Teaching in the operating room: results of a national survey

Resident training in a teaching hospital: How do attendings teach in the real operative environment?

BACKGROUND

The study aim was to explore the nature of intraoperative education and its interaction with the environment where surgical education occurs.

METHODS

Video and audio recording captured teaching interactions between colorectal surgeons and general surgery residents during laparoscopic segmental colectomies. Cases and collected data were analyzed for teaching behaviors and workflow disruptions. Flow disruptions (FDs) are considered deviations from natural case progression.

RESULTS

Across 10 cases (20.4 operative hours), attendings spent 11.2 hours (54.7%) teaching, using directing (M = 250.1), and confirming (M = 236.1) most. FDs occurred 410 times, accounting for 4.4 hours of case time (21.57%). Teaching occurred with FD events for 2.4 hours (22.2%), whereas 77.8% of teaching happened outside FD occurrence. Teaching methods shifted from active to passive during FD events to compensate for patient safety.

CONCLUSIONS

Understanding how FDs impact operative learning will inform faculty development in managing interruptions and improve its integration into resident education.

From novice to master surgeon: improving feedback with a descriptive approach to intraoperative assessment

BACKGROUND

A developmental and descriptive approach to assessing trainee intraoperative performance was explored.

METHODS

Semistructured interviews with 20 surgeon educators were recorded, transcribed, deidentified, and analyzed using a grounded theory approach to identify emergent themes. Two researchers independently coded the transcripts. Emergent themes were also compared to existing theories of skill acquisition.

RESULTS

Surgeon educators characterized intraoperative surgical performance as an integrated practice of multiple skill categories and included anticipating, planning for contingencies, monitoring progress, self-efficacy, and "working knowledge." Comments concerning progression through stages, broadly characterized as "technician," "anatomist," "anticipator," "strategist," and "executive," formed a narrative about each stage of development.

CONCLUSIONS

The developmental trajectory with narrative, descriptive profiles of surgeons working toward mastery provide a standardized vocabulary for communicating feedback, while fostering reflection on trainee progress. Viewing surgical performance as integrated practice rather than the conglomerate of isolated skills enhances authentic assessment.

Use of a formal assessment instrument for evaluation of resident operative skills in pediatric neurosurgery

OBJECT Currently there is no standardized tool for assessment of neurosurgical resident performance in the operating room. In light of enhanced requirements issued by the Accreditation Council for Graduate Medical Education's Milestone Project and the Matrix Curriculum Project from the Society of Neurological Surgeons, the implementation of such a tool seems essential for objective evaluation of resident competence. Beyond compliance with governing body guidelines, objective assessment tools may be useful to direct early intervention for trainees performing below the level of their peers so that they may be given more hands-on teaching, while strong residents can be encouraged by faculty members to progress to conducting operations more independently with passive supervision. The aims of this study were to implement a validated assessment tool for evaluation of operative skills in pediatric neurosurgery and determine its feasibility and reliability. METHODS All neurosurgery residents completing their pediatric rotation over a 6-month period from January 1, 2014, to June 30, 2014, at the authors' institution were enrolled in this study. For each procedure, residents were evaluated by means of a form, with one copy being completed by the resident and a separate copy being completed by the attending surgeon. The evaluation form was based on the validated Objective Structured Assessment of Technical Skills for Surgery (OSATS) and used a 5-point Likert-type scale with 7 categories: respect for tissue; time and motion; instrument handling; knowledge of instruments; flow of operation; use of assistants; and knowledge of specific procedure. Data were then stratified by faculty versus resident (self-) assessment; postgraduate year level; and difficulty of procedure. Descriptive statistics (means and SDs) were calculated, and the results were compared using the Wilcoxon signed-rank test and Student t-test. A p value < 0.05 was considered statistically significant. RESULTS Six faculty members, 1 fellow, and 8 residents completed evaluations for 299 procedures, including 32 ventriculoperitoneal (VP) shunt revisions, 23 VP shunt placements, 19 endoscopic third ventriculostomies, and 18 craniotomies for tumor resection. There was no significant difference between faculty and resident self-assessment scores overall or in any of the 7 domains scores for each of the involved residents. On self-assessment, senior residents scored themselves significantly higher (p < 0.02) than junior residents overall and in all domains except for "time and motion." Faculty members scored senior residents significantly higher than junior residents only for the "knowledge of instruments" domain (p = 0.05). When procedure difficulty was considered, senior residents' scores from faculty members were significantly higher (p = 0.04) than the scores given to junior residents for expert procedures only. Senior residents' self-evaluation scores were significantly higher than those of junior residents for both expert (p = 0.03) and novice (p = 0.006) procedures. CONCLUSIONS OSATS is a feasible and reliable assessment tool for the comprehensive evaluation of neurosurgery resident performance in the operating room. The authors plan to use this tool to assess resident operative skill development and to improve direct resident feedback.

Development of Technical Skills: Education, Simulation, and Maintenance of Certification

The goal of this article is to provide a focused overview of technical skills education inside the operating room (OR), opportunities for learning outside of the OR (with a focus on simulation), and methods for measuring technical skills. In addition, the authors review the role of maintenance of certification in continuing education and quality improvement and consider the role that simulation plays in this process. The perspectives on teaching in the OR of both residents and faculty going into the case affect the learning environment, and preoperative interactions between attendings and residents to establish learning needs and goals are important. Furthermore, in regards to attending surgeons improving their skills, interaction with more experienced peers and feedback during and after a procedure can be beneficial. Simulation is increasingly being utilized as an education tool outside of the OR. Training in plastic surgery is poised to exploit simulation in multiple technical areas. There is potential to utilize these simulation environments to collect real-time data, such as motion, visual focus, and pressure. How to incorporate technical skill evaluation results in ways that are most beneficial for learning should be the focus of future research and curriculum development. Finally, simulation could be better utilized as a mechanism for both self and peer evaluation and assessment for continuing education and quality improvement. Professional development for faculty and surgery trainees on how to engage with simulation for teaching and learning and how to translate these experiences into improving patient care will be required.

The effect of video review of resident laparoscopic surgical skills measured by self- and external assessment

BACKGROUND

Video review of surgical skills is an educational modality that allows trainees to reflect on self-performance. The purpose of this study was to determine whether resident and attending assessments of a resident's laparoscopic performance differ and whether video review changes assessments.

METHODS

Third-year surgery residents were invited to participate. Elective laparoscopic procedures were video recorded. The Global Operative Assessment of Laparoscopic Skills evaluation was completed immediately after the procedure and again 7 to 10 days later by both resident and attending. Scores were compared using t tests.

RESULTS

Nine residents participated and 76 video reviews were completed. Residents scored themselves significantly lower than the faculty scores both before and after video review. Resident scores did not change significantly after video review.

CONCLUSIONS

Attending and resident self-assessment of laparoscopic skills differs and subsequent video review does not significantly affect Global Operative Assessment of Laparoscopic Skills scores. Further studies should evaluate the impact of video review combined with verbal feedback on skill acquisition and assessment.

Residents as Educators: A Modern Model

Education during surgical residency has changed significantly. As part of the shifting landscape, the importance of an organized and structured curriculum has increased. However, establishing this is often difficult secondary to clinical demands and pressure both on faculty and residents. We present a peer-assisted learning model for academic institutions without professional non-clinical educations. The "resident as educator" (RAE) model empowers residents to be the organizers of the education curriculum. RAE is built on a culture of commitment to education, skill development and team building, allowing the upper level residents to develop and execute the curriculum. Several modules designed to address junior level residents and medical students' educational needs have been implemented, including (1) intern boot camp, (2) summer school, (3) technical skill sessions, (4) trauma orientation, (5) weekly teaching conferences, and (4) a fourth year medical student surgical preparation course. Promoting residents as educators leads to an overall benefit for the program by being cost-effective and time-efficient, while simultaneously promoting professional development of residents and a culture of education.

The positive impact of structured teaching in the operating room

BACKGROUND

A survey of obstetric and gynaecology trainees in Australia found the trainee's opinion of the consultants' teaching ability for laparoscopic procedures and procedures dealing with complications as 'poor' in 21.2% and 23.4% of responses, respectively (Aust NZ J Obstet Gynaecol 2009; 49: 84). Surgical caseload per trainee is falling for a variety of reasons. Strategies need to be adopted to enhance the surgical learning experience of trainees in the operating room.

AIMS

We describe the use of a structured encounter template to facilitate the teaching of surgery in the operating room and report the response of the trainees to this intervention.

METHODS

Trainees attached to a gynaecologic surgery unit all underwent surgical training using a set format based on the surgical encounter template, including briefing, goal setting and intra-operative teaching aims as well as debriefing. Data on the trainees' experience and perception of their learning experience were then collected and analysed as quantitative and qualitative data sets.

RESULTS

The trainees reported satisfaction with the use of a structured encounter template to facilitate the surgical teaching in the operating room. Some trainees had not received such clarity of feedback or the opportunity to complete a procedure independently prior to using the structured encounter template.

CONCLUSIONS

A structured surgical encounter template based on andragogy principles to focus consultant teaching in the operating room is highly acceptable to obstetric and gynaecology trainees in Australia. Allowing the trainee the opportunity to set objectives and receive feedback empowers the trainee and enhances their educational experience.

Planning to avoid trouble in the operating room: experts' formulation of the preoperative plan

OBJECTIVE

The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process.

DESIGN

HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency.

SETTING

Division of General Surgery, University of Toronto.

PARTICIPANTS

HPB surgeons affiliated with the University of Toronto.

RESULTS

A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans.

CONCLUSION

These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

Standardizing the culture of trauma rotation handoffs

OBJECTIVE

One of the General Surgery milestones focuses on effective handoffs between residents as they change shifts. Although the content of handoffs is crucial, we recognized that the culture of handoffs was equally important. After the reorganization of the trauma service at our institution, there were difficulties in maintaining the standardized handoff culture. We analyzed the culture of handoffs on the trauma service to create an environment more conducive to effective handoffs.

DESIGN

All trauma activations from 2012 to 2013 were evaluated from our institution's trauma data registry. Data on timing of activations and disposition of the patient were analyzed to understand service work flow. A survey was developed and administered to the residents to assess the culture of trauma handoffs.

SETTING

This work occurred at an academic, state-designated level 1 trauma center.

PARTICIPANTS

All current residents in the general surgery residency who rotated on the trauma service in the last 5 years.

RESULTS

There were 1654 admissions to the trauma service from June 2012 to July 2013. The single busiest hour for trauma admissions (7% of admissions) was the same time the residents were designated to handoff. Interruptions occurred often; 83% of residents indicated that a handoff interruption occurred daily, and 73% indicated a new activation interrupted handoffs weekly. A large majority, 61%, felt patient care was frequently compromised by an ineffective handoff. Similarly, as a direct result of inadequate handoffs, 50% felt uncomfortable answering nurses' pages at night.

CONCLUSIONS

The unique situation of the trauma service impaired the handoff culture for residents. Assessment of our trauma activation flow indicates the timing of handoffs was adversely affecting our resident's ability to handoff effectively, requiring interventions to improve the efficacy and safety of handoffs.

Effective teaching and feedback strategies in the or and beyond

Maintaining a standard of excellence for graduating surgical residents requires a comprehensive and consistent approach to surgical education. The omnipresent and increasing barriers to education must also be recognized and addressed. The implementation of effective teaching strategies is largely dependent on the resources available at each institution and the vision of education. Unfortunately, allocating time for surgeons to teach both inside and outside the operating room has become a foreign concept to administration. Furthermore, the reduction in case numbers performed by trainees now demands "quality over quantity" to ensure success. Quality teaching moments will only be realized when emphasis is placed on preparation, useful instruction during the procedure, and postoperative feedback. Ideal preparation entails a detailed discussion between the trainee and surgeon about the specific learning goals for the case. During the procedure, the faculty surgeon must strive to maximize the experience through effective communication while performing an efficient and safe operation. Numerous validated objective assessment tools exist for postprocedure evaluation but are grossly underutilized. Surgical education must thoughtfully be approached with the same fervor and detail as patient care. As faculty, it is our responsibility to train the next generation of surgeons and therefore "every case must count."

Development of a Validated HPLC/Photodiode Array Method for the Determination of Isomenthone in the Aerial Parts of Ziziphora tenuior L

BACKGROUND

Ziziphora tenuior L. known as Kakuti in Persian, is used in traditional medicine for fever, dysentery, uterus infection and as an analgesic. It is used also in the treatment of gastrointestinal disorders as carminative, or remedy of diarrhea or nausea. Major components of plant essential oil including pulegone, isomenthone, thymol, menthone, and piperitone are suggested to be responsible for the mentioned medicinal properties.

OBJECTIVES

In the present study, a normal high performance liquid chromatography (HPLC)/photodiode array validated method for quantification of isomenthone, one of the major constituents of Ziziphora, was established for the first time with a simple, rapid and accurate method.

MATERIALS AND METHODS

HPLC analysis was done on a Waters system, equipped with 515 HPLC pump and waters 2996 photodiode array detector. The column was a Nova-Pak Silica (3.9 × 150 mm), and Empower software was used for the determination of the compounds and processing the data. The method was validated according to USP 32 requirements.

RESULTS

A SELECTIVE METHOD FOR THE RESOLUTION OF ISOMENTHONE FROM TWO NEAREST PEAKS, THYMOL, AND CARVACROL WAS OBTAINED WITH GRADIENT SYSTEM OF HEXANE (A), AND HEXANE: ethyl acetate (9:1) (B), starting with A: B (100:0) for 2 minutes, then 0-20% B in 5 minutes, A:B (80:20) for 5 minutes, then 20-30% B in 3 minutes, 30-100% B for 5 minutes, A:B (0:100) for 4 minutes following with equilibrating for 10 minutes. The flow rate was 1 mL/min at 22˚C and the injection volume for the standards and the samples was 20 μL. The retention time for isomenthone was found to be 7.45 minutes. The regression equation was y = 143235x - 2433 with the correlation co-factor R(2) = 0.9992 and the percent recovery of 65.4 ± 3.85%. The sample obtained from 5 g of Z. teniour dried powder in 6 mL extract was standardized to contain 1.14 ± 0.030 μL/mL isomenthone which is equivalent to % 1.37 μL/g of the dried powdered plant. Limit of detection (LOD) and Limit of Quantification (LOQ) were 0.037, and 0.122 µL/mL determined by using the formula based on the signal to noise ratio.

CONCLUSIONS

Due to this fact that plant extracts may cause irreversible damages to the capillary GC columns, using validated HPLC method for the analysis of these compounds in cruse plant extracts is recommended.