The Plan-Do-Study-Act (PDSA): An Iterative Approach to Optimize Residents Performance in the American Board of Surgery in-Training Exam (ABSITE).

INTRODUCTION: American Board of Surgery (ABS) In-Training Examination (ITE), or ABSITE, preparation requires an effective study approach. In 2014, the ABS announced the alignment of ABSITE to the SCORE® Curriculum. We hypothesized that implementing a Plan-Do-Study-Act (PDSA) approach would help surgery residents improve their performance on the ABSITE. METHOD: Over 20 years, in a single institution, residents' ABSITE performance was evaluated over 3 timeframes: Time A (2004-2013), no specific curriculum; Time B (2014-2019), an annual comprehensive ABSITE-simulated SCORE®-based multiple-choice exam (MCQ) was administered; and Time C (2020-2023), like Time B with the addition of the PDSA approach for those with less than 60% correct on the ABSITE-simulated SCORE®-based exam. At the beginning of the academic year, in July, all residents are encouraged to (1) initiate a study plan for the upcoming ABSITE using SCORE® guided by the published ABSITE outlines content topics (Plan), (2) take an ABSITE-simulated SCORE®-based exam in October (Do), (3) assess the results/scores (Study), and (4) identify appropriate next steps (Act). Correlational analysis was performed to evaluate the association between ABSITE scores and ABSITE-simulated SCORE®-based exam scores in Time B and Time C. The primary outcome was the change in the proportions of ABSITE scores <30th percentile. RESULTS: A total of 294 ABSITE scores of 94 residents (34 females and 60 males) were analyzed. We found stronger correlation between the correct percentage on ABSITE and ABSITE-simulated SCORE®-based exam scores in Time C (r = 0.73, p < 0.0001) compared to Time B (0.62, p < 0.0001). The percentage of residents with ABSITE scores lower than 30th percentile dropped significantly from 14.0% to 3.7% (p = 0.016). CONCLUSION: Implementing the Plan-Do-Study-Act (PDSA) approach using the SCORE® curriculum significantly enhances residents' performance on the ABSITE exam. Surgery residents are encouraged to use this approach and to utilize the SCORE-contents outlined by the ABS in their study plan.

Management of Locally Advanced Basal Cell Carcinoma with Sonic Hedgehog Pathway Targeted Therapy: A Case Report and Discussion.

Introduction: Basal cell carcinoma (BCC) is the most common skin malignancy in the world. While most lesions are treated using surgical methods, others may present as locally advanced or metastatic disease and are not amenable to surgical therapy alone. Treatment with sonic hedgehog pathway inhibitors (vismodegib, sonidegib) is designed to inhibit key signaling proteins and gene pathways involved with BCC to reduce the uncontrolled proliferation of basal cells in complicated disease and can be invaluable in treating patients with advanced disease. Case Presentation: We describe the course of a 68-year-old man who presented with a 7.2 × 6 cm exophytic and ulcerated locally invasive BCC of his upper back. The patient was started on daily vismodegib treatment with the goal of eventual surgical resection. After 11 weeks of therapy, he had significant improvement in both wound size and appearance. After 18 weeks of therapy, he had achieved a near complete clinical response of the central aspect of lesion with three remaining small peripheral lesions. These lesions were biopsied, and two were found to be negative for malignancy, while a small inferior nodule was positive for squamous cell carcinoma (SCC). Vismodegib therapy was discontinued after a total of 26 weeks of therapy. Excision of the SCC was performed, and the patient remains disease free at 2 years. Conclusion: This case report shows the efficacy of hedgehog pathway inhibitor therapy in the treatment of a locally advanced BCC with complete pathologic response, not requiring surgical intervention.

Psychologic assessment in patients undergoing bariatric surgery.

BACKGROUND: Psychological Clearance level (PCL) for patients undergoing metabolic and bariatric surgery (MBS) is a critical step for successful postoperative outcomes. This study aims to assess the relationship between the level of psychologic fitness and postoperative outcomes in patients undergoing MBS. METHODS: We retrospectively analyzed the data of patients who underwent MBS (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y Gastric Bypass [LRYGB]) and completed two years follow-up, between 2012 and 2019, in a single medical center. The patients were divided into four groups based on PCL, suggesting level of readiness for surgery: Group A (PCL-0: guarded), group B (PCL-1: Fair/reasonable), group C (PCL-2: Good/appropriate), and group D (PCL-3: Strong/excellent). Primary outcome was the percent of total body weight loss (%TWL), and the absolute change in BMI units. Secondary outcomes were missed postoperative visits and patient compliance. Differences between the groups were analyzed using a generalized linear model (GLM), chi-squared and exact Fisher tests, as appropriate. RESULTS: Of 1411 total patients, 607 (43.20%) had complete data at two years follow-up. 512 (84.34%) were females. LSG was performed in 361 (59.5%). No difference was found in %TWL between the four groups (22.14% vs. 28.0% vs. 26.0% vs. 24.8%, p = 0.118). We found a small difference in the mean (SD) of absolute change in BMI between the groups, and on post-hoc analysis it was found between groups B (PCL-1) and D (PCL-3). Overall, no difference between the groups in number of follow-up visits, or compliance issues. However, patients who attended more follow-up visits had less compliance issues (p < 0.001). PCL is inversely correlated with number of psychologic diagnoses (r = - 0.41, p < 0.001) and medical comorbidities (r = - 0.20, p < 0.001). CONCLUSION: We found no difference in the percent of TWL in patients who underwent MBS based on PCL at two -years follow-up. Medical comorbidities and psychiatric diagnoses impact the PCL.

History of surgical training in Kalamazoo.

This narrative reviews the history and evolution of surgical training in Southwest Michigan, particularly Kalamazoo, over the past 100 years. During this time, the de novo growth of medical treatment and the gradual and progressive establishment of medical and surgical training, paralleled with innovation, have shaped the clinical practices in Southwest Michigan. The surgical expertise that exists in Kalamazoo has made it one of the most important headquarters for surgical innovation, not only in the United States, but in the world. The surgical training program in Kalamazoo began in the 1960s, and this accredited general surgery residency program has graduated numerous successful surgeons. Currently this program is one of several training programs at Western Michigan University Homer Stryker M.D. School of Medicine (WMed), the only medical school in Southwest Michigan. Under the leadership of Dean Surgeon Dr. Paula Termuhlen and Chair Dr. Robert Sawyer, a bright future in surgical education, research, and innovation is highly anticipated. Expectations of future growth in this program will provide a significant pipeline for graduating physicians and surgeons for decades to come.

The Effects of Pre-medical Anatomy and Clinical Experiences on Medical School Anatomy-Related Academic Performance.

PURPOSE: The objective of this study was to examine the effects that pre-medical patient care clinical experiences and anatomical education had on undergraduate medical course grades and anatomy practical exam scores. This study provides a unique perspective to this line of inquiry in that it included data from 9 class year cohorts between academic years 2010-2011 and 2018-2019, all from a single institution. METHODS: A survey to assess pre-medical clinical and anatomical experiences was completed by each new matriculate. Results were compared to each student's course grades and anatomy practical exam scores. The effects of pre-medical experiences on practical scores and final grades were evaluated using generalized linear mixed models. RESULTS: Several positive and negative associations were identified. The most obvious effect revealed by data analysis was the class year cohort effect, seen as variation in the academic performance of each cohort from year-to-year. Other significant results included a positive association between pre-medical comparative anatomy coursework and anatomy assessment performance over the entire year's anatomy curriculum. Counterintuitively, some pre-medical clinical experiences, such as nursing experience, had a negative effect on course grades and practical exam performance. CONCLUSIONS: Pre-medical students can use this information to decide whether to enroll in undergraduate anatomy courses or engage in extra pre-medical clinical work. It may also be valuable to medical school admissions departments in regard to determining the anatomy coursework and clinical experience requirements for their applicants.

Effect of Grading and Class Rank on Performance in a Surgical Simulation Course.

OBJECTIVE: This study seeks to evaluate the psychological and academic effects of grading a medical school simulation course. This study also seeks to evaluate whether a student's class rank affects these results and whether the academic effects of a simulation course persist long-term. DESIGN: Two separate medical school classes were evaluated. The first class participated in an ungraded surgery simulation course with only formative feedback. The second class participated in a tier-graded course. Qualitative assessment of both courses included daily standardized and self-reported stress surveys, student feedback surveys at the end of the course, and student feedback surveys at the end of the surgery clerkship. Quantitative assessment included pre and postcourse examinations, NBME Surgery Subject Assessment percentile ranks, and COMLEX 2 surgery subscores. Qualitative and quantitative assessments were compared between classes as a whole and between students in the upper and lower half of each class. Results were analyzed using a Student two-tailed t test. SETTING: Rocky Vista University College of Osteopathic Medicine Institute of Simulation, Parker, Colorado. PARTICIPANTS: One hundred forty-eight students from the Rocky Vista University College of Osteopathic Medicine Class of 2017 and one hundred fifty-one students from the Rocky Vista University College of Osteopathic Medicine Class of 2018. RESULTS: Daily standardized stress surveys indicated some increase in stress for students in the graded course, especially for students in the upper half of the graded class. All students adapted to stress significantly by the end of each course, but upper-half students adapted more significantly. Students' self-reported stress levels demonstrated a significant decrease during the ungraded course, but a slight increase during the graded course. Students' self-reported confidence levels rose significantly during the ungraded course, but less significantly during the graded course. Student feedback surveys demonstrated a positive student perception of both courses, but, when stratified, some responses were significantly different between students in the upper and lower half of each class, with upper-half students generally giving a higher rating to the graded course. Clinical knowledge examination scores and improvement in scores within the course were significantly higher for the graded course, with no significant differences between students in the upper and lower half of each class. Students' mean NBME Surgery Subject Assessment percentile rank did not differ significantly between the two classes, but were significantly higher than for previous classes who had not participated in a simulation course. Mean NBME Surgery Subject Assessment percentile rank and COMLEX 2 mean surgery subscore were significantly higher for students in the upper half than for students in the lower half of each class. COMLEX 2 mean surgery subscore did not differ significantly between classes who had participated in a simulation course and previous classes who had not. Students in the upper half of each class in this study performed significantly better than students in the lower half of each class on the mean COMLEX 2 surgery subscore. CONCLUSIONS: This study reaches the following conclusions: (1) objective stress level measurements did not correlate with students' self-reported stress levels; (2) grading a simulation course raises objective stress levels in higher-performing students more than in lower-performing students, but higher-performing students demonstrate the ability to effectively adapt to the increased levels of stress and achieve significant increases in confidence; (3) higher performing students generally demonstrate a greater sense of satisfaction with the simulation course experience when the course is graded; (4) higher-performing and lower-performing students within a class perform in a similar fashion on examinations within the intensely structured environment of a simulation course, whether the course is graded or not; (5) grading a course stimulates all students to perform better on examinations within the course; (6) this higher level of performance and similarity of performance between higher and lower-performing students does not continue when students are not in a structured environment, and students stratify into disparate performance groups in accordance with their class rank; and (7) students exposed to a surgical simulation course perform better on NBME surgery subject examinations than students who have not participated in a simulation course, but this increased level of performance does not extend long-term to national board exams.

Validation of a blocking enzyme-linked immunosorbent assay for detection of antibodies against porcine reproductive and respiratory syndrome virus.

Porcine reproductive and respiratory syndrome (PRRS) continues to be one of the most significant diseases of swine. IDEXX HerdChek PRRS, a commercially available enzyme-linked immunosorbent assay (ELISA), has become the industry standard for the detection of antibodies against PRRS virus (PRRSV). The need to accurately determine the PRRSV serostatus of herds and individual animals has prompted the development of several follow-up assay methods. A highly specific and repeatable blocking ELISA (bELISA) was developed on the basis of the use of an expressed PRRSV nucleocapsid (N) protein as the antigen and a biotinylated monoclonal antibody. Validation of the bELISA used sera from 316 animals experimentally and naturally infected with North American PRRSV and sera from 370 uninfected animals. Receiver operating characteristic analysis of the data calculated a diagnostic sensitivity of 97.8% and a diagnostic specificity of 100%. The between-run coefficient of variation of an internal quality control serum was 4.24%. The bELISA was able to detect seroconversion as well as the IDEXX ELISA and the indirect fluorescent antibody (IFA) assay; kappa values were 0.94 and 0.96, respectively. A collection of 133 serum samples with unexpected positive IDEXX ELISA results was obtained from 4,038 diagnostic samples submitted from farms from which PRRS-negative results were expected. The bELISA identified 97% of the samples as PRRS seronegative, while the IFA identified 100% as seronegative. The anticipated use of the bELISA is as a follow-up test to the IDEXX ELISA for determining the PRRSV serostatus of individual animals with unexpected positive test results from swine herds from which negative results are expected.