Medical student quality-of-life in the clerkships: a scale validation study.

Many aspects of medical school are stressful for students. To empirically assess student reactions to clerkship programs, or to assess efforts to improve such programs, educators must measure the overall well-being of the students reliably and validly. The purpose of the study was to develop and validate a measure designed to achieve these goals. The authors developed a measure of quality of life for medical students by sampling (public domain) items tapping general happiness, fatigue, and anxiety. A quality-of-life scale was developed by factor analyzing responses to the items from students in two different clerkships from 2005 to 2008. Reliability was assessed using Cronbach's alpha. Validity was assessed by factor analysis, convergence with additional theoretically relevant scales, and sensitivity to change over time. The refined nine-item measure is a Likert scaled survey of quality-of-life items comprised of two domains: exhaustion and general happiness. The resulting scale demonstrated good reliability and factorial validity at two time points for each of the two samples. The quality-of-life measure also correlated with measures of depression and the amount of sleep reported during the clerkships. The quality-of-life measure appeared more sensitive to changes over time than did the depression measure. The measure is short and can be easily administered in a survey. The scale appears useful for program evaluation and more generally as an outcome variable in medical educational research.

FLS skill acquisition: a comparison of blocked vs interleaved practice.

INTRODUCTION: Fundamentals of Laparoscopic Surgery (FLS) certification is required for general surgery. The recommended practice for learning FLS is to practice tasks one at a time until proficient (blocked practice). Learning theory suggests that interleaved practice, a method in which tasks are rotated rather than learned one at a time, may result in superior learning. METHOD: Residents were randomized into 1 of 2 groups: blocked practice or interleaved practice. We compared the performance of residents across groups over 20 trials of each of 4 FLS tasks (peg transfer, pattern cut, extracorporeal suture, and intracorporeal suture). Four weeks later, participants returned to the laboratory and completed 2 additional trials of each of the 4 tasks. RESULTS: Performance on each of the tasks improved with increased practice. The interleaved group showed significantly better performance on the peg transfer task; trends favoring the interleaved group resulted for the other tasks. Standardized mean differences in favor of the interleaved group were substantial both at the end of practice and at follow-up (with the exception of the pattern cut). CONCLUSION: Interleaved practice appears to have advantages over blocked practice in developing and retaining FLS skills. We encourage others to experiment with the method to confirm our findings.

A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage.

OBJECTIVE: To test by randomized prospective multicenter trial the hypothesis that pancreaticoduodenectomy (PD) without the use of intraperitoneal drainage does not increase the frequency or severity of complications. BACKGROUND: Some surgeons have abandoned the use of drains placed during pancreas resection. METHODS: We randomized 137 patients to PD with (n = 68, drain group) and without (n = 69, no-drain group) the use of intraperitoneal drainage and compared the safety of this approach and spectrum of complications between the 2 groups. RESULTS: There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage. CONCLUSIONS: This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.

Surgical interest and surgical match for third-year students: results of a prospective multivariate longitudinal cohort study.

BACKGROUND: Numerous factors have been linked to surgical career choice, including the quality of third-year surgical clerkship. The vast majority of studies also selectively evaluate one or only a few variables that link to surgical career choice, so relative impact cannot be assessed. This study simultaneously evaluates the majority of variables linked to surgical career choice in previous research so that the relative contributions of each of these variables with respect to surgical career choice can be determined. STUDY DESIGN: Surveys before, during, and after the third-year surgical clerkship included student demographics, background, and values (eg, importance of money, controllable lifestyle), and student reactions to the third-year surgical clerkship. The dependent variables in this study included interest in surgery at the beginning and end of the clerkship and matching into a surgical residency. RESULTS: Both univariate and multivariate analyses generally supported findings in the literature, but the strengths of these associations reported previously might not have been accurate. In this study, the surgical resident match odds ratio for students starting the clerkship already knowing they wanted to be a surgeon was 22.46; the next highest associations were 4.65 and 3.37, which corresponded to earlier exposure to a surgical specialty and earlier exposure to general surgery, respectively. Differences in career choice for general surgeons and surgical specialists were also explored. CONCLUSIONS: Although the experience of the clerkship is related to career choice, the largest impact of the clerkship is for those already interested in a surgical career. Interest in a surgical career largely develops before the third-year clerkship. Implications of the results for recruiting greater numbers of students into surgical careers are discussed.

The certifying examination of the american board of surgery: the effect of improving communication and professional competency: twenty-year results.

PURPOSE: In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS: Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS: There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION: Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

Psychometrics of Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) scores.

A sample of 183 medical students completed the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT V2.0). Scores on the test were examined for evidence of reliability and factorial validity. Although Cronbach's alpha for the total scores was adequate (.79), many of the scales had low internal consistency (scale alphas ranged from .34 to .77; median = .48). Previous factor analyses of the MSCEIT are critiqued and the rationale for the current analysis is presented. Both confirmatory and exploratory factor analyses of the MSCEIT item parcels are reported. Pictures and faces items formed separate factors rather than loading on a Perception factor. Emotional Management appeared as a factor, but items from Blends and Facilitation failed to load consistently on any factor, rendering factors for Emotional Understanding and Emotional Facilitation problematic.

Laparoscopic drainage of a hepatic echinococcal cyst: a case report.

The Echinococcus granulosus tapeworm causes hepatic echinococcosis. It is endemic in the Mediterranean region, Middle East, and South America. Human infection is secondary to accidental consumption of ova in feces. Absorption through the bowel wall and entrance into the portal circulation leads to liver infection. This case involves a 34 y/o Moroccan male with an echinococcal liver cyst. His chief complaint was RUQ pain. The patient was treated with albendazole and praziquantel. His PMH and PSH was noncontributory. Patient was not on any other medications. ROS was otherwise unremarkable. The patient was AF VSS. He was tender to palpation in RUQ. Liver function tests were normal. Echinococcal titers were positive. CT demonstrated a large cystic lesion in the right lobe of the liver measuring 13.5 cm in diameter. The patient underwent successful laparoscopic drainage and excision of echinococcal cyst. Final pathology demonstrated degenerating parasites (E. granulosus) of echinococcal cyst.

A second case report of lleuprolide acetate for depot suspension-induced mania.

This is the second published case report of Lleuprolide acetate for depot suspension (LD)-induced mania. Both reports detail a patient with a prior psychiatric history of both depressive and hypomanic episodes. While depression is a predictable and documented side effect of LD and menopause (especially in those with a previoushistory of symptoms), manic reactions are rare and unexplained. Possible causative mechanismsbehind the LD-induced manic episodes are discussed, and we suggest that patients with a single previous hypomanic episode are at risk for LD-induced mania.

Comparison of trait and ability measures of emotional intelligence in medical students.

CONTEXT: Emotional intelligence (EI), the ability to perceive emotions in the self and others, and to understand, regulate and use such information in productive ways, is believed to be important in health care delivery for both recipients and providers of health care. There are two types of EI measure: ability and trait. Ability and trait measures differ in terms of both the definition of constructs and the methods of assessment. Ability measures conceive of EI as a capacity that spans the border between reason and feeling. Items on such a measure include showing a person a picture of a face and asking what emotion the pictured person is feeling; such items are scored by comparing the test-taker's response to a keyed emotion. Trait measures include a very large array of non-cognitive abilities related to success, such as self-control. Items on such measures ask individuals to rate themselves on such statements as: 'I generally know what other people are feeling.' Items are scored by giving higher scores to greater self-assessments. We compared one of each type of test with the other for evidence of reliability, convergence and overlap with personality. METHODS: Year 1 and 2 medical students completed the Meyer-Salovey-Caruso Emotional Intelligence Test (MSCEIT, an ability measure), the Wong and Law Emotional Intelligence Scale (WLEIS, a trait measure) and an industry standard personality test (the Neuroticism-Extroversion-Openness [NEO] test). RESULTS: The MSCEIT showed problems with reliability. The MSCEIT and the WLEIS did not correlate highly with one another (overall scores correlated at 0.18). The WLEIS was more highly correlated with personality scales than the MSCEIT. CONCLUSIONS: Different tests that are supposed to measure EI do not measure the same thing. The ability measure was not correlated with personality, but the trait measure was correlated with personality.

Reproductive factors and risk of pancreatic cancer in women: a review of the literature.

PURPOSE: Pancreatic cancer (PCA) is the fourth leading cause of cancer death in the United States. The male-to-female incidence and mortality ratio of PCA is 1.1-2.0. One possible explanation for this difference is that female hormone exposure is protective for the development of PCA. Several hypotheses were investigated in this systematic review: (1) increased exposure to estrogen through early menarche and later menopause is associated with a decreased risk of PCA; (2) increased exposure to pregnancy is associated with decreased risk of PCA; and (3) increased exposure to oral contraceptives and/or hormone replacement therapy is associated with decreased risk of PCA. METHODS: Of 371 articles identified, 10 case-control and 5 cohort studies met the criteria for our review. Odds ratios for case-control studies and hazard ratios for cohort studies and their accompanying 95% confidence intervals for analyses relevant to our hypotheses were considered in the review. RESULTS: For all 3 hypotheses, studies displayed inconsistent results, and this may have been due to the diversity of study populations, exposure quantification, analysis approach, confounding and other limitations, and biases across studies. CONCLUSIONS: As there was no strong support for any of the 3 hypotheses, it appears that reproductive factors are not associated with the development of PCA in women.

Pancreaticoduodenectomy for suspected periampullary cancers: the mimes of malignancy.

BACKGROUND: Pancreaticoduodenectomies are often undertaken with suspicion of malignancy. We undertook this study to determine if and how unnecessary pancreaticoduodenectomies can be avoided. METHODS: Data from patients undergoing pancreaticoduodenectomy were prospectively collected. Operative indications, including presenting symptoms and results with imaging, with or without biopsy, were reviewed. RESULTS: From 1996 through to 2007, 551 patients underwent pancreaticoduodenectomy at our institution. Chronic pancreatitis was the operative indication in 3% of patients; premalignant/malignant lesions were present in 86% of patients. Eleven per cent of patients underwent 'unnecessary' pancreaticoduodenectomies with presumptive diagnoses of cancer but were without premalignant/malignant disease on final report by Pathology [pancreatitis in 63%, serous cystadenomas (<4 cm) in 14%]. Of the unnecessary resections, 20% had histories and imaging sufficient to diagnose pancreatitis, 18% had inaccurate preoperative brushings/biopsies 'documenting' cancer, 11% had clear misinterpretations of their imaging studies and 7% had inadequate preoperative evaluations. However, 45% had signs/symptoms of cancer with a pancreatic head mass/biliary stricture. CONCLUSION: Only a small minority of patients undergoing pancreaticoduodenectomy for suspicion of periampullary cancer do so unnecessarily. Preoperative review of biopsies, better considerations of pancreatitis and careful evaluation of imaging, particularly for cystic masses, will decrease unnecessary pancreaticoduodenectomies.

Reducing errors from the electronic transcription of data collected on paper forms: a research data case study.

We conducted a reliability study comparing single data entry (SE) into a Microsoft Excel spreadsheet to entry using the existing forms (EF) feature of the Teleforms software system, in which optical character recognition is used to capture data off of paper forms designed in non-Teleforms software programs. We compared the transcription of data from multiple paper forms from over 100 research participants representing almost 20,000 data entry fields. Error rates for SE were significantly lower than those for EF, so we chose SE for data entry in our study. Data transcription strategies from paper to electronic format should be chosen based on evidence from formal evaluations, and their design should be contemplated during the paper forms development stage.

32P as an adjunct to standard therapy for locally advanced unresectable pancreatic cancer: a randomized trial.

This prospective randomized trial was undertaken to determine the added efficacy of (32)P in treating locally advanced unresectable pancreatic cancer. Thirty patients with biopsy proven locally advanced unresectable adenocarcinoma of the pancreas were assessable after receiving 5-fluorouracil and radiation therapy with or without (32)P, followed by gemcitabine. Intratumoral (32)P dose was determined by tumor size and volume and was administered at months 0, 1, 2, 6, 7, and 8. Tumor cross-sectional area and liquefaction were determined at intervals by computed tomography scan. Tumor liquefaction occurred in 78% of patients receiving (32)P and in 8% of patients not receiving (32)P, although tumor cross-sectional area did not decrease. Serious adverse events occurred more often per patient for patients receiving (32)P (4.2 +/- 3.1 vs. 1.8 +/- 1.9; p = 0.03) leading to more hospitalizations. Death was because of disease progression (23 patients), gastrointenstinal hemorrhage (4 patients), and stroke (1 patient). One patient not receiving (32)P and one receiving (32)P are alive at 28 and 13 months, respectively. (32)P did not prolong survival (7.4 +/- 5.5 months with (32)P vs. 11.5 +/- 8.0 months without (32)P, p = 0.16). (32)P promoted tumor liquefaction, but did not decrease tumor size. Intratumoral (32)P was associated with more serious adverse events and did not improve survival for locally advanced unresectable pancreatic cancer.

An aggressive approach to extrahepatic cholangiocarcinomas is warranted: margin status does not impact survival after resection.

BACKGROUND: With cholangiocarcinoma, the only hope of a cure is resection. This study was undertaken to determine the impact of margin status, stage, tumor location, and adjuvant therapy on survival after resection of extrahepatic cholangiocarcinoma. METHODS: From 1985-2006, 91 patients underwent resections of cholangiocarcinomas. Margin status was codified as micro-/macroscopically negative, microscopically positive/ macroscopically negative, or micro-/macroscopically positive. Stage was determined using the AJCC classification (6th edition). Tumor location was classified as proximal, mid, or distal. Proximal tumors were resected by extrahepatic biliary resection with/without concomitant hepatic resection (n = 48), distal extrahepatic cholangiocarcinomas by pancreaticoduodenectomy (n = 35), and mid tumors by extrahepatic biliary resection alone (n = 8). Regression analysis and survival curve analysis were utilized. Data are presented as median, mean +/- standard deviation (SD). RESULTS: Overall survival after resection was 21 months, 38 +/- 46.0. Survival was not impacted by margin status (R0 20 months, 35 +/- 45.1 versus R1 32 months, 45 +/- 49.4). AJCC stage inversely correlated with survival (p = 0.004, Spearman regression analysis). Tumor location did not impact upon survival (p = 0.57, log-rank test). For proximal tumors, survival after biliary resection was significantly impacted by the need for concomitant hepatectomy (15 months, 27 +/- 31.4 versus 41 months, 67 +/- 17.1). Utilization of adjuvant therapy significantly improved survival (33 months, 56 +/- 63.1 versus 19 months, 33 +/- 40.0) (p = 0.046, Spearman regression). CONCLUSIONS: Survival after resection of extrahepatic cholangiocarcinoma is significantly impacted by AJCC stage, the use of adjuvant therapy, and in patients with proximal tumors, the need for concomitant hepatectomy. Margin status and tumor location do not impact survival. Cholangiocarcinomas should be aggressively resected irrespective of tumor location, even if resection might result in microscopically positive margins, and adjuvant therapy applied.

Frequency with which surgeons undertake pancreaticoduodenectomy continues to determine length of stay, hospital charges, and in-hospital mortality.

INTRODUCTION: This study was undertaken to determine changes in the frequency of, volume of, and outcomes after pancreaticoduodenectomy 6 years after a study denoted that, in Florida, the frequency and volume of pancreaticoduodenectomy impacted outcome. METHODS: Using the State of Florida Agency for Health Care Administration database, the frequency and volume of pancreaticoduodenectomy was correlated with average length of hospital stay (ALOS), in-hospital mortality, and hospital charges for identical periods in 1995-1997 and 2003-2005. RESULTS: Compared to 1995-1997, 88% more pancreaticoduodenectomy was performed in 2003-2005 by 6% fewer surgeons; the majority of pancreaticoduodenectomies were conducted by surgeons doing <1 pancreaticoduodenectomy every 2 months. In-hospital mortality rate did not decrease from 1995-1997 to 2003-2005 (5.1 to 5.9%); in-hospital mortality rate increased for surgeons undertaking <1 pancreaticoduodenectomy every 2 months (5.5 to 12.3%, p<0.01). For 2003-2005, frequency with which pancreaticoduodenectomy is conducted inversely correlates with ALOS (p=0.001), hospital charges (p=0.001), and in-hospital mortality (p=0.001). CONCLUSIONS: In Florida, more pancreaticoduodenectomies are carried out by fewer surgeons. Mortality has not decreased because of surgeons infrequently performing pancreaticoduodenectomy. Most pancreaticoduodenectomies are still undertaken by surgeons who conduct pancreaticoduodenectomy infrequently with greater lengths of stay, hospital costs, and in-hospital mortality rates. To an even greater extent than previously documented, patients are best served by surgeons frequently performing pancreaticoduodenectomy.