A longitudinal cadaver-based simulation curriculum creates sustainable increases in resident confidence and exposure to fundamental techniques: Results of a 5-year program evaluation

Cadaveric analysis of surgical techniques and working space for retroperitoneal tumors as model for improving resection of neuroblastoma

PURPOSE

Neuroblastoma, the most common extracranial solid tumor in children under 5 years, often surrounds visceral arteries. This study aimed to analyze the working space provided by standardized surgical techniques at key arterial landmarks in adult cadavers.

METHODS

We assessed in eight adult cadavers the mobilization of the left colon, spleen and pancreas, right colon, duodenum and mesenteric root, access to the bursa omentalis. The average working space score (AWSS) was evaluated at the left and right renal artery, left and right side of the coeliac trunk, superior mesenteric and common hepatic artery. The score was defined as: (0) vessel not visible, (1) working space at the vessel ≤ 1x diameter of the aorta, (2) < 3x the diameter of the aorta, (3) ≥ 3x diameter of the aorta.

RESULTS

The maximum AWSS of 3 was achieved at key vascular landmarks through specific mobilization techniques.

CONCLUSION

Additional mobilization of spleen, pancreas and mesenteric root and access to the bursa omentalis increase surgical working space at major visceral arteries. The results of our investigation provide surgeons with a useful guide to prepare for abdominal neuroblastoma resection.

Use of Simulation For Training Advanced Colorectal Procedures

OBJECTIVE

Simulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC).

DESIGN

LLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses.

SETTING

Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri.

PARTICIPANTS

Senior general surgery residents at large academic surgery program.

RESULTS

Fifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts.

CONCLUSIONS

Surgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

Investigating First Year Surgery Residents' Expectations of Demand, Control, and Support During Training

OBJECTIVE

To provide a more granular understanding of the expectations of general surgery interns regarding workplace demand, control, and support prior to starting training.

SUMMARY/BACKGROUND DATA

General surgery (GS) interns are at highest risk for burnout and attrition. Maslach frames burnout as resulting from a mismatch between workplace expectations and reality. Occupational science demonstrates workplace demand, control, and support (DCS) as strong influencers of job strain. GS interns' realistic expectations of demands are associated with decreased likelihood of attrition, but their expectations regarding this factor are poorly understood.

METHODS

Semi-structured interviews were conducted with 14 incoming surgical residents at UCSF: University of California, San Francisco (57% women, 71% non-White), exploring expectations regarding workplace DCS. Transcripts were uploaded to analytic software and coded in dyads using an iterative approach to consensus. Transcripts were thematically analyzed using inductive and deductive reasoning, applying job-demand-resource theory frameworks, and following a published 6-step approach.

RESULTS

Four main themes emerged: past experiences, expected rewards, anticipated challenges, and the desire to belong. Past experiences describes the expectation to successfully cope with future stressors via self-reliance. Rewards such as professional mastery, personal growth, and sense of meaning were expected outcomes seen as balancing anticipated challenges. Anticipated challenges included low control, toxic cultural elements, and discrimination. Desire to belong (i.e., earned recognition as a peer, inclusion in an elite culture) emerged as a powerful motivator, with survival connotations for women and non-Whites.

CONCLUSION

Our results suggest incoming interns overestimate the efficacy of self-reliance for coping; count on specific rewards; express realistic expectations regarding challenges; and see inclusion among surgeons as an aspiration that off-sets prolonged effort. Further study is warranted to understand expectation-reality mismatch and potential interventions to target dissonance.

MINI-ABSTRACT

In this institutional study of general surgery interns, we provide a more granular understanding of the expectations of general surgery interns regarding workplace demand, control, and support prior to starting training, and how we might target "expectations-reality" mismatch and the "desire to belong" as a means of mitigating burnout and minimizing attrition from training.

Inducing a Closed Ankle Fracture in a Cadaveric Model to Create Interdisciplinary Teaching Models for Preclinical Medical Students

This paper describes a cost-effective fracture simulation that aids in preclinical learning of fracture identification. This project establishes feasibility of inducing closed fractures in a donated cadaver. The study team made an identified Weber C ankle fracture in this donor, maintaining the soft tissue envelope surrounding the fracture, using minimal materials in a stepwise process that will be reproducible across educational programs regardless of access to highly specialized equipment. The resulting fracture can be used to help students identify fractures during their preclinical education and has demonstrated educational potential for future use and adaptation.

Advancing Urology Resident Surgical Autonomy

PURPOSE OF REVIEW

This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy.

RECENT FINDINGS

Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.

Negotiating humanity: an ethnography of cadaver-based simulation

Human body donation (HBD) serves an essential function in many medical schools, particularly in institutions where people engage in cadaver-based simulation (CBS) as a pedagogical approach. The people who facilitate HBD and CBS have a highly specialized skill set, yet their expertise remains largely unacknowledged, and takes place out of sight from the broader medical school community. This manuscript, based on a two-year practice-based ethnography (Structured Observations n = 68 h, Unstructured Observations n = 150 + hours; Interviews n = 24; and Document/Policy Analysis n = 14) illuminates the complex work of HBD. We identify three primary functions of HBD and CBS (1. Cadaver Intake & Administration, 2. Cadaver Preparation, and 3. Cadaver-Based Pedagogy). We describe how medical educators involved in CBS have developed a skillset specific to their role: negotiating humanity.

How We Do It: Remediation Pathways in a Surgical Simulation Curriculum for Competency Improvement

OBJECTIVE

Validated assessment of procedural knowledge and skills with formative remediation is a foundational part of achieving surgical competency. High-fidelity simulation programs provide a unique area to assess resident proficiency and independence, as well as to assist in identifying residents in need of further practice. While several studies have validated the use of simulation to attain proficiency of specific technical skills, few have validated remediation pathways for their trainees objectively. In this descriptive analysis, we review 2 remediation pathways within our simulation training curricula and how these are used in assessments of resident proficiency.

MATERIALS AND METHODS

Two methods of remediation were formulated for use in high-fidelity simulation labs. One remediation pathway was a summative process, where ultimate judgment of resident competency was assessed through intra-operative assessments of a holistic skill set. The second remediation pathway was a formative "coaching" process, where feedback is given at several intervals along the pathway towards a specific technical skills competence. All general surgery residents are enrolled in the longitudinal, simulation curricula.

RESULTS

Approximately one-third of surgical residents entered into a remediation pathway for either of the high-fidelity simulation curricula. Both residents and faculty expressed support for the summative and formative remediation pathways as constructed. Residents who entered remediation pathways believed it was a beneficial exercise, and the most common feedback was that remediation principles should be expanded to all residents. Interestingly, faculty demonstrated stronger support for the formative coaching feedback model than the summative assessment model.

CONCLUSIONS

Through the complementary use of both formative and summative remediation pathways, resident competence can be enriched in a constructive, nonpunitive method for self-directed performance improvement. Both trainees and faculty express high satisfaction with programs explicitly organized to ensure that skills are rated through a standardized process.

Evolving anatomy education strategies for surgical residents: A scoping review

INTRODUCTION

Dedicated anatomy educational time in medical schools has decreased significantly, disproportionately affecting surgical residents. In this scoping review, we aim to consolidate existing evidence, describe ongoing research, and highlight future directions for surgical anatomy education.

METHODS

Two independent investigators searched MEDLINE, EMBASE, and the Cochrane library, for educational interventions targeting anatomy knowledge in surgical residents. English articles until October 28, 2021, were reviewed.

RESULTS

1135 abstracts were considered, and 59 (5.2%) included. Agreement on inclusion was excellent (k = 0.90). The majority were single-cohort studies (53%) and prospective cohort studies (17%). The most common disciplines were General Surgery (17%) and Obstetrics and Gynecology (17%).

DISCUSSION

Cadavers consistently produce positive knowledge gains and are heavily favored by residents. They remain the educational method to which new educational models are compared. New technologies do not yet match cadaver fidelity. Research showing knowledge translation from cadaver labs to patient outcomes remains limited.