Exercise stage of change, barriers, expectations, values and preferences among breast cancer patients during treatment: a pilot study.

With increasing evidence supporting physical activity benefits during breast cancer treatment, addressing exercise adherence with consideration of the unique exercise barriers, outcome expectations and preferences of cancer patients is needed. Our pilot study aimed to determine the following during breast cancer treatment: (1) exercise barriers, outcome expectations/values and associations with exercise stage of change and (2) exercise preferences. A cross-sectional survey was administered to 23 breast cancer patients during treatment. Participants were primarily aged 50-60 years (52%), Caucasian (91%), with stage I (30%), II (44%) or III (26%) disease. A total of 48% were receiving chemotherapy. In total, 50% were in the pre-contemplation/contemplation stage of change, with 34% in action/maintenance. Common exercise adherence barriers (i.e. lack of priority, self-discipline, procrastination and fatigue) demonstrated statistically significant negative associations with exercise. Frequent outcome expectations included improving heart/lungs, reducing disease risk, building muscle strength and losing weight. Important outcomes included improving state of mind, reducing fatigue and avoiding injury. Outcome expectations (i.e. less depression, boredom and nausea) were positively associated with exercise. The majority preferred walking (100%), moderate-intensity (61%), home-based (78%) exercise. Among breast cancer patients during treatment, exercise adherence barriers are general and disease specific. Outcome expectations are physical benefits, with the most important outcomes being psychological or avoidance of risk (i.e. injury).

Development of physical examination skills in a third-year surgical clerkship.

BACKGROUND: Previous studies have revealed deficiencies in physical examination (PE) skills of third-year medical students. The purpose of this study was to determine if formal teaching of PE skills and more supervised experiences with clinical faculty would increase the competency of these skills. METHODS: Forty-nine third-year medical students were assigned to one of two groups: group A was given formal instruction on PE skills at the beginning of the clerkship, and group B received the same instruction at the midpoint of the clerkship. The two groups received an assessment of the PE skills before, in the middle, and at the end of clerkship, utilizing a physician-developed checklist. RESULTS: Group A had a pretest score of 57.7%. Group B scored 59.8% on the pretest. Independent groups t tests were used to compare the two groups. At the midterm examination, group A increased their score to 71.0%, while group B decreased their score to 55.6%. From beginning to final, both groups had significant improvements in all areas, with group A scoring an overall mean of 75.1% (P = 0.0001), and group B scoring 75.5% (P = 0.0001). CONCLUSION: These findings show the effectiveness of structured learning situations for improving third-year surgery students' PE skills. There is also an indication that usual clerkship activities may not enhance learning of PE skills.

An evaluation of study habits of third-year medical students in a surgical clerkship.

BACKGROUND: This study was developed to assess study habits of medical students in a third-year surgical clerkship and to determine the relationship of these study habits to performance outcomes. METHODS: A questionnaire designed to assess medical student study habits was administered at the end of five consecutive 10-week multidisciplinary surgical clerkships. The results of questionnaires from 81 students were analyzed in respect to results on the National Board of Medical Education (NBME) surgical subtest and the multiple stations clinical examination (MSCE) given at the end of each clerkship. RESULTS: Although only 18 of the total 81 students reported studying in formal but self-directed groups, students who reported studying in a group on average scored 4 points higher on the MSCE than those who did not study in a group (P = 0.001). However, no significant differences or correlations were discovered between any of the study habits and the individual results on the NBME. CONCLUSION: Students may benefit from collaborative studying when it comes to clinical experience as demonstrated by improved performance on the MSCE.

A ten-year analysis of surgical education research.

BACKGROUND: Surgical education peer-reviewed publications have markedly increased over the last decade. The purpose of this study was to review the surgical education literature published over the last 10 years and address the following questions: What subjects in surgical education tend to be studied? What are the most to least commonly employed research designs and statistics? Has there been a change in how research data are collected? Where are these studies published? METHODS: A literature search encompassing surgical education papers published between January 1988 and August 1998 was performed. Four investigators coded qualifying abstracts on journal type, subject of research, data collection methods, research design, and statistics. Each investigator was asked to code 10 articles at the start of the study to assess interrater reliability. RESULTS: A total of 420 abstracts were evaluated. Interrater reliability yielded percent agreements ranging from 82% to 96%. Curriculum and teaching were the most frequent topics studied (40%), followed by assessment (23%) and program evaluation (18%). Most research designs used were descriptive (41%). Experimental design has progressively increased from 2% in 1988-89 to 16% in 1998. A total of 551 statistical methods were accounted for in the 420 abstracts. The most common statistical analyses used were descriptive statistics (32%). The predominant mode of data collection was through testing or direct observations (34%). Survey instruments followed closely as a popular data collection method at 27%. The majority of papers were published in peer-reviewed surgical journals (64%),followed by medical education journals (22%) and "other" journals (14%). CONCLUSIONS: An analysis of the surgical education literature demonstrates the growing emphasis on the use of educational research to explore relevant issues and problems. Descriptive research is most popular, with an increasing trend in experimental research. Publication of educational research in peer-reviewed surgical journals is becoming more popular. This study informs those interested in the surgical education research literature of current trends, and what they need to know for a more critical appraisal of this body of literature.

The standardized vascular clinic: an alternative to the traditional ambulatory setting.

PURPOSE: To investigate the effectiveness of a standardized vascular clinic (SVC) in teaching diagnostic and management skills for common vascular problems, as compared with that of the traditional ambulatory setting. METHODS: Third-year medical students participating in the required surgical clerkship participated in this study. Students were randomly assigned to attend either a 4-hour SVC experience (group 1, n = 64) or a 4-hour traditional ambulatory experience (group 2, n = 60). Students completed a satisfaction rating scale and a preencounter and postencounter self-efficacy rating scale at the end of the experience. Student t tests were used to compare the groups in the areas of knowledge acquisition, problem solving, clinical skills and satisfaction with the encounter. Analysis of covariance was used to compare the change between pre and post self-efficacy ratings. RESULTS: Students in group 1 performed significantly higher than students in group 2 in the areas of problem solving, clinical skills, and student satisfaction. They also demonstrated a higher level of confidence in their vascular skills than students assigned to the traditional setting. CONCLUSION: The SVC may be more effective in teaching problem-solving and clinical skills. It also may promote more student satisfaction with the experience and confidence in clinical skills than the traditional ambulatory setting.

Factors contributing to success in surgical education research.

BACKGROUND: Surgeons who have demonstrated excellence through extensive publication in the medical education literature can provide valuable guidance for new surgeons interested in educational research. METHODS: National databases identified members of the Association for Surgical Education (ASE) who have accumulated the greatest number of peer-reviewed, original educational research publications. The top 15 surgeons completed an open-ended survey exploring surgical education research issues. RESULTS: The top three factors contributing to success in this field were (1) chair support, (2) collaboration with peers and mentors, and (3) participation in the ASE. The top three barriers were (1) perception at their institution of educational research as lacking credibility, (2) lack of adequate funding, and (3) lack of time. Eighty-five percent (11 of 13) reported having tenure or equivalent, of which 45% reported educational research as playing a significant role. All respondents advised formal training in education. CONCLUSIONS: Credibility of educational research is bolstered by quality research and a supportive chair. Scholarly work in this field can form the basis for an academic career.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral.

OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.

Peer and self assessment during problem-based tutorials.

BACKGROUND: Peer and self assessment may contribute a unique and insightful perspective to a students' performance. This study investigates the association between self, peer, and faculty evaluations in the intimate setting of a problem-based tutorial group. METHODS: Third-year medical students participating in the required third-year surgical clerkship during the 1996-97 academic year (n = 154) were randomly assigned to problem-based learning groups and completed self and peer evaluations at the end of the last tutorial. These evaluations were compared with expert tutor ratings using Pearson correlation coefficients. RESULTS: A moderate correlation was found between peer and tutor ratings. There was very little correlation between self and tutor ratings. CONCLUSIONS: The results of this study suggest that peer and self ratings in the setting of a tutorial group may provide additional valuable information regarding medical student performance during a surgery clerkship.

MDR1 gene expression in primary and advanced breast cancer.

P-glycoprotein (Pgp)-associated multidrug resistance (MDR) is related to intrinsic and acquired cross resistance to anthracyclines, vinca alkaloids, and other antineoplastic antibiotics. Expression of MDR1 is widely considered to play an important role in conferring resistance to adjuvant chemotherapy in women with breast tumor cells in women with disseminated disease, although data supporting this view is, at best, conflicting. The expression of MDR1 gene and its gene product, P-glycoprotein, was investigated in primary and advanced breast cancers (both previously untreated and previously treated on specific treatment protocols) to assess the role of P-glycoprotein in determining responsiveness to adjuvant chemotherapy. Expression was assessed by immunohistochemistry, reverse transcription-PCR (RT-PCR), Northern Blot and Western Blot. MDR1 mRNA was detected in 40% of the breast cancers tested by RT-PCR with 40 cycles of PCR amplification. When reducing the PCR amplification cycles to 28, the MDR1 gene expression signal disappeared from breast cancers of the highest expressers; however, known MDR1 positive control normal tissues, such as adrenal, kidney, and liver continued to show an expression product. Western and Northern blots failed to demonstrate the MDR1 gene product, P-glycoprotein, in these breast cancers. In contrast, physiologic levels of P-glycoprotein was clearly detected in normal adrenal, kidney, and liver by these techniques. Immunohistochemistry confirmed that breast carcinoma cells lacked P-glycoprotein expression; however, interstitial mononuclear cells, morphologically consistent with lymphocytes or macrophages did show immunostaining in some of these breast tumors. MDR1 gene expression identified by RT-PCR was not correlated either with response to paclitaxel therapy (29 patients able to be evaluated, p = 0.34, Fisher Exact Test) or overall survival (32 breast cancer patients with clinical follow-up information, p = 0.336, log rank). In conclusion, P-glycoprotein was not expressed in breast carcinoma cells at significant levels, although it was expressed in stomal lymphocytes or macrophages. These results suggest that P-glycoprotein does not play a significant role in multidrug resistance of breast cancer.

A prospective randomized trial of a residents-as-teachers training program.

PURPOSE: To develop, implement, and evaluate a course for improving the teaching skills of surgery residents. METHOD: Responses from residents at four general surgery training programs to a needs assessment survey were used to develop a two-day course for improving teaching skills. Residents at two surgical training programs were randomly assigned to experimental and control groups, and experimental residents participated in and evaluated the newly devised course. Six to seven months later, experimental and control residents' teaching performances were evaluated using a five-station objective structured teaching evaluation (OSTE). Differences between the residents' performances were calculated using Mann-Whitney U, chi-square analysis, or Fisher's exact test. RESULTS: Participating residents rated the course highly. They considered the interactive nature of the course its greatest strength. As measured by the OSTE, the performances of the residents differed least significantly in the feedback station, where the residents in the experimental groups showed significant improvement on only one of seven items at one institution, and only one of nine items at the other. The greatest differences occurred in the microskills teaching station, where the residents at one institution performed significantly better than did their control counterparts on four of five items and in overall performance. CONCLUSION: This study demonstrates the value of a needs assessment in developing a course to improve residents' teaching skills. Such courses must provide active learning with opportunities for practicing skills and, following the course, ongoing feedback to maintain changes in teaching behaviors. The curriculum developed in this study has been put into a transportable form that includes an instructor's manual providing guidelines and suggestions for implementation.

Do our current assessments assure competency in clinical breast evaluation skills?

BACKGROUND: The focus of teaching for clinical breast evaluation has been the technique of breast examination. This study questions the relationship between breast examination technique and the ability to detect physical findings. METHODS: This study examines the relationship between breast examination skills of 66 graduating primary care physicians as measured during an objective structured clinical examination (OSCE) and lump detection sensitivity and specificity on breast models. RESULTS: Overall breast examination performance revealed 50% of maneuvers performed correctly. Mean breast model sensitivity for lump detection was 40% and the mean breast model specificity was 77%. While a mild correlation existed between breast examination skills and lump detection sensitivity (r = .34, P = 0.01), no relationship was found between lump detection specificity and examination skills. CONCLUSIONS: There is a limited relationship between correct performance of breast examination maneuvers and the ability to detect a breast lump when present. Breast examination skills and palpation skills to detect masses may represent independently acquired skills with need for separate instructional methodology. These results raise serious concerns about the reliance on standardized patients alone for training in physical examination skills.

Comprehensive needs assessment of clinical breast evaluation skills of primary care residents.

BACKGROUND: Health care reform places primary care (PC) physicians in an increasingly significant role for breast cancer screening and diagnosis. This study assessed the adequacy of traditional PC resident training to prepare physicians for this front-line role. METHODS: Sixty-eight primary care residents, representing seven training programs, participated in a multidimensional needs assessment study of clinical breast evaluation skills. RESULTS: Performance deficiencies noted in each component were most significant in (1) common breast problem management (problem-solving mean 44.51 +/- 11.01); (2) breast examination skills (mean 49.65 +/- 14.48%); and (3) lump detection sensitivity (mean 40.20 +/- 17.10%). Overall examination reliability was good (alpha = .82). Factorial ANOVA revealed significant performance differences among training programs. Residency programs with higher performance levels reported dedicated breast curricula, and residents rated these programs as providing more adequate training. Programs with poorer performance in breast examination lacked curriculum emphasis, with residents describing training received as poor to fair. CONCLUSION: This study demonstrated performance deficits in the clinical breast evaluation skills of graduating PC residents that have not been captured by traditional evaluation methodologies. This may represent a limitation in the ability of many PC physicians to effectively screen and diagnose patients with breast cancer.

Original p53 status predicts for pathological response in locally advanced breast cancer patients treated preoperatively with continuous infusion 5-fluorouracil and radiation therapy.

PURPOSE/OBJECTIVE: 1) To test feasibility of preoperative continuous infusion (c.i.) 5-Fluorouracil (5-FU) and radiation (RT) in locally advanced breast cancer. 2) To study clinical and pathological response rates of 5-FU and radiation. 3) To attempt preliminary correlations between biological probes and pathological response. METHODS AND MATERIALS: Previously untreated, locally advanced breast cancer patients were eligible: only patients who presented with T3/T4 tumors that could not be resected with primary wound closure were eligible, while inflammatory breast cancer patients were excluded. The protocol consisted of preoperative c.i. infusion 5-FU, 200 mg/m2/day with radiotherapy, 50 Gy at 2 Gy fractions to the breast and regional nodes. At mastectomy, pathological findings were classified based on persistence of invasive cancer: pathological complete response (pCR) = no residual invasive cells in the breast and axillary contents; pathological partial response (pPR) = presence of microscopic foci of invasive cells in either the breast or nodal specimens; no pathological response (pNR) = pathological persistence of tumor. For each patient pretreatment breast cancer biopsies were analyzed by immunohistochemistry for nuclear grade, ER/PR hormonal receptors, her2/neu and p53 overexpression. RESULTS: Thirty-five women have completed the protocol and are available for analysis. 5-FU was interrupted during radiation in 10 of 35 patients because of oral mucositis in 8 patients, cellulitis in 1, and patient choice in another. Objective clinical response rate before mastectomy was 71% (25 of 35 patients): 4 CR, 21 PR. However, in all 35 patients tumor response was sufficient to make them resectable with primary wound closure. Accordingly, all patients underwent modified radical mastectomy: primary wound closure was achieved in all patients. At mastectomy there were 7 pCR (20%), 5 pPR (14%) and the remaining 23 patients (66%) had pathological persistence of cancer (pNR). Variables analyzed as potential predictors for pathological response (pPR and pCR) were: initial TNM clinical stage, clinical response, nuclear grade, hormonal receptor status, p53 overexpression, and Her2/neu overexpression in the pretreatment tumor biopsy. Only initial p53 status (lack of overexpression at immunohistochemistry) significantly correlated with achievement of a pathological response to this regimen (p = 0.010). CONCLUSION: The combination of c.i. 5-FU and radiation was well tolerated and generated objective clinical responses in 71% of the patients. With the limitation of the small sample size, the complete pathological response achieved (20%) compares favorably with that reported in other series of neoadjuvant therapy for similar stage breast cancer. These preliminary data suggest that initial p53 status predicts for pathological response (pPR and pCR) to the combination of c.i. 5-FU and radiotherapy in locally advanced breast cancer.

Preoperative 5-fluorouracil and radiation therapy for locally advanced breast cancer.

BACKGROUND: Fifteen percent of breast cancer patients present with large tumors involving skin or chest wall. Often, surgery with primary wound closure is impossible. We used neoadjuvant chemoradiation in locally advanced breast cancer patients, in hopes of increasing resectability. METHODS: Eligible patients had locally advanced breast cancer deemed unresectable with primary wound closure. Patients received 8 weeks of infusional 5-fluorouracil (5-FU) 200 mg/m2 per day and radiation therapy to 50 Gy. Patients rendered resectable underwent modified radical mastectomy (MRM) followed up by chemotherapy. RESULTS: Of 30 evaluable patients, 73% had an objective clinical response. All were able to undergo MRM with primary wound closure; 63% had residual disease, 20% had minimal microscopic disease, and 17% had complete pathologic response. Treatment-related toxicity was minimal. Surgical morbidity was not increased. CONCLUSIONS: Infusional 5-FU with concomitant radiotherapy is well tolerated and effective at producing shrinkage in the majority of patients, converting inoperable breast cancer to easily resectable disease.

High negative appendectomy rates are no longer acceptable.

BACKGROUND: A 10% to 20% negative appendectomy rate has been accepted in order to minimize the incidence of perforated appendicitis with its increased morbidity. We reviewed our experience with appendicitis in order to determine the incidence of negative appendectomies and perforation, and the role of delay in diagnosis or treatment. METHODS: We reviewed 659 appendectomies performed over a 12-month period. Incidental and pediatric appendectomies were excluded. RESULTS: Seventy-five percent of patients were male and 25% female. Nine percent had negative appendectomies and 28% had perforated appendicitis. Perforated appendicitis resulted in increased morbidity and length of stay. Delay in presentation greater than 12 hours after the onset of symptoms significantly increased the perforation rate. In-hospital delay did not affect perforation rate. CONCLUSIONS: We have achieved a negative appendectomy rate lower than that in other reported series, while maintaining an acceptable perforation rate. In the majority of patients, perforated appendicitis is a result of late presentation.

Standardized patients: a new method to assess the clinical skills of physicians.

A growing concern about the deterioration of the clinical skills of physicians has stimulated a renewed interest in the teaching and assessment of these skills. Standardized patients can be an effective means to teach or assess a physician's competence in clinical skills, such as history taking, physical examination, and patient-physician interaction skills. This article will describe this new method and delineate its emerging role in medical school education, residency training, and its potential role in continuing education and quality assurance for practicing physicians within a managed care setting.

Ambulatory teaching "lite": less clinic time, more educationally fulfilling.

Typically, the primary instructional method for ambulatory care education is direct interaction between a preceptor and a learner during a patient encounter. This paper describes instructional strategies teachers and learners can use in ambulatory care training that can occur before or after scheduled clinic hours, thus providing instruction without disrupting a preceptor's busy clinic. First, they describe how preceptors and clerkship or residency-program directors can orient learners prior to their arrival at assigned sites, so that learners are better prepared to assume their patient-care responsibilities. Then they discuss strategies for making use of various types of conferences and independent learning activities to enhance learners' clinical experiences. Conferences and independent study projects that occur before clinic hours can help learners bring a higher level of thinking and clinical sophistication to their role in the ambulatory care site; conferences and independent study activities that occur after clinic hours give learners an opportunity to reinforce and expand on what they have learned during clinic. In this way, learners' educational experiences are enhanced, the best use is made of preceptors' time and expertise, and clinic efficiency is not disrupted.

Strategies for efficient and effective teaching in the ambulatory care setting.

Medical education in the ambulatory care setting is characterized in part by the question of how to ensure educational effectiveness while simultaneously providing high-quality, cost-effective patient care. The constraints associated with managed care have only served to escalate the intensity of this dilemma. However, in spite of the difficulties faced by ambulatory care preceptors, there are educationally sound and time-efficient strategies clinical teachers may employ to improve ambulatory care education. Emphasizing the basic three-step process of planning, teaching, and reflection, the authors describe five such strategies: "wave" scheduling, orienting learners to patients, having learners do their case presentations in the examination room, employing the microskills of the "one-minute preceptor," and effectively reflecting on one's teaching in order to develop effective teaching scripts. Research in ambulatory care learning has indicated that learners must be given significant roles in patient care and that preceptors must observe trainees as they care for patients so that they can provide trainees with helpful feedback. Employing these strategies in the ambulatory care setting will help educators to accomplish these two objectives while minimizing disruption to cost-effective, high-quality clinical practice.

Educational practice guidelines for a surgical clerkship.

Similar to the Residents Review Committee's "Essentials for a Residency Training Program," this article provides Educational Practice Guidelines for a required surgical clerkship. The Guidelines presented are ones that can be adopted by any department of surgery in the United States, but in some cases not without significant increase in resources and faculty effort. The 10 essential components provide an opportunity for intensive program evaluation of all medical student clerkship experiences.