Anne C. Larkin

A Human Factors Curriculum for Surgical Clerkship Students

HYPOTHESIS Early introduction of a full-day human factors training experience into the surgical clerkship curriculum will teach effective communication skills and strategies to gain professional satisfaction from a career in surgery. DESIGN In pilot 1, which took place between July 1, 2007, and December 31, 2008, 50 students received training and 50 did not; all received testing at the end of the rotation for comparison of control vs intervention group performance. In pilot 2, a total of 50 students were trained and received testing before and after rotation to examine individual change over time. SETTING University of Massachusetts Medical School. PARTICIPANTS A total of 148 third-year medical students in required 12-week surgical clerkship rotations. INTERVENTIONS Full-day training with lecture and small-group exercises, cotaught by surgeons and educators, with focus on empathetic communication, time management, and teamwork skills. MAIN OUTCOME MEASURES Empathetic communication skill, teamwork, and patient safety attitudes and self-reported use of time management strategies. RESULTS Empathy scores were not higher for trained vs untrained groups in pilot 1 but improved from 2.32 to 3.45 on a 5-point scale (P < .001) in pilot 2. Students also were more likely to ask for the nurses perspective and to seek agreement on an action plan after team communication training (pilot 1, f = 7.52, P = .007; pilot 2, t = 2.65, P = .01). Results were mixed for work-life balance, with some trained groups scoring significantly lower than untrained groups in pilot 1 and no significant improvement shown in pilot 2. CONCLUSIONS The significant increase in student-patient communication scores suggests that a brief focused presentation followed by simulation of difficult patient encounters can be successful. A video demonstration can improve interdisciplinary teamwork.

Has the 80-Hour Workweek Improved Surgical Resident Education in New England?

OBJECTIVE To evaluate the effect of the 80-hour workweek restrictions on resident education within surgical programs in the New England area. DESIGN Web-based survey. SETTING All Accreditation Council for Graduate Medical Education (ACGME) accredited surgical residency programs in New England (n = 20). PARTICIPANTS Program directors/coordinators in each surgical residency program in New England. MAIN OUTCOME MEASURES First, American Board of Surgery In-Training Examination (ABSITE) scores and the passing rate of the ABS certifying examination were recorded for the years 2001, 2002, 2005, and 2006. Second, the changes in the curriculum of surgical education were documented as perceived by program coordinators and directors. RESULTS In all, 85% (17/20) of surgical programs in New England responded to the survey. The programs began to implement the 80-hour workweek from 2002 to 2004. An equal distribution of community (n = 8) and university programs (n = 9) was sampled. Prior to the initiation of the 80-hour workweek, residency programs emphasized weekly didactic sessions given by attending physicians (88%), mock orals (88%), and conventional journal club (76%). After the 80-hour workweek was implemented, the education curriculum most often consisted of didactic sessions by attending (100%), mock orals (88%), and simulation laboratories (75%). No difference was observed in ABSITE scores and first-time pass rates of the ABS examination before or after the introduction of the 80-hour workweek (20% response). Only 25% of programs felt that surgical education was improved after the implementation of the 80-hour workweek, whereas 31% felt education was worse. Overall, 44% of respondents believed that there was no difference in surgical education. CONCLUSIONS Despite the positive effects the 80-hour workweek has had on resident quality of life and patient care, it does not seem that either significant improvements or detrimental effects have occurred on surgical education within residency programs in New England.

Simulation-based training to teach open abdominal aortic aneurysm repair to surgical residents requires dedicated faculty instruction.

OBJECTIVE We assessed the impact of abdominal aortic aneurysm (AAA)-specific simulation training on resident performance in simulated open AAA repair (SOAAAR) and determined whether simulation training required dedicated faculty instruction. METHODS We randomized 18 residents (postgraduate years 3-5) to an AAA simulation course consisting of two mandatory practice sessions proctored either by a surgical skills lab coordinator (Group A, n = 8) or by a vascular surgery faculty instructor (Group B, n = 10). All residents received a detailed manual and video demonstrating the technique of open AAA repair. Using a validated tool, vascular faculty who were blinded to resident identity, level of training, and randomization status graded SOAAAR performance via videos that were recorded before and after the course. RESULTS Characteristics and baseline scores between Groups A and B were not different. Postcourse, there was a no significant improvement in performance in Group A. Group B performance was improved significantly from baseline with regard to task-specific checklist scores (44.1 ± 6.3 vs 34.9 ± .5; P = .02), global rating scores (28.4 ± .6 vs 25.3 ± 5.0; P = .049), and overall assessment of operative competence (P = .02). Time to complete SOAAAR improved in both groups (P = .02). Baseline performance varied significantly with year of training as measured by task-specific checklist scores, global rating scores, final product analysis, time to complete repair, and overall operative competence. Improvement varied inversely with year of training (P < .05) and postcourse scores were equivalent for postgraduate year 3-5 residents. CONCLUSIONS An AAA-specific simulation training course improved resident performance in simulated open AAA repair. Dedicated faculty instruction during the simulation training was required for significant improvement in resident performance. The impact of simulation training was greatest in more junior residents. Procedure-specific simulation training with dedicated faculty can be used to effectively teach simulated open AAA repair.

Effect of Paget's Disease on Survival in Breast Cancer: An Exploratory Study

OBJECTIVE To explore whether Pagets disease (PD) has an effect on outcome in patients with breast cancer. DESIGN Retrospective analysis of comprehensive pathology database, medical records, and slides of samples showing pathologic features. SETTING UMass Memorial Health Care. PATIENTS All patients with breast cancer and PD with records in a prospectively maintained database between January 1, 1990, and December 31, 2008, were identified. Each participant was matched (criteria: age within 5 years, year of treatment, and stage of breast cancer) with 2 controls (1:2 ratio). MAIN OUTCOME MEASURES Overall and disease-free survival were analyzed using Kaplan-Meier statistics and Cox proportional hazards modeling, accounting for matching in the latter analyses by using robust standard error estimates. RESULTS Mean (SD) follow-up was 47 (33) months. Treatment involved mastectomy in 29 (91%) PD vs 16 (25%) non-PD patients (P < .001), radiotherapy in 14 (44%) PD vs 53 (83%) non-PD patients (P < .001), and hormonal therapy in 14 (44%) PD vs 33 (52%) non-PD patients (P = .004). Biological markers were not significantly different except for ERBB2 (formerly HER2 or HER2/neu) overexpression in 14 (44%) PD vs 16 (25%) non-PD patients (P = .008). The PD group had an overall 5-year survival of 81.2% vs 93.8% of the non-PD group (Kaplan-Meier log-rank, P = .03). The unadjusted hazard ratio for the PD vs non-PD group was 5.31 (95% CI, 1.74-16.27; P = .003). The corresponding hazard ratio after adjusting for local and systemic treatment was 2.26 (95% CI, 0.46-11.06; P = .32). CONCLUSIONS These exploratory data show that PD may have a negative effect on breast cancer survival. This finding needs to be substantiated in larger data sets.