Self-monitoring in Surgical Practice: Slowing Down When You Should. In: Fry H, Kneebone R, editors. Surgical Education. Dordrecht: Springer Netherlands; 2011. pp. 169-82. [DOI: 10.1007/978-94-007-1682-7_10]

The medical pause: Importance, processes and training

Research has shown that taking 'timeouts' in medical practice improves performance and patient safety. However, the benefits of taking timeouts, or pausing, are not sufficiently acknowledged in workplaces and training programmes. To promote this acknowledgement, we suggest a systematic conceptualisation of the medical pause, focusing on its importance, processes and implementation in training programmes. By employing insights from educational and cognitive psychology, we first identified pausing as an important skill to interrupt negative momentum and bolster learning. Subsequently, we categorised constituent cognitive processes for pausing skills into two phases: the decision-making phase (determining when and how to take pauses) and the executive phase (applying relaxation or reflection during pauses). We present a model that describes how relaxation and reflection during pauses can optimise cognitive load in performance. Several strategies to implement pause training in medical curricula are proposed: intertwining pause training with training of primary skills, providing second-order scaffolding through shared control and employing auxiliary tools such as computer-based simulations with a pause function.

Use of a Novel Measure of Nontechnical Skills in Surgical Trainees: Is There an Association With Technical Skills Performance?

OBJECTIVE

To investigate whether scores on a psychological measure of concentration and interpersonal characteristics, The Attentional and Interpersonal Style Inventory (TAIS), are associated with performance of surgical skills.

DESIGN

Postgraduate surgical trainees completed an operative surgical skills assessment in the simulation laboratory and the psychological measure (TAIS). The surgical skills assessment consisted of 6 tasks (3 per trainee): laceration suturing; lipoma excision; incision and closure of a laparotomy wound; bowel anastomosis; saphenofemoral junction ligation and basic laparoscopic skills. The association between operative surgical skill performance and TAIS factors was investigated.

SETTING

The TAIS assessments and surgical skills assessments were conducted at the National Surgical Training Centre at the Royal College of Surgeons in Ireland (RCSI).

PARTICIPANTS

One hundred and two surgical trainees in years one and two (PGY 2-3 equivalent) participated in the study.

RESULTS

Performance on 2 of the 6 tasks assessed (bowel anastomosis and lipoma excision) were positively associated with multiple TAIS factors (energy, confidence, competitiveness, extroversion, self-criticism and performing under pressure). Another factor, focus over time, was significantly associated with scores on the lipoma excision task.

CONCLUSIONS

Trainees with high levels of energy, confidence, competitiveness, extroversion, and focus over time and low levels of self-criticism demonstrated better performance on specific technical skills tasks.

Mental imagery and learning: a qualitative study in orthopaedic trauma surgery

CONTEXT

Good preparation for surgical procedures has been linked to better performance and enhanced learning in the operating theatre. Mental imagery is increasingly used to enhance performance in competitive sport and there has been recent interest in applying this in surgery.

OBJECTIVES

This study aims to identify the mental imagery components of preoperative preparation in orthopaedic trauma surgery and to locate these practices in existing socio-material theory in order to produce a model useful for surgical skills training.

METHODS

Semi-structured interviews were conducted with nine orthopaedic surgeons. Participants were identified by personal recommendation as regularly performing complex trauma operations to a high standard, and by affiliation to an international instruction course in trauma surgery. Interviews were audio-recorded and transcripts were independently analysed using thematic analysis.

RESULTS

Analysis revealed that surgeons interact intensively with multiple colleagues and materials during their preparatory activities. Such interactions stimulate mental imagery in order to build strategy and rehearse procedures, which, in turn, stimulate preparatory interactions. Participants identified the discussion of a preoperative 'plan' as a key engagement tool for training junior surgeons and as a form of currency by which a trainee may increase his or her participation in a procedure.

CONCLUSIONS

Preoperative preparation can be thought of as a socio-material ontology requiring a surgeon to negotiate imaginal, verbal and physical interactions with people, materials and his or her own mental imagery. Actor-network theory is useful for making sense of these interactions and for allowing surgeons to interrogate their own preparative processes. We recommend supervisors to use a form of preoperative plan as a teaching tool and to encourage trainees to develop their own preparatory skills. The ability of a trainee to demonstrate sound preparation is an indicator of readiness to perform a procedure.

Reconceptualizing variable rater assessments as both an educational and clinical care problem

The public is calling for the U.S. health care and medical education system to be accountable for ensuring high-quality, safe, effective, patient-centered care. As medical education shifts to a competency-based training paradigm, clinician educators' assessment of and feedback to trainees about their developing clinical skills becomes paramount. However, there is substantial variability in the accuracy, reliability, and validity of the assessments faculty make when they directly observe trainees with patients. These difficulties have been treated primarily as a rater cognition problem focusing on the inability of the assessor to make reliable and valid assessments of the trainee.The authors' purpose is to reconceptualize the rater cognition problem as both an educational and clinical care problem. The variable quality of faculty assessments is not just a psychometric predicament but also an issue that has implications for decisions regarding trainee supervision and the delivery of quality patient care. The authors suggest that the frame of reference for rating performance during workplace-based assessments be the ability to provide safe, effective, patient-centered care. The authors developed the Accountable Assessment for Quality Care and Supervision equation to remind faculty that supervision is a dynamic, complex process essential for patients to receive high-quality care. This fundamental shift in how assessment is conceptualized requires new models of faculty development and emphasizes the essential and irreplaceable importance of the clinician educator in trainee assessment.

What Is Shared in Shared Decision Making? Complex Decisions When the Evidence Is Unclear

Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients’ preferences fully, and/or patients are unclear about their desired level of involvement. In these situations, preferences are shaped by affect, framing, and “collaborative cognition” among clinicians, patients, and their families; thus, decisions are often relational, dynamic, iterative, provisional, and/or conditional. Clinicians can help patients achieve greater autonomy by engaging both intuitive and deliberative decision-making processes (“whole mind”) and involving others in exploring, clarifying, and co-constructing patients’ preferences (“shared mind”). Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.