Abdominal wall reconstruction with large polypropylene mesh: is bigger better?

PURPOSE: Hernia repair for large and complex hernias presents challenges related to the availability of larger mesh sizes. When sizes beyond those manufactured are required, multiple meshes (MM) may be sutured to create a larger graft. With the availability of large polypropylene mesh up to 50 × 50 cm (LM), abdominal wall reconstruction (AWR) may be accomplished with a single mesh. This study evaluates clinical and economic outcomes following AWR with component separation utilizing MM and LM. METHODS: A retrospective study was performed with review of health records and cost accounting data. Patients that underwent AWR with LM were case matched 1:1 with patients undergoing MM repair based upon comorbidities, defect size and wound class. RESULTS: Twenty-four patients underwent AWR with LM. Twenty patients (10F, 10 M) who underwent AWR with LM were matched with 20 MM AWR (11F, 9 M). Age, BMI, ASA 3 + , never smoker, diabetes, and hernia characteristics were similar between LM and MM. Operative cost ($4295 vs $3669, p = 0.127), operative time (259 min vs 243 min, p = 0.817), length of stay (5.5 vs 6.2, p = 0.484), wound complication (30% vs 20%, p = 0.716), infected seroma (5% vs 5%, p = 1), and readmission (5% vs 15%, p = 0.605) were similar between LM and MM, respectively. CONCLUSIONS: This is the first report of patients undergoing AWR with a large 50 × 50 cm prolene mesh. In this small cohort, clinical outcomes were similar between those undergoing repair with multiple sutured mesh sheets and a single large mesh.

Cancer pain management skills among medical students: the development of a Cancer Pain Objective Structured Clinical Examination.

Recent surveys suggest that most physicians have inadequate knowledge to assess and manage cancer pain; however, the important domain of clinical performance has not yet been clearly evaluated. The Objective Structured Clinical Examination (OSCE) has become a widely- used and accepted method to evaluate the clinical abilities of medical students. The purpose of this study was to develop and test a Cancer Pain OSCE for medical students evaluating their clinical competence in the area of cancer pain management. A four-component Cancer Pain OSCE was developed and presented to 34 third-year medical students during a sixteen-week combined medicine/surgery clerkship. The content of the objective criteria for each component of the OSCE was developed by a multidisciplinary group of pain experts. The OSCE was designed to assess the students' cancer pain management skills of pain history-taking, focused physical examination, analgesic management of cancer pain, and communication of opioid analgesia myths. Actual cancer survivors were used in the five-minute individual stations. The students were asked to complete a cancer pain history, physical examination, manage cancer pain using analgesics, and communicate with a family member regarding opioid myths. Clinical performance was evaluated using pre-defined checklists. Results showed the student's average performance for the history component was the highest of all four components of the examination. Out of 34 points possible on this clinical skills item, students on average (SD) scored 24.5 (5.2), or 72%. For the short-answer analgesic management component of the Cancer Pain OSCE, the overall score was 32%. Most students managed cancer pain with opioids, however, very few prescribed regular opioid use, and the use of adjuvant analgesics was uncommon. Student performance on the focused cancer pain physical examination was, in general, poor. On average students scored 61% on the musculoskeletal system, but only 31% on both the neurological and lymphathic examination. The overall percent score for the cancer pain OSCE was 48%. We conclude that the Cancer Pain OSCE is a useful performance-based tool to test individual skills in the essential components of cancer pain assessment and management. Of the four components of the Cancer Pain OSCE, medical students performed best on the cancer pain history and performed poorly on the cancer pain physical examination. Information gained from this study will provide a foundation on which future small-group medical student structured teaching will be based.

Cancer pain education: a structured clinical instruction module for hospice nurses.

The learning experience with the Cancer Pain Structured Clinical Instruction Module (SCIM), a highly structured skills training course for medical students, has been reported favorably. The purpose of this study was to present the Cancer Pain SCIM to registered nurses employed in a hospice setting. The goal of the study was to pilot test a structured cancer pain educational program for hospice nurses and to determine the perceived effectiveness of this course on the participants' cancer pain assessment and management skills. A multidisciplinary Cancer Pain SCIM was presented to 25 hospice nurses to improve their understanding of the management of cancer pain. The development group identified essential aspects of cancer pain management and then developed checklists defining specific station content. During the 2-hour Cancer Pain SCIM, nurses rotated through 8 stations in groups of 3, spending 15 minutes at each station. Eight instructors and 6 standardized patients, 5 of whom were survivors of cancer, participated in the course. All participants (students, instructors, and patients) evaluated the course, using a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree). Nurses provided self-assessments of their perceived competence on important aspects of cancer pain management both before and after the SCIM. The self-assessment items used a 5-point scale ranging from 1 (not competent) to 5 (very competent). Twenty-five hospice nurses, averaging 4.1 years (range 1-30 years) postgraduation, participated in the Cancer Pain SCIM. Overall, nurses agreed that they improved on each of the 8 teaching items (P < 0.001). The average (SD) pretest score of 2.8 (0.72) improved to 3.8 (0.58) on the post-test (P < 0.001). Nurses believed that their mastery of specific clinical skills, taught in all 8 stations, improved as a result of participation in the course. Nurses strongly agreed (mean +/- SD) that it was beneficial to use patients with cancer in the course (4.6 +/- 0.82). Faculty members enjoyed participating in the course (4.9 +/- 0.35) and indicated a willingness to participate in future courses (4.7 +/- 0.49). Significant perceived learning among hospice nurses took place in all aspects of the Cancer Pain SCIM. Participating nurses, instructors, and patients with cancer appreciated the SCIM format. Nurses and faculty considered the participation of actual patients with cancer highly beneficial. The SCIM format has great potential to improve the quality of cancer pain education.

Junior medical students' perceptions of an introductory hospice experience.

INTRODUCTION: The importance of palliative care education in the medical school curriculum is becoming more recognized. The purpose of this study was to assess medical students' perceptions of an introductory hospice experience. METHODS: Forty-one second-year medical students took part in an introductory hospice experience in which they were acquainted with a wide range of hospice services provided to patients and families by an interdisciplinary team involved in hospice care. In addition, the students visited patients' homes individually with an experienced hospice nurse or social worker. At the end of their experience, the students were asked to complete a multi-item evaluation questionnaire in order to share their perceptions of the hospice experience and their suggestions for improvement of the course. RESULTS: The students spent an average of four hours on their introductory hospice experience, and they indicated that all of their personal goals for their experience had been met. Suggestions for improvement of the course were to increase the amount of course time allotted and to provide further opportunity to see more patients. Overall, the students rated their experience as "above average" to "excellent." CONCLUSIONS: According to the medical students who participated, the introductory hospice experience was a worthwhile and valuable educational experience. An equal or increased amount of hospice time should be allotted in the education of future junior medical students.

Cancer pain education: the use of a structured clinical instruction module to enhance learning among medical students.

The Structured Clinical Instruction Module (SCIM) is an educational format developed for the teaching of clinical and interpersonal skills. The purpose of this study was to develop and pilot-test a SCIM to enhance medical students' learning and understanding about cancer pain assessment and management. The Cancer Pain SCIM was presented to 34 third-year medical students. Eight instructors and six standardized patients (five cancer patients) participated in the course. All participants evaluated the course using a five-point Likert scale (1 = strongly disagree; 5 = strongly agree). Students self-assessed their clinical skills before and after the course using a five-point scale (1 = not competent; 5 = very competent). Students agreed [mean (S.D.)] very strongly that the SCIM was a valuable educational experience [4.4 (0.56)] and that it was beneficial to use actual cancer patients in the SCIM [4.5 (0.63)]. Students believed their skills in the assessment and management of cancer pain significantly improved after the course. The SCIM is a valuable and novel instructional format to teach essential skills in the assessment and management of cancer pain to medical students.

Cancer survivors as standardized patients: an innovative program integrating cancer survivors into structured clinical teaching.

BACKGROUND: Increasingly, standardized patients are involved in medical education; however, reports of cancer survivors functioning as standardized patients have not been available. This study describes the participation of cancer survivors as standardized patients in structured clinical teaching. METHODS: Forty-two cancer survivors, 354 trainees, and 54 faculty members took part in the structured clinical instruction modules (SCIMs) at five academic institutions. After completing the SCIMs, the cancer survivors answered evaluation questionnaire items concerning their perceptions of the course, and all participants (cancer survivors, faculty members, medical students, and residents) rated the benefit of the participation of cancer survivors. The evaluation items were rated on a five-point scale ranging from 1 = "strongly disagree" to 5 = "strongly agree. RESULTS: The evaluation responses were very positive, and the cancer survivors expressed a strong willingness to participate in future courses. Faculty members, residents, and medical students all rated the benefit of using cancer survivors highly. CONCLUSIONS: The participation of cancer survivors in structured clinical teaching was considered beneficial not only by the cancer survivors themselves, but also by the faculty members, residents, and medical students who were involved in the educational program. The role of cancer survivors in the education of physicians needs to be expanded.

Improving residents' clinical skills with the structured clinical instruction module for breast cancer: results of a multiinstitutional study. Breast Cancer Education Working Group.

BACKGROUND: The purpose of this study was to determine, in a multiinstitutional setting, the effectiveness of the structured clinical instruction module (SCIM) as an instructional format for surgical residents. METHODS: The breast cancer SCIM is an abbreviated (3-hour) clinical skills course that places residents in realistic clinical settings. The curriculum encompasses all aspects of breast cancer patient assessment. The SCIM was administered to 137 residents at five institutions. Sixty-six faculty members and 52 patients participated. All participants were surveyed with multiitem questionnaires. The residents were also asked to perform a self-assessment of their skills before and after the SCIM. RESULTS: The SCIM was delivered at all institutions without difficulty. All participants rated the SCIM highly (from "above average" to "outstanding"). Mean ratings (on a 5-point scale) for the overall effectiveness of the SCIM as an educational format follow: [table: see text] The pretest mean (on a 5-point scale) on the self-assessment was 2.46 ("less than competent"); the posttest mean was 3.54 ("more than competent") (p < 0.0001). CONCLUSIONS: Residents are acutely aware of their deficiencies in understanding breast cancer. The SCIM is a standardized, reproducible, portable, and effective educational vehicle.

The multidisciplinary structured clinical instruction module as a vehicle for cancer education.

BACKGROUND: The Structured Clinical Instruction Module (SCIM) modifies the Objective Structured Clinical Examination (OSCE) for teaching purposes. This study determined the effectiveness of a breast cancer SCIM in enhancing residents' clinical skills. METHODS: Twenty-five residents, 15 faculty members, and 12 breast cancer patients (simulated and actual) participated in the multistation, multidisciplinary SCIM. Afterward, faculty members, residents, and patients evaluated the SCIM. Residents completed an 18-item self-assessment of their skills before and after the SCIM. RESULTS: All residents, faculty members, and patients rated the SCIM as either outstanding or above average as an educational experience. The residents' self-assessments of their skills were significantly higher after the SCIM than before. CONCLUSIONS: This study shows that residents are aware of their deficiencies in breast cancer management. The SCIM provides an excellent format for residents to improve their clinical skills.