Laura M. Mazer

Effectiveness of the Surgery Core Clerkship Flipped Classroom: a prospective cohort trial.

BACKGROUND The flipped classroom has been proposed as an alternative curricular approach to traditional didactic lectures but has not been previously applied to a surgery clerkship. METHODS A 1-year prospective cohort of students (n = 89) enrolled in the surgery clerkship was taught using a flipped classroom approach. A historical cohort of students (n = 92) taught with a traditional lecture curriculum was used for comparison. Pretest and post-test performance, end-of-clerkship surveys, and National Board of Medical Examiners (NBME) scores were analyzed to assess effectiveness. RESULTS Mean pretest and post-test scores increased across all modules (P < .001). There was no difference between mean NBME examination score in the prospective and historical cohorts (74.75 vs 75.74, P = .28). Mean ratings of career interest in surgery increased after curriculum completion (4.75 to 6.50, P < .001), with 90% reporting that the flipped classroom contributed to this increase. CONCLUSIONS Implementation of a flipped classroom in the surgery clerkship is feasible and results in high learner satisfaction, effective knowledge acquisition, and increased career interest in surgery with noninferior NBME performance.

Complementing Operating Room Teaching With Video-Based Coaching

Importance Surgical expertise demands technical and nontechnical skills. Traditionally, surgical trainees acquired these skills in the operating room; however, operative time for residents has decreased with duty hour restrictions. As in other professions, video analysis may help maximize the learning experience. Objective To develop and evaluate a postoperative video-based coaching intervention for residents. Design, Setting, and Participants In this mixed methods analysis, 10 senior (postgraduate year 4 and 5) residents were videorecorded operating with an attending surgeon at an academic tertiary care hospital. Each video formed the basis of a 1-hour one-on-one coaching session conducted by the operative attending; although a coaching framework was provided, participants determined the specific content collaboratively. Teaching points were identified in the operating room and the video-based coaching sessions; iterative inductive coding, followed by thematic analysis, was performed. Main Outcomes and Measures Teaching points made in the operating room were compared with those in the video-based coaching sessions with respect to initiator, content, and teaching technique, adjusting for time. Results Among 10 cases, surgeons made more teaching points per unit time (63.0 vs 102.7 per hour) while coaching. Teaching in the video-based coaching sessions was more resident centered; attendings were more inquisitive about residents’ learning needs (3.30 vs 0.28, P = .04), and residents took more initiative to direct their education (27% [198 of 729 teaching points] vs 17% [331 of 1977 teaching points], P < .001). Surgeons also more frequently validated residents’ experiences (8.40 vs 1.81, P < .01), and they tended to ask more questions to promote critical thinking (9.30 vs 3.32, P = .07) and set more learning goals (2.90 vs 0.28, P = .11). More complex topics, including intraoperative decision making (mean, 9.70 vs 2.77 instances per hour, P = .03) and failure to progress (mean, 1.20 vs 0.13 instances per hour, P = .04) were addressed, and they were more thoroughly developed and explored. Excerpts of dialogue are presented to illustrate these findings. Conclusions and Relevance Video-based coaching is a novel and feasible modality for supplementing intraoperative learning. Objective evaluation demonstrates that video-based coaching may be particularly useful for teaching higher-level concepts, such as decision making, and for individualizing instruction and feedback to each resident.

A Mixed-methods Analysis of a Novel Mistreatment Program for the Surgery Core Clerkship

Purpose To review mistreatment reports from before and after implementation of a mistreatment program, and student ratings of and qualitative responses to the program to evaluate the short-term impact on students. Method In January 2014, a video- and discussion-based mistreatment program was implemented for the surgery clerkship at the Stanford University School of Medicine. The program aims to help students establish expectations for the learning environment; create a shared and personal definition of mistreatment; and promote advocacy and empower ment to address mistreatment. Counts and types of mistreatment were compared from a year before (January–December 2013) and two years after (January 2014–December 2015) implementation. Students’ end-of-clerkship ratings and responses to open-ended questions were analyzed. Results From March 2014–December 2015, 141/164 (86%) students completed ratings, and all 47 (100%) students enrolled from January–August 2014 provided qualitative program evaluations. Most students rated the initial (108/141 [77%]) and final (120/141 [85%]) sessions as excellent or outstanding. In the qualitative analysis, students valued that the program helped establish expectations; allowed for sharing experiences; provided formal resources; and provided a supportive environment. Students felt the learning environment and culture were improved and reported increased interest in surgery. There were 14 mistreatment reports the year before the program, 9 in the program’s first year, and 4 in the second year. Conclusions The authors found a rotation-specific mistreatment program, focused on creating shared understanding about mistreatment, was well received among surgery clerkship students, and the number of mistreatment reports decreased each year following implementation.

Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees

Key Points Question What programmatic and curricular attempts have been reported to decrease the incidence of mistreatment of medical trainees? Findings After a systematic review of more than 3300 articles, only 10 peer-reviewed studies presented outcomes from an implemented program to prevent mistreatment. Overall, quality of included studies was low, and few studies reported any outcome data. Meaning There are very few published descriptions of programs attempting to decrease mistreatment of medical trainees, and there is a need for improved quantity and quality of such reports.

A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

BackgroundPatient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient–physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction.ObjectiveTo determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers.DesignInternal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre–post comparisons.ParticipantsTwenty-two internal medicine residents in their second or third postgraduate year.InterventionAn educational dinner describing the format and potential benefits of using the CPI.Main MeasuresRetrospective pre–post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians.Key ResultsAll night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups.ConclusionsResident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician–physician communication. These results suggest that the method should be taught and implemented more frequently.

The Obesity Epidemic

Obesity is a worldwide epidemic and represents one of the most pressing public health challenges of the modern era. Obesity carries significant health implications, including diseases such as diabetes, cardiovascular disease, cancer, osteoarthritis, and liver and kidney diseases, and ultimately a decreased life expectancy. On a societal level, obese patients incur significantly greater health costs. This chapter reviews potential determinants of obesity, including genetics, diet, and environment, and some of the preventative efforts that have been levied against this problem.

Who Orders a Head CT?: Perceptions of the Cirrhotic Bleeding Risk in an International, Multispecialty Survey Study.

Objective: Traditional coagulopathic indices, including elevated international normalized ratio, do not correlate with bleeding risk in patients with cirrhosis. For this reason, head computed tomography (CT) has a low yield in cirrhotic patients with altered mental status and no trauma history. The initial diagnostic evaluation, however, is often made by nongastroenterologists influenced by the so-called “coagulopathy of cirrhosis.” We sought to examine the prevalence, impact, and malleability of this perception in an international, multispecialty cohort. Design: An electronic survey was distributed to internal medicine, surgery, emergency medicine, and gastroenterology physicians. Respondents were presented with a cirrhotic patient with hepatic encephalopathy, no history of trauma, and a nonfocal neurological examination. Respondents rated likelihood to order head CT at presentation, after obtaining labs [international normalized ratio (INR) 2.4 and platelets 59×103/&mgr;L], and finally after reading the results of a study demonstrating the low yield of head CT in this setting. Results: In total, 1286 physicians from 6 countries, 84% from the United States. Of these, 62% were from internal medicine, 25% from emergency medicine, 8% from gastroenterology, and 5% from surgery. Totally, 47% of respondents were attending physicians. At each timepoint, emergency physicians were more likely, and gastroenterologists less likely, to scan than all other specialties (P<0.0001). Evidence on the low yield of head CT reduced likelihood to scan for all specialties. Qualitative analysis of open-ended comments confirmed that concern for “coagulopathy of cirrhosis” motivated CT orders. Conclusions: Perceptions regarding the coagulopathy of cirrhosis, which vary across specialties, impact clinical decision-making. Exposure to clinical evidence has the potential to change practice patterns.

Post-Game Analysis: Postoperative Video-Based Coaching for Residents

METHODS: Between 2002 and 2012, 133 PGY1 general surgery residents completed the OSATS. Pass/fail status was assigned using a contrasting groups (CG), borderline groups (BG) and borderline regression (BR) methodology. Technical skill data were collected from in-training evaluation reports (ITERs), giving each resident a technical score for PGY2 and PGY4 years. A Mann-Whitney U test was used to compare technical skill of those who passed and failed the OSATS at the PGY2 and PGY4 levels.