Training surgical residents: the current Canadian perspective

Procedure-specific simulation for vaginal surgery training: A randomized controlled trial

INTRODUCTION

Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence.

MATERIAL AND METHODS

We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05).

CLINICALTRIALS

gov: Registration no. NCT05887570.

RESULTS

We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups.

CONCLUSIONS

Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Motivation to access laparoscopic skills training: Results of a Canadian survey of obstetrics and gynecology residents

Objective

Competency based medical education (CBME) requires novel approaches to surgical education. Significant investment has been made in laparoscopic simulation, which has been shown to foster skill development prior to patient encounters. However, research suggests variable voluntary use of these resources by residents, and little is known about the motivational factors that influence their utilization. The purpose of this study was to characterize factors that motivate residents to seek laparoscopic simulation experience outside of the formal curriculum.

Design

We developed a questionnaire grounded in Expectancy Value Theory, an established psychological theory of motivation, by adapting validated measures to fit the study context. We conducted a cross sectional survey of Canadian obstetrics and gynecology residents.

Setting

We invited residents enrolled in English-language obstetrics and gynecology training programs in Canada to participate.

Participants

All residents engaged in clinical duties during Winter 2018 were invited to complete the questionnaire. Forty-four Obstetrics and Gynecology (Ob/Gyn) residents participated in the study.

Results

Residents reported limited use of simulation resources and identified multiple barriers including lack of time, access, and supervision. They expressed concern about development of bad habits during independent practice, and simulation use was positively correlated with perceived utility. Compared to junior residents, senior residents reported greater enjoyment of laparoscopic surgery, less emotional costs, and higher self-efficacy for learning laparoscopy.

Conclusions

Residents’ perception of utility and barriers impede voluntary simulation use and overall use was limited. As programs undertake curricula redevelopment for CBME, mitigating barriers and improving perceived utility of laparoscopic simulation is vital to increase use and enhance skill development.

ASPiH standards for simulation-based education: process of consultation, design and implementation

There is widespread enthusiasm and emerging evidence of the efficacy of simulation-based education (SBE) but the full potential of SBE has not been explored. The Association for Simulated Practice in Healthcare (ASPiH) is a not-for-profit membership association with members from healthcare, education and patient safety background. ASPiH's National Simulation Development Project in 2012 identified the lack of standardisation in the approach to SBE with failure to adopt best practice in design and delivery of SBE programmes. ASPiH created a standards project team in 2015 to address this need. The article describes the iterative process modelled on implementation science framework, spread over six stages and 2 years that resulted in the creation of the standards. The consultation process supported by Health Education England resulted in a unique document that was driven by front line providers while also having strong foundations in evidence base. The final ASPiH document consisting of 21 standards for SBE has been extensively mapped to regulatory and professional bodies in the UK and abroad ensuring that the document is relevant to a wide healthcare audience. Underpinning the standards is a detailed guidance document that summarises the key literature evidence to support the standard statements. It is envisaged the standards will be widely used by the simulation community for quality assurance and improving the standard of SBE delivered.

Plastic Surgery Inclusion in the Undergraduate Medical Curriculum: Perception, Challenges, and Career Choice-A Comparative Study

OBJECTIVE

The undergraduate medical curriculum has been overcrowded with core learning outcomes with no formal exposure to plastic surgery. The aim of this study was to compare medical students from two educational settings for the basic understanding, preferred learning method, and factors influencing a career choice in plastic surgery.

DESIGN AND SETTING

A prospective cohort study based on a web-based anonymous questionnaire sent to final year medical students at Birmingham University (United Kingdom), McGill University (Canada), and a control group (non-medical staff). The questions were about plastic surgery: (1) source of information and basic understanding; (2) undergraduate curriculum inclusion and preferred learning methods; (3) factors influencing a career choice. A similar questionnaire was sent to non-medical staff (control group). The data was analysed based on categorical outcomes (Chi-square χ2) and level of significance p ≤ 0.05.

RESULTS

Questionnaire was analysed for 243 students (Birmingham, n = 171/332, 52%) (McGill n = 72/132, 54%). Birmingham students (14%) considered the word "plastic" synonymous with "cosmetic" more than McGill students (4%, p < 0.025). Teaching was the main source of knowledge for McGill students (39%, p < 0.001) while Birmingham students and control group chose the media (70%, p < 0.001). McGill students (67%) more than Birmingham (49%, p < 0.010) considered curriculum inclusion. The preferred learning method was lectures for McGill students (61%, p < 0.01) but an optional module for Birmingham (61%). A similar proportion (18%) from both student groups considered a career in plastic surgery.

CONCLUSIONS

Medical students recognised the need for plastic surgery inclusion in the undergraduate curriculum. There was a difference for plastic surgery source of information, operations, and preferred method of learning for students. The study highlighted the urgent need to reform plastic surgery undergraduate teaching in collaboration with national educational bodies worldwide.

Balancing the Needs of Patients and Learners in Surgery

In this commentary, we explore the need for academic physicians to balance the needs of their patients and of learners during surgery. We approach this discussion from the perspective of the duty of care to the patient and reflect on methods to respect this duty of care but still maximize the educational experience of the learner without jeopardizing the patient's health. We also identify pedagogical methods to facilitate this balance, both in routine situations and during unforeseen events.

Design and implementation of the 2012 Canadian shoulder course for senior orthopedic residents

BACKGROUND

The objective of the present paper is to analyze the first edition of a comprehensive shoulder course for senior orthopedic surgery residents and the chosen evaluation tools.

HYPOTHESIS

A course focusing on shoulder surgery, requested by graduating residents in orthopedic surgery, will have a strong level of satisfaction and help improve skills, knowledge, and problem solving abilities in this domain as measured by a pre and post-test.

MATERIAL AND METHODS

A two-day course was created with practical sessions, lectures, and case studies. Participants were given a multiple choice pre and post course test and evaluation questionnaires after each session.

RESULTS

Sixty residents attended the course. Nine of the fifteen sessions scored above the 90% satisfaction cut-off; none of the sessions scored below 80%. However, only one question showed a statistically significant improvement after the course.

DISCUSSION

Response to this course was overwhelmingly positive and the sessions received positive evaluations. However, the method to evaluate residents was not adequate; residents reported learning on their freeform evaluations but this was not represented on the multiple choice evaluation method. Evaluation tools and course duration will be modified in future iterations to improve assessment and teaching.

LEVEL OF EVIDENCE

IV.

STUDY DESIGN

Observational.

Surgical Simulation and Competency

Simulation in surgical training is playing an increasingly important role as postgraduate medical education programs navigate an environment of increasing costs of education, increased attention on patient safety, and new duty hour restrictions. In obstetrics and gynecology, simulation has been used to teach many procedures; however, it lacks a standardized curriculum. Several different simulators exist for teaching various routes and aspects of hysterectomy. This article describes how a formal framework of increasing levels of competencies can be applied to simulation in teaching the procedure of hysterectomy.

Teaching Vaginal Surgery to Junior Residents: Initial Validation of 3 Novel Procedure-Specific Low-Fidelity Models

OBJECTIVE

Competency-based surgical education relies on operative models to teach surgical skills within a curriculum. Low fidelity simulation has been shown to improve surgical performance. Our objectives were: to develop procedure-specific models to teach anterior repair (AR), posterior repair (PR), and vaginal hysterectomy (VH) to junior residents; to establish model reliability and validity.

DESIGN

Residents were randomized to control (no training) and intervention (model training) groups. They were filmed while performing a series of tasks. Experts were also filmed. Each video was scored by 2 blinded raters.

SETTING

Multicenter collaboration within the Western Society of Pelvic Medicine (Vancouver, Calgary, and Edmonton). Face and content validity were evaluated. A standard scoring tool was developed for performance evaluation. Interrater reliability was assessed using intraclass correlation coefficient. Cronbach α was calculated for internal consistency. Jonckheere-Terpstra test verified whether the scores increased with operator skill level.

PARTICIPANTS

A total of 14 junior gynecology residents, 2 urogynecology fellows, and 3 staff urogynecologists were rated by a total of 6 gynecologic surgeons who scored 42 videos each.

RESULTS

Experienced pelvic surgeons from 3 participating sites agreed the models captured essential elements of real surgical skills (face validity) and of the true procedures (content validity). Intraclass correlation coefficient was adequate (AR = 0.86, PR = 0.90, and VH = 0.87). Cronbach α for the total scores was adequate (AR = 0.85, PR = 0.8, and VH = 0.71). Performance score increased with operator skill level for all 3 procedures (AR, p = <0.001; PR, p = 0.008; and VH, p = 0.007).

CONCLUSIONS

Our low fidelity procedure-specific vaginal surgery models had adequate initial validity. Future research will investigate transferability of acquired skills to the operating room.

The Changing Scenario of Obstetrics and Gynecology Residency Training

BACKGROUND

Significant changes have been noted in aspects of obstetrics-gynecology (ob-gyn) training over the last decade, which is reflected in Accreditation Council for Graduate Medical Education (ACGME) operative case logs for graduating ob-gyn residents.

OBJECTIVE

We sought to understand the changing trends of ob-gyn residents' experience in obstetric procedures over the past 11 years.

METHODS

We analyzed national ACGME procedure logs for all obstetric procedures recorded by 12 728 ob-gyn residents who graduated between academic years 2002-2003 and 2012-2013.

RESULTS

The average number of cesarean sections per resident increased from 191.8 in 2002-2003 to 233.4 in 2012-2013 (17%; P < .001; 95% CI -47.769 to -35.431), the number of vaginal deliveries declined from 320.8 to 261 (18.6%; P < .001; 95% CI 38.842-56.35), the number of forceps deliveries declined from 23.8 to 8.4 (64.7%; P < .001; 95% CI 14.061-16.739), and the number of vacuum deliveries declined from 23.8 to 17.6 (26%; P < .001; 95% CI 5.043-7.357). Between 2002-2003 and 2007-2008, amniocentesis decreased from 18.5 to 11 (P < .001, 95% CI 6.298-8.702), and multifetal vaginal deliveries increased from 10.8 to 14 (P < .001, 95% CI -3.895 to -2.505). Both were not included in ACGME reporting after 2008.

CONCLUSIONS

Ob-gyn residents' training experience changed substantially over the past decade. ACGME obstetric logs demonstrated decreases in volume of vaginal, forceps, and vacuum deliveries, and increases in cesarean and multifetal deliveries. Change in experience may require use of innovative strategies to help improve residents' basic obstetric skills.

Audiovisual preconditioning enhances the efficacy of an anatomical dissection course: A randomised study

The benefits of incorporating audiovisual materials into learning are well recognised. The outcome of integrating such a modality in to anatomical education has not been reported previously. The aim of this randomised study was to determine whether audiovisual preconditioning is a useful adjunct to learning at an upper limb dissection course. Prior to instruction participants completed a standardised pre course multiple-choice questionnaire (MCQ). The intervention group was subsequently shown a video with a pre-recorded commentary. Following initial dissection, both groups completed a second MCQ. The final MCQ was completed at the conclusion of the course. Statistical analysis confirmed a significant improvement in the performance in both groups over the duration of the three MCQs. The intervention group significantly outperformed their control group counterparts immediately following audiovisual preconditioning and in the post course MCQ. Audiovisual preconditioning is a practical and effective tool that should be incorporated in to future course curricula to optimise learning. Level of evidence This study appraises an intervention in medical education.

LEVEL OF EVIDENCE

Kirkpatrick Level 2b (modification of knowledge).

Computer-aided feedback of surgical knot tying using optical tracking

BACKGROUND

Quantifying the information content of hand motion during surgical knot tying using information theory based entropy measures enables the comparison of different groups: novice and expert. We hypothesized that complexity would differ between the 2 groups and predicted based on motor learning models that complexity/information would reduce with increased expertise.

METHODS

Six degrees of freedom hand-motion data during surgical knot tying were acquired using an infrared optical hand tracking device. Multiple data samples were obtained from 2 groups: novice (third-year medical students) and expert (attending surgeons). After preprocessing each knot tying data sample into a binary symbolic time series, 3 nonlinear complexity measures were calculated: Lempel Ziv complexity, Shannon entropy, and Renyi entropy. The Shannon and Renyi entropies were calculated using a word length of 6. A Student t test was used to test whether the 2 groups were from the same population when using these entropy measures, applying a p value of 0.05 to reject the null hypothesis.

RESULTS

The expert surgeons were found to have less complex patterns of motion compared with the novice group. This finding was statistically significant using Lempel Ziv complexity (p = 0.004), Shannon entropy (p = 0.006), and Renyi entropy with q = 2 (p = 0.006). Using Renyi entropy with q = 0.5, the 2 groups were not significantly different (p = 0.26).

CONCLUSIONS

The ability to separate novice from expert populations during surgical knot tying using information theory entropy measures could form the basis of a low-cost educational tool to provide feedback and to assess skill acquisition using low-fidelity bench models.