Small Bowel Intussusception Secondary to Malignant Melanoma 11 Years After Melanoma-In-Situ Excision.

Small bowel is a well-described site of malignant melanoma; however, it is a rare cause of intussusception. A patient presented with malignant melanoma causing jejunojejunal intussusception 11 years after resection of melanoma-in-situ. The patient was managed with exploration and resection. Despite complete resection of melanoma-in-situ and limited literature about its metastatic potential, malignant melanoma as a lead point for intussusception should be on the differential for any patient with pertinent history. To our knowledge, this appears to be the first case of melanoma-in-situ causing small bowel intussusception.

Resident work hours: can we meet the ACGME requirements?

The Accreditation Council for Graduate Medical Education (ACGME) requires all programs to limit resident work hours to 80 hours per week with some programs allotted an extra 10 per cent for specific educational purposes. The purpose of this study was to evaluate data reflecting changes in resident schedules made in 2002-2003 to be compliant with ACGME requirements without compromising patient care or resident education. Surgery residents originally completed a work-hour survey in May 2002. The survey contained 14 daily time sheets. Residents were asked to document how their time was spent between 14 different categories delineating in-house and out-of-house hours. Changes were made to resident schedules in order to become compliant with the new regulations. After making changes in the schedule, two more surveys were completed and evaluated, once in May 2003 and again in November 2003. Final analyses compared results from May 2002 to November 2003. Surveys were distributed to 30 residents in May 2002. Twenty-two residents completed the survey with 16 surveys eligible for analysis following exclusion of abnormal rotations (i.e., research and vacation). Eighty-eight per cent of junior residents (PGY 1, 2, and 3), 50 per cent of senior residents (PGY 4-5), and 33 per cent of chief residents (PGY 6) worked more than 88 hours per week. In November 2003, surveys were sent to 32 residents. Twenty-four residents who were on our normal call schedule completed the survey. Fourteen per cent of junior residents, 33 per cent of senior residents, and 0 per cent of chief residents worked more than 88 hours per week. By making the changes described, we have substantially reduced the number of resident work-hours while maintaining our academic and patient care missions.

Is there declining interest in general surgery training?

PURPOSE: To monitor and report the quality of categorical first-year surgery residents matched to U.S. general surgery training programs from 1996 to 2001. METHODS: A survey was sent to 258 program directors of accredited general surgery training programs. In this survey, data were requested regarding United States Medical Licensing Exam (USMLE) Step 1 and 2 scores, matched residents' rank list position, Alpha Omega Alpha (AOA) status, number of applications received, and interviews granted pertaining to all National Residency Matching Program (NRMP) residents matched. In addition, the USMLE and NRMP were petitioned for national data regarding Step 1 and 2 scores in all entering surgery residents and first-time USMLE takers. RESULTS: Usable survey data were received on 1241 residents. The number for each year (and percent of total matched PGY-1 residents) was as follows: 1996-196 (20.0), 1997-206 (20.4), 1998-204 (19.9), 1999-212 (21.0), 2000-212 (20.7), and 2001-211 (21.7). The mean Step 1 scores increased over time (p < 0.001), and programs with 5 or more categorical spots had higher scores than those with 4 or less (p < 0.001). The depth required to fill the rank list increased over the study period (p < 0.05). National data received from the NRMP from 1994 to 2001 (mean of 916 residents at each year) showed a similar increase in USMLE Step 1 scores when compared with our survey. The proportion of AOA students matching into general surgery has decreased from 30% in 1996 to 15% in 2001 (p < 0.001). CONCLUSIONS: Over the 6 years of our study, USMLE Step 1 scores increased and the results of our survey are in agreement with the national data. However, the proportion of AOA students declined, implying the top 10% of the medical school class found general surgery training less attractive. Also, programs went deeper into their rank lists to fill, implying a shrinking pool of candidates.