David C. Mayer

Get on your boots: Preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism

INTRODUCTION Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeons formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. METHODS We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. RESULTS A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). CONCLUSIONS Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

Central hemodynamic effects of oxytocin and interaction with magnesium and pregnancy in the isolated perfused rat heart

OBJECTIVE Our purpose was to determine the cardiac effects of oxytocin in the isolated perfused rat heart model and to see whether pregnancy or pharmacologic levels of magnesium modifies the hormones action. STUDY DESIGN Hearts were excised from 30 female Sprague-Dawley rats (15 pregnant, 15 nonpregnant) and attached to a Langendorfs apparatus. Heart rate, left ventricular systolic pressure, and contractility were measured. Hearts were exposed serially to 2, 4, and 6 mU/ml concentrations of oxytocin. The experiment was repeated in 15 pregnant animals at a magnesium level of 5 mEq/L. RESULTS Hearts from pregnant rats had lower heart rates than did hearts from nonpregnant animals. Oxytocin exposure diminished heart rate but increased left ventricular systolic pressure and contractility in a dose-dependent manner. Pregnancy did not alter this response. Magnesium levels of 5 mEq/L reversed the effects of oxytocin on contractility and left ventricular systolic pressure. CONCLUSION Oxytocin is a negative chronotropic and positive inotropic agent in hearts from pregnant and nonpregnant rats. Magnesium reserves the positive inotropic effects of oxytocin.

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

BACKGROUND In a flipped classroom approach, learners view educational content prior to class and engage in active learning during didactic sessions. OBJECTIVE We hypothesized that a flipped classroom improves knowledge acquisition and retention for residents compared to traditional lecture, and that residents prefer this approach. METHODS We completed 2 iterations of a study in 2014 and 2015. Institutions were assigned to either flipped classroom or traditional lecture for 4 weekly sessions. The flipped classroom consisted of reviewing a 15-minute video, followed by 45-minute in-class interactive sessions with audience response questions, think-pair-share questions, and case discussions. The traditional lecture approach consisted of a 55-minute lecture given by faculty with 5 minutes for questions. Residents completed 3 knowledge tests (pretest, posttest, and 4-month retention) and surveys of their perceptions of the didactic sessions. A linear mixed model was used to compare the effect of both formats on knowledge acquisition and retention. RESULTS Of 182 eligible postgraduate year 2 anesthesiology residents, 155 (85%) participated in the entire intervention, and 142 (78%) completed all tests. The flipped classroom approach improved knowledge retention after 4 months (adjusted mean = 6%; P = .014; d = 0.56), and residents preferred the flipped classroom (pre = 46%; post = 82%; P < .001). CONCLUSIONS The flipped classroom approach to didactic education resulted in a small improvement in knowledge retention and was preferred by anesthesiology residents.

Central hemodynamic effects of an oxytocin receptor antagonist (Atosiban) in the isolated, perfused rat heart

Objective: Atosiban is a selective oxytocin receptor antagonist capable of inhibiting oxytocin-induced contractility of the uterus. Trials of this agent in intact animals and women as a tocolytic agent for preterm labor have shown atosiban to be devoid of cardiac effects. This is in contast to other tocolytic agents, which have profound hemodynamic effects. We conducted this study to determine the cardiac effects of atosiban in the isolated, perfused rat heart model. Methods: hearts were excised from 60 female Sprague-Dawley rats and attached to a Langendorff apparatus. Left ventricular systolic pressure, heart rate, and contractility were measured. Hearts from half of the animals were exposed serially to 300 μg/min, 600 μg/min, and 1200 μg/min of atosiban. The remaining hearts formed the control group and were exposed to aerated Krebs solution. Results: There were no significant differences between hearts exposed to atosiban and hearts within the control group for heart rate, left ventricular systolic pressure, and contractility. P values ranged from .12 to .73. Conclusions: Using a classic physiologic model to study cardiac performance and drug effects, we were unable to detect any central hemodynamic effects of atosiban. This is in contrast to oxytocin, which we previously studied and found negative chronotropic and positive ionotropic effects.

Diabetes Insipidus and Epidural Analgesia for Labor

iabetes insipidus (DI) is a complication of pregnancy with an incidence of 2-4 cases per 100,000 pregnancies (1). Patients with DI com- plain of unremitting thirst, a symptom which should raise suspicion of hypovolemia. Peripartum DI can occur in combination with hypertension and abnor- malities in liver and kidney function, making differ- entiation from preeclampsia difficult (2,3). Because urinary output does not decrease with mild hypovo- lemia in patients with DI, dehydration is likely if fluid intake is not adequate. When regional anesthetic tech- niques for labor are used, attention to the potential hazard of hypovolemia is mandatory. Although epi- dural analgesia is used routinely at many centers, it is rare that central venous pressure (CVP) monitoring is required to ensure its safety. This case illustrates the utility of CVP monitoring when noninvasive assess- ment of volume status is difficult. It also shows that thirst does not necessarily imply volume depletion.