25. Teaching Breaking Bad News Using Mixed Reality Simulation

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  • three systems (11:1). The most common additional suggested crite-rion was in-hospital cardiac arrest, which occurred in nine pa-tierecmea ctalImliapaodscar




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    over the 7-year study period. All patients had started ARV beforeadmission. Procedures performed before and after the availability ofhigananurgopeateou(OpweFo(OpCDc/mpweCoemopeforinvanopeme



    182 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONSABSTRACTSnts. Five of these patients died during their admission, but noneeived a palliative care consultation. Conclusion: 77% of patientseting expert-derived guidelines for palliative care did not receiveonsultation. One half of patients who did not survive their hospi-ization met a criterion, but only 30% received a consultation.plementation of consultation triggers will increase access to pal-tive care services in the SICU. However, the overall number oftients meeting these triggers was low, suggesting that other meth-will be necessary to significantly increase the use of palliativee services in the SICU.

    Clinical Triggers forPalliative CareConsultation

    Criterion metn, (% total)

    Consult obtained n,(% criterion met)

    mily request 4 (1.3) 4 (100)mily disagreement witheam, advance directive,r each other 7 days

    1 (0.33) 1 (100)

    U stay 30 days 4 (1.3) 1 (25)ath expected duringame SICU stay

    5 (1.7) 1 (20)

    lti-system organ failure3 systems

    11 (3.7) 1 (9.1)

    iagnosis with medianurvival 6 monthsapplies only to 51ancer patients]

    3 (5.9) 0 (0)

    SICU admissionsuring sameospitalization

    3 (1.0) 0 (0)

    sgow coma score 8or 1 week in a patient75 years old

    0 (0) n/a

    sgow outcome score3 (i.e. persistentegetative state)

    0 (0) n/a

    tility considered oreclared by medicaleam

    0 (0) n/a


    ckground: Despite an increasing population of individuals un-going surgical procedures with a pre-operative diagnosis of HIVd AIDS, factors which predict post-operative mortality remainrly defined. Methods: In British Columbia (BC), Canada, allV/AIDS patients receiving any form of anti-retroviral therapyV) are followed prospectively by the BC Centre for Excellence inV/AIDS. Our retrospective review examined all patients who un-went any surgical procedure (excluding dental and endoscopiccedures) between June 1995 and March 2002. The primary out-e evaluated was the 30-day post-operative mortality. Demo-phic, clinical, and hospitalization-related variables were exam-d with logistic regression analyses to assess possible associationsh this outcome. A sub-analysis was carried out for a subset ofcedures for which additional laboratory data was available withinmonths prior to surgical admission. Results: A total of 3213cedures in 1840 patients (1480 [80.4%] males) were carried outhly-active anti-retroviral therapy (HAART) totalled 508 (15.8%)d 2705 (84.2%), respectively. A total of 1026 patients (31.9%) hadAIDS diagnosis prior to surgery. Admissions were identified asent/emergent in 1840 procedures (57.3%). Overall, 30-day post-rative mortality was 7.4% (238 deaths). In a stepwise multivari-analysis, older age (10yr increment) (OR1.32; p0.001), previ-

    s AIDS diagnosis (OR1.50; p0.001), injection-drug naivetyR1.58; p0.007), surgery at a teaching hospital (OR1.63;0.009), and urgent/emergent admission (OR7.32; p 0.001)re significantly associated with 30-day post-operative mortality.r the sub-analysis of 1825 procedures, injection-drug naivetyR1.62; p0.036), older age (10yr increment) (OR1.64;0.001), urgent/emergent admission (OR4.60; p0.001),4200 cell/mm3 (OR1.67; p0.032), plasma viral load100,000L (OR2.06; p0.001), hemoglobin120 g/L (OR2.38;0.001), and white blood cell count11 g/L (OR2.55; p0.003)re significantly associated with 30-day post-operative mortality.nclusions: In HIV/AIDS patients undergoing surgery, urgent/ergent admission is the strongest predictor for 30-day post-rative mortality. Pre-operative assessment of HIV/AIDS patientselective surgical procedures should include specific laboratoryestigations such as CD4 count, plasma viral load, hemoglobin,d white blood cell count. This is useful for prediction of post-rative mortality and is thus important in surgical risk assess-nt and patient counselling.


    . TEACHING BREAKING BAD NEWS USING MIXED RE-ALITY SIMULATION. M. W. Bowyer1, J. L. Hanson1, E. A.Pimentel1, A. K. Flanagan1, L. M. Rawn2, A. G. Rizzo1, E. Ritter1,J. O. Lopreiato1; 1Uniformed Services University, Bethesda, MD;2Vanderbilt University, Nashville, TN

    troduction: Breaking bad news (BBN) compassionately is a vitalrt of medical practice but is not a focus of most training curricula.r novel approach to teaching BBN involves having students ac-ely participate in an unsuccessful trauma resuscitation (gunshotund to the chest) on a high fidelity human patient simulatorannequin) followed immediately by BBN to a standardized patiente (SPW) portrayed by an actress. Methods: 553 3rd year medicaldents starting a surgery clerkship completed a baseline question-ire that included self-assessment of their current ability to andn for BBN. They were then divided into four groups as follows:oup 1 (n163) received no training prior to speaking with theW. Group 2 (n 163) watched a 15 minute video on the SPIKEStting, Perception, Invitation, Knowledge, Empathize, and Sum-ry) protocol for BBN immediately prior to speaking to the SPW.oup 3 (n109) received a lecture on SPIKES and observed anmple of BBN (Informing a woman that she had miscarried) inctored small groups the day prior to the resuscitation and BBN.oup 4 (n118) received the same training as group 3 but alsotched the SPIKES video immediately prior to speaking with theW. After the encounter, students completed a self assessment ofir ability to have a plan for and to BBN and were evaluated by theWs (blinded to their training group) on a 5 point Likert scale on 21ms related to the students appearance, communication skills, andotional affect. All Groups received cross-over training after thecounter. Results: All groups had received approximately twours of prior training in BBN during the first two years of medicalool and believed that learning this skill was very importantean 4.1 on Likert scale of 1-5). Of those students who had already

  • done a clinical rotation, 17% had been placed in a situation wherethey had to break bad news to a patient. All four groups self assessedabbameexp4.2(wbotapwhthaSPSPsiostuimnoLepro



    TABLE 1






    Inthefirscomperlyiflacharoseffa gtiotasrewnopaplo(Ycurachnudembain(nwa(ra(ralowcurbuverin(raing(ra

    183ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONSABSTRACTSility to BBN and ability to have a plan improved significantly overse line (p value range 3.7 1013 to p 3.5 1045). Improve-nt over baseline was most pronounced in group 2. All rated theerience as extremely valuable (mean 4.5) and very realistic (meanon a 5 point scale). Students who received any sort of training

    atching the SPIKES video, didatic lecture and demonstration, orh) prior to BBN were rated higher on several of the parameters ofpearance, communication, and emotions by the SPWs. The groupsose performance was most consistently rated superior were thoset watched the SPIKES video immediately prior to speaking to theW. The performance benefit of receiving a didactic lecture onIKES and observing an example was not as pronounced. Conclu-n: This novel approach to teaching BBN to 3rd year medicaldents was well received by the students and resulted in markedprovement of self assessed skills over baseline. The most pro-unced benefit came from watching a brief SPIKES protocol video.ssons learned from this study have enhanced our curricular ap-ach to this vital component of medical education.

    . EARLY AND INTERMEDIATE EFFECTS OF A SURGI-CAL SKILLS BOOT CAMP ON AN OBJECTIVE ASSESS-MENT OF TECHNICAL SKILLS: A RANDOMIZED CON-TROLLED SUDY. R. Parent1, E. Long1, D. Zimmer1, M.Teshome1, D. Ly1, C. Mohr2, T. Hernandez-Boussard2, M. Curet2,S. Dutta2; 1Stanford Hospital, Stanford, CA; 2Stanford Univer-sity, Stanford, CA

    troduction: Surgical interns enter residency with variable tech-al abilities and may feel unprepared to perform necessary skills.hypothesized that interns exposed to a pre-internship intensivegical skills curriculum would demonstrate improved scores overexposed colleagues on a test of surgical skills and that this effectuld persist into internship. Methods: We designed a 3 day inten-e skills boot camp with hands-on simulation-based training intopics. We randomized interns to intervention (boot camp) andtrol (no boot camp) groups. All interns also completed a survey tolect demographic information, report previous experience, andess comfort with basic surgical skills on a 5-point Likert scale.llowing the boot camp, both groups completed a clinical skillsessment that focused on 4 of the topics: (1) chest tube insertion,central line placement, (3) wound closure, and (4) the Fundamen-s of Laparoscopic Surgery (FLS) peg transfer task. For the firstee stations we assessed performance using (1) an essential itemscklist, (2) economy of time and motion scale (score of 1 to 5), andimpression of global competence (yes/no). The laparoscopic tasks assessed using the FLS assessment tool. We assessed bothups (a) immediately (month 0) and (b) early post curriculumonth 1). Evaluators were blinded to randomization scheme. Re-lts: Fifteen were in the intervention group (10M:5F) and 13 weretrol (9M:4F). Prior to boot camp, mean comfort levels were aslows for the intervention vs. control groups: wound closure 4.23.6, chest tubes 1.73 vs. 1.73, central lines 1.67 vs. 2.00, andaroscopy 2.60 vs. 2.67. All participants had minimal priorerience. Table 1 shows the results of the clinical skills assess-nts. We demonstrated no differences between groups for woundsure. Conclusion: A surgical skills boot camp accelerates therning curve for interns in basic surgical skills as measured by ahnical skills exam. This may augment the learning experienceh attendings, increase confidence with procedures, and translateo less patient errors early in residency. We plan to repeat thells assessments at month 6 and 12 to see how long this effectsists, and also determine if this effect translates to task perfor-nce on real patients.Assessment Results

    InterventionMonth 0(n 15)

    ControlMonth 0(n 13)

    InterventionMonth 1(n 15)

    ControlMonth 1(n 13)

    st tube Mean checklistitems (max 11)

    9.93 (90%)* 7.00 (64%)* 10.33 (94%)^ 9.54 (87%)^

    Economy ofmotion (15)

    4.33* 3.08* 4.47^ 3.83^


    10 (67%)* 3 (23%)* 15 (100%)^ 8 (62%)^

    tral line Mean checklistitems (max 11)

    13.20 (88%)* 10.31 (69%)* 13.60 (91%)^ 12.54 (84%)^

    Economy ofmotion (15)

    3.60* 2.54* 3.60 3.23


    11 (73%)* 1 (8%)* 13 (87%)^ 6 (46%)^


    Mean time(seconds)

    232.58 283.39 160.41 187.47

    Mean path(cm)

    9992.24 11481.68 7016.78 8063.44

    Mean FLSscore (max 127)

    27.50 2.67 58.42 46.93

    p 0.05 between groups at month 0.p 0.05 between groups at month 1.


    troduction: The term learning curve is used in surgery to describephenomenon that improvement in performance tends to be rapid att, then levels off with experience until a plateau is reached. Althoughmonly analyzed by splitting the data into arbitrary chunks of ex-ience, this approach provides limited information about the under-ng curve and does not allow for precise estimation of where the curvettens or at what level. Our objective was to develop a simple way toracterize the learning curve for performance of a fundamental lapa-copic task, in order to facilitate its use as an outcome for educationalectiveness studies.Methods: 16 medical students rotating througheneral surgery service performed 4 weekly sessions of 10 repeti-ns of the Fundamentals of Laparoscopic Surgery (FLS) pegboardk. Each repetition was scored using validated metrics, whichard speed and penalize errors. The previously reported mean

    rmalized score for a PGY5 level subject was used to define assing score (76). Using the 40 attempts, a learning curve wastted and nonlinear regression was used to fit an inverse curvea-b/X) for each subject. Two values were estimated for eachve: learning potential, defined as the theoretical best scoreievable (when X, Ya) and the learning rate, defined as thember of trials to 90% of potential (Y0.9a when X10*b/a). Basicographic information and career interests were documented at

    seline. ANOVA was used to compare subjects reporting an interesta surgical career (n4) to those not interested (n4) or undecided8). Data expressed as mean (SD). Results: The starting scores 48(24) (range 2-88), while the score for the 40th trail was 94 (8)nge 78-106). All subjects eventually passed, after 4.8(3) attemptsnge 1-12), although 12 subjects had between 1 and 16 subsequenter scores. An inverse curve was an acceptable fit for most learningves (R2 0.75 in 3, 0.5 to 0.75 in 5, 0.35 to 0.5 in 6, all p0.001)t did not fit 2 curves well (ie, no learning curve effect - one withy high scores to start and one with a cluster of poor performanceweeks 2 and 3). Estimated mean learning potential was 89.6(9.6)nge 61-99) while the slope was 51.9(18). Estimated mean learn-rate, or the number of trials to 90% of potential, was 5.9(2.3)nge 1.8-10.6). Subjects who were not interested in a surgical