Gary L. Dunnington

The New ACS/APDS Skills Curriculum: Moving the Learning Curve Out of the Operating Room

Surgical education has dramatically changed in response to numerous constraints placed on residency programs, but a substantial gap in uniform practices exist, especially in the area of skills laboratory availability and usage. Simulation-based training has gained significant momentum and will be a requirement for residencies in the near future. In response, the American College of Surgeons and the Association of Program Directors in Surgery have formed a Surgical Skills Curriculum Task Force with the aim of establishing a National Skills Curriculum. The first of three phases will undergo implementation in 2007, with subsequent phases scheduled for launch in 2008. The curriculum has been carefully structured and designed by content experts to enhance resident training through reproducible simulations, with verification of proficiency before operative experience. Free-of-charge distribution is planned through a web-based platform, and widespread adoption is encouraged. In the future, these simulation-based strategies may be useful in assuring the competency of practicing surgeons and for credentialing purposes.

Surgeon Information Transfer and Communication: Factors Affecting Quality and Efficiency of Inpatient Care

Objective:To determine the nature of surgeon information transfer and communication (ITC) errors that lead to adverse events and near misses. To recommend strategies for minimizing or preventing these errors. Summary Background Data:Surgical hospital practice is changing from a single provider to a team-based approach. This has put a premium on effective ITC. The Information Transfer and Communication Practices (ITCP) Project is a multi-institutional effort to: 1) better understand surgeon ITCP and their patient care consequences, 2) determine what has been done to improve ITCP in other professions, and 3) recommend ways to improve these practices among surgeons. Methods:Separate, semi-structured focus group sessions were conducted with surgical residents (n = 59), general surgery attending physicians (n = 36), and surgical nurses (n = 42) at 5 medical centers. Case descriptions and general comments were classified by the nature of ITC lapses and their effects on patients and medical care. Information learned was combined with a review of ITC strategies in other professions to develop principles and guidelines for re-engineering surgeon ITCP. Results:A total of 328 case descriptions and general comments were obtained and classified. Incidents fell into 4 areas: blurred boundaries of responsibility (87 reports), decreased surgeon familiarity with patients (123 reports), diversion of surgeon attention (31 reports), and distorted or inhibited communication (67 reports). Results were subdivided into 30 contributing factors (eg, shift change, location change, number of providers). Consequences of ITC lapses included delays in patient care (77% of cases), wasted surgeon/staff time (48%), and serious adverse patient consequences (31%). Twelve principles and 5 institutional habit changes are recommended to guide ITCP re-engineering. Conclusions:Surgeon communication lapses are significant contributors to adverse patient consequences, and provider inefficiency. Re-engineering ITCP will require significant cultural changes.

A randomized trial to increase physical activity in breast cancer survivors

PURPOSE Interventions to increase physical activity among breast cancer survivors are needed to improve health and quality of life and possibly to reduce the risk of disease recurrence and early mortality. Therefore, we report the feasibility and preliminary outcomes of a pilot randomized trial designed to increase physical activity in sedentary breast cancer survivors receiving hormone therapy. METHODS Forty-one sedentary women on estrogen receptor modulators or aromatase inhibitors for stage I, II, or IIIA breast cancer were randomly assigned to receive a 12-wk multidisciplinary physical activity behavior change intervention or usual care. RESULTS Recruitment was 34%, intervention adherence was 99%, and complete follow-up data were obtained on 93%. Most participants (93%) were white with mean age of 53 +/- 9 yr. Differences favoring the intervention group were noted for accelerometer physical activity counts (mean difference = 72,103; 95% confidence interval (CI) = 25,383-119,000; effect size (d) = 1.02; P = 0.004), aerobic fitness (mean difference = 2.9; 95% CI = -0.1 to 5.8; d = 0.64; P = 0.058), back/leg muscle strength (mean difference = 12.3; 95% CI = 0.4-15.9; d = 0.81; P = 0.017), waist-to-hip ratio (mean difference = -0.05; 95% CI = -0.01 to -0.08; d = -0.77; P = 0.018), and social well-being (mean difference = 2.0; 95% CI = 0.3-3.8; d = 0.76; P = 0.03). However, the intervention group also reported a greater increase in joint stiffness (mean difference = 1.1; 95% CI = 0.1-2.2; d = 0.70; P = 0.04). CONCLUSIONS A behavior change intervention for breast cancer survivors based on the social cognitive theory is feasible and results in potentially meaningful improvements in physical activity and selected health outcomes. Confirmation in a larger study is warranted.

Strategies for efficient and effective teaching in the ambulatory care setting

Medical education in the ambulatory care setting is characterized in part by the question of how to ensure educational effectiveness while simultaneously providing high-quality, cost-effective patient care. The constraints associated with managed care have only served to escalate the intensity of this dilemma. However, in spite of the difficulties faced by ambulatory care preceptors, there are educationally sound and time-efficient strategies clinical teachers may employ to improve ambulatory care education. Emphasizing the basic three-step process of planning, teaching, and reflection, the authors describe five such strategies: “wave” scheduling, orienting learners to patients, having learners do their case presentations in the examination room, employing the microskills of the “one-minute preceptor,” and effectively reflecting on ones teaching in order to develop effective teaching scripts. Research in ambulatory care learning has indicated that learners must be given significant roles in patient care and that preceptors must observe trainees as they care for patients so that they can provide trainees with helpful feedback. Employing these strategies in the ambulatory care setting will help educators to accomplish these two objectives while minimizing disruption to cost-effective, high-quality clinical practice.

Social cognitive theory and physical activity during breast cancer treatment

PURPOSE/OBJECTIVES To measure the association between physical activity and social cognitive theory constructs during breast cancer treatment. DESIGN Cross-sectional survey. SETTING Midwestern, academic oncology clinic. SAMPLE 21 primarily Caucasian (90%) female patients with breast cancer undergoing treatment. 76% were > 50 years old; 76% had stage I or II disease. 17 completed the study. METHODS Survey (structured interview or self-administration), chart audit, pedometer, and seven-day physical activity recall. MAIN RESEARCH VARIABLES Steps per day, energy expenditure, self-efficacy, barriers, partners and role models, prior physical activity counseling, physical activity knowledge, pretreatment physical activity, outcome expectations and values, goals, reinforcement management, and emotional well-being. FINDINGS A higher average of steps per day was significantly associated with having an exercise role model and higher annual income. A higher daily energy expenditure (kilocalories per kilogram body weight per day) was significantly associated with higher barrier self-efficacy, higher task self-efficacy, having an exercise partner, having an exercise role model, higher physical activity enjoyment, and lower negative value score. CONCLUSIONS Social cognitive theory may provide a useful framework for understanding physical activity among patients with breast cancer during treatment, but correlation strength varies with physical activity measurement type. IMPLICATIONS FOR NURSING Social cognitive theory and physical activity during breast cancer treatment warrant additional study with larger sample sizes and multivariate analyses. Interventions to increase physical activity among patients with breast cancer may use social cognitive theory and assess theory constructs as potential mediators or moderators in intervention evaluation.

An investigation of medical student reactions to feedback: a randomised controlled trial

Background  Medical educators have indicated that feedback is one of the main catalysts required for performance improvement. However, medical students appear to be persistently dissatisfied with the feedback that they receive. The purpose of this study was to evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments.

High negative appendectomy rates are no longer acceptable

BACKGROUND A 10% to 20% negative appendectomy rate has been accepted in order to minimize the incidence of perforated appendicitis with its increased morbidity. We reviewed our experience with appendicitis in order to determine the incidence of negative appendectomies and perforation, and the role of delay in diagnosis or treatment. METHODS We reviewed 659 appendectomies performed over a 12-month period. Incidental and pediatric appendectomies were excluded. RESULTS Seventy-five percent of patients were male and 25% female. Nine percent had negative appendectomies and 28% had perforated appendicitis. Perforated appendicitis resulted in increased morbidity and length of stay. Delay in presentation greater than 12 hours after the onset of symptoms significantly increased the perforation rate. In-hospital delay did not affect perforation rate. CONCLUSIONS We have achieved a negative appendectomy rate lower than that in other reported series, while maintaining an acceptable perforation rate. In the majority of patients, perforated appendicitis is a result of late presentation.

The changing face of surgical education: simulation as the new paradigm.

Surgical simulation has evolved considerably over the past two decades and now plays a major role in training efforts designed to foster the acquisition of new skills and knowledge outside of the clinical environment. Numerous driving forces have fueled this fundamental change in educational methods, including concerns over patient safety and the need to maximize efficiency within the context of limited work hours and clinical exposure. The importance of simulation has been recognized by the major stake-holders in surgical education, and the Residency Review Committee has mandated that all programs implement skills training curricula in 2008. Numerous issues now face educators who must use these novel training methods. It is important that these individuals have a solid understanding of content, development, research, and implementation aspects regarding simulation. This paper highlights presentations about these topics from a panel of experts convened at the 2008 Academic Surgical Congress.

Exploring social cognitive theory constructs for promoting exercise among breast cancer patients

Physical activity during breast cancer treatment can significantly reduce treatment-related fatigue and improve quality of life. Unfortunately, the majority of women with breast cancer either do not exercise at all or exercise below recommended levels. Little is known about how to enhance physical activity among breast cancer patients. The social cognitive theory, a useful framework for the design of physical activity interventions, has not been studied among breast cancer patients. Our study purpose was to explore physical activity knowledge, attitudes, and behaviors among breast cancer patients during adjuvant therapy utilizing social cognitive theory constructs in preparation for a larger, survey study and future intervention research. Twelve breast cancer patients attended 1 of 3 focus group sessions. Focus group questions were based on the social cognitive theory constructs of self-efficacy, environment, behavioral capability, expectations, expectancies, self-control and performance, observational learning, and reinforcement. The focus group participants generally felt confident in their ability to exercise during treatment if fatigue, time management, and social networking were addressed. The majority of participants had not been given information related to exercise by their physicians during treatment. The participants felt that exercise was more beneficial than harmful during treatment, with the 2 most important benefits identified as reduced fatigue and the potential for improved survival. The use of reinforcements by participants was minimal. The participants consistently expressed the desire for education and guidance by knowledgeable staff during an exercise program. Walking was the most acceptable exercise modality. Social cognitive theory may be a useful framework for future study of exercise behavior among breast cancer patients and measurement of constructs related to this theory should be included in such studies. Future exercise intervention studies should consider the unique barriers and program preferences of breast cancer patients while focusing on self-efficacy, outcome expectations/ expectancies, observational learning, and reinforcements.

Physical Activity and Health Outcomes Three Months After Completing a Physical Activity Behavior Change Intervention: Persistent and Delayed Effects

Purpose: We previously reported the effectiveness of a 12-week physical activity behavior change intervention for breast cancer survivors postintervention with this report, aiming to determine delayed and/or persistent effects 3 months after intervention completion. Methods: Forty-one sedentary women with stage I, II, or IIIA breast cancer currently receiving hormonal therapy were randomly assigned to receive the 12-week Better Exercise Adherence after Treatment for Cancer intervention or usual care. Assessments occurred at baseline, postintervention, and 3 months postintervention. Results: Weekly minutes of greater than or equal to moderate intensity physical activity measured by accelerometer showed a significant group by time interaction (F = 3.51; P = 0.035; between group difference in the mean change from baseline to 3 months postintervention, 100.1 minute, P = 0.012). Significant group by time interactions also showed sustained improvements from baseline to 3 months postintervention in strength (F = 3.82; P = 0.027; between group difference, 11.2 kg; P = 0.026), waist-to-hip ratio (F = 3.36; P = 0.041; between group difference, −0.04; P = 0.094), and social well-being (F = 4.22; P = 0.023; between group difference, 3.9; P = 0.039). A delayed reduction in lower extremity dysfunction 3 months postintervention was noted (F = 3.24; P = 0.045; between group difference in the mean change from postintervention to 3 months follow-up; P = −7.6; P = 0.015). No group by time effect was noted for fitness, body mass index, percent fat, bone density, total quality of life (Functional Assessment of Cancer Therapy-General), fatigue, endocrine symptoms, cognitive function, or sleep. Conclusions: The intervention resulted in sustained improvements in physical activity, strength, central adiposity, and social well-being with lower extremity function benefits appearing 3 months after intervention completion. Testing translation in a multisite study is warranted. (Cancer Epidemiol Biomarkers Prev 2009;18(5):1410–8)