David W. Page

Boot Camp: Educational Outcomes After 4 Successive Years of Preparatory Simulation- Based Training at Onset of Internship

PURPOSE Preparatory training for new trainees beginning residency has been used by a variety of programs across the country. To improve the clinical orientation process for our new postgraduate year (PGY)-1 residents, we developed an intensive preparatory training curriculum inclusive of cognitive and procedural skills, training activities considered essential for early PGY-1 clinical management. We define our surgical PGY-1 Boot Camp as preparatory simulation-based training implemented at the onset of internship for introduction of skills necessary for basic surgical patient problem assessment and management. This orientation process includes exposure to simulated patient care encounters and technical skills training essential to new resident education. We report educational results of 4 successive years of Boot Camp training. Results were analyzed to determine if performance evidenced at onset of training was predictive of later educational outcomes. METHODS Learners were PGY-1 residents, in both categorical and preliminary positions, at our medium-sized surgical residency program. Over a 4-year period, from July 2007 to July 2010, all 30 PGY-1 residents starting surgical residency at our institution underwent specific preparatory didactic and skills training over a 9-week period. This consisted of mandatory weekly 1-hour and 3-hour sessions in the Simulation Center, representing a 4-fold increase in time in simulation laboratory training compared with the remainder of the year. Training occurred in 8 procedural skills areas (instrument use, knot-tying, suturing, laparoscopic skills, airway management, cardiopulmonary resuscitation, central venous catheter, and chest tube insertion) and in simulated patient care (shock, surgical emergencies, and respiratory, cardiac, and trauma management) using a variety of high- and low-tech simulation platforms. Faculty and senior residents served as instructors. All educational activities were structured to include preparatory materials, pretraining briefing sessions, and immediate in-training or post-training review and debriefing. Baseline cognitive skills were assessed with written tests on basic patient management. Post-Boot Camp tests similarly evaluated cognitive skills. Technical skills were assessed using a variety of task-specific instruments, and expressed as a mean score for all activities for each resident. All measurements were expressed as percent (%) best possible score. Cognitive and technical performance in Boot Camp was compared with subsequent clinical and core curriculum evaluations including weekly quiz scores, annual American Board of Surgery In-Training Examination (ABSITE) scores, program in-training evaluations (New Innovations, Uniontown, Ohio), and operative assessment instrument scores (OP-Rate, Baystate Medical Center, Springfield, Massachusetts) for the remainder of the PGY-1 year. RESULTS Performance data were available for 30 PGY-1 residents over 4 years. Baseline cognitive skills were lower for the first year of Boot Camp as compared with subsequent years (71 ± 13, 83 ± 9, 84 ± 11, and 86 ± 6, respectively; p = 0.028, analysis of variance; ANOVA). Performance improved between pretests and final testing (81 ± 11 vs 89 ± 7; p < 0.001 paired t test). There was statistically significant correlation between Boot Camp final cognitive test results and American Board of Surgery In-Training Examination scores (p = 0.01; n = 22), but not quite significant for weekly curriculum quiz scores (p = 0.055; n = 22) and New Innovations cognitive assessments (p = 0.09; n = 25). Statistically significant correlation was also noted between Boot Camp mean overall skills and New Innovations technical skills assessments (p = 0.002; n = 25) and OP-Rate assessments (p = 0.01; n = 12). CONCLUSIONS Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents correlate with subjective and objective clinical performance evaluations. This concurrent correlation with multiple traditional evaluation methods used to express competency in our residency program supports the use of Boot Camp performance measures as needs assessment tools as well as adjuncts to cumulative resident evaluation data.

Variability of the obturator vessels

The obturator artery and vein are usually described as branches or tributaries of the internal iliac vessels although variations with connections to the external iliac or inferior epigastric vessels have been reported. Because these anomalous vessels are at risk in groin or pelvic surgeries that require dissection or suturing along the pelvic rim, we measured the frequency of these variations in 105 pelvic walls (45 in the United States and 60 in China). Our data show that 70–82% of pelvic halves and 83–90% of whole pelves had an artery, vein, or both in the variant position. Arteries were most often found in the normal position only but normal and anomalous veins were most frequently found together. These data show that it is far more common to find a vessel coursing over the pelvic rim at this site than not and have implications for both pelvic surgeons and anatomists. Clin. Anat. 10:328–332, 1997.

Variations in the inferior pelvic pathway of the lateral femoral cutaneous nerve: implications for laparoscopic hernia repair

Laparoscopic repair of inguinal hernias is gaining acceptance in the repertoire of the general surgeon. However, nerve entrapment sequelae have been reported and appear to be higher with the laparoscopic approach. Contributing factors include pelvic variations in nerve pathways and the use of staples. We examined the pelvic relations of the lateral femoral cutaneous nerve (LFCN) to the anterior superior iliac spine (ASIS) and the iliopubic tract (IPT) because of the high morbidity of entrapment of this nerve, despite its low incidence. The LFCN, ASIS, and IPT were identified and their relationships measured in 48 male and 24 female cadavers ranging in age from 61 to 96 yr. The LFCN was located 1.7 (±1.2) cm medial to the ASIS along the IPT and 1.4 (±0.7) cm posterior (deep) to the IPT at this point, with no significant sex differences. The intrapelvic pathway of the LFCN, including its branches, varied widely so that in 18% of these specimens the LFCN was in either the vertical plane of the ASIS (13%) or in the plane of the IPT (5%). In 11% this nerve was within 1 cm of the ASIS. These data indicate that exclusive use of the ASIS as a guide for staple placement may result in entrapment of this nerve or its branches.

Use of preincisional ketorolac in hernia patients: Intravenous versus surgical site†

Background and Objectives. This study was designed to determine whether administration of ketorolac directly in the surgical site results in enhanced analgesia. Methods. A randomized double‐blind study was undertaken at a university‐affiliated tertiary care hospital. Thirty outpatients undergoing unilateral inguinal hernia repair by one of two surgeons under local anesthesia with sedation were evaluated. Patients were invited to participate in this investigation at the time of the preoperative surgical visit. Patients who had a contraindication to the use of ketorolac or who refused repair under local anesthesia with sedation were excluded. Patients received ketorolac 60 mg either via the parenteral route or directly in the surgical site (mixed with the local anesthetic). The outcome measures included visual analog pain scores, measured at two different times in the hospital, pain scores at rest and with movement 24 hours after surgery, time to first analgesic, and total analgesic requirement. Results. The study revealed lower 24 hour movement‐associated pain scores (P < .02), increased time to first analgesic (P < .03), and decreased oral analgesic consumption (P < .0002) in the surgical site group. Conclusions. Ketorolac provides enhanced patient comfort when it is administered in the surgical site in patients undergoing inguinal hernia repair. It is recommended that clinicians add ketorolac to the local anesthetic solution in such patients.

Shigellosis among swimmers in a freshwater lake.

Objective: Shigella infection is highly communicable; however, outbreaks associated with swimming in recreational fresh water are rarely identified. Materials and Methods: A cohort study of lake visitors was performed. Results: Seventeen (24.6%) case patients among 69 persons who visited the lake over the holiday weekend were identified. Attack rates increased with increasing exposure to lake water; the risk of illness was greatest among swimmers who reported getting lake water in their mouths (relative risk = 5.37, 95% confidence interval = 2.2, 13.3). Shigella sonnei was isolated from stool samples of four of eight swimmers tested. Conclusions: The outbreak likely was caused by fecal contamination of lake water by an infected swimmer; there was no evidence of sewage contamination into the lake. Fresh water is a potential source of infection in patients with acute gastroenteritis and recent exposure. Since testing and chlorination of lake water is impractical, prevention relies on avoidance of fecal contamination and/or minimizing ingestion of the water.

Use of clonidine in hernia patients: intramuscular versus surgical site.

BACKGROUND AND OBJECTIVES This study was designed to determine if administration of clonidine in hernia patients enhances analgesia. It was also designed to determine whether administration directly in the surgical site further improves the analgesia. METHODS A randomized, double-blinded study was undertaken at a tertiary care hospital. Forty-five outpatients undergoing unilateral inguinal hernia repair by one of two surgeons (D.P. or M.A.) under local anesthesia with monitored anesthesia care were evaluated. Patients were invited to participate in this investigation at the time of the preoperative surgical visit. Patients who had a contraindication to the use of clonidine or who refused repair under local anesthesia with sedation were excluded. Patients were randomized to one of three groups: (a) clonidine 0.5 microg/kg intramuscularly and saline in the surgical site (mixed with the local anesthetic); (b) clonidine 0.5 microg/kg in the surgical site and saline intramuscularly; or (c) saline in both the surgical site and intramuscularly. The outcome measures included visual analog pain scores twice in the hospital, pain scores at rest and with movement 24 hours postoperatively, the time to first analgesic, and total analgesic requirement. RESULTS The pain scores were lower in both clonidine groups at 2 hours postoperatively than in the control group (P < .03). No difference was observed with respect to the time to first analgesic, 24-hour analgesic use, or 24-hour pain scores among the groups. CONCLUSIONS When clonidine is administered to patients undergoing hernia repair, the 2-hour pain scores are lowered. No difference was exhibited when clonidine was administered intramuscularly or directly into the hernia site.

Blood, sweat and tears: are surgeons prepared for the challenges of self-reflection?

625 HISTORICALLY, SURGEONS HAVE ENDEAVORED to cure disease by designing operations to remove cancers, bypass stenotic blood vessels, resect scarred flesh, replace worn out tissues, and recycle organs. The work sustains immeasurable good. However, when the end of a patient’s life arrives, the final phase of the caring continuum finds many surgeons ill at ease with their dying patients. It is certainly not indifference as much as a sense of non-ownership, the surgeon’s focus narrow, unfettered by ambiguity. The mind-body dichotomy many surgeons embrace leaves the patient’s personal experience of surgery, the emotional minefield beyond cure, to someone else. Not only have surgeons done poorly treating pain,1 we rarely reflect on how we contribute to our patient’s suffering. In this regard, Eric Cassell2 has pointed out that the identification of suffering strictly with somatic pain is misleading and distorts the issue because it depersonalizes the sick patient. Richard Selzer, M.D., spoke of the agony of metastatic pancreatic cancer in “Mercy,” a story from his prescient 1982 book, Letters to a Young Doctor. He wrote, “In his bed at home he seemed an eighty-pound concentrate of pain from which all other pain must be made by serial dilution.”3 When a patient transitions from a goal of cure to a need for caring, surgeons often drift away from the bedside, as if practicing “emotional itinerant surgery.” Behaving thus, surgeons risk no small measure of self-extinction, losing little pieces of themselves each time they turn away from the bedside. This is unfortunate because surgery runs at the head of the therapeutic pack in absolute cures and innovative solutions to old problems. Yet, something in our professionalism seems amiss.4 Medical students who are disenchanted with the surgical persona often suggest we have no one to blame but ourselves.5 Women comprise 25% of general surgical residents,6 despite harboring doubts about whether surgical educators can meet their special needs.7 Why are we only now learning about our own inadequacies as preceptors? The contention that surgeons often are not tuned in to the needs of students and patients is supported by Cassell’s remark that to successfully alleviate suffering, doctors need to know more about illness than the name of the disease and the science behind it.8 Surgeons champion aggressive invasions of the body, accomplished with a measure of indifference and a talent for maintaining a tight focus on the architecture of the flesh; yet the spasms of terror on the outskirts of bloodshed remain invisible to us. This insouciance, if not outright disdain for pity, has a well-documented historical origin in the era before anesthesia. Still, a surgeon’s professional life is surely more than sutures and silastic. As Rachael Remens, M.D., admonishes, life is small when defined only by science (R. Remens, personal communication). Anthropologist Pearl Katz wrote in her book, The Scalpel’s Edge,9 “Who but a surgeon routinely and boldly cuts into the most intimate depths of people’s live bodies, penetrates their innermost body cavities, exposing blood, guts, and excreta, and cut and remove their organs, burn blood vessels, saw bones, and sew layers of skin?” Katz

Surgical competence today: What have we gained? What have we lost?

The complexity of modern surgical practice and the cognitive and technical overload to which trainees are subjected places practitioners and residents alike in jeopardy of developing areas of incompetence. Inadequate exposure to essential operations during residency forces trainees to seek further expertise in fellowships. At the same time, practice burdens increase stress levels on academic and community surgeons, resulting in a 30 to 40% burnout rate. Solutions include modification of restricted duty hours for residents and the institution of a simulation-based national surgical curriculum.

A Tale of Two Domains—Opportunity in the Face of Despair

At the joint meeting of the Association for Surgical Education (ASE) and the Association of Program Directors in Surgery (APDS) in Nashville in March 2001, the (mis)match captured the creative energy and angst of most of the audience and many speakers and panel members. Electrified dialog from the floor followed on the heels of numerous podium presentations, but attention returned often to the nagging issue on everyone’s mind: our failure to attract adequate numbers of talented medical students into surgery’s residency applicant pool. Other topics discussed were the attrition of residents during their training, attrition of ATLS skills and knowledge over time, the key role of M&M conferences in resident education, issues associated with residents seeking informed consent, professionalism, the “surgical personality,” and the impact of tension among operating room personnel. Yet, the conundrum knotting the collective surgical brow was how to assure a steady stream of highly qualified and motivated students into careers in surgery. This overarching dilemma was revisited throughout the week, and a few paradigm shifts were suggested for American surgery’s “March madness.” When the American Association of Clinical Anatomists