182 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS

three systems” (11:1). The most common additional suggested crite-rion was “in-hospital cardiac arrest,” which occurred in nine pa-tients. Five of these patients died during their admission, but nonereceived a palliative care consultation. Conclusion: 77% of patientsmeeting expert-derived guidelines for palliative care did not receivea consultation. One half of patients who did not survive their hospi-talization met a criterion, but only 30% received a consultation.Implementation of consultation triggers will increase access to pal-liative care services in the SICU. However, the overall number ofpatients meeting these triggers was low, suggesting that other meth-ods will be necessary to significantly increase the use of palliativecare services in the SICU.

Clinical Triggers forPalliative CareConsultation

Criterion metn, (% total)

Consult obtained n,(% criterion met)

Family request 4 (1.3) 4 (100)Family disagreement with

team, advance directive,or each other � 7 days

1 (0.33) 1 (100)

SICU stay � 30 days 4 (1.3) 1 (25)Death expected during

same SICU stay5 (1.7) 1 (20)

Multi-system organ failure� 3 systems

11 (3.7) 1 (9.1)

A diagnosis with mediansurvival � 6 months[applies only to 51cancer patients]

3 (5.9) 0 (0)

�3 SICU admissionsduring samehospitalization

3 (1.0) 0 (0)

Glasgow coma score � 8for �1 week in a patient� 75 years old

0 (0) n/a

Glasgow outcome score�3 (i.e. persistentvegetative state)

0 (0) n/a

Futility considered ordeclared by medicalteam

0 (0) n/a

24. FACTORS PREDICTIVE OF 30-DAY POST-OPERATIVEMORTALITY IN HIV/AIDS PATIENTS BEING TREATEDWITH ANTI-RETROVIRAL THERAPY. J. Chan, R. Hogg, B.Yip, C. Chiu, A. Levy, S. M. Wiseman; University of BritishColumbia, Vancouver, BC, Canada

Background: Despite an increasing population of individuals un-dergoing surgical procedures with a pre-operative diagnosis of HIVand AIDS, factors which predict post-operative mortality remainpoorly defined. Methods: In British Columbia (BC), Canada, allHIV/AIDS patients receiving any form of anti-retroviral therapy(ARV) are followed prospectively by the BC Centre for Excellence inHIV/AIDS. Our retrospective review examined all patients who un-derwent any surgical procedure (excluding dental and endoscopicprocedures) between June 1995 and March 2002. The primary out-come evaluated was the 30-day post-operative mortality. Demo-graphic, clinical, and hospitalization-related variables were exam-ined with logistic regression analyses to assess possible associationswith this outcome. A sub-analysis was carried out for a subset ofprocedures for which additional laboratory data was available within6 months prior to surgical admission. Results: A total of 3213

procedures in 1840 patients (1480 [80.4%] males) were carried out

over the 7-year study period. All patients had started ARV beforeadmission. Procedures performed before and after the availability ofhighly-active anti-retroviral therapy (HAART) totalled 508 (15.8%)and 2705 (84.2%), respectively. A total of 1026 patients (31.9%) hadan AIDS diagnosis prior to surgery. Admissions were identified asurgent/emergent in 1840 procedures (57.3%). Overall, 30-day post-operative mortality was 7.4% (238 deaths). In a stepwise multivari-ate analysis, older age (10yr increment) (OR�1.32; p�0.001), previ-ous AIDS diagnosis (OR�1.50; p�0.001), injection-drug naivety(OR�1.58; p�0.007), surgery at a teaching hospital (OR�1.63;p�0.009), and urgent/emergent admission (OR�7.32; p �0.001)were significantly associated with 30-day post-operative mortality.For the sub-analysis of 1825 procedures, injection-drug naivety(OR�1.62; p�0.036), older age (10yr increment) (OR�1.64;p�0.001), urgent/emergent admission (OR�4.60; p�0.001),CD4�200 cell/mm3 (OR�1.67; p�0.032), plasma viral load�100,000c/mL (OR�2.06; p�0.001), hemoglobin�120 g/L (OR�2.38;p�0.001), and white blood cell count�11 g/L (OR�2.55; p�0.003)were significantly associated with 30-day post-operative mortality.Conclusions: In HIV/AIDS patients undergoing surgery, urgent/emergent admission is the strongest predictor for 30-day post-operative mortality. Pre-operative assessment of HIV/AIDS patientsfor elective surgical procedures should include specific laboratoryinvestigations such as CD4 count, plasma viral load, hemoglobin,and white blood cell count. This is useful for prediction of post-operative mortality and is thus important in surgical risk assess-ment and patient counselling.

EDUCATION 1: SKILLS ASSESSMENT/SIMULATION

25. 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

Introduction: Breaking bad news (BBN) compassionately is a vitalpart of medical practice but is not a focus of most training curricula.Our novel approach to teaching BBN involves having students ac-tively participate in an unsuccessful trauma resuscitation (gunshotwound to the chest) on a high fidelity human patient simulator(mannequin) followed immediately by BBN to a standardized patientwife (SPW) portrayed by an actress. Methods: 553 3rd year medicalstudents starting a surgery clerkship completed a baseline question-naire that included self-assessment of their current ability to andplan for BBN. They were then divided into four groups as follows:Group 1 (n�163) received no training prior to speaking with theSPW. Group 2 (n �163) watched a 15 minute video on the SPIKES(Setting, Perception, Invitation, Knowledge, Empathize, and Sum-mary) protocol for BBN immediately prior to speaking to the SPW.Group 3 (n�109) received a lecture on SPIKES and observed anexample of BBN (Informing a woman that she had miscarried) inproctored small groups the day prior to the resuscitation and BBN.Group 4 (n�118) received the same training as group 3 but alsowatched the SPIKES video immediately prior to speaking with theSPW. After the encounter, students completed a self assessment oftheir ability to have a plan for and to BBN and were evaluated by theSPWs (blinded to their training group) on a 5 point Likert scale on 21items related to the student’s appearance, communication skills, andemotional affect. All Groups received cross-over training after theencounter. Results: All groups had received approximately twohours of prior training in BBN during the first two years of medicalschool and believed that learning this skill was very important

(mean 4.1 on Likert scale of 1-5). Of those students who had already

183ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS

done a clinical rotation, 17% had been placed in a situation wherethey had to break bad news to a patient. All four groups self assessedability to BBN and ability to have a plan improved significantly overbase line (p value range �3.7 � 10�13 to p �3.5 � 10�45). Improve-ment over baseline was most pronounced in group 2. All rated theexperience as extremely valuable (mean 4.5) and very realistic (mean4.2 on a 5 point scale). Students who received any sort of training(watching the SPIKES video, didatic lecture and demonstration, orboth) prior to BBN were rated higher on several of the parameters ofappearance, communication, and emotions by the SPWs. The groupswhose performance was most consistently rated superior were thosethat watched the SPIKES video immediately prior to speaking to theSPW. The performance benefit of receiving a didactic lecture onSPIKES and observing an example was not as pronounced. Conclu-sion: This novel approach to teaching BBN to 3rd year medicalstudents was well received by the students and resulted in markedimprovement of self assessed skills over baseline. The most pro-nounced benefit came from watching a brief SPIKES protocol video.Lessons learned from this study have enhanced our curricular ap-proach to this vital component of medical education.

26. 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

Introduction: Surgical interns enter residency with variable tech-nical abilities and may feel unprepared to perform necessary skills.We hypothesized that interns exposed to a pre-internship intensivesurgical skills curriculum would demonstrate improved scores overunexposed colleagues on a test of surgical skills and that this effectwould persist into internship. Methods: We designed a 3 day inten-sive skills “boot camp” with hands-on simulation-based training in10 topics. We randomized interns to intervention (boot camp) andcontrol (no boot camp) groups. All interns also completed a survey tocollect demographic information, report previous experience, andassess comfort with basic surgical skills on a 5-point Likert scale.Following the boot camp, both groups completed a clinical skillsassessment that focused on 4 of the topics: (1) chest tube insertion,(2) central line placement, (3) wound closure, and (4) the Fundamen-tals of Laparoscopic Surgery (FLS) peg transfer task. For the firstthree stations we assessed performance using (1) an essential itemschecklist, (2) economy of time and motion scale (score of 1 to 5), and(3) impression of global competence (yes/no). The laparoscopic taskwas assessed using the FLS assessment tool. We assessed bothgroups (a) immediately (month 0) and (b) early post curriculum(month 1). Evaluators were blinded to randomization scheme. Re-sults: Fifteen were in the intervention group (10M:5F) and 13 werecontrol (9M:4F). Prior to boot camp, mean comfort levels were asfollows for the intervention vs. control groups: wound closure � 4.2vs. 3.6, chest tubes � 1.73 vs. 1.73, central lines � 1.67 vs. 2.00, andlaparoscopy � 2.60 vs. 2.67. All participants had minimal priorexperience. Table 1 shows the results of the clinical skills assess-ments. We demonstrated no differences between groups for woundclosure. Conclusion: A surgical skills boot camp accelerates thelearning curve for interns in basic surgical skills as measured by atechnical skills exam. This may augment the learning experiencewith attendings, increase confidence with procedures, and translateinto less patient errors early in residency. We plan to repeat theskills assessments at month 6 and 12 to see how long this effectpersists, and also determine if this effect translates to task perfor-

mance on real patients.

TABLE 1

Assessment Results

InterventionMonth 0(n � 15)

ControlMonth 0(n � 13)

InterventionMonth 1(n � 15)

ControlMonth 1(n � 13)

Chest tube Mean checklistitems (max� 11)

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

Economy ofmotion (1–5)

4.33* 3.08* 4.47^ 3.83^

#Competent(%)

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

Central line Mean checklistitems (max� 11)

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

Economy ofmotion (1–5)

3.60* 2.54* 3.60 3.23

#Competent(%)

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

Peg transfertask

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.

27. A METHOD TO CHARACTERIZE THE LEARNING CURVEFOR PERFORMANCE OF A FUNDAMENTAL LAPARO-SCOPIC SIMULATOR TASK: DEFINING “LEARNING PO-TENTIAL” AND “LEARNING RATE”. L. S. Feldman, J. Cao,G. M. Fried; McGill University, Montreal, QC, Canada

Introduction: The term “learning curve” is used in surgery to describethe phenomenon that improvement in performance tends to be rapid atfirst, then levels off with experience until a plateau is reached. Althoughcommonly analyzed by splitting the data into arbitrary chunks of ex-perience, this approach provides limited information about the under-lying curve and does not allow for precise estimation of where the curveflattens or at what level. Our objective was to develop a simple way tocharacterize the learning curve for performance of a fundamental lapa-roscopic task, in order to facilitate its use as an outcome for educationaleffectiveness studies. Methods: 16 medical students rotating througha general surgery service performed 4 weekly sessions of 10 repeti-tions of the Fundamentals of Laparoscopic Surgery (FLS) pegboardtask. Each repetition was scored using validated metrics, whichreward speed and penalize errors. The previously reported meannormalized score for a PGY5 level subject was used to define apassing score (76). Using the 40 attempts, a learning curve wasplotted and nonlinear regression was used to fit an inverse curve(Y�a-b/X) for each subject. Two values were estimated for eachcurve: “learning potential”, defined as the theoretical best scoreachievable (when X�, Y�a) and the “learning rate”, defined as thenumber of trials to 90% of potential (Y�0.9a when X�10*b/a). Basicdemographic information and career interests were documented atbaseline. ANOVA was used to compare subjects reporting an interestin a surgical career (n�4) to those not interested (n�4) or undecided(n�8). Data expressed as mean (SD). Results: The starting scorewas 48(24) (range 2-88), while the score for the 40th trail was 94 (8)(range 78-106). All subjects eventually passed, after 4.8(3) attempts(range 1-12), although 12 subjects had between 1 and 16 subsequentlower scores. An inverse curve was an acceptable fit for most learningcurves (R2 �0.75 in 3, 0.5 to 0.75 in 5, 0.35 to 0.5 in 6, all p�0.001)but did not fit 2 curves well (ie, no learning curve effect - one withvery high scores to start and one with a cluster of poor performancein weeks 2 and 3). Estimated mean “learning potential” was 89.6(9.6)(range 61-99) while the slope was 51.9(18). Estimated mean “learn-ing rate”, or the number of trials to 90% of potential, was 5.9(2.3)

(range 1.8-10.6). Subjects who were not interested in a surgical