Initial performance of a modified milestones global evaluation tool for semiannual evaluation of residents by faculty.

OBJECTIVES: To determine whether faculty could successfully evaluate residents using a competency-based modified Milestones global evaluation tool. DESIGN: A program's leadership team modified a draft Surgery Milestones Working Group summative global assessment instrument into a modified Milestones tool (MMT) for local use during faculty meetings devoted to semiannual resident review. Residents were scored on 15 items spanning all competencies using an 8-point graphic response scale; unstructured comments also were solicited. Arithmetic means were computed at the resident and postgraduate year cohort levels for items and competency item sets. Score ranges (highest minus lowest score) were calculated; variability was termed "low" (range <2.0 points), "moderate" (range = 2.0), or "high" (range >2.0). A subset of "low" was designated "small" (1.0-1.9). Trends were sought among item, competency, and total Milestones scores. MMT correlations with examination scores and multisource (360°) assessments were explored. The success of implementing MMT was judged using published criteria for educational assessment methods. SETTING: Fully accredited, independently sponsored residency. PARTICIPANTS: Program leaders and 22 faculty members (71% voluntary, mean 12y of experience). RESULTS: Twenty-six residents were assessed, yielding 7 to 13 evaluations for MMT per categorical resident and 3 to 6 per preliminary trainee. Scores spanned the entire response scale. All MMT evaluations included narrative comments. Individual resident score variability was low (96% within competencies and 92% across competencies). Subset analysis showed that small variations were common (35% within competencies and 54% across competencies). Postgraduate year cohort variability was higher (61% moderate or high within competencies and 50% across competencies). Cohort scores at the item, competency, and total score levels exhibited rising trajectories, suggesting MMT construct validity. MMT scores did not demonstrate concurrent validity, correlating poorly with other metrics. The MMT met multiple criteria for good assessment. CONCLUSIONS: A modified Milestones global evaluation tool can be successfully adopted for semiannual assessments of resident performance by volunteer faculty members.

Multi-institutional study of self-reported attitudes and behaviors of general surgery residents about ethical academic practices in test taking.

PURPOSE: Correlation exists between people who engage in academic dishonesty as students and unethical behavior once in practice. Previously, we assessed the attitudes of general surgery residents and ethical practices in test taking at a single institution. Most residents had not participated in activities they felt were unethical, yet what constituted unethical behavior was unclear. We sought to verify these results in a multi-institutional study. METHODS: A scenario-based survey describing potentially unethical activities related to the American Board of Surgery In-training Examination (ABSITE) was administered. Participants were asked about their knowledge of or participation in the activities and whether the activity was unethical. Program directors were surveyed about the use of ABSITE results for resident evaluation and promotion. RESULTS: Ten programs participated in the study. The resident response rate was 67% (186/277). Of the respondents, 43% felt that memorizing questions to study for future examinations was unethical and 50% felt that using questions another resident memorized was unethical. Most felt that buying (86%) or selling (79%) questions was unethical. Significantly more senior than junior residents have memorized (30% vs 16%; p = 0.04) or used questions others memorized (33% vs 12%; p = 0.002) to study for future ABSITE examinations and know of other residents who have done so (42% vs 20%; p = 0.004). Most programs used results of the ABSITE in promotion (80%) and set minimum score expectations and consequences (70%). CONCLUSION: Similar to our single-institution study, residents had not participated in activities they felt to be unethical; however the definition of what constitutes cheating remains unclear. Differences were identified between senior and junior residents with regard to memorizing questions for study. Cheating and unethical behavior is not always clear to the learner and represents an area for further education.

Nondesignated preliminary residents in general surgery: 25-year outcomes.

BACKGROUND: This study assesses the outcomes of nondesignated preliminary (NDP) residents in general surgery (GS) at an independent, nonuniversity training program. METHODS: Records of all NDP residents from 1984-1985 through 2008-2009 were reviewed, and residents' careers were followed. Designated preliminary and categorical residents were excluded. RESULTS: Sixty-two residents completed the NDP year. Three of these residents also completed a second postgraduate NDP year. A total of 60 NDPs (97%) continued in accredited postgraduate programs. Forty-eight graduates (77%) pursued surgery-associated careers: 26 (42%) in GS and 22 (35%) in other surgery-related specialties. Eleven of the 26 NDPs who entered GS (42%) became categorical residents in our program. All NDP GS graduates are board certified, board eligible, or are residents in training. CONCLUSIONS: After a preliminary year in GS, NDPs continued in postgraduate medical education followed by board certification, usually in GS or surgery-related specialties. NDPs often obtain categorical positions in the parent GS program.

The present and future use of physician extenders in general surgery training programs: one response to the 80-hour work week.

BACKGROUND: The aim of this study was to assess the use of physician extenders (PEs) in general surgery residency programs. STUDY DESIGN: We surveyed the program directors in surgery for the number of chief residents, PEs on general surgery services, PE duties, whether PEs were hired in response to Accreditation Council for Graduate Medical Education work-hour restrictions, plans to hire additional PEs, and program type. Data were analyzed using the Student's t-test; p values are two-tailed and considered significant if <0.05. RESULTS: There were 163 programs (65%) that responded, (87 university, 70 nonuniversity, and 6 military programs), with a total of 689 graduating chief residents per year. One hundred sixty programs use 840 PEs (median, 3.5 PEs per program; mean, 5.3 PEs per program, 2 PEs per chief resident). One hundred twenty-seven programs (79%) use at least 1 PE (range 1 to 50 PEs); 93 programs (57%) hired 513 (61%) PEs in response to work-hour restrictions. Before 2003, the mean number of PEs per program was 2.0; after 2003, there were 5.3 per program (p=0.0001). Most common uses of PEs included taking histories and physicals (84%), seeing consults (58%), first-assisting (52%), and seeing patients in the emergency department (47%). Forty-seven of 162 (29%) programs plan to hire more PEs in the next 3 years, 76 programs (47%) would like to, but are unsure of funding; 23 programs (14%) are not planning to increase the total, and 16 programs (10%) are unsure. With available funding, 431 additional PEs may be hired in the next 3 years, for a total of 1,271 PEs in 163 programs, or an average of 7.8 PEs per program and 1.8 PEs per chief resident. CONCLUSIONS: PEs have been hired in large numbers to assist on general surgery teaching services, with most hired in response to Accreditation Council for Graduate Medical Education work-hour restrictions, and most of their duties are intended to aid resident education. Almost 80% of programs currently use PEs; 76% would like to hire more. Currently 1.2 PEs are used per graduating chief resident; this could increase to 1.8 PEs per chief resident in the next 3 years.

Do men and women use the same criteria in selecting a general surgery residency program? Results of a 20-year study in a non-university program.

BACKGROUND: To assess applicant preferences in general surgery program selection, we surveyed current and former residents of our non-university general surgery residency program over the last 20 years, with particular emphasis on male and female selection preferences. METHODS: Surveys were distributed to current and former categorical residents. Respondents were asked to rate 25 residency criteria using a Likert scale. Responses by males and females were compared using the Mann-Whitney U-test. Results are reported as mean scores, with p-values indicating statistical significance of trends toward higher scores. RESULTS: Of 50 former (76% male, 24% female) and 18 current residents (56% male, 44% female), 56 responded (38 male, 18 female), for an overall response rate of 82%. For both male and female respondents, the top 4 selection criteria by mean average score were identical: variety and number of cases, friendly training environment, camaraderie among residents, and quality of relationships with attendings. Selection criteria that received significantly higher scores among women were camaraderie among residents, the number of female residents, and the number of female attendings (p < 0.05). For men, a suburban location, compensation and benefits, and the reputation of the program director received significantly higher scores (p < 0.05). Gender-related selection preference was most marked for the number of female residents (mean, 2.4 for women vs 1.3 for men) and the number of female attendings (mean, 2.3 for women vs 1.4 for men). These 2 criteria, however, were ranked 20th and 21st (of the 25), respectively, by the female respondents. CONCLUSIONS: The most important selection criteria, regardless of gender, relate to operative experience, training environment, and quality relationships. Gender-based preferences seem to play only a minor role in general surgery program selection.

Safely increasing the efficiency of thyroidectomy using a new bipolar electrosealing device (LigaSure) versus conventional clamp-and-tie technique.

Operative time in thyroid surgery can be safely reduced through use of a new bipolar electrosealing device (LigaSure). We evaluated consecutive patients undergoing thyroid surgery from January 2003 through January 2005 (n=155). During the first half of the study, hemostasis was obtained using silk ties (conventional group, n=70). During the second half of the study period, hemostasis was obtained with a bipolar electrosealing device (LigaSure group, n=85). The mean operative time was 130 +/- 37 minutes in the conventional group and 110 +/- 33 minutes (P < 0.001) in the LigaSure group. EBL in the LigaSure group was statistically significantly less (43 +/- 53 vs 33 +/- 33 mL; P < 0.05). Postoperative calcium level was statistically significantly higher in the LigaSure group (8.2 +/- 0.5 vs 8.4 +/- 0.6 mg/dL, P < 0.05). Hospital length of stay (LOS) did not differ significantly. One patient in each group developed neck hematoma requiring reoperation. One permanent recurrent nerve injury occurred in the conventional group and one transient bilateral recurrent nerve injury occurred in the LigaSure group. The occurrence of symptomatic hypocalcemia was similar between the two groups. The training level of the surgical resident had no significant impact on the operative time, estimated blood loss (EBL), LOS, or complication rate. LigaSure bipolar electrosealer as the primary means of hemostasis during thyroidectomy significantly reduces mean operative times. Rates of operative complications were unchanged. LigaSure use in thyroid surgery can safely increase efficiency.

Suspicious findings in reduction mammaplasty specimens: review of 182 consecutive patients.

Breast reduction mammaplasty allows examination of specimens from a seemingly healthy population for the presence of proliferative breast disease. The authors reviewed the charts of all reduction mammaplasty patients of a single surgeon over 7.5 years for age, family history, mammographic results, unilateral or bilateral nature of the procedure, and final pathologic diagnosis. Of 182 patients, 168 had bilateral and 14 had unilateral breast reductions. Ages ranged from 16 to 79 years (average and median: 37 years and 35 years respectively). Fifty-seven patients (31%) were younger than 30 years, 53 patients (29%) were between the ages 30 years and 39 years, for a total of 110 patients (60%) younger than 40 years in this study. A total of 163 patients (89%) had a diagnosis of normal breast tissue. Nineteen patients (10%) had proliferative changes: 9 patients (5%) without atypia, 5 patients (3%) with atypia, 3 patients (2%) with sclerosing adenosis, and 1 patient each (0.5%) with papillomatosis and lobular carcinoma in situ. A total of 95% of patients with proliferative changes were older than 30 years. Women ages 30 to 39 years may be at higher risk (15%) of having proliferative changes than previously reported, and histologic examination of all reduction mammaplasties is recommended.

Breast conservation surgery using nipple-areolar resection for central breast cancers.

HYPOTHESIS: Resection of the nipple-areolar complex (NAC) for central breast cancers that involve the nipple or areola, with postoperative radiation therapy, adheres to the oncologic principles established for breast conservation surgery of other breast cancers. Good or excellent cosmetic results can be achieved. The rate of ipsilateral breast recurrence will be similar to that seen with peripheral breast cancers. The indications for breast conservation surgery can be safely extended to include patients with breast cancers that involve the NAC. DESIGN: Retrospective medical record review; follow-up patient questionnaire. SETTING: Community teaching hospital. PATIENTS: Fifteen patients, aged 46 to 88 years, whose central breast cancers involved the NAC precluding preservation of the NAC. INTERVENTIONS: Nipple-areolar complex resection, postoperative radiation therapy. MAIN OUTCOME MEASURES: Ipsilateral breast recurrence, survival, cosmesis. RESULTS: Ten patients had subareolar cancers that directly involved the nipple or areola; 5 patients had Paget disease of the nipple. Average tumor size was 1.6 cm (range, 0.2-3.5 cm). With a mean follow-up of 32 months (range, 4-109 months), there has been only 1 recurrence (7%), which was treated successfully by modified radical mastectomy. All 15 patients are alive and free of disease. Cosmetic results are satisfactory to excellent, as judged by both the patients and the surgeons. CONCLUSIONS: Nipple-areolar complex resection for central subareolar cancers that directly involve the NAC, as well as for Paget disease of the nipple, extends the indications for breast conservation in other areas of the breast, and with acceptable cosmesis.

Internal hernia as a complication of colonoscopy: report of a case.

After screening colonoscopy, a 65-year-old female developed small-bowel obstruction as demonstrated on abdominal CT scan. The obstruction was caused by a large herniation of the small intestine seemingly caused by the colonoscopic procedure. This is only the second report in the literature of incarcerated intestinal hernia as a complication of colonoscopy.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM.

These clinical practice guidelines summarize the recommendations of the American Association of Clinical Endocrinologists for the diagnostic evaluation of hyperthyroidism and hypothyroidism and for treatment strategies in patients with these disorders. The sensitive thyroid-stimulating hormone (TSH or thyrotropin) assay has become the single best screening test for hyperthyroidism and hypothyroidism, and in most outpatient clinical situations, the serum TSH is the most sensitive test for detecting mild thyroid hormone excess or deficiency. Therapeutic options for patients with Graves' disease include thyroidectomy (rarely used now in the United States), antithyroid drugs (frequently associated with relapses), and radioactive iodine (currently the treatment of choice). In clinical hypothyroidism, the standard treatment is levothyroxine replacement, which must be tailored to the individual patient. Awareness of subclinical thyroid disease, which often remains undiagnosed, is emphasized, as is a system of care that incorporates regular follow-up surveillance by one physician as well as education and involvement of the patient.

An unusual initial manifestation of metastatic papillary thyroid carcinoma: radioiodine uptake in lymph node metastatic lesions in a patient with Graves' disease.

OBJECTIVE: To report an unusual manifestation of metastatic papillary thyroid carcinoma with functional metastatic lesions demonstrated by radioiodine scanning and to discuss the relationship of Graves' disease and thyroid carcinoma. METHODS: A case report is presented, and the current literature is reviewed. RESULTS: An 82-year-old man had symptoms and laboratory results suggestive of thyrotoxicosis. 123I thyroid uptake scanning demonstrated lateral uptake, which directed attention to the lateral aspect of the neck and resulted in subsequent identification of previously overlooked lymphadenopathy. Total thyroidectomy, including excision of the central compartment and right jugular chain lymph nodes, was performed. CONCLUSION: In two previous reports of similar cases of metastatic thyroid carcinoma, imaging was done with use of a different scanning agent. To our knowledge, this is the first published case report of functional metastatic lesions imaged with 123I before thyroidectomy. This preoperative finding facilitated clinical management of the patient's thyroid cancer and thyrotoxicosis.

Recent experience with preoperative fine-needle aspiration biopsy of thyroid nodules in a community hospital.

HYPOTHESIS: The application and reliability of fine-needle aspiration (FNA) biopsy in community hospitals may be less efficacious in the clinical assessment of patients with thyroid nodules than in tertiary referral centers. DESIGN: Retrospective review. SETTING: One community teaching hospital. PATIENTS: One hundred eighty-three patients who underwent thyroidectomy after FNA biopsy. INTERVENTIONS: Preoperative FNA biopsy cytopathologic testing and thyroidectomy and postoperative histopathologic testing. MAIN OUTCOME MEASURE: Preoperative cytopathologic reports were compared with postthyroidectomy histopathologic reports. RESULTS: Thyroid cancer was confirmed postoperatively in 70 patients (38%). An FNA biopsy diagnosis of papillary carcinoma (in 29 patients) correlated with a predictive accuracy of 93% (27 patients). Suspicious for papillary carcinoma (n = 14) correlated with malignancy in 8 patients (57%). Indeterminate follicular lesion (n = 60) correlated with malignancy in 18 patients (30%), of whom 16 (89%) had papillary carcinoma (10 patients had follicular variant) and 2 (11%) had follicular carcinoma. Indeterminate Hürthle cell lesion (n = 20) correlated with malignancy in 7 patients (35%). Atypical cell clusters (n = 5) did not correlate with malignancy. Benign FNA biopsy findings (n = 44) in patients who underwent thyroidectomy for other clinical features correlated with malignancy in 8 (18%). Of 11 patients who underwent thyroidectomy for insufficient number of cells after repeated FNA biopsy attempts, 2 (18%) had carcinoma. CONCLUSIONS: The accuracy of an FNA biopsy of thyroid nodules in a community hospital setting is comparable to results from major endocrine referral centers. An indeterminate follicular lesion was the most common FNA biopsy indication for thyroidectomy and correlated with the presence of differentiated thyroid cancers in 18 (30%) of 60 patients.