A comparison of unguided vs guided case-based instruction on the surgery clerkship

BACKGROUND

Guided case-based instruction is an effective and efficient means of learning for third year medical students on the surgery clerkship. Compared with an unguided format for teaching biliary disease, we observed greater student satisfaction as well as a more efficient utilization of student as well as faculty time with the guided instruction.

OBJECTIVE

While case-based instruction (CBI) has become an extremely popular teaching modality during the first 2 years of medical school, there has been little published regarding its utilization during the clinical years of medical school. The purpose of our study was to compare guided CBI (G-CBI) to unguided CBI (UG-CBI) during the surgery clerkship.

DESIGN

From July 2007 to July 2008, we utilized a UG-CBI format to teach biliary disease, formerly taught by a standard lecture. The unguided style is used by our institution for the first 2 years of medical school education, where the role of the facilitator is minimal. From July 2008 to December 2010, we changed to a G-CBI format where 5 different clinical scenarios were presented that all dealt with some form of biliary disease. A Likert-like scale was used to analyze student opinion comparing guided to the traditional unguided format. Questions regarding biliary disease contained in the National Board of Medical Examiners (NBME) shelf examination, given to all students at the end of the rotation, were also compared between the 2 groups. Cohen's d statistic was used to assess effect size.

SETTING

The study took place at the University of Arizona College of Medicine.

PARTICIPANTS

There were 88 students in the UG-CBI group and 146 in the G-CBI group.

RESULTS

Ninety-six percent of the students preferred G-CBI over the unguided format utilized during the basic science years. Eighty-two percent felt that the guided format sessions were a more efficient method of instruction and 91% of students agreed or strongly agreed that time was more efficiently utilized in preparing for the case discussion during the guided format. Shelf examination scores analyzing biliary disease questions (2-4 per examination) showed a moderate size effect favoring the G-CBI, although the numbers were too small to draw definite conclusions in this regard.

CONCLUSIONS

G-CBI is more suited for the surgery clerkship than the UG-CBI utilized during the first 2 years of medical school. Lack of a clinical knowledge base among the students rotating on the surgery clerkship as well as time limitations for both the student and clinical faculty favor this more efficient means of learning.

Effect of a mandatory research requirement on categorical resident academic productivity in a university-based general surgery residency

BACKGROUND

Our general surgery residency (46 residents, graduating 6 categoricals per year) offers the opportunity for 2 categorical residents at the end of their second year to choose a 2-year research track. Academic productivity for the remaining categorical residents was dependent on personal interest and time investment. To increase academic productivity within the residency, a mandatory research requirement was implemented in July 2010. We sought to examine the effect of this annual individual requirement.

METHODS

The research requirement consisted of several components: a curriculum of monthly research meetings and lectures, assigned faculty to act as research mentors, an online repository of research projects and ideas, statistical support, and a faculty member appointed Director of Research. In July 2010, the requirement was applied to all categorical postgraduate year 1-3 residents and expanded to postgraduate year 1-4 in 2011. The research requirement culminated in an annual research day at the end of the academic year. We compared the number of abstract presentations in local, national, and international meetings between the first 2 years of the research program and the 2 years before it. We also compared the total number of publications between the 2 periods, acknowledging that any differences at this point do not necessarily reflect an effect of the research requirement.

RESULTS

From July 2008 to June 2010 (Period A), there were 18 podium and poster presentations in local, national, and international meetings, and 30 publications in peer-reviewed journals, whereas between July 2010 and June 2012 (Period B), there were 58 presentations and 32 publications. In Period A 9 of 60 (15%) categorical residents had a podium or poster presentation in comparison with Period B when 23 of 58 (40%) categorical residents had a podium or poster presentation (p < 0.01).

CONCLUSION

The institution of a mandatory research requirement resulted in a 3-fold increase in scientific presentations in our surgical residency. We believe that the mandatory nature of the program is a key component to its success. We expect to see an increase in the number of publications as a result of this research requirement in the next several years.

Multi-institutional study of self-reported attitudes and behaviors of general surgery residents about ethical academic practices in test taking

PURPOSE

Correlation exists between people who engage in academic dishonesty as students and unethical behavior once in practice. Previously, we assessed the attitudes of general surgery residents and ethical practices in test taking at a single institution. Most residents had not participated in activities they felt were unethical, yet what constituted unethical behavior was unclear. We sought to verify these results in a multi-institutional study.

METHODS

A scenario-based survey describing potentially unethical activities related to the American Board of Surgery In-training Examination (ABSITE) was administered. Participants were asked about their knowledge of or participation in the activities and whether the activity was unethical. Program directors were surveyed about the use of ABSITE results for resident evaluation and promotion.

RESULTS

Ten programs participated in the study. The resident response rate was 67% (186/277). Of the respondents, 43% felt that memorizing questions to study for future examinations was unethical and 50% felt that using questions another resident memorized was unethical. Most felt that buying (86%) or selling (79%) questions was unethical. Significantly more senior than junior residents have memorized (30% vs 16%; p = 0.04) or used questions others memorized (33% vs 12%; p = 0.002) to study for future ABSITE examinations and know of other residents who have done so (42% vs 20%; p = 0.004). Most programs used results of the ABSITE in promotion (80%) and set minimum score expectations and consequences (70%).

CONCLUSION

Similar to our single-institution study, residents had not participated in activities they felt to be unethical; however the definition of what constitutes cheating remains unclear. Differences were identified between senior and junior residents with regard to memorizing questions for study. Cheating and unethical behavior is not always clear to the learner and represents an area for further education.

Initial performance of a modified milestones global evaluation tool for semiannual evaluation of residents by faculty

OBJECTIVES

To determine whether faculty could successfully evaluate residents using a competency-based modified Milestones global evaluation tool.

DESIGN

A program's leadership team modified a draft Surgery Milestones Working Group summative global assessment instrument into a modified Milestones tool (MMT) for local use during faculty meetings devoted to semiannual resident review. Residents were scored on 15 items spanning all competencies using an 8-point graphic response scale; unstructured comments also were solicited. Arithmetic means were computed at the resident and postgraduate year cohort levels for items and competency item sets. Score ranges (highest minus lowest score) were calculated; variability was termed "low" (range <2.0 points), "moderate" (range = 2.0), or "high" (range >2.0). A subset of "low" was designated "small" (1.0-1.9). Trends were sought among item, competency, and total Milestones scores. MMT correlations with examination scores and multisource (360°) assessments were explored. The success of implementing MMT was judged using published criteria for educational assessment methods.

SETTING

Fully accredited, independently sponsored residency.

PARTICIPANTS

Program leaders and 22 faculty members (71% voluntary, mean 12y of experience).

RESULTS

Twenty-six residents were assessed, yielding 7 to 13 evaluations for MMT per categorical resident and 3 to 6 per preliminary trainee. Scores spanned the entire response scale. All MMT evaluations included narrative comments. Individual resident score variability was low (96% within competencies and 92% across competencies). Subset analysis showed that small variations were common (35% within competencies and 54% across competencies). Postgraduate year cohort variability was higher (61% moderate or high within competencies and 50% across competencies). Cohort scores at the item, competency, and total score levels exhibited rising trajectories, suggesting MMT construct validity. MMT scores did not demonstrate concurrent validity, correlating poorly with other metrics. The MMT met multiple criteria for good assessment.

CONCLUSIONS

A modified Milestones global evaluation tool can be successfully adopted for semiannual assessments of resident performance by volunteer faculty members.

Early experience in establishing and evaluating an ACGME-approved international general surgery rotation

BACKGROUND

In 2011, the Accreditation Council for Graduate Medical Education Surgery Residency Review Committee first provided guidelines for elective international general surgery rotations. The Vanderbilt general surgery residency program received Surgery Residency Review Committee approval for a fourth-year elective in Kenya beginning in the 2011-2012 academic year. Because this rotation would break ground culturally and geographically, and as an educational partnership, a briefing and debriefing process was developed for this ground-breaking year.

OBJECTIVES

Our objectives were to prepare residents to maximize the experience without competing for cases with local trainees or overburdening the host institution and to perform continuous quality assessment and improvement as each resident returned back.

METHODS

Briefing included health protection strategies, a procedures manual containing step-by-step preparation activities, and cultural-sensitivity training. Institutional Review Board exemption approval was obtained to administer a questionnaire created for returning residents concerning educational value, relations with local trainees, physical environment, and personal perceptions that would provide the scaffold for the debriefing conference.

RESULTS

The questionnaire coupled with the debriefing discussion for the first 9 participants revealed overall satisfaction with the rotation and the briefing process, good health, and no duty hours or days-off issues. Other findings include the following: (1) emotional effect of observing African families weigh cost in medical decision making; (2) satisfactory access to educational resources; (3) significant exposure to specialties such as urology and radiology; and (4) toleration of 4 weeks as a single and expressed need for leisure activity materials such as books, DVDs, or games. The responses triggered adjustments in the briefing sessions and travel preparation. The host institution invited the residents to return for the 2012-2013 year as well as 2013-2014.

CONCLUSION

Detailed preparation and the follow-up evaluation for assessment and improvement of this nascent international surgery experience are associated with resident satisfaction and the host institution has agreed to continue the rotation.

The influence of surgeon personality factors on risk tolerance: a pilot study

OBJECTIVE

This study attempts to assess the association between surgeon personality factors (measured by the Myers-Briggs Type Indicator personality inventory (MBTI(®))) and risk tolerance (measured by the Revised Physicians' Reactions to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales).

DESIGN

Instrument assessing surgeon personality profile (MBTI) and 2 questionnaires measuring surgeon risk tolerance and risk aversion (PRU and PRA).

SETTING

Saint Raphael campus of Yale New Haven Hospital in New Haven, Connecticut.

PARTICIPANTS

Twenty categorical surgery residents and 7 surgical core faculty members.

RESULTS

The following findings suggest there might be a relationship between surgeon personality factors and risk tolerance.

CONCLUSIONS

In certain areas of risk assessment, it appears that surgeons with personality factors E (Extravert), T (Thinking), and P (Perception) demonstrated higher tolerance for risk. Conversely, as MBTI(®) dichotomies are complementary, surgeons with personality factors I (Introvert), F (Feeling), and J (Judgment) suggest risk aversion on these same measures. These findings are supported by at least 2 studies outside medicine demonstrating that personality factors E, N, T, and P are associated with risk taking. This preliminary research project represents an initial step in exploring what may be considered a fundamental component in a "successful" surgical personality.

Small community hospitals programs affiliation with university programs; "lessons learned" in 28-year successful affiliation

OBJECTIVE

Community hospitals affiliation with university hospitals in post graduate surgical education is essential for the 2 types of training programs. Many factors affect the success of the affiliation process. Additionally, various pitfalls and challenges are encountered. The goal of this work is to study the lessons learned in 28 years successful affiliation.

DESIGN/SETTING

small community hospital affiliation with university program for 28 years.

PARTICIPANTS

surgery residency programs in small community hospital and university hospital.

RESULTS

successful affiliation for 28 years between community hospital and university program.

The cost of intraoperative plastic surgery education

PURPOSE

Within the surgical community, it is commonly accepted that the length and cost of a surgical case increase when a resident physician participates. Many accountable care organizations, however, believe the opposite, that is, resident assistance enhances efficiency and diminishes operative time. The purpose of this study is to determine the opportunity cost to the attending surgeon for intraoperative teaching during index plastic surgery cases.

METHODS

A single senior surgeon's experience over a 7-year period was evaluated retrospectively for Current Procedural Terminology codes 40700 (repair of primary, unilateral cleft lip) and 42200 (palatoplasty). Variables collected include operative time, the presence or absence of a physician learner, and postgraduate year level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. A cost analysis was performed to quantify the effect of longer operative times in terms of relative value units (RVUs) lost.

RESULTS

During the study period, a total of 45 patients had primary, unilateral cleft lip repair; 70 patients had cleft palate repair. Of those cases, 39 (87%) cleft lip repairs and 60 (86%) cleft palate repairs were performed with a resident or fellow present. There was a statistically significant difference in the amount of time required to perform either surgery with a physician learner than without, with operative times being 60% (p = 0.020) longer for cleft lip repair and 65% (p = 0.0016) longer for cleft palate repair. The results were further stratified based on level of training, with craniofacial fellows and plastic surgery residents (independent and integrated) compared separately. Cases where a craniofacial fellow was present required the longest operative times: 103% (p = 0.0012) longer for cleft lip repairs and 104% (p < 0.0001) longer for cleft palate repairs when compared with the senior surgeon operating alone. Using the 2011 physician work RVUs for these surgeries and the 2011 Medicare conversion factor for RVUs to dollars, the opportunity cost is over $275 per case per trainee for any physician learner. When craniofacial fellows are analyzed separately, over $440 is invested in intraoperative teaching per case per fellow.

CONCLUSIONS

Resident involvement in the operating room is crucial to the education of independent surgeons. This involvement, however, comes at a significant opportunity cost to the attending surgeon. As an incentive to retain academic surgeons and uphold a quality academic environment in the OR, compensation should be offered for intraoperative teaching.

Laparoscopy training in surgical education: the utility of incorporating a structured preclinical laparoscopy course into the traditional apprenticeship method

OBJECTIVE

To investigate whether preclinical laparoscopy training offers a benefit over standard apprenticeship training and apprenticeship training in combination with simulation training.

DESIGN

This randomized controlled trial consisted of 3 groups of first-year surgical registrars receiving a different teaching method in laparoscopic surgery.

SETTING

The KU LEUVEN Faculty of Medicine is the largest medical faculty in Belgium.

PARTICIPANTS

Thirty final-year medical students starting a general surgical career in the next academic year.

METHODS

Thirty final-year medical students were randomized into 3 groups, which differed in the way they were exposed to laparoscopic simulation training but were comparable in regard to ambidexterity, sex, age, and laparoscopic psychomotoric skills. The control group received only clinical training during surgical residentship, whereas the interval group received clinical training in combination with simulation training. The registrars were allowed to do deliberate practice. The Centre for Surgical Technologies Preclinical Training Programme (CST PTP) group received a preclinical simulation course during the final year as medical students, but was not exposed to any extra simulation training during surgical residentship. At the beginning of surgical residentship and 6 months later, all subjects performed a standardized suturing task and a laparoscopic cholecystectomy in a POP Trainer. All procedures were recorded together with time and motion tracking parameters. All videos were scored by a blinded observer using global rating scales.

RESULTS

At baseline the 3 groups were comparable. At 6 months, for suturing, the CST PTP group was better than both the other groups with respect to time, checklist, and amount of movements. The interval group was better than the control group on only the time and checklist score. For the cholecystectomy evaluation, there was a statistical difference between the CST PTP study group and both other groups on all evaluation scales in favor of the CST PTP group.

CONCLUSIONS

Structured, preclinical proficiency-based training is better than clinical training combined with laboratory training or clinical training alone.

Assessment of robotic simulation by trainees in residency programs of the Southeastern Section of the American Urologic Association

OBJECTIVES

To assess the Southeast Section of the American Urological Association (SESAUA) trainee exposure to and thoughts on robotic simulation.

DESIGN

Questionnaire-based study of SESAUA residency trainees to determine their access to robotic simulation, live robotic experience to date, and opinion regarding the adequacy of current robotic training.

SETTING

Three trainees from each SESAUA training program were invited to Orlando, Florida for a formal 2-day robotic training course. Day 1 was a 3-component didactic session. Day 2 involved faculty directing the trainees in set tasks on a live porcine model for 4 hours and another 4 hours on the Mimic dV-Trainer (Mimic Technologies, Inc, Seattle, WA) for directed exercises.

PARTICIPANTS

Thirty-two trainees from 14 programs in the SESAUA participated in the course and filled out a 1-page, 8-item questionnaire following their simulator exposure.

RESULTS

Seventeen (53.1%) trainees, including 5 urology year-3 trainees, reported never having had robotic console time. Of the trainees, 65.6% (21 of 32) had access to the Mimic dV-Trainer or Mimic "backpack" whereas 10 had no exposure to robotic simulation; 84.4% (27 of 32) felt that the simulator replicated real-life robotic console surgery and 90.6% (29 of 32) felt the simulator was helpful or would be helpful for training in their program. Trainees felt the "tubes 2" drill, which mimics a vesicourethral anastomosis, was the most difficult drill to perform.

CONCLUSIONS

A majority of trainees in the SESAUA have had limited to no robotic console time. A high number of resident trainees in the SESAUA have exposure to virtual reality robotic simulation. Trainees believe that the simulator replicates real-life robotic console movements and almost all believe they would be benefit from having access to robotic simulation.

The incidence and reporting of sharps exposure among medical students, orthopedic residents, and faculty at one institution

OBJECTIVE

To compare the incidence of sharps injuries among medical students, orthopedic residents/fellows, and orthopedic faculty at one institution and to determine the rate of reporting exposures.

DESIGN

Cross-sectional survey. Surveys were completed by 44% (53/120) of medical students, 76% (23/30) of residents/fellows, and 56% (17/30) of full-time faculty.

SETTING

Academic medical center.

PARTICIPANTS

Medical students, orthopedic surgery residents/fellows, full-time academic orthopedic surgery faculty.

RESULTS

Twenty-eight percent of medical students, 83% of residents/fellows, and 100% of faculty had been exposed to a sharps injury at some point in their career; 42% of residents/fellows had experienced a sharps exposure within the past year. The most common single instrument responsible for sharps injuries among all groups was the solid-bore needle; students and residents were significantly more likely than faculty to have a sharps injury from a solid-bore needle than all other devices combined (p = 0.04). Medical students were more likely to ignore the exposure than residents/fellows (p = 0.004) or faculty (p = 0.036). Only 12.5% of medical students followed all the steps of the postexposure protocol.

CONCLUSION

Sharps exposures occur among orthopedic surgeons and their trainees. Interventions are needed to increase safety among residents and medical students. Further research should evaluate factors suppressing medical student reporting of sharps exposures.

Educational value of a preoperative CT sinus checklist: a resident's perspective

OBJECTIVE

The objective of this study is to evaluate the educational value and effectiveness of a preoperative computed tomography (CT) sinus anatomy checklist as a teaching method from the perspective of otolaryngology residents.

DESIGN

Between 2009 and 2011, 15 otolaryngology residents completed a CT sinus anatomy checklist prior to the start of sinus surgery cases. A cross-sectional brief Likert-type questionnaire assessed the resident experience with the checklist. Nine items explored its perceived utility, role in the preoperative setting, incorporation into practice, and recall.

SETTING

St. Michael's Hospital, tertiary care hospital.

PARTICIPANTS

Otolaryngology residents rotating through St. Michael's Hospital between 2009 and 2011 were enrolled into this study. A total of 15 residents entered and finished the study.

RESULTS

Overall, all residents strongly agreed that the checklist was useful. It ensured that the CT imaging was properly reviewed and increased their comfort level with the relevant anatomy. Nearly all the residents continue to use this checklist even after completing the rotation with the senior author (JML).

CONCLUSIONS

The CT sinus anatomy checklist was perceived as useful overall by otolaryngology residents. In the future, checklists should be applied to other areas of head and neck surgical training to further standardize preoperative planning.

Open surgical simulation--a review

BACKGROUND

Surgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation.

CURRENT STATE OF OPEN SURGICAL SIMULATION

Open surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment.

FUTURE OF OPEN SURGICAL SIMULATION

The skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient's safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools.

A critical evaluation of the Intercollegiate Surgical Curriculum and comparison with its predecessor the "Calman" curriculum

BACKGROUND

The increasing need for doctors to be accountable and an emphasis on competency have led to the evolution of medical curricula. The Intercollegiate Surgical Curriculum Project succeeded the Calman curriculum for surgical training in 2007 in the UK. It sought to provide an integrated curriculum based upon a website platform. The aim of this review is to examine the changes to the curriculum and effect on surgical training.

METHODS

A comparison was made of the Calman Curriculum and the ISCP and how they met training needs.

RESULTS

The new curriculum is multifaceted, providing a more prescriptive detail on what trainees should achieve and when, as well as allowing portfolio, learning agreements, and work-based assessments to be maintained on an easily accessed website. The increasing emphasis on work-based assessments has been one of the major components, with an aim of providing evidence of competence. However, there is dissatisfaction amongst trainees with this component which lacks convincing validity.

CONCLUSION

This new curriculum significantly differs from its predecessor which was essentially just a syllabus. It needs to continuously evolve to meet the needs of trainees whose training environment is ever changing.

Surgeons' attitude toward a competency-based training and assessment program: results of a multicenter survey

BACKGROUND

Currently, most surgical training programs are focused on the development and evaluation of professional competencies. Also in the Netherlands, competency-based training and assessment programs were introduced to restructure postgraduate medical training. The current surgical residency program is based on the Canadian Medical Education Directives for Specialists (CanMEDS) competencies and uses assessment tools to evaluate residents' competence progression. In this study, we examined the attitude of surgical residents and attending surgeons toward a competency-based training and assessment program used to restructure general surgical training in the Netherlands in 2009.

METHODS

In 2011, all residents (n = 51) and attending surgeons (n = 108) in 1 training region, consisting of 7 hospitals, were surveyed. Participants were asked to rate the importance of the CanMEDS competencies and the suitability of the adopted assessment tools. Items were rated on a 5-point Likert scale and considered relevant when at least 80% of the respondents rated an item with a score of 4 or 5 (indicating a positive attitude). Reliability was evaluated by calculating the Cronbach's α, and the Mann-Whitney test was applied to assess differences between groups.

RESULTS

The response rate was 88% (n = 140). The CanMEDS framework demonstrated good reliability (Cronbach's α = 0.87). However, the importance of the competencies 'Manager' (78%) and 'Health Advocate' (70%) was undervalued. The assessment tools failed to achieve an acceptable reliability (Cronbach's α = 0.55), and individual tools were predominantly considered unsuitable for assessment. Exceptions were the tools 'in-training evaluation report' (91%) and 'objective structured assessment of technical skill' (82%). No significant differences were found between the residents and the attending surgeons.

CONCLUSION

This study has demonstrated that, 2 years after the reform of the general surgical residency program, residents and attending surgeons in a large training region in the Netherlands do not acknowledge the importance of all CanMEDS competencies and consider the assessment tools generally unsuitable for competence evaluation.

The "July effect" does not have clinical relevance in liver transplantation

In the beginning of the academic year, medical errors are often attributed to inexperienced medical staff. This potential seasonal influence on health care outcomes is termed the "July effect." No study has demonstrated the July effect in liver transplantation. We reviewed retrospectively collected data from the United Network for Organ Sharing for patients who underwent liver transplantation from October 1987 to June 2011 to determine if surgical outcomes were worse in July compared with rest of the year. We found no clinical difference in early graft survival (91.11% vs. 90.72%, p = 0.045) and no difference in early patient survival (94.71% vs. 94.42%, p = 0.057). Survival at 1 year, 3 years, and 5 years was also compared and no notable differences were detected. Because the Model for End-stage Liver Disease (MELD) score implementation in 2002 affected the acuity of liver transplant recipients, we further stratified our data to compare pre- and post-MELD survival to remove subjectivity as a confounding factor. MELD stratification revealed no seasonal difference in outcomes. There was no difference in rate of graft failure and acute and chronic rejection between groups. Our findings show no evidence of the July effect in liver transplantation. Each July, thousands of medical residents take on new responsibilities in patient care. It has been suggested that these new practitioners may produce errors that contribute to worse patient outcomes in the beginning of the academic year-a phenomenon called the "July effect." Currently, there are few research studies with controversial evidence of poorer outcomes in July, and no articles address the effect of new medical staff in the setting of liver transplantation. Our study compares short-, medium-, and long-term graft and patient survival between July and August and the remaining months using national data. We also examine survival before and after the implementation of the MELD scoring system to determine its effect on outcomes in the beginning of the academic year.

Application of stereoscopic visualization on surgical skill acquisition in novices

OBJECTIVE

The use of stereoscopic imaging can provide additional depth cues that may increase trainee performance on surgical tasks, but it has yet to be evaluated using a validated surgical skill system. This study examines the influence of monoscopic vs stereoscopic visualization in novice trainees performing the McGill Inanimate System for Training and Evaluation of Laparoscopic Skill (MISTELS) tasks, a validated laparoscopic skill-evaluation system, predicting a difference in performance based on visualization modality.

DESIGN

A total of 31 first- and second-year medical students at the University of Western Ontario were selected, each performed the MISTELS battery of tasks (circle cutting, peg transfer, ligated loop Placement, intracorporeal knot tying, and extracorporeal knot tying) using either monoscopic or stereoscopic visualization displays. Performance was evaluated in accordance with the MISTELS protocol. Participant visual spatial ability and manual dexterity skills were also analyzed and compared with performance. p values less than 0.05 were considered significant.

RESULTS

For ligated loop placement, extracorporeal knot tying, and intracorporeal knot tying, no significant difference was found between monoscopic and stereoscopic visualization on task performance (p > 0.05). Monoscopic visualization was shown to produce significantly better performance in the peg transfer task alone (p = 0.001). Qualitatively, 57.1% of participants believed their performance was aided by stereoscopic visualization and 68.8% believed that future learners would benefit from its implementation into surgical education. Most participants rated the peg transfer task to be the least difficult task (60%) and rated the intracorporeal knot-tying task to be the most difficult (65.9%).

CONCLUSIONS

These results suggest that the intrinsic difficulty of the MISTELS tasks may exceed a novice user's skill. No benefit with additional 3-dimensional cues in naïve surgical trainees was found. Additional visual cues in stereoscopic visualization may only serve to increase cognitive load and potentially decrease skill acquisition and learning.

Current concepts of team training in surgical residency: a survey of North American program directors

OBJECTIVES

The purpose of the present survey was to (1) establish the prevalence of Crew Resource Management (CRM)- and team-training interventions among general surgery residency programs of the United States and Canada; (2) to characterize current approaches to training and assessment of nontechnical skills; and (3) to inquire about program directors' (PDs') recommendations for future curricula in graduate medical education.

DESIGN

An online questionnaire was developed by the authors and distributed via email to the directors of all accredited general surgery residency programs across the United States and Canada. After 3 email reminders, paper versions were sent to all nonresponders.

PARTICIPANTS AND SETTING

PDs of accredited general surgery residency programs in the United States and Canada.

RESULTS

One hundred twenty (47%) PDs from the United States and 9 (53%) from Canada responded to the survey. Of all respondents, 32% (n = 40) indicated conducting designated team-training interventions for residents. Three main instructional strategies were identified: combined approaches using simulation and didactic methods (42%, n = 16); predominantly simulation-based approaches (37%, n = 14); and didactic approaches (21%, n = 8). Correspondingly, 83% (n = 93) of respondents recommended a combination of didactic methods and opportunities for practice for future curricula. A high agreement between responding PDs was shown regarding learning objectives for a proposed team-based training curriculum (α = 0.95).

CONCLUSIONS

The self-reported prevalence of designated CRM- and team-training interventions among responding surgical residency programs was low. For the design of future curricula, the vast majority of responding PDs advocated for the combination of interactive didactic methods and opportunities for practice.

Spouses of thoracic surgery applicants: changing demographics and motivations in a new generation

INTRODUCTION

Applications to thoracic residency have decreased. The causes are multifactorial, but include changing motivations such as lifestyle concerns. Thoracic residents (TRs) have been well studied, but no one has ever characterized the influence or motivations of their spouses. We sought to evaluate the demographics and interests of TR spouses.

METHODS

An electronic survey was sent to all TR applicants over 2 years at 2 training programs and to all current TRs in 2010. Recipients were asked to forward the survey to their spouses. Responses were analyzed globally and compared in subgroups.

RESULTS

Sixty-six surveys were completed and returned for a response rate of 19%. Among them, 86% of respondents were female, with 82% being married for a mean of 4.3 years. Fifty-nine percent of respondents had children and 64% were planning on having more children within 3 years. Hundred percent felt optimistic that they would be financially stable after training, but only 57% were optimistic about quality of life after training. Eighty-four percent felt that they had influence on the choice of training program. Almost 80% wanted more information on salary, housing, and access to faculty spouses. Quality of fellowship, geographic location, and proximity to family were the top 3 factors in choosing a program.

CONCLUSIONS

Nearly 90% of respondents reported they want to travel to more interviews, and nearly 90% of respondents reported having some to complete influence over which training program to attend. It is safe to presume, therefore, that applicant spouses are not only highly influential on TR applicants but also interested in greater inclusion in the interview process. The results show numerous demographic and characteristic trends which, if further validated by definitive studies, would be applicable to all post-surgery residency training programs and may help TR programs to be more competitive in attracting applicants and their families.