high-risk patients, or vagotomy-antrectomy for the lower-risk patient. Bleeding gastric ulcers should be resected, if possible. For massive hemorrhage from stress ulceration requiring surgery, near-total or total gastrectomy should be performed. Perforated duodenal ulcers are best managed by closure and a definitive ulcer operation, such as vagotomy-pyloroplasty. Perforated gastric ulcers are best excised but may be simply closed if conditions do not favor resection. In these situations, biopsy should be performed. We recommend truncal vagotomy-antrectomy for patients presenting with obstruction. Vagotomy (truncal or proximal gastric) with drainage is an acceptable alternative in this situation. For patients with intractable ulcer disease or for those who are noncompliant, proximal gastric vagotomy is the preferred operation. However, other operations may need to be considered, depending on the specific situation. Recurrent ulceration needs appropriate work-up to determine the possible cause. Although patients with ulcer recurrence initially may be placed on medical treatment, about 50% will require reoperation. The most effective procedure for peptic ulcer disease is truncal vagotomy-antrectomy, which has a recurrence rate of less than 1%. The procedure with the least morbidity and the fewest undesirable side effects is proximal gastric vagotomy. Ulcer recurrence after proximal gastric vagotomy or truncal vagotomy-pyloroplasty is in the range of 10% to 15%.

Identification of human appendicitis by in vitro nuclear magnetic resonance

The spin-lattice relaxation time, T1 as determined by nuclear magnetic resonance techniques, correlates positively with tissue water content. The latter relationship has been observed in rabbits with experimentally induced appendicitis whose inflamed appendiceal tissues had significantly higher T1's and water contents than tissue from normal controls. The present experiment studied these relationships in humans. Tissue water content and T1 were measured on appendiceal tissue from 10 patients with documented appendicitis and from 6 controls without the disease. All T1's were determined within 30-60 min of removal of the appendix at operation. The mean in vitro T1 of appendiceal tissue from patients with appendicitis was significantly higher than that of controls (527 +/- 15 msec versus 430 +/- 17 msec, mean +/- SEM, P less than 0.002). In addition, a strong positive correlation was noted between T1 and tissue water content (r = 0.70, P less than 0.01). Based on these findings, the use of in vivo magnetic resonance imaging techniques to detect human appendicitis noninvasively warrants investigation.

The identification of experimentally induced appendicitis using in vitro nuclear magnetic resonance

Appendicitis was induced in six New Zealand white rabbits. The appendices from these animals had significantly higher spin-lattice relaxation times, T1, as determined in vitro by nuclear magnetic resonance (NMR) (10 controls vs 6 experimentals, 413 +/- 23 vs 455 +/- 41, X +/- SD, P less than (0.02). T1 correlated significantly with the water content of the appendiceal tissue (P less than 0.001). These findings suggest that in vivo NMR imaging techniques weighted on T1 might be able to identify human appendicitis noninvasively by detecting localized edema.

Metronidazole in prevention and treatment of bacteroides infections in elective colonic surgery

A double-blind randomised trial was carried out among 46 patients undergoing elective colonic surgery; 27 patients received prophylactic metronidazole and 19 received placebo. Anaerobic infections did not develop in any of the metronidazole-treated patients, but did develop in 11 (58%) of 19 controls who were subsequently successfully treated with metronidazole.

Axillary artery occlusion and pulmonary tuberculosis

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