Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

IMPORTANCE: Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. OBJECTIVE: The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. DESIGN, SETTING, PARTICIPANTS: Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. MAIN OUTCOME MEASURES: Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. RESULTS: Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. CONCLUSIONS AND RELEVANCE: Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

The case of the entitled resident: a composite case study of a resident performance problem syndrome with interdisciplinary commentary.

BACKGROUND: Residents with performance problems create substantial burden on programs and institutions. Understanding the nature and quality of performance problems can help in learning to address performance problems. AIM: We sought to illuminate the effects of resident performance problems and the potential solutions for those problems from the perspectives of people with various roles in health care. METHODS: We created a composite portrait from several residents who demonstrated a cluster of common performance characteristics and whose chronic or serious maladaptive behavior and response to situations created problems for themselves, for their clinical colleagues, and for faculty of their residency program. The composite was derived from in-depth interviews of program directors and review of resident records. We solicited practitioners from multiple fields to respond to the portrait by answering a series of questions about severity, prognosis, and how and whether one could reliably remediate a person with these performance characteristics. We present their perspectives in a manner borrowed from the New England Journal of Medicine's "Case Records of the Massachusetts General Hospital." RESULTS: We created a composite portrait of a resident whose behavior suggested he felt entitled to benefits his peers were not entitled to. Experts reflecting on his behavior varied in their opinion about the effect the resident would have on the health care system. They suggested approaches to remediation that required substantial time and effort from the faculty. CONCLUSION: Programs must balance the needs of individual residents to adjust their behaviors with the needs of the health care system and other people within it.

Teaching operating room conflict management to surgeons: clarifying the optimal approach.

CONTEXT: Conflict management has been identified as an essential competence for surgeons as they work in operating room (OR) teams; however, the optimal approach is unclear. Social science research offers two alternatives, the first of which recommends that task-related conflict be managed using problem-solving techniques while avoiding relationship conflict. The other approach advocates for the active management of relationship conflict as it almost always accompanies task-related conflict. Clarity about the optimal management strategy can be gained through a better understanding of conflict transformation, or the inter-relationship between conflict types, in this specific setting. The purpose of this study was to evaluate conflict transformation in OR teams in order to clarify the approach most appropriate for an educational conflict management programme for surgeons. METHODS: A constructivist grounded theory approach was adopted to explore the phenomenon of OR team conflict. Narratives were collected from focus groups of OR nurses and surgeons at five participating centres. A subset of these narratives involved transformation between and within conflict types. This dataset was analysed. RESULTS: The results confirm that misattribution and the use of harsh language cause conflict transformation in OR teams just as they do in stable work teams. Negative emotionality was found to make a substantial contribution to responses to and consequences of conflict, notably in the swiftness with which individuals terminated their working relationships. These findings contribute to a theory of conflict transformation in the OR team. CONCLUSIONS: There are a number of behaviours that activate conflict transformation in the OR team and a conflict management education programme should include a description of and alternatives to these behaviours. The types of conflict are tightly interwoven in this setting and thus the most appropriate management strategy is one that assumes that both types of conflict will exist and should be managed actively.

Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools.

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

Attendings' Perceptions of Authentic Evaluation Criteria for Effective Surgical Consults.

OBJECTIVE: The authors aimed to investigate faculty evaluation criteria for an effective oral surgical presentation in actual patient care contexts. DESIGN: We conducted a 2-step observation-based qualitative study. Residents audiotaped oral presentations of a surgical consult to an attending. Evaluation panels listened to the recordings and discussed to develop joint feedback for the resident. The panel discussions were recorded and served as the data source for this study. We analyzed the data following the grounded theory approach using open coding and axial coding. SETTING: The study setting was at Southern Illinois University School of Medicine, a 5-year general surgery residency program in Springfield, Illinois. PARTICIPANTS: Thirteen residents out of 19 in the program participated by virtue of having submitted recordings of a patient care consult presentation via phone. Evaluation panels consisted of general surgery academic and community faculty, as well as senior residents. RESULTS: Several criteria for effective oral presentations emerged that have rarely been discussed in prior literature. Themes included: (1) The strategic opening is critical as it "sets the stage" and frames how the attending will listen. Situational factors, such as consideration of time of the day and urgency, should be accounted for in the opening. (2) A deductive structure defines the relevance of the presented information. Clinical judgement should precede supporting evidence. Attending physicians perceive important information as unnecessary if provided outside of this framework. (3) Established trust between a resident and a surgeon determines the level of detail expected of the presenting resident. With increasing trust, surgeons expect residents to present fewer details; if too much detail is included, the presentation may be assessed as ineffective. (4) Surgical descriptions are appreciated for their value in promoting the attending's visualization or mental picture of the patient condition. (5) Oral emphasis using voice tone and pace can be helpful for capturing attending attention. CONCLUSIONS: These findings can be utilized to improve the current training program and assessment rubrics toward contextualized work-based assessment practices in surgery. Oral patient presentation skills are neither static nor universal, but fluid and reflexive, based on trust, and situational factors.

Medical students' reflections on surgical educators' professionalism: Contextual nuances in the hidden curriculum.

INTRODUCTION: Surgical educators' professional behavior constitutes a hidden curriculum and impacts trainee's professional identity formation. This study explores the nuances of professional behaviors as observed in varying surgical settings. METHODS: 411 Transcripts originated from essays written by MS3 students during their surgical clerkship from 2010 to 2016 were collated. Employing a qualitative research methodology, we conducted a thematic analysis to uncover specific meaning emerging from medical student reflections' on surgical professionalism. RESULTS: In clinics, taking time and protecting patient privacy; in the OR, control over emotion during difficult situations and attention to learners; and in the inpatient setting, showing accountability above normal expected behavior were noted as professional. Similarly, unprofessional behaviors in these contexts paralleled lack of these attributes. CONCLUSIONS: Behaviors observed and the attributes of professionalism in the surgical learning environment have contextual nuances. These variations in professionalism can be utilized in deliberate development of professionalism in surgery.

A theory-based curriculum for enhancing surgical skillfulness.

BACKGROUND: Curricula for surgical technical skills laboratories have traditionally been designed to accommodate the clinical activities of residents, so they typically consist of individual, episodic training sessions. We believe that the skills laboratory offers an opportunity to design a surgical skills curriculum based on the fundamental elements known to be important for motor skill instruction. We hypothesized that training novices with such a curriculum for a 1-month period would yield skills performance levels equivalent to those of second year surgery residents who had trained in a traditional program. STUDY DESIGN: Fourth-year medical students served as study subjects (novice group) during a 4-week senior elective. They were taught each skill during a 1-week period. Subjects received instruction by a content expert followed by a 1-week period of deliberate practice with feedback. The novice performances were videotaped both before and after the intervention, and each videotape was evaluated in a blinded fashion by experts using a validated evaluation instrument. These results were compared with skill performance ratings of first- and second-year surgery residents that had been accumulated over the previous 3 years. RESULTS: Average performance ratings for the novices substantially improved for all four skills after training. There was no marked difference between average performance ratings of postintervention novice scores when compared with the average scores in the resident group. Inter-rater agreement in scoring for the videotaped novice performances exceeded 0.87 (intraclass correlation) for all ratings of pre- and posttraining. CONCLUSIONS: These results demonstrate the effectiveness of a laboratory-based training program that includes fundamentals of motor skills acquisition.

Do Surgeons and Gastroenterologists Describe Endoscopic Retrograde Cholangiopancreatography Differently? A Qualitative Study.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure performed by both surgeons and gastroenterologists. There is controversy in the field regarding the training necessary to perform ERCP. Widely disparate requisite volumes of experience to achieve proficiency have been published by representatives of each specialty. The basis for these differences has not been fully explored, with particular reference to the cognitive mindset of the different specialties. METHODS: Structured cognitive task analytic interviews were conducted with 7 expert gastroenterologists and 4 expert surgeons from 4 institutions, each of whom performs ERCP as a common procedure in their clinical practice. A qualitative analysis and grounded theory approach was used, focusing specifically on duct cannulation as a critical procedural element. Transcripts were analyzed using Atlas.ti software. RESULTS: The qualitative analysis of 11 transcripts identified 173 unique codes from a total of 653 quotes. In all, 5 themes were found to describe the codes: judgment, teaching, techniques, principles, and equipment. Significant differences were noted between gastroenterologists and surgeons across these themes. Gastroenterologists placed emphasis on issues of judgment including rationale, and emphasized explanation and clarification in teaching. Surgeons placed more emphasis on use of visual cues, and emphasized technique and equipment nuances. CONCLUSION: The data suggest that gastroenterologists deconstruct ERCP competence based on application of rules and rationale through reflection. Surgeons focus more on visual and tactile cues in task deconstruction, and may be more likely to measure proficiency based on technical response to such cues. Based on this study, it is proposed that both specialties might have complementary roles in training therapeutic endoscopists.

Feasibility, reliability and validity of an operative performance rating system for evaluating surgery residents.

BACKGROUND: Resident evaluation traditionally involves global assessments including clinical performance, professional behavior, technical skill, and number of procedures performed. These evaluations lack objective assessment of operative skills. We describe an operative performance rating system (OPRS) designed to provide objective operative performance ratings using a sentinel procedure format. METHODS: Ten-item procedure-specific rating instruments were developed. Items included technical skills, operative decision making, and general items. A 1 to 5 (5 = excellent) scale was used for evaluation. Six procedures had sufficient forms returned to allow evaluation. Inter-rater reliability was determined by having faculty evaluators view 2 videotaped operations. RESULTS: Return rates for the Internet-based form were full-time faculty (92%), volunteer faculty (27%), and overall (67%). Reliability, (average interitem correlation), and total procedures evaluated were excisional biopsy, 0.90, (0.48), 77; open inguinal herniorraphy, 0.94, (0.62), 51; laparoscopic cholecystectomy, 0.95, (0.64), 75; small-bowel and colon resection, 0.92, (0.58), 30; parathyroidectomy, 0.70, (0.19), 30; and lumpectomy, 0.92, (0.51), 38. Years of training accounted for 25% to 57% of the variation in scores. Inter-rater variability was observed; however, the average rater agreement was reliable. CONCLUSIONS: Internet-based management made obtaining the data feasible. The OPRS complements traditional evaluations by providing objective assessment of operative decision-making and technical skills. Interitem correlations indicate the average rating of items provides a reliable indicator of resident performance. The OPRS is useful in tracking resident development throughout postgraduate training and offers a structured means of certifying operative skills.

Interdisciplinary cognitive task analysis: a strategy to develop a comprehensive endoscopic retrograde cholangiopancreatography protocol for use in fellowship training.

BACKGROUND: Endoscopic retrograde cholangiopancreatography is a challenging procedure performed by surgeons and gastroenterologists. We employed cognitive task analysis to identify steps and decision points for this procedure. METHODS: Standardized interviews were conducted with expert gastroenterologists (7) and surgeons (4) from 4 institutions. A procedural step and cognitive decision point protocol was created from audio-taped transcriptions and was refined by 5 additional surgeons. RESULTS: Conceptual elements, sequential actions, and decision points were iterated for 5 tasks: patient preparation, duodenal intubation, selective cannulation, imaging interpretation with related therapeutic intervention, and complication management. A total of 180 steps were identified. Gastroenterologists identified 34 steps not identified by surgeons, and surgeons identified 20 steps not identified by gastroenterologists. CONCLUSION: The findings suggest that for complex procedures performed by diverse practitioners, more experts may help delineate distinctive emphases differentiated by training background and type of practice.

Medical student contact with patients on a surgery clerkship: is there a chance to learn?

BACKGROUND: Earlier studies of medical students on nonsurgical rotations have shown that clinical clerks usually first interact with their patients late in the clinical course. This would seem disadvantageous to the student's learning because they would have less opportunity to generate diagnoses or a management plan. STUDY DESIGN: A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to third year medical students during their surgical clerkship. Students received questionnaires each day to evaluate their clinical experiences from the previous day. RESULTS: The results from 311 student-patient encounters were collected and analyzed by clinical site as follows: outpatient clinics, outpatient surgery, inpatient surgery, day of surgery admission, inpatient consults, or emergency room consults. Students reported significantly more opportunities to elicit chief complaint, generate potential diagnosis, develop or suggest a management plan, and perform the initial examination when in the clinic setting. CONCLUSIONS: Overall, students were given relatively few opportunities to be the first to interact with any patient in any setting. They infrequently had an opportunity to independently generate a hypothesis or generate a management plan. Currently, the clinic offers the best opportunity for the student to complete these processes.

Do individual attendings' post-rotation performance ratings detect residents' clinical performance deficiencies?

PURPOSE: To determine whether attending physicians' post-rotation performance ratings and written comments detect surgery residents' clinical performance deficits. METHOD: Residents' performance records from 1997-2002 in the Department of Surgery, Southern Illinois University School of Medicine, were reviewed to determine the percentage of times end-of-rotation performance ratings and/or comments detected deficiencies leading to negative end-of-year progress decisions. RESULTS: Thirteen of 1,986 individual post-rotation ratings (0.7%) nominally noted a deficit. Post-rotation ratings of "good" or below were predictive of negative end-of-year progress decisions. Eighteen percent of residents determined to have some deficiency requiring remediation received no post-rotation performance ratings indicating that deficiency. Written comments on post-rotation evaluation forms detected deficits more accurately than did numeric ratings. Physicians detected technical skills performance deficits more frequently than applied knowledge and professional behavior deficits. More physicians' post-rotation numeric ratings contradicted performance deficits than supported them. More written comments supported deficits than contradicted them in the technical skills area. In the applied knowledge and professional behavior areas, more written comments contradicted deficits than supported them. CONCLUSIONS: A large percentage of performance deficiencies only became apparent when the attending physicians discussed performance at the annual evaluation meetings. Annual evaluation meetings may (1) make patterns of residents' behavior apparent that were not previously apparent to individual physicians, (2) provide evidence that strengthens the individual attending's preexisting convictions about residents' performance deficiencies, or (3) lead to erroneous conclusions. The authors believe deficiencies were real and that their findings can be explained by a combination of reasons one and two.

Who are the surgery clerkship directors and what are their educational needs?

BACKGROUND: The surgery clerkship director is a key individual in the surgery department's educational mission and yet there has been no prior effort to describe this group or identify their learning needs. The purpose of this study was to develop a demographic profile and an educational needs assessment for surgery clerkship directors. METHODS: A survey instrument was designed based on existing literature and distributed to surgery clerkship directors in the United States and Canada. RESULTS: Surveys were returned from 108 subjects (77%). The majority of clerkship directors strongly agree that directing is a positive experience but express concern that the job demands may impede their professional careers. The perceived educational needs identified related primarily to the development and management of the student education curriculum. CONCLUSIONS: Surgery clerkship directors are experienced academic surgeons who report high levels of satisfaction. They identify a number of important educational needs of the position and express concern about the requirements of the position on their academic careers.

A senior elective designed to prepare medical students for surgical residency.

BACKGROUND: The transition from medical student to surgery internship can be stressful. The goal of this project was to design, implement, and evaluate a 1-month long elective course that would meet the majority of the American College of Surgeons Graduate Medical Education Committee prerequisites for graduate surgical education METHODS: The major elements of the curriculum included faculty- and resident-facilitated case-based sessions and cadaver dissections. In addition, the students participated in skills laboratory experiences, Intensive Care Unit rounds, and mock interviews and clinical pages. The students took a knowledge pretest and post-test that was compared with the performance of 8 surgical interns on the same examination. RESULTS: The highest rated elements of the course were those that provided hands-on experience or practical knowledge. The post-test knowledge examination scores were significantly higher than pretest scores and surgical intern scores. CONCLUSIONS: It was possible to develop a 1-month senior medical student elective course that provided students with the essential prerequisites believed to be essential for all surgical interns.

Variables influencing medical student learning in the operating room.

BACKGROUND: The operating room (OR) is an important venue where surgeons do much of medical student teaching and yet there has been little work evaluating variables that influence learning in this unique environment. We designed this study to identify variables that affected medical student learning in the OR. METHODS: We developed a questionnaire based on surgery faculty observations of learning in the OR. The medical students completed the questionnaire on 114 learning episodes in the OR. Pearson correlation coefficient was used to establish the strength of association between various variables and the student's overall perception of learning. RESULTS: The students evaluated 27 variables that might impact their learning in the OR. Strong correlations were identified between the attending physician's attitude, interactions and teaching ability in the OR and the environment being conducive to learning. CONCLUSIONS: Surgical faculty behavior is a powerful determinant of student perceptions of what provides for a favorable learning environment in the OR.

How prepared are your interns to take calls? Results of a multi-institutional study of simulated pages to prepare medical students for surgery internship.

BACKGROUND: This study evaluated a simulated pages curriculum that was developed to assess communication and clinical decision making in medical students and interns. METHODS: A curriculum consisting of 14 simulated pages was administered across 5 institutions to 150 senior medical students. A 3-case subset was administered to interns who did not participate in the curriculum. Six expert surgeons identified critical fails and set passing scores for case-specific assessments using the Graphical Hofstee Method. RESULTS: Participants in the curriculum demonstrated superior clinical decision making compared with non-participants across all cases scenarios (P < .01). Average medical student scores for clinical decision making were 46.9%. Global ratings averaged 6.0 for communication and 5.2 for patient care. Passing rates averaged 46%. CONCLUSIONS: Participation in a mock page curriculum improved performance. The performance of participants based on expert standards set for simulated page performance highlight the need for innovative approaches to improve interns' preparedness to take calls.

The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study.

INTRODUCTION: Colonoscopic simulators offer the opportunity for skill acquisition in the preclinical setting. Currently available simulators vary widely with respect to level of fidelity and technological sophistication. Despite the belief that more realistic is better, there is a paucity of evidence regarding the relative effectiveness of simulator fidelity (high vs low) on the acquisition of basic colonoscopic skills. We hypothesized that novice learners can acquire basic colonoscopic skills using simulators, however fidelity of the simulator does not make a difference. METHODS: We randomly assigned novice third-year and fourth-year medical students to practice on either a low-fidelity or high-fidelity colonoscopy model. The low-fidelity model used is described in the module 16 of the American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for residents, Phase 1: basic or core skills and tasks < http://elearning.facs.org/mod/resource/view.php?1d=450 >. The high-fidelity model was the AccuTouch colonoscopy simulator, Immersion Medical (AccuTouch CS) that has 6 different simulated scenarios for diagnostic colonoscopy (level 1-6). Both groups had 16 students and were given standard instruction by an expert with respect to the procedure and instrument handling on both models. Both groups were pretested and posttested on level 1 of the AccuTouch CS. The high-fidelity group practiced on level 2 and 4 of the AccuTouch CS, whereas the low-fidelity group practiced on the low-fidelity model for 2 sessions of 1 hour each. The computer-based evaluation parameters available on the AccuTouch CS were used to compare performances. RESULTS: Both groups had similar demographics. There were no significant differences in the baseline performances of either group. Each group demonstrated significant improvement for insertion time and percentage of mucosa visualized. However, there were no significant differences between the groups on posttesting on any of the measured parameters. CONCLUSIONS: Colonoscopic skill training on a low-fidelity model appears to be as effective as high-fidelity model training for basic endoscopic skill acquisition for novice learners.

Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors.

BACKGROUND: Developing an operating room conflict management educational program for surgeons requires a formal needs assessment and information about behaviors that represent effective conflict management. METHODS: Focus groups of circulating room nurses and surgeons were conducted at 5 participating centers. Participants responded to queries about conflict management training, conflict consequences, and effective conflict management behaviors. Transcripts of these sessions served as the data for this study. RESULTS: Educational preparation for conflict management was inadequate consisting of trial and error with observed behaviors. Conflict and conflict mismanagement had negative consequences for team members and team performance. Four behaviors emerge as representing effective ways for surgeons to manage conflict. CONCLUSIONS: There is a clear educational need for conflict management education. Target behaviors have now been identified that can provide the basis for a theoretically grounded and contextually adapted instruction and assessment of surgeon conflict management.

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict.

BACKGROUND: Prior research has shown that surgeons who effectively manage operating room conflict engage in a problem-solving stage devoted to modifying systems that contribute to team conflict. The purpose of this study was to clarify how systems contributed to operating room team conflict and clarify what surgeons do to modify them. METHODS: Focus groups of circulating nurses and surgeons were conducted at 5 academic medical centers. Narratives describing the contributions of systems to operating room conflict and behaviors used by surgeons to address those systems were analyzed using the constant comparative approach associated with a constructivist grounded theory approach. RESULTS: Operating room team conflict was affected by 4 systems-related factors: team features, procedural-specific staff training, equipment management systems, and the administrative leadership itself. Effective systems problem solving included advocating for change based on patient safety concerns. CONCLUSIONS: The results of this study provide clarity about how systems contribute to operating room conflict and what surgeons can do to effectively modify these systems. This information is foundational material for a conflict management educational program for surgeons.