Biomedical subjects

D A Sloan

Publications and source records attributed to D A Sloan.

At least 19 recordsLinked to original sources

PubMed1999

Surgical teaching quality makes a difference.

BACKGROUND: This study examined the influence of the quality of faculty members' teaching on student performance in a third-year surgery clerkship. METHODS: Eighty-nine third-year students on a surgery clerkship completed preceptor evaluation forms. The faculty member's overall score was the mean of ratings from all the third-year students for whom that faculty member served as preceptor during the year. We examined associations between these ratings and student performance on the National Board of Medical Examiners (NBME) surgery subject examination and clerkship Objective Structured Clinical Examination (OSCE) by using an analysis of covariance that controlled for prior academic achievement [United States Medical Licensure Examination (USMLE) Part I]. RESULTS: The average mean teaching evaluation score was associated with the scores on the NBME surgery subject examination (P = 0.0005). Students with attendings who received poor teaching evaluations performed more poorly on OSCE data-gathering stations than did students with attendings rated as average or good. CONCLUSIONS: The study results indicate that the teaching quality of surgery faculty appears to have an impact on student performance.

Adult↗

PubMed1999

Advances in the pathogenesis and treatment of thyroid cancer.

Thyroidectomy remains the mainstay of treatment for thyroid carcinoma. The extent of surgical resection, however, remains controversial as most patients will have excellent long-term prognosis and because some of the standard staging and prognostic information are not available at the time of surgical resection. The different staging and risk group definitions for thyroid carcinoma are not superior to the Tumor-Node-Metastasis classification of the American Joint Commission in Cancer (AJCC), which is universally available and accepted and should be used to report treatment outcomes. Recent advances in the molecular pathogenesis of thyroid malignancy will help identify high-risk patients who would benefit from aggressive surgical resection and adjuvant treatment.

Biomarkers, Tumor↗

PubMed1998

Critical assessment of the head and neck clinical skills of general surgery residents.

Head and neck surgery is an important part of general surgery. There is, however, little information about the quality of residents' clinical skills in this important field. In an Objective Structured Clinical Examination (OSCE), residents encounter multiple patients with various clinical problems and are rated by faculty members using objective criteria. This study was undertaken to assess the head and neck surgery skills of a group of general surgical residents. Fifty-one general surgery residents examined the same nine patients with head and neck disease. Faculty members graded each clinical interaction according to preset objective criteria. Both actual (e.g., thyroid nodule, oral cancer follow-up examination) and simulated (e.g., dysphagia) patients were used in the OSCE. The reliability of the examination was assessed by coefficient alpha. The construct validity was determined by a two-way analysis of variance with one repeated measure. The reliability was 0.75 for the clinical examination. Performance varied by level of training: Residents performed at a higher level than interns (p < 0.0001), but overall scores were poor (mean score 55%). Important deficits in skills were identified at all levels of training. It is concluded that more attention should be focused on specific outcome assessments of surgical training programs and on strategies for upgrading the clinical skills of surgical residents.

Analysis of Variance↗

PubMed1998

The effectiveness of the structured clinical instruction module.

BACKGROUND: The Structured Clinical Instruction Module (SCIM) provides students with a structured educational experience related to clinical skills on a single clinical topic. This study examined the effect of the SCIM on students' performances on breast stations in an objective structured clinical examination (OSCE). METHODS: Three student groups each experienced a different type of instruction about breast care and treatment (condition A = lecture; condition B = nine-station SCIM, lecture, and manual; and condition C = five-station SCIM). All students subsequently participated in a surgery OSCE that included standardized patient stations on taking a breast history and performing breast examinations. RESULTS: One-way analysis of variance (ANOVA) tests consistently found that the mean scores of students in conditions B and C were significantly (P < 0.05) higher than those of students in condition A. CONCLUSIONS: These results suggest that the SCIM is an effective patient-based standardized instructional program that enhances the instruction of clinical skills to students.

Analysis of Variance↗

PubMed1998

Physical symptoms, distress, and breast cancer risk perceptions in women with benign breast problems.

Physical symptoms, general and breast cancer-specific distress, and perceived breast cancer risk were assessed in 66 women with benign breast problems (BBP) and 66 age-matched healthy comparison (HC) women. BBP women reported significantly greater worry about breast cancer than HC women. Breast symptom incidence and breast cancer risk perceptions were found to mediate group differences in breast cancer worry. Hierarchical regression analyses indicated that perceptions of control over a potential breast cancer prognosis moderate the impact of breast symptoms on reports of breast cancer worry. Implications for risk counseling with BBP women are discussed.

Adult↗

PubMed1998

Advances in the diagnosis and therapy of adrenal tumors.

There continues to be controversy regarding the optimal evaluation and treatment of adrenal tumors. Magnetic resonance imaging, metaiodobenzylguanidine scan, single-photon emission tomography imaging, endoscopic ultrasound, and radiolabeled somatostatin analogues are just a few of the newer imaging techniques being investigated to improve our ability to obtain a specific diagnosis of an adrenal mass. Although the diagnosis and treatment of pheochromocytomas are relatively straightforward, the evaluation and treatment of incidentally discovered adrenal masses is less clear-cut. The management of an incidentaloma is guided by two principle considerations: whether the tumor has hormonal activity, and its malignant potential. In addition to diagnostic advances, refinements continue to be made regarding surgical management of these lesions. Laparoscopic adrenalectomy is fast becoming the procedure of choice for benign-appearing adrenal masses with appropriate indications for operative removal.

Adolescent↗

PubMed1998

The reliability of six faculty members in identifying important OSCE items.

PURPOSE: To measure the agreement among faculty members about the importance of items on a checklist used to grade an objective structured clinical examination (OSCE) station. METHODS: Six faculty members rated the importance of 47 items for an OSCE station in which students took the history of a patient with sore throat and hoarseness. RESULTS: Of the 47 items, the raters independently identified 15 items as very important. The reliability of each individual rater was fair (averaged value of alpha = .63.) The reliability of the mean rating of the six raters was high (alpha = .91). CONCLUSIONS: The results strongly suggest that when a group of faculty members cooperatively identifies the important items to be included in an OSCE checklist, the reliability of the checklist is superior to one created by a single author.

Algorithms↗

PubMed1998

Thyroid lymphoma: is there a role for surgery?

The role of surgery in the treatment of Stage I and II non-Hodgkin's thyroid lymphoma (NHTL) is not well defined. At our institution, we have treated seven patients (six women and one man) with NHTL during the past 6 years. Three patients (43%) had a prior history of thyroid disease, usually lymphocytic thyroiditis. Clinical symptoms included a rapidly enlarging neck mass (86%), dysphagia (71%), dyspnea (71%), and hoarseness (71%). Five patients (71%) had hypothyroidism; one patient, hyperthyroidism; and one patient, normal thyroid function. Five patients underwent fine-needle aspiration (FNA) at our institution. In three instances, FNA results were indicative of NHTL; the remaining FNA tests yielded no diagnosis. Surgical procedures were varied: incisional biopsy (n = 4), limited tumor debulking with tracheostomy (n = 2), and thyroidectomy (n = 1). Each of the seven patients was found to have large cell lymphoma. Treatment consisted of combination chemotherapy with consolidative irradiation. All tumors dramatically decreased in size soon after the initiation of therapy. One patient refused radiotherapy. All patients except one are still alive (median follow-up, 24 months). In conclusion, 1) a diagnosis of NHTL, although rare, should be considered when patients have rapidly growing goiters; 2) FNA is a useful first step in diagnosing NHTL; 3) NHTL is exquisitely sensitive to both chemotherapy and radiation; 4) surgical intervention is generally confined to incisional biopsy with occasional limited pretracheal tumor debulking; and 5) when a biopsy is obtained from a patient suspected of having NHTL, immediate processing by the pathologist is recommended so that material can be obtained for special studies as needed.

Aged↗

PubMed1998

Assessing residents' clinical performance: cumulative results of a four-year study with the Objective Structured Clinical Examination.

BACKGROUND: The Objective Structural Clinical Examination (OSCE) is an objective method for assessing clinical skills and can be used to identify deficits in clinical skill. During the past 5 years, we have administered 4 OSCEs to all general surgery residents and interns. METHODS: Two OSCEs (1993 and 1994) were used as broad-based examinations of the core areas of general surgery; subsequent OSCEs (1995 and 1997) were used as needs assessments. For each year, the reliability of the entire examination was calculated with Cronbach's alpha. A reliability-based minimal competence score (MCS) was defined as the mean performance (in percent) minus the standard error of measurement for each group in 1997 (interns, junior residents, and senior residents). RESULTS: The reliability of each OSCE was acceptable, ranging from 0.63 to 0.91. The MCS during the 4-year period ranged from 45% to 65%. In 1997, 4 interns, 2 junior residents, and 2 senior residents scored below their group's MCS. MCS for the groups increased across training levels in developmental fashion (P < .05). CONCLUSIONS: Given the relatively stable findings observed, we conclude (1) the OSCE can be used to identify group and individual differences reliably in clinical skills, and (2) we continue to use this method to develop appropriate curricular remediation for deficits in both individuals and groups.

Clinical Competence↗

PubMed1997

Efficacy of postoperative radiation therapy for recurrent squamous cell carcinoma of the head and neck.

PURPOSE: Postoperative radiation therapy (RT) following surgical resection is often the recommended treatment for recurrent squamous cell carcinoma (SCC) of the head and neck. Despite common use, there are few published series evaluating such a management approach. METHODS AND MATERIALS: We evaluated the efficacy of postoperative RT in 31 patients with recurrent SCC of the head and neck treated between 1981 and 1993. None of the patients had prior RT. All had complete resection of recurrent gross disease and no distant metastases. Maximum postoperative RT doses ranged from 59.4-70 Gy (median = 66 Gy). RESULTS: The 5-year disease-specific survival (DSS) and local control (LC) rate for all patients were 32 and 46%, respectively. Several prognostic factors were analyzed including site and stage of original primary tumor, disease-free interval, site of recurrence, status of surgical margins, and dose. Only site of recurrence significantly influenced both DSS and LC. Patients whose recurrence was limited to previously undissected tissue had 5-year DSS and local control rates of 60 and 74%, respectively, as compared to 19 and 29%, respectively, for patients whose recurrence was within previously dissected tissue (p = 0.05). CONCLUSIONS: Patients with recurrent SCC of the head and neck treated with standard postoperative RT following surgical resection do relatively well if the recurrence is within previously undissected tissue (i.e., nodal only); however, patients whose recurrence is within previously dissected tissue do poorly. Every effort to prevent locoregional disease recurrence at the time of primary therapy should be emphasized.

Adult↗

PubMed1997

Measuring the ability of residents to manage oncologic problems.

BACKGROUND: An OSCE was used to measure the ability of a cohort of residents to manage oncologic problems. METHODS: Nine oncologic clinical problems were presented to 56 surgical residents. Each problem contained a 5-minute data-gathering period (DGP) and a 5-minute data-interpretation period (DIP). A performance score was determined for each resident for each problem. Reliability was estimated by coefficient alpha; validity, by the construct of experience. Wilks's lambda criterion was used to determine whether training level could be identified by OSCE performance. RESULTS: The DGP reliability was 0.80; the DIP, 0.49. Senior residents performed significantly better than junior residents (P = 0.0001), who performed significantly better than interns (P = 0.0009). Of the residents, 62% were competent on the DGP, but only 21% on the DIP. Important deficits in knowledge and clinical skills were apparent at all levels of training. CONCLUSION: The education and evaluation of residents in oncology need improvement.

Clinical Competence↗

PubMed1997

Ward evaluations: should they be abandoned?

Even in the era of the objective structured clinical examination (OSCE), the predominant method of resident evaluation is the faculty ward evaluation (WE), despite many concerns about its reliability. The aim of this study was to determine the value of the WE as a measurement of clinical competence in terms of both reliability and validity. In a one-year period, surgery faculty members evaluated 72 residents. An average of 7 faculty members evaluated each resident. The evaluation form contained 10 specific performance ratings and an overall evaluation. Inter-rater reliability of the overall performance ratings was calculated by using the intraclass correlation. Validity of the WE was evaluated in four ways. Inter-rater reliability of the overall performance rating was 0.82; the reliability of a single overall rating was 0.39. (1) A discriminant function analysis indicated that residents at advanced levels of training received more positive evaluations than residents at less advanced levels (P < 0.0001). (2) The overall rating was significantly correlated (r = 0.55, P < 0.0001) with the overall score of a concurrent OSCE. (3) A factor analysis showed high correlations among the items, indicating a lack of discrimination between the skills. (4) Overall ratings were insensitive to performance deficiencies. Only 1.3% of the ratings were unsatisfactory or marginal. The WE was sufficiently reliable to estimate the faculty's view of each resident. The fact that the ratings tended to differentiate residents by level of training and that ratings significantly correlated with the OSCE provides strong evidence of their validity. However, factor analysis indicated that the faculty members were making one global, undifferentiated judgment and that these ratings did not identify deficient performance skills. We conclude that ward evaluations have a place in the assessment of residents.

Clinical Competence↗

PubMed1997

Residents' evaluation of a problem-based learning curriculum in a general surgery residency program.

METHODS: To determine residents' satisfaction with problem-based learning and its tutors, to determine how residents prepare for sessions, and to identify the characteristics of both effective sessions and tutors, we analyzed 132 evaluations from 24 residents who completed 1 or more of the 9 cases presented during the first 9 months of our program. The 38-item evaluation questionnaire asked residents to rate tutor characteristics, various aspects of the sessions, and methods used to prepare for the sessions. RESULTS: Residents were well satisfied with the problem-based learning sessions and with the logistics of our program; they found the overall quality of the tutor more important than that of the case; they valued an active, thought-provoking tutor more than a traditional facilitator; and they most often used standard textbooks to prepare for the sessions. CONCLUSIONS: Problem-based learning is a practical, enjoyable graduate curricular vehicle when implemented with well-written cases and active tutors.

Adult↗

PubMed1997

The multidisciplinary structured clinical instruction module as a vehicle for cancer education.

BACKGROUND: The Structured Clinical Instruction Module (SCIM) modifies the Objective Structured Clinical Examination (OSCE) for teaching purposes. This study determined the effectiveness of a breast cancer SCIM in enhancing residents' clinical skills. METHODS: Twenty-five residents, 15 faculty members, and 12 breast cancer patients (simulated and actual) participated in the multistation, multidisciplinary SCIM. Afterward, faculty members, residents, and patients evaluated the SCIM. Residents completed an 18-item self-assessment of their skills before and after the SCIM. RESULTS: All residents, faculty members, and patients rated the SCIM as either outstanding or above average as an educational experience. The residents' self-assessments of their skills were significantly higher after the SCIM than before. CONCLUSIONS: This study shows that residents are aware of their deficiencies in breast cancer management. The SCIM provides an excellent format for residents to improve their clinical skills.

Attitude of Health Personnel↗

PubMed1997

Improving residents' clinical skills with the structured clinical instruction module for breast cancer: results of a multiinstitutional study. Breast Cancer Education Working Group.

BACKGROUND: The purpose of this study was to determine, in a multiinstitutional setting, the effectiveness of the structured clinical instruction module (SCIM) as an instructional format for surgical residents. METHODS: The breast cancer SCIM is an abbreviated (3-hour) clinical skills course that places residents in realistic clinical settings. The curriculum encompasses all aspects of breast cancer patient assessment. The SCIM was administered to 137 residents at five institutions. Sixty-six faculty members and 52 patients participated. All participants were surveyed with multiitem questionnaires. The residents were also asked to perform a self-assessment of their skills before and after the SCIM. RESULTS: The SCIM was delivered at all institutions without difficulty. All participants rated the SCIM highly (from "above average" to "outstanding"). Mean ratings (on a 5-point scale) for the overall effectiveness of the SCIM as an educational format follow: [table: see text] The pretest mean (on a 5-point scale) on the self-assessment was 2.46 ("less than competent"); the posttest mean was 3.54 ("more than competent") (p < 0.0001). CONCLUSIONS: Residents are acutely aware of their deficiencies in understanding breast cancer. The SCIM is a standardized, reproducible, portable, and effective educational vehicle.

Breast Neoplasms↗

PubMed1997

Cancer pain education among family physicians.

This study used performance-based testing (objective structured clinical evaluation, OSCE) to evaluate the skills of family physicians in assessing and managing the severe pain of a cancer patient, and evaluated a new method of education about the management of cancer pain. Twenty-four primary care physicians completed a detailed pain assessment of the same standardized cancer pain patient (Part A). A proctor observed the interviews and rated the physicians on a variety of pre-determined items believed to be important for pain assessment. The physicians were then allowed 5 min to answer management questions about the patient's cancer pain (Part B). After reviewing each physician's performance on Parts A and B, the proctor provided immediate feedback and instruction (Part C) on basic principles of cancer pain assessment and management. On average, the primary care physicians asked 52% (+/-4.5%) of the indicated questions of a detailed pain assessment. Performance was poorest in asking about previous pain history, temporal pattern of pain, and pain intensity. Performance on the pain assessment was best for eliciting pain location and pain-relieving factors. Primary care physicians obtained mean scores of 36% (+/-3%) on Part B of the OSCE. Although opioid therapy was frequently prescribed, only 42% of prescriptions were for regular administration. Performance on Parts A and B correlated poorly with years in practice, and older physicians tended to perform a less detailed pain assessment than their younger colleagues. Most physicians enjoyed participating in this instructional formal and believed that the proctor feedback increased the educational value of the module. The results of our study suggest that many family physicians may be inadequate in their clinical assessment and management of cancer pain. Our study supports the need for continuing education in cancer pain management, regardless of years in practice. Further study should evaluate the effects of different educational programs on clinical practice in patient care.

Education, Medical, Graduate↗

PubMed1997

Residents' management of the symptoms associated with terminal cancer.

The principal aim of palliative care is to bring symptomatic relief to patients with progressive disease. Residents graduating from a university general surgery training program should be competent to manage common symptoms associated with advanced cancer. This study used performance-based testing to evaluate the skills of resident physicians in managing common symptoms of a patient with advanced cancer. Thirty-three resident physicians (PGY 1 to 6) were presented with four clinical symptoms of a patient with advanced cancer: (1) nausea and vomiting associated with regular morphine use; (2) lack of appetite in the last weeks of life of a terminally ill patient; (3) constipation associated with codeine analgesia; and (4) dyspnea associated with diffuse lung metastases. The management plan for the symptom problems was evaluated by using a predefined checklist. A significant number of residents showed deficits in the management of common symptoms of advanced cancer. Scheduled dosing of antiemetics was infrequently prescribed for opioid-related nausea and vomiting. Most physicians inappropriately managed lack of appetite by using forced feeding. Opioids were infrequently used in the management of terminal dyspnea. The absence of difference in scores between junior and senior residents suggests that adequate management of the symptoms of terminal cancer is not being effectively taught in postgraduate training programs.

Anorexia↗

PubMed1997

Diagnosis and management of pheochromocytoma.

Pheochromocytomas are rare endocrine tumors. They can be associated with a wide variety of symptoms, although hypertension is the most consistent clinical sign. Ultrasonography is very effective in localizing these tumors, but extra-adrenal pheochromocytomas are best diagnosed with 131I-metaiodobenzylguanidine scanning. Extensive investigation is ongoing to determine markers for the presence of these tumors and diagnostic tests that localize the site of pheochromocytomas, with extensive research at the molecular level. New surgical techniques are being employed, particularly laparoscopic adrenalectomy. Finally, complications of pheochromocytomas are discussed in several papers; the primary concern is cardiac problems.

Adrenal Gland Neoplasms↗