Changing the student clerkship from traditional lectures to small group case-based sessions benefits the student and the faculty.

BACKGROUND: Attempts to improve the third year surgery clerkship led to the implementation of faculty-led small group teaching instead of large group lecture-style dissemination of the general surgical curriculum. The intent was to facilitate better faculty-to-student relationships, provide more favorable balance between classroom and clinical surgery, and enhance overall surgical education. METHODS: Didactic student sessions were reduced from 33 lectures to 8 small group sessions and surgical specialty lectures. A case-based surgical curriculum was utilized and students were organized into small groups led by assigned faculty members. A uniform schedule of topics was prearranged to ensure continuity and avoid duplication of material. The National Board of Medical Examiners (NBME) surgery subject examination raw score and percentile rank assignments were analyzed for 1 medical graduating class taught using the traditional method and compared with the subsequent class taught in small groups. A survey was administered to assess student and faculty regarding the new format. RESULTS: Average NBME percentile rank score for students educated in small groups versus lecture-only groups improved significantly (61.2 vs 55.9, p = 0.04, Student t test). The students reported increased time spent preparing for small group over lecture and more satisfaction with the small group teaching environment. Faculty members reported an increase in time needed to deliver the session but otherwise gave strong positive feedback. CONCLUSIONS: Concerns that student performance on standardized testing would suffer from the proposed change were not substantiated as performance on NBME subject examinations actually improved. Additional preparation time, method preference, favorable balance of classroom to clinical exposure, and direct interactions with faculty may be responsible for the observed increase in NBME examination percentile scores. Faculty members were overwhelmingly in favor of the new model and the additional direct contact with students may prove beneficial in junior faculty promotion and career development.

Utilization of intensive care resources in bariatric surgery.

BACKGROUND: Obese patients occasionally require either elective or emergency critical care services following bariatric surgery. We describe this subgroup of patients. METHODS: From July 1, 1991 to July 31, 2004, we performed 1,279 bariatric operations; 241 (19%) required admission to the surgical critical care service. We retrospectively reviewed medical records for gender, body mass index (BMI), age, whether the operation was initial or revisional, and whether critical care admission was elective or emergent. 3 complication clusters (thromboembolic, pulmonary, and anastomotic) were identified using discharge ICD-9 codes. The costs and length of stay of these subpopulations was calculated. RESULTS: Patients were on average 46+/-10 years old, with BMI 59+/-13. Critical care admission was emergent in 52.7% (n=127) of cases. Revisional cases did not differ from the initial cases in BMI (56.4 vs 59.2, P=0.42) and they were no more likely to require emergent critical care admission than initial cases (P=0.16). Revisional cases were hospitalized longer (27.2+/-25.6 vs 12.5+/-18.7 days, P=0.003); had higher total hospital costs (US$ 60,631+/-78,337 vs 27,697+/-52,351, P=0.025); and were more likely to die from their complications (revisional surgery mortality 6.5% vs 1.9% for initial surgery [P=0.002]). CONCLUSIONS: An increasing number of surgical revisions will likely accompany the recent increase in popularity of bariatric surgery. In our experience, these patients require significant critical care services, and have longer, complicated, and more costly hospitalizations.