Surgery residents' perception of the Objective Structured Clinical Examination (OSCE).

PURPOSE: Beginning in July 2003, residency programs will be required to incorporate new educational assessment methods as defined by the Accreditation Council for Graduate Medical Education (ACGME) outcome initiative. The Objective Structured Clinical Examination (OSCE) is an assessment tool that is favorably viewed by the ACGME. Our institution has utilized the OSCE for evaluation of surgery trainees since 1996. Despite the positive acceptance of the OSCE by students, residents expressed dissatisfaction with the examination. This study was therefore undertaken to specifically evaluate resident perception of the OSCE. METHODS: Two sequential surveys were administered to surgery residents at the Medical College of Ohio. Response of medical students to a standard survey following completion of the OSCE was tabulated. RESULTS: On the first, general survey, residents felt that the OSCE was not an adequate measure of either clinical (15 of 17 residents) or technical (15 of 18 residents) skills; 14 of 16 residents felt that the OSCE should not be used when considering promotion. When specifically queried in a follow-up survey, residents indicated that the OSCE was an adequate measure of clinical knowledge (2.2 +/- 0.3); however, most still felt that the OSCE should not be used when considering promotion (4.3 +/- 0.3). (Scores = mean +/- SEM on a Likert scale where 1 = strongly agree and 5 = strongly disagree). By contrast, 97.6% of 663 medical students surveyed (September 1996 through February 2002) felt the OSCE was useful. CONCLUSIONS: The OSCE has been shown to be a reliable and valid measure of basic clinical and technical competence. Despite our residents' current perception, we believe that the OSCE is an important method for resident evaluation, particularly within the context of the current ACGME outcome initiative.

Intraoperative radiation therapy in surgical oncology.

This is the first publication about intraoperative radiation therapy (IORT) to be written for surgeons through a collaborative effort of surgeons and radiation therapists. This article introduces the basic concepts of radiation therapy and the rationale of its use in the operating room, and presents the advantages for the surgeon and radiation therapist to work together for the benefit of our patients.

Intraoperative radiation therapy in the multimodality approach to hepatobiliary tract cancer.

IOERT is a reasonable option to consider in patients who have biliary tract cancers above AJCC or Bismuth stage I disease. Inherent resistance of biliary tract cancer cells to ionizing radiation would indicate that IOERT alone would not eradicate most of the tumor clonagen. EBRT (either preoperatively or postoperatively) should be used in combination with IOERT at experienced institutions that have access to both modalities. The single IOERT dose ranges are 10 to 20 Gy [55,67], whereas the EBRT dose ranges from 45 to 50 Gy in 25 to 28 fractions [67]. The most common energy level used is 8 MeV or less. In addition, IOERT port sizes of less than 6 cm in diameter, and often 4 cm or less, are recommended. Finally, intraoperative reconstruction of severely damaged blood vessels may decrease the clinical manifestation of radiation-induced injury to vessels [68].

Intraopertive radiation therapy for breast cancer.

The rapid patient accrual observed in the European breast IORT studies reported since 2000 indicates that surgeons, radiation oncologists, and women who have breast cancer are no longer content to continue to travel down the well-worn path of disfiguring ablative treatment. Breast conservation is currently viewed as the preferred mode of therapy for early-stage breast cancer in most clinical situations. Determination of the optimal combination of whole breast EBRT and localized IORT, for dose and fractionation, is a critical issue that only recently has been addressed [20,21]. Clearly, such clinical investigative endeavors should be regarded as high priority. The very low incidence of local in-breast recurrence of cancer to date suggests that another avenue for investigation might be the determination of the extent to which the lumpectomy procedure can be safely minimized when used in conjunction with IORT. For example, physicians might ask, "Are microscopically negative surgical margins still mandatory when IORT is applied at the time of lumpectomy?" If the answer to that question should turn out to be "no," then it should be much easier for surgeons to achieve the desired excellent cosmetic results when dealing with early-stage breast cancer. Another question remaining to be addressed pertains to the utility of IORT in the management of in-breast recurrence of cancer following conservative therapy. The incidence of local failure after organ-conserving treatment is generally reported to be approximately 5% to 10%. Currently, the preferred mode of salvage therapy in such a clinical situation is mastectomy. The proven efficacy of IORT concurrent with lumpectomy in the primary treatment of early-stage breast cancer suggests that even local recurrences following conventional conservative treatment might be dealt with effectively and expeditiously by means of local excision plus IORT. Such treatment, if safe and effective, could prove to be much less disfiguring than mastectomy. Because breast irradiation routinely produces a desmoplastic tissue response in the breast, there seems to be an opportunity here to address local recurrences of breast cancer with local surgical extirpation enhanced by IORT. Because there are currently few data regarding the use of IORT in this clinical situation, pilot studies would seem to be justified. The remarkably low incidence of local recurrence of breast malignancy observed in every breast IORT study reported to date may portend an important advancement in physicians' ability to better achieve local control of mammary carcinoma. It is hoped that such a putative improvement in the local control of breast cancer will soon translate into improved patient survival rates for this common malignancy.

Future directions in intraoperative radiation therapy.

It is difficult to establish the degree of effectiveness of IORT as a component of treatment in some of the malignancies currently being treated by IORT. Locally advanced pancreatic cancer is a typical example of a neoplasm for which it has been challenging to find effective advances in treatment. The survival time of patients who have this disease is limited to 9 to 12 months (median), with a 2-year survival rate of 10% to 20% following even the most effective chemoradiation. It is perhaps overly optimistic to expect that IORT will significantly enhance survival, because currently available systemic treatment options have not meaningfully affected either overall patient survival times or the rate of distant metastasis in either the adjuvant setting or for metastatic disease. It is encouraging, however, that Willett has reported five patients with 5-year survival times in the Massachusetts General Hospital IOERT series for unresectable pancreatic cancer (C.G. Willett, personal communication, 2002). Also encouraging is the report from the Medical College of Ohio of a 5-year rate of 33% in a small group of patients with resectable pancreatic cancers treated with single IORT doses (without EBRT or chemotherapy) as the sole adjuvant to surgical resection. At the same institution, during the same time period, the same group of surgeons observed that no patient with resectable pancreatic cancer survived longer than 13 months following surgical resection alone [7]. Exciting possibilities involve the use of IORT when treating early-stage malignant disease, as is detailed in the chapter on breast cancer. The use of [table: see text] IORT as adjuvant therapy seems to be associated with an extremely low incidence of in-breast local recurrence. Whether this is because of early stage of the disease or the adjuvant EBRT is not entirely clear at the time of this writing. (The results of ongoing randomized studies may not be powered sufficiently to resolve the question.) Because the local recurrence rate currently is extremely low (only one reported recurrence), however, this finding is promising. Also exciting is the use of IORT as the sole radiation [table: see text] treatment following limited excision of breast cancer. The results of the Lanciano and Milano trials (see chapter 12) are awaited with great interest. Equally exciting is the finding of meaningful survival of 20% to 40% of patients who have local or regionally recurrent cancers when IORT is used as a component of treatment together with EBRT, maximal resection, and chemotherapy, as indicated. Many of these patients still have excessive rates of both local and distant relapse, however, necessitating the rationale for well-controlled multi-institutional studies that involve alternate systemic therapies, radiation sensitizers, among other criteria.

Ability of the objective structured clinical examination to differentiate surgical residents, medical students, and physician assistant students.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) has been used extensively to evaluate the clinical abilities of medical students and residents. The purpose of this study was to investigate whether the standard OSCE would differentiate performance of subjects with different levels and/or types of training. METHODS: We conducted a blinded OSCE, during which we simultaneously evaluated surgical residents from all 5 years of the general surgery training program, third-year medical students, and second-year physician assistant students. All examinees went through the same clinical evaluation stations, which consisted of history-taking, physical examination, technical skills, trauma management, and X-ray interpretation. The students and residents were rated at each station by a trained standardized patient evaluator or a faculty evaluator using a checklist for performance evaluation. All subjects wore surgical scrubs without name tags or identification of program or year of training. RESULTS: Overall mean performance scores (P = 0.09, NS) were for surgical residents 71.2% (+/-9.7); for medical students 66.9% (+/-5.7); for physician assistant students 64.7% (+/-5.8). This shows a significant trend toward higher scores with more training. Surgical residents scored higher on technical stations, history-taking, and X-ray interpretation. Medical students scored higher in performance of physical examination. Physician assistant students scored quite close to the other two groups. CONCLUSIONS: The differences among group performance appeared to reflect the level of experience of the learners. Some components of the OSCE appear to better differentiate levels of training.