An Appreciative Inquiry Approach to the Core Competencies: Taking it From Theory to Practice.

OBJECTIVE: To operationalize the surgical core competencies by using a qualitative inquiry strategy to explore how surgical competence is behaviorally demonstrated by faculty. DESIGN: Categorical general and vascular surgery residents completed a survey soliciting opinions regarding which faculty were deemed most representative of each core competency. The surveys served as a theoretical sample, as surgeons selected were then interviewed, and interviews transcribed. A qualitative research approach using grounded theory coding methods was used for transcript analysis. Iterative coding was performed, and emergent themes were then extracted from transcript analysis. SETTING: Southern Illinois University School of Medicine, Department of Surgery in Springfield, IL, a tertiary academic center. PARTICIPANTS: Fourteen of 19 residents completed the survey (74% response rate). Two surgeons were selected for each competency. A total of 7 interviews were performed, with 4 surgeons being chosen for 2 competencies. RESULTS: Emergent themes revealed that competent surgeons shared qualities that drove their development and execution of each competency. These qualities included self-awareness, a selfless character, responsibility and ownership, context awareness, reliance on relationships and community, and a pattern of habit formation and discipline. Additionally, the competencies were noted to be pursued in an interrelated and interdependent fashion. CONCLUSIONS: Surgeons deemed competent in any core domain shared common qualities. Further study exploring how each of these is identified, developed and taught is warranted. The competencies are an inter-related matrix whose development and execution correlates with foundational personal disciplines.

Engaging medical students in the feedback process.

BACKGROUND: There are potential advantages to engaging medical students in the feedback process, but efforts to do so have yielded mixed results. The purpose of this study was to evaluate a student-focused feedback instructional session in an experimental setting. METHODS: Medical students were assigned randomly to either the intervention or control groups and then assigned randomly to receive either feedback or compliments. Tests of knowledge, skills, and attitudes were given before and after the intervention. RESULTS: There was a significant gain of knowledge and skill in the group that received instruction. Satisfaction was higher after compliments in the control group but higher after feedback in the instructional group. There was no change in the subject's willingness to seek feedback. CONCLUSIONS: A student-focused component should be carefully included as part of an overall effort to improve feedback in surgical education. The role of medical student attitudes about feedback requires further investigation.

Neurogenic tumors of the pelvis: clinicopathologic features and surgical outcomes using a multidisciplinary team.

BACKGROUND: Few data exist regarding the outcomes in patients undergoing surgery for pelvic tumors of neurogenic origin. Our aim was to characterize the clinical and pathologic features of pelvic neurogenic tumors and assess surgical outcomes. METHODS: All patients who underwent operations for pelvic neurogenic tumors at our institution between 1956 and 2004 were identified. Data analyzed included demographics, clinical features, histopathology, local recurrence, and survival. RESULTS: Eighty-nine patients were identified, of whom 44 were male. Median age was 38 years. The most common presenting symptom was low back or pelvic pain (56%). Malignant lesions were found in 43 patients (48%). Schwannomas were the most common benign tumor (61%) and malignant peripheral nerve sheath tumors the most common malignant lesion (81%). Median tumor size was 9.5 cm (range 0.8-32 cm). Malignant tumors had histopathologic evidence of infiltration of surrounding structures in 49% of cases. Intralesional resection was the most common surgical technique for both benign and malignant tumors. Thirty-day mortality was nil; major morbidity was seen in 13%. Adjuvant therapy was given to 91% of the patients with malignant disease. Five-year local recurrence rates for benign and malignant lesions were 35.9% and 35.0%, respectively. Distant recurrence for malignant lesions was 65.1% at 5 years. Five-year disease-free survival for malignant tumors was 25.9%. CONCLUSION: Pelvic neurogenic tumors occurring in young patients may be large when detected and present with nonspecific symptoms. Benign and malignant tumors had a high local recurrence rate and survival for malignant tumors was poor. Early detection and aggressive surgical intervention should improve outcome.

Outcomes of primary liver cancer in children: an appraisal of experience.

INTRODUCTION: Hepatoblastoma (HB) and hepatocellular carcinoma (HCC) are the most common primary liver cancers in children. Recent advances in management of pediatric liver cancer have improved disease-specific survival (DSS). This is a review of our experience with childhood liver malignancy over the past 3 decades. MATERIALS AND METHODS: A retrospective chart review from 1975 to 2005 identified patients who were 18 years old or younger with a histologically confirmed diagnosis of primary liver cancer. Patients were staged according to the Children's Cancer Group and Pediatric Oncology Group (CCG/POG) system. Patients were followed up prospectively through clinic visits and mail correspondence. Standard statistical methods were used for comparison, risk, and survival analyses. RESULTS: Fifty-two patients were confirmed to have primary liver cancers, where 24 (46%) patients had HB, 22 (42%) had HCC, 3 (6%) had sarcomas, and 3 (6%) had other histologies. Mean ages at presentation for HB and HCC were 3.2 and 13.1 years old, respectively. The most common presentations were abdominal mass (67%) and pain (40%). Most patients underwent major liver resection (n = 45, 87%), including: lobectomy (n = 25, 48%), and trisegmentectomy (n = 11, 21%). Three patients underwent liver transplantation (n = 3, 6%) for advanced local disease. Forty-five (87%) received primary or neoadjuvant and/or adjuvant chemotherapy. Patients had the following CCG/POG stages: I (n = 31, 60%), II (n = 6, 11.5%), III (n = 9, 17%), and IV (n = 6, 11.5%). Complete gross resection (stage I and II) was achieved in 37 (71%) patients. The perioperative mortality and morbidity rates were 0% and 29%, respectively. Patients with complete resection had significantly better 5-year DSS and median survival compared with incomplete gross resection: 62% vs 9% and 216 vs 18 months, P < .001. Patients treated during the period 1995-2005 had better 5-year DSS and median survival compared with those treated during 1975-1994: 68% vs 32% and 117 vs 27 months, P = .032. All 3 patients who underwent transplantation for conventionally unresectable disease are alive without disease recurrence (follow-up period, 1-15 years). CONCLUSION: Complete resection of the pediatric primary liver tumors remains the cornerstone of treatment to achieve cure. Major liver resection can be performed with minimal perioperative mortality and morbidity. Patients with HB appeared to have better survival compared with patients with HCC, and there was significant improvement in the DSS of children treated in the recent decade. Liver transplantation in conjunction with chemotherapy may have an increasing role in the management of locally advanced primary liver cancers.