An exploration of "real time" assessments as a means to better understand preceptors' judgments of student performance.

Clinical supervisors are known to assess trainee performance idiosyncratically, causing concern about the validity of their ratings. The literature on this issue relies heavily on retrospective collection of decisions, resulting in the risk of inaccurate information regarding what actually drives raters' perceptions. Capturing in-the-moment information about supervisors' impressions could yield better insight into how to intervene. The purpose of this study, therefore, was to gather "real-time" judgments to explore what drives preceptors' judgments of student performance. We performed a prospective study in which physicians were asked to adjust a rating scale in real-time while watching two video-recordings of trainee clinical performances. Scores were captured in 1-s increments, examined for frequency, direction, and magnitude of adjustments, and compared to assessors' final entrustability judgment as measured by the modified Ottawa Clinic Assessment Tool. The standard deviation in raters' judgment was examined as a function of time to determine how long it takes impressions to begin to vary. 20 participants viewed 2 clinical vignettes. Considerable variability in ratings was observed with different behaviours triggering scale adjustments for different raters. That idiosyncrasy occurred very quickly, with the standard deviation in raters' judgments rapidly increasing within 30 s of case onset. Particular moments appeared to generally be influential, but their degree of influence still varied. Correlations between the final assessment and (a) score assigned upon first adjustment of the scale, (b) upon last adjustment, and (c) the mean score, were r = 0.13, 0.32, and 0.57 for one video and r = 0.30, 0.50, and 0.52 for the other, indicating the degree to which overall impressions reflected accumulation of raters' idiosyncratic moment-by-moment observations. Our results demonstrated that variability in raters' impressions begins very early in a case presentation and is associated with different behaviours having different influence on different raters. More generally, this study outlines a novel methodology that offers a new path for gaining insight into factors influencing assessor judgments.

Vascular Access Complications and Clinical Outcomes of Vascular Surgical Repairs Following Transcatheter Aortic Valve Implantation (TAVI).

BACKGROUND: Transcatheter aortic valve implantation (TAVI) procedures have revolutionized the treatment of aortic stenosis. However, due to large sheaths, improperly deployed closure devices, and the comorbidities and challenges innate to this population, vascular access complications can be devastating. The objective of this study is to evaluate vascular access complications in one of the largest TAVI sites in North America. METHODS: This was a retrospective single center review between January 2014 and December 2018 of vascular access complications necessitating operative intervention by vascular surgery. Patient demographics and preoperative comorbidities were collected. Type of vascular access complication, types of repair, closure device used, and postoperative outcomes were analyzed. RESULTS: A total of 37 cases out of a total of 985 TAVI procedures were identified. TAVI was carried out in the operating suite (70%) or the catheterization lab (30%). Consults to vascular surgery were requested intraoperatively (60%), immediately postoperative (14%), later in the day of the TAVI (20%), and on postoperative day 1 (6%). The location of injury included common femoral artery (49%), superficial femoral artery (11%) and external iliac artery (41%), with some cases injuring multiple vessels. Closure devices were found in the subcutaneous tissue (26%), anterior wall (37%), posterior wall (11%), intra-arterial (11%), closing the anterior to the posterior wall (16%), and in the inguinal ligament (5%). Injuries included tears (11%), dissections (38%), and vessel rupture (19%). The majority of repairs were done primarily (64%), with patch (28%) and bypass (8%) less frequently. Four patients died perioperatively (11%), 2 from hemorrhage, 1 from cardiac arrest, and 1 from progressive respiratory disease. CONCLUSIONS: Access complications during TAVI procedures predispose complex patients to increased risk of morbidity and mortality. Careful patient selection, proper access techniques, and performing high risk patients in the operating suite with vascular surgery are fundamental in minimizing complications.

Educational Impact Drives Feasibility of Implementing Daily Assessment in the Workplace.

Construct: Authors investigated the perspectives of stakeholders on feasibility elements of workplace-based assessments (WBA) with varying designs. Background: In the transition to competency-based medical education, WBA are taking a more prominent role in assessment programs. However, the increased demand for WBA leads to new challenges for implementing suitable WBA tools with published validity evidence, while also being feasible and useful in practice. Despite the availability of published WBA tools, implementation does not necessarily occur; a more fulsome understanding of the perspectives of stakeholders who are ultimately the end-users of these tools, as well as the system factors that both deter or support their use, could help to explain why evidence-based assessment tools may not be incorporated into residency programs. Approach: We examined the perspectives of two groups of stakeholders, surgical teachers and resident learners, during an assessment intervention that varied the assessment tools while keeping the assessment process constant. We chose diverse exemplars from published assessment tools that each represented a different response format: global rating scales, step-by-step surgical rubrics, and an entrustability scale. The primary purpose was to investigate how stakeholders are impacted by WBA tools with varying response formats to better understand their feasibility for assessment of cataract surgery. Secondarily, we were able to explore the culture of assessment in cataract surgery education including stakeholders' perceptions of WBA unrelated to assessment form design. Semi-structured interviews with teachers and a focus group with the residents enabled discussion of their perspectives on dimensions of the tools such as acceptability, demand, implementation, practicality, adaptation, and integration. Findings: Three themes summarize teachers' and residents' experiences with the assessment tools: (1) Feedback is the priority; (2) Forms informing coaching; and (3) Forcing the conversation. The tools helped to facilitate the feedback conversation by serving as a reminder to initiate the conversation, a framework to structure the conversation, and a memory aid for providing detailed feedback. Surgical teachers preferred the assessment tool with a design that best aligned with their approach to teaching and how they wanted to provide feedback. Orientation to the tools, combined with established remediation pathways, may help preceptors to better use assessment tools and improve their ability to give critical feedback. Conclusions: Feedback, more so than assessment, dominated the comments provided by both teachers and residents after using the various WBA tools. Our typical assessment design efforts focus on the creation or selection of a robust assessment tool according to good design and measurement principles, but the current findings would encourage us to also prioritize the coaching relationship and include efforts to design WBA tools to function as a mediator to augment teaching, learning, and feedback exchange within that relationship in the workplace.

Pure flat epithelial atypia identified on core needle biopsy does not require excision.

BACKGROUND: Routine excision of flat epithelial atypia (FEA) of the breast found on core needle biopsy (CNB) is being questioned and a policy of selective excision of FEA was adopted in our area. The purpose of this study was to evaluate the upstage rate to malignancy across multiple diagnostic centers in our area following the policy of selective excision and to identify factors predictive of malignancy. METHODS: Patients having excision of CNB FEA at our regional Hospital between 2013 and 2017 were identified. The primary endpoint was upstage to malignancy after excision. We also assessed for clinical, radiological, and pathological features associated with malignancy. RESULTS: We identified 187 patients. Eighty-nine had pure FEA, 71 had concurrent ADH, and 18 had other pathological lesions. Following surgical excision, 9 patients were upstaged to malignancy (4. 8%) with 8 having concurrent ADH (2 invasive ductal carcinoma, 6 DCIS) and 1 with concurrent Complex Sclerosing Lesion (DCIS). None of the pure FEA cases upstaged. The presence of ADH or CSL in the CNB were the only factors found to be predictive of upstaging (p = 0.001, p = 0.0001 respectively). CONCLUSIONS: The upstage rate to malignancy after excision of pure FEA at out center is 0%. Therefore, we recommend that pure FEA with radiology and pathology concordance does not require surgical excision and can instead be followed with serial imaging. However, patients with FEA in association with other high-risk lesions should be managed as per indicated for the other high-risk lesion and FEA with ADH should be excised.

Risk of malignancy in papillary neoplasms of the breast.

PURPOSE: In recent years, routine excision of papillary neoplasms (PN) of the breast has been questioned and controversy exists over when excision is necessary. The aim of this study was to evaluate the upstage rate to malignancy of core needle biopsy (CNB) diagnosed PNs from multiple diagnostic centers in our area and to identify factors predictive of malignancy. METHODS: Patients presenting to our surgical center between 2013 and 2017 for excision of CNB PN were evaluated. The primary endpoint was upstage to malignancy. The association of age, diagnostic center where CNB performed, type of CNB, palpability, discharge, clinical exam size, imaging size, family history of breast cancer, and presence of atypia, as risk factors for upstaging to cancer were also evaluated. RESULTS: Of the 317 PN cases, 83 upstaged to malignancy following surgical excision. 77% of patients with CNB of Atypical PN upstaged, 39% of PN with concurrent atypical ductal hyperplasia, and 0% of PN with concurrent atypical lobular hyperplasia/flat epithelial atypia. Of the 206 non-atypical PNs on CNB, 3.4% upstaged to malignancy, but further review demonstrated a 1% upstage rate when atypia excluded. Factors found to be associated with malignancy included: older patient age, larger size, and presence of atypia. CONCLUSION: We recommend excision of PN with atypia, concurrent cancerous lesion, or radiologic-pathologic non-concordance, and serial imaging follow up may be considered for image detected PN, less than 1 cm, with no atypia.

An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients.

OBJECTIVE: Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65-79 years, >80 years) to determine whether protocols should be modified to account for advanced age. METHODS: All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan-Meier survival and Cox hazards models were used to compare access patency and risk factors for failure. RESULTS: There were 941 autogenous arteriovenous accesses (median follow-up, 23 months; range, 0-89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss. CONCLUSIONS: Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.

Professional paradox: identity formation in qualified doctors pursuing further training.

CONTEXT: Many newly qualified specialists and subspecialists pursue additional training. Although their motivations are many, the pursuit of further training as an alternative to unemployment is an emerging trend. Paradoxically, doctors continue as trainees with a consultant's credentials, and without the guarantee of eventual employment. This study explores seven doctors' experiences, the effects of further training on their professional identity formation (PIF), and how these effects are reconciled on a personal and professional level. METHODS: This phenomenological study involved interviews with seven qualified Canadian specialists (three were female) who pursued additional training in response to a lack of available positions in their respective specialties. Template analysis generated theoretical constructs of influences on their PIF, and characteristics of their lived experiences. RESULTS: Four themes shaped PIF: setting and context; language and communication; responsibilities and privileges; and participants' visions of their future selves. Professional identity formation (PIF) continued to develop in further training, but was inconsistently affirmed by participants' communities of practice. Four major themes characterised training experiences: prescription; managing multiple masters; limiting access to others and community ties; and constantly questioning the value of extra training. CONCLUSION: Qualified doctors traverse professional paradoxes as they seek further education with no guarantee of employment and provide consultant-level care as 'trainees'. An identity dissonance emerges that may continue until a clear identity is prescribed for them. Although disruptive to these doctors' PIF and personal and professional lives, the long-term effects of additional training are unknown. Its utility and influence on securing employment and future job satisfaction are areas for further research.

Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective, Multicenter Novel Endovascular Access Trial (NEAT).

BACKGROUND: Hemodialysis arteriovenous fistulas (AVFs) are suboptimally used primarily due to problems with maturation, early thrombosis, and patient nonacceptance. An endovascular approach to fistula creation without open surgery offers another hemodialysis vascular access option. STUDY DESIGN: Prospective, single-arm, multicenter study (Novel Endovascular Access Trial [NEAT]). SETTINGS & PARTICIPANTS: Consecutive adult non-dialysis-dependent and dialysis-dependent patients referred for vascular access creation at 9 centers in Canada, Australia, and New Zealand. INTERVENTION: Using catheter-based endovascular technology and radiofrequency energy, an anastomosis was created between target vessels, resulting in an endovascular AVF (endoAVF). OUTCOMES: Safety, efficacy, functional usability, and patency end points. MEASUREMENTS: Safety as percentage of device-related serious adverse events; efficacy as percentage of endoAVFs physiologically suitable (brachial artery flow ≥ 500mL/min, vein diameter ≥ 4mm) for dialysis within 3 months; functional usability of endoAVFs to provide prescribed dialysis via 2-needle cannulation; primary and cumulative endoAVF patencies per standardized definitions. RESULTS: 80 patients were enrolled (20 roll-in and 60 participants in the full analysis set; the latter are reported). EndoAVFs were created in 98% of participants; 8% had a serious procedure-related adverse event (2% device related). 87% were physiologically suitable for dialysis (eg, mean brachial artery flow, 918mL/min; endoAVF vein diameter, 5.2mm [cephalic vein]). EndoAVF functional usability was 64% in participants who received dialysis. 12-month primary and cumulative patencies were 69% and 84%, respectively. LIMITATIONS: Due to the unique anatomy and vessels used to create endoAVFs, this was a single-arm study without a surgical comparator. CONCLUSIONS: An endoAVF can be reliably created using a radiofrequency magnetic catheter-based system, without open surgery and with minimal complications. The endoAVF can be successfully used for hemodialysis and demonstrated high 12-month cumulative patencies. It may be a viable alternative option for achieving AVFs for hemodialysis patients in need of vascular access.

The association for surgical education CESERT grant program: the first 15 years.

BACKGROUND: The Association for Surgical Education established the Center for Excellence in Surgical Education Research and Training (CESERT) program in 1999 to support innovative research and education projects and programs that will advance surgical education. We sought to examine scholarly outcomes of the projects during the first 15 years of the program. METHODS: E-mail surveys were sent to the 24 researchers who were awarded CESERT grants. Data collection focused on recipient professional experiences, publications, and presentations stemming from CESERT-funded research and impact on career development. For grant recipients who were unable to complete the survey, we obtained publication information on studies authored by the grant recipients that described the same grant-funded topic, described similar methods, and fell within the study timeline. RESULTS: Complete survey data were obtained from 18 of the 24 grant recipients. Grants were most commonly awarded to General Surgeons (40%) and Education and Psychology PhDs (24%). Overall, 23 of the 25 projects had reached completion at the time of contact, and from these, 70 articles were published or in press. Abstract presentations were more common, with respondents documenting 84 projects locally, nationally, and internationally. Grant awards ranged from $8,122 to $97,000, with an average of $39,026. In total, the Association for Surgical Education Foundation distributed $988,000 in grant funding from 1999 to 2013. Respondents reported that CESERT funding was critical to their career as it legitimized their pursuit of educational research, helped them establish multidisciplinary and multi-institutional collaborations, provided greater visibility for their research, and helped them develop an understanding of educational principles and grant writing skills. CONCLUSIONS: Overall, the CESERT program has produced remarkable results. The careful review process and monitoring protocol have ensured that high-potential studies are funded and successful. These data support continued efforts to garner resources such that CESERT grants may be awarded to fund high-quality, high-impact projects.

How to recruit, retain, and reap the rewards of working with PhD/EdD educators in surgery.

BACKGROUND: PhD and EdD educators in departments of surgery have and are increasingly becoming valuable colleagues. Professional educators typically assist chairpersons and program directors by positively impacting the education, research, and service missions. OBJECTIVE: The purpose of this article is 3-fold: (1) to identify ways of finding prospective PhD/EdD educators, (2) to recognize ways to work with educators in a complimentary way so the educator and directors mutually benefit, and (3) to identify various ways departments and programs can benefit from employing a professional educator.

The use of thoracoscopy to enhance medical students' interest and understanding of thoracic anatomy.

AIM: To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students' stimulation and motivation for learning anatomy. METHODS: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the video's usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained. RESULTS: Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175). CONCLUSION: Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students' interest in learning, in clinically applying anatomic fact, and in surgery as a future career.

Effects of implementation of an urgent surgical care service on subspecialty general surgery training.

BACKGROUND: In July 2007, a large Canadian teaching hospital realigned its general surgery services into elective general surgery subspecialty-based services (SUBS) and a new urgent surgical care (USC) service (also know in the literature as an acute care surgery service). The residents on SUBS had their number of on-call days reduced to enable them to focus on activities related to SUBS. Our aim was to examine the effect of the creation of the USC service on the educational experiences of SUBS residents. METHODS: We enrolled residents who were on SUBS for the 6 months before and after the introduction of the USC service. We collected data by use of a survey, WEBeVAL and recorded attendance at academic half days. Our 2 primary outcomes were residents' attendance at ambulatory clinics and compliance with the reduction in the number of on-call days. Our secondary outcomes included residents' time for independent study, attendance at academic half days, operative experience, attendance at multidisciplinary rounds and overall satisfaction with SUBS. RESULTS: Residents on SUBS had a decrease in the mean number of on-call days per resident per month from 6.28 to 1.84 (p = 0.006), an increase in mean attendance at academic half days from 65% to 87% (p = 0.028), at multidisciplinary rounds (p = 0.002) and at ambulatory clinics and an increase in independent reading time (p = 0.015), and they reported an improvement in their work environment. There was no change in the amount of time residents spent in the operating room or in their overall satisfaction with SUBS. CONCLUSION: Residents' education in the SUBS structure was positively affected by the creation of a USC service. Compliance with the readjustment of on-call duties was high and was identified as the single most significant factor in enabling residents to take full advantage of the unique educational opportunities available only while on SUBS.

Occlusion of the common and internal iliac arteries for aortoiliac aneurysm repair: experience with the Amplatzer vascular plug.

BACKGROUND: We sought to evaluate and describe our centre's experience with the Amplatzer vascular plug (AVP) for the occlusion of common and internal iliac arteries (CIA; IIA) during endovascular aortic aneurysm repair (EVAR). METHODS: We performed a retrospective analysis of 20 consecutive patients between October 2006 and December 2007, who underwent occlusion of the CIA or IIA before or during EVAR to prevent endoleak. RESULTS: Among these 20 patients, 21 occlusion procedures occurred and 20 were successful. In the only unsuccessful case, the patient had EVAR, but occlusion with an AVP was not possible because of severe narrowing at the origin of the vessel. Of the successfully treated patients, 2 presented with ruptured aneurysms, whereas the others had elective procedures. Eleven patients received aortouni-iliac grafts and femoral-femoral bypass, and 9 patients received a bifurcated stent graft. In 5 patients, the AVP occlusion and EVAR procedures were staged; in these cases occlusion occurred first, followed by EVAR on average 29 (standard deviation [SD] 23) days later. We deployed 7 AVPs in the CIA, whereas 13 were deployed in the IIA. The average diameter of the vessels occluded was 10 (SD 1) mm and the average size of the device used was 13 (SD 1) mm, representing a device diameter 28% (SD 2%) greater than the vessel diameter. We used a single device in 18 patients, whereas 2 devices were deployed in the same artery in 2 patients. Four patients underwent concomitant coil embolization. On follow-up computed tomography (CT) scans, all occlusion procedures were clinically successful. At the 14-month (SD 1 mo) follow-up, 4 patients had a small type-II endoleak unrelated to the occlusion procedure and 1 had a type-I endoleak that required graft limb extension. Four patients had buttock claudication but none had changes in sexual function, ischemic complications or device dislodgement on CT scans. CONCLUSION: The AVP is a safe and effective method to occlude the CIA and IIA in patients undergoing EVAR.

Reliability and acceptance of the mini-clinical evaluation exercise as a performance assessment of practicing physicians.

BACKGROUND: The purpose of this study was to evaluate the reliability and acceptance of the mini-Clinical Evaluation Exercise (mini-CEX) as an assessment of practicing primary care physicians. METHOD: Six raters were recruited to conduct the assessments. After a training session, their ability to discriminate between levels of performance was evaluated using videotaped clinical scenarios. Fifteen physicians were assessed in an office setting by the raters who scored multiple clinical encounters using a validated mini-CEX form for each encounter. Participants were given a postassessment survey regarding the process. RESULTS: Raters distinguished between performance levels on the videotaped scenarios (P < .001). A total of 188 physician-patient interactions were assessed. The generalizability coefficient for 10 encounters was 0.92. In the postassessment survey, the raters (94%) and physicians assessed (75%) both felt that the mini-CEX is an acceptable assessment. CONCLUSIONS: The mini-CEX seems to be a reliable and acceptable instrument for the assessment of practicing physicians.

Use of short-radius centrifugation to augment ankle-brachial indices.

BACKGROUND: Peripheral arterial disease is mainly caused by atherosclerosis and is characterized by decreased circulation, lower blood pressure, and insufficient tissue perfusion in the lower extremities. The hemodynamics of standing and altered gravity environments have been well studied relative to arm blood pressures but are less well understood for ankle pressures. METHODS: Because regional blood pressure depends, in part, on the gravitational pressure gradient, we hypothesized that artificial gravity exposure on a short-arm centrifuge with the center of rotation above the head would increase blood pressure in the lower extremities. Cardiovascular parameters for 12 healthy subjects were measured during exposure to supine short-arm centrifugation at 20, 25, and 30 revolutions per minute (rpm), corresponding to centripetal accelerations of 0.94, 1.47, and 2.11 Gz at the foot level, respectively. RESULTS: Systolic ankle blood pressure significantly increased at all levels of centrifugation. Ankle-brachial indices (the ratio of systolic ankle to arm blood pressures) increased significantly from 1.17 +/- 0.03 to 1.58 +/- 0.03 at 0.94 Gz (P < 0.005), 1.74 +/- 0.02 at 1.47 Gz (P < 0.005), and 1.89 +/- 0.06 at 2.11 Gz (P < 0.005). Systolic arm blood pressure significantly increased at 2.11 Gz, but heart rate did not change significantly. All parameters returned to normal after cessation of centrifugation. CONCLUSIONS: We demonstrated that short-radius centrifugation leads to an increase in ankle-brachial indices. This could have potential implications for the treatment of peripheral arterial disease.

Objective assessment of surgical decision making in trauma after a laboratory-based course: durability of cognitive skills.

BACKGROUND: Because surgical trainees have less exposure to surgical trauma, there is a greater potential of having gaps in decision-making skills. We previously validated a novel assessment tool for decision making in surgical trauma and have documented improvement in resident decision-making skills after a hands-on course. However, brief intensive courses have been criticized for not imparting long-term changes in practice. The purpose of this study was to assess the durability of cognitive skills learned after a 2-day course. METHODS: Twenty-two residents participated in a 2-day interactive didactic lecture series as well as an animal laboratory focused on practical strategies in dealing with surgical trauma. All participants underwent precourse and immediate postcourse assessment of surgical decision making through a validated short-answer examination. Six months after the course, 12 of these 22 residents completed a third similar examination-the retention test. RESULTS: The retention test showed good reliability (Cronbach's alpha, .81) and construct validity as evidenced by a positive correlation between test scores and postgraduate year level (r = .9, P < .001). There was no significant difference between retention test scores and posttest scores. However, both were significantly higher than pretest scores (P < .05). This did not change after adjusting for differing degrees of difficulty between the examinations. CONCLUSIONS: In the context of residency trauma education, there is a measurable positive impact of an intensive, hands-on course on surgical decision making. This impact is durable and cognitive skills persist after the immediate postcourse period. These data support the continued supplementation of traditional residency experiential learning with appropriate laboratory-based skills training.

Examination stress leads to improvements on fundamental technical skills for surgery.

BACKGROUND: This study was conducted to assess the effects of examination-induced stress on the technical performance of junior surgery residents. METHODS: Twelve first-year surgery residents completed 2 surgical tasks (skin excision, tracheotomy) in low- and high-stress condition (in-training examination--Objective Structured Assessment of Technical Skills [OSATS]). Residents rated their subjective stress levels on a 10-point Likert-like scale. Performances were videotaped and assessed by 3 blinded experts using checklist and global rating scales. RESULTS: Residents reported moderately higher stress levels in the exam condition than in the low-stress conditions (P < .05). Their performance was rated higher in the exam condition on the checklist scales (P < .05) but not on the global rating scales (P = .79). CONCLUSIONS: Residency in-training exams induce moderate stress levels in junior surgery residents and are accompanied by improvements in technical performance as assessed by checklist-based scales. There were no differences on the global rating scales due to stress conditions, suggesting that residents were better at following the itemized sequence of movements when stressed, but their overall global performance was not altered.

Teaching and learning in the operating room is a two-way street: resident perceptions.

BACKGROUND: The transformation of a trainee into a surgeon is influenced strongly by communication patterns in the operating room (OR). In the current era of limited educational opportunities, elucidation of teaching and learning strategies in this environment is critical. The aim of this study was to further understand the elements of an effective communicative instructional interaction (CII) as perceived by surgical residents. METHODS: Qualitative research methodology was used to explore University of British Columbia surgery residents' perceptions of what constitutes an effective CII in the OR. Purposeful sampling was used to select participants from various years of training. Eighteen residents participated in semistructured interviews to facilitate reflection of their OR experiences. Interviews were transcribed, analyzed, and fed back to residents to confirm their accuracy. Independent coding and analysis led to the development of key emergent themes. RESULTS: Themes represented the interplay of ideals expressed by the residents. The primary emergent theme was that both teacher and learner play a major role in the creation of an effective CII. The ideal teacher had an instructional plan, facilitated surgical independence, and showed support and empathy for the surgical resident. The ideal resident was receptive, prepared, and acknowledged limitations. The contextual constraints of the OR played a central role in learning, and residents identified ways to maintain educational value despite primarily nonmodifiable contextual elements (ie, time constraints). CONCLUSIONS: In a unique environment such as the OR, both teacher and learner may benefit by an enhanced understanding of the elements of an effective CII.

A universal global rating scale for the evaluation of technical skills in the operating room.

BACKGROUND: The ideal assessment of technical skills should be defensible and practical. The purpose of this study was to evaluate the utility of a Global Rating Scale (GRS) Assessment tool of resident operating room performance. METHODS: Residents were assessed in the operating room on multiple occasions during a 6-month study period using a 9-item GRS. Data were analyzed to assess scale reliability and sensitivity to year of training. Feasibility was evaluated with a post-study questionnaire. RESULTS: Seven residents had a total of 32 procedures assessed. One-way analysis of variance (ANOVA) showed that scores increased with year of training (P = .009). Reliability was excellent. (Cronbach's alpha .91). The post-study survey identified feedback and faculty interaction as strengths of this tool, but time constraint was a barrier. CONCLUSIONS: The GRS tool is a valid and reliable method that has the potential to be a practical, useful assessment tool of resident operating room performance.