Benefits of mock oral examinations in a multi-institutional consortium for board certification in general surgery training.

The Southeast Michigan Center for Medical Education (SEMCME) is a consortium of teaching hospitals in the Greater Detroit metropolitan area. SEMCME pools its resources for several educational means, including mock oral board examinations. The educational and cost benefits to mock oral examinations on a multi-institutional basis in preparation for the American Board of Surgery (ABS) certifying examination were analyzed. Ten-year multi-institution data from the mock oral examinations were correlated with ABS certifying examination pass rates. Mock oral examination scores were available for 107 of 147 graduates, which included 12 candidates who failed their certifying examination on the first attempt (pass rate = 89%). Four of 31 examinees who had a low score (4.9 or less) in their mock oral exams failed their certifying examination in their first attempt. The cost of running the mock examination was low (approximately $35/resident for 50 residents). When graduates from the last 10 years were surveyed, the majority of respondents believed that the mock oral examination helped in their success and with their preparation for the certifying examination. Thus, the many benefits of administering the examination with the resources of a consortium of hospitals result in the accurate reproduction of real-life testing conditions with reasonable overall costs per resident.

Urolithiasis: the influence of stone size on management.

BACKGROUND: A 37-year-old female presented with pain in the right lower lateral abdomen. She had experienced a ureteral stone in the past. INVESTIGATIONS: Serum electrolyte levels, blood urea nitrogen, serum creatinine level, full blood count, urinalysis, CT. DIAGNOSIS: Urolithiasis. MANAGEMENT: Cystoscopy and right retrograde pyelogram.

The utilization of a morcellator during laparoscopic sleeve gastrectomy.

Obesity continues to plague much of the western world. With the novel approach of laparoscopic sleeve gastrectomy (LSG), there are exciting results being reported in weight loss. One key problem in this patient population is hernia occurrences, particularly at the largest site where the specimen was retrieved. Using an interdisciplinary research design, a new technological breakthrough was proposed. A morcellator was introduced through the existing 15 millimeter (mm) incision to retrieve the resected portion of the stomach. This technology utilized widely by the obstetricians and gynecologists has been proven to retrieve specimens through smaller incisions fostering less pain, greater mobility, earlier discharge from hospitals--ultimately greater patient care. When applied to general bariatric surgery this technology is human centered, is exceedingly affordable, practical yet very forward looking. The morcellator's role in bariatric surgery is drawn from interdisciplinary communication regarding human technology, however the use of this innovative device has the potential to revolutionize the removal of resected specimens. The application of the morcellator in this regards has never been utilized to our knowledge.

Residents' working hours in a consortium-wide surgical education program.

Traditional work schedules of surgical residents have been cited as a factor that negatively influences education and the quality of patient care. Demands by federal and state legislators as well as the general public have forced a re-evaluation of the issue. Long working hours and resulting sleep deprivation affect the lives of residents profoundly, but the question remains does it lower the quality of medical care? The justification for the long hours is that they are vital to medical education, but residents are so drained by their schedules that they are rarely in the best state of mind to learn from their experiences. Under the scrutiny of the Resident Review Committee (RRC), many programs and institutions have been cited in the recent past in violation of resident working hour requirements. As a result, many institutions have implemented reforms, thereby reducing the number of citations they received. In spite of having the highest number of citations, the field of general surgery has failed to show any improvement. The Oakland Health Education Programme Center for Medical Education (OHEP), a consortium of 16 teaching hospitals in the State of Michigan, set out to review the components of general surgery residency training in order to be able to make recommendations that might assist program directors in making appropriate changes where necessary to enhance resident education and the quality of patient care as well as to meet the personal demands of residents. Questionnaires on residents' attitudes concerning their working hours and possible reforms were sent to all general surgery residency programs in the OHEP consortium. The questionnaire consisted of 25 questions divided into three major sections: the first section encompassed demographic information including current work hours and on-call schedules. The second section consisted of questions relating to attitudes toward work hours and the options for change. The third section consisted of questions that viewed the perceived effects of limited work hours. From the seven participating hospitals with surgery residency programs in OHEP, 92 residents responded to our survey. The majority of residents were in the first 3 years of postgraduate training. The mean age of residents was 30 years old. Sixty-four per cent of respondents were male, and 18 per cent were female. Residents reported an average of 56 with a range of 0 to 110 hours on call. Variations in the number of hours had to do with the various rotations residents were on, in that during certain elective rotations, residents were not assigned to any call. The on-call schedule varied; alternate nights were reported by 11 per cent, every third night by 33 per cent, and every fourth night or more by 53 per cent. The majority of surgical residents did express the need for reform and did not feel that reforms would affect the quality of resident education. However, residents did not want to lengthen residency training beyond the 5 years. The results of our study indicates that the majority of residents in general surgery programs in Michigan perceive a need for reform of work schedules. Surgical educators may have underestimated this need in the past. Most residents thought that long hours impaired their educational experience and at times compromised their clinical care.

Upper extremity deep venous thrombosis.

PURPOSE: To determine the prevalence of symptomatic upper extremity deep venous thrombosis (DVT) and its association with symptomatic acute pulmonary embolism (PE) in a community teaching hospital. METHODS: The prevalence of symptomatic upper extremity DVT was evaluated retrospectively at a community teaching hospital during the 2-year period between July 1, 1998, and June 30, 2000. Patients were identified by International Classification of Disease, ninth revision, clinical modification, discharge codes and a review of the records of all compression Doppler ultrasonograms, venograms of the upper extremities, and magnetic resonance angiograms of the upper extremities. RESULTS: Symptomatic upper extremity DVT was diagnosed in 65 of 44,136 patients of all ages (0.15%) [or 64 of 34,567 adult patients >or= 20 years of age; 0.19%]. In seven patients, the upper extremity DVT was shown by venography to extend proximally to the brachiocephalic vein. Among these, the DVT extended to the superior vena cava in two. All of the patients received anticoagulant therapy for upper extremity DVT. No patients developed symptomatic PE. Central lines at the site of the upper extremity DVT were inserted in 39 of 65 patients (60%). Cancer was diagnosed in 30 of 65 patients (46%), 23 cancer patients also had central lines, and 19 patients (29%) had upper extremity DVT with no apparent cause. All patients had swelling of the upper extremities. Erythema over the affected site was present in four patients (6%). Pain was present in 26 patients (40%), although some discomfort due to swelling was present in all patients. CONCLUSION: Symptomatic upper extremity DVT is not uncommon in hospitalized patients. Symptomatic PE resulting from upper extremity DVT was not observed in these patients, all of whom were treated with anticoagulants.

Thromboembolic disease involving the superior vena cava and brachiocephalic veins.

PURPOSE: To evaluate the frequency of diagnosis and the characteristics of brachiocephalic vein and superior vena cava (SVC) thromboembolic disease. BACKGROUND: Thromboembolic disease of the brachiocephalic veins or SVC rarely has been reported. In view of the frequent use of central venous access lines, it would seem that the percentage of hospitalized patients with thromboembolic disease of the brachiocephalic veins or SVC should be higher than is generally recognized. METHODS: A retrospective search for thromboembolic disease involving the brachiocephalic veins and SVC was made of patients who were hospitalized over a 2-year period. RESULTS: Thromboembolic disease of the brachiocephalic veins or SVC was diagnosed in 23 of 34,567 hospitalized adults (0.06%) who were > or = 20 years old. Two of 23 patients (8.7%) had pulmonary embolism. Cancer was present in 17 of 23 patients (74%), and 15 of 23 patients (65%) had central venous access lines. Edema of the arm, face, or neck was present in 21 of 23 patients (91%). Pain or discomfort was present 15 of 23 patients (65%). CONCLUSION: Isolated brachiocephalic vein and SVC thrombosis occur in a sufficient number of hospitalized patients to merit consideration of the diagnosis in patients who have cancer, central venous access lines, or both. The signs and symptoms of brachiocephalic vein thrombosis have features in common with SVC syndrome as well as with upper extremity deep venous thrombosis. In a patient with appropriate clinical findings, venography or other imaging may be indicated.

Deep venous thrombosis in a general hospital.

PURPOSE: To determine the prevalence of proximal deep venous thrombosis (DVT) in a general hospital. BACKGROUND: In spite of the importance of proximal DVT, its prevalence in hospitalized patients has been only sparsely studied. METHODS: Patients hospitalized with DVT between July 1998 and June 2000 were identified by a computer search of discharge diagnoses. The discharge diagnosis was confirmed by a review of the records for positive findings on compression ultrasound or venogram of the lower extremities. In addition, records of all compression ultrasound examinations and venograms during that period were examined. RESULTS: The prevalence of proximal DVT in adults > or = 20 years old was 271 of 34,567 patients (0.78%). DVT was associated with pulmonary embolism in 57 of 271 patients (21.0%). The prevalence of DVT in adult men was 117 of 13,722 patients (0.85%), and in adult women was 154 of 20,845 patients (0.74%) [not significant]. The prevalence of DVT among men aged 20 to 49 years was higher than in women the same age: 19 of 3,982 patients (0.48%) vs 22 of 9,442 patients (0.23%), respectively (p < 0.02). The prevalence of DVT, however, was comparable among men and women > or = 50 years old. The prevalence of DVT was also comparable in black adults (30 of 4,344 patients; 0.69%) and in white adults (240 of 28,615 patients; 0.84%) [not significant]. CONCLUSION: Proximal DVT continues to be a frequent illness among hospitalized patients.