The effect of peer-group size on the delivery of feedback in basic life support refresher training: a cluster randomized controlled trial.

BACKGROUND: Students are largely providing feedback to one another when instructor facilitates peer feedback rather than teaching in group training. The number of students in a group affect the learning of students in the group training. We aimed to investigate whether a larger group size increases students' test scores on a post-training test with peer feedback facilitated by instructor after video-guided basic life support (BLS) refresher training. Students' one-rescuer adult BLS skills were assessed by a 2-min checklist-based test 1 year after the initial training. METHODS: A cluster randomized controlled trial was conducted to evaluate the effect of student number in a group on BLS refresher training. Participants included 115 final-year medical students undergoing their emergency medicine clerkship. The median number of students was 8 in the large groups and 4 in the standard group. The primary outcome was to examine group differences in post-training test scores after video-guided BLS training. Secondary outcomes included the feedback time, number of feedback topics, and results of end-of-training evaluation questionnaires. RESULTS: Scores on the post-training test increased over three consecutive tests with instructor-led peer feedback, but not differ between large and standard groups. The feedback time was longer and number of feedback topics generated by students were higher in standard groups compared to large groups on the first and second tests. The end-of-training questionnaire revealed that the students in large groups preferred the smaller group size compared to their actual group size. CONCLUSIONS: In this BLS refresher training, the instructor-led group feedback increased the test score after tutorial video-guided BLS learning, irrespective of the group size. A smaller group size allowed more participations in peer feedback.

Assessing clinical reasoning abilities of medical students using clinical performance examination.

PURPOSE: The purpose of this study is to investigate the reliability and validity of new clinical performance examination (CPX) for assessing clinical reasoning skills and evaluating clinical reasoning ability of the students. METHODS: Third-year medical school students (n=313) in Busan-Gyeongnam consortium in 2014 were included in the study. One of 12 stations was developed to assess clinical reasoning abilities. The scenario and checklists of the station were revised by six experts. Chief complaint of the case was rhinorrhea, accompanied by fever, headache, and vomiting. Checklists focused on identifying of the main problem and systematic approach to the problem. Students interviewed the patient and recorded subjective and objective findings, assessments, plans (SOAP) note for 15 minutes. Two professors assessed students simultaneously. We performed statistical analysis on their scores and survey. RESULTS: The Cronbach α of subject station was 0.878 and Cohen κ coefficient between graders was 0.785. Students agreed on CPX as an adequate tool to evaluate students' performance, but some graders argued that the CPX failed to secure its validity due to their lack of understanding the case. One hundred eight students (34.5%) identified essential problem early and only 58 (18.5%) performed systematic history taking and physical examination. One hundred seventy-three of them (55.3%) communicated correct diagnosis with the patient. Most of them had trouble in writing SOAP notes. CONCLUSION: To gain reliability and validity, interrater agreement should be secured. Students' clinical reasoning skills were not enough. Students need to be trained on problem identification, reasoning skills and accurate record-keeping.

Experience of clinical skills assessment in the Busan-Gyeongnam Consortium.

PURPOSE: The purpose of this study is to judge the quality of clinical skills assessment in Busan-Gyeongnam Consortium. METHODS: Fourth grade medical school students (n=350 in 2012 and n=419 in 2013) in the Busan-Gyeongnam Consortium were included in the study. The examination was consisted of 6 clinical performance examination (CPX) and 6 objective structured clinical examination (OSCE) stations. The students were divided into groups to take the exam in 4 sites during 3 days. The overall reliability was estimated by Cronbach alpha coefficient across the stations and the case reliability was by alpha across checklist items. Analysis of variance and between-group variation were used to evaluate the variation of examinee performance across different days and sites. RESULTS: The mean total CPX/OSCE score was 67.0 points. The overall alpha across-stations was 0.66 in 2012 and 0.61 in 2013. The alpha across-items within a station was 0.54 to 0.86 in CPX, 0.51 to 0.92 in OSCE. There was no significant increase in scores between the different days. The mean scores over sites were different in 30 out of 48 stations but between-group variances were under 30%, except 2 cases. CONCLUSION: The overall reliability was below 0.70 and standardization of exam sites was unclear. To improve the quality of exam, case development, item design, training of standardized patients and assessors, and standardization of sites are necessary. Above of all, we need to develop the well-organized matrix to measure the quality of the exam.

Learning curve for a laparoscopic appendectomy by a surgical trainee.

PURPOSE: The laparoscopic appendectomy has been a basic part of the principal of a more complex laparoscopic technique for the surgical trainee. As the number of laparoscopic appendectomies performed by surgical trainees has increased, we are trying to check the stability of, which is controversial, and the learning curve associated with a laparoscopic appendectomy. METHODS: We studied the demographics, histologic diagnoses, operative time, the number of complicated cases, and hospital duration of one hundred and three patients who underwent an open appendectomy (group A, 53) or a laparoscopic appendectomy (group B, 50) retrospectively through a review of their medical records. The learning curve for the laparoscopic appendectomy was established through the moving average and ANOVA methods. RESULTS: There were no differences in the operative times (A, 64.15 ± 29.88 minutes; B, 58.2 ± 20.72 minutes; P-value, 0.225) and complications (A, 11%; B, 6%; P-value, 0.34) between group A and group B. Group B was divided into group C who underwent the operation in the early period (before the learning curve) and group D who underwent the operation in the later period (after the learning curve). The average operative time for group C was 66.83 ± 21.55 minutes, but it was 45.25 ± 10.19 minutes for group D (P-value < 0.0001). Although this difference was statistically significant, no significant difference in the complication rate was observed between the two groups. CONCLUSION: A laparoscopic appendectomy, compared with an open appendectomy, performed by a surgical trainee is safe. In this study, the learning curve for a laparoscopic appendectomy was thirty cases.

Experience of implementation of objective structured oral examination for ethical competence assessment.

PURPOSE: We developed an objective structured oral examination (OSOE) case to assess the medical ethics of students. The aim of this study was to assess the reliability of OSOE with generalizability theory. METHODS: One 10-minute OSOE that contained key questions was developed. The evaluation sheet consisted of 4 domains: moral sensitivity, moral reasoning, decision making, and attitude. The total number of items was 13. The numbers of checklist items and global rating items were 11 and 2, respectively. Items and key questions were validated by 6 professionals. Standardization of the raters and the pilot study was performed before the OSOE. Fifty-four third-year medical students participated in the OSOE. The OSOE was duplicated, and 2 professors assessed 1 student independently. Each station lasted 8 minutes and was followed by a 2-minute interval,during which raters completed the checklist forms. We analyzed the reliability of the OSOE with the GENOVA program. RESULTS: The reliability (generalizability coefficient) was 0.945, and the interrater agreement was 0.867. The type of item, checklist or global rating, was the largest variance component. The reliability of the checklist alone was 0.668 and that of the global rating alone was 0.363. CONCLUSION: The OSOE is reliable and can be used to assess ethics. More research should focus on achieving validity.

Outcome of hepatic resection for metastatic gastric cancer.

The role of hepatic resection for metastatic gastric cancer is less well defined due to the tendency of gastric cancer to widely metastasize. The purpose of this study is to examine the beneficial effect of hepatic resection in patients with metastatic gastric cancer. The clinicopathologic features and long-term results of 11 patients who underwent hepatic resection for metastatic gastric cancer from January 1988 to December 1996 at Seoul National University Hospital were analyzed retrospectively. All resected hepatic metastases were solitary lesions. Among eight patients with synchronous hepatic metastases, one patient with early gastric cancer and lymph node metastases (T1N2M1) remained alive for 8 years 6 months after hepatic resection without recurrence. Among three patients with metachronous hepatic metastases, two patients with advanced gastric cancer and lymph node metastases (T3N2MO, T2N1MO at the initial operation, respectively) survived 8 years 6 months and 3 years after hepatic resection, respectively. Median survival times of synchronous and metachronous hepatic metastases were 13.0 and 74.3 months, respectively. In solitary hepatic metastatic lesions from gastric cancer, surgical resection should be considered as one of the treatment options.

Clinical outcomes and apomucin expression of intrahepatic cholangiocarcinoma according to gross morphology.

BACKGROUND: The clinicopathologic characteristics and the expression of apomucin (MUC) in intrahepatic cholangiocarcinoma (ICC) with respect to gross morphology have not been comprehensively examined. STUDY DESIGN: We reviewed the clinical data of 98 patients with ICC who underwent resection at Seoul National University Hospital from 1980 to 1998. We also examined the expression profiles of MUC1 and MUC2 in 30 ICC tissues by immunohistochemistry using mouse monoclonal antibodies. RESULTS: Of 98 cases, 42 were of the mass-forming type of ICC, 22 were of the periductal-infiltrating type, 21 were of the intraductal-growth (IG) type, and 13 were of the mixed type, and the overall 5-year cumulative survival rate was 23.3% in the mass-forming type, 0% in the periductal-infiltrating type, and 76.2% in the IG type. MUC1 was expressed in all types (mass-forming type 75.0%, periductal-infiltrating type 100%, and IG type 73.3%), but significantly, MUC2 was expressed only in the IG type (80.0%), which had better prognosis than the other types. CONCLUSIONS: It is apparent that the IG type of ICC should be distinguished from the other types of ICC because a favorable prognosis can be expected after complete surgical resection.