Successful implementation of change in postgraduate medical education - a qualitative study of programme directors.

INTRODUCTION: Leaders in postgraduate medical education are responsible for implementing educational change. Although difficulties in implementing change are described both in the general leadership literature as well as in the field of medical education, knowledge of what characterises successful change leadership in postgraduate medical education is limited. The aim of this study is to explore the process used by educational leaders in successful change implementation in postgraduate medical education. METHODS: Semi-structured interviews were conducted with 16 programme directors to explore how they had implemented successful change projects. The sample consisted of programme directors who had reported in a previous survey having high educational impact at their workplace. Interviews were analysed using Ödman's qualitative interpretative method. RESULTS: The interviews identified similarities in how participating programme directors had implemented changes. Five interconnected themes crystallised from the data: (1) belonging to a group, (2) having a vision and meaning, (3) having a mandate for change, (4) involving colleagues and superiors, and (5) having a long-term perspective. CONCLUSIONS: Our findings illuminate important aspects of successful change management in postgraduate medical education. Change is ideally based on a clear vision and is implemented in coalition with others. A long-term strategy should be planned, including involvement and anchoring of key persons in several discrete steps as change is implemented. While some of these findings are congruent with the general literature on change management, this study emphasises the importance of a mandate, with successful change leadership dependent on coalition and the facilitation provided by the next level of leadership.

The Ki-67 Proliferation Index as a Marker of Time to Recurrence in Intracranial Meningioma.

BACKGROUND: There are examples of incongruence between the WHO grade and clinical course in meningioma patients. This incongruence between WHO grade and recurrence has led to search for other prognostic histological markers. OBJECTIVE: To study the correlation between the Ki-67 proliferative index (PI), risk of recurrence, and recurrence rates in meningioma patients. METHODS: We prospectively collected pathological diagnosis of de novo consecutive meningiomas. In total, we followed 159 patients with clinical controls until recurrence, death, or emigration. We estimated the correlation between risk of recurrence and Ki-67 PI when adjusted for age at diagnosis, sex, WHO grade, extent of surgical resection, and tumor location. We estimated the cumulative incidence of recurrence when considering death without recurrence a competing risk. We report recurrence rates per 100 person-years. RESULTS: A 1%-point increase of Ki-67 PI yielded a hazard ratio of 1.12 (95% CI: 1.01-1.24) in a multivariate analysis. The cumulative incidence of recurrence was 3% for Ki-67 0% to 4% vs 19% for Ki-67 > 4% meningiomas after 1 yr, but 24% vs 35%, respectively, after 10 yr. There was no significant difference in mean Ki-67 PI between nonrecurrent and recurrent meningioma in a 2-sample t-test (P = .08). The strongest relationship was detected between Ki-67 PI and time to recurrence: Ki-67 < 4% meningiomas recurred after median 4.8 yr, compared to 0.60 to 0.75 yr for patients with higher Ki-67 PI. CONCLUSION: Ki-67 PI was a marker for time to recurrence rather than a predictor of recurrence. Ki-67 PI may be utilized for patient tailored follow-up.

Factors related to the role of programme directors in association with quality in postgraduate medical education - a cross-sectional study.

BACKGROUND: Educational leaders have been pointed out as being important for quality of medical education. However, their actual influence on the education can be limited. At the postgraduate level, educational leadership and its connection with quality is underexplored and knowledge about how to increase its impact is lacking. An increased understanding could be used in order to prioritize actions for strengthening the role. The aim of this study was to investigate factors related to the role of programme director associated with quality in postgraduate medical education. METHODS: A cross-sectional study was carried out. A questionnaire was sent to programme directors in Sweden (n = 519) comprising questions about background factors, work characteristics, work tasks, hindering and enabling factors, and the Utrecht Work Engagement Scale. A logistic regression and classification tree were used to identify factors associated with high qualitative education, defined as compliance with national regulations. RESULTS: The response rate was 54% (n = 279). In total, 62% of the programme directors reported high quality and factors associated with high quality included experiences of communication with residents, superiors and supervisors, and support from the supervisors. Other factors were consensus regarding postgraduate medical education at the workplace, adequate financial resources, the programme directors' competence, and their perceived impact on education. Factors of particular importance seemed to differ depending on whether the programme directors were responsible for one or for multiple units. Most high-quality education was found in cases where programme directors were responsible for a single unit and perceived sufficient impact on education. CONCLUSIONS: These results indicated that there was an association between factors related to programme director and quality in postgraduate medical education. The findings pointed out the importance of combining activities at both individual, group and organizational levels. Relational aspects should not be underestimated; faculty development and involvement are crucial.

Gentamicin loading of calcium phosphate implants: implications for cranioplasty.

BACKGROUND: Surgical site infections (SSI) are a significant risk in cranioplasty, with reported rates of around 8-9%. The most common bacteria associated with these nosocomial infections are of the Staphylococcus species, which have the ability to form biofilm. The possibility to deliver antibiotics, such as gentamicin, locally rather than systemically could potentially lower the early postoperative SSI. Various antibiotic dosages are being applied clinically, without any true consensus on the effectiveness. METHODS: Drug release from calcium phosphate (CaP), polyetheretherketone (PEEK), and titanium (Ti) samples was evaluated. Microbiological studies with Staphylococcus aureus (SA) and Staphylococcus epidermidis (SE) including strains from clinical infection were used to establish clinically relevant concentrations. RESULTS: The CaP samples were able to retain and release gentamicin overtime, whereas the Ti and PEEK samples did not show any drug uptake or release. A gentamicin loading concentration of 400 µg/ml was shown to be effective in in vitro microbiological studies with both SA and SE. CONCLUSIONS: Out of the three materials studied, only CaP could be loaded with gentamicin. An initial loading concentration of 400 µg/ml appears to establish an effective gentamicin concentration, possibly translating into a clinical benefit in cranioplasty.

Factors influencing effectiveness in postgraduate medical education - a qualitative study of experiences of the responsible clinical consultants.

BACKGROUND: Medical education leaders are important for educational quality in postgraduate medical education. Their work tasks are complex and contain different components. However, factors that are influencing leaders´ effectiveness in completing these tasks are unexplored. Understanding and developing these factors is most likely essential to strengthen postgraduate medical education and to consequently improve the quality in health care delivery. This study explores the experiences of factors that influence effectiveness of clinical consultants responsible for postgraduate medical education at clinical departments. Effectiveness was defined as fulfillment of work tasks. METHODS: A qualitative study was performed with data gathered through semi-structured face-to-face interviews with 17 consultants responsible for postgraduate medical education. Data was analyzed by qualitative content analysis. RESULTS: Findings clustered into four themes of factors influencing effectiveness: individual (being an expert, social competence), relational (support and cooperation, communication), attitudinal (shared vision, organizational values, colleagues' attitudes) and structural (organizational characteristics, regulations and guidelines, conditions for the role). The factors were experienced to influence effectiveness in a positive or a negative direction. CONCLUSIONS: This study shed light on the complex and interrelated factors experienced to have impact on the role of consultant responsible for postgraduate medical education. Viewing the result through the concept of power, the role mainly relies on personal power sources like expert and referent power whereas power connected to the position often are lacking. To increase effectiveness of the role, a differentiated strategy which involves activities at both individual, group and organizational levels is needed.

Long-term control and predictors of seizures in intracranial meningioma surgery: a population-based study.

BACKGROUND: The aim of this retrospective study was to investigate the long-term seizure control and antiepileptic drug (AED) prescriptions, as well as identifying predictors of seizure(s) before and after surgery in a population-based cohort of operated intracranial meningioma patients. METHODS: A total of 113 consecutive adult (> 18 years old) patients with newly diagnosed meningioma operated at the Karolinska University Hospital between 2006 and 2008 were included and followed up until the end of 2015. Data on seizure activity and AED prescriptions were obtained through chart review and telephone interview. Logistic regression and survival analysis were applied to identify risk factors for pre- and postoperative seizures. RESULTS: A total of 21/113 (18.6%) patients experienced seizures before surgery of which 8/21 (38.1%) went on to become seizure-free after surgery. Thirteen (14%) patients experienced new-onset seizures after surgery. The regression analysis revealed tumor diameter ≥ 3.5 cm as a risk factor for preoperative seizures (OR 3.83, 95% CI 1.14-12.87). Presence of headache (OR 0.19, 95% CI 0.05-0.76) and skull base tumor location (OR 0.14, 95% CI 0.04-0.44) decreased the risk of preoperative seizures. Postoperative seizures were associated with tumor diameter ≥ 3.5 cm (OR 2.65, 95% CI 1.06-6.62) and history of preoperative seizures (OR 3.50, 95% CI 1.55-7.90). CONCLUSION: Seizures are common before and after intracranial meningioma surgery. Approximately one third of patients with preoperative seizures become seizure-free on long-term follow-up after surgery, while 14% experienced new-onset seizures after surgery. Larger tumor size, absence of headache, and non-skull base location were associated with preoperative seizures, while tumor size and preoperative seizures were associated with postoperative seizures.

Safety and Efficacy of TachoSil (Absorbable Fibrin Sealant Patch) Compared With Current Practice for the Prevention of Cerebrospinal Fluid Leaks in Patients Undergoing Skull Base Surgery: A Randomized Controlled Trial.

BACKGROUND: Cerebrospinal fluid (CSF) leakage associated with incomplete sealing of the dura mater is a major complication of intradural procedures. OBJECTIVE: To compare the efficacy and safety of adjunctive TachoSil (Takeda Pharma A/S, Roskilde, Denmark) with current practice for the prevention of postoperative CSF leaks in patients undergoing elective skull base surgery involving dura mater closure. METHODS: Patients were intraoperatively randomized to TachoSil or current practice immediately before primary dura closure by suturing ± duraplasty. Choice of adjunctive treatment in the current practice group was at the surgeon's discretion. Primary efficacy endpoint was occurrence of clinically evident verified postoperative CSF leak or clinically evident pseudomeningocele within 7 weeks after surgery or treatment failure (third application of trial treatment or use of other treatment). RESULTS: A total of 726 patients were randomized to TachoSil (n = 361) or current practice (n = 365). More current practice patients had sutures plus duraplasty for primary dura closure compared with TachoSil (49.6% vs 35.7%) and fewer had sutures only (45.5% vs 63.2%). The primary endpoint of estimated leak rate favored TachoSil with events in 25 (6.9%) patients vs 30 (8.2%) current practice patients; however, this was not statistically significant (odds ratio: 0.82; 95% confidence interval: 0.47, 1.43; P = .485). Both treatments were well tolerated with similar frequency of adverse events. CONCLUSION: Very low rates of postoperative CSF leaks can be achieved in patients undergoing skull base surgery of various indications. Although the study did not meet its primary endpoint, TachoSil appears to be safe and effective for the prevention of CSF leaks and associated complications.

Bioceramic Implant Induces Bone Healing of Cranial Defects.

Autologous bone or inert alloplastic materials used in cranial reconstructions are techniques that are associated with resorption, infection, and implant exposure. As an alternative, a calcium phosphate-based implant was developed and previously shown to potentially stimulate bone growth. We here uncover evidence of induced bone formation in 2 patients. Histological examination 9 months postoperatively showed multinuclear cells in the central defect zone and bone ingrowth in the bone-implant border zone. An increased expression of bone-associated markers was detected. The other patient was investigated 50 months postoperatively. Histological examination revealed ceramic materials covered by vascularized compact bone. The bone regenerative effect induced by the implant may potentially improve long-term clinical outcome compared with conventional techniques, which needs to be verified in a clinical study.

Roles, tasks and educational functions of postgraduate programme directors: a qualitative study.

BACKGROUND: A programme director is often required to organise postgraduate medical education. This leadership role can include educational as well as managerial duties. Only a few published studies have explored programme directors' own perceptions of their role. There is a need to explore the use of theoretical frameworks to improve the understanding of educational roles. OBJECTIVE: To explore programme directors' own perceptions of their role in terms of tasks and functions, and to relate these roles to the theoretical framework developed by Bolman and Deal. METHODS: Semi-structured interviews were conducted with 17 programme directors between February and August 2013. The data were subjected to content analysis using a deductive approach. RESULTS: The various roles and tasks included by participants in their perceptions of their work could be categorised within the framework of functions described by Bolman and Deal. These included: structuring the education (structural function); supporting individuals and handling relations (human resource function); negotiating between different interests (political function); and influencing the culture at the departmental level (symbolic function). The functions most often emphasised by participants were the structural and human resource functions. Some tasks involved several functions which varied over time. CONCLUSIONS: Programme directors' own perceptions of their roles, tasks and functions varied widely. The theoretical framework of Bolman and Deal might be helpful when explaining and developing these roles.

Long-term follow-up of incidentally discovered meningiomas.

BACKGROUND: Many incidental meningiomas are detected and need to be assessed for further management. Better knowledge of the long-term natural history is necessary for optimal management. METHODS: We have retrospectively evaluated a cohort of consecutive patients who were referred to the authors at the Department of Neurosurgery with incidentally diagnosed asymptomatic meningiomas from 1991-1998 and followed prospectively. All patients were followed for a minimum of 10 years or until they reached the endpoint of demonstrated tumour growth or died. RESULTS: During follow-up, 35.4 % of the tumours grew, resulting in a 75 % 15-year growth rate by life-table statistics. The growth rates were similar in smaller (<2 cm) and larger tumours, while calcified tumours grew at a lower rate. The latter difference was, however, not statistically significant. CONCLUSION: Long-term tumour growth of incidentally detected asymptomatic meningiomas appeared to be much higher than expected. This information needs to be considered when discussing surgery, since the indication for surgery may be stronger than previously stated, especially for younger patients with tumours that can be reached at low risk.

The Swedish duty hour enigma.

BACKGROUND: The Swedish resident duty hour limit is regulated by Swedish and European legal frameworks. With a maximum average of 40 working hours per week, the Swedish duty hour regulation is one of the most restrictive in the world. At the same time, the effects of resident duty hour limits have been neither debated nor researched in the Swedish context. As a result, little is known about the Swedish conceptual framework for resident duty hours, their restriction, or their outcomes: we call this "the Swedish duty hour enigma." This situation poses a further question: How do Swedish residents themselves construct a conceptual framework for duty hour restrictions? METHODS: A case study was conducted at Karolinska University Hospital, Stockholm--an urban, research-intensive hospital setting. Semi-structured interviews were carried out with 34 residents currently in training in 6 specialties. The empirical data analysis relied on theoretical propositions and was conducted thematically using a pattern-matching technique. The interview guide was based on four main topics: the perceived effect of duty hour restrictions on (1) patient care, (2) resident education, (3) resident well-being, and (4) research. RESULTS: The residents did not perceive the volume of duty hours to be the main determinant of success or failure in the four contextual domains of patient care, resident education, resident well-being, and research. Instead, they emphasized resident well-being and a desire for flexibility. CONCLUSIONS: According to Swedish residents' conceptual framework on duty hours, the amount of time spent on duty is not a proxy for the quality of resident training. Instead, flexibility, organization, and scheduling of duty hours are considered to be the factors that have the greatest influence on resident well-being, quality of learning, and opportunities to attain the competence needed for independent practice.

Meningiomas engaging major venous sinuses.

BACKGROUND: Meningiomas with growth onto or into the major venous sinuses, that is, venous meningiomas, provide management problems regarding their radical removal and preservation of venous drainage. The relationship to venous structures often precludes radical surgery; the risk of recurrence and aggressive histology is greater for parasagittal meningiomas than in other locations. Older series reflect the conflict between radical surgery and subtotal removal followed by the "wait-and-scan" approach for the residual. This review summarizes our experience of a more contemporary series of venous meningiomas, after to the introduction of gamma-knife radiosurgery, for residual tumors and a long follow-up of 10 years. METHODS: Treatment, histopathology, and follow-up data of 100 consecutive patients undergoing surgery for venous meningiomas were prospectively collected. Gamma-knife surgery was considered as a direct postsurgical adjunct or as an adjunct after a period of radiological follow-up. The proliferation marker MIB-1 was prospectively analyzed. Two patients were lost to follow-up after 5 years, and 98 were followed until their death or a minimum of 10 years. RESULTS: The 6-month outcome was good-to-excellent in 94 patients; one patient died. Eighteen patients died within 10 years. Ten had aggressive or anaplastic meningiomas. In 10 years, tumor recurrence or progression was noted in 23 patients. One important reason was that only 42% of patients undergoing Simpson grade 1 removal had free resection margins at microscopic examination. Patients with Simpson grade 1 surgery had a recurrence rate of 10%. Patients with deliberate nonradical surgery (Simpson grade IV) had a tumor recurrence rate of 72%, whereas a combined treatment of direct gamma-knife radiosurgery after a tailored microsurgical resection (Simpson IV gamma) allowed return to a low recurrence rate of 10%. The tumor proliferation indices (MIB-1/Ki-67) were prognostically relevant for recurrence after either microsurgery or gamma-knife radiosurgery. CONCLUSION: Surgical microscopic radicality was unexpectedly difficult to achieve. Gamma-knife radiosurgery was a useful adjunct but only in patients with tumors of low proliferative index. It should probably be used as part of the initial surgical management. As expected, treatment results for these patients seem to have improved during the last decades but recurrence and malignancy remained a problem, which is not always solved by repeated radiosurgery.

Development of a bioactive implant for repair and potential healing of cranial defects.

The repair of complex craniofacial bone defects is challenging and a successful result is dependent on the size of the defect, quality of the soft tissue covering the defect, and choice of reconstruction method. The objective of this study was to develop a bioactive cranial implant that could provide a permanent reconstructive solution to the patient by stimulating bone healing of the defect. In this paper the authors report on the feasibility and clinical results of using such a newly developed device for the repair of a large traumatic and therapy-resistant cranial bone defect. The patient had undergone numerous attempts at repair, in which established methods had been tried without success. A mosaic-designed device was manufactured and implanted, comprising interconnected ceramic tiles with a defined calcium phosphate composition. The clinical outcome 30 months after surgery revealed a restored cranial vault without postoperative complications. Computed tomography demonstrated signs of bone ingrowth. Examination with combined (18)F-fluoride PET and CT provided further evidence of bone healing of the cranial defect.

Variation in calvarial bone healing capacity: a clinical study on the effects of BMP-2-hydrogel or bone autograft treatments at different cranial locations.

BACKGROUND: Bone morphogenetic protein-2 (BMP-2) together with a suitable carrier is an attractive option that may be used for craniofacial bone reconstruction. In this prospective randomized study, a hyaluronan-based hydrogel with BMP-2 was used to achieve bone healing in standardized critical-size cranial defects in humans after neurosurgery. METHODS: Twelve patients were randomized into the treatment group (N = 6) or control group (N = 6). In the treatment group, holes made during craniotomy were treated with hydrogel with BMP-2, 250 µg/mL, or hydrogel without BMP-2. In the remaining hole/s in the same patient, Spongostan (Ethicon) alone or Tisseel (Baxter) mixed with autologous bone matrix were used as negative and positive controls, respectively. In the control group, the holes were treated with Spongostan or Tisseel mixed with bone autograft. Bone healing was assessed with CT scans after 3 and 6 months. Bone areas in treated defects were measured and statistical analysis was performed. RESULTS: Independent of location, bone healing in defects treated with Tisseel with autograft, hydrogel alone, or hydrogel with BMP-2 was significantly increased compared to negative control (P < 0.001, P = 0.002, and P = 0.005, respectively). In general, all defects healed significantly better in the frontal bone as compared to parietal-temporal location, except for defects treated with Tisseel and autograft, which healed well independently of location. No local or systemic side effects, including excessive bone overgrowth or inflammatory reaction, were seen in treated patients. CONCLUSIONS: Tissue engineering of bone with hyaluronan-based hydrogel shows good healing of cranial defects, comparable with bone autografts. The hydrogel itself may represent a novel alternative to autologous bone transplants in craniofacial bone repair. The study also reveals a general superior healing capacity in the frontal bone as compared to parietal/temporal bones.