Laparoscopic surgery: surgical education in the People's Republic of China: changes after 15 years.

The introduction of laparoscopic surgery education in Mainland China took place in 1991, when Chinese surgeons rushed to the hospital where the first laparoscopic cholecystectomy in the country was performed to learn the keyhole technique; and different groups of surgeons from Western countries visited the land to convey their experience and foresight with their friendship. The situation in laparoscopic surgery and its education has changed a lot in the last 15 years. Communication via conference and workshops are used heavily as a teaching method in laparoscopic surgery education. Technical training is conveyed mainly in laparoscopic centers. Simple simulators created by Chinese surgeons, technical support by the Western forerunners, financial support, and other resources from major companies, and the large population contributed a lot to the fast development of laparoscopic surgery in China.

24-hour pretreatment with delta opioid enhances survival from hemorrhagic shock.

OBJECTIVES: Delta opioids have been shown to confer ischemic preconditioning and pharmacologic ischemic preconditioning to the myocardium. However, their role in providing extended pharmacologic ischemic preconditioning in hemorrhagic shock has not been explored. The authors examined the effects of 24-hour preinfusions of a selective delta opioid receptor agonist, Deltorphin-Dvariant (Delt-Dvar), on hemodynamic stability and duration of survival in a rat model of severe hemorrhagic shock. METHODS: Conscious Sprague-Dawley rats with indwelling catheters were hemorrhaged at a rate of 3.18 mL/l00 g over 20 minutes. Twenty-four hours before hemorrhage, the control group (n = 14) was infused with 1.0 mL lactated Ringer's solution, and the Delt-Dvar-treated group (n = 22) was infused with 5.0 mg/kg Delt-Dvar in 1.0 mL lactated Ringer's solution. Rats were continuously monitored for heart rate (HR), mean arterial pressure, and four-hour survival rates. Plasma lactate levels were determined at the beginning of hemorrhage and the end of hemorrhage. RESULTS: At 240 minutes, only one of 14 controls (7.1%) survived, while 16 (72.7%) of the 22 experimental rats survived. No significant differences in heart rate between controls and Delt-Dvar-treated rats were noted. Increases in mean arterial pressure of Delt-Dvar-treated rats at the beginning of hemorrhage and at the end of hemorrhage were found to be significant (p < 0.05). At 240 minutes, heart rate and mean arterial pressure were not different between the single surviving control and the Delt-Dvar group. At the end of hemorrhage, lactate levels in the Delt-Dvar-treated group were 8.5 (+/- 0.5) mmol/L versus 10.8 (+/- 0.6) mmol/L (p < 0.05) in the control group. CONCLUSIONS: Twenty-four-hour pretreatment with Delt-Dvar decreases plasma lactate levels and improves hemodynamic stability and survival during hemorrhagic shock. The use of delta-specific opioids may improve survival from hemorrhagic shock and have clinical utility in providing ischemic protection in scenarios of planned ischemia.

Validating dental and medical students' evaluations of faculty teaching in an integrated, multi-instructor course.

As more students from various health professions are combined into integrated courses, evaluating the teaching quality of individual faculty in these typically large, multi-instructor contexts becomes increasingly difficult. Indeed, students who lack sufficient recall of a given faculty member or are not committed to the evaluation process may respond by marking identical responses to all evaluation items (e.g., 3-3-3-3-3), regardless of the specific content of the items on the faculty evaluation questionnaire. These "straight-lining" behaviors-more formally referred to as monotonic response patterns (MRPs)-often reflect students' inattention to the task at hand or lack of motivation to be discriminating, which may result in invalid data. This study examines the prevalence of MRP ratings in relation to indicators reflective of students' lack of attention to evaluating the quality of faculty teaching. Dental and medical students in a required, second-year (medicine) basic science course conducted by the medical school and taught primarily by medical school faculty completed seven-item faculty evaluation forms, along with an anonymous questionnaire measuring their need to evaluate, attitudes toward faculty evaluation, and recall of instructors. MRP ratings failed to correlate significantly with students' need to evaluate or their attitudes toward faculty evaluation. However, among medical students, MRP "straight-line" responses were more prevalent for raters who recalled faculty members "very well" (p=.04). For dental students, MRPs were associated with less accurate recall (p=.01). As such, the validity of faculty evaluations within integrated, multi-instructor courses may vary when students rate distinct aspects of a teacher's performance identically. In this case-in which medical students' greater recall of instructors coincides with MRPs-ratings may suffice as global, holistic assessments of an instructor's teaching. For dental students, similar ratings may be less viable. Individual item analysis is cautioned under any circumstances.

A valid method of laparoscopic simulation training and competence assessment.

BACKGROUND: The purpose of our study was to evaluate the construct validity of laparoscopic technical performance measures and the face validity of three laparoscopic simulations. MATERIALS AND METHODS: Subjects (N = 27) of varying levels of surgical experience performed three laparoscopic simulations, representing appendectomy (LA), cholecystectomy (LC), and inguinal hemiorrhaphy (LH). Five laparoscopic surgeons, blinded to the identity of the subjects, rated the subjects on procedural competence on a binary scale and in four skills categories on a 5-point scale: clinical judgment, dexterity, serial/simultaneous complexity, and spatial orientation. Using a task-specific checklist, non-clinical staff assessed the technical errors. The level of surgical experience was correlated with the ratings, the technical errors, and the time for each procedure. Subject responses to a survey regarding the utility of the inanimate models were evaluated. RESULTS: Years of experience directly correlated with the skills ratings (all P < 0.001) and with the competence ratings across the three procedures (P < 0.01). Experience inversely correlated with the time for each procedure (P < 0.01) and the technical error total across the three models (P < 0.05). Nearly all subjects agreed that the corresponding procedures were well represented by the simulations (LA 96%, LC 96%, LH 100%). CONCLUSION: The laparoscopic simulations demonstrated both face and construct validity. Regardless of the level of surgical experience, the subjects found the models to be suitable representations of actual laparoscopic procedures. Task speed improved with surgical experience. More importantly, the quality of performance increased with experience, as shown by the improvement in the skills assessments by expert laparoscopic surgeons.

Clinical skills as demonstrated by a comprehensive clinical performance examination: who performs better - men or women?

PURPOSE: Determine whether gender predicted student performance on a clinical performance examination (CPX) when controlling for pre-matriculation and medical school performance. METHOD: A sixteen-station CPX, utilizing standardized patients (SPs), was administered to the fourth-year students three successive years at one United States medical school. Scores for each student by discipline and skills across stations were generated. Bivariate correlation and multiple regression analyses were performed to determine relationships between students' scores and pre-matriculation information (age, gender, MCAT, and undergraduate GPA) and medical school performance (first-, second- and third-year GPA, and USMLE Step 1). RESULTS: The CPX mean score for all students was 65.1% (SD 6.2). The mean total score for men (n = 182) and women (n = 93) was 64.0% and 67.0%, respectively. Being a woman, positively affected a student's score in two models controlling for pre-matriculation and medical school performance by 2.8% or 0.47 standard deviations (SD) and 2.3% or 0.39 SD, respectively. Women scored numerically higher than men in all seven disciplines (internal medicine, obstetrics/gynecology, pediatrics and psychiatry, p < 0.05) and for nine skills across all stations (introduction, history, physical examination, counseling and interpersonal, p < 0.05). CONCLUSION: Women performed better than men on the University of Kentucky CPX. Being a woman was a positive and independent predictor of performance.

Reproducibility of subclassification of squamous intraepithelial lesions: conventional versus ThinPrep paps.

OBJECTIVE: Liquid-based cytologic methods are increasingly used, and classification of squamous intraepithelial lesions (SIL) affects patient management. This study compared interobserver reproducibility in SIL subclassification on conventional (CV) and ThinPrep (TP) cytologic specimens. MATERIALS AND METHODS: Four reviewers independently subclassified SIL on 69 CV and 60 TP Paps. Specimens were retrieved by computer search of biopsy-confirmed SIL cases. A consensus interpretation of low-grade SIL (LSIL) or high-grade SIL (HSIL) was assigned when three or four observers agreed. RESULTS: All four observers agreed in 40 of 69 CV with consensus reached in 56 of 69 CV Paps (81%; 20 LSIL, 36 HSIL). For TP Paps, 38 of 60 had 100% agreement, with consensus reached in 56 of 60 TP Paps (93%; 28 LSIL, 26 HSIL, 2 SIL, difficult to grade). kappa values for all four observers were 0.48 for CV (fair agreement) and 0.63 for TP (substantial). Pairwise kappa values ranged from 0.44 to 0.60 for CV and 0.54 to 0.76 for TP. Most of the nonconsensus cases included SIL, difficult to grade interpretations; in several, the original cytologic or biopsy SIL classification, or both, was also indeterminate, or cytologic and biopsy results did not correlate exactly. High-grade biopsies followed 15% of LSIL CV and 36% of LSIL TP. CONCLUSIONS: Interobserver reproducibility in SIL subclassification may be better on TP Paps; however, both CV and TP have indeterminate lesions with low interobserver agreement. The TP specimens did not show improved correlation with histologic analysis, and specimens with consensus do not always have correlating biopsy findings.

Gender discrimination and sexual harassment in medical education: perspectives gained by a 14-school study.

PURPOSE: The authors attempted to determine male and female medical students' exposures to and perceptions of gender discrimination and sexual harassment (GD/SH) in selected academic and nonacademic contexts. METHOD: An anonymous, self-report questionnaire was administered in the spring of 1997 to senior medical students at 14 U.S. medical schools. Data were collected about students' exposures to GD/SH during undergraduate medical education and outside the medical training environment. Students' perceptions of GD/SH in various medical specialties and practice settings were also measured. RESULTS: Of the 1,911 questionnaires administered, 1,314 were completed (response rate, 69%). Both men and women reported exposures to GD/SH. More women than men reported all types of exposures to GD/SH across all academic and nonacademic contexts. Differences between men and women in the frequencies of exposures were greatest outside the medical training environment (t = 15.67, df = 1171, p

Medical students' ratings of faculty teaching in a multi-instructor setting: an examination of monotonic response patterns.

Realizing that the psychometric properties of a measure may be highly variable is especially relevant in a multi-instructor context, since an implicit assumption is that student ratings are equally reliable and valid for all faculty ratees. As a possible indicator of nonattending (i.e. invalid) responses, the authors examined the effects of monotonic response patterns on the reliabilities of students' ratings of faculty teaching - including how an alternative presentation format may reduce the prevalence of this behavior. Second-year medical and dental students (n = 130) enrolled in a required basic science course during the 1998-99 academic year were randomly assigned to one of two groups - each of which evaluated the teaching of 6 different faculty across 6 distinct dimensions (i.e. overall quality, organization, preparation, stimulation, respectfulness, and helpfulness). Using a 'split ballot' design, two versions of the conceptually equivalent faculty evaluation form were distributed at random to students in each group. Form A contained the 'traditional' items-within-faculty format, while Form B listed faculty-within-item.The number of monotonic forms (i.e. the identical rating of all 6 items) varied measurably across faculty ratees, as did the respective effects on scale reliabilities. Alpha was especially inflated where a sizeable proportion of monotonic patterns were located on response categories that were either very high (> +1.28 z(m) deviations) or very low (< -1.28 z(m) deviations) compared to the group mean. Lastly, the prevalence of monotonic response patterns was significantly (p = < or = 0.01) less when a faculty-within-item format is used (Form B). These findings suggest that monotonic response patterns differentially impact the reliabilities and, hence, the validity of students' ratings of individual faculty in a multi-instructor context.

Training and educational approaches to minimally invasive surgery: state of the art.

Current training in minimally invasive surgery (MIS) is inadequate given the demands of patients on practitioners and the number of surgeons and residents who still need to be trained. The training that is provided is neither widespread nor is it standardized, resulting in graduate surgeons with a wide range of competence. There is little guidance in what a training program needs to be effective. We provide a brief review of the state of the art of MIS training with some emphasis given to training methods including perceptual motor training, MIS learning laboratories, virtual reality, evaluation and assessment, cost, simulation fidelity, credentialing, certification, privileging, and ergonomics. We conclude that the state of the art is left wanting.