Effect of Multidisciplinary Cancer Conference on Treatment Plan for Patients With Primary Rectal Cancer.

BACKGROUND: Although multidisciplinary cancer conferences have been reported to lead to improved patient outcomes, few studies have reported results of these for rectal cancer. OBJECTIVE: The purpose of this work was to assess the quality of multidisciplinary cancer conferences, the effect of the conference on the initial treatment plan, compliance with the conference treatment recommendations, and clinical outcomes for rectal cancer. DESIGN: This was a prospective, longitudinal study. SETTINGS: The study was conducted at a tertiary care academic hospital. PATIENTS: Patients with primary rectal cancer were included in this study. INTERVENTION: The intervention was a rectal cancer-specific multidisciplinary cancer conference. MAIN OUTCOME MEASURES: The quality of the multidisciplinary cancer conference was assessed using the Cancer Care Ontario Multidisciplinary Cancer Conference standards score. A change in treatment plan was defined as a change from the initial treatment plan selected by the treating physician to an alternate treatment plan recommended at the conference. RESULTS: Twenty-five multidisciplinary cancer conferences were conducted over a 10-month study period. The Cancer Care Ontario Multidisciplinary Cancer Conference standards score was 7 (from a maximum score of 9). Forty-two patients with primary rectal cancer were presented, and there was a 29% (12/42) change in the initial treatment plan. A total of 42% (5/12) of these changes were attributed to reinterpretation of the MRI findings. There was 100% compliance with the conference treatment recommendations. The circumferential resection margin was positive in 5.5% (2/36). LIMITATIONS: Selection bias may have led to an overestimate of effect, and there is no control group for comparison of clinical outcomes. CONCLUSIONS: A high-quality rectal cancer-specific multidisciplinary cancer conference led to a 29% change in the treatment plan for patients with primary rectal cancer, with almost half of these changes attributed to reinterpretation of the magnetic resonance images.

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

PURPOSE: Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients. METHODS: Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups. RESULTS: Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002). CONCLUSIONS: The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Reconceptualizing Ethics Through Morbidity and Mortality Rounds.

BACKGROUND: Surgeons face ethical tensions daily, yet ethics education continues to prove challenging. Two possible reasons for these challenges may be the different conceptions of knowledge between technical training vs those that underpin ethical practice, and the potential devaluing of ethics as a focus for education given false assumptions about its inherent nature. This study implemented and evaluated an innovation meant to prioritize and contextualize ethics in surgical learning and practice. STUDY DESIGN: After implementation of Ethics Morbidity and Mortality (M&M) rounds as an educational intervention, a qualitative evaluation consisted of interviews with 12 residents and 9 faculty. Analysis was informed by principles of constructivist grounded theory and the theoretical framework of Habermas' 3 types of knowledge: technical, practical, and emancipatory. For comparative purposes, analysis was conducted of how participants described ethics and ethics education and learning in relation to the traditional ethics teaching model vs the M&Ms. RESULTS: In the traditional model, ethics teaching was seen as disconnected from real life, and not valuable. Within M&Ms, ethics was viewed as integral to practice, engaging, valuable, and relevant. In the traditional model, ethics principles were seen as acquired through role modeling and as a fixed part of character. Within M&Ms, ethics principles were seen as learnable and transformable parts of identity. CONCLUSIONS: Traditional teaching of surgical ethics may result in physicians armed with knowledge, but unable to apply it. Our findings suggest that incorporating ethics into M&Ms allows not only learning the tools of ethics, but the knowledge that ethical principles were becoming integrated into professional identity.

Quiet eye training improves surgical knot tying more than traditional technical training: a randomized controlled study.

BACKGROUND: We examined the effectiveness of technical training (TT) and quiet eye training (QE) on the performance of one-handed square knot tying in surgical residents. METHODS: Twenty surgical residents were randomly assigned to the 2 groups and completed pretest, training, retention, and transfer tests. Participants wore a mobile eye tracker that simultaneously recorded their gaze and hand movements. Dependent variables were knot tying performance (%), QE duration (%), number of fixations, total movement time (s), and hand movement phase time (s). RESULTS: The QE training group had significantly higher performance scores, a longer QE duration, fewer fixations, faster total knot tying times, and faster movement phase times compared with the TT group. The QE group maintained performance in the transfer test, whereas the TT group significantly decreased performance from retention to transfer. CONCLUSIONS: QE training significantly improved learning, retention, and transfer of surgical knot tying compared with a traditional technical approach. Both performance effectiveness (performance outcome) and movement efficiency (hand movement times) were improved using QE modeling, instruction, and feedback.

Performing under pressure: quiet eye training improves surgical knot-tying performance.

BACKGROUND: We examined the effectiveness of traditional technical training (TT) and quiet eye training (QET) on the performance of 1-handed square knot tying among first-year surgery residents under normal and high-anxiety conditions. METHODS: Twenty surgery residents were assigned randomly to 1 of 2 groups and completed pretest, training, and simple and complex retention tests under conditions of high and low anxiety. The TT group received traditional instruction on improving hand movements; the QET group received feedback on their gaze behaviors. Participants wore an eye tracker that recorded simultaneously their gaze and hand movements. Dependent variables were knot tying performance (%), quiet eye duration (%), number of fixations, and total movement time (s). RESULTS: Both groups improved their knot tying performance (P < .05) from pretest to the low anxiety conditions (mean difference: QET, 28%; TT, 17%); however, only the QET group maintained their knot tying performance under the high-anxiety conditions (mean difference: QET, 18%; P < .05), with the TT group decreasing their performance close to pretest levels (P > .05). The QET group also demonstrated more efficient gaze and hand movements post training. CONCLUSION: These data demonstrate the effectiveness of training gaze behaviors, not only to improve the effectiveness and efficiency of performance, but also to mediate negative effects of anxiety on performance. These findings may have important implications for medical educators and practitioners, as well as surgeons who may be (re)training or learning new procedures.

Expert surgeon's quiet eye and slowing down: expertise differences in performance and quiet eye duration during identification and dissection of the recurrent laryngeal nerve.

BACKGROUND: Long quiet eye (QE) duration is central to expertise in sports, while cognitive "slowing down" has been identified as a perceptual skill possessed by skilled surgeons. Eye-tracking evidence is lacking about the relationship of QE duration to slowing down in surgeons. The aim of this study was to examine QE duration, hand movement time (MT), fixation location, and fixation duration in highly experienced (HE) and less experienced (LE) surgeons. METHODS: A mobile eye tracker and camera recorded coupled gaze and hand movements. Performance was quantified by blinded review. RESULTS: HE surgeons were rated higher than LE surgeons but did not differ in operating time or MT. HE and LE surgeons differed in fixation duration on the ligament of Berry during phases 1 and 2 and QE duration on the recurrent laryngeal nerve in phase 2. CONCLUSIONS: Long-duration fixation on the ligament of Berry and long-duration QE on the recurrent laryngeal nerve combined with no significant differences in MT provide empirical evidence that HE surgeons cognitively slow down more than LE surgeons during critical phases of the operation.