Nancy Schindler

Quiescent-interval single-shot unenhanced magnetic resonance angiography of peripheral vascular disease: Technical considerations and clinical feasibility.

We performed technical optimization followed by a pilot clinical study of quiescent‐interval single‐shot MR angiography for peripheral vascular disease. Quiescent‐interval single‐shot MR angiography acquires data using a modified electrocardiographic (ECG)‐triggered, fat suppressed, two‐dimensional, balanced steady‐state, free precession pulse sequence incorporating slice‐selective saturation and a quiescent interval for maximal enhancement of inflowing blood. Following optimization at 1.5 T, a pilot study was performed in patients with peripheral vascular disease, using contrast‐enhanced MR angiography as the reference standard. The optimized sequence used a quiescent interval of 228 ms, α/2 catalyzation of the steady‐state magnetization, and center‐to‐out partial Fourier acquisition with parallel acceleration factor of 2. Spatial resolution was 2‐3mm along the slice direction and 0.7‐1mm in‐plane before interpolation. Excluding stented arterial segments, the sensitivity, specificity, and positive and negative predictive values of quiescent‐interval single‐shot MR angiography for arterial narrowing greater than 50% or occlusion were 92.2%, 94.9%, 83.9%, and 97.7%, respectively. Quiescent‐interval single‐shot MR angiography provided robust depiction of normal peripheral arterial anatomy and peripheral vascular disease in less than 10 min, without the need to tailor the technique for individual patients. Moreover, the technique provides consistent image quality in the pelvic region despite the presence of respiratory and bowel motion. Magn Reson Med 63:951–958, 2010.

Teaching operating room conflict management to surgeons: clarifying the optimal approach

Medical Education 2011:45: 939–945

Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors

BACKGROUND Developing an operating room conflict management educational program for surgeons requires a formal needs assessment and information about behaviors that represent effective conflict management. METHODS Focus groups of circulating room nurses and surgeons were conducted at 5 participating centers. Participants responded to queries about conflict management training, conflict consequences, and effective conflict management behaviors. Transcripts of these sessions served as the data for this study. RESULTS Educational preparation for conflict management was inadequate consisting of trial and error with observed behaviors. Conflict and conflict mismanagement had negative consequences for team members and team performance. Four behaviors emerge as representing effective ways for surgeons to manage conflict. CONCLUSIONS There is a clear educational need for conflict management education. Target behaviors have now been identified that can provide the basis for a theoretically grounded and contextually adapted instruction and assessment of surgeon conflict management.

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict

BACKGROUND Prior research has shown that surgeons who effectively manage operating room conflict engage in a problem-solving stage devoted to modifying systems that contribute to team conflict. The purpose of this study was to clarify how systems contributed to operating room team conflict and clarify what surgeons do to modify them. METHODS Focus groups of circulating nurses and surgeons were conducted at 5 academic medical centers. Narratives describing the contributions of systems to operating room conflict and behaviors used by surgeons to address those systems were analyzed using the constant comparative approach associated with a constructivist grounded theory approach. RESULTS Operating room team conflict was affected by 4 systems-related factors: team features, procedural-specific staff training, equipment management systems, and the administrative leadership itself. Effective systems problem solving included advocating for change based on patient safety concerns. CONCLUSIONS The results of this study provide clarity about how systems contribute to operating room conflict and what surgeons can do to effectively modify these systems. This information is foundational material for a conflict management educational program for surgeons.

Questioning skills: the effect of wait time on accuracy of medical student responses to oral and written questions.

Background. Pauses (wait time) after asking questions in precollege classes result in improved discussion and answer accuracy. The authors hypothesized that this would extend to medical students. Method. Third-year surgery clerks were randomized to three-second or six-second wait times after questions asked of them during a scripted lecture. Students were randomized within each session to answer 21 scripted questions. Students also completed a post-lecture written examination. Results. Correct responses ranged from 17% to 100% for oral and 22% to 100% for written questions. Answer accuracy could not be distinguished between three- and six-second wait times for oral or written questions. Conclusions. The benefit of increasing wait times from three to six seconds appears not to extend to medical students. This may represent evolution of learning or different learning modes in medical students. Alternatively, maximum benefit may be achieved in medical students with shorter wait times.

Implementing a resident acute care surgery service: Improving resident education and patient care

Background. To simulate the duties and responsibilities of an attending surgeon and allow senior residents more intraoperative and perioperative autonomy, our program created a new resident acute care surgery consult service. Methods. We structured resident acute care surgery as a new admitting and inpatient consult service managed by chief and senior residents with attending supervision. When appropriate, the chief resident served as a teaching assistant in the operation. Outcomes were recorded prospectively and reviewed at weekly quality improvement conferences. The following information was collected: (1) teaching assistant case logs for senior residents preimplentation (n = 10) and postimplementation (n = 5) of the resident acute care surgery service; (2) data on the proportion of each case performed independently by residents; (3) resident evaluations of the resident acute care surgery versus other general operative services; (4) consult time for the first 12 months of the service (June 2014 to June 2015). Results. During the first year after implementation, the number of total teaching assistant cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4–44) for preresident acute care surgery residents to 30.8 ± 8.8 (range 27–36) for postresident acute care surgery residents (P < .01). Of 323 operative cases, the residents performed an average of 82% of the case independently. There was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, P < .01 on a 6‐point Likert scale) and complexity of cases (mean 5.35 vs 4.94, P < .01) on service evaluations of resident acute care surgery (n = 27) in comparison with other general operative services (n = 127). In addition, creation of a 1‐team consult service resulted in a more streamlined consult process with average consult time of 22 minutes for operative consults and 25 minutes for nonoperative consults (range 5–90 minutes). Conclusion. The implementation of a resident acute care surgery service has increased resident autonomy, teaching assistant cases, and satisfaction with operative case variety, as well as the efficiency of operative consultation at our institution.

Surgeon-patient communication during awake procedures.

BACKGROUND Surgeons are increasingly performing procedures on awake patients. Communication during such procedures is complex and underexplored in the literature. METHODS Surgeons were recruited from the faculty of 2 hospitals to participate in an interview regarding their approaches to communication during awake procedures. Three researchers used the constant comparative method to transcribe, code, and review interviews until saturation was reached. RESULTS Twenty-three surgeons described the advantages and disadvantages of awake procedures, their communication with the awake patient, their interactions with staff and with trainees, the environment of awake procedures, and how communication in this context is taught and learned. CONCLUSIONS Surgeons recognized communication during awake procedures as important and reported varied strategies for ensuring patient comfort in this context. However, they also acknowledged challenges with multiparty communication during awake procedures, especially in balancing commitments to teaching with their duty to comfort the patient.

Resection of Intracaval Leiomyomatosis Using Abdominal Approach and Venovenous Bypass

BACKGROUND Intravenous leiomyomatosis is the venous involvement of a histologically benign uterine tumor. This uncommon tumor can present contemporaneously with the primary uterine tumor or in a delayed fashion. Tumor extends up the venous system, via the iliac or ovarian veins, and can involve portions or all of the inferior vena cava and can extend into the heart as well. Complete resection of this tumor is the therapeutic goal. Previous reports have described the use of combined thoracic and abdominal approaches, cardiopulmonary bypass, circulatory arrest, and a single report of an entirely abdominal approach to resection without bypass. METHODS AND RESULTS We present a review of the existing literature describing surgical intervention for intravenous leiomyomatosis and describe two cases of tumor extending up the intra-abdominal vena cava. Using venovenous bypass without need for thoracotomy, we were able to resect both tumors with minimal blood loss and no hemodynamic instability. CONCLUSIONS We suggest that venovenous bypass is an excellent tool in resection of these tumors and should be considered for many cases in lieu of full cardiopulmonary bypass or circulatory arrest.

Bridging the Gap: Interdepartmental Quality Improvement and Patient Safety Curriculum Created by Hospital Leaders, Faculty, and Trainees

Background The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education. Objective Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting. Methods The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3-PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents. Results From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P < .001), and 72% of residents demonstrated increased knowledge. Confidence comprehending quality dashboards increased (13% versus 49%, P < .001). PGY-1 posttest responses were similar to those of 252 graduate controls for accessibility of hospital leaders, filing event reports, and quality dashboards. PGY-1 residents in the QI/PS curriculum reported more patient safety events than PGY-1 residents not exposed to the curriculum (0.39 events per trainee versus 0.10, P < .001). Conclusions An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.

Needs assessment survey of obstetrics and gynecology subspecialty fellowship program directors

OBJECTIVE: Recently, obstetrics/gynecology subspecialty fellowship training programs transitioned to accreditation by the Accreditation Council for Graduate Medical Education from the American Board of Obstetrics and Gynecology. With the transition comes new terminology and accreditation standards that create an opportunity to refocus on faculty development for fellowship directors (FDs). FDs are responsible for institutional program development and mentoring future leaders and researchers in obstetrics and gynecology. Most graduate medical education leadership training occurs in the form of lectures, role modeling, and