William J. Adamas-Rappaport

The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship—a response to the economic pressures facing academic medicine today

BACKGROUND In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship. METHODS Sixty-three medical students participated in a skills training laboratory. The first part of the laboratory taught basic suturing skills, and the second involved a cadaver with pig skin grafted to different anatomic locations. Clinical scenarios were simulated, and students performed essential procedural skills. RESULTS Students learned most of their suturing skills in the laboratory skills sessions, compared with the emergency room or the operating room (P = .01). Students reported that the laboratory allowed them greater opportunity to participate in the emergency room and operating room. Students also felt that the suture laboratory contributed greatly to their skills in wound closure. Finally, 90% of students had never received instruction on suturing, and only 12% had performed any procedural skills before beginning the surgery rotation. CONCLUSIONS The laboratory described is an effective way of insuring that necessary technical skills are imparted during the surgery rotation.

Development of a fresh cadaver model for instruction of ultrasound-guided breast biopsy during the surgery clerkship: pre-test and post-test results among third-year medical students.

BACKGROUND The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions. METHODS Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist. RESULTS Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 (P < .001). CONCLUSIONS Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students.

A Comparison of Unguided vs Guided Case-Based Instruction on the Surgery Clerkship

BACKGROUND Guided case-based instruction is an effective and efficient means of learning for third year medical students on the surgery clerkship. Compared with an unguided format for teaching biliary disease, we observed greater student satisfaction as well as a more efficient utilization of student as well as faculty time with the guided instruction. OBJECTIVE While case-based instruction (CBI) has become an extremely popular teaching modality during the first 2 years of medical school, there has been little published regarding its utilization during the clinical years of medical school. The purpose of our study was to compare guided CBI (G-CBI) to unguided CBI (UG-CBI) during the surgery clerkship. DESIGN From July 2007 to July 2008, we utilized a UG-CBI format to teach biliary disease, formerly taught by a standard lecture. The unguided style is used by our institution for the first 2 years of medical school education, where the role of the facilitator is minimal. From July 2008 to December 2010, we changed to a G-CBI format where 5 different clinical scenarios were presented that all dealt with some form of biliary disease. A Likert-like scale was used to analyze student opinion comparing guided to the traditional unguided format. Questions regarding biliary disease contained in the National Board of Medical Examiners (NBME) shelf examination, given to all students at the end of the rotation, were also compared between the 2 groups. Cohens d statistic was used to assess effect size. SETTING The study took place at the University of Arizona College of Medicine. PARTICIPANTS There were 88 students in the UG-CBI group and 146 in the G-CBI group. RESULTS Ninety-six percent of the students preferred G-CBI over the unguided format utilized during the basic science years. Eighty-two percent felt that the guided format sessions were a more efficient method of instruction and 91% of students agreed or strongly agreed that time was more efficiently utilized in preparing for the case discussion during the guided format. Shelf examination scores analyzing biliary disease questions (2-4 per examination) showed a moderate size effect favoring the G-CBI, although the numbers were too small to draw definite conclusions in this regard. CONCLUSIONS G-CBI is more suited for the surgery clerkship than the UG-CBI utilized during the first 2 years of medical school. Lack of a clinical knowledge base among the students rotating on the surgery clerkship as well as time limitations for both the student and clinical faculty favor this more efficient means of learning.

A Fresh Cadaver Model for the Instruction of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules

Objective The aim of our study is to determine if a fresh cadaver model (FCM) for the instruction of ultrasound (US)–guided fine-needle aspiration (FNA) of thyroid nodules is a practical method for instruction. Study Design Pre- and postinstruction assessment of medical students’ ability to perform US-guided FNA of artificially created thyroid nodules placed adjacent to the thyroid gland of a fresh cadaver. Setting University-based fresh cadaver laboratory. Subjects and Methods Study participants included a total of 17 first- and second-year medical students with minimal US training. Technical skills were assessed using a 10-item checklist. In addition, a cognitive assessment regarding the indications, contraindications, and complications of the procedure was completed. A postinstruction assessment was provided for participants 5 weeks after their initial assessment. Differences between pre- and postinstruction assessment scores of technical skills were analyzed using McNemar’s test. The mean cognitive knowledge gain was analyzed using a paired 2-sample t test. Results Eight of 10 items on the skills checklist were statistically significant between pre- and postinstruction skills assessment (P < .05). There was a statistically significant change in cognitive knowledge gain regarding the contraindications of the procedure (P = .001), but not for indications or complications (P = .104 and P = .111, respectively). Conclusion US-guided FNA continues to be an important diagnostic procedure in the workup of thyroid nodules, making it an essential skill to integrate into surgical skills lab. Our FCM for the instruction of US-guided FNA is the first of its kind, and this pilot study shows this is a viable method for instruction.

Cadaver-based abscess model for medical training

Ultrasound imaging is a rapid and noninvasive tool ideal for the imaging of soft tissue infections and is associated with a change of clinician management plans in 50% of cases. We developed a realistic skin abscess diagnostic and therapeutic training model using fresh frozen cadavers and common, affordable materials. Details for construction of the model and suggested variations are presented. This cadaver-based abscess model produces high-quality sonographic images with internal echogenicity similar to a true clinical abscess, and is ideal for teaching sonographic diagnostic skills in addition to the technical skills of incision and drainage or needle aspiration.

Assessment of alcohol withdrawal in Native American patients utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale.

Background:The Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) is a commonly used scale for assessing the severity of alcohol withdrawal syndrome in the acute setting. Despite validation of this scale in the general population, the effect of ethnicity on CIWA-Ar scoring does not appear in the literature. The purpose of our study was to investigate the validity of the CIWA-Ar scale among Native American patients evaluated for acute alcohol detoxification. Methods:A case series of all patients seen for alcohol withdrawal at an Acute Drug and Alcohol Detoxification facility was conducted from June 1, 2011, until April 1, 2012. The CIWA-Ar scores were recorded by trained nursing staff on presentation to Triage Department and every 2 hours thereafter. At our institution, a score of 10 or greater indicates the need for inpatient hospital admission and treatment. Ethnicity was self-reported. Age, sex, blood alcohol concentration, blood pressure, and pulse were recorded on presentation and vital signs repeated every 2 hours. Patients were excluded from the study if other drug use was noted by history or initial urine drug screen. A multivariate logistic regression model was utilized to identify statistically significant variables associated with admission to the inpatient unit and treatment. The relationship of CIWA-Ar scores and ethnicity was compared using analysis of variance. Results:A total of 115 whites, 45 Hispanics, and 47 Native Americans were included in the analysis. Native Americans had consistently lower CIWA-Ar scores at 0, 2, 4, and 6 hours than the other 2 ethnic groups (P = 0.002). In addition, Native Americans were admitted to the hospital less often than the other 2 groups for withdrawal (P < 0.001). Conclusions:The CIWA-Ar scale may underestimate the severity of alcohol withdrawal syndrome in certain ethnic group such as Native Americans. Further prospective studies should be undertaken to determine the validity of the CIWA-Ar scale in assessing alcohol withdrawal across different ethnic populations.

“Flipped classroom” for academic and career advising: an innovative technique for medical student advising

Introduction Career advising for medical students can be challenging for both the student and the adviser. Our objective was to design, implement, and evaluate a “flipped classroom” style advising session. Methods We performed a single-center cross-sectional study at an academic medical center, where a novel flipped classroom style student advising model was implemented and evaluated. In this model, students were provided a document to review and fill out prior to their one-on-one advising session. Results Ninety-four percent (95% CI, 88%–100%) of the medical students surveyed felt that the advising session was more effective as a result of the outline provided and completed before the session and that the pre-advising document helped them gain a better understanding of the content to be discussed at the session. Conclusion Utilization of the flipped classroom style advising document was an engaging advising technique that was well received by students at our institution.