Ravi Sidhu

Examination stress leads to improvements on fundamental technical skills for surgery

BACKGROUND This study was conducted to assess the effects of examination-induced stress on the technical performance of junior surgery residents. METHODS Twelve first-year surgery residents completed 2 surgical tasks (skin excision, tracheotomy) in low- and high-stress condition (in-training examination--Objective Structured Assessment of Technical Skills [OSATS]). Residents rated their subjective stress levels on a 10-point Likert-like scale. Performances were videotaped and assessed by 3 blinded experts using checklist and global rating scales. RESULTS Residents reported moderately higher stress levels in the exam condition than in the low-stress conditions (P < .05). Their performance was rated higher in the exam condition on the checklist scales (P < .05) but not on the global rating scales (P = .79). CONCLUSIONS Residency in-training exams induce moderate stress levels in junior surgery residents and are accompanied by improvements in technical performance as assessed by checklist-based scales. There were no differences on the global rating scales due to stress conditions, suggesting that residents were better at following the itemized sequence of movements when stressed, but their overall global performance was not altered.

Objective assessment of surgical decision making in trauma after a laboratory-based course: durability of cognitive skills

BACKGROUND Because surgical trainees have less exposure to surgical trauma, there is a greater potential of having gaps in decision-making skills. We previously validated a novel assessment tool for decision making in surgical trauma and have documented improvement in resident decision-making skills after a hands-on course. However, brief intensive courses have been criticized for not imparting long-term changes in practice. The purpose of this study was to assess the durability of cognitive skills learned after a 2-day course. METHODS Twenty-two residents participated in a 2-day interactive didactic lecture series as well as an animal laboratory focused on practical strategies in dealing with surgical trauma. All participants underwent precourse and immediate postcourse assessment of surgical decision making through a validated short-answer examination. Six months after the course, 12 of these 22 residents completed a third similar examination-the retention test. RESULTS The retention test showed good reliability (Cronbachs alpha, .81) and construct validity as evidenced by a positive correlation between test scores and postgraduate year level (r = .9, P < .001). There was no significant difference between retention test scores and posttest scores. However, both were significantly higher than pretest scores (P < .05). This did not change after adjusting for differing degrees of difficulty between the examinations. CONCLUSIONS In the context of residency trauma education, there is a measurable positive impact of an intensive, hands-on course on surgical decision making. This impact is durable and cognitive skills persist after the immediate postcourse period. These data support the continued supplementation of traditional residency experiential learning with appropriate laboratory-based skills training.

How to Recruit, Retain, and Reap the Rewards of Working with PhD/EdD Educators in Surgery

BACKGROUND PhD and EdD educators in departments of surgery have and are increasingly becoming valuable colleagues. Professional educators typically assist chairpersons and program directors by positively impacting the education, research, and service missions. OBJECTIVE The purpose of this article is 3-fold: (1) to identify ways of finding prospective PhD/EdD educators, (2) to recognize ways to work with educators in a complimentary way so the educator and directors mutually benefit, and (3) to identify various ways departments and programs can benefit from employing a professional educator.

The use of thoracoscopy to enhance medical students' interest and understanding of thoracic anatomy

AIM: To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students’ stimulation and motivation for learning anatomy. METHODS: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the videos usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained. RESULTS: Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175). CONCLUSION: Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students’ interest in learning, in clinically applying anatomic fact, and in surgery as a future career.

Carotid Revascularization: Carotid Endarterectomy

Carotid endarterectomy (CEA) is a procedure that has reliably decreased the risk of cerebrovascular events and death in patients with severe carotid stenosis. In this chapter, important concepts in the preoperative assessment of patients undergoing CEA will be reviewed. An overview of the clinical trials highlighting current indications will be provided, followed by a discussion of the surgical technique, complications, and controversies related to CEA.

Use of short-radius centrifugation to augment ankle-brachial indices.

Background Peripheral arterial disease is mainly caused by atherosclerosis and is characterized by decreased circulation, lower blood pressure, and insufficient tissue perfusion in the lower extremities. The hemodynamics of standing and altered gravity environments have been well studied relative to arm blood pressures but are less well understood for ankle pressures. Methods Because regional blood pressure depends, in part, on the gravitational pressure gradient, we hypothesized that artificial gravity exposure on a short-arm centrifuge with the center of rotation above the head would increase blood pressure in the lower extremities. Cardiovascular parameters for 12 healthy subjects were measured during exposure to supine short-arm centrifugation at 20, 25, and 30 revolutions per minute (rpm), corresponding to centripetal accelerations of 0.94, 1.47, and 2.11 Gz at the foot level, respectively. Results Systolic ankle blood pressure significantly increased at all levels of centrifugation. Ankle-brachial indices (the ratio of systolic ankle to arm blood pressures) increased significantly from 1.17 ± 0.03 to 1.58 ± 0.03 at 0.94 Gz (P < 0.005), 1.74 ± 0.02 at 1.47 Gz (P < 0.005), and 1.89 ± 0.06 at 2.11 Gz (P < 0.005). Systolic arm blood pressure significantly increased at 2.11 Gz, but heart rate did not change significantly. All parameters returned to normal after cessation of centrifugation. Conclusions We demonstrated that short-radius centrifugation leads to an increase in ankle-brachial indices. This could have potential implications for the treatment of peripheral arterial disease.

Professional paradox: identity formation in qualified doctors pursuing further training

Many newly qualified specialists and subspecialists pursue additional training. Although their motivations are many, the pursuit of further training as an alternative to unemployment is an emerging trend. Paradoxically, doctors continue as trainees with a consultants credentials, and without the guarantee of eventual employment. This study explores seven doctors’ experiences, the effects of further training on their professional identity formation (PIF), and how these effects are reconciled on a personal and professional level.

An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients

Objective: Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65‐79 years, >80 years) to determine whether protocols should be modified to account for advanced age. Methods: All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan‐Meier survival and Cox hazards models were used to compare access patency and risk factors for failure. Results: There were 941 autogenous arteriovenous accesses (median follow‐up, 23 months; range, 0‐89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss. Conclusions: Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.