David G. Brauer

The integrated curriculum in medical education: AMEE Guide No. 96

Abstract The popularity of the term “integrated curriculum” has grown immensely in medical education over the last two decades, but what does this term mean and how do we go about its design, implementation, and evaluation? Definitions and application of the term vary greatly in the literature, spanning from the integration of content within a single lecture to the integration of a medical schools comprehensive curriculum. Taking into account the integrated curriculums historic and evolving base of knowledge and theory, its support from many national medical education organizations, and the ever-increasing body of published examples, we deem it necessary to present a guide to review and promote further development of the integrated curriculum movement in medical education with an international perspective. We introduce the history and theory behind integration and provide theoretical models alongside published examples of common variations of an integrated curriculum. In addition, we identify three areas of particular need when developing an ideal integrated curriculum, leading us to propose the use of a new, clarified definition of “integrated curriculum”, and offer a review of strategies to evaluate the impact of an integrated curriculum on the learner. This Guide is presented to assist educators in the design, implementation, and evaluation of a thoroughly integrated medical school curriculum.

Cost variation in a laparoscopic cholecystectomy and the association with outcomes across a single health system: implications for standardization and improved resource utilization

BACKGROUND Payers and regulatory bodies are increasingly placing emphasis on cost containment, quality/outcome measurement and transparent reporting. Significant cost variation occurs in many operative procedures without a clear relationship with outcomes. Clear cost-benefit associations will be necessary to justify expenditures in the era of bundled payment structures. METHODS All laparoscopic cholecystectomies (LCCKs) performed within a single health system over a 1-year period were analysed for operating room (OR) supply cost. The cost was correlated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outcomes. RESULTS From July 2013 to June 2014, 2178 LCCKs were performed by 55 surgeons at seven hospitals. The median case OR supply cost was

Optimal extent of surgical and pathologic lymph node evaluation for resected intrahepatic cholangiocarcinoma

513 ± 156. There was variation in cost between individual surgeons and within an individual surgeons practice. There was no correlation between cost and ACS NSQIP outcomes. The majority of cost variation was explained by selection of trocar and clip applier constructs. CONCLUSIONS Significant case OR cost variation is present in LCCK across a single health system, and there is no clear association between increased cost and NSQIP outcomes. Placed within the larger context of overall cost, the opportunity exists for improved resource utilization with no obvious risk for a reduction in the quality of care.

Operative Site Drainage after Hepatectomy: A Propensity Score Matched Analysis Using the American College of Surgeons NSQIP Targeted Hepatectomy Database

BACKGROUND Lymph node (LN) status is an important predictor of overall survival for resected IHCC, yet guidelines for the extent of LN dissection are not evidence-based. We evaluated whether the number of LNs resected at the time of surgery is associated with overall survival for IHCC. METHODS Patients undergoing curative-intent (R0 or R1) resection for IHCC between 2004 and 2012 were identified within the US National Cancer Database. LN thresholds were evaluated using maximal chi-square testing and five-year overall survival was modeled using Kaplan-Meier and Cox regressions. RESULTS 57% (n = 1,132) of 2,000 patients had one or more LNs resected and pathologically examined. In the 631 patients undergoing R0 resection with pN0 disease, maximal chi-square testing identified ≥3 LNs as the threshold most closely associated with overall survival. Only 39% of resections reached this threshold. On multivariable survival analysis, no threshold of LNs was associated with overall survival, including ≥3 LNs (p = 0.186) and the current American Joint Committee on Cancer recommendation of ≥6 LNs (p = 0.318). CONCLUSION In determining the extent of lymphadenectomy at the time of curative-intent resection for IHCC, surgeons should carefully consider the prognostic yield in the absence of overall survival benefit.