How well do we understand our patients' perioperative experience? A qualitative analysis of themes derived from patient-centric resident conferences

BACKGROUND

Patient-centric resident conferences (PCRCs) provide meaningful time to connect with and learn from patients. This qualitative study explores themes of patients' perioperative experiences from PCRCs through patient and resident perspectives.

METHODS

General Surgery residents participated in six PCRCs, which include condensed standard didactics to accommodate a patient panel regarding their perioperative experience. Panel transcripts and resident survey responses describing what they learned were coded using grounded theory methodology. Themes were evaluated and compared.

RESULTS

76 identified codes were grouped into major categories: "Medical/Surgical Knowledge," "Patient Perspective," "Patient-Physician Relationship," and "Communication." Themes from resident responses predominantly paralleled patient discussion, with common themes including "impact of disease and surgery on patient" and "compassion/empathy." "Medical/surgical knowledge" was only present in resident responses while themes regarding quality of life were more frequent in patient transcripts.

CONCLUSIONS

PCRCs are a valuable tool in resident education to understand patients' perioperative experiences. Themes from patient panels complement, but do not replace, information covered in didactic lectures.

Revitalizing the Patient-Surgeon Relationship: Surgical Curriculum Including the Patient Perspective

OBJECTIVE

General Surgery residents have increasing obligations that limit time with patients. This affects the patient-physician relationship, decreases meaning in work and increases burnout. Patient-Centric Resident Conferences (PCRC)¹ incorporate patients in resident didactics to promote meaning in work and improve resident confidence in counseling and consenting patients for surgery.

DESIGN

Prospective cohort study of General Surgery residents who participated in standard didactic conferences (control) and modified conferences (PCRC) between 2017 and 2019. Control conferences covered a relevant surgical topic. PCRC had shortened didactics and discussions with patients who had undergone the relevant index operation. Pre- and postconference surveys measured teaching effectiveness, confidence in counseling and consenting, and resident perception of how well the conference supported their decision to pursue surgery. Survey data was compared using chi-squared tests. Qualitative data analysis used ground theory methodology.

SETTING

This study was performed by the Department of Surgery at Oregon Health and Science University in Portland, Oregon.

PARTICIPANTS

All active General Surgery residents were asked to participate in conferences.

RESULTS

Eighty-one residents completed 136 surveys over 5 control conferences and 207 surveys over 7 PCRC. Residents reported increased confidence in counseling and consenting for surgery following control conferences (p < 0.0001) and PCRC (p < 0.0001). Residents' perception of effectiveness of teaching pathophysiology (p = 0.008) and operative steps (p = 0.013) was greater in control conferences whereas effectiveness of teaching surgical complications was greater in PCRC (p = 0.006). Resident responses indicated greater support for a surgical career following PCRC compared to control conferences (p = 0.013). Themes like "patient perspective," "impact on surgeon," and "psychological effects of surgery" were common in PCRC and rare in control conferences.

CONCLUSIONS

PCRC were associated with stronger motivations for a surgical career and included patient-centered themes, which can enhance meaning in work. These conferences complement but do not replace standard didactics.

What is the Cost-Effective Treatment for Melanoma Patients with a Positive Sentinel Node?

BACKGROUND

Survival for positive sentinel lymph node (SLN) patients does not differ between completion lymph node dissection (CLND) and nodal observation (OBS). However, treating these patients with CLND and checkpoint inhibitors, such as pembrolizumab (PEM), improves outcomes. This study evaluated the cost-effectiveness of OBS, CLND, and CLND with PEM (CLND-PEM) treatments.

METHODS

A Markov model was designed to simulate treatment for a theoretical cohort of 1000 positive SLN patients per therapy with a 5-year follow-up period. An intervention was cost-effective if its incremental cost-effectiveness ratio among therapies was below the willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY).

RESULTS

Compared with CLND or CLND-PEM, OBS resulted in fewer lymphedema cases but in more disease recurrences. Compared with OBS, CLND had higher costs and lower QALYs. Although CLND-PEM had a lower number of recurrences and deaths than OBS or CLND, it had higher costs and lower QALYs than OBS, and thus was not cost-effective. However, with the effects of CLND from CLND-PEM removed, allowing evaluation of PEM effects alone (PEM alone), the resulting QALYs were the highest, but PEM alone still was not cost-effective compared with OBS ($1.2 million per QALY). By reducing the drug cost to less than $14,404 per patient, PEM alone would become cost-effective.

CONCLUSIONS

Compared with CLND, CLND-PEM, and PEM alone, OBS was cost-effective for managing positive SLN patients. Although CLND-PEM and PEM alone result in fewer recurrences and deaths, these therapies were not cost-effective due to the quality-of-life decrement of CLND and the current high drug cost of PEM.