Identification of communication apprehension in medical students starting a surgery rotation.

BACKGROUND: Most methods used to critically evaluate young surgeons for advancement or certification in surgery require oral communication skills, eg, case and research presentations, rounds, morbidity and mortality conferences, interviews, journal clubs and oral examinations. The irony, though, is that much of surgery training focuses on technical skill lists, and the rhetorical aspects are often neglected until the surgeon encounters failure in an oral examination or is sued for not "talking" appropriately. Early identification of those at risk for difficulty with oral skills would provide programs with time needed to arrange for the appropriate types of interventions. Therefore, the purpose of this study was to identify those medical students with high communication apprehension scores in dyadic, group, or public speaking situations before they encountered failure and caused problems, not only for themselves, but also for their programs and practices. METHODS: Two scales, Willingness to Communicate (WTC) and the Personal Report of Communication Apprehension (PRCA-24), were administered to medical students at two large university medical centers during new student orientation to the surgery rotation. The WTC is a 20-item probability-estimate scale designed to measure one's predisposition toward approaching or avoiding the initiation of communication. The PRCA-24 is a scale designed to measure one's fear associated with either real or anticipated communication in four different contexts. In addition to the 44 items, a lengthy list of demographic items was added for possible correlations. These items were based on the student's perception of the communication or language environment in which he was raised. Therefore, a student ranked past and future socioeconomic status (eg, blue collar or white collar) according to his or her own criteria. The chairman was provided with a list of individual scores. Those students who were below the group means on skills required during a surgery rotation were identified for immediate intervention. RESULTS: The published data show a norm mean of 65.6 for PRCA-24 and 65.2 for WTC for college students. The current study found medical students to be more willing to communicate (WTC) and less anxious about communication (PRCA-24) than college students (mean 70.7 versus 65.2, P = 0.003, and 61.6 versus 65.6, P = 0.01, respectively). This difference was accentuated for blue-collar medical students compared with college students and persisted when blue-collar medical students were compared with white-collar medical students (73.9 blue-collar versus 70.9 college students, P = 0.15 for WTC, and 58.5 blue-collar versus 63.6 white-collar, P = 0.002 for PRCA-24). Male medical students were found to be less anxious about communication than female medical students. CONCLUSIONS: These instruments are easily administered at orientation and produce simple class lists with individual scores. They can be used to identify students who are below the mean for specific forms of communication before they encounter failure.

A time to listen.

As methods of health care delivery, and advances in technology change our lives and practices, an essential element of personal and professional relationships has become neglected. We have stopped listening to each other, to our patients, and to ourselves; we have lost the art of communication. The essential aspects of optimal communication and the power of nonverbal signals are reviewed. Only by recognizing the importance of communication in surgical education, practice, and in fact in all aspects of daily life, will this encroaching societal deafness be rebuffed.

A surgery oral examination: interrater agreement and the influence of rater characteristics.

BACKGROUND: Poor interrater reliability is a common objection to the use of oral examinations. METHOD: In 1990 the authors measured the agreement of 140 U.S. and Canadian surgical raters and the influences, if any, of age, years in practice, and experience as an examiner on individual oral examination scores. Eight actor examinees memorized transcripts of actual oral examinations and were videotaped using a single examiner. Examinee verbal style, dress, content of answers, and gender were purposefully adjusted. A repeated-measures analysis of variance was used for data analysis. RESULTS: Three aspects of examinee performance influenced scores (verbal style, dress, and content of answers). No rater characteristic significantly affected scores. Raters showed high agreement (86%) when rating "good" performances but less agreement (67%) when rating "poor" performances. CONCLUSION: The oral examination scores were not influenced by rater selection. The raters ranked good performances more consistently than poor performances. Therefore, more than one examiner appears necessary to confirm a poor performance during an examination.

Evaluation of gastrointestinal hemorrhage in patients with neurofibromatosis.

Over a 3-year period, two patients with neurofibromatosis were referred to our medical center for evaluation of repeated episodes of melena. Upper endoscopy was unrevealing in each case, as was colonoscopy. Arteriography during active hemorrhage was helpful in localizing the source of bleeding in one patient but not in the other. The source of bleeding in each patient was obvious at surgical exploration. Large neurofibromas protruded from the serosal surface of a short region of jejunum in both cases and an additional segment of ileum in one case. Hemorrhage had occurred as a result of erosion of mucosa stretched over these tumors. Local resection of the involved segments produced long-term control of the hemorrhage. Since these tumors were grossly visible on the serosal surface of the involved intestinal segments, laparoscopic evaluation could have been used to hasten diagnosis in each case.

Spontaneous rupture of the liver.

A case of spontaneous hepatic rupture associated with bacterial cholangiohepatitis, an entity not previously described as an etiologic factor, is reported and the literature reviewed. Awareness of the pathophysiology of this process and avoidance of certain procedures are important parts of the surgical armamentarium.

Influence of effective communication by surgery students on their oral examination scores.

This study investigated the influences of specific elements of surgery students' verbal and nonverbal communication on evaluators' "objective" ratings of several categories of the students' performances on oral examinations. Three actors and two actresses, dressed as surgery students in a wide range of attire, were videotaped as they reenacted five transcripts of actual students' responses in their oral examinations. For each examination, the actors portrayed the students' responses to the same examining surgeon in two formats, one using direct eye contact with a moderate response rate (Style A) and the other using indirect eye contact with a slower response rate (Style B). All transcripts were taped at least twice. The resulting 255 videotaped "examinations" were randomly distributed in 1988 to 78 clinical surgery faculty representing 46 institutions throughout the United States and Canada. These faculty viewed the reenactments (under the impression they were actual examinations) and rated the "students" performances overall and in ten categories concerning different aspects of the students' knowledge, clinical decision-making skills, and personal characteristics. The performances done in Style A were rated significantly higher than those done in Style B (1) in every performance category except decision making and (2) when the scores were classified by the content of the responses and how professionally dressed the students were. There were also a significant relationship between scores on communication skills and the overall all scores on examinations. These findings suggest that regardless of the content of a student's responses on an oral examination, evaluators are strongly influenced by how well the student communicates.

Evaluation of the accuracy of reporting residents' operative experience.

To study the accuracy of residents' operative experience reports, operations were monitored for 6 months. Independent scores for participation (on a scale from 0 to 10) and rating for credit "as surgeon" were obtained from attending surgeons and residents. There was extremely close agreement on acceptance of credit (n = 1,049 of 1,139; p less than 0.00001); where disparity existed, it was predominant in the first two postgraduate years (62% of 90 cases). There was also significant correlation between scores (p less than 0.001). When analyzed in low- (0-3.0), intermediate- (3.5-6.0), and high-score (6.5-10) groups, there was significantly better correlation in the low- and high-score groups (p less than 0.000000001). Sixty-five percent of procedures in the intermediate group were performed by first or second postgraduate year residents; these residents performed 493 (43%) of all procedures. The overall reporting accuracy appeared excellent. Counseling and monitoring may be required at the junior levels.

Does the presence of hepatic portal venous gas mandate an operation? A reassessment.

The presence of HPVG has been said to constitute a mandatory indication for exploratory laparotomy, given the high incidence of concomitant bowel necrosis and abdominal sepsis. HPVG has also been associated with increased intraluminal pressure in the absence of bowel ischemia. Most cases are iatrogenic, usually due to barium enema or colonoscopy in patients with inflammatory bowel disease, but in a few cases, HPVG is associated with simple intestinal or gastric distention. The English literature on the subject describes only eight such cases. We recently treated a patient in whom HPVG was caused by intestinal pseudo-obstruction. Such an etiologic mechanism has not been previously reported. The relevance of this observation and a reassessment of the absolute obligation to operate prompted this review.

Correlation between mammography and the pathology of nonpalpable breast lesions.

One hundred consecutive needle localization biopsies were performed for nonpalpable breast lesions discovered on low-dose mammography of asymptomatic women between June, 1984, and August, 1986. Malignant disease was found on 21 biopsies. Four were carcinoma in situ, and 17 were infiltrating carcinomas. Only three of the infiltrating carcinomas had metastasized to regional nodes, as confirmed by subsequent axillary dissection. Two of these metastatic tumors involved two nodes and the third only one. The findings on the remaining 79 biopsies were benign. Forty-eight mammograms were read as "benign"; all (100%) were benign pathologically. Thirty-one mammograms were considered "malignant"; 19 (61%) were malignant pathologically. Only two of the 21 mammograms given "suspicious" interpretations were malignant. Microcalcifications correlated with malignancy only 30% of the time (12/42).

Intestinal anastomosis after preoperative radiation therapy for carcinoma of the rectum.

A retrospective review was conducted on 133 patients who underwent anterior resection and primary intestinal anastomosis for adenocarcinoma of the rectum from 1973 to 1983 at the Baystate Medical Center. Forty patients received a moderate dose, 4,500 rads, of radiation therapy preoperatively. Twenty-six of these patients (65 per cent) underwent protective colostomy at operation. An additional 93 patients underwent an operation without radiation and 38 of these (42 per cent) had a colostomy. We found no significant difference between patients who did or did not undergo radiation therapy in the over-all rate of complications (25 per cent for those who underwent radiation and 29 per cent for those who did not). Furthermore, there was no significant difference in anastomotic leak rates between the two groups (10 and 7 per cent respectively), even after controlling for the presence of a protective colostomy. We did find that leak rates for both groups were markedly higher for patients with a colostomy (14 per cent) than for patients without (1 per cent) (p less than 0.005). We conclude that a moderate dose of radiation therapy preoperatively does not increase the risk of anastomotic leakage or other operative complications with anterior resection. Colorectal intestinal anastomosis may be safely performed without routine colostomy after planned preoperative adjuvant radiation therapy if the anastomosis is technically satisfactory.

Apathetic thyrotoxicosis presenting as an abdominal emergency: a diagnostic pitfall.

Thyrotoxicosis may present with a hyperkinetic clinical picture typically associated with Graves' or Plummer's disease, or in an apathetic form characterized by lethargy, weakness, and withdrawal. Both the hyperkinetic and apathetic forms of thyrotoxicosis may be associated with or masked by predominantly extrathyroidal manifestations, occasionally referable primarily to the abdomen. We present two cases of apathetic thyrotoxicosis that suggested the need for urgent surgical intervention, and review the literature on apathetic thyrotoxicosis as an abdominal emergency, as well as laboratory studies and possible etiology.

In vivo assessment in sheep of thromboresistant materials by determination of platelet survival.

The thromboresistance of 13 potentially blood-compatible polymers was assessed in sheep by determining survival of 51Cr-labeled platelets. Polymer tubing (120-150 cm x 2.0-2.3 mm i.d.) coiled around the neck was incorporated into the circulation through silicone rubber connectors as a carotid artery-external jugular vein shunt. The mean platelet half-life in control animals ("shunt control") was 78.2 +/- 2.8 (SEM) hours. Eleven of the 13 polymers tested significantly shortened platelet half-life. Polyvinyl chloride (T1/2 = 45.4 +/- 3.0 hours), polyperfluoro ethylene (T1/2 = 47.0 +/-1.6 hours), and a polymethylacrylate (PMA)/acrilonitrile copolymer (T1/2 = 50.7 +/- 7.0 hours) produced the greatest shortening. Only silica-free polydimethyl siloxane (T1/2 = 74.7 +/- 4.9 hours) and PMA (T1/2 = 81.5 +/- 3.4 hours) were indistinguishable from shunt controls. Pretreatment of PMA tubing with autologous plasma in a paired trial significantly increased platelet half-life (P less than 0.05 vs. untreated PMA). This system offers an economical, reproducible, sensitive, and biologically relevant method for assessment of the reactivity of artificial surfaces with platelets.

Prevention of deep vein thrombosis in neurosurgical patients: a controlled, randomized trial of external pneumatic compression boots.

A prospective, randomized clinical trial in 95 patients undergoing neurosurgical operative procedures was performed to investigate the efficacy of external pneumatic compression (EPC) of the calves as compared with results in a control group that received no specific form of prophylaxis for prevention of deep vein thrombosis (DVT). The diagnosis of DVT was established by the I125 fibrinogen scan and radiographic contrast phlebography. The data indicate that EPC provides significant protection against the development of DVT in comparison with results in the control group (p less than 0.005). There were no known pulmonary emboli in any of the EPC-treated patients. There were no complications of EPC.

Prevention of deep vein thrombosis in urological patients: a controlled, randomized trial of low-dose heparin and external pneumatic compression boots.

A prospective, randomized clinical trial in 83 patients undergoing open urological operations was performed to compare the relative prophylactic efficacy of low-dose heparin and external pneumatic compression (EPC) of the calves in comparison to no treatment in the prevention of deep vein thrombosis (DVT). The diagnosis of deep vein thrombosis was established by the I125 fibrinogen scan and contrast phlebography. The data indicate that EPC is more effective than no treatment (p less than 0.04) and more effective than low-dose heparin (p less than 0.04) in the prevention of DVT. There was one pulmonary embolus in each of the three groups, and in the treatment groups this occurred without evidence of DVT.

Thrombosis and intravascular coagulation.

Stress, including trauma and sepsis, is associated with a state of hypercoagulability. In these circumstances the patient is at risk of generalized or local thrombotic complications. New laboratory investigative procedures facilitate diagnosis and permit improved assessment of therapy, which at present remains of unproven efficacy both in the general and local situation.

The intravascular magnetic suspension of a test device for in vivo hemocompatibility evaluation of biomaterials.

To advance hemocompatibility evaluation techniques, a new in vivo method has been developed for the dynamic testing of candidate biomaterials in suitably-sized experimental animals. One of the salient features this method is that the material to be evaluated constitutes the blood contact surface of a slender body of revolution which is coaxially suspended in a large canine vessel by electromagnetic forces only. The insertion site of the specimen is distal and downstream to the test region, reducing the influence of thrombotic tissue substances. These experimental conditions also insure that the only chronically exposed foreign surface is that of the test material, whose interactions with blood components are not affected by contact with the vessel intima. As demonstrated in simulated Circulation Model experiments, macroscopic thromboembolic phenomena induced by the test material can be continuously monitored. Preliminary in vivo trials have verified the validity of the underlying principles; the feasibility of the required surgical techniques, and the adequate performance of the suspension system.