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

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

Cowden's disease is a well-described clinical syndrome, the primary symptoms of which are orocutaneous hamartomas and disseminated gastrointestinal polyposis. In general, the gastrointestinal polyps are benign, and the incidence of malignant transformation is believed to be low. Other associated manifestations of Cowden's disease include breast cancer and thyroid disease (benign and malignant). A patient with previously unrecognized Cowden's disease underwent upper gastrointestinal endoscopy for surveillance of hyperplastic gastric polyps, and a gastric carcinoma in situ was detected. During the course of follow-up the patient was found to have primary hyperparathyroidism resulting from a parathyroid adenoma. Although several benign proliferative and malignant conditions are associated with Cowden's disease, neither parathyroid adenoma nor gastric carcinoma has been reported previously.

Background: Surgical residents have traditionally been evaluated by ward evaluations and multiple-choice testing; overall resident performance has seldom been objectively evaluated. We developed a comprehensive evaluation program for senior residents. The purpose of this study was to determine whether the several different assessment methods included in this program provide similar information about senior residents' clinical knowledge and performance., Methods: Sixteen senior general surgery residents were evaluated by subjective faculty ward evaluations, a structured oral examination, the American Board of Surgery In-Training Examination, and an objective structured clinical examination (OSCE). The OSCE was divided into two parts: part A required the resident to obtain a directed history or to perform a physical examination; part B required the resident to answer questions about the patient seen in part A., Results: The various evaluation methods differed in their estimates of clinical competence (ward evaluations rated residents highest; the OSCE, lowest). The American Board of Surgery In-Training Examination correlated with both the structured oral examination and OSCE part B, indicating that all are adequate measures of knowledge. Neither the total OSCE score nor OSCE part A correlated with other measures, but the fact that both are highly reliable suggests that they evaluate different clinical skills. Faculty ward evaluations are inflated and do not correlate with other measures., Conclusions: We conclude that developing a comprehensive program for evaluating resident competence is desirable and feasible.

Autometastasis of colon cancer to the intestinal mucosa is a condition that has not been previously described. The 70-year-old man presented in this case report was seen for routine surveillance colonoscopy 14 months after low anterior resection, without anastomosis, of a Dukes' stage C mucinous adenocarcinoma of the rectosigmoid. The patient had received adjuvant chemotherapy according to Southwest Oncology Group protocol 8899. The routine colonoscopy revealed many new polypoid lesions in the remaining left and transverse colon, and the patient underwent completion total abdominal colectomy. Examination of the specimen revealed more than 100 polyps; the histologic examination identified these polyps as metastatic signet ring mucinous adenocarcinoma.

Background: Three types (functioning solid, nonfunctioning solid, and functioning cystic) of neuroendocrine neoplasms (benign and malignant) of the pancreas have been reported., Patients: We report three patients with nonfunctioning neuroendocrine neoplasms of the pancreas with cystic components, a type of neoplasm not previously reported. One of the neoplasms we report was benign; the other two were malignant. The patients were admitted with abdominal pain. In each case an abdominal computed tomography scan defined a large multicystic pancreatic mass., Results: In all instances, immunochemical staining was positive for neuroendocrine markers, confirming the neuroendocrine nature of the tumors. The nonfunctional nature of the neoplasms was confirmed by (1) the absence of clinical symptoms traditionally attributed to neuroendocrine secretagogues and (2) the lack of gastroenteropancreatic peptide serum levels., Conclusions: Two of these three cases represent another subset of pancreatic neuroendocrine pathology: a nonfunctional cystic neoplasm. Increased clinical awareness, appropriate operation, and better immunohistochemical staining techniques may yield more, heretofore unrecognized, subtypes. These cases reemphasize the need for proper surgical exploration and biopsy of all unexplained pancreatic cystic lesions, particularly if they are multicystic.

Noting that noncognitive factors may be more predictive of success in a medical career than is intellectual ability or cognitive performance, we undertook a study to determine whether a surgical personality exists and to delineate the temperament and personality traits that contribute to its definition. The Krug Adult Personality Inventory, the Strelau Temperament Inventory, and Barclay's adjective checklist were administered to 110 physicians, 35 in a "controllable lifestyle" specialty, 28 in primary care, and 47 in surgery or a surgery subspecialty. In addition, participants completed a stress inventory. Results showed that surgeons form a distinct and homogeneous group based on temperament and personality traits. We suggest that noncognitive factors can be of use to medical educators in the selection, counseling, training, and evaluation of medical personnel.

Background: Traditional ward ratings and multiple-choice tests do not reliably assess clinical competence. This study determined the reliability of the Objective Structured Clinical Examination (OSCE) and its sensitivity in detecting the performance gains and deficits in surgical interns., Methods: A comprehensive 35-station OSCE was administered to 23 incoming interns and seven outgoing interns. The OSCE comprised 17 two-part clinical problems, relying primarily on actual or simulated patients. The reliability of the examination was assessed by coefficient alpha. Significant differences in performance between the two intern groups, between parts A and B, and among the 17 problems were determined by a three-way ANOVA: OSCE performance was also correlated with National Board of Medical Examiners Part II scores., Results: The reliabilities of part A, part B, and parts A and B combined were 0.72, 0.70, and 0.82, respectively. Overall, the outgoing interns performed significantly better than the incoming interns: 58% +/- 1% mean OSCE score versus 47% +/- 1% (p = 0.0001). The 17 clinical problems differed significantly in difficulty; major performance deficits were seen in both groups of trainees. The correlation of OSCE scores with National Board of Medical Examiners Part II scores was not significant (r = 0.11, p = 0.633)., Conclusions: We conclude that the OSCE is an innovative, reliable tool for evaluating resident competence. Although outgoing interns performed better than did incoming interns, the OSCE scores clearly indicated major performance deficits in all interns.

The simultaneous occurrence of hyperthyroidism and primary hyperparathyroidism is rare in the absence of previous neck irradiation. We report two cases from our institution. Hypercalcemia secondary to hyperthyroidism is common and may obfuscate the diagnosis of concomitant primary hyperparathyroidism. Therefore the continued presence of hypercalcemia in a patient with successfully treated hyperthyroidism should lead the physician to search for primary hyperparathyroidism. Treatment of these concomitant disease processes consists of combined thyroidectomy and parathyroidectomy.

Primary solid tumors of the greater omentum are rare, with only 42 reported cases. Malignant hemangiopericytomas constitute only three of these cases. The 40-year-old patient described in this report had abdominal pain, a palpable abdominal mass, early satiety, and weight loss. At laparotomy a large omental hemangiopericytoma was excised, and no other evidence of disease was grossly evident. Eighteen months after initial laparotomy, the patient had widespread progression of the tumor and, despite chemotherapy, died 2 months later. A review of reported cases shows that abdominal discomfort (56%) and mass (35%) are the most common clinical characteristics of a primary omental tumor. Weight loss, ascites, and peritoneal implants usually indicate malignancy. Rare long-term follow-up prevents definitive conclusions regarding therapy and prognosis. At present, surgical excision alone appears to be the treatment of choice, with no demonstrable benefit from either chemotherapy or radiation.

To learn more about the prognosis of young patients with atherosclerotic cardiovascular disease we reviewed our experience with patients 40 years of age or younger who required surgical intervention for cardiovascular occlusive disease. We identified 47 patients, 25 of whom required peripheral vascular reconstruction and 22 of whom underwent coronary artery bypass grafting. All but one patient were extremely heavy cigarette smokers. Of the 11 women with peripheral vascular disease, eight required operations for limb salvage and three for renovascular hypertension. Four of the 11 women required a total of 11 subsequent operations because of recurrent or progressive disease. Of the 14 men, 13 required intervention for limb salvage and one for renovascular hypertension. Forty-five additional operations, including 15 amputations, were required in these 14 male patients because of recurrent or progressive disease. Of the 22 patients (21 men and one woman) who underwent coronary artery bypass operations, there was one postoperative death. Five patients (23.8%) required a second bypass operation and one patient (4.8%) required a third procedure bypass because of recurrent symptoms and occluded grafts. One patient has occluded grafts and inoperable disease. Atherosclerotic cardiovascular disease in young patients appears to be a virulent disease process and is associated with a high rate of recurrent or progressive disease. There is a striking association between the premature development of atherosclerotic cardiovascular disease and cigarette smoking.

Roux-en-Y gastric bypass (RGB) is an accepted operation for the control of body weight in morbidly obese patients. Early technical complications and inadequate weight loss, well-known sequelae of this procedure, necessitated reoperation in 42 patients of 920 who underwent RGB in a 10-year period. Indications for reoperation included dilated gastrojejunal anastomosis (16), inadequate weight loss without demonstrable enlargement of the anastomosis (10), staple line breakdown (6), anastomotic obstruction (4), anastomotic leak (4), and enlarged proximal gastric pouch (2). Reoperation consisted of completely redoing the initial RGB in 20 patients, redoing the anastomosis alone in 17 patients, staple line revision in four patients, and intraoperative dilatation of the anastomosis in one patient. After initial RGB, 26 of the 42 patients (61.9%) experienced major complications. After revision of RGB, there were major complications in 21 patients (50%). In conclusion, major postoperative complications may contribute to RGB failure, RGB revision for early technical failure or inadequate weight loss is associated with a high incidence of major complications and, subsequently, negligible weight loss. Therefore repair of RGB for technical failure or complications is not recommended.

A focus of medullary thyroid cancer was found at frozen section analysis of tissue from a patient with Graves' disease undergoing thyroid lobectomy. An increased incidence of papillary-follicular thyroid cancer has been noted in Graves' disease. This report describes the unique association of medullary thyroid cancer and Graves' disease.