Lauren M. Wancata

Using the ACMGE Milestones as a Handover Tool From Medical School to Surgery Residency

OBJECTIVE To map current medical school assessments for graduating students to the Accreditation Council for Graduate Medical Education (ACGME) milestones in general surgery, and to pass forward individual performance metrics on level 1 milestones to receiving residency programs. DESIGN The study included 20 senior medical students who were accepted into surgery internship positions. Data from medical school performance assessments from the third-year surgery clerkship, fourth-year surgery rotations, fourth-year surgery boot camp, Clinical Competency Assessment Examination, and United States Medical Licensing Examination (USMLE) Step 1 and 2 examinations were used to map each students competency assessments to the General Surgery Milestones based on a scoring system created and validated by independent assessors. This Milestones Assessment was then provided to each students receiving program director. SETTING The study was conducted at the University of Michigan Medical School, in Ann Arbor, Michigan. PARTICIPANTS Fourth-year medical students entering into surgical internship. RESULTS Of 16 Accreditation Council for Graduate Medical Education (ACGME) General Surgery Milestones subcompetencies, 12 were able to be evaluated with current medical school assessments. Of the 20 students, 11 met criteria for all the level 1 milestones and 9 needed improvement in at least 1 domain. CONCLUSIONS It was feasible to use medical school assessments to feed forward information about senior medical students on 12 of the 16 General Surgery Milestones subcompetency domains.

Implications of age and conditional survival estimates for patients with melanoma

Overall cancer incidence is decreasing, whereas melanoma cases are increasing. Conditional survival estimates offer a more accurate prognosis for patients the farther they are from time of diagnosis. The effect of age and stage on a melanoma patient’s conditional survival estimate is unknown. Surveillance, Epidemiology, and End Results data were utilized to identify newly diagnosed cutaneous melanoma patients (N=95 041), from 1998 to 2005, with up to 12 years of follow-up. Estimates of disease-specific survival by stage and age were determined by Cox regression analysis and transformed to estimated conditional 5-year survival. Localized melanoma patients have an excellent 5-year survival at diagnosis and over subsequent years. For patients with localized and regional disease, an age effect is present for disease-specific mortality when comparing older patients (70–79 years) with younger patients (<30 years): hazard ratio (HR) for mortality 3.79 [95% confidence interval (CI) 3.01–4.84] and HR 2.36 (95% CI 1.93–2.91), respectively. No age effect difference is observed in disease-specific survival for advanced disease: HR 1.14 (95% CI 0.87–1.53). Over time, conditional survival estimates improve for older patients with localized and regional disease. This improvement is not seen in distant disease, neither is the age gradient. Disease-specific mortality and conditional survival for patients with localized and regional melanomas are initially impacted by older age, with effects dissipating over time. Age does not affect survival in patients with advanced disease. Understanding the conditional 5-year disease-specific survival of melanoma based on age and stage can help patients and physicians, informing decision-making about treatment and surveillance.

Conditional survival in advanced colorectal cancer and surgery

BACKGROUND Recent data show patients with advanced colorectal cancer (CRC) are surviving longer. What is unknown is how specific treatment modalities affect long-term survival. Conditional survival, or survival prognosis based on time already survived, is becoming an acceptable means of estimating prognosis for long-term survivors. We evaluated the impact of cancer-directed surgery on long-term survival in patients with advanced CRC. METHODS We used Surveillance, Epidemiology, and End Results data to identify 64,956 patients with advanced (Stage IV) CRC diagnosed from 2000-2009. Conditional survival estimates by stage, age, and cancer-directed surgery were obtained based on Cox proportional hazards regression model of disease-specific survival. RESULTS A total of 64,956 (20.1%) patients had advanced disease at the time of diagnosis. The proportion of those patients who underwent cancer-directed surgery was 65.1% (n = 42,176). Cancer-directed surgery for patients with advanced stage disease was associated with a significant improvement in traditional survival estimates compared to patients who did not undergo surgery (hazard ratio = 2.22 [95% confidence interval, 2.17-2.27]). Conditional survival estimates show improvement in conditional 5-y disease-specific survival across all age groups, demonstrating sustained survival benefits for selected patients with advanced CRC. CONCLUSIONS Five-year disease-specific conditional survival improves dramatically over time for selected patients with advanced CRC who undergo cancer-directed surgery. This information is important in determining long-term prognosis and will help inform treatment planning for advanced CRC.

Milestones for the Final Mile: Interspecialty Distinctions in Primary Palliative Care Skills Training

CONTEXT Primary palliative care (PPC) skills are useful in a wide variety of medical and surgical specialties, and the expectations of PPC skill training are unknown across graduate medical education. OBJECTIVES We characterized the variation and quality of PPC skills in residency outcomes-based Accreditation Council for Graduate Medical Education (ACGME) milestones. METHODS We performed a content analysis with structured implicit review of 2015 ACGME milestone documents from 14 medical and surgical specialties chosen for their exposure to clinical situations requiring PPC. For each specialty milestone document, we characterized the variation and quality of PPC skills in residency outcomes-based ACGME milestones. RESULTS We identified 959 occurrences of 29 palliative search terms within 14 specialty milestone documents. Within these milestone documents, implicit review characterized 104 milestones with direct saliency to PPC skills and 196 milestones with indirect saliency. Initial interrater agreement of the saliency rating among the primary reviewers was 89%. Specialty milestone documents varied widely in their incorporation of PPC skills within milestone documents. PPC milestones were most commonly found in milestone documents for Anesthesiology, Pediatrics, Urology, and Physical Medicine and Rehabilitation. PPC-relevant milestones were most commonly found in the Interpersonal and Communication Skills core competency with 108 (36%) relevant milestones classified under this core competency. CONCLUSIONS Future revisions of specialty-specific ACGME milestone documents should focus on currently underrepresented, but important PPC skills.

Impact of pancreatic cancer treatment on hospice utilization.

52 Background: There is an increasing incidence of pancreatic cancer over time, a cancer with a 5-year survival rate of only 7.2%.For patients with poor prognosis cancers, hospice is an important resource, but it is often not utilized or underutilized. Factors influencing hospice use are difficult to determine. We sought to evaluate the impact of pancreatic cancer treatment on hospice utilization. METHODS National Surveillance Epidemiology and End Results (SEER)-Medicare data was utilized to identify all incident cases of pancreatic cancer patients who died (2005-09, with follow up to 2011). Patients were stratified by primary treatment strategy: surgery, chemotherapy, or no treatment. Hospice utilization in the last 6 months of life, including average and median days enrolled in hospice and average time from diagnosis to hospice was evaluated. RESULTS 17,031 patients were identified, with 68.5% enrolling in hospice in the last 6 months of life. Patients undergoing surgery were less likely to enroll in hospice compared to patients not undergoing surgery (58.7% vs 69.4%, p < 0.0001). Interestingly, surgical patients spent on average 31.2 days in hospice (median 15.0 days) which was comparable to the non-surgical cohort (average 32.7 days, median 16.0 days; p = 0.32). Patients who received any chemotherapy spent an average of 29.2 days in hospice (median 15 days) compared to those who did not undergo chemotherapy, who spent an average of 34.5 days in hospice (median 16 days); p < 0.0001. While total hospice enrollment was equivalent between the chemotherapy and no chemotherapy cohorts (67.5% vs 69.1%), the time spent in hospice was significantly different (p < 0.0001). Patients not receiving any cancer-directed treatment enrolled in hospice at an average of 78.6 days (median 32 days) from diagnosis. CONCLUSIONS Pancreatic cancer patients undergoing surgery enrolled in hospice to a much lesser extent than patients who did not have surgery. Patients not receiving cancer-directed treatment spend a relatively short time in hospice. Overall, hospice appears to be underutilized, and the majority of patients with this poor prognosis cancer are not realizing the full benefits of hospice.