Nonstandard Programs: the University of Pittsburgh Medical Center's next frontier in graduate medical education.

The University of Pittsburgh Medical Center has seen continuous growth in the number and types of graduate training programs not accredited by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Medical Specialties, or the American Osteopathic Association. For the purposes of ensuring best educational products and of controlling unrecognized competition with our accredited programs, a sequential process of centralized oversight of these nonstandard programs was undertaken. The first step involved programs whose fellows were hired and tracked like accredited fellows (i.e., not instructors). The basic process began with consensus among leadership, writing of policy with consultation as necessary, establishment of a registry of programs and graduates, and a committee to allow sharing of best practices and dissemination of policy. The second step applied the same process to instructor-level programs. Whereas the previous group of programs was made subject to ACGME regulations, more latitude in duty hours and progressive responsibility were allowed for instructor programs. The final step, in progress, is extending a similar but modified approach to short-duration clinical experiences and observerships. The outcomes of these efforts have been the creation of a centralized organizational structure, policies to guide this structure, an accurate registry of a surprising number of training programs, and a rolling record of all graduates from these programs. Included in the process is a mechanism that ensures that core program directors and department chairs specifically review the impact of new programs on core programs before allowing their creation.

Maternity policy and practice during surgery residency: how we do it.

BACKGROUND: Pregnancy during general surgery residency has traditionally been discouraged. METHODS: In 2001, using an approved protocol, we anonymously surveyed 25 residents (PGY3 level or greater) concerning their experiences working with each other during episodes of resident pregnancy and maternity leave. RESULTS: From 1995 to 2001, 13 of 59 residents in general surgery were female (22%). While training, 6 of 13 residents reported 8 pregnancies with 2 miscarriages. Five residents (39%) gave birth to 6 children and adopted 1 child. Residents worked until the day of term delivery in 5 of 6 cases; 1 pregnancy was complicated by placental abruption at 33 weeks. Residents were off work postpartum for a median of 6 weeks (range 2-6). Nursing was universal for > or = 3 months but at-work problems with privacy and stress were frequent. On survey, all resident mothers believed they had been treated very fairly, and 94% of surveyed male peers stated that the coworker's status had no effect or a positive effect on their own work life. Fatherhood was reported to occur during residency by 42% of male respondents. CONCLUSIONS: Parenthood during residency is frequent. The complexities of resident maternity can be handled with mutual safety, equity, and satisfaction by the residents and faculty of a surgical training program.

Effect of intraluminal thrombus on wall stress in patient-specific models of abdominal aortic aneurysm.

PURPOSE: The role of intraluminal thrombus (ILT) on abdominal aortic aneurysm rupture is still not clear. Rupture of an aneurysm occurs when the wall stress exceeds the wall strength at any location on the wall. The purpose of this study was to address the hypothesis that the presence of ILT alters the wall stress distribution or wall stress magnitude in AAA. METHODS: Patient-specific 3D AAA geometries were reconstructed from computed tomographic images. Two geometric features, ILT surface ratio (ILT surface area divided by the total AAA surface area) and ILT volume ratio (ILT volume divided by the total AAA volume), were calculated for each AAA. Two models were created for each patient: one with ILT and one without ILT. Systolic pressure measured at the time of computed tomographic imaging was applied to the internal surface of each model. A nonlinear large deformation algorithm was used to compute wall stress distribution with the finite element method. The Wilcoxon matched pairs test was used to compare the peak wall stress between the two models of each patient. RESULTS: Four patients were studied with ILT surface ratios that ranged from 0.29 to 0.72 and ILT volume ratios that ranged from 0.12 to 0.66. The peak wall stress was reduced (range, 6% to 38% reduction; P =.067) for all models with ILT included (range, 28 to 37 N/cm(2)) as compared with models with no ILT (range, 30 to 44 N/cm(2)). Visual inspection also revealed a marked effect of ILT on the wall stress distribution. CONCLUSION: The presence of ILT alters the wall stress distribution and reduces the peak wall stress in AAA. For this reason, ILT should be included in all patient-specific models of AAA for evaluation of AAA wall stresses.