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Objective At present, neither the American College of Surgeons (ACS) nor the Society for Vascular Surgery (SVS) provides curriculum recommendations for medical students rotating on a vascular surgery service. We sent a targeted needs assessment to vascular surgeons across the country in order to investigate the need for a structured curriculum for medical students participating in a vascular surgery rotation during their clinical clerkships. Methods The survey was developed with input from medical students, vascular surgeons, and medical educators. Respondents were identified from the Fellowship and Residency Electronic Interactive Database (FREIDA). The needs assessment was sent to program directors of vascular residencies and fellowships and to other vascular surgery educators. The survey collected data regarding the existing vascular surgery curriculum at the respondent's institution, the need for a standardized curriculum, desired experiences for medical students, and important vascular topics for medical students to cover while on rotation. Results Responses were obtained from 50 of the 146 surveyed individuals (response rate = 34.2%). Forty-eight respondents (96%) worked in an academic hospital or academic affiliated hospital. With regard to the existing vascular surgery curriculum, only twenty-eight respondents (61%) indicated that they had a curriculum approved by the surgery clerkship director. Thirty-seven respondents (77.1%) said there were at least goals and objectives for students on the vascular surgery service, and 29 respondents (60.4%) indicated that there was dedicated time for didactic sessions. Only 17 respondents (35.4%) indicated students gave a case presentation on the service. Twenty-nine respondents (63%) agreed or strongly agreed that there should be a standardized vascular curriculum for medical students. When asked to rank nine topics from most important to least important for students to learn, respondents ranked peripheral arterial disease, aortic disease, and carotid disease highest. Simulation experience was most frequently indicated as a desired addition to the curriculum, and only 16 respondents (33.3%) reported opportunities for vascular surgery specific simulation experiences. Conclusions This study identified the lack of an existing structured curriculum for medical students, the desire for a standardized curriculum, and key topics and experiences that are felt to be important for students to cover. With this information in hand, vascular educators have the potential to enhance the learning experience of medical students rotating through the service by developing a standardized curriculum.

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 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.

Brain growth and function are regulated by insulin-like growth factors I and II (IGF-I and IGF-II) but also by IGF-binding proteins (IGFBPs), including IGFBP-2. In addition to modulating IGF activities, IGFBP-2 interacts with a number of components of the extracellular matrix and cell membrane via a Cardin–Weintraub sequence or heparin binding domain (HBD1). The nature and the signalling elicited by these interactions are not fully understood. Here, we examined transgenic mice (H1d-hBP2) overexpressing a mutant human IGFBP-2 that lacks a specific heparin binding domain (HBD1) known as the Cardin–Weintraub sequence. H1d-hBP2 transgenic mice have the genetic background of FVB mice and are characterized by severe deficits in brain growth throughout their lifetime (p < 0.05). In tissue lysates from brain hemispheres of 12–21 day old male mice, protein levels of the GTPase dynamin-I were significantly reduced (p < 0.01). Weight reductions were also found in distinct brain regions in two different age groups (12 and 80 weeks). In the younger group, impaired weights were observed in the hippocampus (− 34%; p < 0.001), cerebellum (− 25%; p < 0.0001), olfactory bulb (− 31%; p < 0.05) and prefrontal cortex (− 29%; p < 0.05). At an age of 12 weeks expression of myelin basic protein was reduced (p < 0.01) in H1d-BP-2 mice in the cerebellum but not in the hippocampus. At 80 weeks of age, weight reductions were similarly present in the cerebellum (− 28%; p < 0.001) and hippocampus (− 31; p < 0.05). When mice were challenged in the elevated plus maze, aged but not younger H1d-hBP2 mice displayed significantly less anxiety-like behaviour, which was also observed in a second transgenic mouse model overexpressing mouse IGFBP-2 lacking HBD1 (H1d-mBP2). These in vivo studies provide, for the first time, evidence for a specific role of IGFBP-2 in brain functions associated with anxiety and risk behaviour. These activities of IGFBP-2 could be mediated by the Cardin–Weintraub/HBD1 sequence and are altered in mice expressing IGFBP-2 lacking the HBD1.

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

Background Poor communication is a known contributor to disasters in aviation and medicine. Crew members are trained to raise concerns about superiors' plans, yet literature exploring surgical trainees' responses to analogous concerns is sparse. Methods Surgical residents were interviewed about approaches to concerns about supervisors' clinical decisions using a semistructured guide. Emerging themes were developed using the constant comparative method. Results Eighteen residents participated. They expressed a tension between conceding ultimate decision-making authority to supervisors and prioritizing obligations to the patient. Systemic (eg, departmental culture, resident autonomy), supervisor (eg, approachability), trainee (eg, knowledge), and clinical (eg, risk of harm, evidence quality) factors influenced the willingness to voice concerns. Most described verbalizing concerns in question form, whereas some reported expressing concerns directly. Conclusions Several factors affect surgical trainees' management of concerns about supervisors' plans. No consistent method is used. A tailored curriculum addressing strategies to raise concerns appears warranted to optimize patient safety.

Introduction Residents learn technical and communication skills during training and practice both concurrently during awake surgical procedures. Patients have expressed mixed views on resident involvement in their surgical care, making this context challenging for residents to navigate. We sought to qualitatively explore resident perspectives on teaching during awake surgical procedures. Methods Residents in Urology, Obstetrics and Gynecology, and General Surgery who had been exposed to 10 or more awake surgical procedures were recruited for recorded focus groups at the University of Chicago. Recordings were transcribed, coded, and reviewed by 3 researchers using the constant comparative method until thematic saturation was reached. Results Twenty-five residents participated in 5 focus groups. Residents identified positive educational techniques during awake surgery including preprocedural communication, explaining teaching and the resident role, whispering/nonverbal communication, involving the patient in education, and confident educator. Residents described challenges and failures in education, including hesitating to ask questions, hesitating to correct a learner, whispering/nonverbal communication, and taking over. In discussing informed consent during awake procedures, some residents described that the consent process should or did change during awake procedures, for example, to include more information about the resident role. Conclusions Residents participating in awake surgical procedures offer new insights on successful techniques for teaching during awake surgery, emphasizing that good communication in the procedure room starts beforehand. They also identify challenges with teaching in this context, often related to a lack of open and clear communication.

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.

Medical Education 2011:45: 939–945 CONTEXT Conflict management has been identified as an essential competence for surgeons as they work in operating room (OR) teams; however, the optimal approach is unclear. Social science research offers two alternatives, the first of which recommends that task-related conflict be managed using problem-solving techniques while avoiding relationship conflict. The other approach advocates for the active management of relationship conflict as it almost always accompanies task-related conflict. Clarity about the optimal management strategy can be gained through a better understanding of conflict transformation, or the inter-relationship between conflict types, in this specific setting. The purpose of this study was to evaluate conflict transformation in OR teams in order to clarify the approach most appropriate for an educational conflict management programme for surgeons. METHODS A constructivist grounded theory approach was adopted to explore the phenomenon of OR team conflict. Narratives were collected from focus groups of OR nurses and surgeons at five participating centres. A subset of these narratives involved transformation between and within conflict types. This dataset was analysed. RESULTS The results confirm that misattribution and the use of harsh language cause conflict transformation in OR teams just as they do in stable work teams. Negative emotionality was found to make a substantial contribution to responses to and consequences of conflict, notably in the swiftness with which individuals terminated their working relationships. These findings contribute to a theory of conflict transformation in the OR team. CONCLUSIONS There are a number of behaviours that activate conflict transformation in the OR team and a conflict management education programme should include a description of and alternatives to these behaviours. The types of conflict are tightly interwoven in this setting and thus the most appropriate management strategy is one that assumes that both types of conflict will exist and should be managed actively.

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, alpha/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.

Recent studies suggest that insulin-like growth factor-binding protein-2 (IGFBP-2) affects both growth and metabolism. Whereas negative growth effects are primarily due to negative interference with IGF-I, the mechanisms for metabolic interference of IGFBP-2 are less clear. As we demonstrate, overexpression of IGFBP-2 in transgenic mice is correlated with a decelerated clearance of blood glucose after oral administration. IGFBP-2 carries an integrin-binding domain (RGD motif), which has been shown to also mediate IGF-independent effects. We thus asked if higher serum levels of IGFBP-2 without an intact RGD motif would also partially block blood glucose clearance after oral glucose application. In fact, transgenic mice overexpressing mutated IGFBP-2 with higher levels of IGFBP-2 carrying an RGE motif instead of an RGD were not characterized by decelerated glucose clearance. Impaired glucose tolerance was correlated with lower levels of GLUT4 present in plasma membranes isolated from muscle tissues after glucose challenge. At the same time, activation of TBC1D1 was depressed in mice overexpressing wild-type but not mutated IGFBP-2. Although we do not have reason to assume altered activation of IGF-I receptor or PDK1/Akt activation in both models, we have identified increased levels of integrin-linked kinase and focal adhesion kinase dependent on the presence of the RGD motif. From our results we conclude that impaired glucose clearance in female IGFBP-2 transgenic mice is dependent on the presence of the RGD motif and that translocation of GLUT4 in the muscle may be regulated by IGFBP-2 via RGD-dependent mechanisms.

Summary Impaired growth is often associated with an extension of lifespan. However, the negative correlation between somatic growth and life expectancy is only true within, but not between, species. This can be observed because smaller species have, as a rule, a shorter lifespan than larger species. In insects and worms, reduced reproductive development and increased fat storage are associated with prolonged lifespan. However, in mammals the relationship between the dynamics of reproductive development, fat metabolism, growth rate, and lifespan are less clear. To address this point, female transgenic mice that were overexpressing similar levels of either intact (D‐mice) or mutant insulin‐like growth factor‐binding protein‐2 (IGFBP‐2) lacking the Arg‐Gly‐Asp (RGD) motif (E‐ mice) were investigated. Both lines of transgenic mice exhibited a similar degree of growth impairment (−9% and −10%) in comparison with wild‐type controls (C‐mice). While in D‐mice, sexual maturation was found to be delayed and life expectancy was significantly increased in comparison with C‐mice, these parameters were unaltered in E‐mice in spite of their reduced growth rate. These observations indicate that the RGD‐domain has a major influence on the pleiotropic effects of IGFBP‐2 and suggest that somatic growth and time of sexual maturity or somatic growth and life expectancy are less closely related than thought previously.

IGFBP-2 affects growth and metabolism and is thought to impact on energy homeostasis and the accretion of body fat via its heparin binding domains (HBD). In order to assess the function of the HBD present in the linker domain (HBD1) we have generated transgenic mice overexpressing mutant human IGFBP-2 lacking the PKKLRP sequence and carrying a PNNLAP sequence instead. Transgenic mice expressed high amounts of human IGFBP-2, while endogenous IGFBP-2 or IGF-I serum concentrations were not affected. In both genders we performed a longitudinal analysis of growth and metabolism including at least 4 separate time points between the age of 10 and 52 weeks. Body composition was assessed by nuclear magnetic resonance (NMR) analysis. Food intake was recorded by an automated online-monitoring. We describe negative effects of mutant human IGFBP-2 on body weight, longitudinal growth and lean body mass (p

Objective: Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, particularly in the face of contralateral internal carotid artery (ICA) occlusion. We examined the results of CEA with continuous electroencephalography in patients without and with contralateral ICA occlusion. Design and Setting: We reviewed 564 primary CEAs with routine electroencephalography and general anesthesia performed between April 1, 1989, and March 31, 1999, in a community teaching medical center. Main outcome measures were perioperative stroke, temporary lateralizing neurologic deficit, and death. Shunts were placed primarily for significant electroencephalographic changes after carotid clamping but also selectively for contralateral ICA occlusion, prior stroke, or surgeon choice. CEA was performed for asymptomatic disease in 35% of cases. Results: Significant electroencephalographic changes occurred in 16% versus 39% (P

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.

The purpose of this study is to identify factors that predict outcome after intervention for early (

Objectives: Carotid endarterectomy has been shown to be of clear benefit to selected patients. However, recent trials of carotid endarterectomy versus best medical therapy have excluded octogenarians, and some authors have suggested that carotid endarterectomy would have an unfavorable cost-benefit relationship in octogenarians. We compared patients and results for carotid endarterectomy in octogenarians and younger patients. Methods: We reviewed the results for 582 primary carotid endarterectomies (90 in octogenarians and 492 in younger patients) performed in 528 patients between February 1, 1985, and January 31, 1998 (all data were collected prospectively for the most recent 301 carotid endarterectomies). Conventional surgical technique was used with general anesthesia, selective shunting, and selective patching. Main outcome measures were perioperative and late ipsilateral stroke and death. Results: The two groups were similar with respect to indications for carotid endarterectomy and patient characteristics, except that octogenarians were more likely to have histories of congestive heart failure or hypertension and less likely to have histories of smoking or chronic lung disease. Carotid endarterectomy was performed for asymptomatic disease in 27% of the octogenarians and 33% of the younger patients ( P =.31). Stenosis was ≥80% in 90% of the octogenarians and 78% of the younger patients ( P =.014). Perioperative strokes, all of which were ipsilateral, occurred in one octogenarian (1.1%) and eight younger patients (1.6%, P = 1.00). No octogenarians and two younger patients died within 30 days of surgery ( P = 1.00). Length of stay and direct costs associated with carotid endarterectomy were similar for octogenarians and younger patients. Late strokes occurred in two octogenarians (one ipsilateral) and four younger patients (two ipsilateral). Life table estimates of freedom from ipsilateral stroke at 2 years were 98% and 97% for octogenarians and younger patients, respectively (log-rank P =.69), and life table estimates of patient survival at 4 years were 81% and 89% for octogenarians and younger patients, respectively ( P =.11). Octogenarians represented an increasing fraction of the carotid endarterectomies performed during the study period. Conclusions: Octogenarians selected for carotid endarterectomy were similar to younger patients with respect to indications for carotid endarterectomy and comorbidities. Early mortality, early and late neurologic outcome, complications, and resource utilization were similar for the two groups, and more than 75% of octogenarians survived 4 years after undergoing carotid endarterectomy. Cost-benefit analyses for carotid endarterectomy, which are highly sensitive to expected patient survival, might not be pertinent to individual patient situations. Intellectually intact octogenarians without unusually severe comorbidities are good candidates for and should be offered the benefits of carotid endarterectomy. (J Vasc Surg 2000;31:927-35.)

Purpose: The objective of this study was to compare clinical outcome and costs for two widely used treatment strategies for hemodialysis graft thrombosis. Methods: During a 4-year period, 80 patients with thrombosed dialysis grafts were randomly assigned to surgical thrombectomy with or without graft revision (SURG) or thrombolytic therapy with urokinase with the pulse-spray technique (ENDO), with adjunctive percutaneous transluminal angioplasty as indicated. All the procedures were performed in an endovascular operating suite with fistulography. The clinical and cost data were tabulated, and the outcome was analyzed with the life-table method. Results: Fifty-six women and 24 men ranged in age from 33 to 90 years (mean, 63.7 years). The patients had undergone a mean of 2.8 prior access procedures in the ipsilateral extremity. All the grafts were upper extremity expanded polytetrafluoroethylene grafts. Lesions that were presumed to be the primary cause of graft thrombosis were identified in 73 of 80 grafts, and 60 of these were at the venous anastomosis. The procedure time averaged 99 minutes for the patients in the SURG group and 113 minutes for the patients in the ENDO group (P = .12). Eleven patients in the ENDO group crossed over to surgical revision as compared with two patients in the SURG group who required adjunctive percutaneous transluminal angioplasty (P = .005). The mean cost of treatment (including room and supply costs but not professional fees) was significantly higher for the ENDO group than for the SURG group ($2945 vs $1512; P < .001). There were no procedure-related complications in either group. At a median follow-up time of 24 months, there was no difference in primary or assisted primary patency between groups, which averaged 6 and 7 months, respectively. Conclusion: Although thrombolytic therapy combined with endovascular treatment can extend the life of dialysis grafts with results similar to surgical revision, there is a high rate of technical failure necessitating surgery and a substantially higher cost for thrombolysis. (J Vasc Surg 1999;30:1016-23.)

Superior vena cava (SVC) syndrome was first described in 1757 by Hunter, who described a patient with a syphilitic thoracic aortic aneurysm causing obstruction of the SVC. During that era, the most common cause of SVC syndrome was infectious, but over time, the spectrum of causes has changed, and, currently, most cases are secondary to malignancy. Obstruction of the SVC is a clinical entity that affects approximately 15,000 people per year in the United States. Because the vena cava is a thin-walled, low-pressure vessel, it is particularly prone to mechanical obstruction, and this fact, combined with its location in close proximity to lymph nodes, lung, and major vascular structures, explains the development of the syndrome in patients with a wide variety of intrathoracic diseases.

Retrievable inferior vena cava (IVC) filters are appealing because they are designed for either retrieval or long-term use. However, the long-term safety of indwelling retrievable compared with permanent filters is largely unknown. This study was undertaken to compare complication rates and types associated with indwelling retrievable and permanent filters.A retrospective review identified 1234 IVC filters (449 retrievable, 785 permanent) placed in 1225 patients from 2005 to 2010. Patients with retrievable filters removed electively were excluded, yielding 383 patients in whom retrievable filters were left in place. These patients with indwelling retrievable filters were compared with those with permanent filters with respect to demographics, comorbidities, survival, and complication rate and type. Differences in patient characteristics were tested with χ(2), Fisher exact, and Wilcox rank-sum tests. Logistic regression was used to identify predictors of complications. Because there were differences in the characteristics of the patients with indwelling retrievable filters and permanent filters, an additional propensity score analysis was performed yielding 319 patients in each group.Patients with indwelling retrievable filters were younger than those with permanent filters (mean age, 62 vs 75 years; P .0001). Patients with indwelling retrievable filters had significantly more complications than those with permanent filters (9% vs 3.0%; P .0001) after mean follow-up of 20 months (range, 0-86 months). Filter complications were categorized as thrombotic, device related, or systemic. While the most common complication type with both indwelling retrievable and permanent filters was thrombotic (4.4% vs 2.2%; P = NS), device-related complications were significantly more common with indwelling retrievable filters compared with permanent filters (3% vs 0.5%; P .006). Propensity score analysis demonstrated that even in the matched groups, indwelling retrievable filters were associated with significantly more complications than permanent filters (9.1% vs 3.5%; P = .0035).Indwelling retrievable IVC filters were associated with significantly higher complication rates than permanent filters. Both thrombotic and device-related complications were more common with retrievable filters. Long-term use of retrievable filters should be avoided, especially considering the younger population in whom they are placed.

Background Providing midclerkship feedback to identify students at risk for failing is a Liaison Committee on Medical Education standard. Objective criteria for that feedback are critical. The investigators studied the value of a formative midterm (MT) test in identifying students at risk for failing a surgery clerkship. Methods A written midclerkship test, which did not contribute to the final grade, was administered (n = 155). The Bayesian specificity, sensitivity, and predictive values for clerkship failure of low MT score, low global clinical performance rating GCPR, and the combination of low MT and low GCPR were computed. Results Low MT as a predictor of clerkship failure was sensitive (1.0) but not specific (.35). Likewise, low GCPR was sensitive (1.0) but not specific (.31). The combination of low MT and GCPR, however, was both specific (1.0) and sensitive (.87). Conclusions The addition of an MT test to clinical performance ratings can stratify students' risk for clerkship failure.

Purpose Teaching awards have been suggested to serve a variety of purposes. The specific characteristics of teaching awards and the associated effectiveness at achieving planned purposes are poorly understood. A needs analysis was performed to inform recommendations for an Excellence in Teaching Recognition System to meet the needs of surgical education leadership. Method We performed a 2-part needs analysis beginning with a review of the literature. We then, developed, piloted, and administered a survey instrument to General Surgery program leaders. The survey examined the features and perceived effectiveness of existing teaching awards systems. A multi-institution committee of program directors, clerkship directors, and Vice-Chairs of education then met to identify goals and develop recommendations for implementation of an "Excellence in Teaching Recognition System." Results There is limited evidence demonstrating effectiveness of existing teaching awards in medical education. Evidence supports the ability of such awards to demonstrate value placed on teaching, to inspire faculty to teach, and to contribute to promotion. Survey findings indicate that existing awards strive to achieve these purposes and that educational leaders believe awards have the potential to do this and more. Leaders are moderately satisfied with existing awards for providing recognition and demonstrating value placed on teaching, but they are less satisfied with awards for motivating faculty to participate in teaching or for contributing to promotion. Most departments and institutions honor only a few recipients annually. Conclusions There is a paucity of literature addressing teaching recognition systems in medical education and little evidence to support the success of such systems in achieving their intended purposes. The ability of awards to affect outcomes such as participation in teaching and promotion may be limited by the small number of recipients for most existing awards. We propose goals for a Teaching Recognition System and provide guidelines for implementation and evaluation of such systems. Future analysis should study the effectiveness of systems designed using these guidelines in achieving the outlined goals.

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.

Conflict management has been identified as an essential competence for surgeons as they work in operating room (OR) teams; however, the optimal approach is unclear. Social science research offers two alternatives, the first of which recommends that task-related conflict be managed using problem-solving techniques while avoiding relationship conflict. The other approach advocates for the active management of relationship conflict as it almost always accompanies task-related conflict. Clarity about the optimal management strategy can be gained through a better understanding of conflict transformation, or the inter-relationship between conflict types, in this specific setting. The purpose of this study was to evaluate conflict transformation in OR teams in order to clarify the approach most appropriate for an educational conflict management programme for surgeons.A constructivist grounded theory approach was adopted to explore the phenomenon of OR team conflict. Narratives were collected from focus groups of OR nurses and surgeons at five participating centres. A subset of these narratives involved transformation between and within conflict types. This dataset was analysed.The results confirm that misattribution and the use of harsh language cause conflict transformation in OR teams just as they do in stable work teams. Negative emotionality was found to make a substantial contribution to responses to and consequences of conflict, notably in the swiftness with which individuals terminated their working relationships. These findings contribute to a theory of conflict transformation in the OR team.There are a number of behaviours that activate conflict transformation in the OR team and a conflict management education programme should include a description of and alternatives to these behaviours. The types of conflict are tightly interwoven in this setting and thus the most appropriate management strategy is one that assumes that both types of conflict will exist and should be managed actively.

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.

MOST ACADEMIC MEDICAL CENTERS (AMCS) HAVE missions that aim for excellence in 3 areas: education, research, and patient care. For decades, “triple-threat” faculty members were able to substantively contribute to all 3. However, heightened competition for research grants, changes in the health care delivery system, more sophisticated instructional and evaluation methods, and increased requirements to account for time and productivity make it less feasible for individual faculty to significantly contribute to all 3. Instead, faculty members are likely to focus their efforts in 1 or 2 of these areas. Although exceptions exist, physician faculty members focus either on patient care and research or on patient care and education. The problem is that promotion and tenure systems work well for faculty members pursuing the former but not as well for those focusing on the latter. For instance, 1 report found that, compared with research faculty, the odds of holding a higher academic rank were 85% lower for academic clinicians and 69% lower for teacher-clinicians. In another report, faculty devoting more than 50% of their time to clinical care were more likely to be on a nontenure track and more likely to report slower career progress than those devoting less than 50% of their time to clinical care. In a third report, the time to promotion was significantly shorter for physician-scientists (with 80% designated research time) than for clinician-scholars (with 30% research time). If this issue is not resolved, AMCs run the risk that faculty charged with patient care and education will view their contributions as having limited value, which will decrease motivation and reduce incentives for future efforts. In this article, we briefly review the evolution and early promise of faculty promotion and tenure tracks. We explore ways clinician-educators are designated within academic promotion and tenure models, address the value of these faculty to the AMC system and the challenges they face, examine measurement and evaluation issues, and offer suggestions for change. History of Faculty Tracks

BACKGROUND Pauses (wait time) after asking questions in pre-college 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.

OBJECTIVE: A faculty productivity profile system was designed to recognize faculty's contributions to administrative, educational, and research activities. It has long been recognized that clinical faculty receive little recognition or compensation for their efforts in education. Our surgery department previously had in place a recognition program for research achievements, but not for educational contributions. The new system was designed to recognize and reward all aspects of faculty contributions, including education. DESCRIPTION: The faculty productivity profile is a simple Excel document sent to each faculty member once a year. We piloted the program for the first time in 2001, recognizing faculty's contributions for the previous year. The pilot began with the formation of a committee whose first function was to identify all possible opportunities for faculty to participate as educators at our institution. This included giving lectures, participating in faculty development programs, serving as mentors, interviewing student or resident candidates, serving in administrative educational roles (e.g., clerkship or residency director), giving oral exams, or attending conferences and journal club. The committee then developed a point scale assigning each activity or contribution a value on a scale of 0-25. Each activity was then listed on the Excel form. Faculty were to fill in the number of times each activity was performed and this was multiplied by the points to obtain a weighted value. Point values for conferences were determined by percentage of conferences attended for a year (i.e., for grand rounds, those attending 0-49%, 50-75%, 75-90%, and more than 90% received 0, 20, 40, and 60 points, respectively). Points were also assigned for teaching awards and high scores on student and resident evaluations. After approval by the committee and the department chairman, the form was presented at a faculty meeting. Each faculty member then received a floppy disk with the form and was asked to complete the form and attach a supporting copy of his or her CV. The form required only input of numbers or a "yes" or "no." After submission, the clerkship coordinator input additional data from a database of conference attendance and student evaluations. Points were then calculated for each faculty member based upon his or her contributions and each activity's weighted value. A dinner was held to recognize outstanding faculty contributions. All faculty completing the form were invited and recognized and those with outstanding contributions received awards. DISCUSSION: Teaching medical students and residents is a rewarding experience; however, it requires significant time and effort. Faculty who feel their contributions are unrecognized may be more likely to burn out and less likely to continue contributing. We believe it is worthwhile to recognize faculty contributions in all areas, including education. Our pilot program had excellent participation due to the ease of using the form. We believe it has improved faculty morale and willingness to participate. We are continuing the program and plan to evaluate its impact on encouraging continued participation in teaching.

We present the first case of in situ replacement of an infected subclavian artery using superficial femoral vein and the fourth reported case of an infected arterial pseudoaneurysm caused by pseudomonas pseudomallei. Sepsis and hoarseness developed in a 58-year-old man after recent travel to Borneo, Indonesia. Indirect laryngoscopy revealed a paralyzed right vocal cord. Computed tomography and arteriography revealed a 6.5-cm pseudoaneurysm of the proximal right subclavian artery. Blood cultures grew pseudomonas pseudomallei. An abnormal cardiac stress test prompted a coronary angiography, which revealed severe coronary artery disease. The patient underwent coronary artery bypass and in situ replacement of the infected subclavian artery pseudoaneurysm with a superficial femoral vein, along with placement of a pectoralis major muscle flap to cover the vein graft. Operative cultures of the pseudoaneurysm grew pseudomonas pseudomallei. The patient was treated with a 6-week course of intravenous ceftazidime and oral doxycycline and then continued on oral amoxicillin-clavulanate. One week after discontinuing intravenous antibiotics, the patient presented to the emergency department with a rapidly expanding, pulsatile mass in the right supraclavicular space. He was taken emergently to the operating room. After hypothermic circulatory arrest was accomplished, the disrupted vein graft and aneurysm cavity were resected and the subclavian artery was oversewn proximally and distally. Parenteral ceftazidime was continued for 3 months and oral amoxicillin-clavulanate (augmentin) was continued indefinitely. There was no evidence of infection clinically or by computed tomographic scan 2 years later. Although autogenous vein replacement of infected arteries and grafts may be successful in the majority of cases, this strategy should probably be avoided when particularly virulent bacteria such as the organism in this case are present. (J Vasc Surg 2002;35:569-72.)

Recently, contrast arteriography has been challenged as the diagnostic test of choice for lower extremity arterial disease because of its associated morbidity and questionable accuracy in identifying suitable distal outflow arteries. The purpose of this report was to analyze our experience to determine if these concerns were justified. We reviewed 500 consecutive contrast arteriograms performed at our hospital for aortoiliac and lower extremity arterial disease between November 1994 and November 1998. Arteriograms performed in conjunction with therapeutic procedures such as balloon angioplasty, stent placement, and thrombolysis were excluded, leaving 244 diagnostic cases for analysis. Forty-six percent (112) of patients had diabetes mellitus, 14% (34) had an elevated baseline serum creatinine (or =1.5 mg/dL), and an additional 7% (17) were dialysis dependent. Radiologists limited contrast volume by imaging only the symptomatic extremity when appropriate and using digital subtraction techniques as indicated. Our results showed that diagnostic contrast arteriography is associated with an acceptably low morbidity, has an accuracy that is unlikely to be surpassed by other modalities, and remains the diagnostic test of choice for lower extremity arterial disease.

This study was done to review the clinical presentation, surgical management, and prognostic factors for primary gastrointestinal sarcomas.We reviewed medical records of 55 patients who were treated for primary gastrointestinal sarcomas from 1981 through 1996. Mean follow-up time was 32 months.Clinical findings included gastrointestinal bleeding (51%), palpable mass (36%), and abdominal pain (33%). The stomach was the most common site of disease (53%), followed by the small intestine (33%). Tumors were high grade in 76% of patients and low-grade in 24% of patients. Complete resection of all gross disease was accomplished in 35 patients (64%), incomplete resection in 17 patients (31%), and biopsy only in 3 patients (5%). Adjacent organ resection was required in 19 patients (35%). Overall actuarial survival was 22% (median survival, 32 months). Unfavorable prognostic factors were incomplete resection, high-grade histologic features, and tumor size of 5 cm or more (P.05). En bloc resection of contiguous organs did not adversely effect survival. In patients with complete resections, tumor grade was the most important prognostic factor (median survival, 55 months vs 19 months for low-grade vs high-grade tumors; P.05).Aggressive surgical resection, including en bloc resection of locally advanced tumors, appears warranted. Despite complete resections, patients with high-grade tumors remain at risk for recurrence.

Purpose: Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants. Methods: During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2- to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months). Results: No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible. Conclusion: Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation. (J Vasc Surg 2000;31:245-52.)