Utilizing Surgical Bootcamps to Teach Core Entrustable Professional Activities to Senior Medical Students.

To promote residency preparedness, the Association of American Medical Colleges defined 13 core entrustable professional activities for entering residency (CEPAERs), which represent tasks that students should be able to perform on day one of residency. At the authors' institution, a four-week surgery boot camp course is offered to senior medical students, which may provide an effective mechanism for teaching the CEPAERs. Nine senior students participating in a surgery boot camp course were subjected to pre- and post-course surveys. Student expectations were closely aligned with the CEPAERs. Competence was demonstrated in all CEPAERs; however, four students did require remediation with Advanced Cardiovascular Life Support before achieving competence. In the "death on the wards module," we found a significant increase in student confidence (19.78, SD 1.47, P > 0.05 vs 31.56, SD 1.49, P < 0.01) and knowledge (16.11, SD 1.32, P > 0.05 vs 31.33, SD 2.04, P < 0.01). In a one-year follow-up survey, all participants agreed that the boot camp course was useful and positively impacted their intern year. Surgical boot camp courses provide an effective and reproducible means for teaching the CEPAERs and was found useful in preparing medical students for residency.

Development of a human cadaver model for training in laparoscopic donor nephrectomy.

BACKGROUND: The organ procurement network recommends a surgeon record 15 cases as surgeon or assistant for laparoscopic donor nephrectomies (LDN) prior to independent practice. The literature suggests that the learning curve for improved perioperative and patient outcomes is closer to 35 cases. In this article, we describe our development of a model utilizing fresh tissue and objective, quantifiable endpoints to document surgical progress, and efficiency in each of the major steps involved in LDN. MATERIALS AND METHODS: Phase I of model development focused on the modifications necessary to maintain visualization for laparoscopic surgery in a human cadaver. Phase II tested proposed learner-based metrics of procedural competency for multiport LDN by timing procedural steps of LDN in a novice learner. RESULTS: Phases I and II required 12 and nine cadavers, with a total of 35 kidneys utilized. The following metrics improved with trial number for multiport LDN: time taken for dissection of the gonadal vein, ureter, renal hilum, adrenal and lumbrical veins, simulated warm ischemic time (WIT), and operative time. CONCLUSION: Human cadavers can be used for training in LDN as evidenced by improvements in timed learner-based metrics. This simulation-based model fills a gap in available training options for surgeons.

Compassionate Options for Pediatric EMS (COPE): Addressing Communication Skills.

INTRODUCTION: Each year, 16,000 children suffer cardiopulmonary arrest, and in one urban study, 2% of pediatric EMS calls were attributed to pediatric arrests. This indicates a need for enhanced educational options for prehospital providers that address how to communicate to families in these difficult situations. In response, our team developed a cellular phone digital application (app) designed to assist EMS providers in self-debriefing these events, thereby improving their communication skills. The goal of this study was to pilot the app using a simulation-based investigative methodology. METHODS: Video and didactic app content was generated using themes developed from a series of EMS focus groups and evaluated using volunteer EMS providers assessed during two identical nonaccidental trauma simulations. Intervention groups interacted with the app as a team between assessments, and control groups debriefed during that period as they normally would. Communication performance and gap analyses were measured using the Gap-Kalamazoo Consensus Statement Assessment Form. RESULTS: A total of 148 subjects divided into 38 subject groups (18 intervention groups and 20 control groups) were assessed. Comparison of initial intervention group and control group scores showed no statistically significant difference in performance (2.9/5 vs. 3.0/5; p = 0.33). Comparisons made during the second assessment revealed a statistically significant improvement in the intervention group scores, with a moderate to large effect size (3.1/5 control vs. 4.0/5 intervention; p < 0.001, r = 0.69, absolute value). Gap analysis data showed a similar pattern, with gaps of -0.6 and -0.5 (values suggesting team self-over-appraisal of communication abilities) present in both control and intervention groups (p = 0.515) at the initial assessment. This gap persisted in the control group at the time of the second assessment (-0.8), but was significantly reduced (0.04) in the intervention group (p = 0.013, r = 0.41, absolute value). CONCLUSION: These results suggest that an EMS-centric app containing guiding information regarding compassionate communication skills can be effectively used by EMS providers to self-debrief after difficult events in the absence of a live facilitator, significantly altering their near-term communication patterns. Gap analysis data further imply that engaging with the app in a group context positively impacts the accuracy of each team's self-perception.

Cost Analysis of Free Colonoscopies in an Uninsured Population at Increased Risk for Colorectal Cancer.

BACKGROUND: Uninsured patients have poor access to screening colonoscopy and subsequently present with advanced stages of colorectal cancer (CRC) that beget worse outcomes and higher total costs. Providing pro bono colonoscopies to uninsured patients at high risk for CRC can detect early stage disease and be cost-effective. STUDY DESIGN: Patients considered at increased risk for CRC were offered free screening colonoscopies. Patient data from these colonoscopies were collected during a 12-month period, and the incidence of CRC was compared with a control group of uninsured patients from the Surveillance, Epidemiology, and End Results (SEER) registry. Published estimates derived from SEER Medicare data of health expenditures by CRC stage were used to develop a cost model. To compare overall costs between our cohort and the SEER control, the mean initial cost of care (up to 1 year) was weighted by the stage-specific CRC incidence in each group. RESULTS: There were 682 uninsured patients screened, with 9 cancers identified (stage 0, n = 1; stage I, n = 3; stage II, n = 2; and stage III, n = 3) for an incidence of 1.3%. A total cost of $388,137 was estimated to be incurred during the initial phase of care. Compared with the SEER control, our cohort included more early stage cancers and subsequently had a marginally lower per-patient initial cost ($43,126 vs $43,736). CONCLUSIONS: Our screening criteria successfully identified a high-risk population with an overall 1.3% incidence of CRC. For these patients, the provision of free screening colonoscopies identified earlier-stage tumors and appears to be cost-neutral.

Minimally invasive surgery fellowship graduates: Their demographics, practice patterns, and contributions.

BACKGROUND: Fellowship opportunities in minimally invasive surgery, bariatric, gastrointestinal, and hepatobiliary arose to address unmet training needs. The large cohort of non-Accreditation Council for Graduate Medical Education -accredited fellowship graduates (NACGMEG) has been difficult to track. In this, the largest survey of graduates to date, our goal was to characterize this unique group's demographics and professional activities. STUDY DESIGN: A total of 580 NACGMEG were surveyed covering 150 data points: demographics, practice patterns, academics, lifestyle, leadership, and maintenance of certification. RESULTS: Of 580 previous fellows, 234 responded. Demographics included: average age 37 years, 84% male, 75% in urban settings, 49% in purely academic practice, and 58% in practice <5 years. They averaged 337 operating room cases/year (approximately 400/year for private practice vs 300/year for academic). NACGMEG averaged 100 flexible endoscopies/year (61 esophagogastroduodenoscopies, 39 colon). In the past 24 months, 60% had submitted abstracts to a national meeting, and 54% submitted manuscripts to peer-reviewed journals. Subset analyses revealed relevant relationships. There was high satisfaction (98%) that their fellowship experience met expectations; 78% termed their fellowships, versus 50% for residencies, highly pertinent to their current practices. 63% of previous fellows occupy local leadership roles, and most engage in maintenance of certification activities. CONCLUSION: Fellowship alumnae appear to be productive contributors to American surgery. They are clinically and academically active, believe endoscopy is important, have adopted continuous learning, and most assume work leadership roles. The majority acknowledge their fellowship training as having met expectations and uniquely equipping them for their current practice.

Letter to (fellow) young doctors: more kairos with less chronos.

Current restrictions on work hours have presented residents with a dilemma: how to derive the same or improved surgical experience and expertise but with less time to do so? The answer clearly must include an increase in efficiency, defined here simply as doing more with less time. Ancient Greek distinguished 2 words for time: chronos, chronological, linear, quantitative time as measured by clocks and calendars; and kairos: qualitative time, time in relation to human activity, a moment of indeterminate duration in which something happens. Our goal as residents should be to gain more kairos given limited chronos. Here we review various tools, both concrete and abstract, useful to maximize efficiency and effectiveness in surgical education. We suggest that residents equipped with adequate tools should be able to benefit from more kairos.

Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit.

BACKGROUND: Patients who sustain cervical spinal cord injury (C-SCI) with neurologic deficit may require a definitive airway and/or prolonged mechanical ventilation. The purpose of this study was to characterize factors associated with a high risk for respiratory failure and/or the need for mechanical ventilation in C-SCI patients. METHODS: Patients with C-SCI and neurologic deficit admitted to a Level I Trauma Center between July 1, 2000 and June 30, 2002 were retrospectively reviewed for demographics, level and completeness of neurologic deficit, need for definitive airway, need for tracheostomy, need for mechanical ventilation at hospital discharge (MVDC), and outcomes. The level and completeness of injury were defined by American Spinal Injury Association standards. RESULTS: One hundred nineteen patients with C-SCI and neurologic deficit were identified over this period. Of these, 45 were identified as complete C-SCI: 12 (27%) patients had levels of C1 to C4; 19 (42%) had a level of C5; and 14 (31%) had levels of C6 and below. There were 37 males and 8 females. There were 36 blunt and 9 penetrating injuries. The average age of these patients was 40 +/- 21, and the average ISS was 45+/-22. Eight of the patients with complete C-SCI died, for a mortality of 18%. Of the 37 survivors, 92% received a definitive airway, 81% received tracheostomy, and 51% required MVDC. All patients with complete injuries at the C5 level and above required a definitive airway and tracheostomy, and 71% of survivors required MVDC. Of the patients with complete injuries of C6 and below, 79% received a definitive airway, 50% required tracheostomy, and 15% of survivors required MVDC. Only 35% of incomplete injuries required a definitive airway, and only 7% required tracheostomy. CONCLUSIONS: The need for definitive airway control, tracheostomy, and ventilator dependence is significant, especially for patients with high complete C-SCI. Based on these results we recommend consideration of early intubation and tracheostomy for patients with complete C-SCI, especially for those with levels of C5 and above.

A multidisciplinary youth violence-prevention initiative: impact on attitudes.

BACKGROUND: In a previous report, enhanced resource commitment at a Level I trauma center was associated with improved outcomes for most major categories of injured patients, except those with gunshot wounds, which disproportionately affected the young (ages 15 to 24 years). We hypothesized that a primary violence-prevention initiative geared toward changing attitudes about interpersonal conflict among at-risk youths can be effective. STUDY DESIGN: Between May 2002 and November 2003, 97 youths (mean age 12.6 years) were recruited from one of two Police Athletic League centers in the catchment area of our Level I trauma center. Participant attitudes about interpersonal conflicts were surveyed with six previously validated scales before and after a hospital tour with a video and slide presentation graphically depicting the results of gun violence. Mean differences in scores between pre- and postintervention surveys were assessed. RESULTS: Of the 97 participants, 48 (49.4%) completed the intervention program with both the pre- and postintervention tests, with a mean of 25.8 days between tests. There was a statistically significant reduction in the Beliefs Supporting Aggression scale (mean -0.38 U; 95% CI, -0.23 to -0.54; p < 0.01), and a trend toward reduced Likelihood of Violence (mean -0.17 U; 95% CI, 0.01 to -0.34; p = 0.06). CONCLUSIONS: A multidisciplinary violence-prevention outreach program can produce short-term improvement in beliefs supporting aggression among at-risk youth. Longterm impact of this attitude change needs to be examined in future studies.