Transfer of training in acquiring laparoscopic skills.

BACKGROUND: Building on skills already learned in acquiring more complex or related skills is termed transfer of training (TOT). This study examined the TOT effects of previous open and laparoscopic surgical experience on a laparoscopic training module. STUDY DESIGN: Intracorporeal knot tying was chosen for evaluating TOT among three groups of surgical residents: interns (n = 11) with limited open and laparoscopic surgical experience, junior residents (n = 9) with recent and ongoing open and laparoscopic surgical experience, and senior residents (n = 8) with remote and limited laparoscopic experience but ongoing open surgical experience. After receiving a lecture, demonstration, and written instructions on three knot-tying techniques, residents rotated through three performance stations, one for each technique, over 2 days. After 15 minutes of practice, the residents were videotaped completing a test knot. Time to completion and economy of motion were recorded and analyzed. RESULTS: Junior residents had fewer performance errors than senior residents (reported as mean +/- standard error of the mean) and were significantly faster than interns. No significant differences between interns and senior residents for mean time or error performance were observed. Senior residents did not demonstrate TOT from open surgical experience to laparoscopic knot tying. No significant differences were obtained across the three sessions for errors or for time. CONCLUSION: No evidence was found for TOT from open surgical experience to newly introduced laparoscopic knot-tying techniques or from one skill training session to a different skill session at least 4 hours later. This study indicates that specific minimally invasive surgery training is needed to develop laparoscopic surgery skills.

A pilot study of new approaches to teaching anatomy and pathology.

PURPOSE: Minimally Invasive Surgery (MIS) has impacted patient care as well as medical training. New medical education opportunities have emerged with MIS. In this pilot study we explore the role of live, interactive MIS to augment and strengthen specific segments of the undergraduate medical curriculum. METHODS: Laparoscopic cholecystectomy (LC) was selected to demonstrate upper abdominal anatomy and pathology. Second year medical students (n=100) in the course of their GI pathology classes attended live LC telesurgery-the telesurgery student group (TSG). Because of technical difficulties, a second class of medical students (n=90) was shown the tape of the MIS procedure one year later instead of the live surgery-the videotape surgery group (VSG). Background clinical information was provided by the program director and the durgeon. During the live and taped LC broadcast living anatomy was demonstrated and a diseased gallbladder was resected. TSG students were able to ask questions of the program director and the surgeon and vice versa using telesurgery technology. After the procedure, the surgeon met with the students for further discussion. VSG students were able to ask questions of the program director during and after the program. Both groups of students completed a pre- and posttest using remote audience responders. Students' responses from the two groups were compared for selected test and evaluation items. RESULTS: Pre-test (Cronbach's alpha=.10) and post-test (Cronbach's alpha =.28) data were obtained from 73 students in the TSG and.22 and.54 respectively from 69 students in the VSG. A significant increase in laparoscopic anatomy knowledge was observed from pretest to posttest for the VSG (31-55%) and from the TSG (30-61%). The majority of VSG students (68%) indicated the method used to teach was outstanding, and 87% indicated that the program was outstanding in keeping their interest. This is contrasted with only 24% of the TSG group responding that the teaching method was outstanding, and 41% indicated that the program was outstanding in keeping their interest. CONCLUSIONS: Medical students can productively be exposed to surgical methods and living anatomy using telesurgery. The high regard the TSG students had for this program suggests that it can be used effectively to teach and inspire medical students. The positive results have encouraged us to have a backup instructional method such as a tape of the MIS procedure, it apparently does not have the positive impact of live surgery.

Concepts in service marketing for healthcare professionals.

Patients are becoming increasingly involved in making healthcare choices as their burden of healthcare costs continues to escalate. At the same time, healthcare has entered a tightened market economy. For these reasons, the marketing of healthcare services has become essential for the financial survival of physicians and healthcare organizations. Physicians can successfully use the fundamental service marketing principles proven by other service industries to win patient satisfaction and loyalty and remain competitive in today's market economy. Understanding concepts such as service quality zone of tolerance, levels of consumer satisfaction, the branding of services, patient participation, and service recovery can be useful in achieving these goals.

Measuring outcomes in surgical patients.

The current emphasis on quality of healthcare, cost effectiveness, and consumer satisfaction demands a better understanding of the relationship between the process of care and the outcomes of care. As patients become more active in defining healthcare quality, outcome measures are becoming increasingly patient focused. To meet these new demands for understanding the process-outcomes relationship, there exists a tremendous need for physician involvement in developing outcomes assessment programs. Such programs are best designed through the cooperative efforts of clinicians and outcomes statisticians. Advances in outcomes assessment will require a combination of increased precision in measurement, greater analysis of outliers, and the development of computerized repositories of clinical and health status data.

Physician leadership: essential skills in a changing environment.

Precisely because they are at the center of clinical service delivery, physicians, especially surgeons, are the ideal leaders for health care in the 21st century. Although most physicians possess the traits essential for leadership, the vast majority lacks the technical skills necessary for major leadership/management roles that will both change and empower the local healthcare service delivery environment. Such skills include strategic and tactical planning, persuasive communication, negotiation, financial decision-making, team building, conflict resolution, and interviewing. Just like surgical training, these skills too require systematic training. With patients beginning to demand value-added service, it is important for healthcare executives to identify those physicians best suited to serve as leaders within the larger healthcare system and to deliberately nurture their growth in these administrative competencies.

Physician leadership is essential to the survival of teaching hospitals.

BACKGROUND: Academic medical centers (AMCs) face severe financial constraints because they must now compete directly with private providers that focus exclusively on cost-effective healthcare delivery. Educational and research capacities developed at AMCs have been supported by government and third party payers, but government support is diminishing. Physicians are ill-equipped to respond to market pressures. DATA SOURCES: Analyses of cultural change and restructuring in corporate giants such as Greyhound, IBM and FedEx are relevant to teaching hospitals. To succeed, organizations must flatten hierarchy, empower staff, train leaders, and mobilize intellectual capital. Effective leadership is essential. CONCLUSION: Physicians must educate themselves on forces impacting the AMC, understand changes needed in the structure and processes of AMC governance and acquire competencies for leadership and management if AMCs are to survive and thrive. Surgeons should acquire competencies that will enable them to become leaders in the process of AMC transformation.

A multidimensional approach to breast cancer education.

BACKGROUND: This study was undertaken to present a multidimensional breast cancer education package (BCEP) to medical students in an effort to improve breast cancer education. METHODS: The students were exposed to a four-part BCEP consisting of a hands-on structured clinical instruction module (SCIM), a lecture, a problem-based learning (PBL) small-group discussion, and a written manual. Each component was evaluated with a questionnaire. Students responded to the items using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). RESULTS: The mean overall evaluations for the BCEP components were: SCIM, 4.6; lecture, 4.0; manual 3.8, and PBL discussion, 3.6. Highly rated qualities of the SCIM included organization (4.7), faculty preparedness (4.8), and opportunity to practice skills (4.5). The students agreed that the lecture (4.1), manual (3.8), and PBL discussion (4.2) had prepared them for the SCIM. CONCLUSION: This innovative BCEP effectively improved students' understanding of breast cancer.

Programs for the development of physician leaders: a curricular process in its infancy.

Physician leaders are crucial as never before to ensure the proper integration of good care and cost containment; such integration is both a reasonable expectation of patients and essential for the survival of health care delivery systems. In today's health care environment, a critical mass of physician leaders must be developed in a systematic fashion so that physicians may truly lead the health care enterprise. The authors (1) describe, with examples, the various types and levels of physician leadership training programs currently being offered; (2) explain the costs and benefits of each program type; and (3) offer a program rationale and model (using a program at their medical school), which they analyze using traditional management concepts such as strategic planning, net present value, and make-versus-buy. The authors emphasize that physician leadership training should be local, offer long-term instruction, and be led by physicians. They conclude by stating that the concept of physician leadership will not and should not be taken seriously by non-physician health care executives until the physician community becomes as serious about leadership and management training as it is about clinical training.

The relative contributions of interpersonal and specific clinical skills to the perception of global clinical competence.

BACKGROUND: The objective structured clinical examination (OSCE), an established instrument for evaluating resident competence, was used to test the hypothesis that faculty assessment of clinical competence in residents at various levels of training may be influenced more by general skills as a physician and less by competency in the actual skills being specifically tested. In this study, advantage was taken of the anticipated observation that general surgery residents did not demonstrate improvement in their ability to perform a focused neurological assessment over time. METHODS: An OSCE, which was administered to 56 general surgery residents at all levels of training, included the assessment of a specific clinical neurosurgical problem (sciatica). Univariate and multivariate analyses were used to evaluate the relationship between the global faculty judgment of competent or noncompetent and the other performance measures that were applied. RESULTS: At different levels of training, there was no observed difference in the specific skills being tested; nevertheless, junior and senior residents were more likely than incoming interns to be judged "competent" and received better evaluations of how well they introduced themselves to the patient. The competence judgment correlated significantly with all of the other performance measures, including the skills being tested. CONCLUSIONS: The perception of competence is not solely dependent upon the particular skills under scrutiny. General competence does not guarantee competence in each specific skill set of a medical specialty.

Interpreting the judgment of surgical faculty regarding resident competence.

BACKGROUND: It is reasonable to propose that competence is a multifaceted characteristic defined in part by some minimum level of knowledge and skill. In this study we examined the relationship between surgical faculty's judgment of clinical competence, as measured by a surgical resident objective structured clinical examination (OSCE), and the residents' objective performance on the skills being tested. METHODS: Fifty-six general surgery residents at all levels of training participated in a 30-station OSCE. At the completion of each station, the faculty proctor made several overall judgments regarding each resident's performance, including a global judgment of competent or not competent. The competence judgment was applied to the objective percentage performance score in three different ways to construct methods for determining competence based solely upon this objective percentage score. RESULTS: The average mean competent score (MCS) across the stations was 61%, and the average mean noncompetent score (MNCS) was 38%. The difference between MCS and MNCS for each station was very consistent. Upper threshold scores above which a judgment of competent was always made, and lower threshold scores below which a judgment of noncompetent was always made were observed. Overall, the average mean and threshold scores for competent and noncompetent groups were remarkably similar. For performance scores in the range between the threshold competent and noncompetent scores at each station, measures other than objective performance on the skills being evaluated determined the judgment of competent or not competent. CONCLUSIONS: Empirically determined minimum acceptable standards for objective performance in clinical skills and knowledge appeared to have been subconsciously applied to the competence judgment by the faculty evaluators in this study. Other factors appeared to have become determinate when the objective performance score fell within a range of uncertainty.

Surgical teaching quality makes a difference.

BACKGROUND: This study examined the influence of the quality of faculty members' teaching on student performance in a third-year surgery clerkship. METHODS: Eighty-nine third-year students on a surgery clerkship completed preceptor evaluation forms. The faculty member's overall score was the mean of ratings from all the third-year students for whom that faculty member served as preceptor during the year. We examined associations between these ratings and student performance on the National Board of Medical Examiners (NBME) surgery subject examination and clerkship Objective Structured Clinical Examination (OSCE) by using an analysis of covariance that controlled for prior academic achievement [United States Medical Licensure Examination (USMLE) Part I]. RESULTS: The average mean teaching evaluation score was associated with the scores on the NBME surgery subject examination (P = 0.0005). Students with attendings who received poor teaching evaluations performed more poorly on OSCE data-gathering stations than did students with attendings rated as average or good. CONCLUSIONS: The study results indicate that the teaching quality of surgery faculty appears to have an impact on student performance.

Assessing residents' clinical performance: cumulative results of a four-year study with the Objective Structured Clinical Examination.

BACKGROUND: The Objective Structural Clinical Examination (OSCE) is an objective method for assessing clinical skills and can be used to identify deficits in clinical skill. During the past 5 years, we have administered 4 OSCEs to all general surgery residents and interns. METHODS: Two OSCEs (1993 and 1994) were used as broad-based examinations of the core areas of general surgery; subsequent OSCEs (1995 and 1997) were used as needs assessments. For each year, the reliability of the entire examination was calculated with Cronbach's alpha. A reliability-based minimal competence score (MCS) was defined as the mean performance (in percent) minus the standard error of measurement for each group in 1997 (interns, junior residents, and senior residents). RESULTS: The reliability of each OSCE was acceptable, ranging from 0.63 to 0.91. The MCS during the 4-year period ranged from 45% to 65%. In 1997, 4 interns, 2 junior residents, and 2 senior residents scored below their group's MCS. MCS for the groups increased across training levels in developmental fashion (P < .05). CONCLUSIONS: Given the relatively stable findings observed, we conclude (1) the OSCE can be used to identify group and individual differences reliably in clinical skills, and (2) we continue to use this method to develop appropriate curricular remediation for deficits in both individuals and groups.