Chronic disease management: a residency-led intervention to improve outcomes in diabetic patients.

BACKGROUND: When quality improvement processes are integrated into resident education, many opportunities are created for improved outcomes in patient care. For Bethesda Family Medicine (BFM), integrating quality improvement into resident education is paramount in fulfilling the Accreditation Council for Graduate Medical Education Practice-Based Learning and Improvement core competency requirements. METHODS: A resident-developed diabetes management treatment protocol that targeted 11 evidence-based measures recommended for successful diabetes management was implemented within the BFM residency and all physician practices under its parent healthcare system. This study compares diabetes management at BFM and at 2 other family medicine practices at timepoints before and after protocol implementation. We measured hemoglobin A1c (HbA1c), low-density lipoprotein (LDL) cholesterol, and systolic blood pressure (SBP) in adult diabetics and compared patient outcomes for these measures for the first and third quarters of 2009 and 2010. RESULTS: In BFM patients, HbA1c, LDL, and SBP levels decreased, but only HbA1c improvement persisted long term. For the comparison groups, in general levels were lower than those of BFM patients but not significantly so after the first measurement period. CONCLUSIONS: A resident-led treatment protocol can improve HbA1c outcomes among residents' diabetic patients. Periodic educational interventions can enhance residents' focus on diabetes management. Residents in graduate medical education can initiate treatment protocols to improve patient care in a large healthcare system.

Improving satisfaction ratings of surgical patients from referral to follow-up in the faculty medical center clinic.

OBJECTIVE: The objective of this study was to evaluate patient satisfaction in an outpatient community-based surgical clinic to seek opportunities for improvement. METHODS: A paper survey was distributed to patients at the Faculty Medical Center Clinic over a 12-week period. The survey allowed patients to rate their experience on a 5-point scale from "very dissatisfied" to "very satisfied." The survey addressed referral to the clinic, appointment scheduling, visit experience, wait times, laboratory testing, and satisfaction with surgery. Separate from the surveys, data were collected regarding wait time in clinic prior to being placed in an examining room, time spent waiting for the physician, time spent with the physician, overall time spent in clinic, and appointment time to surgery. RESULTS: During the 12-week time period, 87 surveys were returned from patients in the surgery clinic for a 69% response rate. Most patients were referred to the surgery clinic from the emergency department or their primary care physicians at 44% and 43%, respectively. Just over half of the patients responded that they were "very satisfied" with their overall experience. Of those surveyed, 40% of patients were "very satisfied" with their wait time for the first visit to the clinic, 52% with time in waiting room, 43% with time in examining room, and 47% with time spent with physician. Only 16.4% of patients were "very dissatisfied" or "mostly dissatisfied" with time waiting for appointment, 17.9% with time available for appointment, 14.3% with time in waiting room, 18.2% in time waiting in examination room for the physician, and 20.9% of time wait to schedule surgery. Data were also collected on 203 surgical clinic patients during this time. Of the 203 patients, 55% were new patients, 31% were postoperative patients, and 14% were in the clinic for another type of visit. CONCLUSIONS: Overall patient satisfaction was good for the clinic, yet there were areas to improve. Efficiency of scheduling patients, improving wait time for waiting room, examining room, and time prior to scheduling surgery are areas that need improvement. Modification of the current practice at the surgery clinic could result in improvement of patient satisfaction in future evaluation.

Good Samaritan Hospital and its department of surgery: a historical perspective.

At the end of the Revolutionary War, the United States government acquired the Northwest Territory, including the city of Cincinnati. Given the city's position on the Ohio River, and the subsequent development and introduction of steamboats in the early 1800s, Cincinnati became a major center for commerce and trade. With a population of over 115,000 in 1850, Cincinnati was the sixth largest city in the United States--larger even than St. Louis and Chicago-the first major city west of the Allegheny Mountains, and the largest inland city in the nation. The city's growth and importance is mirrored by the history of one if its prized institutions, Good Samaritan Hospital--the oldest, largest, and busiest private teaching and specialty-care hospital in Greater Cincinnati and a national leader in many surgical fields.

Does participation in graduate medical education contribute to improved patient outcomes as outlined by Surgical Care Improvement Project guidelines?

BACKGROUND: Patient quality outcomes are a major focus of the health care industry. It is unknown what effect involvement in graduate medical education (GME) has on patient outcomes. The purpose of this study is to begin to examine whether GME involvement in postoperative care impacts patient quality outcomes. METHODS: The retrospective cohort included all patients who underwent a nonemergent colectomy from January 1, 2007 to January 1, 2008 at a 2-hospital system. Data collected included patient demographics, patient quality outcomes, complications, and GME involvement. Patient quality outcomes were based on compliance with the Surgical Care Improvement Project (SCIP) guidelines. RESULTS: A total of 159 nonemergent colectomies were analyzed. The GME group accounted for 116 (73%) patients. A significant difference was found in several SCIP process-based measures of quality when comparing the GME group with the non-GME group. Postoperative antibiotics were more likely to be stopped within 24 hours (p = 0.010), and preoperative heparin and postoperative deep vein thrombosis (DVT) prophylaxis were more likely to be administered (p < 0.001). Additionally, patients in the GME group showed improved quality outcomes as there were significantly fewer postoperative complications (p < 0.001) and a shorter duration of stay (p = 0.008). The use of gastrointestinal prophylaxis was more common in the non-GME group (p = 0.002). No significant differences were observed between the 2 groups in respect to age, sex, diabetes, preoperative antibiotics, antibiotics, 1 hour before surgery, postoperative antibiotics, and continuation of home beta blockade. CONCLUSIONS: GME at teaching institutions has a positive impact on patient quality outcomes. At our institution, many of the SCIP measurable outcomes had improved compliance if an attending physician participated in the GME program.

Reactions of surgical program directors to a web-based interactive educational program focusing on cognitive skills.

OBJECTIVE: To assess reactions by program directors (PDs) to a preview of a scenario from the Fundamentals of Surgery Curriculum (FSC), which is a case-based interactive curriculum developed by the American College of Surgeons's (ACS) Division of Education and designed to be delivered online to first-year (PGY-1) surgical residents. DESIGN: After previewing a scenario, each PD completed a questionnaire requesting age and ratings of comfort using computers, the scenario's utility in addressing 9 educational goals (eg, provides a solid foundation for future learning), and 6 separate features of the scenario (eg, ease of use and feasibility). All ratings were based on a 1-9 scale. For items related to educational goals, ratings were anchored: 1-3 = poor/needs revision; 4-6 = adequate/as good as current methods; 7-9 = excellent/superior to current methods. Informal discussions were also conducted and comments were collected. SETTING: October 2007 ACS Clinical Congress. PARTICIPANTS: In all, 31 PDs participated in the study. RESULTS: Most PDs perceived that the scenario addressed 8 of the 9 educational goals in a manner superior to current methods [eg, provides a solid foundation for future learning (97%), challenges residents (90%), and delivers content consistent with current practices and/or evidence (90%)]. The mean ratings of all scenario features were 7 or greater on the 9-point scale. CONCLUSION: Most PDs reacted very positively to a preview of FSC perceiving that it can address several important educational goals in a manner superior to existing methods. Comments from PDs suggest a high level of interest in incorporating FSC into their residency programs as well as participating in a coordinated multi-institutional evaluation project. The results provide baseline data concerning PD expectations of the utility of FSC that will help to guide and evaluate further developments and applications of this curriculum.

Computerized rounding in a community hospital surgery residency program.

BACKGROUND: With the institution of the 80-hour work week, residency programs have worked to institute programs that decrease the time that residents spend in the hospital while maintaining patient safety. This study was intended to assess the amount of time saved using computerized patient information in the form of a personal data assistant (PDA). METHODS: A community hospital surgical residency program with 22 residents initially collected data daily for 4 weeks without PDA use. Data included preround time, check-out time, total number of patients, number of medical/surgical patients, and number of intensive care unit patients. The definition of prerounding time was started when residents first began collecting information on their patients in the morning until 6:00 am. Check-out time started at 5:00 pm and lasted until the discussion of patient care with the night team had finished. Residents were then given PDAs allowing immediate up-to-date access to patient information, which most importantly included current vital signs, laboratory data, radiological dictations, medication lists, and fluid intake and output. After a 4-week acquaintance period with the PDA had passed, data were again collected from the residents daily for 4 weeks. Daily averages for each week and an overall total average were calculated. Daily averages were also calculated for each PGY level. Paired t-tests compared the pre-PDA and post-PDA total averages. RESULTS: No significant difference was found between the total number of patients pre-PDA and post-PDA (7.6 and 7.6, respectively, p = 0.98), the average number of medical/surgical patients (4.7 and 7.1, respectively, p = 0.16), or the average number of intensive care unit patients (2.6 and 0.4, respectively, p = 0.06). Also, no significant difference was found between pre-PDA and post-PDA with average check-out time (24.5 minutes and 21.9 minutes, respectively, p = 0.06). However, a significant decrease in rounding time occurred with pre-PDA round time at 50.5 minutes and post-PDA round time at 40.7 minutes (p = 0.02). CONCLUSION: Results of this study support the hypothesis that the prerounding time dramatically decreases with the PDA compared to without. Not only does this decrease in time help to keep residents under the 80-hour work week rule, but also it helps to eliminate much of the confusion that can cause patient safety issues.

Multi-institutional validation of a web-based core competency assessment system.

OBJECTIVE: The Association of Program Directors in Surgery and the Division of Education of the American College of Surgeons developed and implemented a web-based system for end-of-rotation faculty assessment of ACGME core competencies of residents. This study assesses its reliability and validity across multiple programs. METHODS: Each assessment included ratings (1-5 scale) on 23 items reflecting the 6 core competencies. A total of 4241 end-of-rotation assessments were completed for 332 general surgery residents (> or =5 evaluations each) at 5 sites during the 2004-2005 and 2005-2006 academic years. The mean rating for each resident on each item was computed for each academic year. The mean rating of items representing each competency was computed for each resident. Additional data included USMLE and ABSITE scores, PGY, and status in program (categorical, designated preliminary, and undesignated preliminary). RESULTS: Coefficient alpha was greater than 0.90 for each competency score. Mean ratings for each competency increased significantly (p < 0.01) as a function of PGY. Mean ratings for professionalism and interpersonal/communication skills (IPC) were significantly higher than all other competencies at all PGY levels. Competency ratings of PGY 1 residents correlated significantly with USMLE Step I, ranging from (r = 0.26, p < 0.01) for Professionalism to (r = 0.41, p < 0.001) for Systems-Based Practice. Ratings of Knowledge (r = 0.31, p < 0.01), Practice-Based Learning & Improvement (PBLI; r = 0.22, p < 0.05), and Systems-Based Practice (r = 0.20, p < 0.05) correlated significantly with 2005 ABSITE Total Percentile. Ratings of all competencies correlated significantly with the 2006 ABSITE Total Percentile Score (range: r = 0.20, p < 0.05 for professionalism to r = 0.35, p < 0.001 for knowledge). Categorical and designated preliminary residents received significantly higher ratings (p < 0.05) than nondesignated preliminaries for knowledge, patient care, PBLI, and systems-based practice only. CONCLUSIONS: Faculty ratings of core competencies are internally consistent. The pattern of statistically significant correlations between competency ratings and USMLE and ABSITE scores supports the postdictive and concurrent validity, respectively, of faculty perceptions of resident knowledge. The pattern of increased ratings as a function of PGY supports the construct validity of faculty ratings of resident core competencies.

Stimulating resident research in a general surgery residency community program.

OBJECTIVE: Resident research teams were established at this community hospital in the 1997 academic year. Research productivity, including publications and presentations in the years before establishing research teams and the 8 years subsequent to establishment of research teams with faculty mentors, was reviewed. METHODS: Each team is supported by a research specialist who provides assistance with project design, data evaluation, statistical analysis, manuscript editing, and preparation of research presentations. Every resident is assigned to a research team that meets monthly. The teams consist of a 4th- or 5th-year resident, 2nd- or 3rd-year resident, surgical intern, research team mentor, and research specialist. The resident is required to be an active contributing co-investigator on 1 team project per year, contributing to the development and performance of the study, participating in writing the manuscript, and must be able to defend the study. By the end of the third year, the resident is required to complete 1 individual project that is submitted to the postgraduate competition for residents. In addition, a completed manuscript must be ready to submit to a peer-reviewed journal. Promotion can be denied if the appropriate time has not been devoted to research. Minimum completion requirements include a case report and a presentation at a national or regional meeting. The research registry was reviewed for all presentations and publications given by the surgical residents during the 8 years before the teams were established and the 8 years after the teams were formed. RESULTS: In the 8 years before the establishment of research teams, 60 papers were published. After the establishment of research teams, 77 papers were published. During the 8 years before research teams were being established, 69 presentations were given. During the subsequent 8 years with the use of mentoring and research teams, 92 presentations were given. The research teams resulted in a 33% increase in presentations and a 13% increase in publications. CONCLUSIONS: Establishment of research teams and mentoring can help stimulate research interest and activity. Continuity on research teams throughout the 5-year residency is also crucial for the progression and development, duration, and completion of projects. Continuity of the mentor and research specialists also helps facilitate productivity and completion of the task. This method has been highly successful in improving the research presentations and publications in a community-based hospital residency.

Operative management of an aberrant splenic artery aneurysm: Utility of the medial visceral rotation approach: a case report and review of the literature.

The authors report an unusual case of a splenic artery aneurysm arising off the superior mesenteric artery. This was an incidental finding on computed tomography scan found during evaluation for a different or a separate disease process.

Mentorship in a community-based residency program.

The concept of mentorship has become a timely issue in surgical residency education. Traditionally, surgical training programs contained resident teams consisting of chiefs, seniors, juniors, and interns on 4- to 8-week blocks. With the new hour regulations, many programs have had to make changes in the format of their teaching programs to accommodate the new hour restrictions and yet still strive to maintain excellence in residency education. We examined a rotation with a mentor or a small group of surgeons in an apprenticeship model. This consists of one resident following one to three surgeons in a practice, in essence being their apprentice. One of the strongest advantages of this is the exposure the resident has to the true lifestyle of a practicing general surgeon. There is also strong continuity of care, because that one resident goes to office with their mentor, scrubs all their cases, rounds with them, and sees the patients in follow up. This continuity concept ultimately results in better outcomes for the patients.

Attracting medical students to surgical residency programs.

With the goals of creating a better match between medical students and general surgery programs and providing a program that is desirable to medical students who are interested in pursuing careers in surgery, a survey was designed to categorize student interests and to determine what factors are used in choosing a general surgery program. The survey focused on the reasons that surgical resident candidates select a program. Each statement was rated for importance on a 5-point scale, and then the top 10 statements were ranked in order of importance. The survey was distributed to 19 community hospitals, 23 university programs, and medical students interviewing for surgical residency. A total of 286 surveys were returned from 18 programs and medical students. The statements with the three highest ratings were "amount of operative exposure," "diversity of operative cases," and "perceived relationships among faculty and residents." "Amount of operative exposure," "diversity of operative cases," and "ability to pursue fellowship training after residency" received the top rankings. There was a significant difference between men and women in the ratings of three statements. However, there was no difference with the ranking of the statements. There was also a significant difference between residents early and late in their training on ratings of five statements and on the ranking of two statements. The ratings of six statements were significantly different between community and university programs. A significant difference between types of program was also found with the rankings of four statements. There was a difference between small and large programs on two ratings of statements and one ranking. This data provides a useful resource for programs and candidates in preparing for candidate/residency selection.

A multidisciplinary approach to carotid paragangliomas.

The surgical management of carotid paragangliomas can be problematic. A multidisciplinary approach was used to include vascular surgery, otolaryngology, and neuroradiology to treat these patients over 9 years. From January 1992 to July 2001, a multidisciplinary team evaluated patients with carotid paragangliomas. Analyzed patient data included age, gender, diagnostic evaluation, tumor size, preoperative tumor embolization, operative exposure, need for extracranial arterial sacrifice/reconstruction, postoperative morbidity including cranial nerve dysfunction, and long-term follow-up. Twenty-five carotid paragangliomas in 20 patients underwent multidisciplinary evaluation and management. Average age was 51 years (range, 28-83 years), and 52% were male. Diagnostic evaluation included computed tomography in 76%, magnetic resonance imaging/magnetic resonance angiography in 52%, catheter angiography in 60%, and duplex ultrasonography in 16%. An extended neck exposure was required in 11 cases (44%), mandibulotomy was used once (4%), and mandibular subluxation was never required. The external carotid artery (ECA) was sacrificed in 8 cases (32%). The carotid bifurcation was resected in 1 patient (4%) requiring interposition reconstruction of the internal carotid artery. Preoperative tumor embolization was performed for 13 tumors (52%). Operative blood loss for patients undergoing preoperative embolization (Group I) was comparable to the nonembolized group (group II): group I lost 365 +/-180 mL versus 360 +/- 101 mL for group II (P = .48). This occurred despite larger tumors (group I - 4.2 cm versus group II - 2.1 cm, P = .03) and a higher mean Shamblin class (group I - 2.5 versus group II - 1.45, P = .001) for group I. There were no perioperative mortalities. Transient cranial nerve dysfunction occurred in 13 CBTs (52%), 2 (8%) of which remained present after 4 months. Patients with carotid paragangliomas benefit from a multidisciplinary team approach. Neuroradiology has been used for selective preoperative embolization, which has decreased estimated blood loss during excision of larger complex tumors. A combined surgical team of otolaryngology and vascular surgery provides for exposure of the distal internal carotid artery as high as the skull base, limited permanent cranial nerve dysfunction, and selective early division and excision of the external carotid artery for complete tumor resection.

Clinical benefit of carotid endarterectomy based on duplex ultrasonography.

Carotid endarterectomy has been shown to significantly reduce the risk of stroke caused by carotid artery stenosis in selected patients. Limiting the morbidity and costs of this process without increasing the risks should further improve the benefits of this procedure. Results were prospectively collected from 123 consecutive carotid endarterectomies performed at a community teaching hospital. All patients underwent duplex ultrasonography for preoperative evaluation. Catheter angiography was used on a selective basis. Preferential use of regional anesthetic and selective use of the intensive care unit were applied. The mortality, morbidity, complications, and costs were then compared for the group receiving only preoperative duplex ultrasonography with those undergoing catheter angiography preoperatively. Age, comorbid risk factors, indications for carotid endarterectomy, and incidence of stroke were similar in both patient groups. The rates of mortality, morbidity, and stroke for carotid endarterectomy were low (mortality 0%, morbidity 6.5%, stroke 0.8%). For preoperative evaluation all patients underwent duplex ultrasonography (100%) and 28 (23%) underwent preoperative catheter angiography in addition to duplex ultrasonography. The complication rate associated with catheter angiography was 6/28 (21%). Complications included groin hematoma (7%), pseudoaneurysm (3.6%), bradycardia (7%), and unstable angina (3.6%). Costs for duplex ultrasonography averaged 165 US dollars and additional costs incurred by the use of catheter angiography averaged 4,200 US dollars. Intraoperative assessment of the carotid endarterectomy site did not change based on the use of preoperative catheter angiography. Morbidity, mortality, and stroke rates were the same for the 2 groups. The preoperative use of duplex ultrasonography for the sole evaluation in carotid endarterectomy is well established. The use of preoperative catheter angiography is still preferred by a subset of surgeons. The use of catheter angiography is associated with significant morbidity and additional costs when compared to performing carotid endarterectomy based solely on preoperative duplex ultrasonography. The added costs and morbidity of angiography increase the societal cost of this procedure without significant clinical improvement in patient outcome.

Diagnostic options in assessing abdominal aortic endograft infection--a case report.

Endovascular treatment of aortic aneurysms has gained widespread popularity in recent years. Stent grafts have emerged as another option in the surgeon's armamentarium in the treatment of aneurysmal disease. The infectivity of endovascular grafts and therapy for associated graft infections is unknown. Aortic graft infections have the potential for disastrous complications. This report presents a 72-year-old woman with persistent fever and an infected aortic stent graft in the early postoperative period.

Professionalism: lifelong commitment for surgeons.

Presently, there is a major initiative to rekindle the humanistic qualities in the practice of medicine. Although there have been many suggestions on ways to rejuvenate this initiative, it has not been a primary focus of graduate medical education until recently. Surgery residents are expected to maintain a high standard of ethical behavior; demonstrate a commitment to continuity of patient care; and demonstrate sensitivity to the age, gender, and culture of patients and fellow health care professionals. We in surgical education must accept the responsibility for the renewal in teaching and evaluating the professional and ethical principles of surgery residents. This change will not happen quickly, but it should be done skillfully because future generations will look back on this time of renewal in medicine and critique us on our ability or inability to achieve this goal.