Gerald A. Isenberg

The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School

Purpose This longitudinal study was designed to examine changes in medical students’ empathy during medical school and to determine when the most significant changes occur. Method Four hundred fifty-six students who entered Jefferson Medical College in 2002 (n = 227) and 2004 (n = 229) completed the Jefferson Scale of Physician Empathy at five different times: at entry into medical school on orientation day and subsequently at the end of each academic year. Statistical analyses were performed for the entire cohort, as well as for the “matched” cohort (participants who identified themselves at all five test administrations) and the “unmatched” cohort (participants who did not identify themselves in all five test administrations). Results Statistical analyses showed that empathy scores did not change significantly during the first two years of medical school. However, a significant decline in empathy scores was observed at the end of the third year which persisted until graduation. Findings were similar for the matched cohort (n = 121) and for the rest of the sample (unmatched cohort, n = 335). Patterns of decline in empathy scores were similar for men and women and across specialties. Conclusions It is concluded that a significant decline in empathy occurs during the third year of medical school. It is ironic that the erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities; this is when empathy is most essential. Implications for retaining and enhancing empathy are discussed.

Multi-Society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes

Flexible gastrointestinal endoscopy is a valuable diagnostic and therapeutic tool for the care of patients with gastrointestinal and pancreaticobiliary disorders. Compliance with accepted guidelines for the reprocessing of gastrointestinal endoscopes between patients is critical to the safety and success of their use. When these guidelines are followed, pathogen transmission can be effectively prevented. Increased efforts and resources should be directed to improve compliance with these guidelines. Further research in the area of gastrointestinal endoscope reprocessing should be encouraged. The organizations that endorsed this guideline are committed to assisting the FDA and manufacturers in addressing critical infection control issues in gastrointestinal device reprocessing.

Longer time interval between completion of neoadjuvant chemoradiation and surgical resection does not improve downstaging of rectal carcinoma

AbstractPURPOSE: An interval of six to eight weeks between completion of preoperative chemoradiation therapy and surgical resection of advanced rectal cancer has been described. Our purpose was to determine whether a longer time interval between completion of therapy and resection increases tumor downstaging and affects perioperative morbidity. METHODS: Forty patients with advanced adenocarcinoma of the rectum underwent preoperative chemoradiation on a prospective trial with irinotecan (50 mg/m2), 5-fluorouracil (225 mg/m2), and concomitant external-beam radiation (45–54 Gy) followed by complete surgical resection of the tumor with total mesorectal excision. The time interval between completion of chemoradiation and surgical resection ranged from 28 to 97 days. The patients were divided into two groups with 33 eligible patients: Group A (4-week to 8-week time interval; 28–56 days) and Group B (10-week to 14-week interval; 67–97 days). Tumor downstaging was compared between these two groups. The number of patients downstaged by at least one T stage, those downstaged by at least one N stage, those with pathologic complete responses, and those with only residual microscopic tumor foci were compared. Postoperative length of stay, estimated blood loss, perioperative morbidity, and sphincter-sparing procedures were also compared. Chi-squared tests and Student’s t-test were calculated. RESULTS: Group A had 19 patients, and Group B had 14 patients. Patient demographics were comparable. Mean age was 52 years, and 70 percent of patients were male. There were no deaths. There were no statistical differences in perioperative morbidity, with three anastomotic leaks in Group A. Tumors were downstaged in 58 percent of patients in Group A and 43 percent of those in Group B (P = 0.61). Nodal downstaging occurred in 78 percent of Group A and 67 percent of Group B (P = 0.9). The pathologic complete response rate was 21 percent in Group A and 14 percent in Group B (P = 0.97), and a residual microfocus of tumor was found in 33 percent of patients in Group A and 42 percent of those in Group B (P = 0.90). These differences were not statistically significant. CONCLUSIONS: Perioperative morbidity is not affected by longer intervals. A longer interval between completion of neoadjuvant chemoradiation and surgical resection may not increase the tumor response rate of advanced rectal cancer in this cohort.

Use of guanylyl cyclase C for detecting micrometastases in lymph nodes of patients with colon cancer

INTRODUCTION: Guanylyl cyclase C appears to be expressed only in colorectal cancer cells in extraintestinal tissues. Thus, guanylyl cyclase C may be useful as a marker to detect colorectal cancer micrometastases not detectable by histopathology in lymph nodes of patients. METHODS: Twelve patients with colon adenocarcinoma, Dukes Stages A through C2, and one patient with a tubulovillous adenoma were included in this study. Forty-two lymph nodes were collected from fresh surgical specimens, and each was examined by histopathology and reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers. Histopathology identified colon cancer cells in 6 of 16 lymph nodes from five Dukes Stage C patients but not in lymph nodes from the patient with a tubulovillous adenoma, the Dukes Stage A patient, or six Dukes Stage B patients. Reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers was performed on all 42 lymph nodes. RESULTS: Guanylyl cyclase C messenger RNA was not detected by reverse transcription followed by polymerase chain reaction in lymph nodes from the patient with the tubulovillous adenoma or the patient with Dukes Stage A colon carcinoma. Seven lymph nodes from Dukes Stage C patients revealed guanylyl cyclase C messenger RNA including six lymph nodes containing histopathologically confirmed metastases. Of significance, guanylyl cyclase C messenger RNA was detected in 6 of 21 lymph nodes from Dukes Stage B patients. Indeed, clinical staging of two patients could be upgraded from B to C using reverse transcription followed by polymerase chain reaction and guanylyl cyclase C-specific primers. CONCLUSION: Reverse transcription followed by polymerase chain reaction using guanylyl cyclase C-specific primers might be useful to more accurately assess micrometastases in lymph nodes of colorectal cancer patients undergoing disease staging.

Colonic Crypt Changes during Adenoma Development in Familial Adenomatous Polyposis : Immunohistochemical Evidence for Expansion of the Crypt Base Cell Population

Familial adenomatous polyposis patients, who have a germline APC mutation, develop adenomas in normal-appearing colonic mucosa, and in the process usually acquire a mutation in the other APC allele as well. Nonetheless, the cellular mechanisms that link these initiating genetic changes with the earliest tissue changes (upward shift in the labeling index) in colon tumorigenesis are unclear. Based on the tenet that colorectal cancer originates from crypt stem cells (SCs) and on our kinetic modeling, we hypothesized that overpopulation of mutant colonic SCs is the missing link. Directly testing this hypothesis requires measuring changes in the size of the SC population, but specific markers for human colonic SCs are lacking. Hence, we used immunohistochemical mapping to study crypt base cells, of which SCs are a subset. Using colectomy specimens from 16 familial adenomatous polyposis and 11 control cases, we determined the topographic profiles of various cell populations along the crypt axis and the proportions of each cell type. In the formation of adenomatous crypts, the distribution of cells expressing crypt base cell markers (MSH2, Bcl-2, survivin) expanded toward the crypt surface and showed the greatest proportional increase (fivefold to eightfold). Cells expressing a marker for the upper crypt (p27(kip1)) shifted to the crypt bottom and showed the smallest increase. This suggests that: 1) during adenoma development, APC mutations cause expansion of the crypt base cell population, including crypt SCs; 2) SC overpopulation can explain the shifts in pattern of proliferative crypt cell populations in early colon tumorigenesis, and 3) mutant crypt SCs clonally expand to form colonic adenomas and carcinomas.

Underlying construct of empathy, optimism, and burnout in medical students

Objectives This study was designed to explore the underlying construct of measures of empathy, optimism, and burnout in medical students. Methods Three instruments for measuring empathy (Jefferson Scale of Empathy, JSE); Optimism (the Life Orientation Test-Revised, LOT-R); and burnout (the Maslach Burnout Inventory, MBI, which includes three scales of Emotional Exhaustion, Depersonalization, and Personal Accomplishment) were administered to 265 third-year students at Sidney Kimmel (formerly Jefferson) Medical College at Thomas Jefferson University. Data were subjected to factor analysis to examine relationships among measures of empathy, optimism, and burnout in a multivariate statistical model. Results Factor analysis (principal component with oblique rotation) resulted in two underlying constructs, each with an eigenvalue greater than one. The first factor involved “positive personality attributes” (factor coefficients greater than .58 for measures of empathy, optimism, and personal accomplishment). The second factor involved “negative personality attributes” (factor coefficients greater than .78 for measures of emotional exhaustion, and depersonalization). Conclusions Results confirmed that an association exists between empathy in the context of patient care and personality characteristics that are conducive to relationship building, and considered to be “positive personality attributes,” as opposed to personality characteristics that are considered as “negative personality attributes” that are detrimental to interpersonal relationships. Implications for the professional development of physicians-in-training and in-practice are discussed.

A novel approach to assessing technical competence of colorectal surgery residents: The development and evaluation of the colorectal objective structured assessment of technical skill (COSATS)

Objective: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery—the Colorectal Objective Structured Assessment of Technical Skill (COSATS). Background: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards. Methods: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at “borderline competent for CR practice.” Results: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent. Conclusions: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.

Survivin-Induced Aurora-B Kinase Activation: A Mechanism by Which APC Mutations Contribute to Increased Mitoses during Colon Cancer Development

APC mutations initiate most colorectal cancers (CRCs), but cellular mechanisms linking this to CRC pathology are unclear. We reported that wild-type APC in the colon down-regulates the anti-apoptotic protein survivin, and APC mutation up-regulates it, explaining why most CRCs display survivin overexpression and apoptosis inhibition. However, it does not explain another hallmark of CRC pathology--increased mitotic figures and cell proliferation. Because survivin activates aurora-B kinase (ABK) in vitro, catalyzing mitosis, we hypothesized that in normal colonic crypts, APC controls ABK activity, while in neoplastic APC-mutant crypts, ABK activity is up-regulated, increasing mitosis. We quantitatively mapped intracryptal distributions of survivin, ABK, and markers of activated downstream signaling and mitosis (INCENP, phospho-histone-H3, phospho-centromere-protein-A). In normal crypts, gradients for these markers, ABK:survivin:INCENP complexes, and ABK activity were highest in the lower crypt (inverse to the APC gradient). In neoplastic crypts that harbor APC mutations, proliferating (Ki-67+) cells and cells expressing survivin, ABK, and phospho-histone-H3 were distributed farther up the crypt. Hence, as cells migrate up neoplastic crypts, transitions between cell phenotypes (eg, from stem to proliferating) appear delayed. In CRC cell lines, increasing wild-type APC, inhibiting TCF-4, or decreasing survivin expression down-regulated ABK activity. Thus, APC mutation-induced up-regulation of the survivin/ABK cascade can explain delayed crypt cell maturation, expansion of proliferative cell populations (including mitotic figures), and promotion of colon tumorigenesis.

Psychometrics of the scale of attitudes toward physician-pharmacist collaboration: A study with medical students

Background: Despite the emphasis placed on interdisciplinary education and interprofessional collaboration between physicians and pharmacologists, no psychometrically sound instrument is available to measure attitudes toward collaborative relationships. Aim: This study was designed to examine psychometrics of an instrument for measuring attitudes toward physician–pharmacist collaborative relationships for administration to students in medical and pharmacy schools and to physicians and pharmacists. Methods: The Scale of Attitudes Toward Physician-Pharmacist Collaboration was completed by 210 students at Jefferson Medical College. Factor analysis and correlational methods were used to examine psychometrics of the instrument. Results: Consistent with the conceptual framework of interprofessional collaboration, three underlying constructs, namely “responsibility and accountability;” “shared authority;” and “interdisciplinary education” emerged from the factor analysis of the instrument providing support for its construct validity. The reliability coefficient alpha for the instrument was 0.90. The instruments criterion-related validity coefficient with scores of a validated instrument (Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration) was 0.70. Conclusions: Findings provide support for the validity and reliability of the instrument for medical students. The instrument has the potential to be used for the evaluation of interdisciplinary education in medical and pharmacy schools, and for the evaluation of patient outcomes resulting from collaborative physician-pharmacist relationships.

The need for standardization of colonoscopic tattooing of colonic lesions.

in 2014 according to nCi seeR data, an estimated 136,830 individuals will be diagnosed with colorectal cancer and 50,130 will die from the disease. Despite the progressive increase in the number of colonoscopies performed every year, studies have shown that the sensitivity of the colonoscopic procedure, gauged by the average adenoma detection rate, can fluctuate. this fluctuation can be induced by the size of the healthcare facility, quality of bowel preparation received, skill level and specialty of the endoscopist, and time spent inspecting the colon. thus, the focus is currently devoted to establishing measures for increased quality in technical performance, often referred to as quality indicators. however, it is essential for superior quality in lesion detection to be paired with a similar high quality in marking detected lesions to help ensure appropriate interventions. in one study, Conaghan et al prospectively followed 52 patients who had a total of 54 lesions and were tattooed during colonoscopy. in each case, the patient subsequently underwent laparoscopic resection. During surgery, the tattoos were visible but inaccurate in 7% of the patients and not visible in 15%. in another study that evaluated the intraoperative visibility of colonic india ink tattoos, the tattoos were not visible in 31.5% of the patients. moreover, during postoperative histologic examination of the specimens, the ink was detected in only 73.6% of the patients. although the study failed to identify whether the tattooing inaccuracies had threatened the safety margins in any of the patients, the authors pointed out that, in one of these instances, an additional intraoperative colonoscopy was required to find the lesion. several other studies have reported intraoperative difficulties in identifying the colonic lesion location solely based on colonoscopy measurements, leading to removal of the wrong bowel segment. these findings reflect the important role of the colonic tattooing technique and the benefit from standardization of the technical variables to achieve a more consistent and successful outcome. the advantages of laparoscopy and minimally invasive surgery in the management of colorectal disease include achieving superior perioperative outcomes in terms of shorter hospital stay, less pain and faster recovery of bowel function, better intraoperative visualization, and decreased blood loss, without affecting the oncologic resection guidelines. to safely and efficiently employ laparoscopy and to preserve as much healthy bowel as possible, it is imperative to be able to rely on a clear visual mark that can identify the pathologic bowel segment. easy visualization of the lesion location during surgery can ensure adequate margin resection and facilitate a shorter operative time. During laparotomy, visual identification of the lesion location is essential in circumstances where tactile identification is impaired. this situation can occur for instance, if a lesion has been previously excised, with flat and small sized lesions, in the presence of dense visceral adhesions, if the colon is engulfed by thick layers of adipose tissue, or if the lesion is facing the mesenteric side of the colon or posterior abdominal wall. several methods have been established to mark a suspicious colonic lesion location, including endoluminal tattooing, placement of endoscopic mucosal clips, and laparoscopic placement of serosal clips guided by colonoscopy. among these techniques colonic tattooing is believed to be the most reliable one and has been the most widely used. tattooing can be a safe, cost-effective, and permanent method to mark a lesion location. most importantly, proper tattooing is indelible and not susceptible to disappearing, as can happen with mucosal and serosal clips. Preoperative tattooing may eliminate potential bowel distension from intraoperative colonoscopy. however, it can be argued that, because of the superior Co 2 gas absorption rate, Co 2 insufflation during colonoscopy can allow for less intraprocedural pain, as well as The Need for Standardization of Colonoscopic Tattooing of Colonic Lesions