Quantification of Surgical Resident Stress “On Call”

A prospective observational study of sleep patterns and work-related communications during home call for a pediatric surgery fellow

Objective

A pediatric surgery fellow is often regarded as a cornerstone of an academic children's hospital due to the need for their clinical services with overnight coverage being an important aspect of the care provided. There is little known about the objective sleep patterns and work-related communications of a pediatric surgery fellow during overnight home call. The aim of this study is to better understand the sleep patterns and interruptions of an on-call pediatric surgery fellow.

Design

A prospective observational study of 60 call nights and 60 non-call nights of a pediatric surgery senior fellow was performed from September 2022 to February 2023.

Setting

An academic Children's Hospital.

Participant

An ACGME-accredited clinical pediatric surgery fellow.

Results

On average, the pediatric surgery fellow spent 6.9 and 5.8 total hours in bed and asleep each night, respectively. The total sleep time was less for call nights compared to non-call nights (5.4 versus 6.3 h, p < 0.0001). The mean number of work-related communications per 12-hour night shift was four. The majority of communications were regarding new consults (63.8 %). The pediatric surgery fellow spent an average of 5.9 min per communication and approximately 23.8 min total during each 12-hour night shift. Approximately half of these communications occurred during sleep hours.

Conclusions

This study reveals overall sleep duration was below recommended levels. There were significant alterations in sleep patterns during call nights. Work-related communications further compounded sleep disturbances. Further research and interventions in this area are warranted.

Extended-Duration Work Shifts in Surgical Specialties: A Systematic Review

INTRODUCTION

There has been widespread international implementation of duration-hour restrictions to prevent surgical resident burnout and promote patient safety and wellbeing of doctors. A variety of Extended-Duration Work Shifts (EDWS) have been implemented, with a variety of studies examining the effect of shift systems on both surgical performance and the stress response unestablished in the literature.

METHODS

This was a systematic review evaluating the impact of extended working hours on surgical performance, cognitive impairment, and physiological stress responses. The review used PubMed, Ovid Medline, Embase, and Google Scholar search engines between September and October 2021 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Filters including studies carried out after 2002 and published in the English language were applied.

RESULTS

In total, 30 studies were included for analysis. General surgery was the most commonly studied rotation, with Neurosurgical, Orthopedic, and ear, nose and throat specialties also included. The majority of studies found no difference or a significant improvement in post-EDWS on simulated performance. EDWS appeared to have the greatest impact on physiological stress markers in junior surgical trainees.

CONCLUSIONS

Experience appears to confer a protective element in the postcall period, with preservation of skill demonstrated. More experienced clinicians yielded lower levels of physiological markers of stress, although variability in hierarchical workload should be considered. Heterogeneity of findings across physiological, cognitive, and psychomotor assessments highlights the need for robust research on the optimum shift pattern prevents worker burnout and promotes patient safety. Future research to evaluate correlation between stress, on-call workload, and performance in the postcall period is warranted.

Routine Assessment of Surgical Resident Wellness-Related Concerns During Biannual Review

BACKGROUND

Surgery residency confers stress burdens on trainees. To monitor and mitigate areas of concerns, our education team implemented a 6-item biannual survey querying potential stressors. We reviewed the initial 5-year experience to assess for trends and improve efforts in maintaining resident well-being.

STUDY DESIGN

Surgery residents from all postgraduate years were asked to complete a survey of common concerns, prioritizing them in order of importance. The items to be ranked were: needs of family/friends; nonwork time for study; financial concerns; personal well-being needs; concerns for clinical performance; and administrative demands. Changes in ranking were trended across 10 review periods. Results were analyzed using a Kruskal-Wallis test.

RESULTS

A completion rate of 96.5% was rendered from the completion of 333 surveys. Rankings changed significantly for nonwork time for study (p = 0.04), personal well-being needs (p = 0.03) and concerns for clinical performance (p = 0.004). Nonwork time for study and concerns on clinical performance were consistently ranked as top two stressors over study period, except for spring 2020. Personal well-being needs ranked highest in spring 2020; 41% of residents placed this as top 2 rankings. A decrease in concerns for clinical performance was observed in spring 2020, corresponding to the coronavirus disease 2019 (COVID-19) pandemic emergency declaration.

CONCLUSIONS

Surgery residents generally prioritized time for study and concerns for assessment of clinical performance as highest areas of concern. With the occurrence of a pandemic, increased prioritization of personal well-being was observed. Used routinely with biannual reviews, the survey was able to identify plausible changes in resident concerns. Determination of levels of actual stress and actual association with the pandemic requires additional study.

Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature

Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.

Determining the Significant Kinematic Features for Characterizing Stress during Surgical Tasks Using Spatial Attention

It has been shown that intraoperative stress can have a negative effect on surgeon surgical skills during laparoscopic procedures. For novice surgeons, stressful conditions can lead to significantly higher velocity, acceleration, and jerk of the surgical instrument tips, resulting in faster but less smooth movements. However, it is still not clear which of these kinematic features (velocity, acceleration, or jerk) is the best marker for identifying the normal and stressed conditions. Therefore, in order to find the most significant kinematic feature that is affected by intraoperative stress, we implemented a spatial attention-based Long-Short-Term-Memory (LSTM) classifier. In a prior IRB approved experiment, we collected data from medical students performing an extended peg transfer task who were randomized into a control group and a group performing the task under external psychological stresses. In our prior work, we obtained "representative" normal or stressed movements from this dataset using kinematic data as the input. In this study, a spatial attention mechanism is used to describe the contribution of each kinematic feature to the classification of normal/stressed movements. We tested our classifier under Leave-One-User-Out (LOUO) cross-validation, and the classifier reached an overall accuracy of 77.11% for classifying "representative" normal and stressed movements using kinematic features as the input. More importantly, we also studied the spatial attention extracted from the proposed classifier. Velocity and acceleration on both sides had significantly higher attention for classifying a normal movement (p <= 0.0001); Velocity (p <= 0.015) and jerk (p <= 0.001) on non-dominant hand had significant higher attention for classifying a stressed movement, and it is worthy noting that the attention of jerk on non-dominant hand side had the largest increment when moving from describing normal movements to stressed movements (p = 0.0000). In general, we found that the jerk on non-dominant hand side can be used for characterizing the stressed movements for novice surgeons more effectively.

Frame-wise detection of surgeon stress levels during laparoscopic training using kinematic data

PURPOSE

Excessive stress experienced by the surgeon can have a negative effect on the surgeon's technical skills. The goal of this study is to evaluate and validate a deep learning framework for real-time detection of stressed surgical movements using kinematic data.

METHODS

30 medical students were recruited as the subjects to perform a modified peg transfer task and were randomized into two groups, a control group (n=15) and a stressed group (n=15) that completed the task under deteriorating, simulated stressful conditions. To classify stressed movements, we first developed an attention-based Long-Short-Term-Memory recurrent neural network (LSTM) trained to classify normal/stressed trials and obtain the contribution of each data frame to the stress level classification. Next, we extracted the important frames from each trial and used another LSTM network to implement the frame-wise classification of normal and stressed movements.

RESULTS

The classification between normal and stressed trials using attention-based LSTM model reached an overall accuracy of 75.86% under Leave-One-User-Out (LOUO) cross-validation. The second LSTM classifier was able to distinguish between the typical normal and stressed movement with an accuracy of 74.96% with an 8-second observation under LOUO. Finally, the normal and stressed movements in stressed trials could be classified with the accuracy of 68.18% with a 16-second observation under LOUO.

CONCLUSION

In this study, we extracted the movements which are more likely to be affected by stress and validated the feasibility of using LSTM and kinematic data for frame-wise detection of stress level during laparoscopic training. The proposed classifier could be potentially be integrated with robot-assisted surgery platforms for stress management purposes.

Identifying Kinematic Markers Associated with Intraoperative Stress during Surgical Training Tasks

Increased levels of stress can impair surgeon performance and patient safety during surgery. The aim of this study is to investigate the effect of short term stressors on laparoscopic performance through analysis of kinematic data. Thirty subjects were randomly assigned into two groups in this IRB-approved study. The control group was required to finish an extended-duration peg transfer task (6 minutes) using the FLS trainer while listening to normal simulated vital signs and while being observed by a silent moderator. The stressed group finished the same task but listened to a period of progressively deteriorating simulated patient vitals, as well as critical verbal feedback from the moderator, which culminated in 30 seconds of cardiac arrest and expiration of the simulated patient. For all subjects, video and position data using electromagnetic trackers mounted on the handles of the laparoscopic instruments were recorded. A statistical analysis comparing time-series velocity, acceleration, and jerk data, as well as path length and economy of volume was conducted. Clinical stressors lead to significantly higher velocity, acceleration, jerk, and path length as well as lower economy of volume. An objective evaluation score using a modified OSATS technique was also significantly worse for the stressed group than the control group. This study shows the potential feasibility and advantages of using the time-series kinematic data to identify the stressful conditions during laparoscopic surgery in near-real-time. This data could be useful in the design of future robot-assisted algorithms to reduce the unwanted effects of stress on surgical performance.

Stress level experienced by participants in realistic simulation: a systematic review

OBJECTIVES

to identify the available evidence regarding stress levels experienced by participants in education based on a realistic simulation.

METHODS

systematic review that included randomized clinic trials on electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Latin-American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus, and Web of Science. The additional search was performed on Google Scholar and OpenGrey. All searches occurred on September 24, 2020. The methodologic quality of the results was evaluated by the Cochrane Collaboration Risk of Bias Tool.

RESULTS

eighteen studies were included, which evaluated the participants' stress using physiologic, self-reported measures, or the combination of both. Stress as experienced in a high level in simulated scenarios.

CONCLUSIONS

evidence of the study included in this systematic review suggest that stress is experienced in a high level in simulated scenarios.

Emergency Medicine Residents Experience Acute Stress While Working in the Emergency Department

INTRODUCTION

Acute stress may impair cognitive performance and multitasking, both vital in the practice of emergency medicine (EM). Previous research has demonstrated that board-certified emergency physicians experience physiologic stress while working clinically. We sought to determine whether EM residents have a similar stress response, and hypothesized that residents experience acute stress while working clinically.

METHODS

We performed a prospective observational study of physiologic stress including heart rate (HR), heart rate variability (HRV), and subjective stress in EM residents during clinical shifts in the emergency department. HR and HRV were measured via 3-lead Holter monitors and compared to baseline data obtained during weekly educational didactics. Subjective stress was assessed before and after clinical shifts via a Likert-scale questionnaire and written comments.

RESULTS

We enrolled 21 residents and acquired data from 40 shifts. Residents experienced an increase in mean HR of eight beats per minute (P < 0.001) and decrease in HRV of 53.9 milliseconds (P = 0.005) while working clinically. Subjective stress increased during clinical work (P <0.001). HRV was negatively correlated with subjective stress, but this did not reach statistical significance (P = 0.09).

CONCLUSION

EM residents experience acute subjective and physiologic stress while working clinically. HR, HRV, and self-reported stress are feasible indicators to assess the acute stress response during residency training. These findings should be studied in a larger, more diverse cohort of residents and efforts made to identify characteristics that contribute to acute stress and to elicit targeted educational interventions to mitigate the acute stress response.

Dealing with the loss of a resident: An analysis of burnout rates in a reduced complement training program

BACKGROUND

Residents in all fields of medicine experience high levels of burnout and less job-related satisfaction due to the stress experienced during training. Reduced complement residency classes often experience increased workloads due to the need to compensate for the fewer number of classmates.

OBJECTIVE

The goal of this study was to examine whether residency classes of reduced size experience higher levels of burnout.

METHODS

The Maslach Burnout Inventory Survey was distributed to all orthopaedic residents at our institution for four consecutive years. Emotional exhaustion≥27 and depersonalization≥10 correlate with high levels of burnout. At our institution, two residents were lost during their second year of training. Group 1 (n = 56) consisted of residents with reduced-size classes, while group 2 (n = 60) consisted of residents with full complement classes.

RESULTS

Mean emotional exhaustion (29 vs. 30) and depersonalization (17 vs. 17) scores were comparable between reduced and full complement classes. The Maslach data from our study showed no statistical difference in burnout levels between classes of full complement and reduced complement.

CONCLUSIONS

When compared to a previous study on burnout conducted in large orthopaedic residency programs, our entire residency program did demonstrate similar levels of emotional exhaustion and depersonalization.

Acute stress in residents during emergency care: a study of personal and situational factors

Providing care for simulated emergency patients may induce considerable acute stress in physicians. However, the acute stress provoked in a real-life emergency room (ER) is not well known. Our aim was to assess acute stress responses in residents during real emergency care and investigate the related personal and situational factors. A cross-sectional observational study was carried out at an emergency department of a tertiary teaching hospital. All second-year internal medicine residents were invited to voluntarily participate in this study. Acute stress markers were assessed at baseline (T1), before residents started their ER shift, and immediately after an emergency situation (T2), using heart rate, systolic, and diastolic blood pressure, salivary α-amylase activity, salivary interleukin-1 β, and the State-Trait Anxiety Inventory (STAI-s and STAI-t). Twenty-four residents were assessed during 40 emergency situations. All stress markers presented a statistically significant increase between T1 and T2. IL-1 β presented the highest percent increase (141.0%, p < .001), followed by AA (99.0%, p = .002), HR (81.0%, p < .001), DBP (8.0%, p < .001), and SBP (3.0%, p < .001). In the multivariable analysis, time of residency had a negative correlation with HR during the emergency (adjusted R-square = .168; F = 8.69; p = .006), SBP response (adjusted R-square = .210; F = 6.19; p = .005) and DBP response (adjusted R-square = .293; F = 9.09; p = .001). Trait anxiety (STAI-t) was positively correlated with STAI-s (adjusted R-square = .326; F = 19.9; p < .001), and number of procedures performed during emergency care had a positive association with HR response (adjusted R-square = .241; F = 5.02; p = .005). In the present study, emergency care provoked substantial acute stress in residents. Resident experience, trait anxiety, and number of emergency procedures were independently associated with acute stress response.

The significant impact of a competency-based preparatory course for senior medical students entering surgical residency

PURPOSE

Previous data suggest that formal, structured preparation might improve knowledge and skills of senior medical students (SMSs) as they transition to surgical residency. However, subsequent impact on clinical performance has not been demonstrated.

METHOD

The authors developed a comprehensive course for SMSs entering surgical residencies and studied the impact of the course on the subsequent performance of 2010 graduates (n = 22) compared with matched peers (16 nonparticipant controls at authors' home institution and 24 nonparticipant peer controls at outside institutions; total n = 62). Through pre- and postcourse surveys, knowledge tests, and technical examinations, they measured confidence and skill acquisition in 32 specific, job-related tasks. They followed participants and matched peers into internship and collected performance evaluations from supervising senior residents to determine whether course graduates would display performance advantages in these same tasks. The authors used t tests for all comparisons, α = 0.05.

RESULTS

Participants demonstrated marked improvement in task-specific confidence in all 32 tasks from course beginning to end, with improved scores on written and technical skill examinations. Further, course participants outperformed peers in all 32 tasks in July, with their performance advantage predictably dissipating into the third month of residency. There was a marked correlation between confidence and competence in all tasks.

CONCLUSIONS

Competency-based preparation for surgical internship resulted in objective gains in task-specific confidence and test performance at course conclusion, translating to improved performance and better patient care upon residency matriculation. These data emphasize the significant impact of formally preparing SMSs before graduation.

Conscious monitoring and control (reinvestment) in surgical performance under pressure

Background

Research on intraoperative stressors has focused on external factors without considering individual differences in the ability to cope with stress. One individual difference that is implicated in adverse effects of stress on performance is “reinvestment,” the propensity for conscious monitoring and control of movements. The aim of this study was to examine the impact of reinvestment on laparoscopic performance under time pressure.

Methods

Thirty-one medical students (surgery rotation) were divided into high- and low-reinvestment groups. Participants were first trained to proficiency on a peg transfer task and then tested on the same task in a control and time pressure condition. Outcome measures included generic performance and process measures. Stress levels were assessed using heart rate and the State Trait Anxiety Inventory (STAI).

Results

High and low reinvestors demonstrated increased anxiety levels from control to time pressure conditions as indicated by their STAI scores, although no differences in heart rate were found. Low reinvestors performed significantly faster when under time pressure, whereas high reinvestors showed no change in performance times. Low reinvestors tended to display greater performance efficiency (shorter path lengths, fewer hand movements) than high reinvestors.

Conclusion

Trained medical students with a high individual propensity to consciously monitor and control their movements (high reinvestors) displayed less capability (than low reinvestors) to meet the demands imposed by time pressure during a laparoscopic task. The finding implies that the propensity for reinvestment may have a moderating effect on laparoscopic performance under time pressure.

Apprenticeships ease the transition to independent call: an evaluation of anxiety and confidence among junior radiology residents

RATIONALE AND OBJECTIVES

The aims of this study were to quantify resident anxiety when beginning independent call and to assess whether an apprenticeship experience (buddy call) can lessen anxiety and improve confidence.

MATERIALS AND METHODS

A prospective cohort comparison of two groups of radiology residents beginning independent call, one of which was provided with a buddy call experience, was performed. Anxiety and confidence were assessed using the Endler Multidimensional Anxiety Scales-State (EMAS-S), with total score, autonomic emotional, and cognitive worry components, and a five-point, Likert-type scale, respectively. Both groups were asked about the perceived value of a buddy call experience.

RESULTS

EMAS-S scores improved significantly over 5 days of call in both groups (control, n = 10, P = .0005; buddy call, n = 9, P = .0001), and image interpretation confidence correspondingly increased (control, P = .0004; buddy call, P = .003). Compared to the control group, autonomic emotional scores were significantly lower in the buddy call group on the first day of independent call (P = .040), and cognitive worry and total EMAS-S scores were significantly lower on day 5 (both P values = .03). Buddy call was independently associated with improved autonomic emotional and film interpretation confidence scores (both P values = .02). All members of the buddy call group indicated that the experience was very helpful in preparing for call.

CONCLUSIONS

Beginning independent call is associated with high anxiety, and buddy call reduces that anxiety, beyond the effect of time alone. Residents who participated in buddy call found it helpful in preparing for independent call. These findings support the use of buddy call and tiered call structures as means to introduce junior residents to independent call.

On-call emergency workload of a general surgical team

Background:

To examine the on-call emergency workload of a general surgical team at a tertiary care teaching hospital to guide planning and provision of better surgical services.

Patients and Methods:

During six months period from August to January 2007; all emergency calls attended by general surgical team of Surgical Unit II in Accident and Emergency department (A and E) and in other units of Civil, Hospital Karachi, Pakistan were prospectively recorded. Data recorded includes timing of call, diagnosis, operation performed and outcome apart from demography.

Results:

Total 456 patients (326 males and 130 females) were attended by on-call general surgery team during 30 emergency days. Most of the calls, 191 (41.9%) were received from 8 am to 5 pm. 224 (49.1%) calls were of abdominal pain, with acute appendicitis being the most common specific pathology in 41 (9.0%) patients. Total 73 (16.0%) calls were received for trauma. Total 131 (28.7%) patients were admitted in the surgical unit for urgent operation or observation while 212 (46.5%) patients were discharged from A and E. 92 (20.1%) patients were referred to other units with medical referral accounts for 45 (9.8%) patients. Total 104 (22.8%) emergency surgeries were done and the most common procedure performed was appendicectomy in 34 (32.7%) patients.

Conclusion:

Major workload of on-call surgical emergency team is dealing with the acute conditions of abdomen. However, significant proportion of patients are suffering from other conditions including trauma that require a holistic approach to care and a wide range of skills and experience. These results have important implications in future healthcare planning and for the better training of general surgical residents.

Use of simulated pages to prepare medical students for internship and improve patient safety

PURPOSE

During the transition from medical school to internship, trainees experience high levels of stress related to pages on the inpatient wards. The steep learning curve during this period may also affect patient safety. The authors piloted the use of simulated pages to improve medical student preparedness, decrease stress related to pages, and familiarize medical students with common patient problems.

METHOD

A multidisciplinary team at Southern Illinois University School of Medicine developed simulated pages that were tested among senior medical students. Sixteen medical students were presented with 11 common patient scenarios. Data on assessment, management, and global performance were collected. Mean confidence levels were evaluated pre- and postintervention. Students were also surveyed on how the simulated pages program influenced their perceived comfort in managing patient care needs and the usefulness of the exercise in preparing them to handle inpatient pages.

RESULTS

Mean scores on the assessment and management portions of the scenarios varied widely depending on the scenario (range -15.6 ± 41.6 to 95.7 ± 9.5). Pass rates based on global performance ranged from 12% to 93%. Interrater agreement was high (mean kappa = 0.88). Students' confidence ratings on a six-point scale increased from 1.87 preintervention to 3.53 postintervention (P < .0001).

CONCLUSIONS

Simulated pages engage medical students and may foster medical student preparedness for internship. Students valued the opportunity to simulate "on call" responsibilities, and exposure to simulated pages significantly increased their confidence levels. Further studies are needed to determine effects on patient safety outcomes.

Improving surgery intern confidence through the implementation of expanded orientation sessions

BACKGROUND

New surgical interns may be unprepared for job-related tasks and harbor anxiety that could interfere with job performance. To address these problems, we extended our intern orientation with the principal aim of demonstrating the need for expanded instruction on execution of daily tasks. Additionally, we sought to show that an enriched orientation curriculum durably augments intern confidence.

METHODS

Twenty-one surgical interns participated in an extended orientation program, consisting of interactive didactics, case scenario presentations, and small group discussions. Evaluations collected at completion of orientation and 1-month follow-up assessed self-reported confidence levels on job-related tasks before, immediately afterward, and 1-month after orientation. Statistical analyses were performed using Student t tests (P < .05 significant).

RESULTS

Self-reports of confidence on job-related tasks before the orientation sessions were low; however, program participation resulted in immediate confidence increases in all areas. Evaluations at 1-month follow-up showed persistence of these gains.

CONCLUSION

Interns reported considerable anxiety in all job-related tasks before orientation. After the sessions, confidence levels were significantly and durably improved in all areas. Our findings suggest the need for specific instruction on job-related tasks of surgical internship and demonstrate the effectiveness of an expanded orientation in improving intern confidence in execution of these tasks.

Using the clinical challenges encountered by junior residents to inform curriculum for paediatric pre-intern students

AIM

To develop and evaluate a novel skills-based education programme for medical students completing a paediatric pre-internship (PrInt) at the Children's Hospital at Westmead (CHW), Sydney which incorporated a mini-clinical evaluation exercise style formative assessment component and was based upon a local needs assessment of junior staff.

METHODS

We designed a teaching programme which included four interactive tutorials and formative assessment tasks using observed clinical exercises (OCE). The final programme was informed by a local need-based assessment of out-of-hours junior doctors' tasks. Students rated their level of confidence prior to and after the tutorial and following the OCE. Students provided structured and free text feedback on the programme.

RESULTS

Of 29 PrInt students (2007-2008), with collectively 85 tutorial attendances, 84% rated the programme excellent (39%) or very good (45%). For each topic students' confidence increased after the tutorial and again after the OCE (P < 0.001). Improvement was most marked for skills for which students rated themselves pre-teaching as having poor confidence (pain management and calculation of rehydration fluids). Overall, the proportion with 'high' confidence increased from 8.2% pre-tutorial to 38.8% post-tutorial and 72.9% post-OCE (P < 0.001). Competence in skills was assessed by OCE and all students achieved scores of >90%. Diaries from junior doctors during 20 shifts at the CHW recorded 398 out-of-hours activities, the most common of which are ordering intravenous fluids (19.6%), reviewing asthmatics (16.6%) and recharting medications (16.3%).

CONCLUSION

PrInt students value structured teaching incorporating OCE, which allows assessment of clinical skills and direct formative feedback and promotes gains in confidence, knowledge and skills. Addition of OCE to the teaching programme significantly increased the confidence of PrInt students in performing specific tasks compared with an educational session alone. Local needs assessment of junior doctors by out-of-hours survey both confirmed selection of appropriate topics (pain, fluids) and informed additional topics (asthma management and bronchodilator weaning regime) for future PrInt student programmes.

The effects of stress and coping on surgical performance during simulations

OBJECTIVE

This study investigates the effects of surgeons' stress levels and coping strategies on surgical performance during simulated operations.

METHODS

Thirty surgeons carried out each a non-crisis and a crisis scenario of a simulated operation. Surgeons' stress levels were assessed by several measures: self-assessments and observer ratings of stress, heart rate, heart rate variability, and salivary cortisol. Coping strategies were explored qualitatively and quantified to a coping score. Experience in surgery was included as an additional predictor. Outcome measures consisted of technical surgical skills using Objective Structured Assessment of Technical Skill (OSATS), nontechnical surgical skills using Observational Teamwork Assessment for Surgery (OTAS), and the quality of the operative end product using End Product Assessment (EPA). Uni- and multivariate linear regression were used to assess the independent effects of predictor variables on each performance measure.

RESULTS

During the non-crisis simulation, a high coping score and experience significantly enhanced EPA (beta1, 0.279; 0.009-0.460; P= 0.04; beta2, 0.571; 4.328-12.669, P< 0.001; respectively). During the crisis simulation, a significant beneficial effect of the interaction of high experience and low stress on all performance measures was found (EPA: beta, 0.537; 2.079-8.543; OSATS: beta, 0.707; 8.708-17.860; OTAS: beta, 0.654; 13.090-30.483; P< 0.01). Coping significantly enhanced nontechnical skills (beta, 0.302; 0.117-1.624, P= 0.03).

CONCLUSIONS

Clinicians' stress and coping influenced surgical performance during simulated operations. Hence, these are critical factors for the quality of health care.

The impact of stress on surgical performance: a systematic review of the literature

BACKGROUND

Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance.

METHODS

A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers.

RESULTS

In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making).

CONCLUSION

Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.

Protected educational rotations: a valuable paradigm shift in surgical internship

OBJECTIVE

The first year of surgical training sometimes includes marginally educational or service-related tasks with limited direct interactions with faculty. We instituted a prototype rotation to address the changing needs and expectations of our intern class. This study was designed to evaluate the new rotation 17 months after it was implemented.

DESIGN

Interns spend 4 weeks in our outpatient surgery center. Elements of the rotation include performance of operative cases and perioperative management of outpatients under direct faculty supervision, daily one-on-one structured teaching sessions with faculty, and call coverage twice monthly. At the conclusion of the rotation, interns make a presentation on a topic of their choosing to a teaching conference. Rotation evaluations and case and work-hour logs for the outpatient surgery rotation (OSR) were compared with those for the remaining intern rotations combined. A faculty survey of the OSR also was conducted.

RESULTS

The OSR consistently received maximum overall ratings (4 of 4), significantly higher than the average overall score for the remaining rotations (3.17, p < 0.01). Similarly, teaching by faculty, time spent in the operating room, and quality of operating room time were rated significantly higher than for the other intern rotations (p </= 0.05). Interns performed an average of 44 cases in 4 weeks of OSR, compared with an average of 94 in the remaining rotations (p < 0.001), and they worked an average of 62 hours per week (range, 49-76 hours). Of the participating faculty, 93% reported that the interaction gave them the opportunity to know the interns better at a personal level, that the sessions were beneficial and improved working relationships with interns, and that the program should continue.

CONCLUSIONS

Changing program requirements, time restrictions, public scrutiny, and increasing awareness for quality of life all obligate a paradigm shift in surgical education. Our outpatient rotation is logistically simple and rewarding both for residents and faculty.

Perceptions of stress among pathology residents: survey results and some strategies to reduce them

We conducted a survey to attempt to identify stressors perceived by pathology residents. A comparison of survey results from pathology residents with stressors perceived by residents in other specialties was done to evaluate whether the stressors in pathology are unique. A confidential e-mail survey of residency programs in the United States generated a response rate from program directors of 23.3% and a resident response rate of 6.4%. Although the study is limited by response rates and the data are primarily from university-based residency programs, the concordance between the identifiable risk factors for stress by the resident and program director groups validates the importance of this issue among pathology residency programs. Both groups identified variability in faculty expectations and work overload that inhibits optimal learning as the top 2 stressors for residents. We discuss various factors that contribute to stress and some strategies that pathology residency programs can implement to address the stressors.