Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

IMPORTANCE: Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. OBJECTIVE: The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. DESIGN, SETTING, PARTICIPANTS: Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. MAIN OUTCOME MEASURES: Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. RESULTS: Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. CONCLUSIONS AND RELEVANCE: Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools.

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

A theory-based curriculum for enhancing surgical skillfulness.

BACKGROUND: Curricula for surgical technical skills laboratories have traditionally been designed to accommodate the clinical activities of residents, so they typically consist of individual, episodic training sessions. We believe that the skills laboratory offers an opportunity to design a surgical skills curriculum based on the fundamental elements known to be important for motor skill instruction. We hypothesized that training novices with such a curriculum for a 1-month period would yield skills performance levels equivalent to those of second year surgery residents who had trained in a traditional program. STUDY DESIGN: Fourth-year medical students served as study subjects (novice group) during a 4-week senior elective. They were taught each skill during a 1-week period. Subjects received instruction by a content expert followed by a 1-week period of deliberate practice with feedback. The novice performances were videotaped both before and after the intervention, and each videotape was evaluated in a blinded fashion by experts using a validated evaluation instrument. These results were compared with skill performance ratings of first- and second-year surgery residents that had been accumulated over the previous 3 years. RESULTS: Average performance ratings for the novices substantially improved for all four skills after training. There was no marked difference between average performance ratings of postintervention novice scores when compared with the average scores in the resident group. Inter-rater agreement in scoring for the videotaped novice performances exceeded 0.87 (intraclass correlation) for all ratings of pre- and posttraining. CONCLUSIONS: These results demonstrate the effectiveness of a laboratory-based training program that includes fundamentals of motor skills acquisition.

Medical student contact with patients on a surgery clerkship: is there a chance to learn?

BACKGROUND: Earlier studies of medical students on nonsurgical rotations have shown that clinical clerks usually first interact with their patients late in the clinical course. This would seem disadvantageous to the student's learning because they would have less opportunity to generate diagnoses or a management plan. STUDY DESIGN: A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to third year medical students during their surgical clerkship. Students received questionnaires each day to evaluate their clinical experiences from the previous day. RESULTS: The results from 311 student-patient encounters were collected and analyzed by clinical site as follows: outpatient clinics, outpatient surgery, inpatient surgery, day of surgery admission, inpatient consults, or emergency room consults. Students reported significantly more opportunities to elicit chief complaint, generate potential diagnosis, develop or suggest a management plan, and perform the initial examination when in the clinic setting. CONCLUSIONS: Overall, students were given relatively few opportunities to be the first to interact with any patient in any setting. They infrequently had an opportunity to independently generate a hypothesis or generate a management plan. Currently, the clinic offers the best opportunity for the student to complete these processes.

Do individual attendings' post-rotation performance ratings detect residents' clinical performance deficiencies?

PURPOSE: To determine whether attending physicians' post-rotation performance ratings and written comments detect surgery residents' clinical performance deficits. METHOD: Residents' performance records from 1997-2002 in the Department of Surgery, Southern Illinois University School of Medicine, were reviewed to determine the percentage of times end-of-rotation performance ratings and/or comments detected deficiencies leading to negative end-of-year progress decisions. RESULTS: Thirteen of 1,986 individual post-rotation ratings (0.7%) nominally noted a deficit. Post-rotation ratings of "good" or below were predictive of negative end-of-year progress decisions. Eighteen percent of residents determined to have some deficiency requiring remediation received no post-rotation performance ratings indicating that deficiency. Written comments on post-rotation evaluation forms detected deficits more accurately than did numeric ratings. Physicians detected technical skills performance deficits more frequently than applied knowledge and professional behavior deficits. More physicians' post-rotation numeric ratings contradicted performance deficits than supported them. More written comments supported deficits than contradicted them in the technical skills area. In the applied knowledge and professional behavior areas, more written comments contradicted deficits than supported them. CONCLUSIONS: A large percentage of performance deficiencies only became apparent when the attending physicians discussed performance at the annual evaluation meetings. Annual evaluation meetings may (1) make patterns of residents' behavior apparent that were not previously apparent to individual physicians, (2) provide evidence that strengthens the individual attending's preexisting convictions about residents' performance deficiencies, or (3) lead to erroneous conclusions. The authors believe deficiencies were real and that their findings can be explained by a combination of reasons one and two.

Who are the surgery clerkship directors and what are their educational needs?

BACKGROUND: The surgery clerkship director is a key individual in the surgery department's educational mission and yet there has been no prior effort to describe this group or identify their learning needs. The purpose of this study was to develop a demographic profile and an educational needs assessment for surgery clerkship directors. METHODS: A survey instrument was designed based on existing literature and distributed to surgery clerkship directors in the United States and Canada. RESULTS: Surveys were returned from 108 subjects (77%). The majority of clerkship directors strongly agree that directing is a positive experience but express concern that the job demands may impede their professional careers. The perceived educational needs identified related primarily to the development and management of the student education curriculum. CONCLUSIONS: Surgery clerkship directors are experienced academic surgeons who report high levels of satisfaction. They identify a number of important educational needs of the position and express concern about the requirements of the position on their academic careers.

A senior elective designed to prepare medical students for surgical residency.

BACKGROUND: The transition from medical student to surgery internship can be stressful. The goal of this project was to design, implement, and evaluate a 1-month long elective course that would meet the majority of the American College of Surgeons Graduate Medical Education Committee prerequisites for graduate surgical education METHODS: The major elements of the curriculum included faculty- and resident-facilitated case-based sessions and cadaver dissections. In addition, the students participated in skills laboratory experiences, Intensive Care Unit rounds, and mock interviews and clinical pages. The students took a knowledge pretest and post-test that was compared with the performance of 8 surgical interns on the same examination. RESULTS: The highest rated elements of the course were those that provided hands-on experience or practical knowledge. The post-test knowledge examination scores were significantly higher than pretest scores and surgical intern scores. CONCLUSIONS: It was possible to develop a 1-month senior medical student elective course that provided students with the essential prerequisites believed to be essential for all surgical interns.

Variables influencing medical student learning in the operating room.

BACKGROUND: The operating room (OR) is an important venue where surgeons do much of medical student teaching and yet there has been little work evaluating variables that influence learning in this unique environment. We designed this study to identify variables that affected medical student learning in the OR. METHODS: We developed a questionnaire based on surgery faculty observations of learning in the OR. The medical students completed the questionnaire on 114 learning episodes in the OR. Pearson correlation coefficient was used to establish the strength of association between various variables and the student's overall perception of learning. RESULTS: The students evaluated 27 variables that might impact their learning in the OR. Strong correlations were identified between the attending physician's attitude, interactions and teaching ability in the OR and the environment being conducive to learning. CONCLUSIONS: Surgical faculty behavior is a powerful determinant of student perceptions of what provides for a favorable learning environment in the OR.

How prepared are your interns to take calls? Results of a multi-institutional study of simulated pages to prepare medical students for surgery internship.

BACKGROUND: This study evaluated a simulated pages curriculum that was developed to assess communication and clinical decision making in medical students and interns. METHODS: A curriculum consisting of 14 simulated pages was administered across 5 institutions to 150 senior medical students. A 3-case subset was administered to interns who did not participate in the curriculum. Six expert surgeons identified critical fails and set passing scores for case-specific assessments using the Graphical Hofstee Method. RESULTS: Participants in the curriculum demonstrated superior clinical decision making compared with non-participants across all cases scenarios (P < .01). Average medical student scores for clinical decision making were 46.9%. Global ratings averaged 6.0 for communication and 5.2 for patient care. Passing rates averaged 46%. CONCLUSIONS: Participation in a mock page curriculum improved performance. The performance of participants based on expert standards set for simulated page performance highlight the need for innovative approaches to improve interns' preparedness to take calls.

The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings.

BACKGROUND: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care. METHODS: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations. RESULTS: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention. CONCLUSIONS: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.

The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study.

INTRODUCTION: Colonoscopic simulators offer the opportunity for skill acquisition in the preclinical setting. Currently available simulators vary widely with respect to level of fidelity and technological sophistication. Despite the belief that more realistic is better, there is a paucity of evidence regarding the relative effectiveness of simulator fidelity (high vs low) on the acquisition of basic colonoscopic skills. We hypothesized that novice learners can acquire basic colonoscopic skills using simulators, however fidelity of the simulator does not make a difference. METHODS: We randomly assigned novice third-year and fourth-year medical students to practice on either a low-fidelity or high-fidelity colonoscopy model. The low-fidelity model used is described in the module 16 of the American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for residents, Phase 1: basic or core skills and tasks < http://elearning.facs.org/mod/resource/view.php?1d=450 >. The high-fidelity model was the AccuTouch colonoscopy simulator, Immersion Medical (AccuTouch CS) that has 6 different simulated scenarios for diagnostic colonoscopy (level 1-6). Both groups had 16 students and were given standard instruction by an expert with respect to the procedure and instrument handling on both models. Both groups were pretested and posttested on level 1 of the AccuTouch CS. The high-fidelity group practiced on level 2 and 4 of the AccuTouch CS, whereas the low-fidelity group practiced on the low-fidelity model for 2 sessions of 1 hour each. The computer-based evaluation parameters available on the AccuTouch CS were used to compare performances. RESULTS: Both groups had similar demographics. There were no significant differences in the baseline performances of either group. Each group demonstrated significant improvement for insertion time and percentage of mucosa visualized. However, there were no significant differences between the groups on posttesting on any of the measured parameters. CONCLUSIONS: Colonoscopic skill training on a low-fidelity model appears to be as effective as high-fidelity model training for basic endoscopic skill acquisition for novice learners.

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.

Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.

OBJECTIVE: To develop an evidence-based approach to the identification, prevention, and management of surgical residents with behavioral problems. DESIGN: The American College of Surgeons and Southern Illinois University Department of Surgery hosted a 1-day think tank to develop strategies for early identification of problem residents and appropriate interventions. Participants read a selection of relevant literature before the meeting and reviewed case reports. SETTING: American College of Surgeons headquarters, Chicago, Illinois. PARTICIPANTS: Medical and nursing leaders in the field of resident education; individuals with expertise in dealing with academic law, mental health issues, learning deficiencies, and disruptive physicians; and surgical residents. MAIN OUTCOME MEASURES: Evidence-based strategies for the identification, prevention, and management of problem residents. RESULTS: Recommendations based on the literature and expert opinions have been made for the identification, remediation, and reassessment of problem residents. CONCLUSIONS: It is essential to set clear expectations for professional behavior with faculty and residents. A notice of deficiency should define the expected acceptable behavior, timeline for improvement, and consequences for noncompliance. Faculty should note and address systems problems that unintentionally reinforce and thus enable unprofessional behavior. Complaints, particularly by new residents, should be investigated and addressed promptly through a process that is transparent, fair, and reasonable. The importance of early intervention is emphasized.

Use of simulated pages to prepare medical students for internship and improve patient safety.

PURPOSE: During the transition from medical school to internship, trainees experience high levels of stress related to pages on the inpatient wards. The steep learning curve during this period may also affect patient safety. The authors piloted the use of simulated pages to improve medical student preparedness, decrease stress related to pages, and familiarize medical students with common patient problems. METHOD: A multidisciplinary team at Southern Illinois University School of Medicine developed simulated pages that were tested among senior medical students. Sixteen medical students were presented with 11 common patient scenarios. Data on assessment, management, and global performance were collected. Mean confidence levels were evaluated pre- and postintervention. Students were also surveyed on how the simulated pages program influenced their perceived comfort in managing patient care needs and the usefulness of the exercise in preparing them to handle inpatient pages. RESULTS: Mean scores on the assessment and management portions of the scenarios varied widely depending on the scenario (range -15.6 ± 41.6 to 95.7 ± 9.5). Pass rates based on global performance ranged from 12% to 93%. Interrater agreement was high (mean kappa = 0.88). Students' confidence ratings on a six-point scale increased from 1.87 preintervention to 3.53 postintervention (P < .0001). CONCLUSIONS: Simulated pages engage medical students and may foster medical student preparedness for internship. Students valued the opportunity to simulate "on call" responsibilities, and exposure to simulated pages significantly increased their confidence levels. Further studies are needed to determine effects on patient safety outcomes.

Robot-assisted laparoscopic skills development: formal versus informal training.

INTRODUCTION: The learning curve for robotic surgery is not completely defined, and ideal training components have not yet been identified. We attempted to determine whether skill development would be accelerated with formal, organized instruction in robotic surgical techniques versus informal practice alone. MATERIALS AND METHODS: Forty-three medical students naive to robotic surgery were randomized into two groups and tested on three tasks using the robotic platform. Between the testing sessions, the students were given equally timed practice sessions. The formal training group participated in an organized, formal training session with instruction from an attending robotic surgeon, whereas the informal training group participated in an equally timed unstructured practice session with the robot. The results were compared based on technical score and time to completion of each task. RESULTS: There was no difference between groups in prepractice testing for any task. In postpractice testing, there was no difference between groups for the ring transfer tasks. However, for the suture placement and knot-tying task, the technical score of the formal training group was significantly better than that of the informal training group (p < 0.001), yet time to completion was not different. CONCLUSION: Although formal training may not be necessary for basic skills, formal instruction for more advanced skills, such as suture placement and knot tying, is important in developing skills needed for effective robotic surgery. These findings may be important in formulating potential skills labs or training courses for robotic surgery.

The nature of general surgery resident performance problems.

BACKGROUND: Residents with performance problems are challenging to program directors and complicate the work of other residents and health care providers. Having an effective, targeted remediation process to address these problems is dependent on being able to diagnose their nature. The purpose of this study was to identify residents who had serious, substantive, and recurring academic, clinical, and/or professional behavior problems, and to describe and classify their nature. METHODS: Raters performed a retrospective record review of general surgery categorical residents in one program over 30 years. Residents with substantial problems were reviewed, described, and classified independently by 3 raters. RESULTS: Seventeen residents had serious enough performance problems to be included. Four had only 1 class of problem (3 were professional behavior problems). Eight residents had 2 problems each (5 academic and clinical performance problems; 3 clinical performance and professional behavior problems). Five residents had 3 problems. The number of performance problem facets per case varied from 11 to 2 with an average of 5.9 facets. Relations with health care workers was identified most frequently, followed closely by insufficient knowledge. Poor communication was third. Performance problems of 14 residents (82%) were identified in their first year. For 15 cases, the resident had unresolved performance problems at the end of the program. CONCLUSION: There are 2 possible explanations for our findings: (1) resident problems similar to these are refractory to remediation; (2) treatments used historically are not well designed for the problems. Choosing among the 2 explanations will require developing remediation strategies targeted to specific patterns of performance problems.

An investigation of medical student reactions to feedback: a randomised controlled trial.

BACKGROUND: Medical educators have indicated that feedback is one of the main catalysts required for performance improvement. However, medical students appear to be persistently dissatisfied with the feedback that they receive. The purpose of this study was to evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments. METHODS: All subjects received identical instruction on two-handed surgical knot-tying. Group 1 received specific, constructive feedback on how to improve their knot-tying skill. Group 2 received only general compliments. Performance was videotaped before and after instruction and after feedback. Subjects completed the study by indicating their global level of satisfaction. Three faculty evaluators observed and scored blinded videotapes of each performance. Intra-observer agreement among expert ratings of performance was calculated using 2-way random effects intraclass correlation (ICC) methods. Satisfaction scores and performance scores were compared using paired samples t-tests and independent samples t-tests. RESULTS: Performance data from 33 subjects were analysed. Inter-rater reliability exceeded 0.8 for ratings of pre-test, pre-intervention and post-intervention performances. The average performance of students who received specific feedback improved (21.98 versus 15.87, P<0.001), whereas there was no significant change in the performance score in the group who received only compliments (17.00 versus 15.39, P=0.181) The average satisfaction rating in the group that received compliments was significantly higher than the group that received feedback (6.00 versus 5.00, P=0.005). DISCUSSION: Student satisfaction is not an accurate measure of the quality of feedback. It appears that satisfaction ratings respond to praise more than feedback, while learning is more a function of feedback.

The effects of group dynamics on resident progress committee deliberations.

BACKGROUND: Prior investigations suggest that resident progress decisions by committee provide a broader perspective on performance and result in less grade inflation. There is countervailing concern that group dynamics may compromise quality of progress decisions. PURPOSE: To determine whether and how group dynamics compromise decision making about resident progress. METHODS: Researchers recorded and analyzed participant comments during a resident progress committee meeting. End-of-rotation (EOR) evaluations were analyzed and compared to progress committee meeting results. RESULTS: EOR and progress committee comments were similar in content. The ratio of specific to general comments was higher for EOR evaluations (5:1) than for progress committee meetings (2:1). EOR evaluation comments provided more supporting evidence for assertions. Individual progress committee participants did not dominate discussion or sway decision making. Participant progress committee meeting comments were consistent with their EOR comments failing to support the presence of progress committee meeting "feeding frenzies." CONCLUSIONS: Results suggest that progress committee meeting group dynamics do not seriously compromise the validity of resident progress decisions.