Evaluation of a system designed to enhance the resident selection process.

The purpose of this research was to evaluate the use and effectiveness of the Universal Medical Student Performance Profile System in enhancing the resident selection process. The Universal Medical Student Performance Profile System involved the use of a standardized student evaluation form completed by surgery clerkship directors to summarize student performance. These student profile forms were then forwarded to general surgery program directors to whom each student applied. Twenty-five surgery clerkship directors volunteered to complete student profile forms on students pursuing surgical careers for the classes of 1986 and 1987. Program directors who had accepted students in their programs on whom these standardized evaluation forms had been completed were asked to complete a similar form based on the graduate's first year of residency performance. Findings showed statistically significant relationships in several assessment categories between clerkship and program directors' ratings. A survey of program directors showed they agreed with the concept of a standardized medical student evaluation form and found the student profile forms helpful in making decisions on resident selection. We concluded form this baseline study that the use of a standardized student evaluation form will have limited predictive validity, unless clerkships improve efforts to standardize clerkship objectives, expectations, and performance measures.

A multidisciplinary surgery clerkship: ten-year experience.

This article describes the principles, logistics, and curriculum of an integrated, multidisciplinary surgery clerkship. This clerkship, tailored to mastery-based instruction, was designed to meet specified goals unique to this institution and structured to obviate weaknesses of traditional clerkship formats. Evaluation methods have been designed to assess the clerkship program, student performance in and reaction to the clerkship, and performance after graduation from medical school. Results indicated clerkship ratings by students are typically above average for all educational modalities and that six out of seven graduating classes rated the surgery clerkship significantly higher (p less than 0.05) than their other clerkship experiences. Other findings showed highly satisfactory to above average performance of graduates whether based on residency supervisors' evaluations or self-evaluations and higher ratings for the graduates who selected surgery residency programs than for those pursuing other disciplines.

What does the American Board of Surgery In-Training/Surgical Basic Science Examination tell us about graduate surgical education?

BACKGROUND: This research sought to identify the strengths and weakness in residents' basic science knowledge and, second, to determine whether they progressively improve in their abilities to recall basic science information and clinical management facts, to analyze cause-effect relationships, and to solve clinical problems. METHODS AND RESULTS: Basic science knowledge was assessed by means of the results of the January 1990 American Board of Surgery's In-Training/Surgical Basic Science Exam (IT/SBSE). Postgraduate year (PGY) 1 residents' scores were compared with those of PGY5 residents. Content related to a question was considered "known" if 67% or more of the residents in each of the two groups answered it correctly. Findings showed 44% of the content tested by the basic science questions were unknown by new and graduating residents. The second research question required the 250 IT/SBSE questions to be classified into one of three levels of thinking abilities: recall, analysis, and inferential thinking. Profile analysis (split-plot analysis of variance) for each pair of resident levels indicated significant (P < 0.001) differences in performance on questions requiring factual recall, analysis, and inference between all levels except for PGY3s and PGY4s. CONCLUSIONS: The results of this research enable program directors to evaluate strengths and weaknesses in residency training curricula and the cognitive development of residents.

Surgical manpower and practice patterns in a nonmetropolitan area. Nonmetropolitan surgical manpower.

Surgical practice in a nonmetropolitan area was studied with a field survey of 33 general surgeons and family practitioners. Instruments included a physician interview and questionnaire, a nurse-receptionist questionnaire, a sample of 3,733 office patient records, and a sample of hospital operating room logbooks. The general surgeons reported spending an average of 22 hours a week seeing an average of 74 patients in their office practices. Twenty-six percent of the presenting problems and 32% of the principal diagnoses identified in the sample of general surgeons' office patient records were defined as primary care problems. Twenty-two percent of the problems and diagnoses were defined as specialty surgical problems, such as urological problems. An indication of patient referral was found in 2% of the records. In hospital practice the surgeons estimated spending an average of 14 hours a week in the operating room, and performed an average of seven to eight procedures a week. The mean California relative value (CRV) for each procedure was 10.0 CRV. The family physicians managed patients with a broad range of problems, including surgical, in their office practices, and performed an average of three operative procedures each week in the hospital.

Determining the content of a surgical curriculum.

The purpose of undergraduate surgical education is to prepare the student for both the residency and eventual practice of medicine. To help determine the surgical knowledge and skills that would eventually the useful to the student, we conducted a survey of residents in training, physicians in practice, and surgical educators (department chairpersons and clerkship directors). Members of the Curriculum Committee of the Association for Surgical Education developed a questionnaire in which the respondents were asked to grade the functional importance of 84 areas of knowledge and 46 skills (0 = unnecessary, 3 = proficiency necessary). Using a modified Delphi technique to collect information, we sent the questionnaire to eight medical school graduation classes of 1975 (730 persons) and 1980 (776 persons) and all department chairpersons and/or clerkship directors (179). The results of the survey (46% response) revealed considerable agreement about the importance of certain skills and areas of knowledge, enabling us to rank order skills and knowledge based on mean responses (0.0 to 3.0). Physicians in practice, residents, and educators believed that certain areas of knowledge (e.g., acute abdominal problems, appendicitis, shock, cancer of the breasts) and skills (e.g., history taking and physical examination, gowning, suture removal) were very important (greater than 2.250, while other areas of knowledge (e.g., transplantation, liver abscess, soft tissue sarcomas) and skills (e.g., insertion of Swan-Ganz catheter, abdominal paracentesis, cricothyroidotomy) were less important (less than 1.3). This approach allows us to assign priorities to areas of knowledge and skills when determining curriculum content and to include functional criteria when developing educational objectives.

Herniation of the gastric wall through a Nissen fundoplication.

Two patients presented several years after Nissen fundoplication with dysphagia and/or hemorrhage. In both, the fundoplication was intact in the original relationship to the cardia but herniated gastric wall was found between the fundic wrap and the distal end of the esophagus. The diagnosis and alternatives for preventing this problem are presented.

Lower extremity arterial insufficiency after long-term methysergide maleate therapy. Its evaluation with Doppler ultrasonic velocity detector.

Iatrogenic ergotism is the primary source of ergot intoxication. The patient whose case is reviewed had migraine headaches and received methysergide maleate for 13 years. She had, in July 1977, severe claudication of the lower extremities. Measurements of the peripheral arterial circulation were made using the Doppler ultrasonic velocity detector. The extent of disease and subsequent reversal were documented using arteriographic examination. Initial measurements showed the patient was able to walk for one minute and 34 seconds on a treadmill (2 mph, 10% grade) before stopping because of claudication. Symptoms cleared after drug withdrawal and repeated testing produced no claudication. The calculated index (posterior tibial/arm pressure) increased from a mean of 0.22 to 0.74 during the eight-month period following discontinuance of methysergide therapy with no recurrence of migraine headaches. A review of the literature is also presented.

Cancer in cystic lesions of the thyroid.

We reviewed the records of 341 patients who underwent thyroidectomy for the suspicion of cancer between 1975 and 1980. Cancer of the thyroid was found in 14% of them. Although cysts of the thyroid (pathologic finding of a fluid-filled cavity greater than 1 cm in diameter) were encountered in 35% of the patients, cysts were similarly distributed among patients with benign conditions (27%) or with cancer (33%). Most of the thyroid cysts in patients with carcinoma measured 2 to 4 cm in diameter. The cancer was found within the cystic cavity. The cysts in patients with cancer appeared to originate from necrosis of the tumor. B-mode ultrasonography was not reliable in differentiating cystic and solid lesions. The demonstration of the cystic nature of a thyroid nodule does not rule out the diagnosis of cancer of the gland.

Is test security a concern when OSCE stations are repeated across clerkship rotations?

PURPOSE: To examine the issue of test security when the same stations on an objective structured clinical examination (OSCE) are repeated across clerkship rotations. Specifically, is there a significant difference in students' scores on stations repeated in three or four rotations within a single academic year? METHOD: The sample consisted of 15 stations in the OSCE given at the end of the third-year surgery clerkship at the Southern Illinois University School of Medicine from 1989-90 through 1993-94. Each station was administered three or four times a year. One-way analyses of variance with contrast coding to test for linear trends were used. Results were considered significant at or below the .05 level. RESULTS: Only three of the 15 stations showed significant linear trends. A two-part couplet orthopedic station showed a significant decreasing linear trend (p=.0001). Two stations showed significant increasing linear trends: a general surgery couplet station (p=.0004) and a plastic surgery station with an essay question (p=.0253). CONCLUSION: There was no consistent evidence that students scored increasingly higher on OSCE stations repeated throughout the year. Thus, it would appear that a clerkship can repeat OSCE stations within an academic year without risk of a trend toward increasing scores.

Adenoma weight: a predictor of transient hypocalcemia after parathyroidectomy.

To evaluate the relationship of parathyroid adenoma weight to perioperative serum calcium levels, 51 selected patients with pathologically confirmed single adenomas and minimal biopsy at operation were reviewed. Three age- and sex-matched groups were established according to adenoma weight. Compared with Group 1 patients who had adenomas of less than 1 g, Group 3 patients with adenomas of more than 2 g demonstrated significantly higher preoperative serum parathyroid hormone and calcium levels, and significantly lower preoperative serum phosphate levels. Multiple regression analysis revealed a strong correlation between adenoma weight to preoperative parathyroid hormone and calcium levels (r = 0.63, p less than 0.001). These results suggest that larger adenomas may be associated with a more severe form of primary hyperparathyroidism. The incidence of transient postoperative hypocalcemia in the 51 patients who underwent adenoma excision was 37 percent. Permanent hypoparathyroidism did not develop in any of them. Compared with Group 1 patients, Group 3 patients demonstrated a higher incidence of postoperative transient hypocalcemia (69 percent versus 14 percent in Group 1, p less than 0.001) and significantly lower mean serum calcium levels on the third and fourth postoperative days. Increased adenoma weight may be a valuable aid in identifying those patients at risk for transient hypocalcemia after neck exploration.

The learning needs of first-year surgical residents in the intensive care unit.

BACKGROUND: Residents are more likely to learn from educational experiences when properly prepared from the start of instruction and expectations are clear and consistent. The purpose of this study was to examine what first year residents need to know and be able to perform before starting their rotation in the intensive care unit (ICU). METHODS: The sample included surgical faculty, first through fifth year general surgery residents, and ICU nurses. A survey was developed that listed 110 knowledge and skill items felt to be possible prerequisite learning objectives. Respondents were asked to evaluate the required level of knowledge or skill on a 5-point Likert-type scale. RESULTS: Items were divided into knowledge or skill categories and then ranked in descending order by their mean ratings. Four knowledge and 10 skill items were ranked highly by all 3 groups of respondents. Kruskall-Wallis analyses found 58 items with statistically significant differences in mean ratings between groups of respondents. CONCLUSION: With this information a self assessment tool was developed to determine the level of performance on these identified learning objectives. A course of instruction can now be developed to assist residents in meeting these objectives before they assume patient care responsibilities in the ICU.

An analysis of the fourth year of medical school for students pursuing surgical careers.

A fourth-year curriculum survey was forwarded to surgery resident program directors, clerkship directors, and residents. A 37 percent response rate was achieved with comparable representation of each respondent type from 130 institutions. The purpose of the survey was to determine how each of the 3 respondent types rated the importance of 42 subjects or clinical experiences to be taken in the fourth year of medical school for students pursuing surgical careers. The survey also included questions on such issues as externships, early match programs, and guidelines used at their institutions for their fourth year students. The results indicated a significantly high agreement among respondent types on what should comprise surgical students' fourth-year curriculum content. The majority feel the fourth year should be planned by students with an electives advisor to equally add breadth to their general professional education as well as provide prerequisite experiences in the career-chosen discipline.

The preoperative liver scan and surgical decision-making in patients with colorectal cancer.

The influence of preoperative liver scans and liver function tests on surgical decision-making was analyzed in 196 patients who underwent surgical therapy for colorectal cancer. One hundred and thirteen patients who had preoperative liver scans were compared with 83 patients who did not. No statistically significant difference existed between the liver scan group and the nonscan group in terms of when surgical decision-making occurred. Likewise, the results of the liver scan did not influence when operative decisions were made. The majority of decision-making occurred intraoperatively when ultimate confirmation of the presence or absence of hepatic metastases was made. Presumptive surgical decisions were made preoperatively, but final decisions occurred intraoperatively when all relevant patient data could be correlated. Liver scanning has limited usefulness in the preoperative evaluation of patients with colon cancer as it does not affect decision-making and is much more costly than liver function testing.

Patients' attitudes toward the involvement of medical students in their care.

BACKGROUND: Research has shown that medical students are generally accepted by patients, but specific details that elucidate patient perceptions of the advantages and disadvantages to student involvement have not been documented. This study was designed to determine variables that influence patient satisfaction with students. PATIENTS AND METHODS: Patients were interviewed by one of two faculty members using a questionnaire-style format that covered 12 variables regarding patient care. Patients were asked to rate the extent to which medical students helped or hindered their hospital stay, with regard to the 12 variables. RESULTS: Patients' attitudes were favorable regardless of the students' extent of clinical experience or clinical abilities or the patients' age or length of hospital stay. Patients reported that students spent time with them and answered their questions. Most patients stated that they would allow students to participate in their future hospital care. CONCLUSION: Positive patient-student interactions can have important effects on patients' expectations and their acceptance of future encounters with students. This fact is becoming increasingly important due to the changes in health care and the decreasing incidence of inpatient surgical encounters.

An evaluation of study habits of third-year medical students in a surgical clerkship.

BACKGROUND: This study was developed to assess study habits of medical students in a third-year surgical clerkship and to determine the relationship of these study habits to performance outcomes. METHODS: A questionnaire designed to assess medical student study habits was administered at the end of five consecutive 10-week multidisciplinary surgical clerkships. The results of questionnaires from 81 students were analyzed in respect to results on the National Board of Medical Education (NBME) surgical subtest and the multiple stations clinical examination (MSCE) given at the end of each clerkship. RESULTS: Although only 18 of the total 81 students reported studying in formal but self-directed groups, students who reported studying in a group on average scored 4 points higher on the MSCE than those who did not study in a group (P = 0.001). However, no significant differences or correlations were discovered between any of the study habits and the individual results on the NBME. CONCLUSION: Students may benefit from collaborative studying when it comes to clinical experience as demonstrated by improved performance on the MSCE.

Development of physical examination skills in a third-year surgical clerkship.

BACKGROUND: Previous studies have revealed deficiencies in physical examination (PE) skills of third-year medical students. The purpose of this study was to determine if formal teaching of PE skills and more supervised experiences with clinical faculty would increase the competency of these skills. METHODS: Forty-nine third-year medical students were assigned to one of two groups: group A was given formal instruction on PE skills at the beginning of the clerkship, and group B received the same instruction at the midpoint of the clerkship. The two groups received an assessment of the PE skills before, in the middle, and at the end of clerkship, utilizing a physician-developed checklist. RESULTS: Group A had a pretest score of 57.7%. Group B scored 59.8% on the pretest. Independent groups t tests were used to compare the two groups. At the midterm examination, group A increased their score to 71.0%, while group B decreased their score to 55.6%. From beginning to final, both groups had significant improvements in all areas, with group A scoring an overall mean of 75.1% (P = 0.0001), and group B scoring 75.5% (P = 0.0001). CONCLUSION: These findings show the effectiveness of structured learning situations for improving third-year surgery students' PE skills. There is also an indication that usual clerkship activities may not enhance learning of PE skills.

Correlates of honor ratings in a clinical clerkship employing a faculty forum evaluation system.

5he purpose of this study was to determine whether or not suspected variables affected a surgery clerk's chances of being awarded an honor rating. Findings indicated a significant relationship between a student receiving an honor rating and his or her preceptor's predetermined level of student advocacy, the number of completed patient interview and physical examination write-ups, and final examination scores. There was no significant relationship found between honor ratings and the preceptor's status, the sequence in which the student was discussed or the length of time spent discussing the student at the final evaluation meeting, or the number of clinical faculty present at the meeting. These results lend support to the faculty forum evaluation approach, but suggest a need for further scrutiny of some influencing variables to ensure all students are fairly considered and honor ratings judiciously awarded.

A comparison of objective and subjective measures of clinical competence.

The purpose of this study was to determine if objective performance measures from a simulated patient practical examination were related to faculty subjective assessments of surgery students' performance. Another purpose was to determine if those students performing well on a simulated patient practical examination were the same students awarded honor ratings by faculty. Faculty ratings of students (n = 72) on history taking ability, physical exam skills, problem identification, use of investigations, problem integration, patient management, and patient relations skills were correlated with objective measures on these same criteria achieved on a practical exam employing three simulated patient cases. Correlations were also calculated to study the relationship between practical exam scores and honor rating recipients. Results indicated significant relationships between faculty subjective ratings and practical exam outcomes on all practical examination skills except physical exam skills and patient management skills. Findings also indicated the performance of honor students on the practical examination was significantly better than non-honor students on two skills: history-taking and patient relations. The implications of these research findings are discussed.