Accuracy of aspiration cytology in detecting breast cancer.

To evaluate the role of needle placement in determining accuracy and to establish criteria for clinical decision making, we used aspiration cytology to diagnose 49 palpable breast masses in patients undergoing excisional biopsy. Closed cytology, obtained by percutaneous aspiration, and open cytology, obtained by aspiration of the excised mass, were compared with histology. Nineteen (39%) of the breast masses were carcinoma. Unsatisfactory cytologic findings were frequent after both closed (37%) and open (24%) aspiration. Most of these aspirates were from mammary dysplasia, suggesting that acellularity rather than needle placement was responsible. Closed aspiration was falsely negative in one patient and falsely suggestive of cancer in five. If atypical, suspicious or malignant cytologic findings were considered to be carcinoma; closed cytology had high sensitivity (94%), low specificity (64%), and a false positive fraction of 36%. The positive predictive value was 76% and the negative predictive value 90%. Accuracy was 81%. If only suspicious or malignant results were considered positive, specificity and positive predictive value increased at the expense of sensitivity and negative predictive value but accuracy did not change. Even with optimal needle placement (open aspiration), accuracy of aspiration cytology was less than 90%.

Description and evaluation of the Surgeons as Educators course.

BACKGROUND: Since 1993, the American College of Surgeons has sponsored an annual 6-day course entitled the Surgeons as Educators. The course was designed to provide academic surgeons with the knowledge and skills necessary to enhance the surgical education curriculum, teaching strategies, educational program administration, and performance evaluation. This article describes the development, implementation, and effect of the course on the classes graduating in 1993 and 1994. STUDY DESIGN: The effect of the course was studied by using a longitudinal survey approach. A survey was mailed to participants 3 to 6 months after they completed the course. Graduates were asked to describe any education-related actions taken attributable to attending the Surgeons as Educators course. The quality of course content and presentations were evaluated by using end-of-course evaluation forms and daily feedback forms and by an external reviewer. RESULTS: Within 6 months of returning from the course, more than one half of the graduates initiated actions related to curriculum development, teaching strategies, or educational administration. One third or more of the graduates modified their performance and program evaluation systems. Using a five-point scale, ratings of the course content ranged from 3.78 to 4.64 for "value of topic" and from 3.77 to 4.76 for "quality of presentation." Items evaluated by the graduates on the end-of-course evaluation forms ranged from 7.8 to 8.7 on a nine-point scale. CONCLUSIONS: The Surgeons as Educators course offered an opportunity for participants to interact among themselves and with course faculty about educational issues and to practice teaching skills. The course was highly rated for educational quality and value. The retreat environment and the length of the program helped attendees become immersed during this "protected time" to analyze strengths and weaknesses of their programs and devise achievable plans to improve their abilities as educators and the effectiveness of their programs.

A prospective randomized trial of a residents-as-teachers training program.

PURPOSE: To develop, implement, and evaluate a course for improving the teaching skills of surgery residents. METHOD: Responses from residents at four general surgery training programs to a needs assessment survey were used to develop a two-day course for improving teaching skills. Residents at two surgical training programs were randomly assigned to experimental and control groups, and experimental residents participated in and evaluated the newly devised course. Six to seven months later, experimental and control residents' teaching performances were evaluated using a five-station objective structured teaching evaluation (OSTE). Differences between the residents' performances were calculated using Mann-Whitney U, chi-square analysis, or Fisher's exact test. RESULTS: Participating residents rated the course highly. They considered the interactive nature of the course its greatest strength. As measured by the OSTE, the performances of the residents differed least significantly in the feedback station, where the residents in the experimental groups showed significant improvement on only one of seven items at one institution, and only one of nine items at the other. The greatest differences occurred in the microskills teaching station, where the residents at one institution performed significantly better than did their control counterparts on four of five items and in overall performance. CONCLUSION: This study demonstrates the value of a needs assessment in developing a course to improve residents' teaching skills. Such courses must provide active learning with opportunities for practicing skills and, following the course, ongoing feedback to maintain changes in teaching behaviors. The curriculum developed in this study has been put into a transportable form that includes an instructor's manual providing guidelines and suggestions for implementation.

Ambulatory teaching "lite": less clinic time, more educationally fulfilling.

Typically, the primary instructional method for ambulatory care education is direct interaction between a preceptor and a learner during a patient encounter. This paper describes instructional strategies teachers and learners can use in ambulatory care training that can occur before or after scheduled clinic hours, thus providing instruction without disrupting a preceptor's busy clinic. First, they describe how preceptors and clerkship or residency-program directors can orient learners prior to their arrival at assigned sites, so that learners are better prepared to assume their patient-care responsibilities. Then they discuss strategies for making use of various types of conferences and independent learning activities to enhance learners' clinical experiences. Conferences and independent study projects that occur before clinic hours can help learners bring a higher level of thinking and clinical sophistication to their role in the ambulatory care site; conferences and independent study activities that occur after clinic hours give learners an opportunity to reinforce and expand on what they have learned during clinic. In this way, learners' educational experiences are enhanced, the best use is made of preceptors' time and expertise, and clinic efficiency is not disrupted.

The art of mentoring.

While the golden era of mentoring may have been the age of apprentice ships in medicine, the birth of the clinical clerkship in the late 1800s provided the structure for the relationship between faculty and medical student. The last few decades, however, have seen a dramatic change in the availability of faculty to mentor students in clinical teaching settings despite a 600% increase in the number of clinical full-time medical school faculty. This work explores some of the reasons for this deterioration in mentoring and looks at the role of the mentor in professional development, specifically in the area of medical education. Recommendations for implementing structured mentoring programs within a department of surgery are provided. The article concludes with discussion of individual characteristics of the effective mentor in surgical education.

Outcome effect of adherence to operative principles of Nissen fundoplication by multiple surgeons. The Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group.

Fifty-eight patients participated in a multi-institutional study designed to assess the outcome of Nissen fundoplication when performed for complicated disease by a variety of surgeons with varied skill and experience with compliance to established technical principles. All patients had an abnormal 24-hour pH study and mucosal injury on endoscopy. The surgical procedures were performed in 8 Veterans Administration hospitals by surgical residents supervised by surgical faculty, after initial agreement on 10 operative principles for the Nissen fundoplication. The mean symptomatic scores at 52 and 104 weeks improved significantly compared with the preoperative score (p < 0.0001). There was significant improvement in total percent time at pH below 4 at 52 weeks (p < 0.01) and 104 weeks (p < 0.01). There was significant improvement in the grade of esophagitis at 1 year (p < 0.0001). Compliance was greater than 90% for 7 of 10 principles of repair. In conclusion, a Nissen fundoplication resulted in relief of symptoms in 93% of patients and a 77% rate of healing of esophagitis. These results in complicated reflux disease were achieved by a variety of surgeons with varied experience in antireflux surgery.

Factors contributing to success in surgical education research.

BACKGROUND: Surgeons who have demonstrated excellence through extensive publication in the medical education literature can provide valuable guidance for new surgeons interested in educational research. METHODS: National databases identified members of the Association for Surgical Education (ASE) who have accumulated the greatest number of peer-reviewed, original educational research publications. The top 15 surgeons completed an open-ended survey exploring surgical education research issues. RESULTS: The top three factors contributing to success in this field were (1) chair support, (2) collaboration with peers and mentors, and (3) participation in the ASE. The top three barriers were (1) perception at their institution of educational research as lacking credibility, (2) lack of adequate funding, and (3) lack of time. Eighty-five percent (11 of 13) reported having tenure or equivalent, of which 45% reported educational research as playing a significant role. All respondents advised formal training in education. CONCLUSIONS: Credibility of educational research is bolstered by quality research and a supportive chair. Scholarly work in this field can form the basis for an academic career.

A pilot experience with competency-based clinical skills assessment in a surgical clerkship.

This investigation examines a competency-based clinical skills assessment program for surgical clerks using checklists and rating forms for precise measurement of physical exam (PE) skills, physician-patient interaction (PPI) skills, and patient write-up (PW) skills. Analysis of variance demonstrated improvement in PW skills across the academic year when measured by the rating instrument, but this improvement was not detected on traditional subjective rating forms (SRF). PPI skills improved between first rotations across 2 academic years with the addition of orientation to expectations (mean, 79% versus 92%, P = 0.000). Poor correlation was noted between the National Board of Medical Examiners Surgery Subtest scores and PE skills (r = .19), PW skills (r = .20), and PPI skills (r = .15). While the overall ratings given by faculty on SRF correlated with the SRF ratings of PE skills (r = .77) and PPI skills (r = .58), these same faculty ratings correlated poorly with these skills as assessed by checklist (r = .16 and r = .14, respectively). This pilot experience demonstrates that PE skills, PW skills, and PPI skills (1) improve only with orientation to expectations and feedback, (2) correlate poorly with fund of knowledge assessment, and (3) are best assessed with precise measurement (eg, checklist, direct observation), which avoids the halo effect of overall evaluation that occurs with subjective rating forms.

A ten-year analysis of surgical education research.

BACKGROUND: Surgical education peer-reviewed publications have markedly increased over the last decade. The purpose of this study was to review the surgical education literature published over the last 10 years and address the following questions: What subjects in surgical education tend to be studied? What are the most to least commonly employed research designs and statistics? Has there been a change in how research data are collected? Where are these studies published? METHODS: A literature search encompassing surgical education papers published between January 1988 and August 1998 was performed. Four investigators coded qualifying abstracts on journal type, subject of research, data collection methods, research design, and statistics. Each investigator was asked to code 10 articles at the start of the study to assess interrater reliability. RESULTS: A total of 420 abstracts were evaluated. Interrater reliability yielded percent agreements ranging from 82% to 96%. Curriculum and teaching were the most frequent topics studied (40%), followed by assessment (23%) and program evaluation (18%). Most research designs used were descriptive (41%). Experimental design has progressively increased from 2% in 1988-89 to 16% in 1998. A total of 551 statistical methods were accounted for in the 420 abstracts. The most common statistical analyses used were descriptive statistics (32%). The predominant mode of data collection was through testing or direct observations (34%). Survey instruments followed closely as a popular data collection method at 27%. The majority of papers were published in peer-reviewed surgical journals (64%),followed by medical education journals (22%) and "other" journals (14%). CONCLUSIONS: An analysis of the surgical education literature demonstrates the growing emphasis on the use of educational research to explore relevant issues and problems. Descriptive research is most popular, with an increasing trend in experimental research. Publication of educational research in peer-reviewed surgical journals is becoming more popular. This study informs those interested in the surgical education research literature of current trends, and what they need to know for a more critical appraisal of this body of literature.

Peer and self assessment during problem-based tutorials.

BACKGROUND: Peer and self assessment may contribute a unique and insightful perspective to a students' performance. This study investigates the association between self, peer, and faculty evaluations in the intimate setting of a problem-based tutorial group. METHODS: Third-year medical students participating in the required third-year surgical clerkship during the 1996-97 academic year (n = 154) were randomly assigned to problem-based learning groups and completed self and peer evaluations at the end of the last tutorial. These evaluations were compared with expert tutor ratings using Pearson correlation coefficients. RESULTS: A moderate correlation was found between peer and tutor ratings. There was very little correlation between self and tutor ratings. CONCLUSIONS: The results of this study suggest that peer and self ratings in the setting of a tutorial group may provide additional valuable information regarding medical student performance during a surgery clerkship.

Description and results of a needs assessment in preparation for the "Surgeons as educators" course.

BACKGROUND: In August 1993 the American College of Surgeons sponsored a course entitled "Surgeons as Educators" (SAE) aimed at equipping academic surgeons with the knowledge and skills necessary to enhance surgical education administration, curriculum, teaching, and evaluation. METHODS: The instructional design model used to construct the course called for a formal needs assessment to determine the importance, current skill level, and priority of what needed to be learned to be an effective educator. The needs assessment was accomplished using a job analysis and questionnaire approach. The 68-item questionnaire was mailed to 320 academic surgeons representing eight medical schools. RESULTS: A 62% response rate was achieved. Results indicated the education-related tasks or activities that faculty felt were important to their careers, as well as their perceived level of development in each area. Descriptive statistics were used to summarize the responses that were critical to the SAE faculty in helping prioritize, sequence, and time ration course content. Collective results became the foundation for developing the SAE curriculum by the course's five faculty members. CONCLUSIONS: A well-done needs assessment does not necessarily guarantee course success; however, it is the first and critical step to planning an educationally sound faculty development course or program designed for adult learners.

Educational practice guidelines for a surgical clerkship.

Similar to the Residents Review Committee's "Essentials for a Residency Training Program," this article provides Educational Practice Guidelines for a required surgical clerkship. The Guidelines presented are ones that can be adopted by any department of surgery in the United States, but in some cases not without significant increase in resources and faculty effort. The 10 essential components provide an opportunity for intensive program evaluation of all medical student clerkship experiences.

Changing surgical education strategies in an environment of changing health care delivery systems.

Emerging changes in health care delivery will have a significant impact on the structure of surgical education in academic departments of surgery. Based on some assumptions as to the probable nature of the final product of this reform, this article encourages a proactive stance by surgical educators to anticipate changes and move toward restructuring in areas of curricular content, the teaching process, performance evaluation strategies, and faculty infrastructure of the academic department. Curriculum changes must bridge the gap between public health and medicine and continue the aggressive trend toward teaching in the outpatient setting. Surgical educators must adapt to evolving computer and instructional technology that will make multimedia presentations, distance education, teleconferencing, hypermedia, and virtual reality commonplace in the teaching setting. Increased emphasis on accountability and accreditation will require stringent criteria in performance and program evaluation methodology. The academic infrastructure will need to adapt to the changing goal of training more general surgeons and fewer specialists and yet maintain the fundamental responsibility of an academic surgeon for mentoring the medical student and surgical resident.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral.

OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.