"The Most Satisfactory Procedure in the Field of Pediatric Surgery": The History of Hypertrophic Pyloric Stenosis.

This historical retrospective explores the history of hypertrophic pyloric stenosis from its initial observations to the first surgical approaches to modern understandings of pathogenesis. The important work of Hirschsprung, Fredet, and Ramstedt remains a foundational part of management for this complex condition.

From the Operating Room to Online: Medical Student Surgery Education in the Time of COVID-19.

BACKGROUND: On March 17, 2020 the Association of American Medical Colleges recommended dismissal of medical students from clinical settings due to the COVID-19 pandemic. Third-year (M3) and fourth-year (M4) medical students were at home, M4s were interested in teaching, and residents and faculty had fewer clinical responsibilities due to elective surgery cancellations. To continue M3 access to education, we created a virtual surgery elective (VSE) that aimed to broaden students' exposure to, and elicit interest in, general surgery (GS). METHODS: Faculty, surgical residents, and M4s collaborated to create a 2-wk VSE focusing on self-directed learning and direct interactions with surgery faculty. Each day was dedicated to a specific pathology commonly encountered in GS. A variety of teaching methods were employed including self-directed readings and videos, M4 peer lectures, case-based learning and operative video review with surgery faculty, and weekly surgical conferences. A VSE skills lab was also conducted to teach basic suturing and knot-tying. All lectures and skills labs were via Zoom videoconference (Zoom Video Communications Inc). A post-course anonymous survey sent to all participants assessed changes in their understanding of GS and their interest in GS and surgery overall. RESULTS: Fourteen M3s participated in this elective over two consecutive iterations. The survey response rate was 79%. Ninety-one percent of students believed the course met its learning objectives "well" or "very well." Prior to the course, 27% reported a "good understanding" and 0% a "very good" understanding of GS. Post-course, 100% reported a "good" or "very good" understanding of GS, a statistically significant increase (P = 0.0003). Eighty-two percent reported increased interest in GS and 64% reported an increase in pursuing GS as a career. CONCLUSIONS: As proof of concept, this online course successfully demonstrated virtual medical student education can increase student understanding of GS topics, increase interest in GS, and increase interest in careers in surgery. To broaden student exposure to GS, we plan to integrate archived portions of this course into the regular third-year surgery clerkship and these can also be used to introduce GS in the preclinical years.

Implementation and evaluation of eight virtual surgical electives for medical students during the COVID-19 pandemic.

BACKGROUND: Eight novel virtual surgery electives (VSEs) were developed and implemented in April-May 2020 for medical students forced to continue their education remotely due to COVID-19. METHODS: Each VSE was 1-2 weeks long, contained specialty-specific course objectives, and included a variety of teaching modalities. Students completed a post-course survey to assess changes in their interest and understanding of the specialty. Quantitative methods were employed to analyze the results. RESULTS: Eighty-three students participated in the electives and 67 (80.7%) completed the post-course survey. Forty-six (68.7%) respondents reported "increased" or "greatly increased" interest in the course specialty completed. Survey respondents' post-course understanding of each specialty increased by a statistically significant amount (p-value = <0.0001). CONCLUSION: This initial effort demonstrated that VSEs can be an effective tool for increasing medical students' interest in and understanding of surgical specialties. They should be studied further with more rigorous methods in a larger population.

Implementation and Evaluation of a Virtual Elective in Otolaryngology in the Time of COVID-19.

OBJECTIVE: To develop and evaluate a virtual otolaryngology medical student elective created during the COVID-19 crisis with the intention of teaching the basic tenets of otolaryngology and increasing exposure to the specialty. STUDY DESIGN: Cross-sectional survey. SETTING: Emory University School of Medicine. METHODS: A 1-week virtual otolaryngology curriculum was offered to third- and fourth-year medical students that centered on the American Academy of Otolaryngology-Head and Neck Surgery Foundation's handbook Primary Care in Otolaryngology (fourth edition). The course covered a variety of topics and was conducted remotely via online video conferencing software. We applied multiple teaching modalities and surveyed students regarding the effectiveness of the course. Mixed methods analysis was employed to analyze the course data. RESULTS: Twelve students participated; 67% reported their baseline precourse understanding of otolaryngology in the "poor-fair" range. After the course, 92% of students reported increased understanding, with 42% and 58% reporting "good" and "very good" understanding, respectively. Following completion of the course, posttest scores on summative assessments were significantly higher than pretest scores (P < .001). Ninety-two percent of students reported either "increased" or "greatly increased" interest in otolaryngology postcourse. Qualitative survey results revealed students' appreciation of course organization, formative assessments, and case-based learning. CONCLUSIONS: An otolaryngology elective administered through a virtual format can be effective at providing an educational experience and garnering interest in the field. Positive exposure to otolaryngology can increase medical students' interest in pursuing the specialty and expand their general knowledge of consultation, diagnosis, and management in otolaryngology.

A Strategy for Undergraduate Medical Education in Urology During the COVID-19 Pandemic.

OBJECTIVE: To provide a framework for a virtual curriculum during the COVID-19 pandemic for medical student educators that introduces and teaches clinical concepts important in urology and surgical specialties in general. METHODS: We created a 1-week virtual urology course utilizing interactive lectures, case-based exercises, and faculty-proctored surgical video reviews. Students were assigned self-study modules and participated in case-based discussions and presentations on a topic of their choice. Students' perceptions of urology as a specialty and the utility of the course was evaluated through pre- and postcourse surveys. Understanding of urologic content was evaluated with a multiple-choice exam. RESULTS: A total of nine students were enrolled in the course. All students reported increased understanding of the common urologic diagnoses and of urology as a specialty by an average of 2.5 points on a 10-point Likert scale (Cohen's measure of effect size: 3.2). Additionally, 56% of students reported increased interest, 22% reported no change and 22% reported a decreased interest in pursuing urology as a specialty following the course. Students self-reported increased knowledge of a variety of urologic topics on a 10-point Likert scale. The average exam score on the multiple-choice exam improved from 50% before the course to 89% after the course. CONCLUSIONS: Various teaching techniques can be employed through a virtual platform to introduce medical students to the specialty of urology and increase clinical knowledge surrounding common urologic conditions. As the longevity of the COVID-19 pandemic becomes increasingly apparent and virtual teaching is normalized, these techniques can have far-reaching utility within the traditional medical student surgical curriculum.

Sustained Clinical Performance During Surgical Rotations Predicts NBME Shelf Exam Outcomes.

OBJECTIVE: To determine if longitudinal, excellent clinical performance reflected in subjective evaluations during a surgery clerkship would be associated with a greater likelihood of National Board of Medical Examiners Surgery Shelf Exam ("shelf exam") success. DESIGN: We retrospectively reviewed medical students' surgical clerkship performance from 2014 to 2019. Clinical evaluations for each rotation were abstracted and students were stratified by performance: excellent performers and non-excellent performers. The rotation performance grades were then combined to classify overall clerkship performance: sustained excellent performers, improved performers, worsened performers, and sustained non-excellent performers. We compared the shelf exam scores between performer class for each clinical rotation and the overall clerkship. Using logistic regression, we also sought to determine if clinical performance predicted passing the shelf exam. SETTING: Emory University School of Medicine in Atlanta, Georgia. PARTICIPANTS: Third-year medical students (N = 674) who completed a surgery clerkship. RESULTS: Excellent performers scored higher than non-excellent performers on the shelf exam during both clinical rotations (all p < 0.01). Sustained excellent performers had the highest exam scores out of all the clerkship performance groups (p < 0.0001). Excellent performers for both rotations were associated with increased odds of passing the shelf exam. Sustained excellent performers had the greatest odds (OR 3, 95% confidence interval 1.5-6.3, p = 0.003) of passing the exam. CONCLUSIONS: Clinical performance during the surgical clerkship and individual rotations correlates with shelf exam scores. Students should be encouraged to excel on the wards to maximize the educational experience and improve their odds of passing the exam.

Medical students impact laparoscopic surgery case time.

BACKGROUND: Medical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. MATERIALS AND METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009-January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. RESULTS: Seven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. CONCLUSIONS: This is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.

Does the amount of time medical students spend in the operating room during the general surgery core clerkship affect their career decision?

BACKGROUND: The amount of time medical students (MS) spend in the operating room (OR) during their general surgery core clerkship has not been previously studied as a predictor for choosing a career in surgery. We hypothesize that MS choosing a career in surgery spend more time in the OR. METHODS: Operative records for surgery cases at our institution from 2009 to 2013 were linked to the schedules of MS from classes of 2010 to 2014. Total number of minutes, cases, and average number of minutes in the OR were calculated and compared with the match lists. Univariate analysis was conducted to assess for associations (P < .05). RESULTS: A total of 117 students and 1,524 procedures were included. Twenty-two MS chose a surgical career (19%). An average of 2,018.5 minutes per rotation was spent in the OR (81.2 min/d), but neither the amount of time nor the number of cases was associated with choosing a career in surgery. CONCLUSIONS: Quality of the educational experience trumps quantity regarding what most influences MS career decision.

Scaling up short-term humanitarian surgery: a global surgery elective for senior medical students.

OBJECTIVES: The proportion of US medical students participating in global health has increased by 24%. These experiences are generally self-directed and lack a formal educational component. This article describes a structured, comprehensive, community-driven global surgery elective for senior-year students. DESIGN: "Surgery and Global Health" is a monthlong elective during which students shadow in the university hospital, lead discussions of an assigned text, attend lectures, and participate in a clinical rotation in rural Haiti. The first week is didactic and takes place in Atlanta, GA. Weeks 2 through 4 are clinical and are conducted in Haiti. Urological and general surgery procedures are performed during weeks 2 and 3, while the final week is reserved for follow-up care. This experience was institutionally supported. SETTING: Emory University Hospital, Atlanta, GA; L'Hôpital St. Thérèse, Hinche, Centre, Haiti. PARTICIPANTS: Emory University School of Medicine students, years 2 through 4, supervised by faculty from the departments of Urology, General Surgery, and Anesthesiology. Senior-year students spent 21 days in central Haiti working in a rural clinical setting. RESULTS: Students participated in all facets of surgical care including preoperative clearance, postanesthesia care, discharge planning, and follow-up. Students felt a level of supervised responsibility that was not afforded at their home institution and were able to take on more advanced clinical roles. CONCLUSIONS: Students planned and executed this innovative experience with multidisciplinary, departmental, and institutional support. Stateside components introduced students to Haitian culture, global surgery ethics, and humanitarian surgical trip logistics. Structured global health experiences such as this give students practical skills and incentive to pursue careers involving global surgery.

Do medical students in the operating room affect patient care? An analysis of one institution's experience over the past five years.

BACKGROUND: Medical students are active learners in operating rooms during medical school. This observational study seeks to investigate the effect of medical students on operative time and complications. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to operative records for nonemergent, inpatient general surgery cases at our institution from 1 January 2009 to 1 January 2013. Cases were grouped into 13 distinct procedure groups. Hospital records provided information on the presence of medical students. Demographics, comorbidities, intraoperative variables, and postoperative complications were analyzed. RESULTS: Overall, 2481 cases were included. Controlling for wound class, procedure group, and surgeon, medical students were associated with an additional 14 minutes of operative time. No association between medical students and postoperative complications was observed. CONCLUSIONS: The educational benefits gained by the presence of medical students do not appear to jeopardize the quality of patient care.

Designing an ethics curriculum to support global health experiences in surgery.

BACKGROUND: The field of global health is rapidly expanding in many medical centers across the US. As a result, medical students have increasing opportunities to incorporate global health experiences (GHEs) into their medical education. Ethics is a critical component of global health curricula, yet little literature exists to direct the further development of didactic training. Therefore, we sought to define ethical encounters experienced by medical students participating in short-term surgical GHEs and create a framework for the design of ethics curriculum specific to global surgery. MATERIALS AND METHODS: Emory University Departments of Surgery, Urology, and Anesthesia, in partnership with the non-profit organization Project Medishare, have taken annual humanitarian surgical trips to Hinche, Haiti. All medical students returning from the trips in 2011 and 2012 received a 35-question survey to assess demographic data, extent of prior ethics education, frequency of exposure and situational confidence to ethical subject matter, as well as ethical conflicts involved in surgical GHEs. The same comparative data were also collected for domestic clinical clerkships. RESULTS: Seventeen out of 21 medical students completed the survey. Nearly all (88.3%) students had previous formal ethics training as an undergraduate or in medical school. Ethical issues were commonly encountered during domestic clinical encounters and volunteerism. However, students reported enhanced exposure to the professional obligation of surgeons (P = 0.025) and truth-telling/surgeon-patient relationships (P = 0.044) during surgical volunteerism. Despite increased exposure, situational confidence did not change. CONCLUSIONS: Ethical issues are commonly confronted during GHEs in surgery and differ from domestic clinical encounters. Healthcare ethics curriculum should be designed to meet the needs of medical students involved in global health.

International surgical clerkship rotation: perceptions and academic performance.

BACKGROUND: Concerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship. METHODS: A 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers. RESULTS: Twenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions. Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement. Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant. CONCLUSIONS: This study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.

The independent plastic surgery match: an in-depth analysis of the applicants and process.

BACKGROUND: The independent plastic surgery match is an extremely competitive process that remains the most common training model for residents. The purpose of this study was to analyze the candidates and the overall process, both quantitative and qualitatively. METHODS: Between 2006 and 2008, an anonymous 25-question online survey was sent to all applicants of the match. Questions regarding demographics, the match process, financial burden, and qualitative issues were all included. Information from the American Board of Plastic Surgery and The San Francisco Match was also used to evaluate the application and distribution process. RESULTS: A total of 137 applicants responded (29.2% response rate). Of the responders, 62.5% were aged 30 to 34 years, 77.2% male, 66.2% white, 94.1% in general surgery residencies, and 66.2% at an academic setting, with 39.7% at an institution that also had a plastic surgery residency program. For successful matchers, an average of 13.6 invitations were awarded, 10.02 interviews were attended, and they matched to number 2.52 on their list. Of all, 64.5% spent more than $4000 on the process, whereas 9.2% spent more than $10,000. Applicants receiving 1 to 4, 5 to 9, and 10 or more interviews had successful match rates of 47.2%, 62.9%, and 92.9%, respectively. In all, 45% of unsuccessful applicants stated that the stress on themselves and their family was the number one reason to not reapply. CONCLUSIONS: Candidates applying to the independent plastic surgery match need to be aware of the competitiveness and financial commitment the process requires.

Carotid artery thrombosis and delayed stroke associated with the use of a shoulder belt in a teenager.

Blunt carotid artery injury caused by shoulder belts is rare and requires a high index of suspicion to diagnose before the onset of neurologic sequelae. Neurologic abnormalities may be erroneously attributed to concomitant head trauma, and the onset of neurologic abnormalities may be delayed for hours or days. The case of a young, teenaged driver with a "seatbelt sign" and presentation of signs and symptoms of carotid artery thrombosis 13 days after injury is described. Occult vascular injury should be suspected if neurologic deterioration occurs after a lucid interval and/or computed tomography of the head is inconsistent with neurologic findings. Screening criteria and possible screening modalities are discussed.

Should surgical novices trade their retractors for joysticks? Videogame experience decreases the time needed to acquire surgical skills.

BACKGROUND: Video game experience (VGE) has been identified as a possible predictive factor for surgical skill. We hypothesized that surgical novices with previous VGE would acquire new surgical skills faster than those without. METHODS: Fourth-year medical students (M4) and first-year surgical residents (PG-1) completed a survey asking about standard demographic data and previous VGE. Gamers had high VGE, defined as more than 3 h per week of videogame playing. Nongamers had little or no VGE. Both groups trained to proficiency on two tasks (AcquirePlace and Traversal) of the MIST-VR simulator, with proficiency defined as meeting previously validated criteria on two consecutive trials. The number of trials required to achieve proficiency for each task was recorded. RESULTS: The 26 participants included 11 M4s and 15 PG-1s: 17 males (8 gamers/9 nongamers) and 9 females (3 gamers/6 nongamers), mean age 27.8 years. There were no differences in time to proficiency between the M4 and PG-1 residents, and there were no significant differences in the relative number of gamers per gender. All participants eventually met proficiency criteria. The 11 gamers reached proficiency more quickly than the 15 nongamers (median 0 trials versus 6 trials, p = 0.01). Gamers scored lower than nongamers on their initial attempts. Women overall took longer to reach proficiency than did men (median 10 trials versus 0 trials, p = 0.002). When stratified according to VGE, female nongamers took longer to reach proficiency than male nongamers (median 11 trials versus 1 trial, p = 0.006) but among gamers, there was no difference between females and males (median 0 trials versus 0.5 trials, NS). CONCLUSION: Previous VGE shortens time to achieve proficiency on two tasks on a validated surgical simulator. The possibility that VGE may ameliorate gender differences in length of time required to acquire surgical skills should be explored further.

Medical student concerns and fears before their third-year surgical clerkship.

BACKGROUND: This study describes the personal concerns of third-year medical students beginning their surgical clerkship. To assess these needs, we studied the expectations, interests, and concerns of beginning surgical clerks. METHODS: Beginning surgical clerks during the 2002-2003 academic year were invited to respond to a written survey. Responses were categorized into domains of interest and domains of concern. Analysis controlled for prior surgical experience, interest in a surgical career, and academic term. RESULTS: The response rate was 83%. Students were most curious about surgical practice, technical skills, and issues of lifestyle/balance among surgeons. Students were most concerned about fatigue, long hours, potential mental abuse, and poor performance. Differences between groups are described. CONCLUSIONS: Beginning surgical clerks have questions and concerns about topics often not addressed in the curriculum or syllabus. This study suggests the nature of improvements that could assist the inexperienced student in creating a positive clerkship experience and guiding their choice of career.

A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs.

BACKGROUND: A delayed diagnosis of injury to cervicothoracic vessels from blunt trauma may cause significant adverse sequelae. The association of a cervicothoracic seat belt sign with such an injury is unknown. METHODS: Algorithms were prospectively studied for the detection of occult vascular injury in patients with cervicothoracic seat belt signs. Patients with neck seat belt signs underwent arteriography or computed tomographic angiography (CTA). Those with thoracic seat belt signs underwent aortography/arteriography if a ruptured thoracic aorta or injury to a great vessel was suspected or a neurovascular abnormality was present. RESULTS: During a 17-month period, 797 patients were admitted to the trauma service secondary to motor vehicle crashes. One hundred thirty-one (16.4%) had cervical or thoracic seat belt signs. Four (3%) of the patients had carotid artery injuries, the presence of which was strongly associated with a Glasgow Coma Scale score < 14, an Injury Severity Score > 16 (p < 0.0001), and the presence of a clavicle and/or first rib fracture (p < 0.0037). Of the remaining patients, 17 had thoracic trauma. There were no vascular injuries in the children and only one had thoracic trauma. CONCLUSION: The algorithms are safe and accurate for the detection of cervicothoracic vascular injury in adult and pediatric patients with seat belt signs. The cervicothoracic seat belt mark and an abnormal physical examination are an effective combination in screening for cervicothoracic vascular injury.