Assessment of Surgical Training for First-Year Postgraduate Trainees; Analysis of Interrater Disagreements / 医学教育

We investigated causes of interrater disagreements in the observational assessment of clinical training for first-year postgraduate trainees. In 1998 25 first-year postgraduates rotated through the Second Department of Surgery for 3 months, including 1 month in cardiovascular surgery, thoracic surgery, and upper-gastrointestinal surgery. Each trainee cared for several patients at most with a senior resident under the supervision of senior staff members. Nine attending physicians (staff members), 3 doctor-course graduates, and 2 chief residents assessed the trainees at the end of the rotation with special reference to clinical, social, and supervisory abilities. Trainees were given scores of “Good, ” “Fair, ” “Pass, ” or “Fail” for each ability. Interrater disagreements often involved responsibility and activeness, which reflected social abilities, and rapid patient consultations, orderly arrangement of laboratory examinations and procedures, and avoiding ordering of unnecessary laboratory examinations and medications, which reflected supervisory abilities. Assessments of poorly performing trainees often disagreed. Some interrater disagreements were seen among 4 of 14 attending physicians, but disagreements were fewer among the 3 doctor-course graduates and 2 chief residents who were graduates of the college. Both the proper training of assessors and a good relationship between assessors and rotators are necessary to make appropriate evaluations that might affect the career of postgraduates trainees.

Education of Doctor's Attitudes toward Patients in Medical Education in Japan / 医学教育

We surveyed in every medical university in Japan on how attitudes development is adopted in its medical educational curriculum so far. There are several universities which in some way have already adopted attitudes development into curriculum or teaching items. However, hours of lesson and the contents are so differed among them. Moreover, both evaluation of these lessons by trainees and judgement as far the educational effect by trainers are not programmed satisfactorily. Some universities complain of manpower shortage, difficulties of fixing curriculum, or shortage of total lesson hours, so that they say they cannot dare work on this attempt. But, there are still an increasing number of universities ready to start their programs, where education arranged by non-medical teachers, practical medical experience at the real front, the introduction of simulated patient (SP) into education, and so on are considerd to be carried out.<BR>Thus, we suppose it is time to have and share some guideline for adequate attitudes development education at this moment. And at the same time, a national system to encourage the medical education, including trainning SP, is urgently required to be planned.

A Survey on Undergraduate Clinical Training with Special Reference to Clinical Procedures Performed by Medical Students on Patients / 医学教育

A questionnaire survey on clinical procedures performed by medical students on patients during undergraduate clinical training was conducted in february 1996. Responses were received from 1328 clinical departments of university cospitals at 80 medical schools. Basic clinical procedures that medical students were permitted to perform on patients were recommended by a committee of the Ministry of Health and Welfare. These procedures are divided into three categories: level 1; procedures that medical students are permitted to perform under the supervision of an instructor; level 2; procedures medical students are permitted to perform with supervision under certain conditions; and level 3; procedures for which medical students are generally limited to assisting instructors or to attending and observing patients. The status of performance of the procedures was investigated. Of level-1 procedures (36 procedures), 8 were performed by medical students at more than 80 % of university hospitals, 19 were performed at from 50% to 70%, 9 were performed at less than 50%. Of level-2 procedures (15 procedures), 8 were performed at from 55% to 79% of hospitals and 7 were performed at less than 50%. For level-3 procedures (15 procedures), medical students were permitted to assist and observe 4 procedures at from 82% to 86% of hospitals, 11 at from 50% to 79%, and 1 at40%. In addition, students were permitted to perform 13 level-3 procedures at from 10% to 44% of hospitals and to perform 3 at from 6% to 9%. In many clinical departments, other kinds of procedures specific to the departments were adopted. Teaching media, such as standardized patients' computer-assisted instruction models, and animal materials, were used, and facilities in the community cooperated in training. Respondents wrote many suggestions and opinions about the difficulties and concerns with the legality of students' performing clinical procedures, patients' consent or agreement, minimal essentials of clinical competence of students, the shortage of instructors, and the training and guidelines for instructors.

Results of a Survey on the Present Status of Undergraduate Clinical Training and Plans for Its Improvement / 医学教育

We used questionnaires to study the present status of undergraduate clinical training at medical schools in Japan in February 1996. Completed questionnaires were returned by 81%(65) of 80 medical schools and approximately 54%(1, 328 clinical departments) of the schools. The results were as follows. Courses for early clinical exposure in the 1st or 2nd year were provided at 83% of the 65 schools; clinical clerkships in the 5th and 6th years were provided at 28%. Specific behavioral objectives for clinical training were clearly shown to students and teaching staff at 75% of schools. Clinical procedures that medical students were permitted to perform were listed and announced to students and teaching staffs at 66% of schools. Patients were informed and gave consent for clinical training of students at 77% of schools. Essential knowledge and skills of students were assessed before the start of clinical training at 40% of schools, and summative assessment was made at the end of the training at 72%. Training of clinical teaching staff for faculty development was conducted at 51% of schools. Eightynine percent of schools reported a shortage of clinical teaching staff. Similar results were obtained in the survey of clinical departments of university hospitals: most departments complained of a shortage of teaching staff, of students not being active, and of students not being competent to enter clinical training courses. To improve clinical training, the introduction of clinical clerkships and cooperation with community facilities outside universities were the main issues.

Introductory Remarks / 医学教育

Innovation of the university chartering standards law, which was enacted on July 1, 1991, has had important effects and brought major changes to most medical schools, A special meeting concerning the innovation law was convened on April 4, 1992, by the Undergraduate Committee of the Japan Society for Medical Education, to examine the revision and its effects. The main topic was covered in the lectures given by Prof. Hori and Prof. Nishizono at the meeting, and innovations in the educational curricula of leading medical schools were presented, that is, Tohoku Univ. by Prof. Itoh, Ninon Univ. by Prof. Sakurai, Tokai Univ. by Assoc. Prof. Otsuka, and Koube Univ. by Prof. Maeda. An explanation of the credit system under the revised law was given by Assoc. Prof. Shimizu, and a workshop on self-evaluation and self-developement was reported by Prof. Tokunaga. This issue should be examined by other medical schools that plan to introduce innovations in their curricula. We will continue to discuss the new program and its implementation at other medical schools in future publications.

Simultaneous Surgery on the Descending Thoracic and Abdominal Aortic Aneurysms / 日本心臓血管外科学会雑誌

A 67-year-old woman underwent simultaneous surgical treatment of aneurysms in the descending thoracic and abdominal aorta. The aneurysm in the descending thoracic aorta was 5.0cm in diameter. The abdominal lesion which was accompanied by closed partial dissection was located below the renal arteries and its diameter was 7.8cm. First, the patient was positioned in right decubitus position and left thoracotomy was made. The descending thoracic aorta was replaced with an artificial graft under partial cardiopulmonary bypass through the left femoral vein and artery. Thoracotomy was closed after removal of cardiopulmonary bypass and neutralization of heparin with protamine sulfate. The patient's position was then changed to supine, and following median laparotomy, her abdominal aorta was replaced with an artificial graft. Her postoperative course was entirely uneventful except for slight hoarseness and transient urine disorder. Although simultaneous operation for multiple aneurysms may give more surgical stress to patients, it can reduce the risk of rupture of the remaining aneurysm as compared with surgical treatment in two stages. The order in which aneurysms are operated on should be considered well in simultaneous operation. It was considered in this case that the thoracic lesion should be treated first because crossclamping of the abdominal aorta may increase cardiac afterloads and result in rise of intraluminal pressure and rupture of the thoracic aortic aneurysm.

Reconstruction Surgery of the Ascending Aorta and the Aortic Arch under Deep Hypothermia with Circulatory Arrest / 日本心臓血管外科学会雑誌

Eight patients with aneurysms in the ascending aorta and the aortic arch underwent reconstructive surgery under deep hypothermia and circulatory arrest between Jan., 1988 and Jun., 1991. The patients consisted of 3 males and 5 females, ranging in age from 45 to 73 years (62.0±11.8, mean ±S.D.). Four patients were operated on in emergency. The lesions in 7 of 8 patients were Stanford type A dissecting aneurysms and the remaining one was a true aneurysm in the ascending aorta and the proximal aortic arch. The operation time, extracorporeal circulation time, and circulatory arrest time were 432.6±147.3, 191.9±66.1, and 31.0±10.8 (16 to 47) min, respectively. In all cases, the ascending aorta and the proximal aortic arch were replaced by an artificial graft through the median sternotomy approach. The brachiocephalic artery was reconstructed in 2 cases. The intraoperative blood loss was 4, 685±2, 943ml and the blood transfusion was 4, 659±2, 779ml. All patients awoke from 2 to 19hr after surgery and no complication in the central nervous system was observed. The postoperative complications which were detected in 3 patients consisted of drug induced renal dysfunction in 1 case, sinus arrhythmia in another, and mild hepatic dysfunction in the last case. There were neither operative deaths nor late deaths during the follow up period which ranged from 1 month to 42 months. Deep hypothermia and circulatory arrest should be regarded as a good circulatory support technique in reconstrutive surgery of the ascending aorta and the proximal aortic arch.

Biochemical Changes of Venous Blood in Abdominal Aortic Surgery: Malondialdehyde Changes in Venous Blood / 日本心臓血管外科学会雑誌

The procedure of cross clamping and declamping of the infra-renal abdominal aorta is common in the reconstructive abdominal aortic surgery. However, little is known to the oxygen free radical formations during the surgery. To evaluate the oxygen radical production, the malondialdehyde (MDA) levels in venous blood were measured prior to, during and after the operation with other metabolites such as C3, C3a, granulocytes, CPK, amylase, BUN, creatinine, beta-2-microglobulin, total protein (TP), hematocrit (Ht), GOT, GPT, LDH, lactate, potassium, and myoglobulin in ten patients of the infra-renal aortic aneurysm. The average of the aortic occlusion time was 63±18min in the patients. The levels of MDA (from 3.2±0.7nmol/ml to 2.3±0.5nmol/ml), C3, TP and Ht were decreased during the operation and there were significant correlations between the levels of MDA (<i>r</i>=0.486, <i>p</i><0.01), C3 (<i>r</i>=0.59, <i>p</i><0.01) and TP. It is, therefore, likely that the reduction of MDA and C3 levels is due to the blood dilution by the bleeding, fluid infusion and blood transfusion during the operation. The levels of C3a did not increase during and after the operation. The levels of CPK (from 73±40U/<i>l</i> to 920±705U/<i>l</i>) and amylase (from 183±87U/<i>l</i> to 444±420U/<i>l</i>) were temporary increased on the first day after the operation. The level of lactate was increased during the occlusion of the aorta (from 9.0±3.0mg/dl to 20.2±5.8mg/dl) and until the just after the operation (23.2±18.6mg/dl). The other metabolites such as GOT, GPT, BUN, creatinine and beta-2 microglobulin did not change throughout the investigation period. There was a substantial ischemia of lower extremities during the aortic occlusion resulted in significant increase of lactate level. These results suggest that the temporary occlusion of the infra-renal aorta during the common reconstructive abdominal aortic surgry does not produce the oxygen free radical formation which increases the lipidperoxidation level in the systemic circulation.

A plan of the curriculum of chemistry for medical students / 医学教育

Based on two years working of “the enlarged working group for the curriculum of chemistry for medical education”, a provisional plan of the curriculum of chemistry for medical students is proposed. The article is consist of four sections; namely A: general problems, B: “chemistry” as a general education, C: purpose and specific problems of the general education for medical students, D: a provisional plan of the curriculum of chemistry for medical students.<BR>The main part D is consist of three subsections: namely (1) a plan of the curriculum of physical and inorganic chemistry, (2) a plan of the curriculum of organic chemistry, (3) a plan of the curriculum of experiments.