On Surgical Education

ProgramHighlights:2006 SurgicalEducation Week

The CyberClassroom as anAdjunct to SmallGroup TeachingSessions

Surgeons Behaving Badly?:Professionalismand Role Models inSurgical Education

Winter2006

Focus on Surgical EducationEditorSusan Kepner, M.Ed.

Focus on Surgical Education is the officialpublication of the Association for SurgicalEducation and the Educational Clearing-house. It is published four times a year atSouthern Illinois University School ofMedicine and entered as third-class mailat Springfield, Illinois. Focus is mailed toall members of the Association as shownin the records of the secretary-treasurer.

Institutional memberships are available atthe rate of $400 annually; Individualmemberships are available at $175 annually. Dues should be sent to:

Susan KepnerAssociation for Surgical Education Department of Surgery P.O. Box 19655Springfield, IL 62794-9655

E-mail: skepner@siumed.edu

Design

Scott RichardsonRichardson DesignworksSpringfield, IL

Focus is printed on recycled paper

Library of Congress: sn84-9316ISSN: 0742-9819

Publication Timetable

We encourage all members of theAssociation for Surgical Education to con-tribute to Focus on Surgical Education.Descriptions of programs and research inprogress, education articles, reviews andletters will be considered. Please note thefollowing schedule:

Issue Articles DueSpring 2006 February 1Summer 2006 May 1Fall 2006 August 1Winter 2007 November 1

From the President 1

Foundation News 2

Committee Reports 3

Annual Meeting 12

Educator’s Corner 13

Review of the Literature 16

Just a Byte 22

Book Review 23

Invited Articles 24

ContentsVolume 23 • Number 1 • Winter 2006

Association for Surgical Education Board of Directors • 2005-2006

PresidentDon Jacobs, MDHennepin Co. Medical Centerjacob041@umn.edu

Vice-President & President ElectDon Risucci, Ph.D.New York Medical Collegedonald_risucci@nymc.edu

Vice-PresidentPhilip Wolfson, MDJefferson Medical Collegepwolfson@nemours.org

SecretaryBarry Mann, MDThe Lankenau Hospitalmannb@mlhs.org

TreasurerDavid Rogers, MDSouthern Illinois Universitydrogers@siumed.edu

AJS RecorderThomas Lynch, MDUniversity of Nebraskatlynch@unmc.edu

Chair - Info. TechnologyWalter Pofahl, MDEast Carolina Universitypofahl@mail.ecu.edu

Chair - CurriculumLinda Barney, MDWright State Universitylinda.barney@wright.edu

Chair - Educational ResearchLinnea Hauge, Ph.D.Rush-St. Luke’s Medical Centerlinnea_hauge@rush.edu

Chair - Faculty DevelopmentBarbara Pettitt, MDEmory Universitybpettit@emory.edu

Chair - MembershipDimitri Anastakis, MDUniversity of Torontodimitri.anastakis@uhn.on.ca

Chair - ProgramPatricia Bergen, MDUniversity of Texas-SWpatricia.bergen@UTSouthwestern.edu

Chair - Assessment & EvaluationLorin Whittaker, MDUniversity of Illinois-Peorialdwjrmd@uic.edu

Chair - Nurses in SurgicalEducationBarb Lewis, R.N., M.S.University of Wisconsin - Madisonlewis@surgery.wisc.edu

Chair - Awards CommitteeMary Ann Hopkins, MDNew York Universitymahopkins@med.nyu.edu

Chair - Coordinators of Surgical EducationDoris LeddyColumbia Universitydl642@solumbia.edu

Executive DirectorEducational ClearinghouseGary Dunnington, MDSouthern Illinois Universitygdunnington@siumed.edu

Executive DirectorAssociation for Surgical EducationSusan Kepner, M.Ed.Southern Illinois Universityskepner@siumed.edu

I am writing this as I look outthe window on a beautiful fall dayhere in Minnesota. It’s Halloween,the golf courses remain open, thetrees are gorgeous and I am sup-posed to be writing this for thewinter edition of FOCUS. Now,that is a sobering thought! I nolonger have a great affection forthe deep chill that will be on itsway to Lake Wobegone all toosoon, so I already find myself daydreaming about our annual meet-ing next March in Tucson…thewarmth, the golf, the friends, thegolf…

Okay, I’ve snapped out of it,at least long enough to give youan update on some progress withour ASE strategic plan.

This past month we held amembers meeting in SanFrancisco, at the AmericanCollege of Surgeons AnnualClinical Congress, and passed theASE Bylaws changes that wereproposed at last spring’s annualmeeting and distributed to themembership for comment. Thechanges passed without opposi-tion and set the stage for moreeffective organizational perform-ance. It is up to all of us to takeadvantage of this more “mature”and explicit organizational charteras we pursue our vision: to impactsurgical education globally.

The former ExecutiveCommittee, now known as theASE Board of Directors, met andtook action on many issues impor-tant to our strategic goals: wereviewed and approved a formal

listing of “duties and responsibili-ties” for members of the ASEBoard, and similar “duties andresponsibilities” for committeemembers will be developed andbrought to the Board for approvalnext March; we approved finan-cial support for our AAMC CASrepresentatives to both attend thespring session of that partnerorganization; we approved theconsideration, with APDS, of SaltLake City, San Diego and Seattlefor our 2009 annual meeting (weare heading to Washington DC in2007 and are committed toToronto for 2008); we approved arequest by Wiley to offer dis-counted rates to ASE members fora subscription to Clinical Anatomyin exchange for a gratis ad for theASE in the journal; and weapproved a number of ongoingimportant projects from our committees.

The finances of our organiza-tion remain stable and healthy butour future success will not beassured by the status quo and willrequire growth in membershipand revenues to fund our objec-tives. The Board heard the reportof the Membership Committeefrom Dimitri Anastakis andapproved a number of recommen-dations: marketing ASE participa-tion and membership to other sur-gical subspecialty organizations;develop strategies for improvedrecruitment of students and resi-dents to ASE; offer online mem-bership renewal and support thiswith a dynamic member database

to enhance organizational pro-grams; and implementation of asingle category for members basedon the individual rather than theinstitution. In addition weapproved in concept the establish-ment of a surgical education grandrounds bursary or traveling fellow-ship to allow ASE to supportmembers specifically to representthe organization by offering andpromoting a “visiting educator”program to academic depart-ments. This will be further dis-cussed at our annual meeting inTucson. We committed to developa web-based “exit” questionnairefor non-returning members in aneffort to improve retention ofmembers, and we committed totake a careful look at our currentmember benefits so as to create aclear incentive to join the organi-zation to have access to keyaspects of our work product.David Rogers, ASE Treasurer,reported the recommendations ofhis Ad Hoc Task Force onRevenues and Expenses, estab-lished by the strategic plan. Therecommendations are too numer-ous to itemize here but will beaddressed over the next year aswe target ways to better balanceour corporate finances. Amongthe many important issues will beour future strategies relative tomembership dues and benefits.

We had a healthy discussionregarding our ASE journal affilia-tion and the Board has directedTom Lynch, the ASE Recorder, to Continued on page 2

1F R O M T H E P R E S I D E N T

Strategic ProgressD O N J A C O B S , M D , Hennepin Faculty Associates, Minneapolis, MN

F O U N D A T I O N N E W S2

The ASE Foundation Officershave been in consultation withthe American College of SurgeonsDepartment of Development, nowformally established as theAmerican College of SurgeonsFoundation, to discuss the possi-bility of utilizing their servicesand, more importantly, expertiseregarding advancement initiativesfor the ASE Foundation.

Fred Holzrichter, ChiefDevelopment Officer of the ACSFoundation, recently presented uswith an Advancement ActivityProposal which was presented tothe entire ASE Foundation Board

at our meeting in October in SanFrancisco and was unanimouslyapproved.

One of the first recommenda-tions in this proposal was to namea physician as “Medical Directorof Development.” ASEFoundation President RichardReznick has asked Hollis Merrick,Vice-President, to serve in thiscapacity. He has graciouslyagreed to do so.

The second recommendationthat was made was to establishtwo separate subcommittees toconcentrate efforts to obtain fund-ing from two specific sources:

Individual and Corporate. Dr.Merrick has agreed to serve onboth of these committees as“Medical Director ofDevelopment.” Members of theIndividual subcommittee are:Don Jacobs, MD, Nick Lang,MD, and Michael Stone, MD.Members of the Corporate sub-committee are Bruce Gewertz,MD, James Hebert, MD, andThomas Riles, MD. Dr. Merrickwill be working with these indi-viduals in the coming months tostrategize on funding initiatives. ■

ASE Foundation FormalizesRelationship with ACS FoundationS U S A N K E P N E R , M E D , Executive Director

Jacobs

Continued from page 1

pursue this issue. Our current con-tract with AJS extends through2006. The Board articulated theprinciples and priorities needed toexplore our future options, andthe recommendations from Tom’sassessment will be made to theBoard at the annual meeting nextMarch.

Mike Stone presented a shortsynopsis of the ASE in his reportto the Alliance for ClinicalEducation. This report was, Ithought, particularly well done

and I’ve asked that it be printed inFOCUS and placed on our web-site. I hope that all of our mem-bership will avail themselves ofthe opportunity to learn a bitmore about our organization, itsaccomplishments and goals.

And finally, the Boardreviewed a number of excitingnew partnership opportunities onthe near horizon. We will belooking carefully at these propos-als and sharing more informationwith you on them soon.

Your ASE Vice PresidentsDon Risucci and Phil Wolfsonhave done an outstanding job offacilitating the communication of

our committees with the Boardand I can’t thank them enough fortheir great effort.

One thing remains obvious asI reflect on the ACS meeting andour organization’s efforts: we are adynamic organization of extraor-dinarily talented individuals withalmost unlimited potential. OurBoard’s goal will be to facilitatethe effective expression and com-munication of the creative talentsof this organization and, to theextent possible, remove the barri-ers to our future success. I amprivileged to work with all of youin our common mission. ■

The Curriculum Committeemet during the annual ASE meet-ing in NY and in October duringthe ACS. Barry Mann completedhis term as chair and those respon-sibilities were turned over to LindaBarney. Nominations for vice-chairhave been provided and votingwill occur via e-mail. The follow-ing items were addressed.

Think Outside the Building

Lunch: There appears to be inter-est and commitment to continuingthe project in 2006 for the Tucsonmeeting. Some concerns wereraised regarding diminishing vol-ume of abstract submissions for theevent. An attempt will be madethis year to send requests out early.Conversations have been initiatedregarding publishing the abstractson the web site in a member’s onlyarea so individuals unable to attendmight benefit.

The Resident, the Students

and the Competencies: Projectdetails were introduced by BarryMann who co-chaired this endeav-or with APDS representative PaulaTermuhlen. Each participatinginstitution (28/30) had a student-resident pair who completed apre-meeting assignment involvingdelineating positive and negativeresident-student interactions anddilemmas that challenged a com-petency. These were collated andbest interactions and interactionsto avoid were developed. The pro-gram involved three sessions witha number of facilitators and ran intandem with both ASE/APDSmeetings.

The program seemed to bewell received. Discussions havebeen initiated for consideration ofa similar project involving resi-dents as teachers paired with stu-dents at the 2007 meeting inWashington, D.C.

PowerPoint® Teaching

Module (PPTM) Project: Projectplan and proposed timelines havebeen updated. The goal is forsponsorship through the ASE as aweb-housed downloadable teach-ing tool geared for faculty, espe-cially junior faculty. Initial plan isfor 15-30 problem-oriented case-based modules (structured afterthe ASE problem-oriented Manualof Surgical Objectives). This was notintended to be a comprehensivePowerPoint lecture or text docu-ment but more of a template struc-tured group discussion modulebased on topics that might permitan increasing number of renditionsto develop over time. For example:Abdominal Pain could morph intoAppendicitis, Diverticulitis,Perforated Viscus, and BowelObstruction, etc.) The hope isthat all clerkship students andtheir faculty would have access toa library of basic symptom-orient-ed problems that represent adiverse surgical experience and arewidely available for instructionalpurposes.

Process issues have includedreliable E-mail addresses and afunctional workspace for theexchange of large files with graph-ics. The committee membershiplist has been cleaned up and hope-

fully any interested new memberswill join in. An ASE TEAMIntranet site has been acquired forproject work exchange until adecision can be made as to wherethe final PPTMs will be locatedfor access by the general ASEmembership.

Twelve to 15 modules are cur-rently being revised, beta testedand standardized for format. A trialsession was held at the ACSClinical Congress with volunteerstudent and faculty facilitators.Initial feedback will enable finetuning of the modules that are alsobeing trialed at CurriculumCommittee member institutions.The Committee hopes to roll outPhase 1 of the project in Tucsonwith a workshop that will demon-strate how to utilize the modulesfor team teaching and how to cre-ate new modules for individualsinterested in new case develop-ment. A preliminary evaluationpiece has been created to accompa-ny the modules and enhance feed-back from participating institutions.

New Business: Other discus-sion items for exploration includedABSITE remediation and learningcontracts, formation of a ClerkshipDirectors Committee, and a multi-media surgical curriculum.

The next formal committeemeeting will be in March inTucson during Surgical EducationWeek. The committee welcomesnew members and encourages any-one interested to contact me atlinda.barney@wright.edu. ■

3C O M M I T T E E R E P O R T S

Curriculum Committee ReportL I N D A M . B A R N E Y , M D , Wright State University

It is my pleasure to continueto serve as the ASE representativeto the American College ofSurgeons. The following are thehighlights from the Division ofEducation at the ACS.

The American College ofSurgeons (ACS), Division ofEducation has established a modelfor ACS Accredited EducationInstitutes, which was formallyapproved by the Board of Regentsin June 2005. Two levels ofaccreditation will be offered:Level I or Comprehensive, andLevel II or Basic, as based on threestandards: Learners, Curriculum,and Technical Support andResources. Level I Institutes willoffer the complete range of edu-cational programs to address com-plex knowledge and skills usingstate-of-the-art simulations, simu-lators, and cutting-edge technolo-gies. These Institutes will alsosupport activities involving pre-ceptoring, mentoring, facultydevelopment, and research anddevelopment. Level II Instituteswill offer education to addressfundamental areas in knowledgeand skills. Simple simulations,including standardized patients,bench models, and basic simula-tors may be used by these centers.The program was launched inOctober 2005.

A Personal Digital Assistant(PDA) and Internet-based CaseLog System has been speciallydesigned by the College to sup-

port practice-based learning andimprovement (PBLI), and is in thefinal stages of pilot testing.Surgeons can use their PDAs orthe Internet to record key datapoints of their cases. The nextsteps will involve benchmarkingindividual surgeons’ data with datafrom other surgeons enrolled inthe program, in order to identifylearning needs in Step I of thePBLI cycle. The program isscheduled for formal launch at the2005 Clinical Congress.

Also scheduled for release atthe 2005 Clinical Congress is thenew CD-ROM Professionalism inSurgery: Challenges and Choices.This CD-ROM outlines the keyprinciples underlying professional-ism as presented in two importantdocuments, the ACS “Code ofProfessional Conduct” and“Medical Professionalism in theNew Millennium: A PhysicianCharter.” The core of the pro-gram is a set of 12 realistic casevignettes that present challengingscenarios involving professional-ism issues. Each case vignette isfollowed by a list of possiblecourses of action, and the implica-tions of each choice are then dis-cussed by an expert within thecontext of professionalism. ThisCD-ROM should serve as a valu-able resource for program direc-tors and for practicing surgeonsinterested in pursuing further edu-cation in professionalism. Alsosoon to be released is the DVD

entitled Disclosing Surgical Error:Vignettes for Discussion, a teach-ing tool to stimulate dialogueregarding strategies for communi-cating effectively about surgicalerrors and adverse outcomes withpatients and their families.

The College and the Societyof American Gastrointestinal andEndoscopic Surgeons (SAGES)have established a partnership foran interactive, hands-on educa-tional program called theFundamentals of LaparoscopicSurgery (FLS). Originally devel-oped by SAGES, the FLS Programis an educational module designedto provide surgical residents andpracticing surgeons an opportuni-ty to learn the fundamentals oflaparoscopic surgery in a consis-tent, scientifically accepted for-mat, and to provide a tool thatcan measure cognitive, clinicaland technical skills. Two multi-media CD-ROMs present materi-als on preoperative and intraoper-ative considerations, basic laparo-scopic procedures, postoperativecare and complications, and man-ual skills instruction. The FLStrainer box can be used to prac-tice technical skills, and improvedexterity and psychomotor skills.The assessment component is aproctored, timed examination thatincludes a cognitive componentusing multiple-choice questionsadministered by computer, and amanual skills component adminis-tered using the FLS trainer box. ■

C O M M I T T E E R E P O R T S4

American College of SurgeonsBoard of Governors ReportR I C H A R D R E Z N I C K , M D , M E D , University of Toronto

The Council of AcademicSocieties (CAS) is one of threegoverning councils of theAssociation of American MedicalColleges (AAMC), along with theCouncil of Deans and the Councilof Teaching Hospitals and HealthSystems. The CAS is presentlycomprised of 94 academic soci-eties devoted to biomedical andbehavioral research, medical edu-cation, and patient care. The col-lective membership of these soci-eties includes essentially all facul-ty members and scientists inAmerican medical schoolsengaged in life sciences research,research training, and medicaleducation. The CAS, thoughdiverse in membership, is a pow-erful forum for discussing andexchanging information of com-mon interest to medical schoolfaculty and for evaluating and rec-ommending policy initiatives tothe Association.

Representation: Each CASmember society may designatetwo representatives to the CAS,which meets semiannually; onceduring the AAMC annual meetingin the fall and again in the spring.CAS meetings engage nationalleaders from academe, industry,and government in the delibera-tions of the Council. CAS mem-bers nominate 12 fellow represen-tatives to serve on the CASAdministrative Board, whichmeets three times a year to formu-late the programs of the fullCouncil and to act on its behalf

on Association business and poli-cy initiatives. The CAS elects itsown chairperson. The chair andfive other CAS AdministrativeBoard members represent facultyinterests as members of theAAMC Executive Council (whichfunctions as the Board ofDirectors of the AAMC). Dr.Robert Desnick, Professor andChair, Department of HumanGenetics at Mount Sinai Schoolof Medicine of New YorkUniversity, is the current chair ofthe CAS. He currently serves asCAS representative from theAssociation of Professors ofHuman and Medical Genetics.The CAS Administrative Board isthe key leadership mechanism bywhich the CAS is engaged inAAMC policy and governanceissues. However, all representa-tives are encouraged to serve byparticipating in AAMC panels,such as advisory and award com-mittees. In addition, CAS repre-sentatives assist the CAS and theAAMC by serving on various CASpanels. Some of the current panelsand their activities include:

Basic Science Chairs

Leadership Forum: This entitywas designed to give a voice tothe basic science chair societies.The Forum organized the 2002national meeting of basic sciencechairs. A second national confer-ence has been scheduled forOctober 2005 in Salt Lake City.

Scholarship Dissemination

Project: The goal of this project

is “to provide faculty, staff andstudents in AAMC memberschools, as well as members ofCAS societies, with a clearer pic-ture of the significant changesthat are taking place in the med-ical and biological sciences asscholarly communication movesfrom predominantly print toonline electronic journals.” Inaddition, the results of this effortwill also inform the Association’spolicy deliberations on publishingissues. Gary Byrd, Ph.D., andShelley Bader, Ed.D., are leadingthe project. A Project AdvisoryCommittee was formed andincludes representative editors andpublishers of CAS society jour-nals, academic health scienceslibrary directors, and faculty.Utilizing the services of academichealth center librarians and agraduate student, a database wascompleted with basic bibliograph-ic, pricing and subscription datafor the 101 print and/or electronicjournal titles currently publishedor sponsored by CAS membersocieties. Additional documentshave been collected describingcopyright and other editorial poli-cies associated with each journal.This data has been verified by theCAS societies. The ProjectAdvisory Committee developed anumber of additional categories ofinformation they wanted to inves-tigate about the journal publishingactivities of CAS member soci-eties, including factors influencingacademic library subscribers to

5C O M M I T T E E R E P O R T S

AAMC Council of AcademicSocieties Activities Report

these journals. A web-based sur-vey instrument was composed andtested. Subsequently, a very simi-lar survey instrument composedby the American Association forthe Advancement of Science, theAssociation of Learned andProfessional Scholarly Publishers,and HighWire Press, came to thepanel’s attention. Those groupsagreed to expand their sample toinclude all of the CAS societiesthat publish journals. Dr. Byrdshared the preliminary results ofthe survey with the CASAdministrative Board in Februaryand with the membership inMarch. The final report has justbeen submitted and will bereviewed by the CASAdministrative Board inSeptember.

Task Force on Dual Degree

Students, Programs and Faculty:

The Task Force, chaired by Dr.Lynn Eckhert, was charged withexploring the impact of dualdegree programs on the medicalschool enterprise. The Task Forcewas provided with extensive datafrom the Faculty Roster System(FRS)/ Faculty AdministrativeManagement On-line UserSystem (FAMOUS), the MedicalStudent Records System, theCurriculum Management &Information Tool (CurrMIT), theLCME, and the MatriculatingStudent (MSQ) and Graduate(GQ) Questionnaires. TheCommittee also received variouspublished and reviewed scholarlyworks related to dual degree pro-grams. The Committee also dis-cussed and provided substantivecomments on the Division ofMedical Education’s study ofMD/MPH programs. The Task

Force’s final report provides a scanof the existing data, discusses theTask Force’s observations aboutthe data, and makes some recom-mendations to AAMC staff andgovernance. The CASAdministrative Board accepted theTask Force’s report in February. Itwas transmitted to Dr. JordanCohen and the AAMC ExecutiveStaff for their consideration andwas shared with the membershipat the CAS Spring Meeting.

Task Force on Faculty

Leadership: Last year, the CASChairs Task Force was re-namedthe Task Force on FacultyLeadership. Dr. Lloyd Michenerchairs the Task Force. The TaskForce developed the very usefulChairs Objectives Project report,which outlines the knowledge,values, skills, and attributes of theideal department chair. Chairsearch committees at many med-ical schools have found this a veryuseful resource.

CAS Membership

Committee: CAS membership hasbeen steady at 94 member soci-eties for several years. TheCommittee reviews new applica-tions for membership and recom-mends initiatives to meet theneeds of member societies. Inaddition to committee and taskforce activities, the CAS has beenactive on several other initiatives:

Responsible Conduct of

Research: In 2002, the AAMCwas awarded a $250,000 coopera-tive agreement from the ORI tofund responsible conduct ofresearch (RCR) activities pro-posed and sponsored by academicsocieties. Although not limited toCAS member societies, they clear-ly are the focus of the program.

Subsequently, ORI extended theprogram for four years. To date,more than $682,458 has beenawarded to 32 academic and sci-entific societies. Efforts are under-way to attract better and morerobust proposals to the program.In an effort to kindle the imagina-tion of the CAS member societiesin developing RCR initiatives asmall invitation-only conferencewas held on July 14th. ORI has provided a conference grant toassist us with this project.

CAS Communication

Activities: The CAS listserve is animportant tool for CAS representa-tives. This news service, exclusive-ly for CAS representatives, pro-vides timely and important infor-mation that helps make CAS rep-resentatives among the mostinformed faculty on campus.Additional listserves are operatedfor clinical and basic sciencedepartment chairs, under the CASumbrella. Through the CAS, avariety of valuable AAMCresources have been made availableto faculty leaders. The CAS privateweb page was recently redesignedand features a general openingpage featuring CAS related materi-als and three specialty pages, pro-viding resources to chairs, programdirectors and clerkship directors.These private, password-protectedinternet web sites offer a numberof useful tools, databases, andinformation resources of greatvalue to faculty leaders CAS socie-ty representatives. ■

C O M M I T T E E R E P O R T S6

The Association for SurgicalEducation was formed in 1980 andits 850 members represent over190 medical schools and institu-tions throughout the United Statesand Canada. Its primary goal is topromote the art and science ofeducation in surgery.

Specific objectives include: • developing innovative teachingaids and programs and effectiveeducational interventions; • designing effective faculty development programs for surgicaleducators; • promoting and supportingresearch in the surgical educationfield; • and maintaining an educationalclearinghouse which offers a variety of materials to be used by faculty and students in surgicaleducation.

Since 1980, the goals and theactivities of the ASE have beenpredicated on seeking and promul-gating educationally and scientifi-cally sound answers to the manycomplex questions, issues and con-cerns that are integral to theadvancement of surgical education.

In 1993 the ASE establishedthe ASE Foundation to secure anddistribute grant funds toresearchers, educators and clini-cians interested in investigatingsuch questions and issues. TheFoundation’s mission is to advancethe quality of surgical education inNorth America by raising and dis-seminating funds to underwrite

high impact, innovative researchprojects and educational programsthat will address the critical issuesrelated to surgical education.

One of the Foundation’s mostpopular and recognized initiativesfor this purpose is the SurgicalEducation Research Fellowshipprogram (SERF), a one year,home-site fellowship designed toequip investigators with the skillsand knowledge needed to plan,implement and report researchstudies in the field of surgical edu-cation. Following acceptance intothe SERF program, each fellow iscarefully matched by the pro-gram’s faculty with a SERFAdvisor, a respected and knowl-edgeable researcher who will serveas the fellow’s mentor and consult-ant on their particular project. Amaximum of 12 fellows is acceptedevery year. Funding is providedjointly by a grant from OrthoBiotech, the ASE, and the fellow’stuition.

This unique fellowship affordsthe opportunity for motivatedindividuals to become proficient ina skill set highly valued by theirhome institutions as well as thefield in general. As new knowl-edge relevant to surgical educationis the key to the growth anddevelopment of the discipline,those educators with the requisite,specialized skills and credentialsbecome important members ofdepartments and institutions thatare committed to securing leader-

ship and prominence in the field. In addition, through working

with their SERF Advisor and meet-ing with other SERF participants,fellows establish an invaluable,life-long network of colleagueswho share their career aspirationsand interests.

The Foundation’s Board ofDirectors has established highstandards of research excellencethat grant applicants must achievebefore receiving ASE funding.Because this high standard pro-vides such confidence to corporatepartners, the ASE Foundation hasreceived several generous invest-ments from national corporationsin recent years. Their support,combined with the financialresources of the Association andthe Foundation, help to under-write innovative research propos-als and important facets of theAssociation’s work such as theAnnual Meeting’s “Best PaperAward” and the Keynote Address.

The Foundation’s Board ofDirectors developed four grant-making priorities that it felt wouldmost effectively advance the mis-sion of the ASE and itsFoundation.

Top Priority: Innovations inTeaching in a ChangingEducational Environment

• Will develop and test new,more effective ways of teachinglearners at all levels.

Performance Evaluation andAssessment

7C O M M I T T E E R E P O R T S

Report to the Alliance for ClinicalEducation, September, 2005M I C H A E L S T O N E , M D , Boston Medical Center

• Will develop and test newways to determine how well learn-ers at all levels have learned therequired information and skillsand can perform the requiredtasks.

Undergraduate, Graduate andFaculty Development

• Will develop and test waysto more effectively disseminateeducational research findings so asto keep both faculty and curriculacurrent.

Curriculum and EducationalAdministration Management

• Will develop and test newways to provide administrators theresources and skills necessary tomaintain accountability in a man-aged care environment.

An especially generous three-year grant from U.S. Surgical in1999, allowed for the develop-ment of the Center for Excellencein Surgical Education, Researchand Training (CESERT). One oftwenty “centers for excellence”funded at major universitiesthroughout North America byU.S. Surgical, CESERT was locat-ed by the Foundation’s Board ofDirectors at the offices of the ASEat the Department of Surgery ofSouthern Illinois University inSpringfield, Illinois.

While grant applicationrequests in any amount will beconsidered, the Foundation Boardexpects that the average CESERTgrant will be in the range of$25,000 to $50,000 annually.While multi-year proposals will beconsidered (three year maximum),regardless of the length of thefunded project, total grant sizemay not exceed $100,000.

The 2005 annual meeting ofthe ASE was held at the Grand

Hyatt in New York City in con-junction with the Annual meetingof the Association of ProgramDirectors in Surgery. The twomeetings dovetail with a joint day,constituting Surgical EducationWeek. Over 750 attendees heard35 manuscript presentations, hadtheir choice of attending 22 differ-ent workshops, and heard the ASEPresidential address, a keynoteaddress and other special presenta-tions on such subjects as “What’sNew in Surgical Education?”Selected papers from the meetingare submitted to the American Journalof Surgery, the official journal of theAssociation for Surgical Education.

The 2006 Surgical EducationWeek will be held in Tucson, AZ,March 21-25, 2006 at the WestinLa Paloma Resort.

The ASE presentsOutstanding Teacher Awards forexcellence in surgical teaching onan annual basis to surgical educa-tors identified from an internation-al nomination and selectionprocess. In addition, the ASEpresents a Distinguished EducatorAward for career long excellenceand productivity in surgical educa-tion. The 2005 DistinguishedEducator Award was presented toHollis Merrick, MD, MedicalUniversity of Ohio. There werefour individuals who were recipi-ents of the ASE OutstandingTeacher Award at the 2005 ASEAnnual Meeting:

• Mary Klingensmith,MD,Washington University

• Andrew MacNeily, MD,University of British Columbia

• John Mellinger, MD,Medical College of Georgia

• Sherry Wren, MD, StanfordUniversity

Focus on Surgical Education is theofficial publication of theAssociation of Surgical Education.It is published four times a year atSouthern Illinois UniversitySchool of Medicine, and is mailedto all current members of the ASE.Focus is a compilation of variousarticles of interest to our member-ship, including, but not limited toMessages from the President, newsfrom our Foundation, Review ofthe Literature, Educator’s Corner,information on the latest technol-ogy used in education, workshopsummaries from the most recentannual meeting, invited articles ona variety of relevant and timelytopics in surgical education as wellas Open Forum, which gives ourmembership a chance to expresstheir ideas and share theirthoughts on current issues.

In addition to the above, theASE has engaged in a yearlongstrategic planning process to fur-ther enhance the productivity ofthe organization. As a result ofthis process, the ASE has initiatedsignificant bylaws changes toenhance the organization’s abilityto adapt rapidly to changes in itsenvironment and that of surgicaleducation in particular. In addi-tion, the Executive Committee hasbeen reorganized into a Board ofDirectors with specific mecha-nisms for reporting and evaluationof the work of the ASE’s variouscommittees. Finally, theAssociation has adopted a methodto evaluate the work plans of itscommittees to ensure progresstoward the specific goals of theASE. ■

C O M M I T T E E R E P O R T S8

The ASE Board of Directorsmet during the meeting of theAmerican College of Surgeons atthe San Francisco Hilton onOctober 15, 2005. ASE PresidentDon Jacobs opened the meetingand the minutes from the April,2005 meeting were read andapproved. In a matter arising fromthe minutes, Don Jacobs notedthat a discussion had been con-ducted at the April meeting toconsider an increase in the budgetdevoted to the J. Roland FolseLectureship at the Annual Springmeeting. This discussion was con-tinued and a motion was passed

to increase the budget for the

lectureship; a cap of $5000 was

set for the honorarium.

Treasurer’s Report

David Rogers presented theTreasurer’s Report. The balancesheet of the ASE’s finances waspresented along with the FiscalYear 2006 budget. David pointedout that a significant percentageof the association’s assets are incash and suggested that a strategymight be developed for more suc-cessful asset management. Hepointed out that financial manage-ment must fall in line with ASE’srecently implemented StrategicPlan. In this regard, a motion was

passed (later in the meeting of

the Board) to create a differen-

tial in the cost structure of

meeting registration for mem-

bers vs. non-members to be the

equivalent of an individual

membership and to allow the

differential to be applied to the

cost of membership for the fol-

lowing year.

Executive Director’s Report

Susan Kepner presented theExecutive Director’s Report.

Despite the high cost of theNew York meeting, a profit of$49,919 was realized.

The meeting welcomed atotal of 777 attendees:

APDS only – 179ARCS only - 181ASE only – 229Joint – 188The ASE Meeting in the

spring of 2006 will be held March21-25, 2006 at the Westin Palomain Tucson, AZ. Room rate is$169/night.

A contract has been securedwith the Hyatt Regency onCapitol Hill in Washington, DCfor April 10-14, 2007 at$229/night.

Negotiations regardingToronto as the possible meetingsite for 2008 were discussed.

Two new offerings in theEducational Clearing House werebrought to the attention of theBoard:

(1) The Virtual Patient: ASelf-directed Study Guide inSurgery and (2) the Manual onEfficiently Writing CompetitiveResearch Abstracts for SurgicalJournals.

As part of the ExecutiveDirector’s report, the issue offunding travel for ASE representa-tives to the Spring AAMC

Council of Academic Societies(CAS) meeting was discussed. Amotion was approved to fund

travel for both ASE representa-

tives to the CAS meeting.

AJS Recorder’s Report

Tom Lynch presented theRecorder’s Report and discussedthe organization’s current relation-ship with the America Journal ofSurgery. He noted that in January2005 the American Journal of Surgerybegan using Editorial Manager®, aweb-based process for the submis-sion and tracking of manuscripts.

Resulting from the 25thAnnual ASE Meeting in NewYork, invitations to submit manu-scripts were sent to 37 authors. 17authors submitted manuscripts. As of 9/30/05: Accepted: 11/17=65%; Rejected: 3/17= 7%;Pending: 4.

Tom presented updates onthe Alliance for ClinicalEducation (ACE) ProceedingsProject and on the American Journalof Surgery Editorial Project.

As a matter of educating theBoard on the options for changesin the journal relationship of theASE, Tom created and explained avaluable matrix comparing AJS,Current Surgery, JACS and Surgery,with regard to cost, exposure(journal reputation), turn-aroundtime to publication, ASE partici-pation in the editorial process,ability to group manuscripts, andability to maintain an independentrelationship with Current Surgery.

Our current contract with the

9C O M M I T T E E R E P O R T S

Board of Directors ReportB A R R Y D . M A N N , M D , The Lankenau Hospital

American Journal of Surgery expiresDecember 31, 2006.

ASE Foundation Report

ASE Foundation Report wasdelivered by Richard Reznick andincluded the following:

Members of the ASEFoundation Board have been inconsultation with the AmericanCollege of Surgeons Departmentof Development (now called theAmerican College of SurgeonsFoundation) to discuss utilizingtheir services and expertise inadvancement initiatives for theASE. In this regard, theFoundation Board announced itsplans to meet officially with FredHolzrichter, Chief DevelopmentOfficer of the ACS Foundation.

Review of CESERT Grantfunding status:

Discussion ensued regardingEthicon Endo-Surgery support forthe continuation of CESERT;plans for a follow-up meeting withEthicon Endo-Surgery’sProfessional Education Divisionwere announced with the purposeof discussing future support ofCESERT. This meeting was totake place October 16th in SanFrancisco and the outcome to bepresented to the FoundationBoard at its meeting October 17.

Barry Mann, Chair of theCESERT Grants ReviewCommittee reported that six pro-posals for CESERT were submit-ted in the June cycle. Of those,two would be recommended forfunding to the Board at itsOctober meeting:• Applying Automaticity Theoryto Simulator Training to EnhanceOperative Performance. PI:Dimitrios Stefanidis, MD, PhD,

Tulane University ($43,460)• Determining the Utility of theMini-Clinical Evaluation Exerciseas a Competency Assessment Toolof Surgical Residents PI: RaviSidhu, MD, MEd, University ofBritish Columbia ($41,191)

Worth Noting: Distributedamong the handouts for the Boardof Directors was a booklet pre-pared by Susan Kepner entitled:“Association for SurgicalEducation Foundation - CESERT:Summary of Completed ResearchGrants as of September 2005.”This summary is an inspiring com-pendium which documents theaccomplishments of the CESERTprogram since its inception.

SERF Report

Donald Risucci updated thecommittee on SERF programactivities and discussed ongoingconsiderations for possible educa-tional innovations within the cur-rent SERF structure. The SERFforum will continue as an integralpart of the spring meeting inTucson.

Program Committee

Patrice Bergen presented theProgram Committee Report. Thisyear the APDS meeting precedesthe ASE meeting. The Tucsonmeeting will have a theme of edu-cation of medical students andresidents in a culture of patientsafety and reduction of surgicalrisk.

In this regard, a panel discus-sion will be presented regarding“Best Practices for PatientHandoffs.” The combined meet-ing day will include invited speak-ers from the ACS, the RRC andthe ABS. “What’s New in SurgicalEducation” will be delivered by

Dimitri Anastakism MD, MEd.The J. Roland Folse

Lectureship in Surgical Educationwill be delivered by Professor SirAra Darzi, Chair of Surgery atImperial College in London andpreviously a tutor in minimalaccess surgery at the RoyalCollege of Surgeons in England.Among his achievements, Dr.Darzi was responsible for settingnational guidelines for educationand training in minimal accesssurgery in England.

This year’s ProgramCommittee Members include:Patrice Bergen, Chair, DonJacobs, Don Risucci, LindaBarney, Myriam Curet, andDimitri Anastakis.

Subsequent to the ProgramCommittee Report, a lively dis-cussion took place regarding thevalue of the entertainment pro-gram which traditionally followsthe annual awards dinner.Members of the board expressedtheir always animated, if diver-gent, views on this issue.

Membership Committee

The report of theMembership committee, submit-ted by Dimitri Anastakis, docu-mented the plateau in member-ship growth in 2003-2004. Thegoal and objectives for the newMembership Committee present-ed at the previous board meetingwere reiterated with emphasis onthe fact that marketing for ASEmembership is now an essentialpart of the strategic plan:

Goal: to strengthen the ASEin both numbers and influence byrecruiting new members and mini-mizing the attrition of currentmembers: Objectives: (1) Develop

C O M M I T T E E R E P O R T S10

and implement a plan for anaggressive, targeted, twelvemonth member marketing pilotprogram;(2) provide or fund thefinancial and human resourcesrequired to implement the pilotprogram; and (3) deliberate thepracticality, challenges and bene-fits of international expansion.

Further specifics discussed byDr. Anastakis included (1) target-ing members of the surgical sub-specialties; (2) inclusion of aninternational membership equiva-lent; (3) new considerations forthe concept of institutional mem-berships. The changes in theMembership Section of the By-Laws, Article IV, will be sent to allASE members under separatecover for their consideration. Avote on these proposed changeswill then be taken at the ASEAnnual Business Luncheon onFriday, March 24, 2006 in Tucson,Arizona.

The following motions,

labeled in the committee report

as “objective 1b” and “objective

1d” were specifically reviewed

and passed as motions:

Objective 1b: Identify thoseconstituencies most likely torespond to a member marketinginitiative and those constituenciesdeemed essential to advancingASE’s mission and activities (e.g.,more PhDs)

Objective 1d: Develop aprocess that identifies the primaryreasons ASE members do notrenew. Depending on the conclu-sions, develop responses andstrategies that may minimize thatattrition.

Information TechnologyCommittee

Walter Pofahl presented theInformation Technology Reportand described the committee’swork on the development, distri-bution, and analysis of aTechnology Needs Assessment.The survey assessed for skill levelsand interest levels in all aspects ofeducation-related technology,including: digital cameras, PDAs,internet, software and web-pages.Survey results were reviewed. TheIT Committee has begun work ondeveloping a workshop for theTucson meeting based on thisneeds assessment.

Curriculum Committee

Linda Barney, Chair of theCurriculum Committee, discussedthe committee’s plans to continuethe Thinking-Out-of-the-Box-Lunch forum at the spring meeting.

Plans were set forth for theCommittee’s PowerPoint® Project,an endeavor to create a bank ofPowerPoints, which would beused to stimulate interactionbetween faculty and students.Process challenges were reviewedand a detailed project plan waspresented. The feasibility of hir-ing of a part-time administratorfor the project was discussed.Linda announced specific plans topilot-test preliminary PowerPointmodules with students attendingthe Medical Student Sessions dur-ing ACS. Ideas for future develop-ment projects were discussed.

Faculty DevelopmentCommittee

Barbara Pettitt presented the report of the FacultyDevelopment Committee and discussed a survey conducted of

over 2000 volunteer facultyregarding: demographics, knowl-edge and impact of current surgi-cal education issues, duty hourrestrictions for residents and theASE competencies. Nearly 500responses have been collected andare being entered into a database.Spring workshop participationwill be discussed and developed at the committee’s October 17meeting at ACS.

Education ResearchCommittee

Linnea Hauge, Chair of theEducational Research Committee,announced the committee’s con-sideration of a project for whichthe committee intends to applyfor funding to the Office ofResearch Integrity of the AAMC.

Assessment & EvaluationCommittee

Lorin Whittaker presentedthe report of the Assessment &Evaluation Committee and dis-cussed the committee’s considera-tions for workshops to be held atthe Tucson meeting.Considerations are: (1) a ques-tion-writing workshop to assisteducators in preparing studentsfor shelf examinations and NBMEexams; and (2) a workshop in theconstruction of the OSCE. TheAssessment & EvaluationCommittee hopes to developthese ideas and formulate defini-tive plans for its 2006 workshopat its committee meeting to takeplace during the ACS.Continued on page 15

11C O M M I T T E E R E P O R T S

The site of the next SurgicalEducation Week is Tucson,Arizona, a city rich in historywith a diversity of cultures, archi-tecture and peoples. TheAssociation of Program Directorsin Surgery (APDS) will meetTuesday, March 21, 2006 andWednesday, March 22, 2006.The Joint Meeting of theAPDS/ASE will be on Thursday,March 23, 2006. The Associationfor Surgical Education will beginour meeting on Friday, March, 24,2006.

Our host city has been con-tinuously settled for over 12,000years taking its name from aNative American village calledStook-zone meaning water at thefoot of black mountain. Thebirthday of the city is considered1775, when Hugo O’Conor estab-lished the Tucson Presidio.Tucson became a part of theUnited States in 1854 with theGadsden Purchase. Tucson’s richcultural heritage includes a uniqueblend of ancient Native Americanpeoples, Spanish explorers, andAnglo frontiersmen. The city’sgeography is a postcard image ofcactus forests, rolling hills, andcraggy mountains. National andState Parks and Forests ring thecity. The city of 900,000 people isserved by 11 airlines with directflights from 16 cities. Our meet-ing venue is The Westin La

Paloma Resort and Spa which isnestled on an expansive propertyin the high Sonoran Desertfoothills of the Santa CatalinaMountains. Preserved on theproperty is a population of morethan 8,000 mature century-oldSaguaro cacti. On the backdropof the Santa Catalina Mountainsthe Spanish Colonial Design ofthe property complements thenatural beauty of the HighDesert. For more informationabout Tucson please visit:http://www.visittucson.org/

On Wednesday evening priorto the Joint APDS/ASE meeting areception for both groups will beheld. Beginning Thursday, theAPDS and ASE with host twopaper sessions reflecting the inter-ests of both groups. The APDShas invited Dr. Jim McGreevy asthe keynote speaker, his topic“Using Aviation Training Tools toWrite a Surgery Curriculum” will

be of interest to both audiences.The APDS has invited a panel ofleaders from the RRC, theAmerican Board of Surgery andthe American College of Surgeonsto discuss important topics in resi-dent education. The ASE willhost a panel whose topic willinclude patient safety curriculum,team building and informationtransfer. Both panels are certainto have wide interest in both theAPDS and the ASE. Dr. DimitriAnastakis will present the ASE’s“What’s New in SurgicalEducation” talk. The very popular“Thinking Out of the Box”Luncheon will be offered againthis year for members to gain anaudience about their innovationsin surgical education. This uniqueformat offered by the CurriculumCommittee is currently solicitingyour submissions for presentation.Capping off the joint day will be Continued on page 21

A N N U A L M E E T I N G12

Program Highlights – SurgicalEducation Week, ASE AnnualMeetingP A T R I C I A C . B E R G E N , M D , U T Southwestern Medical School

Phot

o: St

eve R

enzi

“I do not have ADD!!… ooh look!! a Chicken!!”

ADD, or Attention DeficitDisorder and its variant, ADHD,or Attention Deficit HyperactivityDisorder have been the subjectsof a huge amount of public pressin recent years. Oprah and Dr.Phil have covered the subject sev-eral times with frustrated parents;talk radio hosts opine knowl-edgably about both disorders;school counselors send home wor-risome notes about our kids thatsuggest they may be afflicted.Psychotherapists and psycho-pharmacologists propose treat-ments that run the gamut fromformal cognitive therapy to simpledietary restrictions.

But, what does all of this haveto do with surgical education?Perhaps more than you mightrealize. Many of us have ADD,many of our colleagues do, andmany of our students do. Howwe compensate for or utilize the“gifts” of ADD have a majorimpact on our lives as surgeonsand as educators. How we gearour teaching styles to studentswith ADD/ADHD can dictatesuccess or failure and has bearingon career choices. So, wethought that some “attention” wasneeded for all of us to understandboth ADD and ADHD.

In early education the termADHD is generally used as adescription of a set of traits chil-

dren may be exhibiting. Thesetraits are spread across a broadspectrum of behaviors. WhileADHD includes more of thephysical kinds of restlessness andimpulsivity, ADD people in gener-al share a common set of symp-toms to varying degrees. Theseinclude distractibility, impulsive-ness, frequent ”tuning out” whenothers are talking, a search forhigh stimulation and hypersensi-tivity. Additionally there may beissues of irritability and difficultywith anger management. Thedreamy, unfocussed inattentivechild is very different from thehyperactive one who is “bouncingoff the walls,” unable to stay seat-ed in a classroom.

Since the 1980s, research andwork with ADD has disclosed thepositive qualities often exhibitedby those with the disorder,including creativity, high intelli-gence, a gift for entrepreneurship,the ability to multi-task whenengaged in a rewarding venture oractivity, and a powerful intuitivesense.1 Many teachers and parentswill agree that perhaps a betterterm for ADD might be “theScanning Brain.”

Often when struggling tofind the right help for an ADHDchild, the parent sees light bulbsgoing off regarding his/her ownearly days as a student.Psychologist Lynn Weiss discov-ered while seeking help for one ofher children that she herself was

probably ADD, as was his father.2

There does seem to be a geneticthread running through some fam-ilies in which non-linear thinkersare strongly represented. Severalauthors, among them John Ratey,MD of Harvard, have writtenmovingly of their own experi-ences of ADD. The authors of“Think Fast. The ADDExperience,” suggest that once adiagnosis has been made in adults,coaching may be preferable topsychotherapy, and that medica-tion should be appropriately dis-cussed as a tool to keep down the“noise” of over-stimulation. ManyADD adults have spent years try-ing to self-medicate with alcoholor other substances. Such effortsmay work short-term but end upadversely affecting one’s overallexperience of life.

DSM-IV definitions breakdown the condition into four categories:

• Primarily inattentive type• Hyperactive/impulsive type• Combined type• Not otherwise specified. 1

Can we identify these typesof ADD in surgeons? Most of uswould fall into either the hyperac-tive/hyperfocused or the com-bined category. Cultural anthro-pologists posit that ADD is a wayof learning and being that suitedancient man, “the Hunter,” per-fectly. Attention was kaleidoscop-ic, an ever changing state inwhich one was hypersensitive to

13E D U C A T O R ’ S C O R N E R

A.D.D. and the Physician: Are Youan Attention Deficit “Doctor”?C L A I R E D . S P E N C E , M A A N D R I C H A R D K . S P E N C E , M D

his/her surroundings — the sur-geon in the operating room, any-one? These non-linear thinkerswho process information in a dif-ferent cognitive style are alsocapable of great hyper-focus andimaginative solutions, a valuableasset in surgery. If not controlled,however, it can lead to continuedfrustration and repeated failure.Think of your colleagues withsevere “hospital-itis” who arealways in the hospital trying tocatch up on unfinished work anddon’t even know if they still havea home to go to at night.Consider the resident who can’tseem to get all the informationneeded for morning roundsbecause he/she couldn’t tear them-selves away from that one critical(read: fascinating) patient in theICU. Feedback from many of ourstudents tells us that the hardcharging surgical lifestyle is notfor them, or that they don’t recog-nize themselves as having a surgi-cal personality. These studentsmay be more in the mold of the“Farmer,” or more linear andorganized thinker, who is moreeasily adapted to the classroomlearning process and a slowermental pace. Think of our col-leagues in the so-called “cogni-tive” specialties, or the surgeon-as-scientist in the laboratory.

What we might see as alearning difficulty can actually bea gift of startling proportionswhen keyed into properly.Because ADD students find it dif-ficult to switch from one activityto another abruptly, the idea oflearning as a process appeals tothem. For example, the first yearmedical student’s work in theanatomy cadaver lab can often be

a boost to confidence. He/she isengaged in something that is chal-lenging, changing daily, is totallyaimed at a major goal and is aprocess of discovery, not simply alecture in a hall before 500 sleepystudents. Similarly, the mnemon-ics used by medical students areextremely helpful to the ADD stu-dent. Remember the cranialnerves and the German whovaulted and hopped on Mt.Olympus? Even those in the pri-mary years of school benefit fromsuch aids as flash cards and rhyth-mic music as a background whenstudying. Such white noise actsas a buffer, allowing the ADD per-son to zero in on the job at hand.

So, perhaps Dr. A in OR 1can’t operate without his favoritemusic or the radio on; or Dr. B inOR 2 always tells the same lamejoke while closing, and Dr. C inOR 3 insists on having an 8AMstart time, but routinely arriveslate because somehow he reallybelieves that between 5AM whenhe awoke and 7AM when he lefthome, he can drop a child atschool, go back home to retrievehis forgotten briefcase, pick up aphone message that requires sixfollow-up calls from his car, whichis idling in the drive-through laneat McDonalds as he gets a quickcup of coffee, only to discoverthat it is 7:58 and he is still 12 redlights away from his space in thehospital lot. Then there’s Dr. D,who is going through his fourthdivorce, and whose reaction tofrustration or difficulty results ininstruments being thrown or hisinability to work with any surgicalteam.

What can we do about ourown ADD and that of our stu-

dents? In our family, we joke thathyper-focus is a wonderful thing-it just should always be accompa-nied by a coach. This person isthe most powerful part of theequation for an ADD adult. Thismay be the assistant, secretary,spouse or partner who revels inthe linear world or is a well-com-pensated ADD who understandsthe benefit of a coach. The coachcan be part of the team, therebyassisting the ADD person to planand set goals, develop organiza-tional strategies, and get helpwith time management and priori-tizing, because these are amongthe strategies that help maintainfocus and attention to process.Consider the value of small grouplearning when students unwitting-ly take on these specific roles.Now consider the potential, fur-ther benefit if you, as an educator,recognized the need for an ADDcoach and diversified your groupassignments accordingly.

ADD adults often need a safeplace to practice social skills suchas negotiation, so that frustrationdoesn’t lead to outbursts of anger.The coach is a trustworthy allywho can remind without puttingdown or blaming and can helpcontrol the environment. Thecoach may also take on a watch-dog role if and when a medicalworkup suggests use of medica-tion. The ADD adult should keepa meds titration log that can bereviewed in a confidential mannerif needed. Often meds can beadjusted over time so that theymay only be needed for specifictasks, such as preparing for testsor writing/research work.

Computers have been a boonfor many ADD adults because of

E D U C A T O R ’ S C O R N E R14

15E D U C A T O R ’ S C O R N E R

their need to “graze” intellectually.However, the computer and theinternet can be two-edged swordsfor the ADD. What starts out asa 10-minute search for a medicalreference just may go on for hoursas new ideas pop up and the origi-nal task gets lost in the chase!How many times have you fol-lowed those fascinating links torelated articles and sites onPubMed and completely forgottenwhat you were searching for inthe first place? While we nowcan claim such geniuses asChurchill, Edison, Ben Franklin,Steven Spielberg and RobinWilliams in the pantheon of ADDsuccesses, the computer age willno doubt produce many more.

An especially helpful way todeal with an ADD adult is theclassic exercise of rounds - askthem questions as recommended

by Weiss. 2 This helps themprocess information. Questioningneeds to be pointed, consistent,but not accusatory. (RKS: Goodadvice in general when we aremaking patient rounds or just“pimping” the students!) Be care-ful with this approach if you arelike Dr. D described above. Youcan find more detailed informa-tion in Dr. Weiss’ book.

Many therapists believe thatall adults presenting for treatmentof depression or chemical abuseshould be screened for ADD,since many adults with undiag-nosed or untreated ADD havespent much of their student liveschronically angry, frustrated orout of control. Clutter of everykind seems to shadow them. Thetremendous effort to learn or per-form the way “everyone else” doesis exhausting and produces a pro-

found fear of failure. Whether itresults in anger and depression orpassivity that is paralyzing, thisbarrier to personal growth can behelped.

If you suspect that ADD mayplay a part in your own life, thereare several checklists included inthe cited books that can be uti-lized by you with a therapist’shelp. So, why did the chickencross the road? From an ADDpoint of view: “Who knows? Butit sure saw a lot on the way.” ■

References

1. Hartmann T, Bowman J andBurgess S. Think Fast! The ADDExperience. Underwood Books,Grass Valley, California, 1996.

2. Weiss, L. Attention DeficitDisorder in Adults. Practical Helpand Understanding, Taylor,Dallas, TX, 3rd edition, 1997.

Mann

Continued from page 11

Nurses in Surgical EducationCommittee

Barb Lewis, MSN presentedthe report of the Nurses inSurgical Education Committee.She detailed the mission and goalsof the committee and outlinedpotential projects derived fromthe mission and goals. Projectsmay include: (1) workshops onsimulator education; (2) consider-ation of LCME accreditationrequirements for surgical clerk-ships; (3) website potential; (4)outreach for new committeemembers; and (5) continued workon improving the preparation ofmedical students for the surgeryclerkship.

Coordinators Committee

Doris Leddy, Chair of theCoordinators Committee, dis-cussed the intent of the commit-tee to design a Surgical ClerkshipNewsletter, possibly to beuploaded and housed on the ASE’swebsite. Suggested marketingitems to help students “identify”with the surgical service were alsopresented.

Other Business

The “Compact BetweenResident Physicians and TheirTeachers,” a document submittedby the AAMC to organizationsconsidered partners in medicaleducation, was read and approved.

The SIMMS Project devel-oped at NYU under the directionof Mary Ann Hopkins wasbrought to the attention of the

Board by Vice President PhilWolfson. The project was demon-strated and praised for its educa-tional value and technologicalachievement. Dr. Wolfson pro-posed that the ASE partner withDr. Hopkins and NYU to facili-tate bringing to fruition the cre-ation of a larger number of qualityvirtual cases. Dr. Wolfson and Dr.Hopkins will explore this partner-ship further during the ACS meet-ing and report back to the ASEBoard of Directors.

With no further business todiscuss, President Don Jacobsadjourned the meeting. ■

“At every level of patientcare, hands-on experience is thebest teacher.” So begins the infor-mation packet of the METICorporation (Medical EducationTechnologies, Inc, Sarasota,Fl)describing its human patient simu-lator. Marvin Gaye sang, “Ain’tnothing like the real thing…” andCoca-Cola harmonized, “It’s thereal thing...” in promoting theirmessages. Surgeons for most ofthe prior century and beyondhave believed experience is thebest teacher and trained by doingas they were learning, on thepatient. With obvious shortcom-ings of such a learning system, theacquisition of surgical skills wasslow by the learner, and risky tothe patient. Residents learned pro-cedures by watching and thendoing the procedure while givengraded responsibility. Modern sur-gical training incorporating simu-lation represents a welcome addi-tion to the apprenticeship model.

WordNet defines simulationas “assuming an appearance whichis feigned, or not true,” and a sim-ulator as, “a machine that simu-lates an environment for the pur-pose of training or research.” Inthe surgical simulation environ-ment the patient is no longerpresent as the trainees learn com-ponents of their surgical skills.This training by simulation pro-duces knowledge gained by doingsomething, and with repetition insimulation, this experience can

then be taken to real patient careenvironments by the trainee nowbringing surgical skills and knowl-edge not present before the simu-lation training. Presumably thisadditional experience, knowledgeand skill combined with the expe-rience, knowledge and skill of theteacher produce better interven-tions and outcomes for thepatient, and better trained surgicalresidents.

With the abrupt and wide-spread adoption of laparoscopiccholecystectomy, techniques forminimally invasive surgery signifi-cantly changed the technical skillsrequired of a surgeon. The simplebox trainers and subsequently thevirtual reality trainers have beendeveloped to assist in skill acquisi-tion in a harmless practice envi-ronment. Practice of techniquesby simulation can be repeated andrefined as necessary in theabsence of instructors once theskill and techniques are learned.1

Today, medical education bysimulation is also a real thing anda powerful tool in the overallteaching and learning schemes.Certainly all medical schools andall surgical residency programsutilize simulation in varying pro-portions in their institutions.Simulation facilities vary in com-plexity from multimillion-dollarcenters to skills labs with laparo-scopic box trainers and pig labs.The emergence of simulation inmedicine follows simulation uti-

lized in other professions, i.e.,pilots and astronauts, military per-sonnel and by nuclear powerplants. The science of virtual real-ity provides entirely new opportu-nities in the area of simulation ofsurgical skills using computers fortraining, evaluation and eventuallycertification.2 The actual simula-tion developed needs to be evalu-ated for simulation fidelity beforebeing acceptable.

Review of current literatureon learning from simulation iswarranted in view of the advancedelectronic programmable modelscurrently on the market. To somedegree, the advances are occur-ring faster than they can be pub-lished. For surgical skills training,animal models are still utilized forthe procedural technical skillsacquisition, but their utilization islessening with activity from ani-mal rights activists. For surgicalcritical care skills, the computerbased teaching scenarios providethe background for learning fromhuman patient simulators. Thedriving force behind training byany type of simulation is theimportance of patient safety andavoiding life-threatening errors.Other factors favoring learningskills away from the operatingroom, the hospital wards and theoffice, include costs in the realsettings, the 80-hour work limita-tion, availability of specificpatient(s) and faculty for specificskill being taught, repetition to

R E V I E W O F T H E L I T E R A T U R E16

Concepts Evolving in SurgicalTraining by SimulationL O R I N D . W H I T T A K E R , J R , M D , University of Illinois College of Medicine at Peoria

correct errors and the desire toprovide high quality in the careeventually delivered to thepatient. Learning on a modelwith no chance to harm a patientis very appealing. Eventually thechallenge comes in creating train-ing by simulation of a diversevariety of interactions.3

Surgical simulation training iswidely reported in the literature.Laparoscopic procedure skillsacquisition involves using the boxtrainer exercises, as well as virtualreality programs that containexercises to familiarize the trainerwith the new type of hand-eyecoordination required in thelaparoscopic procedures, withvisual feedback coming from acomputer screen, and loss of thetactile feedback. Also, specificoperations are designed into thevirtual reality unit, to provide thelearner with experience doing thetechniques and the steps of thesurgical procedure. Modern simu-lation trainers produce three-dimensional views and have thebuilt-in capability to objectivelyassess the skill of the learnerdoing the training program. Thetrainee can practice independent-ly, repeatedly, in off hours, andwithout supervision.

The rapid advance of com-puter technology is resulting insimulations entering the curricu-lum of the broad field of healthcare education. The emphasis isnow shifting from technology ofsimulation towards partnershipwith education and clinical prac-tice, and this emphasizes the needfor an integrated learning frame-work where knowledge can beacquired alongside technical skillsand not in isolation from them.4

Simulation may be utilized toassess residents all during and atthe end of training to measuretheir skills. As simulation devicesimprove, surgeons may rehearseprocedures known to them toimprove effectiveness and safetybefore operating on a patient.

The ultimate purpose of sim-ulation training is to increase theskill level that the trainee subse-quently brings to the clinicalencounter. Formal assessment isneeded to determine the degreeto which simulators train medicalskills and the degree to whichskills learned in a simulator trans-fer to the practice of care.5

A Yale study6 showed resi-dents who first trained in a virtualreality simulator were more profi-cient and made fewer errors in theoperating room than their coun-terparts who had no such simula-tor training. This study impliespatient safety is enhanced by theresidents’ simulation training.

In a landmark article in 1993,Satava proposed in detail, surgicaltraining utilizing virtual reality(Ref 26.) Experience has shownnovices did well with new skills(carotid artery catheter insertion)while as expected, the experi-enced physicians did the skill sat-isfactorily from the beginning.7

METI describes their virtualreality surgical simulation withadvanced life-like surgical anato-my, advanced intra-corporealsuturing and knot typing exercis-es, and the learner performancemetrics are collected during eachsession. The exercise is recordedfor immediate replay and feed-back for developing surgical skills.It also provides a video of the realprocedure for ready reference to

reality learning as part of thetraining exercise. The three dif-ferent learning modes allow theinstructor to vary the learningexperience.

Dr. Abcarian’s colorectal sur-gical colleagues reported theirexperience with teaching theintricate special relationshipsamong structures of the pelvicfloor, rectum and anal canal. Acomplex interactive, virtual realitymodel, the Digital Pelvic FloorModel was created. A standardexamination of ten basic anorectaland pelvic floor anatomy ques-tions were administered to surgi-cal residents. Resident evaluationafter taking this instructionalcourse confirmed effectiveness oftheir understanding of pelvicanatomy. Their collaborativelyshared virtual reality environmentallows students and teachers tointeract from world wide locationsto achieve the learning goalsincluding virtual surgery.8

Neurosurgeons developed aninteractive VR dissection model,designed to teach visuo-spatialskills required in a transpetrosalapproach. This involves a learner,a robotically controlled micro-scope, and data from cadaverichead dissection (superimposedanatomic pictures in stereoscopicdigital format). This simulationallows the learner to drill thepetrous bone and identify crucialanatomy, simulating an experi-enced surgeon in the real patient.Teachers can manipulate the virtu-al surgical field for further learn-ing experiences. They feel thissimulation does not replace theneed for practicing surgery oncadavers, but it facilitates learningdrill techniques in complex and

17R E V I E W O F T H E L I T E R A T U R E

unfamiliar surgical approaches tothe trainee.9

The Department of Surgeryat the University of Florida incor-porated surgical skills lab into abroad based Laparoscopy 101course for junior residents, anddocumented good acceptance ofthe training by the residents.PGY1 competencies after simula-tion training became equal toPGY2 residents who received tra-ditional operating room trainingup to that point. There was thensignificant improvement in thePGY2 minimally invasive compe-tencies.10

The University of Michiganhas an extensive ClinicalSimulation Center that supportseducation by simulation to over16 branches of medicine, usingdynamic teaching tools. Thistraining is described as “risk-free”—no live patients present.11

Contrasting the high priced simu-lation lab is the simulated endo-scopic staple-assisted Zenker’sesophagodiverticulostomy surgeryusing literally a rubber band, alatex glove and endotracheal tube,among other items.12 A very fun-damental skill acquisition of intra-venous cannulation by simulationrevealed training improvementwas greater for those trained withthe simulated limbs.13

The human patient simulationis a manikin bringing no threat topatient safety. This complexengineering computerized simula-tor brings realistic patient appear-ances, environment and responseto interventions. Programmableclinical scenarios allow for learn-ers’ responses. Responses whichare management errors can con-tinue as directed by the teacher to

show any undesirable conclusions.Common and uncommon clinicalproblems can be simulated.Critical thinking and problemsolving is required of the learnerswho apply their knowledge, andthe students can see effects ofincorrect decisions, and can prac-tice correct responses as well aslearn team dynamics and practicecommunication skills.

The manikin simulationlearning can be directed andfocused by the faculty in present-ing the desired patient scenarios,and requires correct patient careintervention by the students.Students can fail and repeat thesegment immediately. Scenarioscan be rerun as needed untileveryone “gets it right.” Thisarrangement, as contrasted withthe virtual reality with its imagery,allows for the teaching of essen-tially any and all critical care sce-narios requiring intervention ofintravenous fluids and medica-tions, chest tube insertions, peri-cardiocentesis, tracheostomy,endotracheal tube placement, tubeand needle thoracostomy, urinarybladder catheterization, defibrilla-tion, as well as teaching physicalexaminations of the “patient.”The manikin simulates breathing,reactive pupils, peripheral pulses,heart and lung sounds, urinaryoutput, and is monitored withstandard ICU vital signs monitorscreen (which shows values creat-ed by the computer-based teach-ing scenario.)

These manikin type simula-tors are very widespread in distri-bution with over 1400 of a singlebrand (METI) in use throughoutthe world. These simulators aredistributed in the USA across

medical schools, emergency medi-cine units, military installations,hospital health systems, nursingand allied health science centers,and internationally in a similardistribution.

The educational value of thesimulation will require assessmentand comparison to currently avail-able methods of training in anygiven scenario or lesson. It is alsonecessary to determine by repeat-ed trials whether a given simula-tion actually measures the per-formance parameters it purportsto measure.14 This is an impor-tant concept.

One department of surgery’sexperience with use of the simula-tion manikin in their ATLS courserevealed overall favorableresponse to this learning experi-ence reported by the students.They found the manikin to besuperior to the animal model inteaching surgical airways and formanagement of pneumothorax.They felt their preliminary experi-ence with an interactive humanpatient simulator to teach theATLS surgical skill station waswell received by students whencompared with standard methods,supporting the inclusion of simu-lators in teaching ATLS skills.15

Another trauma managementskills report came from Penn Stateand Stanford. These physiciansalso reported that incorporationof human patient simulators(HPS) with the ATLS courseimproved the teaching/learningand appeared to enhance thedevelopment of trauma manage-ment skills. They felt “in particu-lar, trauma team behaviorimproved significantly after theATLS/HSP course.” They empha-

R E V I E W O F T H E L I T E R A T U R E18

sized, as have others, that theirsurgical interns improved in theirconfidence with completion ofthe course. Their discussionincludes documentation of othercenters showing improved per-formance in trauma managementskills after ATLS. Also, their sen-ior residents’ previous clinicalexperiences, as expected, were thefavorable influences apparent intheir excellent performance incritical decision making in thecourse. Stanford University sur-geons also see the opportunity forsimulation and surgical trainingutilizing their telerobotic sys-tem.16

In the last decade Reznick etal. approached the scoring of theperformance of residents in a skillsexamination consisting of OSCE-like stations. They developed theobjective structured assessment oftechnical skill (OSATS) assess-ment system for surgical residents,and it appears to be a valid andreliable instrument for assessingskills and could be utilized in sur-gical simulation training to pro-vide a common basis for surgeryskills assessment. However, virtu-ally every commercially availablesurgical simulator has its ownevaluation scoring system built into the product.17

An excellent reference in thefield of critical care simulation isthe publication entitled,“Simulators in Critical Care andBeyond,” by William F. Dunn,MD, editor, a publication of theSociety of Critical Care Medicinein 2004. This compendiumincludes James Gordon’s article,High Fidelity in PatientSimulation: A Revolution inMedical Education. His thought-

ful opinions support simulation ineducation “because the approacheffectively targets commonly elu-sive educational objectives: prac-tice without risk, curricular stan-dardization, and pedagogic effi-ciency.” Dr. Dunn’s article evalu-ates training by simulation, andconcludes, “Creating artificialenvironments that can facilitateexperiential learning may truly bea method to ‘raise the bar’ forcoming generations of physiciansand allied personnel learners inthe name of clinical excellenceand patient safety.”

The simulation center at theUniversity of Pittsburgh MedicalCenter reported its experience incritical care teaching, noting thewide applications of its 16SimMan simulators. (LaerdalMedical, Norway). In one aca-demic year, 2003-2004, therewere 8,000 trainees encounteringmore than 8,500 simulations.Their trainees represented a broadspectrum of health care providers.The courses that were taughtincluded involved clinical proce-dures, perioperative medical care,acute medicine problems, pharma-cology, basic and specialty anes-thesiology, difficult airway man-agement, fiberoptic bron-choscopy, pediatric versus adultpatient crisis management, criticalevents in obstetrics, and crisisteam training. Interestingly, theirreport lists fewer malpracticeinsurance claims as an advantageof simulation over traditionalmedical training methods.18

An observational study ofPGY2 residents in a humanpatient simulation experience ofthree unknown scenarios in criti-cal care training revealed that

none of the eight residents suc-cessfully completed the first sce-nario. Of particular interest istheir reluctance to call for helpuntil the scenario reached a criti-cal stage. Subsequently, with rep-etition and education there wasperformance improvement. In theend, resident acceptance of simu-lation scenarios training wasexcellent.19

Limitations of use of thehuman patient simulation werereported in one anesthesiologysimulation training exercise. Thesimulation was used in instructionin the department of anesthesiolo-gy to teach basic skills – respira-tory physiology, cardiovascularhemodynamics, difficult airways,tension pneumothorax, pul-monary embolism and shock.The skill acquisition advantageswere recognized but two limita-tions of this methodology werepresented: clinical realism of thepatient manikin, and facultydevelopment. The manikins arenot real and it takes time to writeand program the scenarios.20

A web and simulation-basedcurriculum for incoming surgicalhouse staff is feasible. Such a cur-riculum was devised to help easethe transition from fourth yearmedical student to first year surgi-cal resident. The confidencescore of the participants signifi-cantly improved after they partici-pated in a combined website edu-cational curriculum and performedhuman patient simulator scenar-ios.21

Contemplating surgical simu-lation in assessing surgical compe-tency, Dr. Satava wrote, “In look-ing at the component competen-cies, it is apparent that training

19R E V I E W O F T H E L I T E R A T U R E

and evaluation on simulatorsapplies to knowledge, patientcare, practice-based learning andimprovement, and system-basedpractice. The role of simulationapplies principally to identifyingcorrect anatomic structures, per-forming the procedure in the cor-rect sequence with steps, under-standing what is an error, etc. Ithas been estimated that a surgicalprocedure is approximately 75%cognitive skill and 25% technicalskill.” Training by simulation hasa role, and Dr. Satava concludes,“…the complex issue of assessingsurgical competency is in itsinfancy.”22

A lengthy review of 109 jour-nal articles on medical simulationlearning reported that 47% of thejournal articles reported that edu-cational feedback to the learner isthe most important feature of sim-ulation-based medical education.Surprisingly, 3% of journal articlesprovided evidence for the directcorrelation of simulation validitywith effective learning. The con-clusion was that high fidelitymedical simulators are education-ally effective and simulation basededucation compliments medicaleducation in patient care set-tings.23

Reznick found a comprehen-sive curriculum based on a highfidelity simulator was effective atimproving skills demonstrated onthe simulator and raised the ques-tion if these skills (amniocentesis)were transferable to the clinicalsetting.24

A study recently reportedsuggested that there is an inverserelationship between the numberof years that a physician has beenin practice, and the quality of care

that the physician provides. Aninteresting editorial appears in thesame issue, entitled “Practicemakes Perfect…or Does It?” Thisis a somewhat irritating conclu-sion for us to accept, but thethrust of the message we cannotcontest, and that is to continuelife long learning, maintenance ofskills, maintenance of competenceand quality of care. For surgeons,training by simulation may be afuture source of continued med-ical education and skill mainte-nance and improvement.25

Over the past decade signifi-cant simulation advances havebeen accomplished, but the wordsof R.M. Satava at Yale in 2001remain valid today. “Enormouschallenges remain, which includeimprovement of technical fidelity,standardization of accurate met-rics for performance evaluation,integration of simulators into arobust educational curriculum,stringent evaluation of simulatorsfor effectiveness and value addedto surgical skills and a businessmodel to implement and dissemi-nate simulation successfullythroughout the medical educationcommunity.”26 ■

References

1. Tendick F, et al.www.itsa.ucsf.edu/frankt/vesta.html.

2. Satava RM. Surgical educationand surgical simulation. World JSurg 2001; 25(11):1484-9.

3. Rotnes, JS et al. A tutorial plat-form suitable for surgical simula-tor training. Stud Health TechnolInform 2002; 85:419-25.

4. Kneebone R. Simulation insurgical training: educationalissues and practical implications.Med Educ 2003; 35:267-277.

5. Magee JH. Validation of med-ical modeling and simulationtraining devices and systems.Stud Health Technol Inform2003; 94:196-8.

6. Seymour NE et al. Virtual real-ity training improves operatingroom performance. Ann Surg2002; 236(4):458-64.

7. Dayal R, et al. Computer simu-lation as a component of catheter-based training. J Vasc Surg 2004;40(6):1112-7.

8. Dobson HD et al. Virtual reali-ty: new method of teachinganorectal and pelvic floor anato-my. Dis Colon Rectum 2003;46(3):349-52.

9. Bernardo A, Preul MC,Zabramski JM, Spetzler RF. Athree-dimensional interactive vir-tual dissection model to simulatetranspetrous surgical avenues.Neurosurgery 2003; 52(3):499-505.

10. Schell SR, Flynn TC. Web-based minimally invasive surgerytraining: competency assessmentin PGY 1-2 surgical residents.Curr Surg 2004; 61(1):120-4.

11. U-M Clinical SimulationCenter, www.med.umich.edu/umcsc.

12. Richtsmeier WJ. SimulatedZenker’s endoscopic staple-assist-ed esophagodiverticulostomy sur-gery. Laryngo 2002; 112(7):1230-34.

13. Scerbo, MW et al. A compar-ison of the CathSim system andsimulated limbs for teaching intra-venous cannulation. Stud HealthTechnol Inform 2004; 98:340-6.

R E V I E W O F T H E L I T E R A T U R E20

21R E V I E W O F T H E L I T E R A T U R E

14. Cosman PH, Cregan PC,Martin CJ, Cartmill JA. Virtualreality simulators: current status inacquisition and assessment of sur-gical skills. ANZ J Surg 2003;73(3):163.

15. Block EF et al. Use of humanpatient simulator for advancedtrauma life support course. AmSurg 2002; 68(7):648-51.

16. Niemeyer G et al. THUMP:an immersive haptic console forsurgical simulation and training.Stud Health Technol Inform2004; 98:272-4.

17. Martin JA et al. Objectivestructured assessment of technicalskill (OSATS) for surgical resi-dents. Brit J Surg 1997; 84(2)273-278.

18.Grenvik A, Schaefer JJ, DeVitaMA, Rogers P. New aspects oncritical care medicine training.Curr Op Crit Care 2004 Aug;10(4):233-7.

19. Hammond J, Bermann M,Chen B, Kushins L. Incorporationof a computerized human patientsimulator in critical care training:a preliminary report. J Trauma2002; 53(6):1064-7.

20. Good ML. Patient simulationfor training basic and advancedclinical skills. Med Educ 2003; 37Suppl 1:14-21.

21. Meier AH, Henry J, Marine R,Murray WB. Implementation of aweb- and simulation-based cur-riculum to ease the transition frommedical school to surgical intern-ship. Am J Surg 2005;190(1):137-40.

22. Satava RM, Gallagher AG,Pellegrini CA. Surgical compe-tence and surgical proficiency:definitions, taxonomy, and met-rics. J Am Coll Surg 2003Jun;196(6):933-37.

23. Isenberg B, McGaghie WC,Petrusa ER, Lee Gordon D,Scalese RJ. Features and uses ofhigh-fidelity medical simulationsthat lead to effective learning: aBEME systematic review. MedTeach 2005; 27(1) 10-28.

24. Pittini R, Oepkes D, MacruryK, Reznick R, Beyene J, WindrimR. Teaching invasive perinatalprocedures: assessment of a highfidelity simulator-based curricu-lum. Ultrasound Obstet Gynecol2002; 19(5):436-7.

25. Choudhry NK, Fletcher RH,Soumerai SB. Systematic review;the relationship between clinicalexperience and quality of healthcare. Ann Intern Med 2005;142:260-273.

26. Satava RM. Accomplishmentsand challenges of surgical educa-tion. Surg Endo 2001; 15:232-41.

Bergin

Continued from page 12our moderated poster sessionwhich has become increasinglyinteresting and lively. Last year’sposter session was standing roomonly with high quality presenta-tions and spirited discussion. ANewcomers/Residents/Studentsreception will follow.

On Friday, the ASE programbegins in full. Eight moderatedresearch presentations will beselected with time for discussion.Dr. Don Jacobs will present hispresidential address. Our annualbusiness meeting and luncheonwill follow. The afternoon willcommence with two workshopsessions and ample opportunity toselect among numerous offerings.

In the evening, the ASE banquetwill be accompanied by classicalmusic to encourage one of ourmost valuable resources, network-ing. Subsequently, Dr. Jacobs willhost the Presidential Reception.

Saturday morning will beginwith the J. Roland FolseLectureship. This year ProfessorSir Ara Darzi of the ImperialCollege of Medicine, London, isour speaker. Dr. Darzi is interna-tionally recognized for his expert-ise in new technologies, acquisi-tion of psychomotor skills, andhuman factors analysis of technicaland team skills among surgicaltrainees. He is a member of ASEand a contributor to our scientificprogram. Last year, his group wonthe ASE best paper award. Two

moderated paper presentationswill follow. The best paper pres-entation award will conclude themeeting to recognize the best sub-mission to our scientific program.

As always, opportunitiesabound for participation in a num-ber of committees and projects.Members are encouraged tobecome involved in the manyopportunities our organizationoffers.

A more comprehensive pro-gram listing will be found in theSpring Issue of Focus. Please plan to join your friends for thisstimulating meeting in a lovelyvenue. ■

J U S T A B Y T E22

The Information TechnologyCommittee recently developedand administered a survey of themembership to determine theirtechnology education needs. Thesurvey was administered on linethrough a link emailed to sub-scribers of the ASE list serve. Atotal of 97 respondents completedthe survey. The content areasassessed were digital photography,personal digital assistants (PDAs),Internet, software programs, webpages, and tools. A total of 27items were covered over the sixtopic areas. Respondents wereasked to rank their expertise foreach item as beginner, novice,intermediate, or advanced. Theywere asked about their interest ina workshop for each item (no,moderate, or strong interest).

The top ten items with thehighest percent of workshopinterest (combine moderate andstrong interest level) and associat-ed skill level (combine beginnerand novice) are listed below:

Looking only at the stronginterest category, usingPhotoshop® software (41.9%) andelectronic portfolios (40%) werethe two highest ranked items onthe needs assessment survey.

To begin addressing the itemsin the needs assessment, theInformation TechnologyCommittee will hold a hands-onworkshop at the 2006 meeting inTucson. The workshop will focuson developing HTML documentsto use in undergraduate and grad-uate education programs.Applications of building HTML

documents to use in educationalsettings include but are not limit-ed to: publishing case-based prob-lems, disseminating goals andobjectives, electronic portfoliosand web portals. Participants willlearn the basics of building anHTML document. Specifically,by the end of the workshop, par-ticipants will be able to insertimages, photos and tables, link totext/documents/objects, formattext style and format backgroundcolor.

The Information TechnologyCommittee plans to use these sur-vey results to guide future work-shops, FOCUS articles, and collab-orations with other ASE commit-tees. Any member who is inter-ested in participating is welcometo join. ■

Report on the ASE TechnologyNeeds AssessmentE L I Z A B E T H R Y A N , M E D , S C O T T E N G U M , M D , M A R Y A N N H O P K I N S ,M D , WA L T E R P O F A H L , M D ; ASE Information Technology Committee

This book offers a carefullyargued approach, based on soundeducational theory, to the post-graduate preparation of surgicaltrainees. The authors emphasizewhat is involved in learning tobecome a surgeon who canengage in professional conductand exercise professional judg-ment as opposed to being trainedin surgical activities in order todemonstrate the behavior expect-ed by assessors. It focuses on theclinical thinking, the professional-ism and the knowledge base thatunderpins good surgical practice.This unique description of clinicalthinking provides a framework tosupport assessment in clinicalpractice and offers examples andideas, which have been developedand refined over several years inpartnership with a group of work-ing surgeons in practical settingsand reflective seminars.

The book explores six mainthemes: being / becoming a grow-ing professional, the practice ofeducation (learning, teaching, andassessment), clinical thinking,knowing, doing and developing,in two separate sections. Part 1lays the educational foundationfor cultivating a thinking surgeonby reviewing traditional practices,and the importance of educationalvalues, principles and aims.Subsequent chapters address nur-

turing the learner, and the impor-tance of reflection and assessment.Part 2 addresses actual teaching,learning, and assessment in surgi-cal settings by discussing clinicalthinking, the surgical knowledgebase, and by assessing technicaland operative procedures in thecontext of teaching and learningsurgery and developing surgicalpractice as well as learningthrough practitioner research.

The authors have broughttogether a combination of a prac-ticing surgeon and a teacher edu-cator who are dedicated to thedevelopment of excellence in sur-gical and educational practice inclinical settings. Linda de Cossartis a consultant vascular surgeon inChester (UK), associate postgrad-uate dean and a member of theCouncil of the Royal College ofSurgeons of England. Della Fish isan educator with the Kent, Surreyand Sussex Deanery and has pub-lished several books on teachingand learning in clinical settings.Each chapter is set out in an easyto read format with the appropri-ate use of tables and summary sec-tions. The book is equally usefulwhether the reader chooses tostudy an entire chapter or look uppoints relevant to their practice.While the book was written pri-marily for trainees and trainers inthe UK system, almost all the

thoughts, practices and aspirationsare applicable to the US trainingenvironment. The authors haveprovided a number of practicaltools: for example one table (p.63)provides an excellent checklist forexploring learner starting points,educational needs and educationalgoals for a clinical rotation.Another summary table (p.182)outlines the thought processesinvolved in clinical judgment withsuggestions for assessment.Throughout the book the authorscite educational theory to supporttheir proposals, exploring Dewey’soriginal work and Kolb’s reflectivecycle in addition to the social –behavioral theories of Bandura,Vygoysky, Wenger and others.This book is essential reading andan invaluable resource for the sur-geon educator. ■

Reviewed by Hilary Sanfey, MD,University of Virginia.

23B O O K R E V I E W

Cultivating A Thinking Surgeon:New Perspectives On ClinicalTeaching, Learning And Assessment Linda de Cossart and Della Fish. tfm Publishing Ltd, Shrewsbury UK. 2005, 250 pages.

This work was presented in poster form atthe AAMC conference, November 2004,in Boston, MA.

New interns present to theirprograms excited, intimidated,and well-rested after a fourth yearof interviews, clerkships, andvacation. Surgical educators startoff their academic years orientingthese new doctors to their sur-roundings and their chosen fields.A “pre-requisite” set of knowledgeand skills that new interns shouldpossess when they start their clin-ical responsibilities has beendefined by the American Collegeof Surgeons, which has publishedthis list of expectations for incom-ing surgical interns;1 other groupshave also published reviews andevaluations of what is expected ofan incoming intern.2,3

Medical schools provide simi-lar core clerkship experiences, butstudents are given significant free-dom to choose sub-internshipsand clerkships in their fourth yearin preparation for their chosenspecialty. The impact of this free-dom of selection on the funda-mental skill set with which internsbegin training has not been stud-ied. When medical school gradu-ates appear on their first day ofinternship, they join their col-

leagues from other regions of thecountry, medical schools, andteaching environments.Interestingly, it has been shownthat incoming interns self-reportdifferences in competencies asso-ciated with differing teachingenvironments. Prince et al.reports that junior doctors whotrained at problem-based learning(PBL) schools felt more preparedby their education for their cur-rent job than their counterparts atnon-PBL schools.4 Sachdeva et al.used the objective structured clin-ical examination (OSCE) to showthat a small group of incomingsurgical interns had significantvariability in their clinical skills asthey entered residency.5 Theseresults were then used to targetindividual deficiencies and plancurricula to ameliorate group-widedeficiencies. In a separate study,Wilson described the use of anOSCE to evaluate baseline skillsof incoming internal medicineinterns and noted significant vari-ability in performances betweeninterns, despite the fact that eachfelt sufficiently prepared for theexercise.6 It was noted that notall subjects had previously donean OSCE prior to this experience.

Variability between residentsis sometimes addressed in residen-

cy programs, but often new doc-tors are welcomed to their newprograms then enter a uniformeducational curriculum. Theassumption is made that, becausethe new residents have all gradu-ated from accredited medicalschools and passed their boards(USMLE Step l and Step 2), theirlearning needs will be similar.Previous research has proven thisnot to be true and intuitively weknow it is unlikely. Ideally, weshould adapt and “tailor” our cur-ricula to the individual needs ofthe learners by early evaluation -prior to the start of residencytraining itself - and planning forinstruction (which could includeself-instruction, as well as moretraditional group-learning and lec-ture-format instruction) to meetthe needs of the learner.

Clearly, there is variabilitybetween individual residents inany given residency program. Wesought to examine this variabilitywith regard to the intended spe-cialty of the resident. With thefreedom to choose fourth yearmedical school electives, do thoseplanning on different careerschoose to learn different skill sets?Do interns in departments ofmedicine, surgery, gynecology,and emergency medicine have dif-

I N V I T E D A R T I C L E24

Specialty Specific SkillsAcquisition of Incoming Post-Graduate Year 1 ResidentsT . E L I Z A B E T H R O B E R T S O N , M D , E M I L Y J . W I N S L O W, M D , L I S AB E R G E R , R N , M A R Y E . K L I N G E N S M I T H , M D , D O R O T H Y A . A N D R I O L E ,M D , Washington University School of Medicine

25I N V I T E D A R T I C L E

ferent skill sets on their first day?Methods: We examined

whether incoming surgical internshave differences in their skill setscompared to interns in other spe-cialties and to more senior surgi-cal house staff. An open-endedquestionnaire was administered onan anonymous basis as a pilotstudy to incoming interns in mul-tiple fields in June, 2003 at a sin-gle institution. IRB approval wasobtained. Twenty-four surgeryinterns (SI), forty-seven internalmedicine (IM) interns, sevenobstetrics and gynecology (OB)interns, eleven emergency medi-cine (EM) interns and thirty sec-ond through fifth year surgeryresidents (SR) were evaluated.Chest radiograph interpretation (4questions), blood gas interpreta-tion (5 questions), fluid and elec-trolyte interpretation (4 ques-tions) and patient managementskills (10 questions) were evaluat-ed. Answers were evaluated to becorrect by an answer key devel-oped by two surgical facultymembers, who evaluated eachanswer sheet independently.Correct answers had to includecritical elements of the responseand be free of defined “critical

errors” – actions which would beinappropriate and also harmful tothe patient. Proportions of com-pletely correct answers by theentire group were comparedbetween groups using T-tests with2 sided p values. Correct answerswere only counted if they werecompletely correct.

Surgical interns were signifi-cantly better at interpreting chestx-rays than were internal medicineinterns. Surgical interns were sig-nificantly better at interpretingfluid and electrolyte than wereinternal medicine and obstetricand gynecology interns.Obstetrics and gynecology internswere significantly better at inter-preting blood gasses than wereinternal medicine and emergencymedicine interns. Emergencymedicine interns were significant-ly better at interpreting fluid andelectrolytes than obstetric interns.All interns were significantlyworse at patient managementquestions than surgical residents.

Summary: Our results sug-gest that incoming interns havedifferent, specialty-specific skillsets. The differences found in thisstudy may be due to differences infourth year preparation for career

choice or group differences inacademic achievement, amongother factors. Our study was con-ducted anonymously, so we couldnot examine possible differencesin performance associated withacademic achievement or comparedifferences in fourth year electivesamong the participants in thisstudy. We surmise that both likelywould have some impact.

Differences in skill sets ofincoming interns have been stud-ied by others. Dugoff et al. evalu-ated pelvic and breast examina-tion skills in entering internalmedicine and obstetrics and gyne-cology interns and found no dif-ferences between the two groups,although significant intragroupvariability was seen.7 The authorswere surprised by the lack of dif-ference between the two sets ofincoming interns, although bothgroups will likely use these skillsin their future careers, which mayhave an impact on their findings.

The University of Michiganhas reported on their comprehen-sive evaluation of interns of all spe-cialties before beginning clinicalduties.8 Their evaluation usedOSCE stations and paper stationsto evaluate baseline skills. Stations

Results: (% correct = proportion correct/total questions x 100)

were adapted to the types ofpatients each group would see intheir residencies (i.e., neonatalproblems for incoming pediatricsresidents). In their study, variancebetween groups was accounted forcompletely by USMLE (Step 1 and2) scores. In contrast, Sachdeva etal. found no correlation betweenUSMLE scores and clinical skillson entry into internship.9 TheMichigan group also noted thatgraduates from their own medicalschool performed better than grad-uates from other schools on theevaluation. This was attributed tothe use of similar stations in train-ing their own medical students.When USMLE scores were con-trolled for, there were no differ-ences between public or privatemedical education, region of thecountry or by specialty.

Much has been reported onintragroup variability and thevalue of determination of baselineknowledge of new doctors.Incoming intern assessment seemsto be useful for program directorsto plan educational curriculum forresidents as some have done.This can also be useful for theinterns to focus their personaleducation with feedback from testresults.

In our study, surgical internsperformed significantly better onchest x-ray interpretation andfluid and electrolyte interpretationthan their counterparts in internalmedicine. This difference couldbe due to surgical intern selectionof fourth year electives to focuson post-operative management,where both skills are emphasizedas opposed to internal medicineintern selection of fourth yearelectives to focus on outpatient

management. This could also bedue to baseline differences in test-ing in the two groups. The rea-sons for the differences werebeyond the scope of the currentstudy.

Interestingly, surgical internswere not significantly differentfrom surgical residents on basicinterpretation skills and faredworse only when managingpatient scenarios. This suggeststhat incoming interns in surgeryin the present study were pre-pared for basic skills at a level toapproximate the skills of moreadvanced residents in surgery.Possibly, incoming interns inother specialties may have pos-sessed skills that more closelymatched those of senior residentsin those respective specialties. Ofnote, all incoming intern groupsperformed significantly morepoorly than the surgical residentgroup on patient managementitems. This supports the thesisthat incoming interns may havewell developed basic skills butadditional clinical experience isrequired for development of morecomplex patient managementskills.

Our study has major limita-tions. As an anonymously admin-istered, pilot study we collecteddata pertaining only to residencyspecialty choice and year of train-ing. Information pertaining toUSMLE scores, class rank, AOAstatus, or rank on departmentalmatch lists, or fourth year electiveexperiences of the interns and res-ident study population was notavailable. In addition, we onlyscored completely correct answersfor subjects, although partiallycorrect answers may be significant

and useful in the classification ofnew doctors.

Future study is warranted inthis area as evaluation of incom-ing interns with basic skills andpatient scenarios may provide use-ful learning needs assessmentinformation to both individuallearners and to their programdirectors that are responsible fordesign and implementation of theeducation curriculum. Is this eval-uation necessary if USMLE scoresreliably predict performance, assuggested by the Michigan group?Correlation of clinical assessmentscores with USMLE data is anarea for future investigation.Reproducibility of data is a keyissue since studies disagree oncorrelation of USMLE scores withclinical skills. Each of the studiesreferred to here involve only onemedical school. Ideally, we wouldevaluate large groups of incominginterns in different specialties inmultiple centers to expand oursample size and add in a determi-nation if where a physicianmatched also accounted for differ-ences in baseline skills. Theimplementation of a multicentertrial may limit the use of OSCEfrom a cost, reproducibility, andtraining perspective. Paper orweb-based evaluations could bethe future of this endeavor. Suchan investigation has been done ina single center: Meier et al used aweb-based curriculum to preparetheir new surgical interns for theirnew jobs with great success.10

New interns were given access tothe web site just after match andcould complete the course at theirleisure. 94% of entering internsutilized the web curriculum withall of them rating the experience

I N V I T E D A R T I C L E26

highly. One can envision a web-based assessment format as anideal way to implement evaluationof new interns with the additionalfeatures of instant feedback andrecommendations for reading andimprovement in areas where defi-ciencies are noted. This assess-ment data would also allow educa-tors to identify new interns withspecific strengths and needs andprovide assistance and support toensure a productive and successfulcareer. Group characteristics arethen easily analyzed for identify-ing focus for early teachingopportunities to the new internclass. Our group is currently con-sidering a web-based multi-institu-tional analysis. ■

References:

1. Graduate Medical EducationCommittee. Prerequisite objec-tives for graduate surgical educa-tion: a study of the graduate med-ical education committee,American College of Surgeons.Journal of the American Collegeof Surgeons 1998; 186:50-62.

2. Scherokman B, Cannard K,Miller J, et al. What should agraduating medical student knowabout neurology? Neurology.1994;44:117-6.

3. Langdale LA, Schaad D, WipfJ, Marshall S, Vontver L, Scott C.Preparing graduates for the firstyear of residency: Are medicalschools meeting the need?Academic Medicine.2003;78:1:39-44.

4. Prince KJ, Van Eijs PW,Boshuizen HP, Van der VleutenCP, Scherpbier AJ. General com-petencies of problem-based learn-ing (PBL) and non-PBL graduates.Medical Education. 2005;39:394-401.

5. Sachdeva AK, Loiacono LA,Amiel GE, Blair PG, Friedman M,Roslyn JJ. Variability in the clini-cal skills of residents enteringtraining programs in surgery.Surgery. 1995:118:300-309.

6. Wilson BE. Performance-basedassessment of internal medicineinterns: Evaluation of baselineclinical and communication skills.Academic Medicine.2002;77(11):1158.

7. Dugoff L, Everett MR, VontverL, Barley GE. Evaluation of pelvicand breast examination skills ofinterns in obstetrics and gynecolo-gy and internal medicine.American Journal of Obstetricsand Gynecology. 2003;189:655-8.

8. Lypson ML, Frohna JG,Gruppen LD, Wooliscroft, JO.Assessing residents’ competenciesat baseline: Identifying the gaps.Academic Medicine. 2004;79:564-570.

9. Sachdeva AK, Loiacono LA,Amiel GE, Blair PG, Friedman M,Roslyn JJ. Variability in the clini-cal skills of residents enteringtraining programs in surgery.Surgery. 1995:118:300-309.

10. Meier AH, Henry J, MarineRM, Murray WB. Implementationof a Web- and simulation-basedcurriculum to ease the transitionfrom medical school to surgicalinternship. The American Journalof Surgery. 2005;190:137-140.

27I N V I T E D A R T I C L E

Holiday ClosureDue to the administrative closure of Southern IllinoisUniversity School of Medicine, the ASE offices will beclosed December 23, 2005 – January 2, 2006.

Over the last century, severalnew technologies have beenapplauded as the holy grails ofeducation, including radio, televi-sion, videotape, computers, andmost recently the Internet. Whilethe lofty educational expectationsof these technologies have notbeen fully realized, each instru-ment has enhanced establishedlearning methods. Virtual reality(VR) represents perhaps the mostfuturistic emerging technologywith potentially powerful educa-tional applications. VR consists ofa collection of technologies thatallow people to interact with andbecome immersed in a computer-generated environment in a natu-ral fashion. VR actively engagesthe learner and therefore it hasbeen shown to be a positiveteaching tool in a number of non-medical fields. For example, VRbeen successfully used to trainmilitary personnel1 and to create avirtual audience to lessen the fearof public speaking.2

The use of VR in medicaleducation is in its infancy and ithas seen its greatest application inscreen-based task trainers, such aslaparoscopic3 and endoscopic sim-ulators.4 VR also has the potentialto be a useful educational tool inlearning complex human interac-tions such as the physician-patientrelationship. Virtual interactionscan produce emotional effects

that are comparable to real inter-actions.5 Virtual patients (VP) arecomputer-based simulations ofreal patients. While VR will notreplace real or standardizedpatient (SP) learning experiences,it can enhance the quality of med-ical education. VR can be used toteach a number of clinical scenar-ios that are not easily learned bytraditional methods.

Virtual patients may offer sev-eral advantages over real patientsor SPs including: 1) limiting vari-ability and expense associatedwith SP training, 2) creating analmost limitless repository ofdiverse and challenging virtualclinical scenarios that are difficultto duplicate with SPs (i.e. infants,children, gender, ethnicity, cultur-al characteristics), 3) maintaininga computerized log or electronicportfolio of student progress withobjective performance data, 4) tai-loring educational methods to fitindividual student learning stylesand rates of progress, 5) providinga controllable, secure, safe learn-ing environment with the oppor-tunity for repetitive practice withfeedback. In addition, the con-trolled VR interface permitsbehavioral and performance track-ing and therefore, it is an excel-lent environment to study humancomputer interactions.Unfortunately, there is little dataregarding the use of VPs in med-

ical education.Through multi-institutional,

interdisciplinary collaborationmedical educators, students andcomputer scientists at the MedicalCollege of Georgia (MCG) andthe University of Florida (UF)have created a highly interactive,life-sized virtual abdominal painscenario.6 The virtual system con-sists of two networked personalcomputers (PCs), one data projec-tor, two web cameras, infraredLEDs to track body movements, atablet PC, and a wireless micro-phone. In the scenario, a life-sizedVP (DIgital ANimated Avatar,DIANA) is projected on the wallof an exam room in SP teachingand testing centers at MCG andUF. Students converse with theVP naturally using a commerciallyavailable speech recognitionengine. Life-sized projection ofthe VP mimics an authentic doc-tor: patient interaction as opposedto other computer-based simula-tions that use traditional interfacessuch as monitors, mice and key-boards (video athttp://www.cise.ufl.edu/research/vegroup/VOSCE/vr2006Submitted.wmv).

Preliminary studies reveal thatmost health professions studentswould use the virtual teachingtool in preparation for interactionwith standardized and realpatients.6-8 Additional work vali-

I N V I T E D A R T I C L E28

The Role of Virtual Patients inMedical Education: Teaching ToolVersus Technological TrendD . S C O T T L I N D , M D , Medical College of Georgia, B E N J A M I N L O K , P H D , University of Florida

dates the use of a virtual scenarioto assess content items related tohistory taking.9 Ongoing effortsinclude developing electronicmeans of assessing verbal andnonverbal communication skillsand subsequently providing learn-er feedback regarding essentialdata gathering and communica-tion skills using a virtual instruc-tor. Finally, we are formally imple-menting and evaluating this inno-vative virtual educational tool intothe health professions curriculumat two institutions. Ultimately,virtual clinical scenarios couldenhance existing standardizedpatient programs at many institu-tions.

This is an exciting time inmedical education and VR isemerging as a teaching tool with avariety of clinical applications. Itis easy, however, to get caught upin hi-tech hype and we cautionagainst unrealistic expectations forVR-based educational tools. It isessential that we demonstrate thatVR can positively influence learn-ing or better yet improve patientoutcomes. Surgical educators mustlead the effort to build, evaluateand embrace these new technolo-gies. Our efforts will foster novelcollaborations with computer sci-entists, engineers and other disci-plines. Finally, if we involvehealth professions students in theevaluative process, we will ensurethese educational tools are learn-er-centered and it will help usidentify with these technological-ly savvy students. ■

References

1. Hill R, Gratch J, Marsella S,Rickel J, Swartout W., and TraumD. Virtual Humans in the MissionRehearsal Exercise System. KIspecial issue on EmbodiedConversational Agents, 2003.

2. Pertaub D, Slater M, and BarkerC. An experiment on publicspeaking anxiety in response tothree different types of virtualaudience. Journal on Presence:Teleoperators and VirtualEnvironments 2001; 11(1): 68-78.

3. Gerson LB, VanDam JTechnology review: the use ofsimulators for training in GIendoscopy. Gastrointest Endosc.2004; 60 (6):992-1001.

4. Schijven M, Jakimowicz J.Virtual reality surgical laparoscop-ic simulators. Surg Endosc.2003;17(12):2041-2.

5. Bearman M, Cesnik B, LiddellM. Random comparison of ‘virtualpatient’ models in the context ofteaching clinical communicationskills. Medical Education 2001;35:824-832.

6. Stevens A, Hernandez J,Johnsen K, Dickerson R, Raij A,Harrison C, DiPietro M, Allen B,Ferdig R , Foti S, Jackson J, ShinM, Cendan J, Watson R, DuersonM, Lok B, Cohen M, Wagner P,Lind DS. The use of virtualpatients to teach medical studentshistory taking and communicationskills. Am J Surg (In Press).

7. Johnsen K, Dickerson R, RaijA, Lok B, Jackson J, Shin M,Hernandez, J, Stevens A, Lind S.Using immersive virtual charactersto educate medical communica-tion skills. Journal on Presence:Teleoperators and VirtualEnvironments (In Press).

8. Dickerson R, Johnsen K, RaijA, Lok B, Bernard T, Stevens A,Lind S. “Virtual Patients:Assessment of Synthesized VersusRecorded Speech,” TheProceedings of Medicine MeetsVirtual Reality 14, 2005.

9. Bernard T, Stevens A, WagnerP, Bernard N, Schumacher L,Johnsen K, Dickerson R, Raij A,Lok B, Duerson M, Cohen M,Lind DS, A Multi-InstitutionalPilot Study to Evaluate the Use ofVirtual Patients to Teach HealthProfessions Students History-Taking and Communication Skills.Abstract submitted to the Societyof Medical Simulation Meeting,January 2006.

29I N V I T E D A R T I C L E

2006Surgical

EducationWeek

March 21-25, 2006

Westen La Paloma

Tucson, AZ

■

Here in Greenville NC weare nearly always in some stage ofcurriculum building, as are mostdepartments of surgery having asurgical residency program. Ourfounding chairperson believed in1978, and believes just as stronglyin 2005, that a curriculum createdby many minds can provide utilityas a roadmap-type guide for abroad assortment of surgical edu-cators and residents. A largenumber of educators closely asso-ciated with the Association forSurgical Education (ASE) and theAssociation of Program Directorsin Surgery (APDS) have workedwith our Greenville team over theyears to produce a curriculumproduct to share, critique, edit,and make better.1-4 We havedetermined that at least one ofour four printed editions some-how, in some shape or form, hasserved hundreds of people aroundthe country, over years of curricu-lum committee work andResidency Review Committee(RRC) visits, beginning in 1990with the 11 surgical residencyprograms who participated in thepilot test of the curriculum.

We, as one education andtraining program for residents,have been faced with organizingand implementing new efforts tobuild, teach, measure, and docu-ment our own resident curriculumduring each of the years since theAccreditation Council for

Graduate Medical Education(ACGME) required “…evidenceof resident attainment of [general]competencies as indicators of aresidency program’s educationaleffectiveness and quality.”5 Wehave tried to incorporate the com-petencies into our learning sched-ule, using many formats. Ourmost recent combination of cur-ricular materials has built a moreuser-friendly collection ofresources from many minds, com-piled and written to provide resi-dents and faculty with thatroadmap curriculum for which wedoggedly strive. These materialsprovide the basis for our educa-tional structure and set the hierar-chy of achievements for our resi-dents’ progression through train-ing. They document our curricu-lum, from start to finish, for theRRC. We share access to thosematerials with you, all in oneplace, in this resource article.

About the same time that wewere notified of the scheduling ofour 2005 RRC site visit, welearned of the upcoming renova-tion for our Office of SurgicalEducation. We heard that oureducation suite, of three roomsstuffed to the rafters with “educa-tion stuff,” would receive anupdate. Dull walls and flattenedcarpeting would be replaced if wejust packed up everything. Afresh office is wonderful in nearlyall instances, but not necessarily

so delightful when slated disrup-tion is for close proximity to thetime of the site visit. Sensibly, weaccepted the RRC schedule, anddelayed the office renovation by afew weeks.

At the time of this writing,our education program recentlyhas become a division in ourdepartment of surgery. To goalong with that importance, ourdivision has just gone through aphysical renovation. The paint isfresh and in brighter colors. Thecarpeting is new and untrodden.We’ve axed old art work, and plansoon to display photos from ourarchives along with an emphasison more pleasant images that willhelp our residents relax as theyspend a few minutes with us “inEducation.”

An updated suite is so muchmore efficient and workable withnearly everything streamlined andcategorized for ease of use andgreater accuracy. In fact, I findthat what we have gone throughfor our office move-out, renova-tion, and move-back-in to be theperfect metaphor for the curricu-lum renovation we have accom-plished over the past three years.Our clerkship director, whoknows the war fronts of Iraq andAfghanistan only too well, com-pared our contortions to movingcamp on the front. Yet, wehaven’t a battlefront, and finallyour new, clean surfaces of frosted

I N V I T E D A R T I C L E30

Curriculum Building from A to C:In Our Future Is D to ZS H E R R A L Y N S . C O X , P H D , East Carolina University

green, textured lavender, andwarm adobe are emerging. Thetwo renovations, office and cur-riculum as comparable transforma-tions, encourage us to invite youto stop by for a visit, whether thatvisit be to our office or ourWebsite.

If you choose the Websitevisit, here are the resources whichyou may wish to consider for yourown curriculum update. Our cur-riculum development philosophyis still the same as it has beenthrough four editions of theSurgical Resident Curriculum(SRC): determine the needs ofyour own residents within therequirements of your faculty sothat you can simultaneously pre-pare a tailor-made curriculum foryour program and for your RRCsite visit.

For considering curricularresources, including educationalgoals and objectives of the resi-dency curriculum, go to www.sur-gery.ecu.edu where you will findour low-tech yet user-friendlyWebsite. You may click on“Residency Program” and then“Residency Curriculum.” At thispoint, you can go directly to aparticular Post Graduate Year(PGY) level, or you can consultone of several resources that wefound significant for preparing ourprogram’s update. Each title inquotation marks below indicates aseparate curriculum buildingresource. The “Trauma andSurgical Critical Care Rotation” isformatted to incorporate theACGME competencies in sixorganizational headings.6

“Curriculum Goals for SurgicalResidents” provides the broadeducational areas of the curricu-

lum along with ACGME compe-tency definitions and programgoals utilized in our faculty andresident program effectivenessassessment instruments. “ACGMEGeneral Competencies” providesthe learning activities and expect-ed outcomes we have defined andperformance targets we observe.“Junior-Senior Objectives for EachRotation” outlines unit objectivesfrom the SRC for each PGY-level.“Surgical Geriatric CurriculumGoals and Objectives” providesthe content basis for increasingresident expertise in caring forspecial needs of elderly patients,as defined by our work with theAmerican Geriatrics Society andthe John A. Hartford Foundation.

Individual links to PGY-levelreflect outcome expectations foreach rotation over six years ofgeneral surgery residency. OurPGY-I link includes learningobjectives selected from the“American College of Surgeons(ACS) Prerequisites for GraduateSurgical Education: A Guide forMedical Students and PGY1Surgical Residents,” “JuniorObjectives for All PGY-IResidents,” and “General SurgeryObjectives for All PGY-I ServiceRotations.” Each level beginswith a reminder of the sixACGME competencies, codedfrom 1-6, with code numberslinked to appropriate learningobjectives. Our PGY-III usually isa research year, so our expecta-tions reflect requirements of theACGME and our faculty for thatyear in the laboratory.

Curriculum building so far,from A to C (from needs “A”ssess-ment to “C”ompetency identifica-tion) has mapped the educational

structure we expect as educators.Now we need to complete theexercise (preparing the “D” to “Z”of the curriculum) in order tomove further along the continuumfor resident learning to meet theneeds of the future. ■

References

1. Smout JC, Pories WJ, eds.Surgical Resident Curriculum.Arlington, VA: Association ofProgram Directors in Surgery.1992.

2. Cox SS, Pories WJ, Foil MB,Patselas TN, eds. The SurgicalResident Curriculum, 2nd ed.Arlington, VA: Association ofProgram Directors in Surgery.1995.

3. Cox SS, Pories WJ, eds.Surgical Resident Curriculum, 3rded. Arlington, VA: Association ofProgram Directors in Surgery.1999.

4. Cox SS, Pofahl WE, Pories WJ,eds. Surgical ResidentCurriculum, 4th ed. Arlington,VA: Association of ProgramDirectors in Surgery. 2002.

5. Batalden P, Leach D, Swing S,et al. General competencies andaccreditation in graduate medicaleducation. Health Affairs 2002;21(5):103-111.

6. Schenarts PJ. Trauma andSurgical Critical Care Rotation:Competency-Based Goals andObjectives. Working paper, EastCarolina University, Departmentof Surgery. Greenville, NC. 2005.

31I N V I T E D A R T I C L E

Small group teaching ses-sions are an invaluable asset tosurgical education. They provideintimate exposure to faculty andare a forum where core surgicalcases can be discussed in a formatdedicated to medical studentsalone.

However, small group teach-ing sessions also have inherentconstraints that limit their poten-tial. At NYU, the clerkship iseight weeks long and tutorialgroups of six to eight studentsmeet for one hour a week, result-ing in a maximum of eight hoursof meeting time per rotation, andsometimes less. This kind of timeconstraint provides fragmentedexposure between faculty and stu-dents, and makes an ongoing dia-logue and assessment of studentsdifficult. A student’s ability torepeatedly demonstrate his or herclinical reasoning skills is verylimited, and this in turn makes itharder for surgical educators toevaluate students’ surgical decisionmaking accurately.

Moreover, the current healthcare delivery environment is anincreasingly difficult forum forstudents to observe a full breadthof cases along the continuum of apatient’s illness. Yet at the sametime, the LCME requires consis-tent exposure to core surgicalcases. This requirement is espe-

cially important in academic med-ical centers where different sitesare used during core clerkshipsand students will have differingclinical experience.

Finally, students in the cur-rent clinical environment usuallyhave limited opportunity to par-ticipate in case discussions or tocollaborate as a team to formulatea differential diagnosis or treat-ment plan. Although competitionis well embedded in medical edu-cation at all levels, cooperation ismuch more difficult to foster andto incorporate into the surgicalcurriculum. As future practicerequires collaboration betweendifferent physicians and specialiststo diagnose and treat patients, theskill to work collaboratively isparamount.

To help address these prob-lems, the NYU Department ofSurgery developed a cyber class-room as an adjunct to small groupteaching sessions. This “class-room” is essentially an asynchro-nous bulletin board which islinked to the weekly tutorial ses-sions. Preset cases, targeted toareas not covered in depth inother areas of the curriculum, arethe focus of weekly discussionsamong students.

Each student is assigned therole of discussion leader once dur-ing the clerkship. The discussion

leader posts the case and guidesthe conversation, whereas theother students are required to posta minimum of two times per week.Guidelines encourage creativethinking and use of evidencebased medicine while discourag-ing “cutting and pasting.”

Students are evaluated on thequality of their postings (see Table1), and the instructions defineclearly the criteria for their evalu-ation. Higher levels of reflectionare demonstrated in the elabora-tion of perspectives where a stu-dent will synthesize information,refer to the literature as well as torelated aspects of the case, andask questions that may relate to orchange treatment perspective.Low levels of reflection includerestating information alone orstating anything without describ-ing its importance.

One of the major goals of thecyber classroom is to foster col-laborative learning among stu-dents. Students are encouraged torespond to each other’s posts tojointly develop a differential diag-nosis for the presented case.Moreover, in the role of discus-sion leader, students learn valuableleadership and teaching skills.

The role of the tutorial lead-ers in the cyber classroom followsthe educational plan of the clerk-ship. They coach the discussion

I N V I T E D A R T I C L E32

The Cyber Classroom as anAdjunct to Small Group TeachingSessionsM A R Y A N N H O P K I N S , M D , NYU School of Medicine

33I N V I T E D A R T I C L E

leader and other students at thestart of the eight week block,guiding the students as they losefocus or steer off track. As theclerkship progresses and the stu-dents grow more confident intheir abilities to work together onthe cases, the tutorial leaders limittheir presence.

An additional advantage ofthe cyber classroom is that theclerkship director can set the cur-riculum to areas where the stu-dents have traditionally scoredpoorly on standardized exams.Moreover, complex material suchas ICU care can be carefullyreviewed at a pace and in a forumwhere the students feel safe,unhurried and comfortable.

We have learned many lessonsover the last year of running thecyber classroom. Both studentsand faculty need a great deal ofguidance in the beginning.Students need to realize that theyare being evaluated on how they

are thinking and the quality of theirpostings. Some students will per-ceive the online forum as a place toshow off or dominate the class-room, and they must be encour-aged to let others participate.

Faculty on the other handmay not all be as comfortablewith the virtual world as an edu-cational milieu. This ease withcomputer based technology is notentirely determined by faculty’sage. Moreover, their role as backseat facilitator needs to be reiter-ated both in their orientation aswell as periodically during theclerkship depending on ourreview of the classroom. This willhelp prevent the classroom frombeing a faculty-run unidirectionaleducational experience and help itbecome a truly student-centeredand student-led dialogue.Moreover, faculty have found thatmonitoring the students’ participa-tion from afar has improved theirability to evaluate the students at

minimal increase in the demandson their time.

In summary, an online cyberclassroom is an invaluable tool inthe educational armamentarium.It provides an additional educa-tional activity without detractingfrom the clinical experience. Itallows students to learn how to beeducators and helps them learnthe value of cooperative and col-laborative patient care. For facul-ty, the cyber classroom provides away to expand the scope of theeducational material for the stu-dents and at the same time givesthem valuable information withwhich to form a more robust eval-uation of the student’s perform-ance. As advances in informationtechnology continue to permeateall aspects of life, surgical educa-tion can find elegant solutions tothe many problems it faces byapplying these advances towardour educational objectives. ■

Table 1: NYU Cyber Classroom – Quality Levels of Student Posts

Level 1: Reporter Reliably gets and reports the facts and identifies problems. This includesthe case presentation and the discussion questions.

Level 2: Interpreter Prioritizes problems and interprets data, asks for additional information,and presents a reasonable differential diagnosis without elaborations.Relates this case to others.

Level 3: Manager Offers diagnostic and therapeutic plan, incorporates patient preferences,accepts responsibility. Presents an elaborated differential diagnosis whichis specific to the patient. Has plans for next steps.

Level 4: Educator Takes initiative, leads by example, develops a plan incorporating uncer-tainties, applies current scholarship critically to the specific patient. Addsa new idea and broadens the conversation to more generalized learning.

A key component of culturalinitiation into medicine, and acornerstone of the ACGMEGeneral Competencies, is profes-sionalism. Professionalism isdefined as “the conduct, aims, orqualities that characterize or marka profession.”1 The process oflearning medical professionalismrequires initiation of students intothe values and attitudes thatundergird the practice of medi-cine. This process is strongly akinto that of learning about a newculture by immersion. Whatremains unclear, however, is ifprofessionalism is something thatmedical educators teach, or if it issimply something that medicaleducators do as a component of a“hidden curriculum.”2

If professionalism is to betaught, a curriculum may takemany forms. Didactic sessions,either with large-group lectures orsmall-group seminars, provide onetype of instruction. Lectures arenot optimal because they fail toconsider the diversity of experi-ences that are present amongadult learners. Small-group didac-tic sessions may provide a moretargeted learning opportunitythan lectures for adult learners.Small-group learning environ-ments should be designed tomove beyond understanding andinto application and analysisthrough activities like role-playing

exercises. Practical experienceslike role-playing or one-on-oneobservation and counseling allowthe adult learner to obtain adirect, concrete experience inwhich they may integrate theirnew knowledge as it is applied,then evaluate the application ofthat knowledge. Role modeling byinstructors, however, provides theclearest demonstration of profes-sionalism for the adult learnerwho is a clinical novice. Rolemodeling accesses the greatestnumber of levels of Bloom’s taxon-omy for the cognitive learningdomain in a single activity. Inaddition, the activity encom-passed by role modeling is inte-gral to medical education, and isfundamental in shaping subse-quent behavior patterns oftrainees. 3-7

Medical education literatureconsistently cites the centrality ofrole models in the development ofvalues, attitudes, and professionalcharacter of medical students.2,4,8,9

Hafferty and Franks provide themost impassioned and cogentargument for the concept of a“hidden curriculum” within whichkey determinants of physicianidentity are taught.2 Theiremphasis on informal curriculumand moral training is consistentwith the idea of medical educa-tion serving as a process of accul-turation. Medical students have

been identified with three pat-terns of identification with rolemodels: active identification,active rejection, and inactive ori-entation (passive reinforcement ofexisting values).5 Role modeling,although pervasive in medicaltraining, must be a consciousbehavior on the part of faculty forit to be an effective teachingmethod.4 Most of the research onrole modeling in medical educa-tion to date has favored descrip-tive, rather than practical, applica-tions. In addition, little of thisdescriptive work has included sur-geons as role models.

Role models also play a piv-otal role in medical student spe-cialty selection.7, 10-13 A particu-larly pertinent aspect of the influ-ence of medical role models onstudent specialty choice is demon-strated by the impact of negativerole models. 10, 11 One Australiansurvey indicated that most stu-dents believed that surgeons werenot approachable.14 This findingwas consistent with a U.S. studyshowing a trend toward studentsfeeling more negative about sur-geon involvement in medical stu-dent education following a clinicalclerkship.15 Students have indi-cated concern about negativeinteractions with other specialtiesby surgeons, and it has been sug-gested that this perception con-tributes to student disinterest in

I N V I T E D A R T I C L E34

Surgeons Behaving Badly?:Professionalism and Role Modelsin Surgical EducationA M A L I A C O C H R A N , M D , University of Utah

surgical careers.15 Althoughattending surgeons have thepotential to be a great source ofpositive influence on studentinterest in surgical careers, theyare also the leading source of neg-ative influence on studentinterest.14 A positive role model-ing experience with a facultymember will leave an impressionupon a medical student, but anegative role modeling experiencemay prove even more influential.

Defined characteristics of sur-geons who medical students per-ceive as good and bad role modelsremain elusive. Establishing prac-tices to encourage faculty who arepositive role models and to correctfaculty who are negative role mod-els cannot occur until these quali-ties are clearly delineated. Ourinterest as surgeons in the devel-opment of professional behavior inour protégés should motivate usforward in these efforts. Thefuture of surgery and surgical sub-specialties may depend upon ourability to do so. ■

References

1. Merriam-Webster’s CollegiateDictionary. Tenth ed. Springfield,MA: Merriam-Webster, Inc.; 1995.

2. Hafferty F, Franks R. The hid-den curriculum, ethics teaching,and the structure of medical edu-cation. Academic Medicine 1994;69(11):861-71.

3. Branch W, Kroenke K,Levinson W. The clinician-educa-tor—present and future roles.Journal of General InternalMedicine 1997; 12 Suppl 2:S1-4.

4. Ficklin F, Browne V, Powell R,Carter J. Faculty and house staffmembers as role models. Journalof Medical Education 1988;36:392-6.

5. Shuval JT, Adler I. The role ofmodels in professional socializa-tion. Social Science Medicine1980; 14A:5-14.

6. Wright S. Examining what residents look for in their rolemodels. Academic Medicine 1996;71(3):290-2.

7. Wright S, Wong A, Newill C.The impact of role models onmedical students. Journal ofGeneral Internal Medicine 1997;12:53-6.

8. Kenny NP, Mann KV, MacLeodH. Role modeling in physicians’professional formation:Reconsidering an essential butuntapped educational strategy.Academic Medicine 2003;78(12):1203-10.

9. Miles S, Lane L, Bickel J,Walker R, Cassel C. Medicalethics education: coming of age.Academic Medicine 1989;64(12):705-14.

10. Katz LA, Sarnacki RE,Schimpfhauser F. The role of neg-ative factors in changes in careerselection by medical students.Journal of Medical Education1984; 59:285-90.

11. Mutha S, Takayama JI, O’NeilEH. Insights into medical stu-dents’ career choices based onthird- and fourth-year students’focus-group discussions. AcademicMedicine 1997; 72(7):635-40.

12. Wright SM, Kern DE,Kolodner K, Howard DM,Brancati FL. Attributes of excel-lent attending physician rolemodels. New England Journal ofMedicine 1998; 339(27):1986-93.

13. Erzurum VZ, Obermeyer RJ,Fecher A, et al. What influencesmedical students’ choice of surgi-cal careers. Surgery 2000;128(2):253-6.

14. Ek EW, Ek ET, MacKay SD.Undergraduate experience of sur-gical teaching and its influence oncareer choice. The Australian andNew Zealand Journal of Surgery2005; 75:713-8.

15. Cochran A, Paukert JL,Neumayer LA. Does a general surgery clerkship influence student perceptions of surgeonsand surgical careers? Surgery2003; 134(2):153-7.

35I N V I T E D A R T I C L E

36 A S E M E M B E R S H I P

Institutional membership in the Association for Surgical Education is available for $400 U.S. funds per year.Institutional membership typically includes the department chair and one designated member. Individual memberships are also available at the rate of $175 U.S. funds annually. The Association for Surgical Educationadvocates institutional memberships for those associated with a medical school or medical center department ofsurgery. International Affiliate Membership is available at the rate of $175 U.S. funds annually. Resident and med-ical student membership are now available at the rate of $15 U.S. funds annually.

Membership year: September 1, 2005 - August 30, 2006

Send to: Susan Kepner, M.Ed., Executive Director, Association for Surgical Education,Department of Surgery, P.O. Box 19655, Springfield, IL 62794-9655

I would like to become a member of the Association for Surgical Education.

Membership type: ❏ Institutional ❏ Individual ❏ International ❏ Resident ❏ Medical StudentEnclosed is a check in the amount of $______________ U.S. funds, annual dues.

Designee 1 or Individual Member Name

Surgical Specialty

Institution

Street Address

City State Zip

Telephone Fax E-mail

Designee 2 (Institutional Memberships only) Surgical Specialty

Street Address

City State Zip

Telephone Fax E-mail

Membership Form

AlabamaBaptist Health SystemUniversity of Alabama Medical Center

ArizonaArizona Health Science CenterMaricopa Medical CenterArkansasUniversity of Arkansas for Medical

Sciences

CaliforniaCedars-Sinai Medical CenterLAC/USC Medical CenterLoma Linda University Medical CenterUCSF Medical CenterUCSF Affiliated HospitalsUniversity of California – Los AngelesUniversity of California -

San FranciscoStanford UniversityUniversity of Southern California

ConnecticutThe Stamford HospitalHospital of St. RaphaelSt. Mary’s HospitalWaterbury Hospital Health Center

District of ColumbiaGeorgetown University Medical CenterWalter Reed Army Medical Center

FloridaUniversity of Florida College of

Medicine

GeorgiaEmory University School of MedicineMedical College of GeorgiaMercer University School of MedicineMorehouse School of Medicine

HawaiiUniversity of Hawaii

IllinoisAmerican College of SurgeonsLoyola UniversityMetropolitan Group HospitalsNorthwestern UniversityRush UniversitySaint Joseph HospitalSIU School of MedicineUniversity of ChicagoUniversity of Illinois - ChicagoUniversity of Illinois - PeoriaUniversity of Illinois - RockfordUniversity of Health Sciences/The

Chicago Medical School

IndianaIndiana University Medical Center

IowaDes Moines University Osteopathic

Medical CenterUniversity of Iowa Hospitals

KansasUniversity of Kansas School of Medicine

KentuckyUniversity of Kentucky College of

MedicineUniversity of Louisville

LouisianaLouisiana State University Health

Science Ctr.Tulane University School of Medicine

MaineUniversity of New England College

of Osteopathic Medicine

MarylandThe Johns Hopkins HospitalSinai HospitalUniformed Services University

of the Health Sciences

MassachusettsBaystate Medical CenterBeth Israel Deaconess Medical CenterBoston Medical CenterBrigham & Women’s HospitalSt. Elizabeth’s Medical CenterUniversity of Massachusetts Medical

Center

MichiganGenesys Regional Medical CenterMetropolitan HospitalMichigan State UniversityOakwood Hospital & Medical CenterProvidence Hospital & Medical CentersSpectrum HealthSt. Joseph Mercy HospitalUniversity of Michigan Medical SchoolWilliam Beaumont Hospital

MinnesotaHennepin County Medical CenterUniversity of Minnesota

MissouriUniversity of Missouri - ColumbiaWashington UniversityUniversity of Missouri – Kansas City

MississippiUniversity of Mississippi Medical Center

NebraskaCreighton UniversityUniversity of Nebraska Medical Center

NevadaUniversity of Nevada

New HampshireDartmouth-Hitchcock Medical Center

New JerseyMonmouth Medical CenterRobert Wood Johnson Medical SchoolRoss University School of MedicineSt. Francis Medical CenterUMDNJ-Robert Wood Johnson Medical

School

New YorkAlbany Medical CollegeAlbert Einstein Medical CenterAlbert Einstein/MontefioreBeth Israel Medical CenterBrookdale University Hospital & Medical

CenterCabrini Medical CenterCatholic Medical CenterColumbia UniversityLenox Hill HospitalLutheran Medical CenterMary Imogene Bassett HospitalMt. Sinai School of MedicineNew York Medical CollegeNew York University Medical CenterStaten Island University HospitalSUNY Health Science Center at BuffaloSUNY Health Science Center at

SyracuseSUNY Health Science Center at

BrooklynSt. Vincent’s HospitalUniversity of BuffaloUniversity of Rochester School of

Medicine

North CarolinaWake Forest University School of

MedicineCarolinas Medical Center

North DakotaUniversity of North Dakota

OhioJewish Hospital of CincinnatiMedical College of OhioMeridia Huron HospitalOhio College of Podiatric MedicineThe Ohio State UniversityUniversity of Cincinnati Medical Center

Oklahoma University of Oklahoma Health Science

CenterUniversity of Oklahoma Health Sciences

Center - Tulsa

OregonOregon Health Sciences University

PennsylvaniaEaston HospitalJefferson Medical CollegeLankenau HospitalMercy Catholic Medical CenterMCP/Hahnemann UniversityPhiladelphia College of Osteopathic

MedicinePinnacle Health HospitalSt. Luke’s HospitalThe Graduate HospitalUniversity of PennsylvaniaUniversity of Pittsburgh School of

MedicineWestern Pennsylvania HospitalYork Hospital

Rhode IslandBrown University School of Medicine

Puerto RicoPonce School of Medicine

South CarolinaMedical University of South CarolinaUSC School of Medicine

South DakotaUSD School of Medicine

TennesseeEast Tennessee State UniversityMeharry Medical SchoolUniversity of Tennessee Medical CenterVanderbilt University School of

Medicine

TexasBaylor College of MedicineMD Anderson Cancer CenterTexas Tech University Health

Sciences CenterUniversity of Texas Health Science

Center at San AntonioUniversity of Texas Medical SchoolUniversity of Texas SouthwestUTMB at Galveston

UtahUniversity of Utah

VermontUniversity of Vermont

VirginiaEastern Virginia Medical SchoolVirginia Commonwealth UniversityInova Fairfax Hospital

WashingtonUniversity of Washington

West VirginiaMarshall University

WisconsinGunderson Lutheran Medical CenterMedical College of WisconsinUniversity of Wisconsin-Madison

AlbertaUniversity of AlbertaUniversity of Calgary

British ColumbiaUniversity of British Columbia

ManitobaUniversity of Manitoba

Nova ScotiaDalhousie University

OntarioMcMaster UniversityOueen’s UniversityUniversity of OttawaUniversity of TorontoUniversity of Western Ontario

QuebecMcGill UniversitySherbrooke UniversityUniversity of Montreal

SaskatchewanUniversity of Saskatchewan

Institutional Members

Association for Surgical EducationEducational ClearinghouseP.O. Box 19655Springfield, IL 62794-9655

Non-Profit Org.U.S. Postage

P A I DSpringfield, IL

Permit No. 680