Mary B. Carter

Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer.

BACKGROUND Intraoperative frozen section pathologic analysis of sentinel lymph node (SLN) may guide immediate (single-stage) completion axillary dissection for patients with nodal metastases. METHODS The results of 203 consecutive patients undergoing SLN biopsy who had intraoperative pathology consultation between January 1998 and September 2000 were reviewed. SLN were analyzed by standard frozen section procedures. Final pathologic analysis included hematoxylin and eosin (H&E) staining of serial sections at 2-mm intervals. RESULTS Frozen section analysis correctly identified a positive or negative result in 185 of 203 cases (overall accuracy 91%). In 17 of 53 cases, the SLNs were negative for tumor by frozen section, but positive on permanent section analysis (sensitivity 68%). The mean size of the nodal metastases was 6.2 mm and 1.5 mm in patients found to have true positive and false negative results, respectively (P <0.003). A single false positive SLN is reported. CONCLUSIONS Two thirds of the patients were spared the need for reoperative axillary lymphadenectomy.

Assessing Medical Students’, Residents’, and the Public’s Perceptions of the Uses of Personal Digital Assistants

Although medical schools are encouraging the use of personal digital assistants (PDAs), there have been few investigations of attitudes toward their use by students or residents and only one investigation of the publics attitude toward their use by physicians. In 2006, the University of Louisville School of Medicine surveyed 121 third- and fourth-year medical students, 53 residents, and 51 members of the non-medical public about their attitudes toward PDAs. Students were using either the Palm i705 or the Dell Axim X50v; residents were using devices they selected themselves (referred to in the study generically as PDAs). Three survey instruments were designed to investigate attitudes of (a) third- and fourth-year medical students on clinical rotations, (b) Internal Medicine and Pediatrics residents, and (c) volunteer members of the public found in the waiting rooms of three university practice clinics. Both residents and medical students found their devices useful, with more residents (46.8%) than students (16.2%) (p < 0.001) rating PDAs “very useful.” While students and residents generally agreed that PDAs improved the quality of their learning, residents’ responses were significantly higher (p < 0.05) than students’. Residents also responded more positively than students that PDAs made them more effective as clinicians. Although members of the public were generally supportive of PDA use, they appeared to have some misconceptions about how and why physicians were using them. The next phase of research will be to refine the research questions and survey instruments in collaboration with another medical school.

Teaching basic lung isolation skills on human anatomy simulator: attainment and retention of lung isolation skills

BackgroundLung isolation skills, such as correct insertion of double lumen endobronchial tube and bronchial blocker, are essential in anesthesia training; however, how to teach novices these skills is underexplored. Our aims were to determine (1) if novices can be trained to a basic proficiency level of lung isolation skills, (2) whether video-didactic and simulation-based trainings are comparable in teaching lung isolation basic skills, and (3) whether novice learners’ lung isolation skills decay over time without practice.MethodsFirst, five board certified anesthesiologist with experience of more than 100 successful lung isolations were tested on Human Airway Anatomy Simulator (HAAS) to establish Expert proficiency skill level. Thirty senior medical students, who were naive to bronchoscopy and lung isolation techniques (Novice) were randomized to video-didactic and simulation-based trainings to learn lung isolation skills. Before and after training, Novices’ performances were scored for correct placement using pass/fail scoring and a 5-point Global Rating Scale (GRS); and time of insertion was recorded. Fourteen novices were retested 2 months later to assess skill decay.ResultsExperts’ and novices’ double lumen endobronchial tube and bronchial blocker passing rates showed similar success rates after training (P >0.99). There were no differences between the video-didactic and simulation-based methods. Novices’ time of insertion decayed within 2 months without practice.ConclusionNovices could be trained to basic skill proficiency level of lung isolation. Video-didactic and simulation-based methods we utilized were found equally successful in training novices for lung isolation skills. Acquired skills partially decayed without practice.

Assessment of reaching proficiency in procedural skills: fiberoptic airway simulator training in novices

Background: The importance of fiberoptic bronchoscopy (FOB) and intubation (FOI) is well established to reduce anesthesia-related morbidity and mortality during airway management in clinical practice. We conducted a trial to determine whether simulation-based training of novices can increase FOB and FOI skills to an expert level. Methods: Eight anesthesiologists as experts and 15 fourth-year medical students as novices were enrolled. The computerized AccuTouch ® Bronchoscopy Simulator (ATBS, Immersion Medical, Gaithersburg, MD) and the Human Airway Anatomy Simulator (HAAS, Medical Plastics Inc, Gatesville, TX) were used for FOB and FOI training and testing, respectively. Data included three discrete variables: the numbers of airway collisions, oral passes, and nasal passes. Experts were tested, while novices were tested, trained, and retested. Twelve novices returned after 2 months and were again tested, retrained, and retested. Data were analyzed by a newly proposed likelihood ratio test based on the assumption that the data follow a Poisson distribution. A testing procedure was derived to compare performance between experts, novices pre- and post-training, and novices after the 2-month lag period. Results: As expected, experts outperformed pre-trained novices on all variables (P , 0.0001). Post-training, novices’ skills improved (P , 0.0001) to the point that there were no significant differences between experts and novices post-training (P = 0.1709, 0.9857, and 0.5014 for collisions, and oral and nasal passes, respectively). After 2 months there was a significant decay in FOB skills among novices compared to the prior level achieved (P , 0.0001), but brief retraining brought their performance back to the expert level (P = 0.2207). Conclusion: Due to the small sample size, normal approximation is not applicable; therefore many existing tests are not appropriate. Our novel likelihood ratio test provided a powerful tool in analyzing the small samples of discrete training data. Simulation can be used to train novices

Board 366 - Research Abstract Teaching Basic Lung Isolation Skills on Human Anatomy Simulator (Submission #263)

Introduction/Background Lung isolation skills (LIS) are essential in anesthesia training and learning how to correctly insert a double lumen tube (DLT) and bronchial blocker (BB) is important. How to teach the novices LIS to an expert level of competency is under explored. We hypothesized that: (a) Novices can be trained to expert competency; (b) Simulation-based teaching is better than Video-didactic teaching; and (c) the LIS decay over time without practice. Methods We recruited 5 thoracic anesthesiologists (Expert), 9 senior residents (Experienced) and 30 medical students (Novice Group). The DLT and BB correct placement and insertion time were assessed on the Human Airway Anatomy Simulator (HAAS). First, Expert Group’s LIS was established. After baseline didactic teaching, Novices were randomized to video-didactic or simulation-based trainings. Video-didactic group watched training videos under supervision. Simulation-based group was trained in HAAS. Novices learning were compared with the Expert Group and within the two training groups on: (a) correct placement on 5-point Global Rating Scale (GRS); (b) pass/fail scoring; and (c) time to insert DLT/BB. Novices were retested 2 months later to assess skill decay. Results After training, there was no difference between the Novice and Expert groups in: (a) correct placement on GRS; (b) pass/fail; and (c) time to insert. There was no difference found between the Novice training groups. LIS decayed in two months without practice. Conclusion The novices can be trained to an expert competency level. The Video-didactic and Simulation-based trainings are equally successful in teaching LIS. However, LIS decay without practice. Disclosures None.

A campaign approach to medical school programme objectives

Context and setting Data on interns obtained during their 1-year pre-registration service were used to induce curriculum change. The initiative resulted in a 5-year, semi-integrated, organ system-based curriculum implemented in 1998. It is the third curriculum to be initiated since our medical school was established in 1965. Why the idea was necessary In 1994, Ministry of Health consultants who supervised our graduates indicated that, although the graduates excelled in knowledge and skills, they lacked leadership qualities, interpersonal and communication skills, teamwork skills, and knowledge of medical economics and recent advances in medicine. What was done A curriculum review carried out in 1996 resulted in the New Integrated Curriculum (NIC). This consisted of 3 vertical strands:

Oral examinations and grading sessions promote faculty and resident enthusiasm for student evaluation and teaching

Most surgical program directors have come to realize that a declining number of domestic medical graduates choose careers in surgery and its specialties. Potential excuses and remedies for student attitudes are numerous. Few remedies have more innate merit than a broad base of surgical faculty taking a genuine interest in student education. Even mature and well-developed medical school departments require assistance to maintain broad faculty interest in undergraduate student evaluation and, indeed, in undergraduate student education itself. Good departments may have difficulty with maintaining both a contemporary and an objective evaluation of students, providing exceptional students the fullest opportunity to show their skills, while simultaneously providing every opportunity for faltering students to show their best skills. The purpose of this editorial is to describe the salutary effects that oral examinations and grading sessions have had at the Department of Surgery, University of Louisville School of Medicine. One of the many benefits that has resulted from this simple process is our faculty’s continuing interest in undergraduate student education. More than 20 years ago, our department chose to include an oral examination as part of the required work for both thirdand fourth-year medical students who were rotating on the service. The oral, patient-oriented examination always constituted a relatively small part of that total grade, ranging over the years from 10% to 20%, and currently is at the former value. The oral examinations are typically given by a full-time faculty member and supplemented by a senior surgical resident or a volunteer faculty member. The mixture of specialties that participate varies, but it generally includes all of the specialties within our department. Immediately after the oral examinations, a grading session is attended by all faculty and residents who participated in the oral examinations. This grading session has promoted broadbased interest in undergraduate education, some innovative curriculum alternatives, and more meaningful faculty recommendations for students seeking competitive residencies. These sessions occur seven times a year; six times a year for junior students completing an 8-week rotation on general surgery, with a lecture series that involves all specialties, and once a year for senior students who complete our 8-week senior honors surgery program. Our intent by this editorial is not to debate the meaningfulness of an oral examination, or even the percentage that it contributes to an overall score, but to point out the benefits of a well-attended faculty– resident evaluation session. Our format is one in which the student is introduced to a pair of examiners, who typically take turns asking clinically relevant patient-oriented questions. We especially encourage faculty who are responsible for outside student and resident rotations to participate in the oral examinations and in the evaluation of the students. For background, it is clear that we have always placed the greatest preponderance of weighting in overall grades on the students’ performance on the wards and clinics and on a written examination, which currently alternates between a local constructed multiple choice examination and the National Board’s “shelf examination” in surgery. A typical student is examined by two people and asked to respond to five or six clinical scenarios. Grading is straightforward but often generous. The grading session that follows the oral examination is moderated by a senior member of the full-time faculty who is usually the coordinator of the undergraduate student curriculum, complemented by a staff person who has supervised the student program for some time. Recently, we have also had a professional educator as a fullor part-time employee. In the 1999 to 2000 academic year, 40 different full-time faculty, 13 volunteer clinical faculty, and 11 senior surgical residents participated in these sessions. The fundamental purpose of the grading session is to Supported in part by Mary and Mason Rudd Surgical Endowment of Jewish Hospital, Louisville, KY.