Association of research timing with surgery resident perceptions of operative autonomy and satisfaction: A multi-institutional study.

BACKGROUND: General surgery residents commonly engage in research years after the second (Post-postgraduate year 2 [PostPGY2]) or third (PostPGY3) clinical training year. The impact of dedicated research training timing on training experience is unknown. Our aim was to examine the progression of residents' perceived meaningful operative autonomy and evaluate career satisfaction, in relation to research timing. METHODS: Categorical surgery residents with 2-year research requirements were surveyed regarding perceived autonomy for laparoscopic appendectomy, laparoscopic cholecystectomy, and right hemicolectomy and satisfaction with the impact of dedicated research training on professional development. Meaningful operative autonomy was defined as Zwisch scores ≥3 (passive help or supervision only). RESULTS: Residents from 17 programs participated (n = 233, 30.6%); 48% were PostPGY2. PostPGY3 residents were more likely to perceive meaningful operative autonomy when starting dedicated research training (laparoscopic appendectomy: 98% vs 74%, P < .001; laparoscopic cholecystectomy: 87% vs 48%, P < .001; right hemicolectomy: 27% vs 3%, P < .001). Meaningful operative autonomy declined during dedicated research training but was still higher for PostPGY3 residents for laparoscopic appendectomy (84% vs 42%, P < .001) and laparoscopic cholecystectomy (68% vs 30%, P < .001). By PGY4, PostPGY2 residents reported rates of meaningful operative autonomy comparable to PostPGY3 through training completion. A higher proportion of PostPGY3 residents reported dedicated research training satisfaction (90% vs 78%, P = .01). Training at PostPGY3 programs (odds ratio, 3.06, 95% confidence interval, 1.38-6.80) and postresearch training stage (compared with preresearch residents, odds ratio, 3.25, 95% confidence interval, 1.06-10.0) were independently associated with satisfaction. CONCLUSION: Significant differences existed in the progression of perceived operative autonomy and dedicated research training satisfaction between PostPGY2 and PostPGY3 residents. These results could help surgical educators make individualized decisions regarding research timing to promote surgical skill acquisition and resident well-being.

An fMRI investigation of neural activation predicting memory formation in children with fetal alcohol spectrum disorders.

Prenatal alcohol exposure (PAE) is associated with physical anomalies, growth restriction, and a range of neurobehavioral deficits. Although declarative memory impairment has been documented extensively in individuals with fetal alcohol spectrum disorders (FASD), this cognitive process has been examined in only one functional magnetic resonance imaging (fMRI) study, and mechanisms underlying this impairment are not well understood. We used an event-related fMRI design to examine neural activations during visual scene encoding that predict subsequent scene memory in 51 right-handed children (age range = 10-14 years, M = 11.3, SD = 1.3) whose mothers had been recruited and interviewed prospectively about their alcohol use during pregnancy. Following examination by expert dysmorphologists, children were assigned to one of three FASD diagnostic groups: FAS/PFAS (nFAS = 7; nPFAS = 4), nonsyndromal heavily exposed (HE; n = 14), and Controls (n = 26). Subsequent memory was assessed in a post-scan recognition test, and subsequent memory activations were examined by contrasting activations during encoding of scenes that were subsequently remembered (hits) to those for incorrectly judged as 'new' (misses). Recognition accuracy did not differ between groups. Pooled across groups, we observed extensive bilateral subsequent memory effects in regions including the hippocampal formation, posterior parietal cortex, and occipital cortex-a pattern consistent with previous similar studies of typically developing children. Critically, in the group of children with FAS or PFAS, we observed activations in several additional regions compared to HE and Control groups. Given the absence of between-group differences in recognition accuracy, these data suggest that in achieving similar memory compared to children in the HE and Control groups, children with FAS and PFAS recruit more extensive neural resources to achieve successful memory formation.

Standardized Multi-Institutional Mock Oral Examination: A Feasible and Valuable Educational Experience for General Surgery Residents.

INTRODUCTION: Mock oral examinations (MOE) are used to prepare residents and assess their readiness for the American Board of Surgery Certifying Exam (ABSCE). Delivery of MOEs varies by institution and previous studies have demonstrated significant implementation barriers such as availability of faculty examiners and exam scenarios. OBJECTIVE: To assess the value and participant satisfaction of a standardized multi-institutional MOE for general surgery residents. PARTICIPANTS: Thirty-three general surgery residents and 37 faculty members from 3 institutions participated in a regional MOE. Residents were examined in three 20-minute sessions. Faculty examiners were given a wide selection of prescripted exam scenarios and instructed to use standardized grading rubrics during a brief orientation on the day of the exam. All participants were surveyed on their overall experience. RESULTS: Of 33 participating residents, 26 (79%) passed the MOE (92% of R5, 91% R4, and 50% of R3). Response rates were 91% for residents, and 57% for faculty members respectively. Most respondents were satisfied with the overall exam experience (88%), standardized question quality (86%) and question variety (82%). A total of 92% of respondents agreed that the time, effort, and cost of the MOE was justified by its educational value to residents. Higher medical knowledge ratings assigned by faculty examiners correlated with stronger trainee performance (ß = 0.48; 95% confidence interval [CI] 0.29-0.66), while patient care and interpersonal communication skill ratings were not associated with trainee performance. The standardized grading rubric achieved moderate inter-rater reliability among examiner pairs with 70.6% agreement (Kappa 0.47). CONCLUSIONS: General Surgery residents and faculty perceived the standardized multi-institutional MOE to be a highly satisfactory educational experience and valuable assessment tool. Developing a repertoire of scripted exam scenarios made it feasible to recruit sufficient faculty participants, and standardizing grading rubrics allowed for a consistent exam experience with moderate inter-rater reliability.

Deficits in arithmetic error detection in infants with prenatal alcohol exposure: An ERP study.

Prenatal alcohol exposure (PAE) is associated with a range of physical, cognitive, and behavioral problems, particularly in arithmetic. We report ERP data collected from 32 infants (mean age = 6.8 mo; SD = 0.6; range = 6.1-8.1; 16 typically developing [TD]; 16 prenatally alcohol-exposed) during a task designed to assess error detection. Evidence of error monitoring at this early age suggests that precursors of the onset of executive control can already be detected in infancy. As predicted, the ERPs of the TD infants, time-locked to the presentation of the solution to simple arithmetic equations, showed greater negative activity for the incorrect solution condition at middle-frontal scalp areas. Spectral analysis indicated specificity to the 6-7 Hz frequency range. By contrast, the alcohol-exposed infants did not show the increased middle-frontal negativity seen in the TD group nor the increased power in the 6-7 Hz frequency, suggesting a marked developmental delay in error detection and/or early impairment in information processing of small quantities. Overall, our research demonstrates that (a) the brain network involved in error detection can be identified and highly specified in TD young infants, and (b) this effect is replicable and can be utilized for studying developmental psychopathology at very early ages.

Efficacy of Maternal Choline Supplementation During Pregnancy in Mitigating Adverse Effects of Prenatal Alcohol Exposure on Growth and Cognitive Function: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

BACKGROUND: We recently demonstrated the acceptability and feasibility of a randomized, double-blind choline supplementation intervention for heavy drinking women during pregnancy. In this study, we report our results relating to the efficacy of this intervention in mitigating adverse effects of prenatal alcohol exposure (PAE) on infant growth and cognitive function. METHODS: Sixty-nine Cape Coloured (mixed ancestry) heavy drinkers in Cape Town, South Africa, recruited in mid-pregnancy, were randomly assigned to receive a daily oral dose of either 2 g of choline or placebo from time of enrollment until delivery. Each dose consisted of an individually wrapped packet of powder that, when mixed with water, produced a sweet tasting grape-flavored drink. The primary outcome, eyeblink conditioning (EBC), was assessed at 6.5 months. Somatic growth was measured at birth, 6.5, and 12 months, recognition memory and processing speed on the Fagan Test of Infant Intelligence, at 6.5 and 12 months. RESULTS: Infants born to choline-treated mothers were more likely to meet criterion for conditioning on EBC than the placebo group. Moreover, within the choline arm, degree of maternal adherence to the supplementation protocol strongly predicted EBC performance. Both groups were small at birth, but choline-treated infants showed considerable catch-up growth in weight and head circumference at 6.5 and 12 months. At 12 months, the infants in the choline treatment arm had higher novelty preference scores, indicating better visual recognition memory. CONCLUSIONS: This exploratory study is the first to provide evidence that a high dose of choline administered early in pregnancy can mitigate adverse effects of heavy PAE on EBC, postnatal growth, and cognition in human infants. These findings are consistent with studies of alcohol-exposed animals that have demonstrated beneficial effects of choline supplementation on classical conditioning, learning, and memory.

Mixed-Method Evaluation of a Cadaver Dissection Course for General Surgery Interns: An Innovative Approach for Filling the Gap Between Gross Anatomy and the Operating Room.

OBJECTIVE: To evaluate an innovative whole cadaver dissection curriculum designed to focus on teaching procedure-relevant anatomy and surgical skills to surgery interns. DESIGN: A mixed methods explanatory sequential design incorporating both quantitative and qualitative evaluations was used to evaluate the cadaver dissection course. Quantitative data were prospectively collected and retrospectively reviewed in order to compare anatomy knowledge and operative skills before and after the course. In the qualitative phase, open-ended telephone interviews were conducted in order to explore the major strengths and weaknesses of the course and gain a more in-depth understanding of resident perceptions and attitudes toward the course. SETTING: All UCLA categorical surgery interns who have undergone the cadaver dissection curriculum between the years 2010 to 2016 were recruited for evaluation and interview. PARTICIPANTS: From 2010 to 2016, 6 to 7 categorical surgery interns were enrolled in the cadaver dissection course each year. RESULTS: Anatomy practical examination scores increased following implementation of the course from 50.5% to 83.5% (p < 0.01). Faculty ratings of operative skills improved as well (average Likert scale rating for technical skills improved from 4.1 ± 0.4 to 4.4 ± 0.3, p = 0.06). Almost all interviewees (96%) reported that the course improved their knowledge of anatomy, and 78% of respondents believed the course was conducive to improving technical skills. CONCLUSIONS: We believe that cadaver dissection courses offer a superior educational model for teaching clinically relevant anatomy as well as surgical skills. We found improvements in anatomy knowledge and technical skills, and trainees expressed strongly favorable views of the program.

Implementation of a flipped classroom approach to promote active learning in the third-year surgery clerkship.

BACKGROUND: Constructivist student-centered instructional models such as the flipped classroom (FC) have been shown to improve learning. METHODS: A FC approach was implemented for the surgery clerkship. Data was collected in phase 1 to evaluate student learning and attitudes. Based on these results, questions for the phase 2 open-ended survey were developed to improve understanding of learner attitudes, and ascertain how well the FC aligns with constructivist principles. RESULTS: There was no significant difference in shelf exam performance between the control and intervention groups. A majority of students agreed that they preferred the FC over lectures, and that their learning improved. Open-ended survey analysis demonstrated that the FC fostered self-directed, active learning, and that the in-class sessions facilitated application of concepts and deeper learning. Areas identified for improvement included better alignment with learning preferences through greater variety of pre-class learning options, improvement of podcast technical quality, and utilization of smaller in-class discussion groups. CONCLUSIONS: Students had a positive perception of the FC. The FC supports self-directed and more active and deeper in-class learning.

Use of Entrustable Professional Activities in the Assessment of Surgical Resident Competency.

Importance: Competency-based assessments of surgical resident performance require metrics of entrustable autonomy. Objectives: To designate entrustable professional activities (EPAs) in global performance and in specific operations, and to identify differences in perceived capability, autonomy, and expectations between surgical faculty and residents. Design, Setting, and Participants: This survey study was conducted from August 9, 2016, through August 24, 2016, in the Department of Surgery at the UCLA David Geffen School of Medicine. The survey instrument consisted of 5-point Likert scales for assessing perceptions of entrustability for 5 global and 5 operative EPAs. Faculty members were surveyed regarding resident capabilities and expected capabilities by postgraduate year. Residents were surveyed regarding their own capabilities, actual autonomy entrusted in the last EPA performed, and expected capabilities. Main Outcomes and Measures: Differences in mean ratings were assessed across 7 comparison domains. Results: Among 78 total faculty members, 31 (40%) participated in the survey. Among 49 residents, 39 (80%) participated in the survey. Residents generally rated their global EPA performance higher than the faculty did (mean, 3.7 vs 2.8; P < .01), but operative EPA performance ratings were equivalent (mean, 2.7 vs 2.4; P < .12). Faculty members perceived senior residents as underperforming expectations in operative EPAs. Most faculty members (80%) expected residents not to be independently capable of performing complex operations by graduation. Faculty members perceived residents in postgraduate years 4 and 5 to have greater operative capability than the level of autonomy entrusted to those residents (95% CI, 3.3-3.5 vs 1.9-2.2). Conclusions and Relevance: Global and operative EPAs are practical for developing competency-based curricula. Graduated autonomy should be granted to improve the operative experience for residents.

Reductions in Corpus Callosum Volume Partially Mediate Effects of Prenatal Alcohol Exposure on IQ.

Disproportionate volume reductions in the basal ganglia, corpus callosum (CC) and hippocampus have been reported in children with prenatal alcohol exposure (PAE). However, few studies have investigated these reductions in high prevalence communities, such as the Western Cape Province of South Africa, and only one study made use of manual tracing, the gold standard of volumetric analysis. The present study examined the effects of PAE on subcortical neuroanatomy using manual tracing and the relation of volumetric reductions in these regions to IQ and performance on the California Verbal Learning Test-Children's Version (CVLT-C), a list learning task sensitive to PAE. High-resolution T1-weighted images were acquired, using a sequence optimized for morphometric neuroanatomical analysis, on a Siemens 3T Allegra MRI scanner from 71 right-handed, 9- to 11-year-old children [9 fetal alcohol syndrome (FAS), 19 partial FAS (PFAS), 24 non-syndromal heavily exposed (HE) and 19 non-exposed controls]. Frequency of maternal drinking was ascertained prospectively during pregnancy using timeline follow-back interviews. PAE was examined in relation to volumes of the CC and left and right caudate nuclei, nucleus accumbens and hippocampi. All structures were manually traced using Multitracer. Higher levels of PAE were associated with reductions in CC volume after adjustment for TIV. Although the effect of PAE on CC was confounded with smoking and lead exposure, additional analyses showed that it was not accounted for by these exposures. Amongst dysmorphic children, smaller CC was associated with poorer IQ and CVLT-C scores and statistically mediated the effect of PAE on IQ. In addition, higher levels of PAE were associated with bilateral volume reductions in caudate nuclei and hippocampi, effects that remained significant after control for TIV, child sex and age, socioeconomic status, maternal smoking during pregnancy, and childhood lead exposure. These data confirm previous findings showing that PAE is associated with decreases in subcortical volumes and is the first study to show that decreases in callosal volume may play a role in fetal alcohol-related impairment in cognitive function seen in childhood.

Prospective Memory Impairment in Children with Prenatal Alcohol Exposure.

BACKGROUND: Prenatal alcohol exposure (PAE) is linked to impaired performance on tests of retrospective memory, but prospective memory (PM; the ability to remember and act on delayed intentions) has not been examined in alcohol-exposed children. We investigated event-based PM in children with heavy PAE and the degree to which associations between PAE and PM are influenced by IQ, executive functioning (EF), retrospective memory, and attention deficit/hyperactivity disorder (ADHD). METHODS: We administered a computerized PM task to 89 children (Mage = 11.1 years) whose mothers were recruited prenatally: 29 with fetal alcohol syndrome (FAS) or partial FAS (PFAS), 32 nonsyndromal heavily exposed (HE), and 28 Controls. We examined effects of diagnostic group, cue focality, and task difficulty on PM performance. The association between a continuous measure of alcohol exposure and PM performance was also examined after controlling for sociodemographic confounders. Mediation of alcohol effects on PM by IQ, EF, and retrospective memory scores was assessed as was the effect of ADHD on PM performance. RESULTS: Children with FAS/PFAS made more PM errors than either HE or Control children. PAE was negatively related to PM performance even after adjusting for sociodemographic confounders, EF, and retrospective memory. This relation was only partially mediated by IQ. PAE was related to ADHD, but ADHD was not related to PM performance. CONCLUSIONS: Fetal alcohol-related impairment in event-based PM was seen in children with FAS/PFAS. The effect of PAE on PM was not attributable to impaired EF and retrospective memory and was not solely attributable to lower IQ. Consistent with previous studies, we found no effect of ADHD on event-based PM performance at this age. This is the first study documenting PM impairment in children with heavy PAE and identifies a new domain of impairment warranting attention in diagnosis and management of fetal alcohol spectrum disorders.

Intraoperative Laparoscopic Near-Infrared Fluorescence Cholangiography to Facilitate Anatomical Identification: When to Give Indocyanine Green and How Much.

Recent technological advances have enabled real-time near-infrared fluorescence cholangiography (NIRFC) with indocyanine green (ICG). Whereas several studies have shown its feasibility, dosing and timing for practical use have not been optimized. We undertook a prospective study with systematic variation of dosing and timing from injection of ICG to visualization. Adult patients undergoing laparoscopic biliary and hepatic operations were enrolled. Intravenous ICG (0.02-0.25 mg/kg) was administered at times ranging from 10 to 180 minutes prior to planned visualization. The porta hepatis was examined using a dedicated laparoscopic system equipped to detect NIRFC. Quantitative analysis of intraoperative fluorescence was performed using a scoring system to identify biliary structures. A total of 37 patients were enrolled. Visualization of the extrahepatic biliary tract improved with increasing doses of ICG, with qualitative scores improving from 1.9 ± 1.2 (out of 5) with a 0.02-mg/kg dose to 3.4 ± 1.3 with a 0.25-mg/kg dose (P < .05 for 0.02 vs 0.25 mg/kg). Visualization was also significantly better with increased time after ICG administration (1.1 ± 0.3 for 10 minutes vs 3.4 ± 1.1 for 45 minutes, P < .01). Similarly, quantitative measures also improved with both dose and time. There were no complications from the administration of ICG. These results suggest that a dose of 0.25 mg/kg administered at least 45 minutes prior to visualization facilitates intraoperative anatomical identification. The dosage and timing of administration of ICG prior to intraoperative visualization are within a range where it can be administered in a practical, safe, and effective manner to allow intraoperative identification of extrahepatic biliary anatomy using NIRFC.

Verbal learning and memory impairment in children with fetal alcohol spectrum disorders.

BACKGROUND: Previous studies using the California Verbal Learning Test-Children's Version (CVLT-C) to examine effects of heavy prenatal alcohol exposure on verbal learning and memory have reported impaired information acquisition (i.e., encoding), rather than retrieval, as the primary mechanism underlying learning and memory impairment. We administered the CVLT-C to 2 independent cohorts to determine whether (i) effects on encoding are also seen at moderate exposure levels, using both categorical (diagnostic/exposure group) and continuous exposure measures; (ii) these deficits are specific or secondary to alcohol-related impairment in IQ; (iii) effects on retrieval can be detected over and above effects on initial encoding; and (iv) effects on learning are attributable to less efficient learning strategy use. METHODS: We administered the CVLT-C and Wechsler Intelligence Scale for Children to 151 Cape Town heavy and nonexposed children (M = 10.3 years), and 291 Detroit adolescents recruited to over-represent moderate-to-heavy prenatal alcohol exposure (M = 14.4 years). RESULTS: Effects on encoding in the heavily exposed Cape Town cohort and on retrieval in both cohorts were significant after adjustment for IQ. Although effects on retrieval were no longer significant in Cape Town after control for initial encoding, effects on recognition memory continued to be evident in Detroit. Children with full or partial fetal alcohol syndrome were less able to use the semantic cluster encoding strategy implicit in the CVLT-C. CONCLUSIONS: Effects on verbal learning were seen primarily in the more heavily exposed Cape Town cohort; effects on recall and recognition memory were also seen at moderate exposure levels in Detroit. These effects were not attributable to alcohol-related impairment in overall intellectual competence. The finding that effects on retention continued to be evident after statistical adjustment for initial encoding in Detroit suggests that a fetal alcohol-related deficit in retrieval is not secondary to a failure to encode the initial information. These data confirm that this impairment in initial learning is mediated, in part, by failure to use the semantic cluster learning strategy.

Trauma system overtriage: are we on track?

The American College of Surgeons (ACS) recommends trauma overtriage rate (OT) below 50 per cent to maximize efficiency while ensuring optimal care. This retrospective study was undertaken to evaluate OT rates in our Level I trauma center using the most recent criteria and guidelines. OT rates during a 12-month period were measured using six definitions based on combinations of Injury Severity Score (ISS), length of hospital stay (LOS, in days), procedures, and disposition after the emergency department. Reason for trauma activation was 55 per cent criteria, 16 per cent guidelines, 11 per cent paramedic judgment, five per cent no reason, and 13 per cent no documentation. OT rates ranged from 22.6 per cent (ISS less than 9, LOS 1 day or less, no consults) to 48.2 per cent (ISS less than 9, LOS 3 days or less, with procedures/consults) and were in compliance with ACS recommendations. Physiologic assessment criteria and anatomic injury had the lowest OT rates and contained all mortalities. Passenger space intrusion (PSI), pedestrian versus automobile (criterion and guideline), and extrication (guideline) all had consistently high rates of OT. We conclude that PSI should be reduced to a guideline, the pedestrian versus automobile criterion and guideline should be combined, and extrication could be removed from the triage scheme.

Metabolic effects of sleeve gastrectomy in female rat model of diet-induced obesity.

BACKGROUND: Although women disproportionately undergo bariatric surgery, the rodent models investigating the mechanisms of bariatric surgery have been limited to males. Female rodent models can also potentially allow us to understand the effects of surgical intervention on future generations of offspring. Sleeve gastrectomy is an attractive weight loss procedure for reproductive-age female patients because it avoids the malabsorption associated with intestinal bypass. We sought to evaluate the effect of sleeve gastrectomy on young female rats with diet-induced obesity at the University of California, Los Angeles, David Geffen School of Medicine. METHODS: Sprague-Dawley female rats were fed a 60% high-fat diet. At 12 weeks of age, the rats underwent either sleeve gastrectomy or sham surgery. The rats were killed 4 weeks after surgery. A chemistry panel was performed, and the serum adipokines and gut hormones were assayed. The homeostasis model assessment score was calculated. The liver histologic findings were graded for steatosis. The 2-sample t test was used to compare the results between the 2 groups. RESULTS: Sleeve gastrectomy was associated with significant weight loss (5% ± 6% versus -4% ± 6%; P < .001), lower leptin levels (1.3 ± 1.2 versus 3.5 ± 2.3 ng/mL; P < .01), and higher adiponectin levels (.43 ± .19 versus .17 ± .14 ng/mL; P < .004) compared with the sham-operated rats. No significant differences were found in the fasting ghrelin levels. Furthermore, we did not observe evidence of insulin resistance or steatohepatitis after 11 weeks of high-fat diet. Despite these limitations, additional gender-specific studies are warranted given that most bariatric surgeries are performed in women. CONCLUSION: Sleeve gastrectomy appears to result in weight loss and improvements in adiponectin and leptin by way of mechanisms independent of ghrelin levels in a female model of diet-induced obesity.

A novel cadaver-based educational program in general surgery training.

OBJECTIVE: To describe the development of a cadaver-based educational program and report our residents' assessment of the new program. DESIGN: An anatomy-based educational program was developed using fresh frozen cadavers to teach surgical anatomy and operative skills to general surgery (GS) trainees. Residents were asked to complete a voluntary, anonymous survey evaluating perceptions of the program (6 questions formulated on a 5-point Likert scale) and comparing cadaver sessions to other types of learning (4 rank order questions). SETTING: Large university teaching hospital. PARTICIPANTS: Medical students, residents, and faculty members were participants in the cadaver programs. Only GS residents were asked to complete the survey. RESULTS: Since its implementation, 150 residents of all levels participated in 13 sessions. A total of 40 surveys were returned for a response rate of 89%. Overall, respondents held a positive view of the cadaver sessions and believed them to be useful for learning anatomy (94% agree or strongly agree), learning the steps of an operation (76% agree or strongly agree), and increasing confidence in doing an operation (53% agree or strongly agree). Trainees wanted to have more sessions (87% agree or strongly agree), and believed they would spend free time in the cadaver laboratory (58% agree or strongly agree). Compared with other learning modalities, cadaver sessions were ranked first for learning surgical anatomy, followed by textbooks, simulators, web sites, animate laboratories, and lectures. Respondents also ranked cadaver sessions first for increasing confidence in performing a procedure and for learning the steps of an operation. Cost of cadavers represented the major expense of the program. CONCLUSIONS: Fresh cadaver dissections represent a solution to the challenges of efficient, safe, and effective general surgery education. Residents have a positive attitude toward these teaching sessions and found them to be more effective than other learning modalities.

Morbidity and mortality as a televideoconference: a randomized prospective evaluation of learning and perceptions.

BACKGROUND: Central morbidity and mortality conferences ensure uniform content and more participants but consume work hours in commuting for programs with multiple teaching hospitals. Internet-based televideoconferencing (TVC) technology has the potential to eliminate commuting and expand participation and retain quality of instruction. STUDY DESIGN: A prospective, randomized pilot study compared a control (home, n = 43) group in a live morbidity and mortality conference with an experimental (remote, n = 35) group exposed to TVC. After the conference, 78 participants (11 faculty, 38 residents, and 29 medical students) completed a survey assessing learning (6 questions) and conference effectiveness and appeal (7 questions). RESULTS: Comparison of pooled scores on the 6 test items showed no difference by home versus remote group (4.9 versus 4.4; p = 0.47) or among faculty, residents, and students (4.5 versus 4.7 versus 4.7; p = 0.89), indicating that learning was not compromised by TVC. Overall perceptions of TVC were similar for home and remote sites (25.5 versus 23.4; p = 0.13); TVC was perceived as slightly less effective as attending a conference in person, but preferable to commuting. Perceptions of TVC grew proportionately more favorable as commuting distances increased. Students had a more positive perception of TVC than did residents, and faculty had the least positive perception (p = 0.048). Participants were comfortable giving a presentation via TVC, but less comfortable asking questions or participating in a discussion. CONCLUSIONS: This is the first study using televideoconferencing for morbidity and mortality. TVC did not hinder overall learning and was preferable to commuting between facilities. TVC can help maximize educational efficiency and opportunities in programs with multiple training sites.

Numerical Versus Pass/Fail Scoring on the USMLE: What Do Medical Students and Residents Want and Why?

BACKGROUND: Although the primary purpose of the US Medical Licensing Examination (USMLE) is assessment for licensure, USMLE scores often are used for other purposes, more prominently resident selection. The Committee to Evaluate the USMLE Program currently is considering a number of substantial changes, including conversion to pass/fail scoring. METHODS: A survey was administered to third-year (MS3) and fourth-year (MS4) medical students and residents at a single institution to evaluate opinions regarding pass/fail scoring on the USMLE. RESULTS: Response rate was 59% (n  =  732 of 1249). Reported score distribution for Step 1 was 30% for <220, 38% for 220-240, and 32% for >240, with no difference between MS3s, MS4s, and residents (P  =  .89). Score distribution for Step 2 Clinical Knowledge (CK) was similar. Only 26% of respondents agreed that Step 1 should be pass/fail; 38% agreed with pass/fail scoring for Step 2 CK. Numerical scoring on Step 1 was preferred by respondents who: (1) agreed that the examination gave an accurate estimate of knowledge (odds ratio [OR], 4.23; confidence interval [CI], 2.41-7.43; P < .001); (2) scored >240 (OR, 4.0; CI, 1.92-8.33; P < .001); and (3) felt that acquisition of knowledge might decrease if the examination were pass/fail (OR, 10.15; CI, 3.32-31.02; P < .001). For Step 2 CK, numerical scoring was preferred by respondents who: (1) believed they gained a large amount of knowledge preparing for the examination (OR, 2.63; CI, 1.52-4.76; P < .001); (2) scored >240 (OR, 4.76; CI, 2.86-8.33; P < .001); (3) felt that the amount of knowledge acquired might decrease if it were pass/fail (OR, 28.16; CI, 7.31-108.43; P < .001); and (4) believed their Step 2 CK score was important when applying for residency (OR, 2.37; CI, 1.47-3.84; P < .001). CONCLUSIONS: Students and residents prefer the ongoing use of numerical scoring because they believe that scores are important in residency selection, that residency applicants are advantaged by examination scores, and that scores provide an important impetus to review and solidify medical knowledge.

Web-based portfolios: a valuable tool for surgical education.

BACKGROUND: Our residency program developed and implemented an online portfolio system. In the present communication, we describe this system and provide an early analysis of its effect on competency-based performance and acceptance of the system by the residents. MATERIALS AND METHODS: To measure competency-based performance, end-of-rotation global evaluations of residents by faculty completed before (n = 1488) and after (n = 697) implementation of the portfolio were compared. To assess acceptance, residents completed a 20-question survey. RESULTS: Practice-based learning and improvement improved following implementation of the portfolio system (P = 0.002). There was also a trend toward improvement in the remaining competencies. In the survey tool (response rate 69%), 95% of the residents agreed that the purpose and functions of the system had been explained to them, and 82% affirmed understanding of ways in which the system could help them, although fewer than half reported that their portfolio had aided in their development of the competencies. All residents appreciated the system's organizational capabilities, and 87% agreed that the portfolio was a useful educational tool. CONCLUSIONS: This web portfolio program is a valuable new instrument for both residents and administrators. Early analysis of its impact demonstrates a positive effect across all competencies, and survey analysis revealed that residents have a positive view of this new system. As the portfolio is further incorporated into the educational program, we believe that our residents will discover new tools to craft a career of genuine self-directed learning.

Early experience with laparoscopic sleeve gastrectomy as a single-stage bariatric procedure.

Laparoscopic sleeve gastrectomy (LSG) as a single-stage restrictive bariatric procedure is becoming increasingly popular, especially in patients who are high risk and/or superobese. Between November 21, 2006, and September 30, 2008, 42 patients underwent LSG at our institution. Average age was 47 +/- 11 years, average body mass index was 54 +/- 10 kg/m2, and 62 per cent were female. Preoperative indications for LSG included contraindication to laparoscopic Roux-en-Y gastric bypass (n = 11), severe coronary artery disease and/or congestive heart failure (n = 3), significant liver disease (n = 3), and patient preference (n = 4). Intraoperative indications for LSG included a foreshortened mesentery with inability to create a gastrojejunostomy (n = 13), extensive adhesions (n = 5), and intraoperative findings concerning for cirrhosis (n = 3). Twelve complications occurred in six patients: laparoscopic to open conversion (n = 1), reoperation (n = 3), nosocomial pneumonia (n = 1), wound infection (n = 1), bleeding (n = 1), pulmonary embolus (n = 1), readmission (n = 3), and superior splenic pole infarction. There was one death resulting from pulmonary embolism that occurred 2 weeks postoperatively. Preliminary excess body weight loss at 3, 6, 9, and 12 months was 29, 32 t, 38, and 30 per cent, respectively, and many patients had improvement or resolution of obesity-related comorbidities. Early review of our experience demonstrates that LSG may be an effective single-stage bariatric procedure. Additional follow up will be necessary to better define its long-term safety and efficacy.