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BACKGROUND: The use of an objective structured clinical examination (OSCE) has been a powerful influence on doctor training but assessments do not always drive study behaviour in predictable ways. AIMS: To investigate the impact an OSCE has on study behaviours by exploring how 5th year medical students identify what to learn for a summative OSCE and the role of the clinical environment in their preparation. METHODS: A semi-structured questionnaire survey asked about strategies used by students to prepare for the OSCE. Focus group interviews explored successful methods of preparation for the OSCE. Themes were identified and classified. RESULTS: The questionnaire response rate was 84%. Topic identification was usually from the list of examinable problems, past OSCE papers and a booklet prepared by a previous student containing a series of OSCE checklists. The study behaviours of students preparing for the OSCE exam were predominantly to practise on each other, and to rehearse routines. Strategic and efficient study habits were favoured over conscious utilization of the clinical environment. CONCLUSION: The expectation that an OSCE drives learning into the clinical workplace was not supported by this study. This suggests the role of clinical experience in helping students prepare for the exam may be more subliminal, or that an OSCE is more as a test of psychomotor skills than a marker of clinical experience. An unexpected benefit may be to drive more collaborative learning. [ABSTRACT FROM AUTHOR]

PURPOSE: A stapled pouch-anal anastomosis without mucosectomy is widely used in restorative proctocolectomy. Uncertainty exists about the longer-term outcome of retaining a columnar cuff of epithelium in the anal canal and about the need for surveillance of the columnar cuff, The aim of this article was to assess the ability to obtain biopsies of the columnar cuff, to assess the risk of dysplasia. and to search for the presence of aneuploidy as an early of marker of dysplasia in nondysplastic epithelium. METHOD: A total of 457 biopsy specimens were taken during 203 examinations of 113 patients. All biopsy specimens were stained with hematoxylin and eosin and examined by microscopy. One hundred thirty-two of these biopsy specimens from 67 patients were frozen and analyzed by flow cytometry for aneuploidy. RESULTS: Mean follow up after pouch formation was 2.5 years, and the time after diagnosis of ulcerative colitis was 10.1 years. Successful columnar cuff biopsies were done on 93 percent of patients. There was no dysplasia. Two biopsy specimens from one patient had aneuploidy. CONCLUSION: To date, neoplastic change in the columnar cuff is rare. A selective policy of surveillance biopsies is recommended that includes patients greater than ten years after the diagnosis of ulcerative colitis and patients with dysplasia or cancer in their proctocolectomy specimen, but long-term follow-up data arc needed. [ABSTRACT FROM AUTHOR]

Background: Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours., Methods: We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates., Results: We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths., Conclusion: Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

As a member of an Indigenous community myself, my research is necessarily undertaken through an emancipatory Indigenist methodological approach. Indigenous methodologies seek to deconstruct Western paradigms of investigation and understandings that perpetuate the invalidation of Indigeneity, and instead attempt to constitute paradigms centred on Indigenous worldviews. However, Indigenous researchers often work with communities that are not their own. In my case, I have collaborated in a small amount of research with Indigenous groups outside of my own country. But, the majority of my research has been with New Zealand Māori communities other than my own. Key for me, has been the development of personal strategies aimed at keeping me culturally safe in my research with other Indigenous communities, while being secure in my own Indigenous identity. I seek to be culturally respectful in the space of others - safeguarding local Indigenous research sovereignty., Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Thompson-Fawcett.)

Aim: There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs., Method: A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines., Results: Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options., Conclusion: While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs., (© 2022 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Aim: There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure., Method: A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses., Results: A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04)., Conclusion: Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies., (© 2022 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards., Methods: Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days)., Results: Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS., Conclusions: Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team's expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.

Background: Loop ileostomy (LI) formation is a common practice for patients undergoing low anterior resection or restorative ileo-anal pouch surgery. Ileostomy closure can be performed using a stapled or hand-sewn technique, with or without resection. If hand-sewn, the closure can be one or two layers. Randomized controlled trials have not demonstrated one technique to be superior, and meta-analyses are limited by the heterogeneity of published studies. Our primary aim is to compare stapled ileostomy closure with single- and two-layer hand-sewn closures., Methods: This retrospective, single-centre cohort study included patients undergoing LI closure between January 1999 and April 2016. Patient demographics, anastomotic technique, operative time and patient outcomes were collected., Results: Our analysis included 244 patients (median age 67 years, 43.4% female). There were no significant differences in mean operative times (71.5, 73.1 and 88.5 min, for stapled, single- and two-layer hand-sewn closures, respectively, adjusted overall P = 0.262), or morbidity (21.5% versus 20.4% versus 17.6%, adjusted overall P = 0.934) between stapled or hand-sewn anastomoses, and no mortality. Once adjusting for age, sex, American College of Anaesthesiology grade, and consultant surgeon, the length of stay was different (overall P = 0.034), being similar between stapled and single-layer closures (4.2 versus 5.5 days, P = 0.105), but significantly different between stapled and two-layer closures (4.2 versus 8.3 days, P = 0.026)., Conclusion: Stapled and single-layered hand-sewn closures are similar in length of procedure, length of stay and complication rates. A two-layer, hand-sewn technique is associated with a significant increase in stay compared to a stapled ileostomy closure., (© 2020 Royal Australasian College of Surgeons.)

Background: Colorectal cancer is one of the most incident cancers in New Zealand. Due to resource limitations, some patients experienced protracted wait times before reaching a definitive diagnosis. We analysed the relationship between time to diagnosis and clinical stage and reviewed the length of time for components of the diagnostic work-up to identify priority areas for service improvement. We benchmarked our timeliness against introduced standards., Methods: This retrospective study included all patients with colonic (not rectal) cancer between October 2007 and September 2009. Patients were stratified into an early and advanced group. Types of delay were calculated from the onset of symptoms to the administration of treatment. The compliance with target waiting times was assessed., Results: Fifty-eight patients were included in the early group and 83 patients in the advanced group. There were no significant differences in demographics or symptoms. The work-up was longer than international benchmarks, but with wide variations. There was no statistical difference between lengths of work-up in the groups. The advanced group had increased utilization of private and emergency investigations. Forty-four per cent met the diagnostic colonoscopy target waiting time of 42 days with a trend in favour of the advanced group and 21% received treatment within 62 days (non-significant)., Conclusion: Current systems are not sophisticated enough to predict the stage of colon cancer. Here, long waiting times were not associated with cancer stage in symptomatic patients. Resources need to be directed to diagnostic colonic imaging., (© 2014 Royal Australasian College of Surgeons.)

Background: Pathogenic mechanisms responsible for the undulating symptom pattern, or indeed causative agents for the development, of inflammatory bowel diseases [IBD] are largely unknown. Many physicians and most patients are convinced that stress affects the course of IBD. As with most factors that contribute to IBD, it is unclear whether stress merely exacerbates established disease or indeed contributes to the development of disease. We designed this study to investigate whether stress induces or aggravates colitis in interkeukin-10 knockout [IL-10 ko] mice and to determine the role of intestinal permeability in this model of stress-related colitis., Methods: The study was divided into two experiments depending on the age of the animals. Stress was induced by placing 5-week old disease-free mice or 8-week-old mice (IL-10ko and wild type [wt]) with mild colitis in movement restrainers for 2h twice daily for 7 days. The development of colitis was assessed clinically [weight and faecal pellet production], histologically [haematoxylin and eosin staining], and biochemically [colonic IL-2, IL-4, IL-6, IL-12p40, TNFα, and IFNγ]. Permeability was measured in Ussing chambers., Results: Faecal pellet production increased significantly in all stressed animals compared with control animals, indicating successful application of stress. Stressed 8-week old mice lost weight [p < 0.001] and stressed IL-10(-/-) mice showed a significantly increased histological score compared with non-stressed or wt mice [p < 0.001]. There was no appreciable difference in cytokine production. Stress did not alter intestinal permeability., Conclusions: Restraint stress aggravates experimental colitis in 8-week old IL-10ko mice but cannot induce colitis in disease-free younger mice. This is not mediated by an increased intestinal permeability., (Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Intravenous acetaminophen is a commonly used analgesic following surgery. The aims of this study were to determine the population pharmacokinetic profile of intravenous acetaminophen and its metabolites in adult surgical patients and to identify patient characteristics associated with acetaminophen metabolism in the postoperative period. 53 patients were included in the dataset; 28 were men, median age (range) 60 years (33-87), median weight (range) 74 kg (54-129). Patients received 1, 1.5 or 2 g of intravenous acetaminophen every 4-6 h. Plasma and urine samples were collected at various intervals for up to 6 days after surgery. Simultaneous modelling of parent acetaminophen and its metabolites was conducted in Phoenix(®) NLME™ to estimate pharmacokinetic parameters. The population mean estimate (CV%) for central (plasma) volume of distribution of parent acetaminophen (VC) was 13.9 (4.41) L, peripheral (tissue) volume of distribution (VT) was 50.9 (2.96) L, and intercompartmental clearance (Q) was 77.5 (9.29) L/h. The population mean (CV%) metabolic clearances for glucuronidation (CLPG) was 8.92 (3.25) L/h, sulfation (CLPS) was 0.903 (3.47) L/h, and oxidation (CLPO) was 0.533 (7.90) L/h. The population mean (CV%) urinary clearances of parent acetaminophen (CLRP) was 0.137 (5.46) L/h, acetaminophen glucuronide (CLRG) was 3.81 (6.71) L/h, acetaminophen sulfate (CLRS) was 3.13 (4.32) L/h, and acetaminophen cysteine + mercapturate (CLRO) was 3.51 (9.98) L/h. Age was found to be a significant covariate on the formation of acetaminophen glucuronide, and renal function (estimated as creatinine clearance) on the urinary excretion of acetaminophen glucuronide.

Introduction: Assessment decisions increasingly rely on synthesis of information from a variety of sources. It is known that aggregation of information to make decisions is open to a number of biases. The aim of this research was to investigate bias, accuracy and confidence of assessment decision making., Methods: The participants were consultation skills assessors. A model for incremental information was developed with participants being shown results from purposefully selected, but authentic, data from the University's final summative 10-station Objective Structured Clinical Examination (OSCE). After each piece of information, participants gave a pass-fail decision and their confidence in that choice. Following the information from 10 OSCE stations the participants were given a discordant fictional anecdote and again participants gave a pass-fail decision and their confidence., Results: When there is overwhelming evidence to support a pass or fail, participants were not as confident as the data would support. Participants were less confident to make a fail decision than a pass. Despite considerable evidence from multiple results some participants altered decisions based on isolated contradictory information from an anecdote., Discussion: These findings are significant in understanding decision-making. Given equivalent levels of evidence, decision makers are less confident to fail than pass and less robust information can undermine more robust information.

Introduction: Sigmoid volvulus typically occurs in older patients who have multiple co-morbidities. Therefore, often, a conservative approach to management is chosen. However, there is little data on long-term outcomes of this approach in Australasia. The aim of this study was to review the recurrence and mortality outcomes of patients admitted to Dunedin Hospital with sigmoid volvulus., Methods: All cases of sigmoid volvulus admitted to the Department of General Surgery at Dunedin Hospital from January 1989 to January 2009 were identified using a prospective database, the Otago Clinical Audit. Mortality data was accessed from the National Births and Deaths Registry., Results: Fifty-seven patients, median age of 68, were included in the study with 84 admissions for sigmoid volvulus. A total of 39 of the 57 patients ultimately had surgery, 26 on the index admission. Thirty-one patients (61%) treated conservatively at index admission had a recurrence at a median of 31 days. Forty-two per cent of the patients treated conservatively a second time suffered a further recurrence at a median of 144 days. There was no recurrence in patients who had surgery. There was no in-hospital mortality reported in either group. There was one anastomotic leak in the surgical group. Minor complications included ileus, respiratory infections, urinary tract infection and a hernia., Conclusion: Early elective operation for cases of sigmoid volvulus is encouraged in patients without prohibitive co-morbidities as this study shows a high recurrence rate in conservatively managed patients and a low morbidity and mortality in surgically managed patients., (© 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.)

Background: Clinical decisions require insight and foresight. When these are lacking, overconfidence and error can occur., Aims: Multiple choice questions (MCQ) responses were used to estimate insight, as determined by confidence in responses, and foresight, as determined by the safety of incorrect responses., Methods: An MCQ response system was developed which reflected confidence in, and safeness of, responses. An optional examination incorporating this system was offered to medical students at one university., Results: A total of 372 students completed the study. There was evidence of insight. The proportion of responses that were correct rose from 32% for low confidence to 77% for high confidence. The proportion that was incorrect and not unsafe fell from 34% for low confidence to 7% for high confidence. There was less evidence of foresight. Of the responses that were incorrect, the proportion that was unsafe increased from 52% for low confidence to 68% for high confidence. Measures of insight and foresight increased with experience. Students with poorer knowledge chose more unsafe responses, but with lower confidence. Five students gave multiple highly unsafe responses held with high confidence., Conclusions: Students had insight but less foresight. Experience and knowledge altered measures of both. This response system identified students who appeared to lack both.

Background: Intravenous (IV) paracetamol is commonly used in the postoperative period for the treatment of mild to moderate pain. The main pathways for paracetamol metabolism are glucuronidation, sulfation, and oxidation, accounting for approximately 55%, 30%, and 10% of urinary metabolites, respectively. The aim of this study was to describe the pharmacokinetics of IV paracetamol and its metabolites in adult patients after major abdominal surgery., Methods: Twenty patients were given 1 g of paracetamol by IV infusion at induction of anesthesia (Interval 1) and every 6 hours thereafter, with the final dose given at 48-72 hours (Interval 2). Plasma and urine samples were collected for up to 8 hours after infusion for both intervals. The samples were analyzed by high-performance liquid chromatography to determine the amount of paracetamol and its metabolites. The data were modeled in Phoenix WinNonlin using a user-defined ASCII parent-metabolite model with linear disposition, to obtain the estimates for volume of distribution, metabolic and urinary clearance., Results: Mean (95% confidence interval) metabolic clearance to paracetamol glucuronide increased from 0.06 (0.05-0.08) to 0.14 (0.11-0.18) L · h⁻¹ · kg⁻¹, P value <0.001 and urinary clearance increased from 0.08 (0.07-0.09) to 0.14 (0.10-0.17) L · h⁻¹ · kg⁻¹, P value 0.002. The mean (95% confidence interval) volume of distribution of paracetamol increased from 0.17 (0.12-0.21) to 0.43 (0.27-0.59) L · kg⁻¹, P value 0.032., Conclusions: After major abdominal surgery, there were apparent increases in the metabolic conversion to paracetamol glucuronide and its urinary clearance suggesting potential induction of paracetamol glucuronidation.

Background: Chronic pouchitis is an important long-term complication following ileal pouch-anal anastomosis for ulcerative colitis. Antibiotic administration reduces symptoms of pouchitis, indicating that bacteria have a role in pathogenesis. The aim of the research was to investigate the bacterial content of pouches using nucleic acid-based methods., Methods: Stool microbiota of 17 patients with normal pouches (NP), 17 patients with pouchitis (CP) utilizing samples collected from each patient when antibiotic-treated (CP-on, asymptomatic) and when untreated (CP-off, symptomatic), and 14 familial adenomatous polyposis (FAP) patients were analyzed by high-throughput sequencing, fluorescence in situ hybridization technologies, and quantitative polymerase chain reaction (qPCR)., Results: Fluorescence in situ hybridization analysis revealed an expanded phylogenetic gap in NP and CP-off patients relative to FAP. Antibiotic treatment reduced the gap in CP stool. The phylogenetic gap of CP-off patients was due to members of the bacterial families Caulobacteriaceae, Sphingomonadaceae, Comamonadaceae, Peptostreptococcaceae, and Clostridiaceae. There was a greater diversity of phylotypes of Clostridiaceae in CP-off subjects. The phylogenetic gap of NP stool was enriched by Ruminococcaceae and Bifidobacteriaceae. CP stool microbiota had reduced diversity relative to NP and FAP stool due largely to a reduction in Lachnospiraceae/Insertae Sedis XIV/clostridial cluster IV groups., Conclusions: Bacterial groups within the expanded phylogenetic gap of pouch patients may have roles in the pathogenesis of pouchitis. Further research concerning the physiology of cultured members of these groups will be necessary to explain their specific roles. Members of the Lachnospiraceae, Incertae Sedis XIV, and clostridial cluster IV could be useful biomarkers of pouch health., (Copyright © 2011 Crohn's & Colitis Foundation of America, Inc.)

We present the first three reported cases of single incision (through the umbilicus) laparoscopic cholecystectomy in New Zealand. The mean operating time was 108 minutes and all patients were discharged 24 hours after the procedure; they were all satisfied with their procedure and were keen to recommend it. We also provide a review of the international literature on this relatively new technique in New Zealand.

Purpose: Sacral nerve stimulation is one of many new surgical modalities for fecal incontinence. Short-term results from sacral nerve stimulation have been more encouraging than those from other modalities. The aim of this study was to report the outcome of percutaneous nerve evaluation tests and sacral nerve stimulation for the treatment of fecal incontinence from a single center covering a period of 6 years since the procedure was introduced., Methods: All of the candidates for a percutaneous nerve evaluation test and sacral nerve stimulation seen at our anal physiology unit between March 2001 and March 2007 were included in the study., Results: A total of 177 patients with fecal incontinence (160 females), median age 59.5 (range, 27-88) years, underwent a percutaneous nerve evaluation test. Of these patients, 142 (80%) had a positive test, including 21 of 25 (84%) patients who required a repeat percutaneous nerve evaluation test. Because of a functional failure, 16 patients underwent a revision of the permanent electrode, 7 of whom (44%) were satisfied with the functional result after the revision. Of 126 patients, 15 (12%) have undergone an explantation, with an infection rate of only 1.6%. Overall, after a median follow-up of 24 (range, 3-72) months, the median Wexner incontinence score decreased from 16 (range, 6-20) to 10 (range, 0-20) (P < .0001). In the 10 patients who underwent at least 6 years of treatment, the effect was sustained, as the median Wexner incontinence score decreased from 20 (range, 12-20) to 7 (range, 2-11) (P < .0001)., Conclusion: Sacral nerve stimulation is a simple, safe, and minimally invasive technique with low morbidity and excellent results, which appear to be maintained for the first 6 years after the procedure. For patients who underwent the treatment, median Wexner incontinence score decreased significantly after a median follow-up of 24 (range, 3-72) months. Twelve percent were explanted. The infection rate was 1.6%.

Aim: To explore ways in which student learning during formal ward rounds can be enhanced., Method: Qualitative study of University of Otago medical students (Dunedin, New Zealand) involving observation of surgical teams during formal ward rounds, and indepth interviews with students and consultant surgeons., Results: Teaching and learning opportunities on ward rounds were often missed by both clinical teachers and students as service provision and patient care took precedence. As a result, students often felt excluded and frequently expressed ambivalence about the educational value of formal whole team ward rounds. Students were more likely to consider themselves part of the team when they felt useful and were included in team discussions about patient care. They reported that they learned more effectively on smaller, more educationally focussed ward rounds that incorporated bedside tutorials and opportunities to practice examination skills., Conclusion: Students and clinical teachers know that students need to make the most of learning opportunities by being proactive, spending time on the ward, being useful, asking questions. Clinical staff can facilitate student learning by consciously including students in the business of patient care. This means inviting students to ask questions and examine wounds, physically guiding hands on examinations, encouraging students to pay attention to discussions among the clinical team, and explaining what is being discussed.