Visual control strategies of surgeons: a novel method of establishing the construct validity of a transurethral resection of the prostate surgical simulator

OBJECTIVE

To examine novice and expert differences in visual control strategies while performing a virtual reality transurethral resection of the prostate (TURP) task and to determine if these differences could provide a novel method for assessing construct validity of the simulator.

SUBJECTS AND METHODS

A total of 11 novices (no TURP experience) and 7 experts (>200 TURPs) completed a virtual reality prostate resection task on the TURPsim (Simbionix USA Corp, Cleveland, OH) while wearing an eye tracker (ASL, Bedford, MA). Performance parameters and the surgeon's visual control strategy were measured and compared between the 2 groups.

RESULTS

Experts resected a greater percentage of prostate than novices (p < 0.01) and had less active diathermy time without tissue contact (p < 0.01). Experts adopted a target-locking visual strategy, employing fewer visual fixations (p < 0.05) with longer mean fixation duration (p < 0.005). With multiple learning trials, novices' performance improved and the adoption of a more expertlike gaze strategy was observed.

CONCLUSION

Significant differences between experts and novices in both performance and visual control strategy were observed. The study of visual control strategies may be a useful adjunct, alongside measurements of motor performance, providing a novel method of assessing the construct validity of surgical simulators.

A standardized patient model to teach and assess professionalism and communication skills: the effect of personality type on performance

INTRODUCTION

Teaching and assessing professionalism and interpersonal communication skills can be more difficult for surgical residency programs than teaching medical knowledge or patient care, for which many structured educational curricula and assessment tools exist. Residents often learn these skills indirectly, by observing the behavior of their attendings when communicating with patients and colleagues. The purpose of this study was to assess the results of an educational curriculum we created to teach and assess our residents in professionalism and communication.

METHODS

We assessed resident and faculty prior education in delivering bad news to patients. Residents then participated in a standardized patient (SP) encounter to deliver bad news to a patient's family regarding a severe burn injury. Residents received feedback from the encounter and participated in an education curriculum on communication skills and professionalism. As a part of this curriculum, residents underwent assessment of communication style using the Myers-Briggs type inventory. The residents then participated in a second SP encounter discussing a severe pulmonary embolus with a patient's family.

RESULTS

Resident performance on the SP evaluation correlated with an increased comfort in delivering bad news. Comfort in delivering bad news did not correlate with the amount of prior education on the topic for either residents or attendings. Most of our residents demonstrated an intuitive thinking style (NT) on the Myers-Briggs type inventory, very different from population norms.

DISCUSSION

The lack of correlation between comfort in delivering bad news and prior education on the subject may indicate the difficulty in imparting communication and professionalism skills to residents effectively. Understanding communication style differences between our residents and the general population can help us teach professionalism and communication skills more effectively. With the next accreditation system, residency programs would need to demonstrate that residents are acquiring these skills in their training. SP encounters are effective in teaching and assessing these skills.

High efficacy and students' satisfaction after voluntary vs mandatory use of an e-learning program in traumatology and orthopedics--a follow-up study

INTRODUCTION

Within the last decade, e-learning has gained a consistent place in surgical teaching. However, as the use of new programs is often voluntary, more information on the implications of the data regarding user acceptance and knowledge with mandatory use is desirable, especially in the context of the long-term developments of courses.

MATERIALS

Starting in 2009, the e-learning program Network for Students in Traumatology and Orthopedics was offered in a voluntary blended learning context. Students' satisfaction and increase in knowledge were evaluated using questionnaires and written tests. With proven effectiveness, the program became a mandatory part of the curriculum, and students' attitudes and gain of knowledge were re-evaluated in 2010 and 2011 to detect differences in voluntary vs mandatory use.

RESULTS

In the evaluation questionnaires (n = 108 voluntary vs n = 361 mandatory), the overall appreciation regarding the offerings remained high. Significantly more students felt better prepared for clinical situations (p < 0.001) and asked for e-tutoring (p = 0.025) with mandatory use. In written tests, both voluntary (n = 70) and mandatory (n = 147) users showed significantly increased knowledge (p < 0.001). Starting with a lower base level (p < 0.001), mandatory users had a significantly higher absolute increase compared with voluntary users (p = 0.015), leading to a similar final level.

DISCUSSION

The presented blended learning concept was an efficient way to teach students orthopedics and traumatology. Data can support the assumption that even if the voluntary evaluation of e-learning offerings might be subject to a selection bias, the results can serve as a representative impression for the students' overall mood and their gain in knowledge. However, as changes would have to be anticipated when shifting to mandatory use, users' perceptions should be constantly evaluated.

Identifying areas of weakness in thoracic surgery residency training: a comparison of the perceptions of residents and program directors

OBJECTIVE

To identify core thoracic surgery procedures that require increased emphasis during thoracic surgery residency for residents to achieve operative independence and to compare the perspectives of residents and program directors in this regard.

METHODS

A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents (12) and program directors (8) addressing the residents' ability to perform 19 core thoracic surgery procedures independently after the completion of residency. Residents were also questioned about the adequacy of their operative exposure to these 19 procedures during their residency training. A descriptive summary including calculations of frequencies and proportions was conducted. The perceptions of the 2 groups were then compared using the Fisher exact test employing a Bonferroni correction. The relationship between residents' operative exposure and their perceived operative ability was explored in the same fashion.

RESULTS

The response rate was 100% for residents and program directors. No statistical differences were found between residents' and program directors' perceptions of residents' ability to perform the 19 core procedures independently. Both groups identified lung transplantation, first rib resection, and extrapleural pneumonectomy as procedures for which residents were not adequately prepared to perform independently. Residents' subjective ratings of operative exposure were in good agreement with their reported operative ability for 13 of 19 procedures.

CONCLUSION

This study provides new insight into the perceptions of thoracic surgery residents and their program directors regarding operative ability. This study points to good agreement between residents and program directors regarding residents' surgical capabilities. This study provides information regarding potential weaknesses in thoracic surgery training, which may warrant an examination of the curricula of existing programs as well as a reconsideration of what the scope of practice of a general thoracic surgeon should entail.

Is current surgical training efficient? A national survey

OBJECTIVES

Evaluation of surgical training in Denmark is competency based with no requirement for a specific number of procedures. This may affect monitoring of surgical progress adversely and cause an underestimation of the time needed to acquire surgical competencies. We investigated the number of common surgical procedures performed by trainees. Trainees' and consultants' expectations from the training program were also investigated.

DESIGN AND PARTICIPANTS

A questionnaire was sent to all 115 surgical trainees in Denmark. We asked how many common surgical procedures the trainees had performed during their postgraduate training, whether self-reported procedural confidence was achieved during their training, and whether their training expectations were met. Another questionnaire dealt with the consultants' expectations of the surgical training.

RESULTS

The total number of common surgical procedures (Lichtenstein hernia repair, appendectomy, laparoscopic appendectomy, and laparoscopic cholecystectomy) that were performed varied between trainees. One group performed few common procedures during training. A low number in 1 procedure correlated with a similar pattern in other procedures. Approximately one-third did not perform common elective procedures independently until their fifth year. Consultants and trainees viewed training differently.

CONCLUSIONS

Our study reveals no common trend in the numbers and types of procedures performed during training. The number of procedures seems to reflect the individual trainee and a local tradition rather than the particular training program. An informal competency-based assessment system with lack of quantitative requirements evidently involves a risk of skewness in training.

Face and content validation of the prostatic hyperplasia model and holmium laser surgery simulator

OBJECTIVE

Although a number of simulators have been introduced for prostate surgery, none have undergone validation for holmium laser enucleation of the prostate training. This study was carried out to assess the face and content validities as well as feasibility and acceptability of the new prostatic hyperplasia model and prostate surgery simulator for holmium laser enucleation of the prostate.

DESIGN

This is a prospective, observational, and comparative study. Participants were given a 30-minute video tutorial followed by a 45-minute simulation session, with one-to-one mentoring. A survey with qualitative and quantitative fields was used to evaluate their experience.

SETTING

This study was carried out in a 2-day modular teaching course hosted by the Holmium User Group at Cambridge University Hospitals, UK, and during the British Association of Urological Surgeons 2013 Annual Meeting.

PARTICIPANTS

A total of 36 participants comprising 13 urology trainees and 23 senior urologists of varying levels from all around the globe were recruited.

RESULTS

Overall, 87% of the participants believed that holmium laser enucleation of the prostate was an effective method of treatment, simulation-based training, and assessment essential for patient safety and 84% believed a validated simulator would be useful for training. Of the participants, 97% agreed that the simulation should be implemented into training programs and only 31% felt it should be part of accreditation. Participants ranked all components of the simulator greater than 7 of 10 on a global rating scale and believed it was a feasible and acceptable method of training and assessment.

CONCLUSIONS

The new simulator for holmium laser enucleation of the prostate has been demonstrated to be useful as a training tool. This study has established face and content validities of the simulator. Senior and trainee urologists believed the simulator was an acceptable tool for training and assessment and its use feasible for novice trainees to acquire skills and knowledge to a predetermined level of proficiency.

Construct validation of the key components of Fundamental Skills of Robotic Surgery (FSRS) curriculum--a multi-institution prospective study

BACKGROUND

Recent incorporation of simulation in surgical training necessitates developing validated platforms for training and assessment. A tool should fulfill the fundamental criteria of validation.

OBJECTIVE

To report the ability of a simulation-based robotic training curriculum-Fundamental Skills of Robotic Surgery (FSRS)-to assess and distinguish between different performance levels of operator experience (construct validity).

MATERIALS AND METHODS

This is a prospective multicenter observational study. Participants were classified as novice (0 robotic cases performed) and experts (>150 robotic cases performed). All participants were required to complete 4 key tasks in a previously validated FSRS curriculum: ball placement, coordinated tool control, fourth arm control, and needle handling and exchange. Using the metrics available in the simulator software, the performances of each group were compared to evaluate construct validation.

RESULTS

A convenience cohort of 61 surgeons participated. Novice group (n = 49) consisted of 41 fellows/residents/medical students and 8 trained open/laparoscopic surgeons, whereas expert group consisted of 12 surgeons. The novice group had no previous robotic console experience, whereas the expert group had >150 prior robotic cases experience. An overall significant difference was observed in favor of the expert group in 4 skill sets (p < 0.05). Time to complete all 4 tasks was significantly shorter in the expert group (p < 0.001). The expert group displayed significantly lesser tool collision (p = 0.002) and reduced tissue damage (p < 0.001). In performing most tasks, the expert group's camera (p < 0.001) and clutch usage (p < 0.001) was significantly greater when compared with the novice group.

CONCLUSION

The components of the FSRS curriculum showed construct validity. This validation would help in effectively implementing this curriculum for robot-assisted surgical training.

"The thyroidectomy story": comic books, graphic novels, and the novel approach to teaching head and neck surgery through the genre of the comic book

As surgical education changes, an instructive need arises to complement the complexity of hands-on manual and visuospatial skills acquired as a result of apprenticing in the operating room (OR) and adjusting to new technologies and robotics. Novel and innovative methods must be employed, not to replace the OR experience but rather to enhance it. Here, we present a fine arts merger with surgical education in the genre of the comic book and graphic novel to address visuospatial skills, motor skills (practice-based learning and improvement), and the narrative, humanistic component (patient care) necessary for a well-rounded surgical education. We examine the important goals of training residents with the development of an "experimental" comic book on the thryoidectomy procedure to enhance textbook and lecture material, where residents and nurses are introduced to technique, narrative, and medical illustration skills (interpersonal communication skills) to assist them in anticipating, reflecting, and potentially facilitating the very proficiency necessary to be successful in the OR while remaining curious and engaged in their craft.

Is there an association between study materials and scores on the American Board of Orthopaedic Surgeons Part 1 examination?

BACKGROUND

Previous studies have shown that certain orthopaedic in-training examination scores can be used to identify which residents may be at risk for failing the American Board of Orthopaedic Surgeons (ABOS) Part 1 examination. However, no studies have examined how study resources may affect residents' ABOS Part 1 scores. The goal of this study is to determine which review sources or review courses, if any, are associated with improved ABOS Part 1 scores.

METHODS

A survey was sent to 221 of the 865 examinees who took the ABOS Part 1 examination in 2012. The questions inquired the respondents how well they performed on previous orthopaedic in-training examinations and ABOS Part 1, along with the study sources they most commonly used, review courses they attended, and resources they would recommended if they were to retake ABOS Part 1 examination.

RESULTS

Overall, 118 of the 221 (53%) survey recipients completed the survey. Six (5%) of the respondents failed ABOS Part 1 examination. Orthobullets and the American Academy of Orthopaedic Surgeons self-assessment examinations were recommended as the primary study source significantly more (p < 0.01) than most other resources, but there was no significant association between study source and passing ABOS Part 1 or scoring in a certain percentile on ABOS Part 1. Similarly, there were no associations between attending a review course and either passing or scoring in a certain percentile for ABOS Part 1. Half of the respondents who failed ABOS Part 1 attended multiple review courses.

CONCLUSIONS

There does not appear to be an association between improved ABOS Part 1 scores and orthopedic study materials or review courses. Further research into the value of certain educational modalities should be conducted to determine the best ways to educate orthopedic residents and determine the value of some of these commonly used orthopedic review modalities.

Evidence-based microsurgical skill-acquisition series part 1: validated microsurgical models--a systematic review

OBJECTIVES

The purpose of this study is to (1) systematically review all the literature pertaining to microsurgical training models and to (2) determine which of these are specific to and validated for microsurgery training.

DESIGN

PubMed, MEDLINE (OVID/EBSCO), Google Scholar, and Cochrane Central Register of Controlled Trials were searched using preset terms. The last search date was in July 2012. Articles of all languages, years of publication, sample sizes, and model types pertaining to microsurgery were included. The eligibility criteria included the use of a microsurgical training model on a subject group with statistical analysis and measures of validation. Two assessors independently reviewed the articles and their references.

RESULTS

Of the 238 articles reviewed, 9 articles met the criteria. Those excluded were predominantly model descriptions that had not been validated in a set of learners. The 9 models whose performances were assessed in a group of learners included an online curriculum, nonliving prosthetics and biologics, and the live rat femoral artery model. Each model was evaluated for content, construct, face, and criterion (concurrent and predictive) validity, as well as selection and observation/expectant bias. Content, construct, concurrent, and face validities were consistently demonstrated for all 9 models. Selection bias was also reliably well controlled with random allocation of participants to each study group. Observation/expectant bias was controlled in 6 of the 8 papers. Predictive validity, an arguably more difficult factor to measure, was only present in 1 article.

CONCLUSIONS

Despite a plethora of papers describing microsurgical learning tools, only 9 were discovered that provided validation of the proposed method of microsurgical skills acquisition. This review depicts the need for basic, yet well-designed studies that substantiate the effectiveness of microsurgical training models by using a subject group and demonstrating a statistical improvement with employment of the model. Ease of access, cost, and assessment tools used also require attention.

A review of the available urology skills training curricula and their validation

BACKGROUND

The transforming field of urological surgery continues to demand development of novel training devices and curricula for its trainees. Contemporary trainees have to balance workplace demands while overcoming the cognitive barriers of acquiring skills in rapidly multiplying and advancing surgical techniques. This article provides a brief review of the process involved in developing a surgical curriculum and the current status of real and simulation-based curricula in the 4 subgroups of urological surgical practice: open, laparoscopic, endoscopic, and robotic.

METHODS

An informal literature review was conducted to provide a snapshot into the variety of simulation training tools available for technical and nontechnical urological surgical skills within all subgroups of urological surgery using the following keywords: "urology, surgery, training, curriculum, validation, non-technical skills, technical skills, LESS, robotic, laparoscopy, animal models." Validated training tools explored in research were tabulated and summarized.

RESULTS AND CONCLUSIONS

A total of 20 studies exploring validated training tools were identified. Huge variation was noticed in the types of validity sought by researchers and suboptimal incorporation of these tools into curricula was noted across the subgroups of urological surgery. The following key recommendations emerge from the review: adoption of simulation-based curricula in training; better integration of dedicated training time in simulated environments within a trainee's working hours; better incentivization for educators and assessors to improvise, research, and deliver teaching using the technologies available; and continued emphasis on developing nontechnical skills in tandem with technical operative skills.

Social media and tomorrow's medical students--how do they fit?

OBJECTIVE

The main aim of our study was to establish the prevalence of social networking accounts among a group of second-level students (aged 15-18 years), to determine whether they used privacy settings, and to examine their attitudes to various aspects of social media use in medicine.

DESIGN

A descriptive study design was employed. The questionnaire was constructed specifically to address the attitudes of students to social media. No similar suitable validated questionnaire could be identified. The questionnaire consisted of 20 questions with a mixture of open answer, yes/no, and Likert scale response options.

PARTICIPANTS

Participation was voluntary and anonymous. Second-level school children interested in studying medicine and aged between 15 and 18 years took part.

SETTING

An annual open day organized by the School of Medicine in University College Cork, Ireland, formed the setting. The day comprised a mixture of lectures, demonstrations, and practical sessions designed to give the students insight into life as a medical student.

RESULTS

A total of 96 students attended, and all were handed the questionnaires. Of them, 88 students completed the survey. Overall, 90.9% of students had Facebook accounts and 53% had Twitter accounts. Of those with social media accounts, 14.8% reported having no privacy settings. Most respondents felt that unprofessional behavior on social media sites should be a factor considered in admission to medical schools.

CONCLUSIONS

Serious consequences can result from lapses in best practice relating to social media behavior. Dedicated reflective learning modules need to be incorporated into undergraduate and postgraduate training programs as a matter of urgency.

The relationship between confidence and competence in the development of surgical skills

BACKGROUND

Confidence is a crucial trait of any physician, but its development and relationship to proficiency are still unknown. This study aimed to evaluate the relationship between confidence and competency of medical students undergoing basic surgical skills training.

METHODS

Medical students completed confidence surveys before and after participating in an introductory workshop across 2 samples. Performance was assessed via video recordings and compared with pretraining and posttraining confidence levels.

RESULTS

Overall, 150 students completed the workshop over 2 years and were evaluated for competency. Most students (88%) reported improved confidence after training. Younger medical students exhibited lower pretraining confidence scores but were just as likely to achieve competence after training. There was no association between pretraining confidence and competence, but confidence was associated with demonstrated competence after training (p < 0.001).

CONCLUSIONS

Most students reported improved confidence after a surgical skills workshop. Confidence was associated with competency only after training. Future training should investigate this relationship on nonnovice samples and identify training methods that can capitalize on these findings.

A proficiency-based skills training curriculum for the SAGES surgical training for endoscopic proficiency (STEP) program

INTRODUCTION

The surgical training for endoscopic proficiency program is a collaborative project between Society of American Gastrointestinal and Endoscopic Surgeons and Olympus America Inc. dedicated to providing flexible endoscopy training to surgery residency programs. Currently it lacks models for proficiency-based training. This study developed 2 novel flexible endoscopy simulators, purchased a third, and established face and content validity as well as proficiency metrics for all 3.

METHODS

Three simulators were tested-a foam and cardboard upper gastrointestinal tract model, a commercially available colonoscopy model (CM-15, Olympus, Japan), and an endoscopic targeting model created from the Operation Game (Hasbro). Time and errors for the performance of 12 expert surgical endoscopists on each model were used to calculate proficiency scores. Face validity and content validity were established through posttest questionnaires using a 5-point Likert scale.

RESULTS

Experts had a mean of 8 years of endoscopic practice (range: 1-24y). Among them, 83% teach residents or fellows using simulation. Most perform more than 50 upper endoscopies (51 to >500) and 100 colonoscopies (101 to >500) per year. The average time for completing the upper gastrointestinal tract model with correct identification of all targets was 133 ± 56 seconds. Complete navigation of the colonoscopy model averaged 325 ± 156 seconds. Proper orientation and targeting using the Operation Game model averaged 273 ± 109 seconds with 3 errors.

CONCLUSIONS

This study proves face and content validity for 3 physical flexible endoscopy simulators that can be used to train upper and lower endoscopy as well as instrument targeting. It also establishes expert proficiency metrics that can be used by trainees for structured rehearsal. These relatively inexpensive models will be incorporated into the surgical training for endoscopic proficiency curriculum.

Injecting realism in surgical training-initial simulation experience with custom 3D models

The traditionally accepted form of training is direct supervision by an expert; however, modern trends in medicine have made this progressively more difficult to achieve. A 3-dimensional printer makes it possible to convert patients imaging data into accurate models, thus allowing the possibility to reproduce models with pathology. This enables a large number of trainees to be trained simultaneously using realistic models simulating actual neurosurgical procedures. The aim of this study was to assess the usefulness of these models in training surgeons to perform standard procedures that require complex techniques and equipment.

METHODS

Multiple models of the head of a patient with a deep-seated small thalamic lesion were created based on his computed tomography and magnetic resonance imaging data. A workshop was conducted using these models of the head as a teaching tool. The surgical trainees were assessed for successful performance of the procedure as well as the duration of time and number of attempts taken to learn them.

FINDINGS

All surgical candidates were able to learn the basics of the surgical procedure taught in the workshop. The number of attempts and time taken reflected the seniority and previous experience of each candidate.

DISCUSSION

Surgical trainees need multiple attempts to learn essential procedures. The use of these models for surgical-training simulation allows trainees to practice these procedures repetitively in a safe environment until they can master it. This would theoretically shorten the learning curve while standardizing teaching and assessment techniques of these trainees.

Achievement in surgical residency: are objective measures of performance associated with awards received in final years of training?

OBJECTIVE

For the past 15 years at our institution's general surgery residency program, 3 of the senior residents have been chosen to be awarded either (1) Best Resident in Research, (2) Best Resident in Teaching, or (3) Best Resident Overall. Considering that these awards serve as data representing outstanding performance as surgical residents, the objective of this study was to determine the association between receiving one of these awards and objective measures of performance.

METHODS

Individual files were reviewed for the 103 residents who graduated from our institution's general surgery program from 1994 to 2010. These data were studied as a whole, and then divided into an award-winning group and a non-award winning group and subsequently compared across several objective parameters, including The United States Medical Licensing Examination (USMLE) scores, American Board of Surgery In-Training Examination (ABSITE) scores, first-time American Board of Surgery Certifying and Qualifying Examination pass rates, Alpha Omega Alpha membership status, and number of research years, using a logistic regression model.

RESULTS

Overall, 103 residents completed their general surgery residency training at our institution from 1994 to 2010, and of these residents, 16 (16%) received the Best Resident in Research award, 15 (16%) received the Best Resident in Teaching award, and 17 (17%) received the Best Resident Overall award in their final years of training. Compared with those who did not receive an award, a hypothesis-based one-tailed test revealed that award winners had a significantly lower median USMLE Step 1 scores (p = 0.04) and marginally lower median USMLE Step 2 scores (p = 0.05). Alpha Omega Alpha membership status, median ABSITE percent correct overall, first-time American Board of Surgery examination pass rates, and number of research years during residency were not significantly different between the 2 groups.

CONCLUSION

Many factors contribute to success during general surgery residency. Our study showed that higher USMLE and ABSITE scores were not associated with receiving top awards in final years of training at one institution over 15 years.

Effect of a short preclinical laparoscopy course for interns in surgery: a randomized controlled trial

OBJECTIVES

Surgical interns are often not well prepared and have high anxiety about the execution of basic technical skills. This study investigates whether a short preclinical course focusing on laparoscopic camera-navigating skills is useful in the preparation for internship.

DESIGN

Through randomization, an experimental group who attended a short laparoscopic training session and a control group were created. Students' interest for this training and their confidence for laparoscopic exposure during surgical internship were inquired. During internship, camera-navigating skills were assessed by the operating surgeons (using a validated global rating scale) as well as by the students themselves (using a 10-points Likert scale).

SETTING

All research was performed in the Center for Surgical Technologies, Leuven, Belgium.

PARTICIPANTS

A total of 205 fifth-year medical students at the University of Leuven, Belgium.

RESULTS

Of the control group students, 80% were interested in attending the training session. There was no difference in confidence between experimental and control group. According to the surgeons and students, there was a significant improvement in clinical performance from the first (scores on global rating and Likert scales ±50%) to the last procedure (scores ±70%) for both groups. However, there was no difference in performance between groups.

CONCLUSIONS

Students are very interested in attending a preclinical laparoscopic training session. However, trained students did not display higher confidence or better clinical performance during internship. Even without previous training, students are fast to acquire the necessary skills during surgical internship.

What surgeons can learn from athletes: mental practice in sports and surgery

BACKGROUND

Mental practice has been successfully applied in professional sports for skills acquisition and performance enhancement. The goals of this review are to describe the literature on mental practice within sport psychology and surgery and to explore how the specific principles of mental practice can be applied to the improvement of surgical performance-both in novice and expert surgeons.

METHOD

The authors reviewed the sports psychology, education, and surgery literatures through Medline, PubMed, PsycINFO, and Embase.

RESULTS

In sports, mental practice is a valuable tool for optimizing existing motor skill sets once core competencies have been mastered. These techniques have been shown to be more advantageous when used by elite athletes. Within surgery, mental practice studies have focused on skill acquisition among novices with little study of how expert surgeons use it to optimize surgical preparation.

CONCLUSIONS

We propose that performance optimization and skills acquisition should be viewed as 2 separate domains of mental practice. Further understanding of this phenomenon has implications for changing how we teach and train not only novice surgeons but also how experienced surgeons continue to maintain their skills, acquire new ones, and excel in surgery.

A broadly applicable surgical teaching method: evaluation of a stepwise introduction to cataract surgery

OBJECTIVE

Although cataract surgery is one of the most commonly performed surgeries in the country, it is a microsurgical procedure that is difficult to learn and to teach. This study aims to assess the effectiveness of a new method for introducing postgraduate year (PGY)-3 ophthalmology residents to cataract surgery.

SETTING

Hospital-based ophthalmology residency program.

DESIGN

Retrospective cohort study.

PARTICIPANTS

PGY-3 and PGY-4 residents of the Harvard Medical School Ophthalmology Residency from graduating years 2010 to 2012.

RESULTS

In July 2009, a new method of teaching PGY-3 ophthalmology residents cataract surgery was introduced, which was termed "the stepwise introduction to cataract surgery." This curriculum aimed to train residents to perform steps of cataract surgery by deliberately practicing each of the steps of surgery under a structured curriculum with faculty feedback. Assessment methods included surveys administered to the PGY-4 residents who graduated before the implementation of these measures (n = 7), the residents who participated in the first and second years of the new curriculum (n = 16), faculty who teach PGY-4 residents cataract surgery (n = 8), and review of resident Accreditation Council for Graduate Medical Education surgical logs. Resident survey response rate was 100%. Residents who participated in the new curriculum performed more of each step of cataract surgery in the operating room, spent more time practicing each step of cataract surgery on a cataract surgery simulator during the PGY-3 year, and performed more primary cataract surgeries during the PGY-3 year than those who did not. Faculty survey response rate was 63%. Faculty noted an increase in resident preparedness following implementation of the new curriculum. There was no statistical difference between the precurriculum and postcurriculum groups in the percentage turnover of cataracts for the first 2 cataract surgery rotations of the PGY-4 year of training.

CONCLUSIONS

The introduction of cataract surgery to PGY-3 residents in an organized, stepwise manner improved resident preparedness for the PGY-4 year of residency. This surgical teaching method can be easily applied to other surgical specialties.

Review of selected national surgical curricula: quantity is not the sole marker of quality

BACKGROUND

Despite marked global variations in length and structure of surgical training programs, their common end product is a trained surgeon capable of independent practice. If variations exist, yet the end product is similar, modifications to curricula could potentially enhance the quality and efficiency of surgical training. This review evaluates global general surgery training programs and compares their curricula against the established standards for assessment of curricula.

METHODS

A convenience sampling method was employed during an online search for nationally recognized general surgery curricula. Curricula of Australia, Canada, Hong Kong, the United Kingdom, and the United States of America were individually reviewed and subsequently evaluated against the General Medical Council's "Standards for curricula and assessment systems."

RESULTS

Postgraduate surgical training is completed in 5 years in Canada and the United States, whereas this takes a minimum of 7, 7, and 10 years in Australia, Hong Kong, and the United Kingdom, respectively. However, when their general surgery curricula are objectively compared, they are remarkably similar. The principle disparities noted were in documentation and standardization of the structured in-training assessment system.

CONCLUSIONS

This review highlights variations in the structure of general surgery training programs globally. There is a need for an objective method to assess training quality, not reliant upon quantity alone. An evidence-based approach is the gold standard in patient care; it is essential to invest resources into developing an evidence-based curricular approach to ensure surgical training quality can be accurately evaluated to maintain and enhance the standards.

Development of Team Action Projects in Surgery (TAPS): a multilevel team-based approach to teaching quality improvement

OBJECTIVES

To meet the Accreditation Council for Graduate Medical Education core competency in Practice-Based Learning and Improvement, educational curricula need to address training in quality improvement (QI). We sought to establish a program to train residents in the principles of QI and to provide practical experiences in developing and implementing improvement projects.

DESIGN

We present a novel approach for engaging students, residents, and faculty in QI efforts-Team Action Projects in Surgery (TAPS).

SETTING

Large academic medical center and health system.

PARTICIPANTS

Multiple teams consisting of undergraduate students, medical students, surgery residents, and surgery faculty were assembled and QI projects developed. Using "managing to learn" Lean principles, these multilevel groups approached each project with robust data collection, development of an A3, and implementation of QI activities.

RESULTS

A total of 5 resident led QI projects were developed during the TAPS pilot phase. These included a living kidney donor enhanced recovery protocol, consult improvement process, venous thromboembolism prophylaxis optimization, Clostridium difficile treatment standardization, and understanding variation in operative duration of laparoscopic cholecystectomy. Qualitative and quantitative assessment showed significant value for both the learner and stakeholders of QI related projects.

CONCLUSION

Through the development of TAPS, we demonstrate a novel approach to addressing the increasing focus on QI within graduate medical education. Efforts to expand this multilevel team based approach would have value for teachers and learners alike.

Orthopedic resident work-shift analysis: are we making the best use of resident work hours?

BACKGROUND

Surgery programs have been tasked to meet rising demands in patient surgical care while simultaneously providing adequate resident training in the midst of increasing resident work-hour restrictions. The purpose of this study was to quantify orthopedic surgery resident workflow and identify areas needing improved resident efficiency. We hypothesize that residents spend a disproportionate amount of time involved in activities that do not relate directly to patient care or maximize resident education.

METHODS

We observed 4 orthopedic surgery residents on the orthopedic consult service at a major tertiary care center for 72 consecutive hours (6 consecutive shifts). We collected minute-by-minute data using predefined work-task criteria: direct new patient contact, direct existing patient contact, communications with other providers, documentation/administrative time, transit time, and basic human needs. A seventh category comprised remaining less-productive work was termed as standby.

RESULTS

In a 720-minute shift, residents spent on an average: 191 minutes (26.5%) performing documentation/administrative duties, 167.0 minutes (23.2%) in direct contact with new patient consults, 129.6 minutes (17.1%) in communication with other providers regarding patients, 116.2 (16.1%) minutes in standby, 63.7 minutes (8.8%) in transit, 32.6 minutes (4.5%) with existing patients, and 20 minutes (2.7%) attending to basic human needs. Residents performed an additional 130 minutes of administrative work off duty. Secondary analysis revealed residents were more likely to perform administrative work rather than directly interact with existing patients (p = 0.006) or attend to basic human needs (p = 0.003).

CONCLUSIONS

Orthopedic surgery residents spend a large proportion of their time performing documentation/administrative-type work and their workday can be operationally optimized to minimize nonvalue-adding tasks. Formal workflow analysis may aid program directors in systematic process improvements to better align resident skills with tasks.

LEVEL OF EVIDENCE

III.

Discordance in current procedural terminology coding for foot and ankle procedures between residents and attending surgeons

OBJECTIVE

Because of the importance of current procedural terminology (CPT) coding in both resident education evaluation and practice management, this study was undertaken to evaluate the correlation and interrater reliability between residents and attending physicians in CPT coding for orthopedic foot and ankle surgeries as well as to determine attending surgeons' and residents' familiarity with and confidence in the coding process.

METHODS

CPT codes from resident case logs were compared with those submitted by attending surgeons, and Pearson's correlation coefficient and interrater reliability were calculated to examine coding congruency. An online survey was also used to examine attending surgeon and resident perceptions and habits regarding CPT codes and the coding process.

RESULTS

CPT codes recorded by 20 residents (1164) were compared with those recorded by 3 attending foot and ankle surgeons (1259). Correlation between attending and resident codes was poor (r = -0.015). Interrater reliability demonstrated a kappa value of 0.04, indicating poor agreement. Compared with attending CPT coding, residents concordantly coded 42% of the time, with an individual resident range from 2% to 65%. Additionally, 43% of residents reported being uncomfortable about foot and ankle CPT coding, and they reported rarely or never discussing CPT codes with attending surgeons in the perioperative period.

CONCLUSIONS

Resident and attending surgeon concordance in CPT coding for foot and ankle procedures is poor, and residents have a low level of confidence in logging CPT codes, possibly because of a lack of training and preparation in coding. Because CPT coding is used not only for practice management but also has implications for evaluating institutions by accreditation bodies, educational initiatives to improve resident confidence and accuracy with CPT coding may be warranted.

The challenge of education in colorectal cancer surgery: a comparison of early oncological results, morbidity, and mortality between residents and attending surgeons performing an open right colectomy

OBJECTIVES

Ongoing education in surgical oncology is mandatory in a modern residency program. Achieving acceptable morbidity and mortality rates, together with oncological adequacy, is mandatory. The aim of the study was to compare early surgical outcomes in 2 groups of patients, those operated on by a surgical resident supervised by an attending surgeon and those operated on by 2 attending surgeons.

DESIGN

Data from consecutive patients with right colon cancer undergoing a right hemicolectomy were collected and analyzed. The patients were divided into 2 groups according to the surgeons' credentials: residents supervised by an attending surgeon and 2 attending surgeons. To evaluate the specific case mix of the 2 groups, the Portsmouth-Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (P-POSSUM) was calculated. Observed over expected 30-day morbidity and mortality rates were compared for the 2 groups. The number of lymph nodes retrieved was chosen to determine oncological appropriateness. Duration of the procedures was also recorded.

RESULTS

From January 2008 to January 2012, 139 patients underwent an right hemicolectomy (76 resections performed by surgical residents and 63 by attending surgeons). Patient characteristics according to the P-POSSUM score and cancer stage were equivalent in the 2 groups. Observed over expected mortality and morbidity rates according to P-POSSUM were 0%/3.5% and 21.6%/40.5%, respectively, for the resident group (p = nonsignificant, p = 0.01) and 4.7%/5.8% and 25.4%/42.9%, respectively, for the attending surgeons (p = nonsignificant). The node count was 23.6 nodes for residents and 23.1 for the attending surgeons. The length of surgery was 159.9 minutes vs 159.4 minutes for residents and attending surgeons, respectively.

CONCLUSIONS

Surgical oncology training of residents by expert surgeons cannot put patient's safety at risk. Our study showed that oncological accuracy and the 30-day complication rate were equivalent to the standard of care in both groups. Duration of the procedure was not affected by the presence of a trainee.

Numeracy among trainees: are we preparing physicians for evidence-based medicine?

INTRODUCTION

In the era of evidence-based medicine, all physicians who communicate with patients need numerical literacy (numeracy). Single-institution studies suggest imperfect numeracy among medical students. Therefore, we sought to examine numeracy and understanding of risk analysis among medical students and surgical residents at several institutions.

METHODS

Following a validated 3-item numeracy questionnaire, 308 medical students and 50 surgical residents from 4 institutions were asked whether they would recommend adjuvant chemotherapy for a patient based on presented survival data. Main outcome measures included numeracy, understanding of risk with a question requiring simple calculation of risk reduction, and confidence in understanding risk reduction using a Likert score (0 = no confidence and 7 = complete confidence). Binary logistic regression analysis identified predictors of misunderstanding of risk and Pearson correlation coefficients measured differences in confidence by level of training and numeracy.

RESULTS

Students across institutions did not differ demographically and were grouped by educational level. Of all participants, 69.0% had perfect basic numeracy (score = 3), with no significant difference in numeracy across training levels (p = 0.433). Mean (standard deviation) confidence in recommending treatment increased from 4.5 (1.6) for first-year medical students to 4.8 (1.1) for fourth-year medical students, and 4.9 (1.5) for surgical residents (p = 0.580). Controlling for other demographics, poorly numerate students had a 7-fold increased likelihood (odds ratio: 7.330; 95% confidence interval: 1.384-38.809) of misunderstanding risk compared with more numerate students.

CONCLUSIONS

A significant number of students at various levels of medical training lack numeracy skills, which increases misunderstanding and miscommunication of risk that can be communicated to patients and families. This deficiency could potentially affect patient safety and care.

Surgical skills acquisition: performance of students trained in a rural longitudinal integrated clerkship and those from a traditional block clerkship on a standardized examination using simulated patients

OBJECTIVES

Rural longitudinal integrated clerkship (LIC) programs for third-year medical students provide strong educational curricula and can nurture interest in rural surgical practice. Students learn technical skills in an apprenticeship model. Variability in instruction and patient experiences across sites, coupled with a lack of simulation facilities, raise some concerns about technical skill development. To explore the adequacy of skills acquisition for students in the University of Minnesota Rural Physician Associate Program (RPAP), this study compared RPAP students' performance on a scenario-based Objective Structured Assessment of Technical Skills (OSATS) with that of traditional surgery block clerkship students (Course 7500).

DESIGN, SETTING, AND PARTICIPANTS

This is a nonexperimental post-only study. All enrolled students (n = 254) completed the OSATS examination. Students in the Course 7500 (n = 222) completed 15 hours of simulation skills training and supervised practice during their 6-week clerkship. RPAP students (n = 32) completed 3 hours of skills training before their 9-month rural assignment. Both groups had access to comprehensive online materials. Mean OSATS checklist, global rating, and total scores were compared at the end of training using t tests (p < 0.05). Self-reported OR and clinical experiences were explored.

RESULTS

Both groups did well on the OSATS. There were no statistical differences in completion time, checklist scores, mean global ratings, or total scores. RPAP students reported significantly more days in the OR, surgery cases, and first assists. Experience with OSATS tasks reported by RPAP students during clinical rotations correlated with their OSATS performance.

CONCLUSION

This study supports the viability of the LIC model for fundamental skills acquisition when augmented with introductory simulation skills training and online resources. It also suggests that simulation fills a training gap for students in a traditional surgery block clerkship program. It opens a dialog about the potential partnership of surgery departments with rural LICs to address rural general surgery shortages. Further research in this aspect is needed.

Face, content, and construct validity of a novel portable ergonomic simulator for basic laparoscopic skills

OBJECTIVE

Laparoscopic skills can be improved effectively through laparoscopic simulation. The purpose of this study was to verify the face and content validity of a new portable Ergonomic Laparoscopic Skills simulator (Ergo-Lap simulator) and assess the construct validity of the Ergo-Lap simulator in 4 basic skills tasks.

DESIGN

Four tasks were evaluated: 2 different translocation exercises (a basic bimanual exercise and a challenging single-handed exercise), an exercise involving tissue manipulation under tension, and a needle-handling exercise. Task performance was analyzed according to speed and accuracy. The participants rated the usability and didactic value of each task and the Ergo-Lap simulator along a 5-point Likert scale.

SETTING

Institutional academic medical center with its affiliated general surgery residency.

PARTICIPANTS

Forty-six participants were allotted into 2 groups: a Novice group (n = 26, <10 clinical laparoscopic procedures) and an Experienced group (n = 20, >50 clinical laparoscopic procedures).

RESULTS

The Experienced group completed all tasks in less time than the Novice group did (p < 0.001, Mann-Whitney U test). The Experienced group also completed tasks 1, 2, and 4 with fewer errors than the Novice group did (p < 0.05). Of the Novice participants, 96% considered that the present Ergo-Lap simulator could encourage more frequent practice of laparoscopic skills. In addition, 92% would like to purchase this simulator. All of the experienced participants confirmed that the Ergo-Lap simulator was easy to use and useful for practicing basic laparoscopic skills in an ergonomic manner. Most (95%) of these respondents would recommend this simulator to other surgical trainees.

CONCLUSIONS

This Ergo-Lap simulator with multiple tasks was rated as a useful training tool that can distinguish between various levels of laparoscopic expertise. The Ergo-Lap simulator is also an inexpensive alternative, which surgical trainees could use to update their skills in the skills laboratory, at home, or in the office.

Integrating the NAS Milestones and handheld technology to improve residency training and assessment

OBJECTIVE

To incorporate the use of an intuitive and robust assessment tool in conjunction with the Next Accreditation System Milestones to maximize opportunities for trainee performance feedback and continuous trainee assessment, with the long-term goal of increasing the rate of performance improvement and mastery of knowledge and surgical skills.

DESIGN

Pilot study.

SETTING

Johns Hopkins Medicine, Baltimore, MD. Primary, tertiary, and quaternary clinical care; institutional environment.

PARTICIPANTS

Experimental group: two randomly selected postgraduate year-1 integrated training program residents per year for 2 consecutive years from the Department of Plastic and Reconstructive Surgery.

CONTROL GROUP

traditionally trained residents from the integrated training program in the Department of Plastic and Reconstructive Surgery. Study duration: 7 years (until residents complete residency training).

ANTICIPATED RESULTS

This assessment strategy would create large amounts of informative data on trainees, which can be cross-referenced to determine trainee progress. Assessment data would be collected continuously from all faculty surgeons. Comparisons of faculty and resident self-assessments would facilitate resident evaluations. Ease of use of the data collection structure would improve faculty evaluation compliance and timely resident case report completion.

CONCLUSIONS

Improving the efficiency and efficacy of competency documentation is critical. Using portable technologies is an intuitive way to improve the trainee assessment process. We anticipate that this 2-pronged approach to trainee assessments would quickly provide large amounts of informative data to better assess trainee progress and inform Milestone assessments in a manner that facilitates immediate feedback. Assessments of faculty and resident satisfaction would help us further refine the assessment process as needed. If successful, this format could easily be implemented by other training programs.

APPLICABLE PROJECT AREA

Innovations in Surgical Education: Milestones.

Visual force feedback improves knot-tying security

BACKGROUND

Residents in surgical specialties suture multiple wounds in their daily routine and are expected to be able to perform simple sutures without supervision of experienced surgeons. To learn basic suture skills such as needle insertion and knot tying, applying an appropriate magnitude of force in the desired direction is essential. To investigate if training with real-time visual force feedback improves the suture skills of novices, a study was conducted using a training platform that measures all forces exerted on a skin pad, i.e., the ForceTRAP.

METHOD

Two groups of novices were trained on this training platform during a suture task. One group (nov-c) received no visual force feedback during training, whereas the test group (nov-t) trained with visual feedback. The posttest and follow-up test were performed without visual force feedback.

RESULTS

A significant difference in reaction force, (nov-c: mean 2.47N standard deviation [SD] ± 0.62, nov-t: mean 1.79N SD ± 0.37), suture strength (nov-c: median 25N interquartile range (IQR) 15, nov-t: median 50N interquartile range 25), and task time (nov-c: mean 109s SD ± 22, nov-t: mean 134s SD ± 31) was found between the control and training group of the posttest.

CONCLUSION

Participants that are trained with visual force feedback produce the most secure knots in the posttest and their suturing results in lower applied forces. Therefore, the results of this study indicate that visual force feedback supports students while learning to insert the needle smoothly, to effectively align the suture threads and to balance the force between instruments during knot tying. However, for long-term learning effects, probably more than 1 training session is required.

Manual laparoscopic skills development using a low-cost trainer box in Tanzania

OBJECTIVES

To explore the feasibility and effectiveness of guided practice using a low-cost laparoscopic trainer on the development of laparoscopic skills by surgeons in a resource-poor setting.

DESIGN

This was a prospective trial involving a pretest/posttest single-sample design. Study participants completed a background survey and pretest on the 5 McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks using a simulator developed and validated by researchers from the University of California, San Francisco. On completion of a 3-month guided practice course, participants were again tested on the MISTELS tasks and completed an exit survey.

SETTING

The Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania.

PARTICIPANTS

Fourteen Tanzanian surgery residents and specialists completed the study.

RESULTS

Most of the subjects were surgical residents (64.3%). Only 2 participants (14.2%) had previous laparoscopic training, and baseline laparoscopic surgical experience was limited to intraoperative observation only. Study subjects practiced the MISTELS tasks for an average of 8.67 hours (range: 4.75-15.25) over the 3-month course. On the posttest, participants improved significantly in performance of each of the MISTELS tasks (p < 0.001). Total scores on the tasks increased from 24 ± 44 on the pretest to 384 ± 49 on the posttest (p < 0.001). All study participants were satisfied with the course, found the training personally valuable, and felt that their laparoscopic skills had improved on completion of the training.

CONCLUSIONS

We have demonstrated the feasibility and effectiveness of training with a low-cost laparoscopic trainer box in Tanzania. Study participants achieved impressive posttest scores on the 5 MISTELS tasks with minimal baseline laparoscopic exposure. We feel that guided training by an expert was key in ensuring correct technique during practice sessions.

The learning styles of orthopedic residents, faculty, and applicants at an academic program

BACKGROUND

To train surgeons effectively, it is important to understand how they are learning. The Kolb Learning Style Inventory (LSI) is based on the theory of experiential learning, which divides the learning cycle into 4 stages: active experimentation (AE), abstract conceptualization (AC), concrete experience, and reflective observation. The purpose of this investigation was to assess the learning styles of orthopedic residents, faculty, and applicants at an east-coast residency program.

METHODS

A total of 90 Kolb LSI, Version 3.1 surveys, and demographic questionnaires were distributed to all residency applicants, residents, and faculty at an academic program. Data collected included age, sex, type of medical school (MD or DO), foreign medical graduate status, and either year since college graduation, postgraduate year level (residents only), or years since completion of residency (faculty only). Seventy-one completed Kolb LSI surveys (14 residents, 14 faculty members, and 43 applicants) were recorded and analyzed for statistical significance.

RESULTS

The most prevalent learning style among all participants was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (p = 0.13). The applicant and resident groups demonstrated a high tendency toward AE followed by AC. The faculty group demonstrated a high tendency toward AC followed by AE. None of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of 31 and older group (p < 0.01).

CONCLUSIONS

The majority of applicants, residents, and faculty in the orthopedic residency program were "convergers." The converging learning style involves problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive reasoning. Learning through AE decreased with age, whereas learning through AC increased.

A prospective randomized controlled blinded study to evaluate the effect of short-term focused training program in laparoscopy on operating room performance of surgery residents (CTRI /2012/11/003113)

INTRODUCTION

Laparoscopic surgery requires certain specific skills. There have been several attempts to minimize the learning curve with training outside the operation room. Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Several randomized controlled trials and systematic reviews have demonstrated that the technical skills learned on these simulators transfer to the operating room. Currently, however, the integration of these simulated models into formal residency training curricula is lacking. In our institute, we have adopted the Tuebingen Trainer devised by Professor GF Buess from Germany. The purpose of this study was to evaluate the training of surgical residents on an ex vivo phantom model for basic laparoscopic skill acquisition and its transferability to the OR performance.

MATERIALS AND METHODS

Seventeen general surgery residents were randomized into 2 groups: Laparoscopic Training Group (n = 9, Group A) and Standard Training Group (n = 8, Group B). Group A underwent training in the Minimally Invasive Surgery Training Centre on the porcine phantom model and did 10 laparoscopic cholecystectomies, whereas Group B did not undergo training in the Minimally Invasive Surgery Training Centre. All the participants performed a laparoscopic cholecystectomy in the operation theater in the presence of a consultant who was blinded to the training status of the participants. The performance of the residents in both groups in the operation theater was assessed using GOALS criteria, surgical performance assessment parameters, task-specific checklists, and visual analog scale for gallbladder perforation difficulty and overall competence.

RESULTS

The Laparoscopic Training Group had better performance than the Standard Training Group regarding operation time, GOALS criteria, and Task-specific checklists. Although the surgical performance assessments, i.e. cystic duct and artery identification scores, gallbladder perforation scores, and liver injury scores, were better in the Laparoscopic Training Groups, they were not statistically significant. The overall difficulty of the surgery was comparable in both the groups. The Laparoscopic Training Group exhibited significant overall competence on visual analog scale scores.

CONCLUSION

Our study has clearly shown that training on the Tuebingen Trainer with integrated porcine organs results in a statistically significant improvement in the operating room performance of surgical residents as compared with the nontrained residents, thereby indicating a transfer of skills from training to the operating room.

Virtual reality robotic surgical simulation: an analysis of gynecology trainees

STUDY OBJECTIVE

To analyze the learning curves of gynecology trainees on several virtual reality da Vinci Skills Simulator exercises.

DESIGN

Prospective cohort pilot study.

SETTING

Academic hospital-based gynecology training program.

PARTICIPANTS

Novice robotic surgeons from a gynecology training program.

METHODS

Novice robotic surgeons from an academic gynecology training program completed 10 repetitions of 4 exercises on the da Vinci Skills Simulator: matchboard, ring and rail, suture sponge, and energy switching. Performance metrics measured included time to completion, economy of instrument movement, excessive force, collisions, master workspace range, missed targets, misapplied energy, critical errors, and overall score. Statistical analyses were conducted to define the learning curve for trainees and the optimal number of repetitions for each exercise.

RESULTS

A total of 34 participants were enrolled, of which 9 were medical students, 22 were residents, and 3 were fellows. There was a significant improvement in performance between the 1st and 10th repetitions across multiple metrics for all exercises. Senior trainees performed the suture exercise significantly faster than the junior trainees during the first and last repetitions (p = 0.004 and p = 0.003, respectively). However, the performance gap between seniors and juniors narrowed significantly by the 10th repetition. The mean number of repetitions required to achieve performance plateau ranged from 6.4 to 9.3.

CONCLUSION

Virtual reality robotic simulation improves ability through repetition at all levels of training. Further, a performance plateau may exist during a single training session. Larger studies are needed to further define the most high-yield simulator exercises, the ideal number of repetitions, and recommended intervals between training sessions to improve operative performance.

Laparoscopic skills maintenance: a randomized trial of virtual reality and box trainer simulators

OBJECTIVE

A number of simulators have been developed to teach surgical trainees the basic skills required to effectively perform laparoscopic surgery; however, consideration needs to be given to how well the skills taught by these simulators are maintained over time. This study compared the maintenance of laparoscopic skills learned using box trainer and virtual reality simulators.

DESIGN

Participants were randomly allocated to be trained and assessed using either the Society of American Gastrointestinal Endoscopic Surgeons Fundamentals of Laparoscopic Surgery (FLS) simulator or the Surgical Science virtual reality simulator. Once participants achieved a predetermined level of proficiency, they were assessed 1, 3, and 6 months later. At each assessment, participants were given 2 practice attempts and assessed on their third attempt.

SETTING

The study was conducted through the Simulated Surgical Skills Program that was held at the Royal Australasian College of Surgeons, Adelaide, Australia.

RESULTS

Overall, 26 participants (13 per group) completed the training and all follow-up assessments. There were no significant differences between simulation-trained cohorts for age, gender, training level, and the number of surgeries previously performed, observed, or assisted. Scores for the FLS-trained participants did not significantly change over the follow-up period. Scores for LapSim-trained participants significantly deteriorated at the first 2 follow-up points (1 and 3 months) (p < 0.050), but returned to be near initial levels by the final follow-up (6 months).

CONCLUSIONS

This research showed that basic laparoscopic skills learned using the FLS simulator were maintained more consistently than those learned on the LapSim simulator. However, by the final follow-up, both simulator-trained cohorts had skill levels that were not significantly different to those at proficiency after the initial training period.

A preliminary report on the initiation of a clinical research program in an orthopaedic surgery department: roadmaps and tool kits

OBJECTIVE

A formal research program enhances resident training experience, productivity and hones critical appraisal skills. This initiative sought to investigate if an academic orthopaedic surgery department could implement a clinical research program, with the goal of increasing resident scholarly activity, a requirement of the Resident Review Committee, and achieve a parallel aim of enhancing the research focus of faculty.

DESIGN

A multifaceted intervention including a needs assessment, appropriation of dedicated research staffing, development of tracking tools and policies, and a formalized research curriculum, followed by additional research time for residents was planned and implemented. The impact of all of these efforts is measured with specific outcomes, pre and post implementation.

SETTING

The North Shore-LIJ Orthopaedic Surgery Department is a high volume clinical and education program with 17 fulltime core faculty and 18 residents at 2 tertiary hospitals.

PARTICIPANTS

Residents were the focus of the intervention. The participation of faculty as principal investigators and sponsors was a key component to ensure success.

RESULTS

The following outcomes were observed post intervention: increases in institutionally-required research training for faculty/residents, number of IRB protocols submitted, abstracts submitted to national meetings, percentage of time faculty report they spend on research activities, additional hours allocated to the new Department sponsored research curriculum and an additional research rotation for trainees.

CONCLUSIONS

The official inception of a formalized program (2012) with a structured research process, invigorated faculty and trainees to formulate clinical research inquiries, generate hypotheses, create protocols and design and implement protocols. Structured tools, an experienced clinical research "champion" and commitment from departmental leadership were demonstrated as effective in transforming the focus of a clinical department into one with a nascent clinical research program, with demonstrable outcomes.

The role of the nonphysician educator in general surgery residency training: from outcome project and duty-hours restrictions to the next accreditation system and milestones

OBJECTIVE

In 2002 and 2003 the ACGME Outcome Project (assessing residents based on competencies) and duty-hours restrictions were implemented. One strategy for assisting PDs in the increased workload was to hire nonphysician educators with training and experience in curriculum design, teaching techniques, adult learning theories, and research methods. This study sought to document prevalence and responsibilities of nonphysician educators.

METHODS

IRB approval was received for a two-part study. All 247 general surgery PDs were e-mailed the question, "Do you have a nonphysician educator as a member of your surgery education office?" Those who replied "yes" or volunteered "not currently but in the past" were e-mailed a link to an electronic survey concerning the role of the nonphysician educator.

SETTING

Residency training programs in general surgery.

PARTICIPANTS

General surgery program directors.

RESULTS

Of the 126 PDs who responded to the initial query, 37 said "yes" and 4 replied "not currently but in the past". Thirty-two PDs of the initial 41 respondents completed the survey. Significant findings included: 65% were hired in the last 6 years; faculty rank is held by 69%; and curriculum development was the most common responsibility but teaching, research, and administrative duties were often listed. PDs perceived that faculty, residents, and medical students had mostly positive attitudes towards nonphysician educators.

CONCLUSIONS

The overall results seem to support the notion that nonphysician educators serve as vital members of the team.

Should general surgery residents be taught laparoscopic pyloromyotomies? An ethical perspective

OBJECTIVES

The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy.

DESIGN/PARTICIPANTS

Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies?

RESULTS

A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies.

CONCLUSIONS

From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no.

DEFINITIONS

We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.

Competency champions in the clinical competency committee: a successful strategy to implement milestone evaluations and competency coaching

OBJECTIVES

To create a clinical competency committee (CCC) that (1) centers on the competency-based milestones, (2) is simple to implement, (3) creates competency expertise, and (4) guides remediation and coaching of residents who are not progressing in milestone performance evaluations.

DESIGN

We created a CCC that meets monthly and at each meeting reviews a resident class for milestone performance, a competency (by a faculty competency champion), a resident rotation service, and any other resident or issue of concern.

SETTING

University surgical residency program.

PARTICIPANTS

The CCC members include the program director, associate program directors, director of surgical curriculum, competency champions, departmental chair, 2 at-large faculty members, and the administrative chief residents.

RESULTS

Seven residents were placed on remediation (later renamed as coaching) during the academic year after falling behind on milestone progression in one or more competencies. An additional 4 residents voluntarily placed themselves on remediation for medical knowledge after receiving in-training examination scores that the residents (not the CCC membership) considered substandard. All but 2 of the remediated/coached residents successfully completed all area milestone performance but some chose to stay on the medical knowledge competency strategy.

CONCLUSIONS

Monthly meetings of the CCC make milestone evaluation less burdensome. In addition, the expectations of the residents are clearer and more tangible. "Competency champions" who are familiar with the milestones allow effective coaching strategies and documentation of clear performance improvements in competencies for successful completion of residency training. Residents who do not reach appropriate milestone performance can then be placed in remediation for more formal performance evaluation. The function of our CCC has also allowed us opportunity to evaluate the required rotations to ensure that they offer experiences that help residents achieve competency performance necessary to be safe and effective surgeons upon completion of training.

S/he who can, does and teaches. S/he who cannot, doesn't

BACKGROUND

The saying, "[h]e who can, does. He who cannot, teaches." suggests that those who have the skills to perform do so, whereas those who do not have those skills become teachers. We hypothesize that this saying as it relates to general surgery residents is not true.

METHODS

This was a retrospective study of general surgery chief residents from 2009 to 2013. Technical ability was assessed with the Fundamentals of Laparoscopic Surgery examination performance. Teaching ability was assessed with medical student evaluations on a 9-point Likert scale as well as with receipt of teaching awards: The Arnold P. Gold Teaching Award, the surgical teaching award given by each graduating class of the medical school, and resident induction into Alpha Omega Alpha. Mann-Whitney U tests were performed between resident groups based on teaching award status and Fundamentals of Laparoscopic Surgery examination outcomes, using an α = 0.05.

RESULTS

For 32 chief residents (7 female), the median score on the Manual Skills Section was 531 (interquartile range [IQR] [478-563]). On the Cognitive Section, the cohort of residents who won each award outperformed the residents who did not win that specific award (all p < 0.05). On the Manual Skills Section, residents who received any teaching award/the Arnold P. Gold Teaching Award (n = 7) performed similar to residents who did not receive this award (n = 25) (584 [IQR {491-620}] vs. 527 [IQR {482-537}]) (p = 0.09). Residents who received the surgical teaching award from the medical school (n = 3) performed similar to residents who did not receive this award (n = 29) (608 [IQR {474-637}] vs. 527 [IQR {482-555}]) (p = 0.23). Eligible residents who were inducted into Alpha Omega Alpha (n = 4) outperformed residents who were not inducted (n = 18) (596 [IQR {564-637}] vs. 527 [IQR {446-551}]) (p = 0.01).

CONCLUSIONS

There is some evidence that superior resident teachers have greater content knowledge and a higher degree of laparoscopic skills.

A framework for improving resident research participation and scholarly output

OBJECTIVES

The Accreditation Council for Graduate Medical Education requires that "faculty should encourage and support residents in scholarly activities." There are no guidelines, however, to illustrate how this should be done, and only a small number of published reports offer examples of successful efforts to spur resident research. We sought to improve our residents' participation in scholarly activities.

DESIGN

We describe a multifaceted program to quickly build resident scholarship at an orthopaedic department.

SETTING

Large academic medical center in the Midwestern United States.

PARTICIPANTS

An experienced medical editor was recruited to assist faculty and mentor residents in coordinating research projects and to direct publishing activity. Additional publishing requirements were added to the resident curriculum beyond those already required by the Accreditation Council for Graduate Medical Education. Residents were required to select a faculty research mentor to guide all research projects toward a manuscript suitable for submission to a peer-reviewed journal. Activities were monitored by the editor and the resident coordinator.

RESULTS

Over 4 years, total department peer-reviewed publications increased from 33 to 163 annually. Despite a decrease in resident complement, the number of peer-reviewed publications with a resident author increased from 6 in 2009 to 53 in 2012.

CONCLUSIONS

The addition of an experienced medical editor, changes in program requirements, and an increased commitment to promotion of resident research across the faculty led to a dramatic increase in resident publications. Our changes may be a model for other programs that have the financial resources and faculty commitment necessary to achieve a rapid turnaround.

Is our residency program successful? Structuring an outcomes assessment system as a component of program evaluation

OBJECTIVE

In an attempt to better define the success of our residency program with regard to resident development, we committed to develop an ongoing assessment of residency performance and devised an outcomes assessment system.

DESIGN

We describe the process and structure that we used to construct an outcomes assessment system. We discuss the process we used to discern whether or not our program is successful as well as offer tips on what data to collect and track should other residency programs decide to devise a similar outcomes assessment database.

CONCLUSION

Taking time to "step back" to take inventory of a residency program and ensure year over year and at the end of training residents have developed and matured as planned is an educationally sound practice. Structuring an outcomes assessment system like the one that we discuss here can aid program directors with this important task.

A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency

OBJECTIVE

To outline a structured approach for general surgery resident integration into institutional quality improvement and patient safety education and development.

DESIGN

A strategic plan to address Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described.

SETTING

Gundersen Lutheran Medical Foundation is an independent academic medical center graduating three categorical residents per year within an integrated multi-specialty health system serving 19 counties over 3 states.

RESULTS

The quality improvement and patient safety education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings.

CONCLUSIONS

Structured education regarding and participation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data.

A low-cost surgical application of additive fabrication

OBJECTIVE

This study was used to test the feasibility of using additive fabrication techniques 3-dimensional (3D) printing to create personalized/patient-specific hepatic 3D physical models from clinical radiology studies for surgical resident education.

DESIGN

Patient-specific imaging data from either computed tomography or magnetic resonance imaging scans, in Digital Imaging and Communications in Medicine format, were rendered and manipulated with computer software, translating the medical imaging data sets into useful 3D geometry files in stereo lithography format for 3D printing. A commercial third party was used to print the 3D models in laser sintered nylon, which provided access to expensive, industrial-grade, high-resolution 3-D printers at a low cost.

RESULTS

Multiple patient-specific preoperative 3D physical models were printed of portal and hepatic venous anatomy at a cost of less than $100 per model.

CONCLUSION

Current 3D printing techniques can be used to create low-cost personalized/patient-specific hepatic 3D models from clinical radiology studies for surgical resident education.

Collaborating to increase access to clinical and educational resources for surgery: a case study

A case study is described in which collaborations between a Department of Surgery, a Department of Information Technology, and an academic health sciences library resulted in the development of an electronic surgical library available at the bedside, the deployment of tablet devices for surgery residents, and implementation of a tablet-friendly user interface for the institution's electronic medical record.

Comparable operative times with and without surgery resident participation

BACKGROUND

Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes.

OBJECTIVE

To evaluate the effect of general surgery resident participation in surgical procedures on operative times and postoperative patient outcomes.

DESIGN

Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality.

SETTING

Academic general surgery residency program.

RESULTS

There were 2280 operative procedures performed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p = 0.14) and male gender (46% vs 45%, p = 0.68), and there was no difference in overall operative time (68min vs 66min, p = 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p = 0.8), thyroidectomy (125 vs 109, p = 0.16), breast procedure (38 vs 26, p = 0.79), hernia repair (61 vs 60, p = 0.74), lower extremity amputation (65 vs 77, p = 0.16), tunneled venous catheter (49 vs 47, p = 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p = 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group (71 vs 66, p = 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p = 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p = 0.45).

CONCLUSIONS

There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing surgical procedures.

How residents learn predicts success in surgical residency

BACKGROUND

Predictors of success in surgical residency have been poorly understood. Previous studies have related prior performance to future success without consideration of personal attributes that help an individual succeed. Surgical educators should consider how residents learn to gain insight into early identification of residents at risk of failing to complete their surgical training.

METHODS

We examined our 14-year database of surgical resident learning-style assessments, Accreditation Council for Graduate Medical Education operative log data of graduating residents from 1999 to 2012, first time pass rates on the American Board of Surgery Qualifying and Certifying examinations, and departmental records to identify those residents who did not complete their surgery training at our institution. Statistical analysis was performed using the chi-square test, Wilcoxon rank-sum, and regression analysis with significance set at p < 0.05.

RESULTS

We analyzed 441 learning-style assessments from 130 residents. Surgical residents are predominantly action-based learners, with converging (219, 49.7%) and accommodating (112, 25.4%) being the principal learning styles. Assimilating (66, 15%) and diverging (44, 10%) learning styles, where an individual learns by observation, were less common. Regression analysis comparing learning style with case volume revealed that residents who are action-based learners completed more cases at graduation (p < 0.05 for each). Additionally, surgical residents who transferred to a nonsurgical residency or nonphysician field were more likely to learn by observation (p = 0.0467).

CONCLUSIONS

Surgical residents are predominantly action-based learners. However, a subset of surgical residents learn primarily by observation. These residents are at risk for a less robust operative experience and not completing surgical training. Learning-style analysis may be utilized by surgical educators to identify the potential at-risk residents in general surgery.

Implementing an excellence in teaching recognition system: needs analysis and recommendations

PURPOSE

Teaching awards have been suggested to serve a variety of purposes. The specific characteristics of teaching awards and the associated effectiveness at achieving planned purposes are poorly understood. A needs analysis was performed to inform recommendations for an Excellence in Teaching Recognition System to meet the needs of surgical education leadership.

METHOD

We performed a 2-part needs analysis beginning with a review of the literature. We then, developed, piloted, and administered a survey instrument to General Surgery program leaders. The survey examined the features and perceived effectiveness of existing teaching awards systems. A multi-institution committee of program directors, clerkship directors, and Vice-Chairs of education then met to identify goals and develop recommendations for implementation of an "Excellence in Teaching Recognition System."

RESULTS

There is limited evidence demonstrating effectiveness of existing teaching awards in medical education. Evidence supports the ability of such awards to demonstrate value placed on teaching, to inspire faculty to teach, and to contribute to promotion. Survey findings indicate that existing awards strive to achieve these purposes and that educational leaders believe awards have the potential to do this and more. Leaders are moderately satisfied with existing awards for providing recognition and demonstrating value placed on teaching, but they are less satisfied with awards for motivating faculty to participate in teaching or for contributing to promotion. Most departments and institutions honor only a few recipients annually.

CONCLUSIONS

There is a paucity of literature addressing teaching recognition systems in medical education and little evidence to support the success of such systems in achieving their intended purposes. The ability of awards to affect outcomes such as participation in teaching and promotion may be limited by the small number of recipients for most existing awards. We propose goals for a Teaching Recognition System and provide guidelines for implementation and evaluation of such systems. Future analysis should study the effectiveness of systems designed using these guidelines in achieving the outlined goals.

Utilizing a novel tool for the comprehensive assessment of resident operative performance

PURPOSE

A mechanism for more effective and comprehensive assessment of surgical residents' performance in the operating room (OR) is needed, especially in light of the new requirements issued by the American Board of Surgery. Furthermore, there is an increased awareness that assessments need to be more meaningful by including not only procedure-specific and general technical skills, but also nontechnical skills (NOTECHS), such as teamwork and communication skills. Our aims were to develop a methodology and create a tool that comprehensively assesses residents' operative performance.

METHODS

A procedure-specific technical skill assessment for laparoscopic colon resections was created through use of task analysis. Components of previously validated tools were added to broaden the assessment to include general technical skills and NOTECHS. Our instrument was then piloted in the OR to measure face and content validity through an iterative process with faculty evaluators. Once the tool was finalized, postgraduate 3 (PG3) and PG5 residents on a 2-month long rotation were assessed by 1 of 4 colorectal surgeons immediately after completing a case together. Construct validity was measured by evaluating the difference in scores between PG3 and PG5 residents' performance as well as the change in scores over the course of the rotation.

RESULTS

Sixty-three assessments were performed. All evaluations were completed within 48 hours of the operation. There was a statistically significant difference between the PG3 and PG5 scores on procedure-specific performance, general technical skills, NOTECHS, and overall performance. Over the course of the rotation, a statistically significant improvement was found in residents' scores on the procedure-specific portion of the assessment but not on the general surgical skills or NOTECHS.

CONCLUSION

This is a feasible, valid, and reliable assessment tool for the comprehensive evaluation of resident performance in the OR. We plan to use this tool to assess resident operative skill development and to improve direct resident feedback.

Jump starting a quality and performance improvement initiative to meet the updated ACGME guidelines

BACKGROUND

The Accreditation Council for Graduate Medical Education requires residents to be trained in practice-based learning and improvement as well as systems-based practice. In an effort to establish a formal curriculum for graduate medical education, a Performance Improvement (PI) Training Program was initiated at Memorial University Medical Center. Training for the chief residents across all residency programs focused on the basic Six Sigma framework. Chief residents chose faculty sponsors and were also mentored by Six Sigma-trained staff. Faculty and physicians who participated in the initiative received PI/Continuing Medical Education credit.

METHODS

A total of 17 presurveys and postsurveys were completed on 7 outcome measures. Nonparametric Wilcoxon signed rank 2-tailed tests were performed to test for significant change from presurvey to postsurvey.

RESULTS

Analysis of the 2-year data (2009-2011) found statistically significant improvement for all 7 outcome measures. The surgical residents' PI Project for 2011 included the development of the Venous Thromboembolism Reassessment Tool. The project included a multidisciplinary team to develop a computer prompt that continued to trigger if the physician launched the prophylaxis or treatment form without ordering anticoagulation. The new prompt resulted in a 391% increase in anticoagulant orders.

CONCLUSIONS

This study demonstrated that the resident-based PI Training Program was innovative, practical, and comprehensive. Education, tools, and skill development were provided on quality and PI theory and practice for resident physicians in support of the Accreditation Council for Graduate Medical Education core competencies of professionalism, practice-based learning and improvement, and systems-based practice.

Senior residents as teaching assistants during laparoscopic cholecystectomy in the 80-hour workweek era: effect on biliary injury and overall complication rates

PURPOSE

The resident as teaching assistant (TA) in the operating room is an important role in the maturation of surgical trainees. One concern in the current 80-hour workweek era is that current senior residents (SRs) are unprepared to serve as TAs, potentially leading to higher complication rates and a significant increase in the length of operations. The aim of this study was to analyze whether SRs serving as TAs during laparoscopic cholecystectomy (LC) resulted in an adverse effect on complication rates in the 80-hour workweek era.

METHODS

A retrospective review was conducted of 1668 LC performed at 2 affiliated general surgery teaching hospitals from 2003 through 2007. Teaching hospital A was a public teaching hospital where junior residents (JR) performed the LC with a scrubbed SR as TA under faculty supervision. Teaching hospital B was a community-based affiliate hospital where the JR performed LC with only scrubbed faculty supervision. Operative case duration, JR level, patient gender/age, operative indication, final pathology, and complication data were gathered and univariate and multivariate analyses were performed.

RESULTS

Despite a higher rate of acute cholecystitis in the TA hospital, LC-associated complications occurred at similar rates with and without SR as TA. The rate of biliary injury was also the same in both hospitals. On multivariable analysis, only male gender was associated with complications (odds ratio = 1.7; p = 0.004).

CONCLUSIONS

In the 80-hour resident workweek era, SRs acting as TAs during LC is not associated with increased total complications or an increased rate of biliary injury.