Resident Self-Entrustment and Expectations of Autonomy: OB > GYN?

INTRODUCTION

Entrustment is a key component connecting to resident preparedness for surgical practice in the operating room (OR). Residents' self-entrustment of their surgical competencies closely associates with their OR training experience and granted autonomy. Some recent studies have investigated how attending surgeons entrusted residents in the OR. There is little to no data, however, in examining these issues from the resident perspective. The goal of this study was to identify the perception and expectations of autonomy from residents' perspective, as well as the self-entrustment of their surgical competencies in obstetrics (OB) and gynecologic (GYN) procedures.

METHODS

Focus group interviews of OB/GYN residents were performed. Residents were selected by convenience sampling. Audio recordings of each interview were transcribed, iteratively analyzed, and emergent themes identified, using a framework method.

RESULTS

A total of 123 minutes of interviews were recorded. Eight junior residents (PGY1-2) and 12 senior residents (PGY3-4) participated. Our data illustrated that (1) the perception of autonomy shifted significantly throughout residency training; (2) residents demonstrated higher expectations and self-entrustment for OB surgical procedures than for GYN surgical procedures upon graduation; and (3) case volume, modalities of OR teaching and mutual communication are 3 factors influencing resident self-entrustment of their surgical competencies.

CONCLUSIONS

Residents showed disparities in their self-entrustment and expectations of autonomy between OB and GYN surgical procedures. Better understanding these differences and the 3 influencing factors could help programs develop a potential solution for improvement in resident entrustment and autonomy upon graduation.

How to Get Ahead: Early-Career Colorectal Surgeons Reflect on Their First Few Years in Practice

OBJECTIVE

To identify strategies and barriers to career progression in early-career colorectal surgeons.

DESIGN

Qualitative research study performed via semi-structured interviews with early-career, board-certified colon, and rectal surgeons. Responses were analyzed, coded, and categorized to understand strategies towards career progression, perceived barriers to career progression, beliefs about case mix, and referral patterns.

SETTING

Interviews conducted in person and via telephone across the United States and Canada.

PARTICIPANTS

Early-career board-certified colorectal surgeons RESULTS: Twenty-two board-certified colorectal surgeons currently employed in 14 states and 1 foreign country were interviewed. Fourty-five percent were female. Their current practice environment was described as academic (77%), private practice (18%), or military (5%). Seventy-seven percent of surgeons were satisfied with their career progression. Seventy-two percent were satisfied with the case volume. Seventy-two percent were satisfied with their case mix. When asked about strategies for career progression, surgeons made 77 comments focused on three main themes: optimization of their job search, optimization of relationships while on the job, and efforts to augment individual achievement. When asked about barriers to career advancement, surgeons most frequently commented on a lack of time and a lack of mentors. When asked about case mix, 63% of surgeons felt that they had no control over it. They were evenly divided between believing that a broad case mix or a niche specialized case mix was more instrumental for career progression.

CONCLUSIONS

Early-career colorectal surgeons were mostly satisfied with their career progression, volume, and case mix. In discussing their careers, many have developed a number of strategies focused on growth as an individual as well as relationship building. They also identified a number of barriers including lack of time and lack of mentorship. Early-career surgeons may be able to utilize these strategies and anticipate barriers prior to starting their first job, leading to greater likelihood of career satisfaction.

Eyes for Ears-A Medical Education Podcast Feasibility Study

BACKGROUND

Downloadable audio files called podcasts have become popular within many areas of medical education. They can be a valuable supplement to traditional teaching methods. Medical educators may wish to incorporate podcasts into their curriculum and disseminate their work to a larger audience, but may not know how.

PURPOSE

We aim to describe the implementation of a novel medical education podcast series for ophthalmology medical student and resident education, and demonstrate feasibility, sustainability, and acceptance of this learning platform.

METHODS

The Basic and Clinical Science Course (BCSC) textbooks and supplementary texts, were used to create a weekly series of ophthalmology review podcasts. Feasibility markers include time and cost of production. Sustainability measures included download markers over time. Acceptance was measured by reviews on Apple iTunes and Twitter followers.

RESULTS

Forty-eight episodes were released from January 10, 2019 to March 31, 2020. Costs included $212.18 startup, and $29 monthly. The podcast has had 122,709 downloads to date (466/month January 2019, increased to 17,500/month February 2020). It obtained 331 Twitter followers, and 114 ratings on iTunes, with an average of 5.0 stars.

CONCLUSIONS

Medical education podcasts are a feasible way of disseminating educational materials to learners. We demonstrate sustainability and acceptance of this learning platform.

Development of the User Experience (UX) and Video Quality Evaluation (VQE) Instruments for Assessment of Intraoperative Video Capture Technology

OBJECTIVE

There exists a lack of technology to reliably and routinely capture high-quality video of open surgical procedures. To critically evaluate and compare new and existing technology solutions, we must have widely accepted evaluation criteria for intraoperative camera devices. The objective, therefore, was to develop evaluation criteria for intraoperative camera devices, as well as the video product they produce.

DESIGN

A modified Delphi process that included 2 iterative surveys was used to build expert consensus and develop 2 evaluation instruments: one to evaluate the user experience (UX) of using an intraoperative camera device, and the second for video quality evaluation (VQE) of the video product.

SETTING

Global, through iterative online surveys.

PARTICIPANTS

Surgeons who perform open surgery and have experience with intraoperative video capture.

RESULTS

Eighty-six experts participated in the first iteration of the survey and 46 in the second. Ten factors met the a priori cutoff for >80% agreement for the UX survey: (1) ease of setup/integration with current practice, (2) comfort, (3) distracting during case, (4) overall satisfaction with wearing the device, (5) would you use this device again, (6) would you recommend this device to colleagues, (7) the weight of wearing the device, (8) sufficient battery life, (9) ability to control device while operating, and (10) degree to which the device interferes or is incompatible with other surgical accessories. Six factors met the cutoff for the VQE survey: (1) camera stability, (2) brightness/exposure, (3) resolution/sharpness, (4) unobstructed view of the surgical field, (5) appropriate field of view, and (6) overall satisfaction with video quality.

CONCLUSIONS

These instruments can be used to critically evaluate camera technologies for intraoperative video capture of open surgery.

Construct Validity and Experience of Using a Low-cost Arthroscopic Knee Surgery Simulator

OBJECTIVE

To validate an affordable and easily reproducible arthroscopic knee surgery simulator made from simple, low-cost materials by demonstrating its ability to distinguish experienced from novice arthroscopists (i.e., construct validity). Additionally, acceptance and usefulness of the simulator in medical training and education were assessed.

DESIGN

The simulator was used to perform a partial meniscectomy in both menisci. External and intra-articular images obtained during the procedures were used to assess objective visual parameters. The Arthroscopic Surgical Skill Evaluation Tool and a Likert scale addressing individual perceptions about the simulator and its applicability in medical education were also used.

SETTING

The study was conducted at Hospital de Clínicas da Universidade Federal do Paraná, a teaching hospital in southern Brazil.

PARTICIPANTS

Thirty sixth-year medical students were recruited, as well as 10 orthopedic surgeons who had knee arthroscopy expertise and were members of a sports traumatology and knee arthroscopy group.

RESULTS

There were statistically significant differences between the groups in all objective parameters. The mean time to perform the procedure was 60% higher among students compared to surgeons. Students needed 72.5% more time on average to perform triangulations and obtained an error rate approximately twice higher in the assessment of the area removed from the menisci. Regarding Arthroscopic Surgical Skill Evaluation Tool scores, statistically significant differences were found between surgeons and students in all 8 domains and in the total score. The simulator was well accepted, as over 90% of participants found it useful for education and training, believed it contributed to teaching and assessing specific surgical steps and procedures, and reported that the task was enjoyable.

CONCLUSIONS

The arthroscopic knee surgery simulator was largely accepted and had good applicability in objective measurement of surgical skills, distinguishing medical students from orthopedic surgeons and thus demonstrating construct validity.

Surgical Residents in the Battle Against COVID-19

In times of public health crises, medical residency program leaders are responsible to maintain the wellbeing of their residents and ensure uninterrupted training. COVID-19 caused significant impact on healthcare industry, depleting resources and manpower, which led to disruption to graduate medical education and residency training. Surgical residents were affected by the pandemic both by reduced operative opportunities in most training centers and inducing stress and concerns about safety and wellbeing among residents. Spread of the SARS-Cov-2 was naturally accompanied with a gradual decrease in numbers of healthcare personnel which consequently increased the burden on residents. During these times of crisis and uncertainty, it is crucial that residency programs find alternative learning opportunities and deploy pre-designed, dynamic operational strategies to ensure high quality surgical services while optimizing resident safety and wellbeing. The COVID-19 crisis was a natural call for the essential need to add another dimension to residency competencies, which is Crisis-based learning and practice. Times of public health crisis are opportunities to reflect on the medical practice from an interdisciplinary and interprofessional perspective and train the residents to function as part of a larger, globally responsible team. It also calls upon adopting innovative instructional and learning strategies such as utilizing digital and online learning tools to complement learning. A holistic approach to the crisis was taken by the surgical residency program at the University of Illinois in Chicago, which addressed the issue from a resident, hospital, and public health standpoints. An operational strategy was introduced to optimize resident safety, maximize learning opportunities, support other non-surgical services, and promote online teaching and learning. This strategy is meant to serve as a dynamic reference for surgical residency programs and as an infrastructure for dealing with this and any upcoming healthcare crises in an efficient and resident-centered way.

Innate Arthroscopic & Laparoscopic Surgical Skills: A Systematic Review of Predictive Performance Indicators Within Novice Surgical Trainees

OBJECTIVE

To query the literature for predictive factors for performance on arthroscopic and laparoscopic surgical simulators in novice surgical trainees. These predictive factors may prove a valuable tool in identifying certain innate potential to becoming a future skilled surgeon that could benefit both surgical residency candidates and program directors alike, while also improving patient care.

DESIGN

Systematic Review.

RESULTS

The initial searches yielded 249 articles. After screening titles/abstracts and implementing inclusion and exclusion criteria, 36 studies were included in the final systematic review.

CONCLUSIONS

Current literature suggests that video game experience/frequency, psychomotor and visuospatial aptitude, and perceptual ability are among the most promising predictive indicators of baseline simulator performance. Study limitations include utilization of different standards for characterizing predictive factors. Future studies should aim to utilize standard guidelines for accurate quantification of innate predictive factors. Future research should also focus on utilizing standardized simulator platforms and aptitude tests to allow for more accurate cross-study comparisons and meta-analyses with larger sample sizes.

Entrustable Professional Activities in General Surgery: Trends in Resident Self-Assessment

OBJECTIVE

Effective self-assessment is a cornerstone of lifelong professional development; however, evidence suggests physicians have a limited ability to self-assess. Novel strategies to improve the accuracy of learner self-assessment are needed. Our institution's surgical entrustable professional activity (EPA) implementation strategy incorporates resident self-assessment to address this issue. This study evaluates the accuracy of resident self-assessment versus faculty assessment across 5 EPAs in general surgery.

DESIGN, SETTING, PARTICIPANTS

Within a single academic general surgery residency program, assessment data for 5 surgery EPAs was prospectively collected using a mobile application. Matched assessments (resident and faculty assessments for the same clinical encounter) were identified and the remainder excluded. Assessment scores were compared using Welch's t test. Agreement was analyzed using Cohen's kappa with squared weights.

RESULTS

One thousand eight hundred and fifty-seven EPA assessments were collected in 17 months following implementation. One thousand one hundred and fifty-five (62.2%) were matched pairs. Residents under-rated their own performance relative to faculty assessments (2.36 vs 2.65, p < 0.01). This pattern held true for all subsets except for Postgraduate Year (PGY)2 residents and Inguinal Hernia EPAs. There was at least moderate agreement between matched resident and faculty EPA assessment scores (κ = 0.57). This was consistent for all EPAs except Trauma evaluations, which were completed by faculty from 2 different departments. Surgery resident self-assessments more strongly agreed with Surgery faculty assessments than Emergency Medicine faculty assessments (κ = 0.58 vs 0.36).

CONCLUSIONS

Resident EPA self-assessments are equivalent or slightly lower than faculty assessments across a wide breadth of clinical scenarios. Resident and faculty matched assessments demonstrate moderate agreement.

Surgery Residents Spend Nearly 8 Months of Their 5-Year Training on the Electronic Health Record (EHR)

OBJECTIVE

Electronic health records (EHRs) are an integral part of the medical system and are used in all aspects of care. Despite multiple advantages of an EHR, concerns exist over the amount of time that residents spend on computers rather than in direct patient care. This study aims to quantify the time a general surgery resident spends on the EHR during their training.

DESIGN/PARTICIPANTS

Active usage time data from our institution's EHR were extracted for 34 unique general surgery residents from October 2014 to June 2019. Career time on the EHR was calculated and a "work month" was defined as a 4-week period of 80 hours per week.

SETTING

Carolinas Medical Center, Charlotte, NC.

RESULTS

Total career EHR usage for a general surgery resident was 2512 continuous hours, corresponding to 31.4 work weeks or 7.9 work months. In total, 7133 charts were opened with an average of 20.5 minutes on the EHR per patient chart. Career time spent on specific tasks included: chart review 10.6 work weeks, documentation 10.4 work weeks, and order entry 5.4 work weeks. The total number of orders entered were 57,739 and total number of documents created were 9222. EHR time in all aspects, patient charts opened, documents created, and number of orders entered decreased as postgraduate year increased.

CONCLUSIONS

This is the first study quantifying the total time a general surgery resident spends on the EHR during their clinical training. Total EHR time equated to nearly 8 work months. General surgery residents spend considerable time on the EHR and this underscores the importance of implementing methods to improve EHR efficiency and maximize time for clinical training.

"Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent

OBJECTIVE

Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations.

DESIGN

This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature.

CONCLUSIONS

We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.

Definition of Proficiency Level by a Virtual Simulator as a First Step Toward a Curriculum on Fundamental Skills for Endovascular Aneurysm Repair (EVAR)

OBJECTIVE

At present, there is no proficiency-based curriculum for endovascular treatment of aortic aneurysm repair (EVAR) using virtual reality (VR) surgical simulators, whereas such curricula are available for the treatment of iliac and/or superficial femoral artery disease. The purpose of this work was to compute proficiency, defined by a benchmark level determined by the performance of experts, using a commercial VR simulator as a first step of a curriculum on EVAR.

MATERIALS AND METHODS

Expert endovascular surgeons (with more than 150 EVAR cases as first operators) from 12 major Italian centers completed three cases of EVAR of increasing difficulty level 3 times each, using the Angio Mentor simulator (by Simbionix) and Gore devices. Proficiency level was based on performance of expert surgeons, as assessed by metrics from a VR simulator.

RESULTS

The participating surgeons had a median of 20 years of experience and executed a median of 440 EVAR. For the 3 simulated cases, the following proficiency values were respectively obtained: total procedure time: 22 minutes 32 seconds, 23 minutes 05 seconds, and 20 minutes 32 seconds; total amount of contrast injected: 85.16 mL, 89.97 mL, and 98.01 mL total fluoroscopy time: 10 minutes 39 seconds, 12 minutes 22 seconds, and 10 minutes 17 seconds; time to contralateral gate cannulation: 5 minutes 51 seconds, 7 minutes 09 seconds, and 3 minutes 32 seconds.

CONCLUSIONS

We computed proficiency levels for 3 simulated cases of EVAR using a VR simulator. Our next step is to determine whether surgical residents can reach this level. Translational research will then be required to assess the impact of such training on real patients.

Use of a Secure Web-Based Data Management Platform to Track Resident Operative Performance and Program Educational Quality Over Time

OBJECTIVE

In surgery residency programs, Accreditation Council for Graduate Medical Education mandated performance assessment can include assessment in the operating room to demonstrate that necessary quality and autonomy goals are achieved by the conclusion of training. For the past 3 years, our institution has used The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) instrument to assess and track operative skills. Evaluation is accomplished in near real-time using a secure web-based platform for data management and analytics (Firefly). Simultaneous to access of the platform's case logging function, the O-SCORE instrument is delivered to faculty members for rapid completion, facilitating quality, and timeliness of feedback. We sought to demonstrate the platform's utility in detecting operative performance changes over time in response to focused educational interventions based on stored case log and O-SCORE data.

DESIGN

Stored resident performance assessments for the most frequently performed laparoscopic procedures (cholecystectomy, appendectomy, inguinal hernia repair, ventral hernia repair) were examined for 3 successive academic years (2016-2019). During this time, 4 of 36 residents had received program-assigned supplemental simulation training to improve laparoscopic skills. O-SCORE data for these residents were extracted from peer data, which were used for comparisons. Assigned training consisted of a range of videoscopic and virtual reality skills drills with performance objectives. O-SCORE responses were converted to integers and autonomy scores for items pertaining to technical skill were compared before and after educational interventions (Student's t-tests). These scores were also compared to aggregate scores in the nonintervention group. Bayesian-modeled learning curves were used to characterize patterns of improvement over time.

SETTING

University of Massachusetts Medical School-Baystate Surgery Residency and Baystate Medical Center PARTICIPANTS: General surgery residents (n = 36) RESULTS: During the period of review, 3325 resident cases were identified meeting the case type criteria. As expected, overall autonomy increased with the number of cases performed. The 4 residents who had been assigned supplemental training (6-18 months) had preintervention score averages that were lower than that of the nonintervention group (2.25 ± 0.43 vs 3.57 ± 1.02; p < 0.0001). During the respective intervention periods, all 4 residents improved autonomy scores (increase to 3.40 ± 0.61; p < 0.0001). Similar improvements were observed for tissue handling, instrument handling, bimanual dexterity, visuospatial skill, and operative efficiency component skills. Postintervention scores were not significantly different compared to scores for the non-intervention group. Bayesian-modeled learning curves showed a similar pattern of postintervention performance improvement.

CONCLUSIONS

The data management platform proved to be an effective tool to track responses to supplemental training that was deemed necessary to close defined skills gaps in laparoscopic surgery. This could be seen both in individual and in aggregated data. We were gratified that at the conclusion of the supplemental training, O-SCORE results for the intervention group were not different than those seen in the non-intervention group.

Sustained Clinical Performance During Surgical Rotations Predicts NBME Shelf Exam Outcomes

OBJECTIVE

To determine if longitudinal, excellent clinical performance reflected in subjective evaluations during a surgery clerkship would be associated with a greater likelihood of National Board of Medical Examiners Surgery Shelf Exam ("shelf exam") success.

DESIGN

We retrospectively reviewed medical students' surgical clerkship performance from 2014 to 2019. Clinical evaluations for each rotation were abstracted and students were stratified by performance: excellent performers and non-excellent performers. The rotation performance grades were then combined to classify overall clerkship performance: sustained excellent performers, improved performers, worsened performers, and sustained non-excellent performers. We compared the shelf exam scores between performer class for each clinical rotation and the overall clerkship. Using logistic regression, we also sought to determine if clinical performance predicted passing the shelf exam.

SETTING

Emory University School of Medicine in Atlanta, Georgia.

PARTICIPANTS

Third-year medical students (N = 674) who completed a surgery clerkship.

RESULTS

Excellent performers scored higher than non-excellent performers on the shelf exam during both clinical rotations (all p < 0.01). Sustained excellent performers had the highest exam scores out of all the clerkship performance groups (p < 0.0001). Excellent performers for both rotations were associated with increased odds of passing the shelf exam. Sustained excellent performers had the greatest odds (OR 3, 95% confidence interval 1.5-6.3, p = 0.003) of passing the exam.

CONCLUSIONS

Clinical performance during the surgical clerkship and individual rotations correlates with shelf exam scores. Students should be encouraged to excel on the wards to maximize the educational experience and improve their odds of passing the exam.

Repeat Attending Exposure Influences Operative Autonomy in Endocrine Surgical Procedures

PURPOSE

There is concern that graduating surgery residents are not prepared for independent practice. This study aimed to identify predictors of performance, autonomy, and readiness for independence ratings of trainees by attendings for thyroidectomy and parathyroidectomy with respect to repeated resident-attending exposure. We hypothesized that increased exposure with a particular attending increases resident autonomy.

METHODS

All residents and faculty at a single institution performing parathyroidectomy or thyroidectomy were invited to complete an operative performance evaluation at case competition using the Zwisch scale to measure performance and autonomy for individual operative steps. In addition, each survey evaluated the trainee's readiness for practice in a straightforward procedure as a binary variable. Categorical variables were evaluated via Chi-squared or Fisher's exact tests and ordinal variables were evaluated with Wilcoxon or Kruskal-Wallis tests. Multivariable analysis was conducted with random effects logistic regression, and learning curves were generated for each procedure.

RESULTS

Operative performance evaluations were obtained from 36 individual learners and 6 faculty members, with a total of 145 evaluations for parathyroidectomy and 116 for thyroidectomy. On bivariate analysis, readiness for practice ratings was significantly associated with increasing chronologic procedure number, but not resident gender or case difficulty. The multivariable model demonstrated that increasing chronologic procedure number, while a significant predictor without accounting for exposure, did not remain a significant predictor of practice-readiness for parathyroidectomy when accounting for resident-attending exposure. Bivariate analysis comparing resident and attending ratings showed no difference between the 2, but there were significant differences in autonomy and performance scores for both groups of raters. Trainees rated by attendings as independence ready completed a median of 7 parathyroidectomies and 5 thyroidectomies. Descriptive learning curves generated serve as a model of the multistate nature that residents undergo when moving from novice to proficiency.

CONCLUSIONS

Not surprisingly, the more operations residents perform with a single attending, the higher their ratings for performance and autonomy from that individual, with increased exposure allowing improved performance with less attending autonomy. By contrast, our data also show that repeated exposure between resident and attending may confound the use of procedural numbers alone when predicting resident ability in the operating room.

Clinical Exposure to Cardiothoracic Surgery for Medical Students and General Surgery Residents

BACKGROUND

The introduction of integrated 6-year cardiothoracic surgery (CTS) residency programs has shifted recruitment efforts to encompass not only general surgery (GS) residents, but also medical students.

OBJECTIVE

The aim of this paper is to assess medical student and GS resident clinical exposure to CTS.

DESIGN

Data from the Association of American Medical Colleges Visiting Student Application Service and the Accreditation Council for Graduate Medical Education Case Log Reports were collected from 2010 to 2017 and 2010 to 2018, respectively. The data extracted included medical students who applied and received an offer for elective rotations and the cases performed as a GS resident.

RESULTS

A mean of 95 ± 28.5 medical students applied for CTS rotations annually and the applicants for CTS rotations increased by an average of 11.8% per year. However, significantly less students received an offer compared to other specialties (53.4% CTS vs 74.1% GS, 79.3% plastic surgery, 86.3% urology, 85.7% otolaryngology, 88.6% neurological surgery, and 89.6% orthopedic surgery) (p < 0.001). GS residents performed a mean of 39.3 ± 0.8 CTS procedures during residency: 32.9 ± 1.0 performed as a junior resident and 6.3 ± 0.7 as a chief resident. Out of all CTS procedures, 7.3% were cardiac procedures, with rates increasing from 5.6% to 8.4% during the study period (p = 0.001).

CONCLUSIONS

Elective rotation opportunities in CTS are high in demand for medical students while GS residents receive limited CTS exposure, especially cardiac cases. Increasing clinical opportunities in both groups will aid in recruiting young talent to the field.

Mentorship of Surgical Interns: Are We Failing to Meet Their Needs?

OBJECTIVE

This study aimed to determine the challenges faced by surgical trainees during their internship and to explore their experience with mentoring.

DESIGN

An internet-based survey comprised of 30 questions was distributed to 59 surgical interns to evaluate their internship experience at the conclusion of the academic year 2018 to 2019.

SETTING

Four academic medical centers in Boston, Massachusetts.

PARTICIPANTS

Both preliminary as well as categorical general surgery interns were included in the study. Twenty-five responses were received (response rate of 42.4%).

RESULTS

The majority of surgical interns (80%) reported having a mentor during their intern year. Gender as well as mentor career status/prestige were both the highest rated factors in selection of a mentor, (4.67/5 and 4.33/5 respectively). Mentoring topics varied by the career status of the mentor, with most surgical interns (80%) selecting senior faculty members for mentoring on career planning, clinical training, and research. Surgical interns relied only on junior faculty members to discuss work-life integration. Very few surveyed interns (only 1 in 10) discussed work-life integration with their mentors despite this being reported as the most significant challenge of their internship year. Only 15% of the interns reported that the effectiveness of the mentor-mentee relationship was reviewed by program administration. About one third (30%) of interns reported that they would not feel comfortable reporting a failed mentorship to their program director. Furthermore, 40% of the surgical interns were not given an option to choose a new mentor in case of failed mentoring.

CONCLUSIONS

Surgical interns report high work demands and challenges with worklife integration in their first year of surgical training, however only a small minority of interns discuss this with their mentors. Surgical residency programs should better supervise and adjust mentoring of surgical interns in order to maximize their performance and wellness.

A Systematic Review of Educational Mobile-Applications (Apps) for Surgery Residents: Simulation and Beyond

INTRODUCTION

The number of mobile-applications (Apps) increases daily. The regulation of App content is minimal yet surgical residents use these in daily educational practice. Surgical educators must be aware of the quality, efficacy, and validity of Apps available to effectively educate residents. The aim of this review was to determine the quality, efficacy, and validity evidence for educational Apps used by surgical residents.

MATERIALS AND METHODS

We searched PubMed, Embase, and ERIC for articles published before September 1, 2019. Controlled vocabulary and natural language describing Apps/surgical residents were used. Two reviewers evaluated abstracts for inclusion.

INCLUSION CRITERIA

studies measuring the quality, efficacy, or validity of educational Apps for surgical residents. Data was extracted from full text of included articles: study design, participants, App investigated, App development, evidence for efficacy, or validity of App.

RESULTS

Initial search identified 278 articles. 64 articles were duplicates and 214 articles were screened. A further 156 were excluded with 58 full text articles assessed for eligibility. Forty-five were included in analysis. Simulation (9/45) and Feedback (15/45) Apps were the most commonly studied in surgical residents. These were the main Apps that provided validity evidence for their use in education.

CONCLUSION

Surgical education is evolving as educational technology becomes more prevalent. To be effective as surgical educators we must understand and appropriately use available tools. Of the educational Apps studied (21 Apps in 8 categories), only 3 categories reported validity evidence. Future studies should take care to measure validity and efficacy of educational Apps for surgical education to ensure quality control.

A Randomized Cross-Over Trial Focused on Clinical Breast Exam Skill Acquisition Using High Fidelity versus Low Fidelity Simulation Models in Rwanda

OBJECTIVE

Breast cancer incidence is rising for women in low and middle income country (LMIC)s. Growing the health care workforce trained in clinical breast exam (CBE) is critical to mitigating breast cancer globally. We developed a CBE simulation training course and determined whether training on a low-fidelity (LF) simulation model results in similar skill acquisition as training on high-fidelity (HF) models in Rwanda.

DESIGN

A single-center randomized educational crossover trial was implemented. A preintervention baseline exam (exam 1), followed by a lecture series (exam 2), and training sessions with assigned simulation models was implemented (exam 3)-participants then crossed over to their unassigned model (exam 4). The primary outcome of this study determined mean difference in CBE exam scores between HF and LF groups. Secondary outcomes identified any provider level traits and changes in overall scores.

SETTING

The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from July 2014 to March 2015 PARTICIPANTS: Medical students, residents in surgery, obstetrics and gynecology, and internal medicine residents participated in a 1-day CBE simulation training course.

RESULTS

A total of 107 individuals were analyzed in each arm of the study. Mean difference in exam scores between HF and LF models in exam 1 to 4 was not significantly different (exam 1 0.08 standard error (SE) = 0.47, p = 0.42; exam 2 0.86, SE = 0.69, p = 0.16; exam 3 0.03, SE = 0.38, p = 0.66; exam 4 0.10 SE = 0.37, p = 0.29). Overall exam scores improved from pre- to post-intervention.

CONCLUSIONS

Mean difference in exams scores were not significantly different between participants trained with HF versus LF models. LF models can be utilized as cost effective teaching tools for CBE skill acquisition, in resource poor areas.

Scoping Evidence Review on Training and Skills Assessment for Open Emergency Surgery

OBJECTIVE

Scope evidence on technical performance metrics for open emergency surgery. Identify surgical performance metrics and procedures used in trauma training courses.

DESIGN

Structured literature searches of electronic databases were conducted from January 2010 to December 2019 to identify systematic reviews of tools to measure surgical skills employed in vascular or trauma surgery evaluation and training.

SETTING AND PARTICIPANTS

Faculty of Shock Trauma Anesthesiology Research Center, University of Maryland School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland and Implementation Science, King's College, London.

RESULTS

The evidence from 21 systematic reviews including over 54,000 subjects enrolled into over 840 eligible studies, identified that the Objective Structured Assessment of Technical Skill was used for elective surgery not for emergency trauma and vascular control surgery procedures. The Individual Procedure Score (IPS), used to evaluate emergency trauma procedures performed before and after training, distinguished performance of residents from experts and practicing surgeons. IPS predicted surgeons who make critical errors and need remediation interventions. No metrics showed Kirkpatrick's Level 4 evidence of technical skills training benefit to emergency surgery outcomes.

CONCLUSIONS

Expert benchmarks, errors, complication rates, task completion time, task-specific checklists, global rating scales, Objective Structured Assessment of Technical Skills, and IPS were found to identify surgeons, at all levels of seniority, who are in need of remediation of technical skills for open surgical hemorrhage control. Large-scale, multicenter studies are needed to evaluate any benefit of trauma technical skills training on patient outcomes.

Surgery Resident Time Consumed by the Electronic Health Record

OBJECTIVE

Time spent on the Electronic Health Record (EHR) influences surgical residents' clinical availability. Objective data assessing EHR usage among surgical residents are lacking and necessary.

DESIGN/PARTICIPANTS

Active EHR usage data for 70 surgical residents were collected from April 2015 through April 2016. Active EHR usage was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. Usage data of different specialties, interns (PGY 1), juniors (PGY 2, 3), and seniors (PGY 4, 5) were compared.

SETTING

Carolinas Medical Center, Charlotte, NC.

RESULTS

Interns spent more time than juniors on total EHR activities per day (134.5 vs 105.5 minutes, p < 0.001) and juniors spent more time per day than seniors (105.5 vs 78.7 minutes, p < 0.001). Among different EHR activities per patient, interns spent greater time than juniors on chart review (8.1 vs 6.2 minutes, p < 0.001), documentation (9.0 vs 6.5 minutes, p < 0.001), and orders (3.6 vs 3.0 minutes, p < 0.001). Juniors spent the same time as seniors on chart review (6.2 vs 6.5 minutes, p = 0.2). Juniors spent more time than seniors on documentation (6.5 vs 5.2 minutes, p < 0.001) and orders (3.0 vs 2.7 minutes, p < 0.05). Comparing EHR activities per patient among different specialties, General Surgery residents spent more time than Orthopedic residents on total EHR time (19.9 vs 15.9 minutes, p < 0.001), chart review (6.8 vs 5.7 minutes, p < 0.001), documentation (6.3 vs 5.6 minutes, p < 0.001), and orders (3.6 vs 2.6 minutes, p < 0.001). General Surgery residents spent less time than OB/GYN residents on total EHR time (19.9 vs 22 minutes, p < 0.01), chart review (6.8 vs. 7.5 minutes, p < 0.05), and documentation (6.3 vs 7.6 minutes, p < 0.001), but more time on orders (3.6 vs 2.9 minutes, p < 0.001).

CONCLUSIONS

These are the first reported objective findings on surgical resident use of the EHR and may provide an opportunity for improvement in EHR training and usage.

Is There Variability in Scoring of Student Surgical OSCE Performance Based on Examiner Experience and Expertise?

OBJECTIVE

To investigate the influence of clinical experience and content expertise on global assessment scores in a Surgical Objective Structured Clinical Exam (OSCE) for senior medical undergraduate students.

DESIGN

Scripted videos of simulated student performance in an OSCE at two standards (clear pass and borderline) were awarded a global score on each of two rating scales by a range of clinical assessors. Results were analysed by examiner experience and content expertise.

SETTING

The study was designed in a large Medical School in Ireland. Examiners were consultant and training grade doctors from three university teaching hospitals.

PARTICIPANTS

147 assessors participated. Of these, 75 (51%) were surgeons and 25 (17%) had sub-speciality surgical expertise directly relevant to the OSCE station. 41 were consultants.

RESULTS

Responsible academic scoring set the benchmark. By multivariable linear regression analysis, neither clinical experience (consultant status) nor relevant content expertise in surgery was independently predictive of assessor grading for either clear pass or borderline student performance. No educational factor (previous examining experience/training, self-rated confidence in assessment or frame of reference) was significant. Assessor gender (male) was associated with award of a fail grade for borderline performance. Trainees were reliable graders of borderline performance but more lenient than the gold standard for clear pass. We report greater agreement with the gold standard score using the global descriptive scale, with strong agreement for all assessors in the borderline case.

CONCLUSIONS

Neither assessor clinical experience nor content expertise is independently predictive of grade awarded in an OSCE. Where non-experts or trainees assess, we find evidence for use of a descriptive global score to maximise agreement with expert gold standard, particularly for borderline performance. These results inform the fair and reliable participation of a range of examiners across subspecialty stations in the surgical OSCE format.

An Analysis of Burnout among Military General Surgery Residents

OBJECTIVES

Resident burnout is an increasing issue in graduate medical education programs. Military graduate medical education is unique in numerous ways and may have different rates of burnout as well as different causes. This study aims to assess resident burnout rates and contributing factors among military general surgery residents.

DESIGN, SETTING, AND PARTICIPANTS

Using Department of Defense approved software, an anonymous survey was created and distributed to all general surgery residents (n = 180) in 6 US medical centers where there are general surgery residency programs. The survey contained an Abbreviated Maslach Burnout Index questionnaire, multiple choice questions including several military-specific questions, and 2 open ended questions. Rates of burnout and potential risk factors associated with burnout were analyzed.

RESULTS

After the collection period, 92 of 180 (51%) residents completed all Abbreviated Maslach Burnout Index questions, demographics, and military specific questions with an opportunity for written comments. Notable demographic findings of the respondents were that 64% were male, 65% were married or engaged, 40% had children, and 69% had no student loan debt. Overall, there was a 66% rate of burnout in any tertile. Variables found to be significant for overall burnout included the likelihood the resident plans to stay beyond their active duty service obligation and the perceived level of autonomy. Of the written responses, the most commonly cited contributing factor was the work burden from nonclinical and/or administrative tasks while the most common protective factor was resident camaraderie.

CONCLUSIONS

Overall, burnout rates are similar among military general surgery residents compared to published reports of civilians. The close association with resident burnout and anticipation of early withdrawal from military service demonstrates this topic is potentially important to retention of the military medical force. The topics of increased resident autonomy, decreased non-clinical duties, and efforts to increase resident camaraderie should be more closely evaluated.

Global Surgery Opportunities in Canadian General Surgery Residencies: A Cross-Sectional Study

OBJECTIVE

In recent years, there has been an explosion of interest in global surgery (GS) among students, residents, and surgeons. However, little information regarding the landscape of GS in general surgery residencies exists. This study was therefore designed to explore the opportunities and the framework for global surgery in Canadian general surgery training programs.

DESIGN

The Program Director (PD) at each Canadian general surgery residency program was invited to complete an online survey.

RESULTS

All 17 PDs participated. Only 3 institutions have a formal curriculum in GS, while 9 have an Office of GS. Seven residencies mention GS on their department website. Ten of 17 residencies have had trainees participate in GS experiences in the last academic year. Funding or pre-experience training is available at less than half of all institutions. Only one residency ranked GS exposure as being "very important" to their program. Across all programs, the average ranking of GS experiences was 2.3 out of 5, which translates descriptively to being of "little importance". Despite this, 10 PDs identified GS as attractive to applicants, and 5 stated their plans to expand GS opportunities at their institution.

CONCLUSIONS

This is the first study to look at the GS landscape in general surgery residencies across Canada. These results may inform graduating medical students and residents about the current status of GS in Canadian residencies. This study may also assist other residencies in the development and tailoring of GS programs.

The "Key" or "Critical" Portions of an Operation: Understanding Attending Supervision and Resident Autonomy From a Legal Perspective

OBJECTIVE

To obtain a legal understanding of the "key" or "critical" portions of an operation, pertaining to attending supervision, resident autonomy, and patient safety.

DESIGN

Snowball sampling, a subset of purposive sampling, was used to develop a population of 47 risk managers and legal counsel, who were given an online, qualitative questionnaire. Interpretive description was used to analyze qualitative data. Individual responses were coded with simultaneous categorization and assessment of underlying relationships.

SETTING

Online, qualitative questionnaire.

PARTICIPANTS

Hospital risk managers and legal counsel from across the United States.

RESULTS

Overall, 25 of 47 (53%) risk managers completed the survey. Qualitative responses could be organized into 3 major themes (1) variation in the definition of "key" or "critical" portions of an operation, (2) differing expectations of attending supervision and resident autonomy, and (3) the need for clear communication and trust among attendings, residents, and patients.

CONCLUSIONS

Among risk managers, the primary liaisons between surgeons and patients in malpractice litigation, there is widespread variation in understanding the "key" and "critical" portions of an operation and the dynamic between appropriate attending supervision and resident autonomy. Better collaboration and transparency between surgeons and legal experts are required to facilitate a shared mental model regarding attending supervision and resident autonomy.

Orthopedic Trainees' Perceptions of the Educational Value of Daily Trauma Meetings

OBJECTIVE

The daily orthopedic trauma meeting is considered to serve a dual purpose; a way of discussing management of trauma patients and as a forum for teaching trainees. This study is first to explore orthopedic trainees' perspectives on the educational value of trauma meetings and identify factors that influence educational benefit across England.

DESIGN

An online questionnaire was created including free text responses questions. After initial pilot testing, orthopedic registrar trainees with a national training number within England were emailed and the questionnaire completed online. Results were analyzed using thematic analysis and online survey software.

SETTING

A national study conducted across England in trauma and orthopedic departments in a secondary care setting.

RESULTS

One hundred and thirteen responses were recorded nationally with wide spread of seniority and geographical location. About 73.5 % of trainees found the trauma meeting to be educationally valuable. However, only 30.1% of trainees felt that they were "often" asked questions that aided their learning and 60.1% of trainees felt that decision making in patient management was only explained "sometimes" in the trauma meeting. Positive perceived educational themes included the volume of cases discussed, constructive questioning, and discussion as a form of learning. Negative themes involved time pressures, adverse consultant attitudes, and an aggressive trauma meeting atmosphere limiting learning. Suggested improvements include clearer explanation of decision making, detailed feedback, and a more supportive atmosphere with incorporation of postoperative radiographic review.

CONCLUSIONS

This is the first nationwide study providing an insight into factors influencing the educational value of the trauma meeting as perceived by trainees with improvements being directly sourced from trainees. Recommendations from this study are applicable internationally and guide the implementation of changes to maximize the educational benefit for trainees during trauma meetings.

Operating Room Virtual Reality Immersion Improves Self-Efficacy Amongst Preclinical Physician Assistant Students

OBJECTIVE

To assess the impact on self-efficacy for preclinical physician assistant (PA) students through immersive virtual reality (VR) operating room simulation.

DESIGN

Randomized double-blinded controlled experiment measuring self-efficacy using Schwarzer and Jerusalem's general self-efficacy scale. An entirely novel operating room was created, casted, and filmed using VR software. Fifty-two preclinical PA students were randomly assigned to VR (n = 26) or traditional lecture (n = 26) and self-efficacy was measured in both conditions using a general self-efficacy scale given before and after the virtual experience. A mixed ANOVA, independent sample t tests, and paired samples t tests were performed.

SETTING

Shenandoah University Physician Assistant program, Winchester, Virginia.

RESULTS

Exposure to VR training after the traditional lecture improves self-efficacy amongst PA students (p < 0.05). Exposure to VR improved self-efficacy compared to traditional methods (p < 0.05). There was no difference in self-efficacy amongst PA students with the traditional model (p < 0.05).

CONCLUSIONS

The introduction of VR simulation improved preclinical PA student self-efficacy in the operating room setting.

Burnout Among United States Orthopaedic Surgery Residents

OBJECTIVE

There is growing interest in the problem of burnout among physicians. Here, we examine the factors associated with burnout in orthopedic surgical training.

DESIGN

An Internet-based anonymous survey assessing workload, work-life balance, education, and resident-specific factors such as marital status and postgraduate year was developed. The survey was distributed to United States orthopedic surgery residency directors in September 2018, and program directors were asked to forward the survey to their trainees. Multivariable analysis assessed correlations with burnout.

SETTING

All 161 Accreditation Council for Graduate Medical Education (ACGME)-accredited United States orthopedic surgery residency programs.

PARTICIPANTS

Two hundred and three United States orthopedic surgery residents.

RESULTS

Thirty-eight percent of respondents reported symptoms of burnout. Even so, the vast majority did not regret choosing a medical career (95%) or their choice of residency program (90%). Greater than half of trainees who responded reported educational debt over $200,000. Thirteen percent reported receiving verbal abuse from faculty more than rarely. On multivariable analysis, 3 factors emerged that were associated with higher burnout: working more than 80 hours per week (odds ratio [OR] 2.8; range, 1.1-7.8), use of electronic medical record more than 20 hours per week (OR 2.1; range 1.0-4.5), and receiving verbal abuse from faculty more than rarely (OR 3.7; range, 1.3-11.5). The perception of adequate nursing support was associated with lower burnout (OR 0.2; range, 0.04-0.5).

CONCLUSIONS

More than one-third of orthopedic trainees are experiencing burnout, but most still maintain high levels of career satisfaction. The key factors strongly associated with resident burnout are modifiable. Targeted interventions related to these factors should be evaluated for their potential to reduce burnout in orthopedic surgery residents.

CLINICAL RELEVANCE

Strategies to reduce the development of burnout have the potential to improve quality of care and decrease medical errors.

Current State of Undergraduate Trauma and Orthopaedics Training in United Kingdom: A Survey-based Study of Undergraduate Teaching Experience and Subjective Clinical Competence in Final-year Medical Students

OBJECTIVE

To assess the quality and duration of trauma and orthopedics (T&O) training in medical schools in United Kingdom (UK), and to evaluate final-year students' self-perceived level of competence in essential T&O skills.

DESIGN

This was a survey-based study of final-year medical students that attended 1-day undergraduate T&O courses held between Feb'17 and Feb'19. Outcome measures were duration and perceived quality of undergraduate T&O placements, students' self-rated competence in essential T&O skills, and impact of teaching methods on their subjective future competence.

SETTING

Four courses held at education centers in 3 different locations in UK (London, Nottingham, and Leeds) PARTICIPANTS: All 414 course attendees from 13 UK medical schools completed the questionnaire.

RESULTS

19.3% of students had not experienced a placement in T&O. Mean duration of T&O placements was 2.5 weeks. 37.4% described their training as "poor". Majority of students attended 1-5 sessions of: lectures (50.5%), small group teaching (58.7%), trauma meetings (58.7%), clinics (65.7%), and theatres (72.5%). Lowest competency scores were reported in management of T&O emergencies, fracture management, and interpretation of T&O radiographs. Self-rated competence in essential T&O skills was significantly higher in students with previous experience of a T&O placement (p < 0.05). There was a strongly positive correlation between small group teaching attendance and perceived competence in management of T&O patients in different clinical settings (p < 0.001).

CONCLUSIONS

Medical schools in UK are currently failing to adequately train medical graduates to manage T&O patients, with students reporting low competency scores in all basic T&O skills. To mitigate the current situation, a minimum duration of a T&O placement for all students must be implemented nationally. Educational boards and medical schools must work in collaboration to improve the delivery of undergraduate T&O curriculum, the structure of the clinical T&O placement, and efficacy of the commonly encountered learning environments.

Skills in Open Surgery do not Predict Arthroscopic Skills in Medical Students

OBJECTIVE

Teaching of basic open surgical skills like skin closure has been well established in medical schools' surgical curricula. The same cannot be said for basic arthroscopic skills even though the importance of arthroscopic surgery in Orthopaedics has been well documented. The goal of this study was to evaluate the relationship between basic skills in open surgery and basic arthroscopic skills in a cohort of medical students. Our hypothesis was that performance in open surgical skills does not correlate with skills in arthroscopic surgery.

DESIGN

The performance of medical students in basic tasks in open surgery (porcine model: subcutaneous and skin suturing) and arthroscopic surgery (bench top model: arthroscopic triangulation and object transfer) was assessed. For both surgical techniques an introductory course was given followed by a standardized assessment. After 1 week both open and arthroscopic tasks were reassessed. All procedures were recorded and scored by 2 independent observers in a blinded fashion.

SETTING

The study was performed at the skills lab of the Clinic for Orthopaedics and Tumororthopaedics at University Hospital Muenster in Muenster Germany.

PARTICIPANTS

A cohort of 21 medical students (average age 22.2 years) participated in this study. The cohort consisted of 17 female (81%) and 4 male (19%) students. All students were in the clinical part of their study and had not received any prior surgical education.

RESULTS

Interobserver reliability was very high for the arthroscopic tasks and high for the open surgery tasks. No correlation was found between open and arthroscopic skills. For the first assessment the correlation coefficient was r = 0.197 (p = 0.391). For the second assessment the correlation coefficient was r = 0.212 (p = 0.356). Significant improvement from first to second assessment was only found for the arthroscopic tasks (p < 0.0001) while improvement in the open surgery performance failed to reach statistical significance (p = 0.184).

CONCLUSIONS

The results of this study suggest that performance in open surgical skills does not correlate with performance in arthroscopic skills and should be taught independent from each other. Arthroscopic skills can effectively be taught with bench top training systems in a time- and resource efficient manner, with measurable results even in a 1-day-course setup. Arthroscopic skills training may be offered in undergraduate curricula in addition to open surgical skills training to students with an interest in Orthopaedics.

Addressing Gender-Related Implicit Bias in Surgical Resident Physician Education: A Set of Guidelines

While it is the goal of academic institutions to train male and female resident physicians equally, gender-related implicit bias may play a role in resident training, thus impacting the quality and fairness of education. Implicit bias may be one of the reasons for the discrepancies that exist in resident training, specifically in learning style, evaluations by faculty members, and treatment of female residents by other clinicians. Patterns of systemic gender-related implicit bias, we argue, remain pervasive in the healthcare system and affect medical education. This review identifies areas of surgical education that are susceptible to gender-related bias and provides recommendations to safeguard gender equity in resident education. We believe behavioral change can help maintain an inclusive learning environment. Using evidence from existing data, we generated guidelines to provide surgical educators in academic centers with information to further understanding of, training in, and steps toward overcoming gender-related implicit bias in resident education. Our guidelines include specific recommendations for educators to require training modules, remove bias from teaching resources, use formal introductory titles, maintain comparable evaluations, encourage women in surgery, adjust instructional methods, and caution self-reporting.

Resident Education in End-of-Life Communication and Management: Assessing Comfort Level to Enhance Competence and Confidence

OBJECTIVES

Our primary objective was to understand residents' baseline comfort with end-of-life (EOL) communication and management and to compare this with their comfort after completion of their surgical intensive care unit (SICU) rotation. We also evaluated the association between prior training with perceived level of comfort with EOL issues, and whether the resident believed in the concept of a "better death."

DESIGN, SETTING, PARTICIPANTS

As a quality improvement initiative, we conducted surveys of trainees before and after their rotation in the Yale New Haven Hospital SICU. Prerotation and postrotation surveys were administered to all residents who rotated during the 2016-2017 academic year and the first half of 2017-2018. The survey consisted of 34 questions querying residents on their level of training in EOL care, their comfort with management and discussions in different EOL domains, and their beliefs about what measures would have improved their ability to provide EOL care. Residents surveyed were from general surgery, emergency medicine, or anesthesia departments.

RESULTS AND CONCLUSIONS

Our study demonstrates that there is a significant correlation between resident comfort with EOL communication and experience providing EOL care. However, concepts in medicolegal aspects of palliative care could be taught through formal didactics, and structured training may allow residents the opportunity to reflect on the importance of a "better death."

Exploring Medical Students' Perceptions of Organ Procurement: Need for a Formalized Medical Student Curriculum

OBJECTIVE

We evaluated the medical student experience with a deceased-donor multiorgan procurement program at a single center. The program provided the opportunity to assist with organ procurement, but no formal curriculum was offered.

DESIGN, SETTING, PARTICIPANTS

In 2018, medical students who registered for the program between 2014 and 2017 completed a voluntary survey about the experience and its impact on surgery interest and organ donation knowledge and advocacy.

RESULTS

Of 139 respondents, 53.3% (N = 74) of students participated in at least one procurement. The experience was resoundingly positive: 81.7% (N = 58) believed it exceeded expectations, with less than one-third missing class and only 4.3% (N = 3) reporting a negative impact on academics. Although 60.6% (N = 43) students studied prior to procurement, 57.8% (N = 41) expressed the need for increased preparation. Preferred learning modalities included videos, discussion with the transplant fellows, and focused anatomy overview. Following participation, 53.5% (N = 38) of students had increased interest in pursuing an acting internship and career in surgery. However, participation was not associated with improved familiarity with organ donation concepts or advocacy.

CONCLUSIONS

Adding a structured curriculum may turn medical students from passive observers into active learners, maximizing the educational value of procurement and better equipping future providers to promote organ donation.

Impact of 3D Printed Calcaneal Models on Fracture Understanding and Confidence in Orthopedic Surgery Residents

OBJECTIVE

To determine if three-dimensionally printed (3Dp) fracture models can improve orthopedic trainee education.

DESIGN

A prospective comparison study of orthopedic trainees and attending surgeons was performed, where a range of calcaneal fractures were used for creating anonymized 3Dp models. Study participants rotated through workstations viewing computed tomography images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. Diagnosis, time for evaluation, confidence of fracture understanding, perceived model accuracy, and proposed treatment were compared using a standardized questionnaire.

PARTICIPANTS

Sixteen resident trainees and 5 attending surgeons participated in this study. Attending surgeons were required to have fellowship training in trauma or foot and ankle surgery and manage calcaneal fractures as part of their current practice.

RESULTS

Junior residents had the slowest time of assessment (mean = 121 ± 54 seconds) and lowest percentage of correct diagnoses (69%), although these findings did not reach significance compared to the other residency years. Residents displayed higher levels of confidence in fracture understanding with increasing residency year of training (p < 0.0001), and this confidence was greater for cases that included a 3Dp model (p < 0.03). Perceived accuracy of cases with 3Dp models was significantly higher than cases without 3Dp models (7.0 vs 5.5 p < 0.001).

CONCLUSIONS

This study found that 3Dp models increase the perceived accuracy of fracture assessment, though no statistically significant improvement in diagnostic accuracy was observed. The 3Dp models did improve trainee confidence, although this effect diminished with increasing residency year. In orthopedic residency training programs, 3Dp models of complex fractures can be a valuable educational tool, especially for junior trainees.

Self-Assessment of Surgical Skills: A Systematic Review

OBJECTIVE

Self-assessment is fundamental in surgical training to enhance learning in the absence of trainer feedback. The primary objective of this review was to assess the factors that influence accuracy of self-assessment at technical skills across all surgical specialties. The secondary objective was to assess whether there are any innate factors or attributes to predict those that will carry out effective self-assessment.

DESIGN

A systematic review was carried out in accordance with PRISMA guidelines. A search strategy encompassing MEDLINE, EMBASE, ERIC, WHO, and the Cochrane database was conducted to identify studies investigating self-assessment at any surgical task. Quality was assessed using the Newcastle-Ottawa scale. A summary table was created to describe specialty, participants, task, setting, assessment tool, and correlation coefficient between self and expert assessment. The review protocol was registered in PROSPERO.

RESULTS

Of 24,638 citations, 40 met inclusion criteria. In total 1753 participants performed 68 procedures. Twenty-six studies investigated skills in general surgery with the remaining 14 in various other surgical specialties. Accuracy of self-assessment is superior in those with greater experience and age, and with use of retrospective video playback. Accuracy tends to be reflected by overestimation of performance. Stressful environments reduce accuracy. There is limited evidence in the literature regarding predicting traits for those who will carry out accurate self-assessment.

CONCLUSIONS

The ability to perform accurate self-assessment is an important skill in surgical training, with accuracy being influenced by a multitude of factors. The use of self-assessment from retrospective video playback may be of benefit in surgical training curricula to enhance learning of technical skills. Further studies are required to define predictors of good self-assessment, which will strengthen recruitment and mentoring to assist trainee learning.

Does Geographical Bias Impact the Match for General Surgery Residents?

OBJECTIVE

As the competitiveness of applicants for general surgery residency grows, it is becoming challenging for programs to differentiate qualified candidates with a genuine interest in matching at their institution. The purpose of this study was to examine geographic trends in the general surgery match in order to elicit regional biases and optimize applicant interview selection strategies.

DESIGN

In this single-center retrospective study, geographical information regarding birth place, college, medical school, and final match institution for general surgery residency applicants was examined.

SETTING

This study was set at the University of Cincinnati College of Medicine.

PARTICIPANTS

All general surgery residency applicants interviewing at our institution between 2015-2017 were included.

METHODS

Academic variables and geographical information were collected for all applicants in the cohort. Statistical analyses were performed using chi-square and logistic regression techniques to determine any association between geography and match outcomes.

RESULTS

Of 198 applicants included in the analysis, approximately 25% matched at an institution located in the same state as their medical school. Total 75% of applicants matched at a residency program located less than 640 miles away from either their birth place, college, or medical school, while only 15% matched at an institution located over 1000 miles away and 4% matched over 2000 miles away. When examining applicant characteristics, there were no significant differences in gender, clerkship grade, United States Medical Licensing Exam scores, Alpha Omega Alpha Honor Society membership, or quality of recommendation letters between applicants who matched in the lowest and highest quartiles of distance to final residency program location.

CONCLUSIONS

A significant proportion of general surgery applicants matched at institutions located in a region near either their birth place, college, or medical school. Given the limited number of interviews able to be offered by institutions and the associated opportunity costs, general surgery programs should consider regional biases when evaluating residency applicants.

Towards Development of an Open Surgery Competency Assessment for Residents (OSCAR) Tool - A Systematic Review of the Literature and Delphi Consensus

OBJECTIVE

Competency-based education has mandated accurate intra-operative assessment tools. We aimed to define consensus-based open surgical skills perceived by experts as critical for assessment.

DESIGN

A mixed-method design was employed: systematic review and e-Delphi methodology.

SETTING

The study was performed at McGill University-affiliated large tertiary academic centers in Montreal, Quebec, Canada.

PARTICIPANTS

Per PRISMA guidelines, a peer-reviewed search strategy was employed. Studies published in English and those describing technical skill assessment of open abdominal surgery were included; subspecialty-specific skills, conference abstracts, academic memoirs were excluded. Most-cited skills were subjected to e-Delphi methodology to identify those deemed essential by experts, based a 3-point Likert scale. Eighteen McGill University-affiliated general surgeons, representing a variety of subspecialties of General Surgery, were invited to answer the questionnaire.

RESULTS

Around 120 of 4285 references were retained for analysis. The 12 most cited skills included suturing, tissue and instrument handling, movement economy, instrument knowledge, knot tying, flow, knowledge of procedure, completion time, dissection technique, knowledge of anatomy and sterile technique; 6 of these achieved high or perfect scores and agreement after 2 rounds of survey: suturing, sterile technique, knot tying, knowledge of anatomy, knowledge of procedure, and tissue handling. Median standard deviation decreased (0.495 to 0.450) from first to second round, indicating improvement in consensus.

CONCLUSION

These results will help develop and validate the OSCAR (objective structured clinical assessment rubric) assessment tool for immediate intra-operative feedback of open technical skills for surgical trainees.

Return to the Real World: A Novel Program to Improve Resident Readiness for the Transplant Surgery Rotation

OBJECTIVE

We describe a novel didactic program to prepare mid-level residents for the operative complexities of the transplant surgery rotation.

DESIGN

A faculty led dry and wet lab experience was held for all residents returning to clinical rotations from a 2-year research experience. Residents were provided instructional video prior to the dry lab and instructed through both labs by transplant faculty and fellows. The culmination of the program entailed a porcine renal autotransplantation.

SETTING

The University of Cincinnati, Department of Surgery, Cincinnati, OH.

PARTICIPANTS

Incoming third year general surgery residents returning to clinical rotations from a 2-year research experience.

RESULTS

This lab was well received by residents and faculty and increased confidence in residents.

CONCLUSIONS

This program increased confidence in complex operations seen on the transplant surgery rotation and can be replicated in a cost-effective manner.

Developing a Novel Scoring System to Objectively Track Orthopaedic Resident Educational Performance and Progression

OBJECTIVE

Objectively determining orthopedic resident competence remains difficult and lacks standardization across residency programs. We sought to develop a scoring system to measure resident educational activity to stratify participation and performance in particular aspects of training and the effect of these measures on board certification.

DESIGN

A weighted scoring system (Average Resident Score, ARS) was developed using the number of logged cases, clinic notes dictated, OITE PGY percentile, case minimums met, and scholarly activity completed each academic year (AY), with clinical activity being more heavily weighted. The Resident Effectiveness Score (RES), a z-score showing the number of standard deviations from the mean, was determined using the ARS. The RES effect on the Accreditation Council for Graduate Medical Education (ACGME) Milestones and American Board of Orthopedic Surgery (ABOS) Part 1 percentile score was determined using a Spearman correlation.

SETTING

Large academic orthopedic residency.

PARTICIPANTS

Thirty one orthopedic residents graduating between 2011 and 2016 were included.

RESULTS

The RES did not differ between classes in the same AY, nor change significantly for individual residents during their training. Milestone z-scores increased as residents progressed in their education. The RES correlated with each Milestone competency subscore. The PGY5 OITE score and achieving ACGME minimums correlated with passing ABOS Part 1 (28/31 1st time pass), but the RES did not predict passing the board examination.

CONCLUSIONS

This study demonstrates a scoring system encompassing multiple facets of resident education to track resident activity and progress. The RES can be tailored to an individual program's goals and aims and help program directors identify residents not maximizing educational opportunities compared to their peers. Monitoring this score may allow tailoring of educational efforts to individual resident needs. This RES may also allow residents to measure their performance and educational accomplishments and adjust their focus to obtain competence and board certification.

A Ward-Round Non-Technical Skills for Surgery (WANTSS) Taxonomy

BACKGROUND

Around half of surgical adverse events occur outside the operating room. However the majority of nontechnical skills (NTS) training programs have been developed for the intraoperative environment. Ward rounds are a crucial part of extraoperative care and to date no specific NTS training manual has been developed targeting emergency general surgical ward rounds.

AIM

To develop a NTS taxonomy for emergency general surgical ward rounds that can be used to improve surgical team members' NTS and improve outcomes.

METHODS

A literature review of existing NTS taxonomies was conducted, followed by semistructured interviews and observational data collection, to determine good and poor surgical ward-round behaviors. These behaviors were reviewed by a panel of subject matter experts and categorized into a taxonomy, using the Non-Technical Skills for Surgeons taxonomy framework as a guide.

RESULTS

The Ward-round Non-Technical Skills for Surgery taxonomy includes examples of good and poor ward-round-specific behaviors, grouped into elements and categories. The taxonomy can be used as both a training and teaching manual for the surgical team.

CONCLUSION

Ward rounds are a crucial part of extraoperative surgical care. The Ward-round Non-Technical Skills for Surgery taxonomy provides surgical teams with a manual to help them improve their ward-round NTS.

A Randomized Cross-Over Trial Focused on Breast Core Needle Biopsy Skill Acquisition and Safety Using High Fidelity Versus Low Fidelity Simulation Models in Rwanda

OBJECTIVE

Breast cancer is the most common cancer diagnosed in low and middle-income countries. Growing the number of health care personnel trained in diagnostic procedures like breast core needle biopsy (BCNB) is critical. We developed a BCNB simulation-training course that evaluated skill acquisition, confidence, and safety, comparing low-cost low fidelity (LF) models to expensive high fidelity (HF) models.

DESIGN

A single-center randomized education crossover trial was implemented. Participants were randomized to HF or LF groups. A preintervention baseline exam followed by lectures and training sessions with a HF or LF model was implemented. A postintervention simulation exam was conducted, and participants crossed over to the other simulation model.

SETTING

The study was implemented at the University Teaching Hospital, Kigali (CHUK) in Rwanda, Africa from October 2014 to March 2015.

PARTICIPANTS

Residents training in surgery or obstetrics and gynecology participated in a 1-day BCNB training course.

RESULTS

A total of 36 residents were analyzed, 19 in the HF arm and 17 in the LF arm. Mean difference in exam scores for HF and LF groups in the baseline exam (exam 1) (0.067, p = 0.94, standard error [SE] of 1.57) postintervention exam (exam 2) (1.85, SE 1.46, p = 0.33), and the crossover exam (exam 3) (4.39, SE = 1.90, p = 0.11) were not significantly different between HF and LF. Overall exam scores improved from pre- to postintervention.

CONCLUSIONS

Our results indicate that mean difference in exams scores were not significantly different between residents trained with HF versus LF models. In resources poor areas-LF models can be utilized as effective teaching tools for skill acquisition for diagnostic surgical procedures.

How Does a New General Surgery Residency Program's Junior Residents Impact Hospital Efficiency and Productivity?

OBJECTIVE

The general surgery workforce deficit is projected to grow to 15% to 21% by 2050. An estimated 6.6% increase to existing general surgery residency (GSR) programs is needed to meet this shortfall. The purpose of this study was to examine the impact of a new GSR program on efficiency and productivity at a regional healthcare center.

STUDY DESIGN

An institutional database was retrospectively queried for all GSR related procedures between July 2015 and June 2018. Procedures done prior to GSR initiation (pre-GSR) were compared to those done after (post-GSR). Univariate and multivariate analyses were performed.

RESULTS

We reviewed 10,617 procedures (6365 pre-GSR vs. 4252 post-GSR). Patients had lower preoperative Hierarchical Condition Category scores in the post-GSR group (0.71 vs. 0.58, p < 0.01). Operative times increased post-GSR (101.7 vs. 109.1 minutes, p < 0.01), but length of stay decreased (6.4 vs. 5.5 days, p = 0.01). Thirty-day readmissions (4.0% vs. 3.4%, p = 0.11) were comparable, but reoperations significantly decreased post-GSR (10.1% vs. 8.6%, p = 0.01). Average hospital costs remained unchanged ($10,765 vs. $10,140, p = 0.12). Multivariate analysis revealed no statistical difference in operative times, length of stay, 30-day readmissions and reoperations, and hospital costs between the 2 groups. Subset analysis based on surgical service also showed no statistical difference. Productivity increased on the general surgery service post-GSR (7.1 vs. 7.8 cases per day, p = 0.02). Patient satisfaction increased post-GSR (76% vs. 81%, p = 0.31), but without statistical significance.

CONCLUSION

The initiation of a new GSR program did not negatively impact operative times, length of stay, 30-day readmissions and reoperations, hospital costs, case volume, or patient satisfaction.

Now Arriving: Surgical Trainees From Generation Z

OBJECTIVE

To provide an overview of the Generation Z, compare and contrast Generation Z with previous generations, and present information on how to best educate members of Generation Z.

DESIGN

Literature review.

SETTING

Not applicable.

PARTICIPANTS

Not applicable.

RESULTS

Historical events and societal trends as well as changes in parenting style has resulted in unique characteristics for Generation Z. The most significant influence on this generation has been the wide-spread use of the smart phone. While this device has great educational potential, it also presents a real risk with digital foot prints influencing residency selection and evolution of mental health problems.

CONCLUSIONS

The characteristics of Generation Z such accountability, emphasis on achievement and dedication to long-term goals makes them different from previous generations.

What Do Former Residents Say About Their Nondesignated Preliminary Year? A Survey of Prelims' Experiences in a General Surgery Residency Program

OBJECTIVE

The nondesignated preliminary (NDP) position in general surgery (GS) offers a 1-year surgical training opportunity for medical school graduates prior to obtaining categorical residency positions. Given that there is little long-term follow-up on the experiences of NDP residents, we sought to determine how NDPs felt about their intern year in GS.

DESIGN

A cross-sectional survey of all NDP GS interns from 1993 to 2018.

SETTING

Academic, tertiary care center with a large GS residency program (Mayo Clinic, Rochester, MN).

PARTICIPANTS

NDP GS interns (n = 151).

RESULTS

Two-hundred and four surveys were emailed and 151 (62%) former NDP residents responded. Exposure to diverse pathology (85%), opportunity to work with experts (85%) and operative experience (72%) were the top 3 positive experiences from the NDP year. The uncertainty of being an NDP resident (78%) and experience compared to categorical counterparts (32%) were cited as the top 2 negative experiences. While 73% (n = 110) considered their NDP year to have laid a "strong" foundation for their future career, most respondents felt that the year was stressful and suggested improving mentoring and support for preliminary residents. Eighty-two percent (n = 124) of respondents stated that, they would be willing to redo their preliminary year. Fifty-four percent (n = 82) of respondents stated that they might have preferred a categorical position at a smaller institution versus a preliminary year. Forty percent of respondents (n = 60) reported fewer interviews and 24% (n = 36) reported a similar number of interviews offered when applying to the Match as a PGY1 prelim resident.

CONCLUSIONS

Pursuing the NDP year is difficult, given the uncertainty that looms and the immense pressure to perform well. While the vast majority of our NDPs obtained categorical residency spots following their 1 year of training, feedback from this survey using 25 years of experience suggests that we can and should do more to mentor, support, and assist these residents.

An Appreciative Inquiry Approach to the Core Competencies: Taking it From Theory to Practice

OBJECTIVE

To operationalize the surgical core competencies by using a qualitative inquiry strategy to explore how surgical competence is behaviorally demonstrated by faculty.

DESIGN

Categorical general and vascular surgery residents completed a survey soliciting opinions regarding which faculty were deemed most representative of each core competency. The surveys served as a theoretical sample, as surgeons selected were then interviewed, and interviews transcribed. A qualitative research approach using grounded theory coding methods was used for transcript analysis. Iterative coding was performed, and emergent themes were then extracted from transcript analysis.

SETTING

Southern Illinois University School of Medicine, Department of Surgery in Springfield, IL, a tertiary academic center.

PARTICIPANTS

Fourteen of 19 residents completed the survey (74% response rate). Two surgeons were selected for each competency. A total of 7 interviews were performed, with 4 surgeons being chosen for 2 competencies.

RESULTS

Emergent themes revealed that competent surgeons shared qualities that drove their development and execution of each competency. These qualities included self-awareness, a selfless character, responsibility and ownership, context awareness, reliance on relationships and community, and a pattern of habit formation and discipline. Additionally, the competencies were noted to be pursued in an interrelated and interdependent fashion.

CONCLUSIONS

Surgeons deemed competent in any core domain shared common qualities. Further study exploring how each of these is identified, developed and taught is warranted. The competencies are an inter-related matrix whose development and execution correlates with foundational personal disciplines.

Systematic Review of Virtual Haptics in Surgical Simulation: A Valid Educational Tool?

BACKGROUND

Virtual reality (VR)-based surgical simulation is an expanding and rapidly advancing modality which aims to serve the increasing demand to acquire surgical skills outside the live operating room. Haptic, or "force-feedback" technology in VR simulation is a rapidly developing field, however the role of haptics in surgical education and its efficacy is unclear.

METHODS

A systematic literature search was carried out until September 2018 in MEDLINE, Embase, and Cochrane Library using the following keywords: (VR OR VR OR simulation OR simulator) AND (Haptic feedback OR Haptics OR Force feedback) AND (Surgery). All randomized controlled studies comparing VR training with and without haptics were included. PRISMA guidelines were adhered to RESULTS: Eight randomized controlled trials that compare VR training with and without haptics were included and 1 survey study with a total of 215 participants, 116 of which received haptic feedback and 99 were assigned to nonhaptic feedback group. Training tasks included basic proficiency based laparoscopic tasks such as object translocation, cutting, camera navigation, and more complex tasks including diathermy, suturing, dissection, knot tying, and operative maneuvers. Six randomized controlled trials demonstrated that haptic enhanced VR simulation is significantly more effective than without haptics for skill training with a reduced learning curve and faster time to proficiency and task completion, particularly in novice learners. Two studies showed no significant differences in task-assessed parameters between the haptics and nonhaptics cohorts, whereas 1 survey study suggested haptics negatively affected training with decreased realism.

CONCLUSION

Haptic feedback has been shown to improve the fidelity, realism and thus the training effect of VR simulators. However, at present haptic simulators are expensive and in a nascent stage and further research as well as cost-benefit analyses of such tools must be considered to determine whether haptics is truly a surgical necessity.

Targeted Intervention to Increase Awareness of Opioid Overprescribing Significantly Reduces Narcotic Prescribing Within an Academic Orthopaedic Practice

OBJECTIVE

To evaluate the impact of a targeted intervention focused on increasing awareness of opioid overprescribing within an academic orthopaedic practice.

DESIGN

Retrospective prescribing data was collected through an electronic chart review. A single time point, a departmental grand rounds titled "Opioid Use, Misuse, & Abuse in Orthopaedics," was conducted on February 8, 2017. Opioid prescribing data was analyzed for the year preceding and year immediately following this targeted intervention. Narcotics were standardized using milligram morphine equivalents (MME) for comparison, and patients were categorized as opioid naive or non-naive based on whether an opioid prescription was written within 90 days prior to surgery. A segmented time series regression model was utilized to determine statistical significance of the educational intervention.

SETTING

Academic Medical Center.

PARTICIPANTS

All patients undergoing orthopaedic procedures at our institution between January 2016 and March 2018.

RESULTS

A total of 5882 patients underwent orthopaedic procedures at our institution during the study period. Of these, 2887 were in the year preceding and 2995 were in the year immediately following the targeted intervention to increase awareness of opioid overprescribing. The interve.ntion was associated with an acute decrease of 167 mean MME from 780 to 613 in opioid naive (p = 0.028) and 154 mean MME from 1,015 to 861 in opioid non-naive patients (p = 0.010). The intervention was also associated with a favorable change in the overall mean MME prescribing trend over time in both naive (p = 0.011) and non-naive (p = 0.064) patients.

CONCLUSIONS

This study demonstrates decreased opioid prescribing within an academic orthopaedic department after a targeted intervention focused on raising the awareness of opioid overprescribing. Ongoing provider education and awareness are critical parts of any plan to continue curtail opioid overprescribing among surgeons.

Undergraduate, Nonmedical Students can Pass the FLS Manual Skills Exam With Minimal Practice

OBJECTIVES

The primary objective of this study is to investigate whether undergraduate, nonmedical students could pass the FLS Manual Skills Exam with minimal practice. The secondary objective is to examine ACGME case log data from graduating chief residents over the past 18 years to examine how laparoscopic experience has evolved over that time period.

DESIGN

Undergraduate, nonmedical students received training and unlimited practice time before being tested on each task of the FLS Manual Skills Exam. Each task was timed and scored using the MISTELS system. ACGME case log data from graduating chief residents over the past 18 years was obtained.

SETTING

The setting is SimPortal, the simulation center associated with the University of Minnesota Medical School.

PARTICIPANTS

The participants are 25 undergraduate, nonmedical students from the University of Minnesota. Participants were recruited on campus.

RESULTS

Twenty-three out of 25 (92%) undergraduate, nonmedical students successfully completed one attempt for each task of the FLS Manual Skills Exam and 21 out of 25 (84%) completed both attempts. The average total practice time was 39 minutes. Over the past 18 years, the average number of laparoscopic cases completed by a graduating chief increased from 142 to 275 cases (93% increase). Additionally, the average number of cases of the top 5 most common laparoscopic operations increased from 25% to over 400%.

CONCLUSIONS

Undergraduate, nonmedical students can pass the FLS Manual Skills Exam with minimal practice. Additionally, general surgery residents and medical students continue to gain more laparoscopic experience throughout medical training as laparoscopic surgery is utilized for more operations. The FLS Manual Skills Exam should be re-examined to determine its utility as a high-stakes exam.

The Surgical Hazardous Attitudes Reflection Profile (SHARP) Instrument - A Prototype Study

OBJECTIVE

There is growing recognition that surgeons' non-technical skills are crucial in guaranteeing optimal quality and safety of patient care. However, insight in relevant attitudes underlying these behavioral skills is lacking. Hazardous attitudes potentially cause risky behavior, which can result in medical errors and adverse events. A questionnaire offering surgeons insight in their attitudinal profile is still missing and would be instrumental in risk reduction. Therefore, the aim of this study is to develop a prototype of a reliable and valid instrument to measure hazardous attitudes among surgeons.

DESIGN

To measure hazardous attitudes, a prototype of the Surgical Hazardous Attitudes Reflection Profile (SHARP) tool was designed using a mixed methods approach, consisting of (1) 2 focus group discussions, (2) a modified Delphi analysis, and (3) a survey followed by (4) statistical analysis of the psychometric properties. Statistical analysis included exploratory factor analysis with varimax rotation, calculation of internal consistency reliability coefficients, and interscale correlations.

SETTING

Fourteen hospitals across the Netherlands were recruited to guarantee demographic variety and the inclusion of academic, tertiary, and general hospitals.

PARTICIPANTS

Nineteen experts participated in the 2 focus groups, and 19 in the modified Delphi study. In total, 302 surgeons (54.1%) completed the SHARP.

RESULTS

In total, 302 surgeons (54.1%) completed the SHARP. Exploratory factor analysis resulted in 6 subscales measuring attitude towards (1) authority (α = 0.78), (2) self-performance (α = 0.69), (3) performance feedback (α = 0.61), (4) own fitness to perform (α = 0.54), (5) uncertainty (α = 0.51), and (6) planned procedures (α = 0.48).

CONCLUSIONS

This study resulted in a prototype instrument identifying 6 potential hazardous attitudes in surgeons. Attitudes towards "authority" and "self-performance" can now be validly and reliably measured. Further research is required to optimize the prototype version of the instrument and could usefully explore the plausible relations between hazardous attitudes and clinical outcomes.

Harvesting the 'SEAD': Long-Term Follow-Up of the Surgical Exploration and Discovery Program

OBJECTIVE

The Surgical Exploration and Discovery (SEAD) program was established to facilitate career decision-making by providing preclerkship students with comprehensive exposure to surgical specialties. Our short-term findings demonstrated that, compared to a control group, SEAD participants showed significantly greater career-related learning. The purpose of this study was to understand the long-term impact of the SEAD program.

DESIGN

This was a prospective cohort study. One group of students participated in a 2-week surgical curriculum (SEAD group) while another group read only the program manual (Manual group). Students were surveyed following their residency selection 3 years later. The outcome measures were final specialty preference (medical or surgical), program utility, and program satisfaction.

SETTING

Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada.

PARTICIPANTS

A total of 18 medical students in the SEAD group, and 18 in the Manual group.

RESULTS

Survey response rate was 100%. There was no significant difference in the number of students who pursued surgical careers in the SEAD and Manual groups. All students who pursued a surgical residency were 'very interested' in surgery prior to SEAD-initial interest in surgery had a significant influence on final residency preference. Ninety-four percent (n = 17) of SEAD participants described the SEAD program as valuable to facilitating their career decision-making.

CONCLUSIONS

Although SEAD does not generate sustained new interest in surgical disciplines, graduating students believe the program is valuable in facilitating career decision-making and perceive the program as a worthwhile time investment. These findings were true for students who selected both surgical and medical specialties, suggesting that early, multifaceted, exposure to surgery is a valuable addition to career exploration even for students who ultimately don't pursue surgical specialties. Going forward, integrating a longitudinal mentorship program may further improve the value of SEAD.

Medical Student Involvement and Learning Objectives in Morbidity and Mortality Conferences: A National Survey of the Association for Surgical Education's Committee of Clerkship Directors

BACKGROUND

Despite implementation of Morbidity and Mortality (M&M) Conference across surgical graduate medical education, sparse literature exists regarding the attendance and involvement of medical students. We sought to examine student involvement and learning objectives for M&M on a national level.

METHODS

A survey was distributed through the Association for Surgical Education Committee of Clerkship Directors. Questions examined demographics, teaching practices regarding M&M, and student learning objectives.

RESULTS

Forty-eight responses were collected reflecting practices of weekly M&M (96%) and required student attendance (93%). Students are observers in 61% of M&Ms, observer with questions in 37%, and presenter at 2%. Learning objectives for M&M highlighted exposing students to conference style (76%), reflective learning (63%), and highlighting medical error (78%).

CONCLUSIONS

It is the national standard for medical students to attend weekly M&M. Student learning objectives reflect desires to improve exposure to this style of teaching conference and understanding the gravity of medical error.