Do resident duty hour restrictions reduce technical complications of emergency laparoscopic cholecystectomy?

BACKGROUND: The impact of resident duty hour restrictions on patient care has not been assessed. STUDY DESIGN: We studied 275 patients undergoing emergency cholecystectomy before and after duty hour regulations instituted by the Accreditation Council for Graduate Medical Education. Operations were stratified into 6-hour intervals from the time in-hospital call began. Procedure-related complications (bile duct injury, cystic duct leak, abdominal hemorrhage, trocar injury, intraabdominal/wound infection, unrecognized retained stone) were the primary outcomes variables. RESULTS: Complications occurred after 7 of 107 (6.5%) operations performed before duty hour restrictions, which was not different from 15 of 168 (8.9%) after duty hour restrictions. In both periods, all complications followed operations that began within the first 18 hours of duty. Patients with complications had longer operative times (p = 0.038) and a higher proportion of operations lasting 120 minutes or longer (p = 0.006). Comparing patients with and without complications, there were no significant differences in patient demographics, operative complexity, or PGY level of the surgeon. Only operative time of 120 minutes or longer retained significance in the multivariable model (p = 0.0023; odds ratio, 4.05; 95% CI, 1.65-9.97). CONCLUSIONS: There was no correlation between imposition of duty hour restrictions and technical complication rates in this study. Duration of operative time of 120 minutes or longer was the only independent marker, suggesting that technical complications are a function of operative complexity, not duration of duty. These data suggest that duty hour restrictions might not have a measurable influence on the surgical complication rate after emergency cholecystectomy.

Do student perceptions of surgeons change during medical school? A longitudinal analysis during a 4-year curriculum.

BACKGROUND: Student recruiting is a top priority for surgical educators. Efforts have focused on improving the junior clerkship, but earlier interventions might prove to be more effective. This study was performed to determine students' perceptions of surgeons across all 4 years, with special emphasis on the effect of the 3(rd)-year clerkship. STUDY DESIGN: During 2004 to 2007, medical students at all levels were surveyed with 21 statements about surgeons' behavior, lifestyle issues, and potential as role models. Subjects responded anonymously using a 5-point Likert scale (1 = strongly agree). Surveys were administered annually to medical student year 1 (MS1), MS2, and MS4, and before and after the clerkship to MS3. Data were analyzed using chi-square contingency table analyses. RESULTS: Three-thousand and sixty surveys were analyzed (MS1, n = 833; MS2, n = 670; MS3, n = 1,193; and MS4, n = 364). Responses among MS1 and MS2 confirm that students enter medical school with negative impressions of surgeons. The surgical clerkship had a positive impact, but this effect was lost by senior year. Changes in perceptions were statistically significant for 20 of 21 statements. This is underscored by the fact that the proportion of students applying to general surgery from our medical school remains essentially unchanged (2004, 5.3%; 2005, 7.4%; 2006, 10%; 2007, 7.4%; and 2008, 6%). CONCLUSIONS: These data suggest that the junior surgery clerkship has a favorable but transient impact on the negative perceptions that medical students have about surgeons. Perceptions return to negative values within 1 year of the clerkship. Recruiting efforts should be focused on earlier interaction with students rather than concentrating on a 2- to 3-month rotation in the junior year.

Preparing medical students to enter surgery residencies.

BACKGROUND: This study was designed to develop and evaluate an integrated cognitive and proficiency-based skills curriculum based on American College of Surgeons Graduate Medical Education Committee (ACGME) competencies to prepare students for surgery internships. METHODS: Course content included cadaver dissections, didactic sessions, team training, and training in clinical and technical skills. Using previously validated skills curricula (12 open and 5 Fundamental Laparoscopic Surgery [FLS] tasks), trainees underwent pretest, self-practice to proficiency, and post-test. Surveys regarding confidence levels and skills were administered. RESULTS: Mean course evaluation score was 4.5 +/- .6 on a 5-point Likert scale. Trainees (n = 9) achieved proficiency on open tasks and FLS tasks 2-5. The mean confidence self-rating on 51 skills increased on a 5-point Likert scale from 2.4 +/- .6 to 4.0 +/- .6 (P < .001). CONCLUSIONS: This integrated curriculum did improve confidence levels, and skills proficiency can be achieved in an abbreviated time. The anticipated result would be enhanced baseline abilities for internship.

Can medical students achieve skills proficiency through simulation training?

BACKGROUND: The purpose of this study was to determine whether third-year medical students can become proficient in open technical skills through simulation laboratory training. METHODS: A total of 204 students participated in a structured curriculum including bladder catheterization, breast examination, and knot-tying. Proficiency was documented using global rating scales and validated, objective, model-based metrics. RESULTS: For catheterization and breast examination, all trainees showed proficiency, and self-rated comfort increased in more than 90%. For knot-tying, 83% completed the curriculum; 57% and 44% of trainees showed proficiency for 2- and 1-handed tasks, respectively. Objective performance scores improved significantly for 2- and 1-handed knot-tying (62.9-94.4 and 49.2-89.6, respectively; P < .001) and comfort rating also increased (28%-91% and 19%-80%, respectively; P < .001). CONCLUSIONS: Objective scores and trainee self-ratings suggest that this structured curriculum using simulator training allows junior medical students to achieve proficiency in basic surgical skills.

Factors related to attrition in surgery residency based on application data.

OBJECTIVE: To determine whether variables in the surgery resident selection process will predict attrition or performance during residency training. DESIGN: Retrospective study. SETTING: A university residency program. PARTICIPANTS: A total of 111 categorical surgery residents matched during a 10-year period (1991-2000). MAIN OUTCOME MEASURES: Satisfactory outcome included successful completion of training and the American Board of Surgery examinations on the first attempt. Participants with a satisfactory outcome were stratified into good or marginal performance based on adverse actions during residency. RESULTS: Of 111 residents studied, 28 (25.2%) had an unsatisfactory outcome; attrition occurred in 25 (22.5%). Univariate analysis identified the following variables as predictors of unsatisfactory outcome: age at entry older than 29 years (P = .005), female sex (P = .02), courses repeated (P = .01), "C" grades on transcript (P = .01), no participation in team sports (P = .02), and lack of superlative comments in the dean's letter (P = .03). The following variables were retained in the multivariate model: age older than 29 years (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.02-0.47; P = .003), summary comments in the dean's letter (OR, 4.57; 95% CI, 2.00-10.43; P < .001), participation in team sports (OR, 4.96; 95% CI, 1.36-18.05; P = .02), and merit scholarship in medical school (OR, 0.25; 95% CI, 0.08-0.78; P = .02). CONCLUSIONS: Attrition can be predicted from factors identified on residency applications, with nonacademic factors being more important. Among residents who completed the program, no predictors of performance were identified.

Teaching trauma care in India: an educational pilot study from Bangalore.

BACKGROUND: Trauma has become a major cause of death and disability in developing countries. In India, most trauma patients receive initial care at general practitioner-staffed hospitals. We hypothesize that general practitioners (GPs) could improve their knowledge of trauma care after attending an educational course. METHODS: A 2-day trauma course was conducted at a teaching hospital (170 bed) in Bangalore, India. Referral GPs, local surgeons and residents in training attended. A pre-course test was given to assess baseline trauma knowledge. The core didactic sessions included: resuscitation/recognition of shock states, airway prioritization, and evaluation/initial management of head, cardiothoracic, abdominal, pelvic/genitourinary, and thermal injuries. A post-course test was used to assess trauma knowledge obtained from the course. Paired t tests were performed on the test scores and demographic data were stratified by specialty and training status. RESULTS: Of the 44 participants, 32 (72%) met study inclusion criteria: MBBS degree and course completion. The study population was 62.5% male with 47% surgeons and 53% GPs. Residents were 71.8% of the entire group. Overall, the pre- and post- course scores improved from 70.7% +/-11.2 to 87.5% +/-8.9, P = 0.000 (95%CI 12.1, 21.2). There was an increase of mean scores: 21.4% (SD +/-13.7) for GPs and 11.3% (SD +/-8.5) for surgeons (P = 0.02). CONCLUSION: Although GPs had significantly lower pre-course scores than surgeons, at the end of the course, GPs performed as well as surgeons. These findings suggest allocation of limited educational resources for trauma care in India may be best used by GPs.