Medical ethics curriculum for surgical residents: results of a pilot project.

INTRODUCTION: This study sought to develop and evaluate a medical ethics curriculum designed specifically for surgical residents. METHODS: The learning needs of surgical residents relevant to ethics were determined by using a structured literature review and synthesis strategy. We identified 5 primary areas of importance for ethics education for surgical residents: withdrawing and withholding treatment, advance directives, do-not-resuscitate orders, informed consent, and communicating bad news. Learning objectives were developed, and teaching plans were designed for four 90-minute interactive teaching episodes on the basis of adult learning principles. We surveyed residents using a published survey instrument modified for surgery to identify residents' beliefs about the usefulness of ethics training, confidence in addressing ethical issues, and factual knowledge of ethics questions. RESULTS: Twenty surgical residents at a single institution completed the pretest and posttest close-ended surveys. Results showed that although 88% had formal ethics exposure in medical school, 93% considered ethics education at the resident level to be a "very important" or "important" topic. Residents' confidence in addressing ethical issues showed statistically significant improvement between pretest and posttest surveys for 13 of 23 items. There were no statistically significant linear relationships between postgraduate year of residency and the pretest confidence items or the number of correct responses on the pretest multiple-choice items. CONCLUSIONS: Despite the prevalence of ethics education during medical school, surgical residents welcome formal instruction on numerous ethical issues pertinent to surgical practice. A focused curriculum can be developed that has a measurable impact on residents' confidence in addressing ethical issues.

Intradermal isotope injection is superior to intramammary in sentinel node biopsy for breast cancer.

BACKGROUND: The optimal sentinel lymph node (SLN) biopsy technique remains undefined in breast cancer. Injecting radiotracer or blue dye by a variety of routes seems to stage the axilla with comparable accuracy, and we have hypothesized that the dermal and the parenchymal lymphatics of the breast drain to the same SLN in most patients. Two previous studies from our institution support this concept: (1) a single-surgeon series of 200 consecutive SLN biopsy procedures demonstrating a high dye-isotope concordance for both intradermal (ID) and intraparenchymal (IP) isotope injection, and (2) a series of 100 procedures validated by a backup axillary dissection (ALND) in which the false-negative rate following ID isotope injection was comparable to that of our previous results with IP injection. Here, we directly compare the results of SLN biopsy using either ID or IP isotope injection for our entire experience of SLN biopsy procedures in which a backup ALND was done. METHODS: This is a retrospective, nonrandomized study of 298 clinical stage I to II breast cancer patients having SLN biopsy with a backup ALND planned in advance, comparing the results of ID (n = 164) and IP (n = 134) isotope injection. All patients had IP injection of blue dye. Endpoints included (1) successful SLN identification, (2) false-negative rate, (3) dye-isotope concordance, and (4) the SLN/axillary background isotope count ratio. RESULTS: ID isotope was more successful than IP, identifying the SLN in 98% versus 89% of cases, respectively. False-negative results (4.8% vs 4.4%) and dye-isotope concordance (92% vs 93%) were comparable between the 2 groups, and SLN/axillary background isotope count ratios were significantly higher with ID than with IP injection (288/1 vs 59/1). CONCLUSIONS: ID isotope injection identifies the SLN more often than IP, stages the axilla with comparable accuracy, and is associated with higher levels of SLN isotope uptake. The dermal and parenchymal lymphatics of the breast drain to the same axillary SLN in most breast cancer patients, and ID isotope injection is the procedure of choice in this setting.

A trend analysis of the relative value of blue dye and isotope localization in 2,000 consecutive cases of sentinel node biopsy for breast cancer.

BACKGROUND: Among the advocates of blue dye, isotope, or combined dye-isotope mapping of the sentinel lymph node (SLN) for breast cancer, there is no universal consensus as to which technique is optimal and whether the relative value of each method changes with increasing experience. The objective of this study was to examine the relative contributions of blue dye and radioisotope to successful identification of the SLN as the SLN-mapping technique evolved over our first 2,000 consecutive cases. STUDY DESIGN: Using the first 2,000 consecutive SLN biopsy procedures for breast cancer, performed by eight surgeons (none previously experienced in SLN techniques) at one institution, using a combined technique of blue dye and isotope mapping, we report the institutional learning curve and the relative contributions of dye and isotope to identifying both the SLN and the positive SLN, by increments of 500 cases. RESULTS: Comparing the first 500 with the most recent 500 cases, success in identifying the SLN by blue dye did not improve with experience, although success in isotope localization steadily increased, from 86% to 94% (p < 0.00005). With the increasing success of isotope mapping, the marginal benefit of blue dye (the proportion of cases in which the SLN was identified by blue dye alone) steadily declined, from 9% to 3% (p = 0.0001). Parallel to this trend, the proportion of positive SLNs identified by blue dye did not change with experience (89% to 90%), but isotope success steadily increased, from 88% to 98% (p = 0.0015). The proportion of positive SLNs identified by blue dye alone declined from 12% to 2% (p = 0.0015). CONCLUSIONS: Using a combined technique of blue dye and radioisotope mapping, and with refinement of the radioisotope technique, we report 97% success identifying the SLN. Although we continue to recommend the use of both methods in SLN mapping for breast cancer, we observe with experience a declining marginal benefit for blue dye.

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.

Development of a model for training and evaluation of laparoscopic skills.

BACKGROUND: Interest in the training and evaluation of laparoscopic skills is extending beyond the realm of the operating room to the use of laparoscopic simulators. The purpose of this study was to develop a series of structured tasks to objectively measure laparoscopic skills. This model was then used to test for the effects of level of training and practice on performance. METHODS: Forty-two subjects (6 each of surgical residents PGY1 to PGY5, 6 surgeons who practice laparoscopy and 6 who do not) were evaluated. Each subject viewed a 20-minute introductory video, then was tested performing 7 laparoscopic tasks (peg transfers, pattern cutting, clip and divide, endolooping, mesh placement and fixation, suturing with intracorporeal or extracorporeal knots). Performance was measured using a scoring system rewarding precision and speed. Each candidate repeated all 7 tasks and was rescored. Data were analyzed by linear regression to assess the relationship of performance with level of residency training for each task, and by ANOVA with repeated measures to test for effects of level of training, of repetition, and of the interaction between level of training and repetition on overall performance. Student's t test was used to evaluate differences between laparoscopic and nonlaparoscopic surgeons and between each of these groups and the PGY 5 level of surgical residents. RESULTS: Significant predictors of overall performance were (a) level of training (P = 0.002), (b) repetition (P < 0.0001), and (c) interaction between level of training and practice (P = 0.001). There was also a significant interaction between level of training and the specific task on performance scores (P = 0.006). When each task was evaluated individually for the 30 residents, 4 of the 7 tasks (tasks 1, 2, 6, 7) showed significant correlation between PGY level and score. A significant difference in performance scores between laparoscopic and nonlaparoscopic surgeons was seen for tasks 1, 2, and 6. CONCLUSIONS: A model was developed to evaluate laparoscopic skills. Construct validity was demonstrated by measuring significant improvement in performance with increasing residency training, and with practice. Further validation will require correlation of performance in the model with skill in vivo.

Evaluation of laparoscopic skills: a 2-year follow-up during residency training.

OBJECTIVE: To evaluate laparoscopic technical skill in surgical residents over a 2-year period. DESIGN: The laparoscopic technical skills of general surgical residents were evaluated using the MISTELS program. This provides an objective evaluation of laparoscopic skill, taking into account precision and speed. SETTING: Inanimate laparoscopic skills centre. PARTICIPANTS: Ten general surgical residents (5 PGY1, 3 PGY2 and 2 PGY3 residents) who were required to complete 3 structured laparoscopic tasks. OUTCOME MEASURES: A composite score incorporating precision and timing was assigned to each task. The paired t-test was used to compare performance of each resident at the 2 levels of their residency training for each task. Linear regression analysis was used to correlated level of training and total score (sum of all tasks). RESULTS: Linear regression analysis demonstrated a highly significant correlation between level of training and total score (r = 0.82, p < 0.01). There was a significant increase in scores in the cutting and suturing task over the 2-year period (p < 0.01). Transferring skills did not improve significantly (p = 0.11). CONCLUSIONS: Performance in the simulator improved over residency training and was correlated highly with postgraduate year. This simulator model is a valuable teaching tool for training and evaluation of basic laparoscopic tasks in laparoscopic surgery.

Profound hypotension in blunt trauma associated with superior gluteal artery rupture without pelvic fracture.

Superior gluteal artery injury is a rare but well-known complication of abdominal trauma, usually in association with pelvic fractures. Embolization has become the most effective treatment for pelvic hemorrhage with regard to superior gluteal artery injury, due to difficult surgical access. We report an unusual case of a superior gluteal artery rupture without pelvic fracture. The patient presented with profound hypotension after blunt trauma. Angiography revealed an injured superior gluteal artery, which was successfully embolized.

The effect of practice on performance in a laparoscopic simulator.

BACKGROUND: Laparoscopic skill was measured objectively in a simulator. Seven tasks were scored in terms of precision and speed. These tasks included transferring, cutting, clip+ divide, placement of a ligating loop, mesh placement+ fixation, and suturing with intracorporeal and extracorporeal knot. METHODS: After baseline evaluation, 12 surgical residents were randomized to either five weekly practice sessions (Group A) or no practice (Group B). Each group was then retested. Performance scores were compared for baseline versus final test, and improvement (baseline to final) for Group A versus Group B. Group A residents had a total of seven repetitions of each task (baseline, five practices, final). Linear regression analysis was used to test for the correlation between score and repetition number. RESULTS: Group A showed significant improvement in their scores (baseline to final) for each task and for the total score (sum of all tasks) (p < 0.05). Group B showed significant improvement in four of seven tasks and for the total score. The magnitude of improvement of Group A versus Group B residents was significantly greater for four of seven tasks (peg transfer, placement of ligating loop, and both suturing skills) and for the total score. The final total score for Group A was 219 +/- 14% of baseline (p < 0.0001), whereas Group B was only 162 +/- 35% of baseline (p = 0.07) and not statistically significant. For Group A residents, there was a highly significant correlation between trial number and performance score (p < 0.05) for each individual task and for the total score. CONCLUSIONS: Laparoscopic skill can be measured objectively in a simulator, and performance improves progressively with practice. These skills can be incorporated into the training and evaluation of residents in laparoscopic surgery.

A simplified simulator for the training and evaluation of laparoscopic skills.

BACKGROUND: Laparoscopic skills can be measured objectively in a video-laparoscopic cart simulator system. These scores have been shown to be sufficiently sensitive to distinguish differences in performance between residents at different levels of training. The purpose of this study was to compare a simplified mirrored-box simulator to the video-laparoscopic cart system. METHODS: A total of 22 surgical residents performed seven structured tasks in both simulators in random order. Scores reflected precision and speed. The tasks were transferring, cutting, clip + divide, looping, mesh placement + fixation, and suturing with intracorporeal and extracorporeal knots. RESULTS: There were no significant differences in mean raw scores between the simulators for six of the seven tasks. Resident total scores correlated well between simulators (r = 0.68, p = 0.001). Resident ranking also correlated well (r = 0.69, p < 0. 001). CONCLUSIONS: A mirrored-box simulator was shown to provide a reasonable reflection of relative performance of laparoscopic skills. Practical, effective laparoscopic skills training and evaluation can be accomplished without the need for cumbersome equipment.

Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator.

BACKGROUND: Laparoscopic skill was measured objectively through a series of seven tasks in an inanimate laparoscopic simulator. Seven analogous skills were tested in an in vivo porcine model. These skills included transferring, cutting, clipping, placement of a ligating loop, mesh placement, and suturing with an intracorporeal and extracorporeal knot. Scoring of each task rewarded precision and speed. METHODS: Twelve PGY3 residents were given a baseline evaluation in the simulator and in the animal model. They were then randomized to either five practice sessions in the simulator (group A) or no practice (group B). Each group was retested in the simulator and in the animal (final test). Scores in vivo were compared by t-test for baseline versus final evaluation for each group. Linear regression analysis was used to correlate in vivo and in vitro scores for each task and for the total score (sum of all scores). RESULTS: Group A showed significant improvement in performance in vivo for cutting, clipping, mesh placement, and suturing with an intracorporeal and extracorporeal knot, as well as in the total score (p < 0.05). Group B showed significant improvement in suturing with an intracorporeal and extracorporeal knot, and in the total score. The magnitude of improvement from baseline to final evaluation was significantly greater for group A (p < 0.05). There was significant correlation between in vitro and in vivo total scores and the score for each task (p < 0.05) except for placement of the ligating loop and mesh. CONCLUSIONS: Performance in an in vitro laparoscopic simulator correlated significantly with performance in an in vivo animal model. Practice in the simulator resulted in improved performance in vivo.