Exploring students' [pre-pandemic] use and the impact of commercial-off-the-shelf learning platforms on students' national licensing exam performance: A focused review - BEME Guide No. 72.

BACKGROUND: Commercial-off-the-shelf learning platforms developed for medical education (herein referred to as MedED-COTS) have emerged as a resource used by a majority of medical students to prepare for licensing examinations. As MedED-COTS proliferate and include more functions and features, there is a need for an up-to-date review to inform medical educators on (a) students' use of MedED-COTS outside the formal medical school curriculum, (b) the integration of MedED-COTS into the formal curriculum, and (c) the potential effects of MedED-COTS usage on students' national licensing exam scores in the USA. METHODS: Due to the limited number of studies published on either the use or integration of MedED-COTS, a focused review of literature was conducted to guide future research and practice. Data extraction and quality appraisal were conducted independently by three reviewers; with disagreements resolved by a fourth reviewer. A narrative synthesis was completed to answer research questions, contextualize results, and identify trends and issues in the findings reported by the studies included in the review. RESULTS: Results revealed consistent positive correlations between students' use of question banks and their licensing exam performance. The limited number of integration studies, combined with a number of methodological issues, makes it impossible to isolate specific effects or associations of integrated commercial resources on standardized test or course outcomes. However, consistent positive correlations, along with students' pervasive use and strong theoretical foundations explaining the results, provide evidence for integrating MedED-COTS into medical school curricula and highlight the need for further research. CONCLUSIONS: Based on findings, we conclude that students use exam preparation materials broadly and they have a positive impact on exam results; the literature on integration of MedED-COTS into formal curriculum and the use by students of resources outside of exam preparation is scant.

Wanted: Effective Followers in Surgery.

BRIEF DESCRIPTION: This SURGICAL PERSPECTIVE paper brings to our readers the general topic of "followership." Leadership has received a lot of attention in the administrative education domain; however, there is a history of academic research on the role and importance of the effective follower. We review some of the critical articles in this field, and present a possible approach for incorporating the notion of effective followership in a surgical context.

Virtual patient simulations and optimal social learning context: a replication of an aptitude-treatment interaction effect.

BACKGROUND: Virtual patients (VPs) offer valuable alternative encounters when live patients with rare conditions, such as cranial nerve (CN) palsies, are unavailable; however, little is known regarding simulation and optimal social learning context. AIM: Compare learning outcomes and perspectives between students interacting with VPs in individual and team contexts. METHODS: Seventy-eight medical students were randomly assigned to interview and examine four VPs with possible CN damage either as individuals or in three-person teams, using Neurological Examination Rehearsal Virtual Environment (NERVE). Learning was measured through diagnosis accuracy and pre-/post-simulation knowledge scores. Perspectives of learning context were collected post-simulation. RESULTS: Students in teams submitted correct diagnoses significantly more often than students as individuals for CN-IV (p = 0.04; team = 86.1%; individual = 65.9%) and CN-VI (p = 0.03; team = 97.2%; individual = 80.5%). Knowledge scores increased significantly in both contexts (p < 0.001); however, a significant aptitude-treatment interaction effect was observed (p = 0.04). At pre-test scores ≤25.8%, students in teams scored significantly higher (66.7%) than students as individuals (43.1%) at post-test (p = 0.03). Students recommended implementing future NERVE exercises in teams over five other modality-timing combinations. CONCLUSION: Results allow us to define best practices for integrating VP simulators into medical education. Implementing NERVE experiences in team environments with medical students in the future may be preferable.

Optimal learning in a virtual patient simulation of cranial nerve palsies: the interaction between social learning context and student aptitude.

BACKGROUND: Simulation in medical education provides students with opportunities to practice interviews, examinations, and diagnosis formulation related to complex conditions without risks to patients. AIM: To examine differences between individual and team participation on learning outcomes and student perspectives through use of virtual patients (VPs) for teaching cranial nerve (CN) evaluation. METHODS: Fifty-seven medical students were randomly assigned to complete simulation exercises either as individuals or as members of three-person teams. Students interviewed, examined, and diagnosed VPs with possible CN damage in the neurological exam rehearsal virtual environment (NERVE). Knowledge of CN abnormalities was assessed pre- and post-simulation. Student perspectives of system usability were evaluated post-simulation. RESULTS: An aptitude-treatment interaction (ATI) effect was detected; at pre-test scores ≤ 50%, students in teams scored higher (83%) at post-test than did students as individuals (62%, p = 0.02). Post-simulation, students in teams reported greater confidence in their ability to diagnose CN abnormalities than did students as individuals (p = 0.02; mean rating = 4.0/5.0 and 3.4/5.0, respectively). CONCLUSION: The ATI effect allows us to begin defining best practices for the integration of VP simulators into the medical curriculum. We are persuaded to implement future NERVE exercises with small teams of medical students.

Decreasing morbidity and mortality in 100 consecutive minimally invasive esophagectomies.

INTRODUCTION: Esophagectomy is a complex invasive procedure that requires exploration of multiple body cavities for removal and subsequent restoration of gastrointestinal continuity. In many institutions, esophagectomy morbidity and mortality rates remain high despite improvement of intensive care treatment. We reviewed our minimally invasive esophagectomy (MIE) experience of a consecutive series of 100 patients to analyze trends in morbidity and mortality as we transitioned from open to MIE. METHODS: A total of 105 consecutive patients who underwent operative exploration for esophagectomy from August 2007 to January 2011 were reviewed. The preoperative evaluation, operative technique, and postoperative care of these cases were evaluated and analyzed for 100 patients who have had a MIE and compared with 32 open esophagectomies 2 years prior. RESULTS: During the time frame of the study, 105 patients underwent an exploration for attempted esophagectomy. Resection was completed in 100 patients and was done for malignant disease in 95 patients and benign disease in 5 patients. There was one in hospital mortality due to a pulmonary embolism. There was no significant difference in postoperative complications consisting of transient left recurrent nerve injury (7 vs. 12.5%) or pneumonia (9 vs. 15.6%) in those who underwent MIE compared with open resection. However, wound infections were significantly less in patients who underwent MIE compared with open esophagectomy (1 vs. 12.5%, respectively, p = 0.01). Anastomotic leak (4 vs. 12.5%, p = 0.05) also was lower in those who underwent MIE. Median length of stay (LOS) was significantly less in patients who underwent MIE compared with open esophagectomy (7.5 vs. 14 days, p < 0.05). Finally, there was a trend toward improvement in median LOS in the 30 patients who underwent MIE during the most recent time period compared with the initial 17 patients who underwent MIE (7.5 vs. 10 days, p = 0.05) CONCLUSIONS: Our results support the continued safe use of esophagectomy for selected esophageal diseases, including malignancy. Morbidity, especially wound infection, anastomotic leak, and length of stay is decreasing with the incorporation of minimally invasive techniques.

Rigorous Curricular Innovation: Development, Integration, and Evaluation of Anatomic Clinical Correlations Module.

OBJECTIVE: To develop an anatomy clinical correlations module utilizing modern instructional design techniques and theoretically structured student feedback for course improvements. DESIGN: A pre-experimental, single group post-test study. Eleven module sessions were structured using the 5-E instructional strategy (engage, explore, explain, elaborate, and evaluate). Learning impact was measured using Keller's ARCS framework (attention, relevance, confidence, and satisfaction) and narrative student feedback was collected to inform case alterations. The course was repeated the following year with the integrated feedback and year-on-year comparisons were drawn. SETTING: Single-institution study at the University of Central Florida College of Medicine. PARTICIPANTS: Medical students currently enrolled in the first-year anatomy course. RESULTS: Year-on-year comparisons for AY18-19 (n = 78) and AY19-20 (n = 118) yielded statistically significant improvements in attention (4.69-4.76, p = 0.01) and relevance (4.54 to 4.75, p ≤ 0.001) with high total combined survey response rates (n = 196/238, 82.4%). Internal consistency was good for attention and strong for the following scales: total scale, relevance, confidence, and satisfaction. Narrative feedback referenced the importance of applied anatomy, clinical context and decision-making, the format of the sessions. CONCLUSIONS: We structured a series of anatomic clinical correlations using an evidence-based instructional strategy, assessed its impact, and improved on the course to optimize the motivation to learn anatomy. Systematic use of structured student feedback is important to ensure case difficulty is within the zone of proximal development.

Minimally invasive esophagectomy is safe and effective following neoadjuvant chemoradiation therapy.

BACKGROUND: Minimally invasive esophagectomy (MIE) is technically demanding, and implementation has been hindered by a steep learning curve. Despite widespread concern about the successful performance of this procedure following neoadjuvant chemoradiotherapy (NACR) treatment, we hypothesized that safe and effective MIE could be performed in this setting. MATERIALS AND METHODS: We reviewed our prospective database of patients undergoing MIE for esophageal cancer at our institution between January 2008 and February 2010. We analyzed the association of NACR on perioperative outcomes and compared them with those patients undergoing MIE without NACR. NACR was used in ≥T2 or N+ tumors. RESULTS: A total of 61 consecutive patients underwent a planned MIE. A complete MIE or hybrid procedure was performed in 58 patients (95%), while 3 patients were unresectable. Median age was 67 years (range 38-85). Anastomoses were performed in the cervical region in 47 patients (81%) while 11 patients had an anastomosis in the right chest. Serious complications included: 3 cervical anastomotic leaks (5%), 2 thoracic duct leaks (4%), 12 pneumonias (21%), 10 atrial fibrillations (18%), and 1 death in a patient not undergoing NACR. NACR was used in 41 patients. There was no significant difference in estimated blood loss (EBL), complications, or negative pathologic margins in patients undergoing NACR with MIE vs. MIE alone (P=NS). Median number of lymph nodes excised and PostOp LOS was 15 and 11 in patients undergoing NACR compared with 13 and 9 in those undergoing MIE alone (P=NS). CONCLUSION: MIE is safe following NACR. Excellent results can be achieved with this operation in patients with advanced tumors.

Enhancing learning through optimal sequencing of web-based and manikin simulators to teach shock physiology in the medical curriculum.

The Association of American Medical Colleges has encouraged educators to investigate proper linkage of simulation experiences with medical curricula. The authors aimed to determine if student knowledge and satisfaction differ between participation in web-based and manikin simulations for learning shock physiology and treatment and to determine if a specific training sequencing had a differential effect on learning. All 40 second-year medical students participated in a randomized, counterbalanced study with two interventions: group 1 (n = 20) participated in a web-based simulation followed by a manikin simulation and group 2 (n = 20) participated in reverse order. Knowledge and attitudes were documented. Mixed-model ANOVA indicated a significant main effect of time (F(1,38) = 18.6, P < 0.001, η(p)(2) = 0.33). Group 1 scored significantly higher on quiz 2 (81.5%) than on quiz 1 (74.3%, t(19) = 3.9, P = 0.001), for an observed difference of 7.2% (95% confidence interval: 3.3, 11.0). Mean quiz scores of group 2 did not differ significantly (quiz 1: 77.0% and quiz 2: 79.7%). There was no significant main effect of group or a group by time interaction effect. Students rated the simulations as equally effective in teaching shock physiology (P = 0.88); however, the manikin simulation was regarded as more effective in teaching shock treatment (P < 0.001). Most students (73.7%) preferred the manikin simulation. The two simulations may be of similar efficacy for educating students on the physiology of shock; however, the data suggest improved learning when web-based simulation precedes manikin use. This finding warrants further study.

Differences in outcome between obese and nonobese patients following severe blunt trauma are not consistent with an early inflammatory genomic response.

OBJECTIVES: Obesity has been demonstrated to alter a number of acute and chronic medical conditions. The effect of obesity on severely injured patients, however, remains incompletely defined. We sought to unravel potential physiologic and genomic alterations induced by obesity in severely injured blunt trauma patients. DESIGN: A retrospective review of clinical and genomic information contained in the Inflammation and the Host Response to Injury multicenter trauma-related database examining the relationship between body mass index and the early genomic response from peripheral blood leukocytes to patient outcome following severe blunt trauma was performed. SETTING: Multicenter collaboration between university-based academic trauma centers. PATIENTS: Severely injured blunt trauma patients enrolled in the database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Univariate analysis of 455 severely injured trauma patients using the National Institutes of Health/World Health Organization body mass index classification system revealed significant increases in morbidity, including longer intensive care unit stays and a greater number of ventilator days, cardiac arrests, episodes of acute renal failure, and patients developing multiple organ failure. Regression modeling identified body mass index class as being independently associated with adverse outcomes and increased morbidity but an inverse relationship with mortality in patients who suffered severe blunt traumatic injury. Initial leukocyte genomic expression patterns between 163 patients in the four different body mass index groupings did not differ; however, analysis of gene differences between body mass index classes occurring over time demonstrated significant changes in 513 probe sets with significant pathway differences being related to cellular metabolism. CONCLUSIONS: Increasing body mass index is associated with increased morbidity following severe blunt trauma. The initial blood leukocyte inflammatory response to blunt trauma does not appear to differ significantly between patients despite increasing body mass index. Resolution of the inflammatory response may differ between patients on the basis of body mass index; however, additional work is needed to clarify the potential causality of this finding.

Traditional resuscitative practices fail to resolve metabolic acidosis in morbidly obese patients after severe blunt trauma.

BACKGROUND: Obesity is a risk factor for postinjury complications; in particular, obese patients develop multiple organ failure (MOF) at a greater rate than do normal weight counterparts. Evaluation of differences in resuscitative practices altered by body mass index (BMI) might provide an explanation for the increased risk of MOF seen in these high-risk patients. METHODS: We used prospectively collected multicenter data to retrospectively compare patients grouped by BMI with regard to resuscitation volumes and traditional end points during the first 48 hours after injury. Marshall MOF score was used as the primary outcome measure. RESULTS: One thousand sixty-six patients were analyzed, with 877 meeting inclusion and exclusion criteria. All patients received similar volumes of resuscitation per kilogram lean and ideal body weight. Morbidly obese patients attained greater central venous pressures but otherwise differed little in attainment of standard cardiovascular end points. Despite this, morbidly obese patients resolved base deficit more slowly and remained in metabolic acidosis for 48 hours postinjury. Morbidly obese patients with persistent metabolic acidosis developed MOF at a significantly greater rate than did normal weight patients with or without persistent metabolic acidosis. CONCLUSIONS: Morbidly obese trauma patients show prolonged metabolic acidosis despite receiving similar volumes and attaining similar end points of resuscitation when compared with patients in other BMI groups. Inadequate resuscitation based on inaccurate end points and metabolic disturbances associated with increased BMI are likely responsible; identification of the etiology, sources, and consequences of this acidosis may provide further insight into the susceptibility of the morbidly obese patient to develop postinjury organ failure.

VR Simulation Leads to Enhanced Procedural Confidence for Surgical Trainees.

OBJECTIVE: Active learning techniques result in greater knowledge acquisition compared to passive methods. For medical students with limited hands-on operative experiences, virtual reality platforms represent active learning and may enhance procedural training. We hypothesize that virtual reality simulators like Toolkit for Illustration of Procedures in Surgery (TIPS) are a more effective modality in teaching laparoscopic surgical techniques to medical students when compared to passive learning tools like videos. DESIGN: In this crossover study, participants were randomly assigned to perform either a TIPS laparoscopic appendectomy followed by video of a laparoscopic cholecystectomy, or video of a laparoscopic appendectomy followed by TIPS laparoscopic cholecystectomy. A knowledge assessment followed each intervention. A postsurvey was used to gather feedback and subjective impressions of the learning experience. SETTING: University of Central Florida College of Medicine. PARTICIPANTS: Second, third, and fourth-year medical students (n = 37). RESULTS: Validation of the content assessments revealed strong internal consistency (Cronbach's α = 0.73). A 2-tailed Fisher's exact test revealed that the video had greater ease of use (p = 0.032), but TIPS had greater utility as a learning tool (p < 0.001) and instilled greater confidence in the ability to reproduce procedural steps (p < 0.001). A 2-tailed t test of the average content quiz scores revealed no significant difference in percentage correct between groups on the laparoscopic appendectomy quiz (p = 0.772), but a difference favoring video learning on the laparoscopic cholecystectomy quiz (p = 0.042) CONCLUSIONS: Video and TIPS both enhanced different aspects of student learning; however, the active TIPS platform produced greater confidence in the ability to reproduce the steps of the procedure and had greater utility as a learning strategy. Videos are simple to use and can serve a complementary role in curriculum design.

Laparoscopic pancreatic surgery: what now and what next?

In recent years, improved laparoscopic skill sets have expanded surgical management of pancreatic disease to encompass pancreatic resection, tumor enucleation, debridement, and drainage. With the aid of radiologically guided drainage catheters, necrosectomy for acute pancreatitis can be delayed and accomplished laparoscopically in a select patient population. Pancreatic pseudocysts from chronic pancreatitis can now be approached via minimally invasive strategies, including emerging combined laparoscopic procedures and natural orifice transluminal endoscopic surgery. It is clear that laparoscopic pancreaticoduodenectomy is possible in experienced hands; pancreatic neoplasms in the body and tail are more suitable for laparoscopic procedures because distal pancreatic resection requires no reconstruction of the biliary or enteric tract. Laparoscopic staging of pancreatic tumors has decreased as preoperative radiographic imaging becomes more sensitive. Similarly, laparoscopic palliative procedures have decreased because of the emergence of other minimally invasive options for relieving gastric outlet obstruction and biliary obstruction. Nonetheless, major advances in minimally invasive pancreatic surgery will continue as technology and skill sets advance.

Patients with Cushing's syndrome are care-intensive even in the era of laparoscopic adrenalectomy.

We report outcomes from laparoscopic adrenalectomy (LA) comparing patients with Cushing's syndrome with those with other adrenal pathology with respect to length of stay (LOS), overall complications, and financial implications. We conducted a retrospective review of 80 continuous patients (103 glands) undergoing LA. The clinical diagnoses were: hypercortisolism (Cushing' syndrome; n=33), hyperaldosteronism (Conn's syndrome; n=20), phaeochromocytoma (n=16), and neoplasm (others; n=11). Advanced care in the intermediate or intensive care unit was necessary in 27 patients, most frequently in our Cushing's population (16 of 33 [48%]). Six patients sustained major complications, including death in two patients; seven patients sustained minor complications. LOS was longer for patients with Cushing's syndrome (mean, 5.5 vs. 3.3 days; P = 0.024). Financially, patients with Cushing's syndrome had statistically higher total hospital (P = 0.009), advanced care (P = 0.002), and anesthetic costs (P = 0.005). LA in patients with Cushing's syndrome is associated with longer hospitalizations, more frequent major complications, and higher advanced care requirements, especially for patients undergoing bilateral adrenalectomy. Minor complications were infrequent and median LOS was brief regardless of diagnosis. Patients with Cushing's syndrome had higher costs for overall hospital charges, advanced care, and anesthesia.

Increasing Students' Publication Productivity: Could Launching a University Scientific Journal be a Catalyst?

Our institution established an online medical journal to promote publication opportunities and to foster a culture of scholarship. In two years of activity, there was an increase in the proportion of students reporting authorship of peer-reviewed publications at our institution suggesting an increase in students' scholarly interest and output.

Simultaneous fundoplication and gastric stimulation in a lung transplant recipient with gastroparesis and reflux.

BACKGROUND: Gastroparesis following lung transplantation can complicate medical management leading to malnutrition, weight loss, and erratic absorption of immunosuppressive medications, which are all important factors in the success of grafts. Gastric electrical stimulation has been shown to reduce the frequency of nausea and vomiting and lead to weight gain in patients with gastroparesis refractory to standard medical treatment; however, it has not yet been reported as being used for the treatment of gastroparesis in lung transplant recipients. METHODS: We report the case of a female bilateral lung transplant recipient suffering from severe gastric reflux and severe gastroparesis, who was successfully treated with simultaneous creation of a laparoscopic Nissen fundoplication and placement of a gastric stimulator. RESULTS: The patient noted an immediate and sustained decrease in her symptoms of nausea and vomiting, and an increased appetite, and less variability in the serum levels of her immunosuppressive medication. CONCLUSION: Lung transplant recipients with severe gastroparesis and reflux may benefit from Nissen fundoplication and gastric electrical stimulation.

Laparoscopic resection of a virilizing adrenocortical tumor.

Virilizing adrenocortical tumors are rare. Laparoscopic unilateral adrenalectomy with serum androgen surveillance may provide curative treatment for benign, functional adenomas. Herein, we describe a case of laparoscopic resection of a testosterone-producing adrenal tumor in a sixteen-year-old female.

Using Assessment Point Accumulation as a Guide to Identify Students at Risk for Interrupted Academic Progress.

PROBLEM: Interruptions in academic progress (IP) are problematic for students and educational programs alike. Early identification of students at risk for IP, to provide remediation, could be beneficial. APPROACH: Considering the clinically familiar pediatric growth curve as a metaphor, researchers hypothesized they could identify students at risk of IP. They organized course-related examination performance data for 518 students in five classes (2013-2014 through 2017-2018), adding students' percentage scores cumulatively over time. At every examination point, they analyzed the data for dis-tribution and calculated a mean class score. They plotted each student's accumulated points and accommodated a linear fit. Using the mean of the class as the horizontal axis, students gaining points against the mean show a positive slope; conversely, students losing points reveal a negative slope. The authors compared their findings against students who had faced IP-those who had repeated at least one course or an academic year, or who had left medical school. OUTCOMES: Using a receiver operating characteristic approach, the authors identified a slope of -5 as an excellent screening test with 85% accuracy (sensitivity = 82%, specificity = 86%, area under curve = 0.917). Of 38 students facing IP, 25 would have been identified at risk for IP as early as the fifth assessment using a slope of -5. NEXT STEPS: Given the outcomes of this innovative, inexpensive, highly accurate approach to identifying students at risk of IP, the authors have plans to optimize interventions and to validate the approach at other programs.

Associated neoplastic disease in inflammatory bowel disease.

The development of intestinal carcinoma in the setting of inflammatory bowel disease (IBD) has been recognized as an unsavory outcome of chronic inflammation of the bowel. Numerous studies have recently documented the clinical and morphologic features of malignant transformation in this closely-followed group of patients. This article highlights the recent findings of these population-based studies with specific attention to surgical concepts and frames these data in the context of surgical approaches to cancer arising in inflammatory disease. Specifically, the authors address the pathobiology of malignant transformation, the management of colorectal cancer in inflammatory bowel disease, the development of dysplasia in ulcerative colitis, surveillance of patients who have IBD, chemoprevention of cancer, and special features of surgical oncologic management.

Primary malfunction of a peritoneal dialysis catheter due to encasement in an encapsulating sheath.

Obstruction of the catheter is one of the potentially serious complications of peritoneal dialysis. Dislocation of the tip of the catheter, intraluminal fibrin formation, and omental wrapping are among the most common etiologies of peritoneal dialysis catheter malfunction that necessitate correction. Here we present a rare case of primary malfunction of a newly placed catheter in which multiple attempts to restore the patency by minimally invasive procedures were unsuccessful. Laparoscopy revealed a thick encapsulating sheath around the entire length of the catheter as the etiology of complete obstruction, without involvement of other intra-abdominal structures. The sheath was opened and the catheter was pulled out in its entirety. There was no intraluminal or orifice obstruction and it subsequently functioned perfectly.