Teaching in the operating room: results of a national survey

Intraoperative teaching methods, models, and frameworks: A scoping review for surgical resident education

BACKGROUND

This review aimed to consolidate the existing literature on intraoperative teaching strategies and highlight areas for future research.

OBJECTIVE

The objective is to review the research conducted regarding the implementation of various teaching frameworks for surgical learners and to present their feasibility, benefits, and limitations within surgical residencies, as well as areas for future research.

METHODS

Two independent investigators searched MEDLINE, EMBASE, and ERIC and reviewed articles on intraoperative teaching strategies for surgical resident education.

RESULTS

3050 abstracts were reviewed, and 66 studies (2.2%) were included. The most common study type was single cohort studies (33%), followed by survey studies (17%). The majority of articles were carried out in General Surgery (50%), or a combination of surgical specialties (17%).

CONCLUSIONS

The BID model encompasses perioperative teaching time points and suggests a universal organizational approach to intraoperative teaching that would likely be compatible with documented competency assessments for residents.

An Open Operative Readiness Standard for Surgical Trainees

INTRODUCTION

The American Board of Surgery is transitioning from a volume-based to a competency-based assessment of residents using Entrustable Professional Activities. This form of feedback and evaluation should also apply to operative procedures to help residents track their own progress. We describe an operative readiness tool that measures perceived competency in trainees across several operative, procedural, and clinical activities.

METHODS

We distributed a survey to General Surgery trainees at our institution. Participants were asked to rate their level of comfort in 28 operative, procedural, or clinical activities using the standard Entrustable Professional Activity scale: (1) Observation Only, (2) Direct Supervision, (3) Indirect Supervision, (4) Unsupervised Practice, or (5) Supervising Others.

RESULTS

43 of 46 residents (93%) responded to the survey. Median perceived comfort level generally increased with post graduate year level across all competencies. Residents reached a median perceived level of "Unsupervised Practice" by post graduate year 5 in 17 of 28 competencies of various complexity levels.

CONCLUSIONS

While residents are not expected to achieve an "Unsupervised Practice" comfort level in all competencies, creating a transparent platform for reporting this information provides programs a tool to guide educational quality improvement efforts. In addition, it allows for program directors to have greater resolution into the operative advancement of residents outside of their own specialty. In the future, this tool may be instrumental in the development of national competency standards.

Examining the Applicability of Surgical Coaching Rules for Resident Autonomy in Non-teaching Hospitals

INTRODUCTION

This retrospective study aims to analyze the impact of standardized rules for teaching in university hospitals on surgical resident autonomy and patient safety, as measured by patient outcomes, and also examines the learning curves for residents and their impact on patient outcomes in a non-teaching hospital.

METHODS

The data for the study was collected retrospectively from medical records of 2000 adult patients who went through surgical procedures from January 2020 to December 2022. Participants were categorized into two groups based on the supervision level provided by attending surgeons and residents. Appropriate statistical methods were used to analyze the data.

RESULTS

It was observed that operative times of cases handled by both attending and resident surgeons were less than those handled by residents alone. On the other hand, the former group had a significantly higher burden of comorbidities and higher rate of perioperative complications than the latter. These results have important implications for the training of medical residents and the overall delivery of healthcare services in university hospitals.

CONCLUSION

The findings will also help towards better understanding of the effectiveness of these rules and their potential for improving the quality of care provided by residents in these settings.

The use of an educational time-out in thyroid and parathyroid surgery to move the needle in periprocedural education

BACKGROUND

As surgical training shifts toward a competency-based paradigm, deliberate practice for procedures must be a point of focus. The purpose of this study was to assess the impact of an educational time-out intervention on educational experience and operative performance in endocrine surgery.

METHODS

For 12 months, third-year general surgery residents used the educational time-out to establish an operative step of focus for thyroidectomy and parathyroidectomy procedures. Data were collected using the System for Improving and Measuring Procedural Learning application and post-rotation surveys. The Zwisch scale was used to classify supervision, with meaningful autonomy defined as passive help or supervision only.

RESULTS

Eight residents and 3 attending surgeons performed the educational time-out for a total of 211 operations (93% completion rate). At the end of each rotation, there was improvement in the frequency of goal setting. There was strong agreement (90%) that the intervention strengthened the educational experience. For most cases (52%), the residents were rated at active help. Residents performed a median of 3/6 thyroidectomy steps at meaningful autonomy and a median of 2/5 parathyroidectomy steps at meaningful autonomy. Review of the qualitative data revealed that optimal feedback was provided in 46% of cases.

CONCLUSION

The educational time-out strengthened educational experiences. Stepwise procedural data revealed the varying levels of supervision that exist within an operation. Broader implementation of this intervention could facilitate competency-based procedural education.

A quantitative cross-sectional study assessing the surgical trainee perception of the operating room educational environment

BACKGROUND

Limited hours and service provision are diminishing training opportunities, whilst increasing standards of surgical proficiency is being sought. It is imperative to maximise the value of each educational event. An objective measure of higher surgical trainee perception of the operating room environment in England has not been performed before and this can steer future change in optimising educational events in theatre. The Operating Room Educational Environment Measure (OREEM) evaluates each component of the learning environment to enable optimisation of these educational events. However, the OREEM has not yet been assessed for reliability in higher surgical trainees in England. The aim of the current study was to explore areas of strength and weakness in the educational environment in the operating room as perceived by surgical trainees' in one English region. The secondary aim was to assess the reliability of the OREEM.

METHODS

Using a quantitative approach, data was collected over one month from surgical trainees in England using the OREEM.

RESULTS

Fifty-four surgical trainees completed the questionnaire. The OREEM had good internal consistency (α = 0.906, variables = 40). The mean OREEM score was 79.16%. Areas for improvement included better learning opportunities (average subscale score = 72.9%) and conducting pre- and post-operative teaching (average score = 70.4%). Trainees were most satisfied with the level of supervision and workload (average subscale score = 82.87%). The learning environment favoured senior trainees (p = 0.017). There was a strong correlation between OREEM and the global satisfaction score (p < 0.001).

CONCLUSIONS

The OREEM was shown to be a reliable measure of the educational environment. It can be used to identify areas of improvement and as an audit tool. The current perception of the education environment is satisfactory, however, areas of improvement include reducing service provision, empowering trainees to plan lists, improving teamwork and using tools to optimise the educational value of each operation. There is a favourable attitude regarding the use of improvement tools, especially for dissatisfied trainees.

Implementation and validation of a competency assessment tool for laparoscopic cholecystectomy

BACKGROUND

Achieving proficiency in a surgical procedure is a milestone in the career of a trainee. We introduced a competency assessment tool for laparoscopic cholecystectomy in our residency program. Our aim was to assess the inter-rater reliability of this tool.

METHODS

We included all laparoscopic cholecystectomies performed by residents under the supervision of board certified surgeons. All residents were assessed at the end of the procedure by the supervising surgeon (live reviewer) using our competency assessment tool. Video records of the same procedure were analyzed by two independent reviewers (reviewer A and B), who were blinded to the performing trainee's. The assessment had three parts: a laparoscopic cholecystectomy-specific assessment tool (LCAT), the objective structured assessment of technical skills (OSATS) and a 5-item visual analogue scale (VAS) to address the surgeon's autonomy in each part of the cholecystectomy. We compared the assessment scores of the live supervising surgeon and the video reviewers.

RESULTS

We included 15 junior residents who performed 42 laparoscopic cholecystectomies. Scoring results from live and video reviewer were comparable except for the OSATS and VAS part. The score for OSATS by the live reviewer and reviewer B were 3.68 vs. 4.26 respectively (p = 0.04) and for VAS (5.17 vs. 4.63 respectively (p = 0.03). The same difference was found between reviewers A and B with OSATS score (3.75 vs. 4.26 respectively (p = 0.001)) and VAS (5.56 vs. 4.63 respectively; p = 0.004)).

CONCLUSION

Our competency assessment tool for the evaluation of surgical skills specific to laparoscopic cholecystectomy has been shown to be objective and comparable in-between raters during live procedure or on video material.

Video Coaching: A National Survey of Surgical Residency Program Directors

OBJECTIVE

Video coaching has been demonstrated to improve resident and attending skills and is overwhelmingly well received by the participants. However, misperceptions about its utility among those who do not use video coaching may be a barrier to widespread implementation.

DESIGN

Cross-sectional web-based survey SETTING: National survey PARTICIPANTS: Surgical program director members of the Association of Program Directors of Surgery STUDY DESIGN: The survey was developed via a deductive approach after a literature review and was piloted with surgical attendings and residents. All Likert scale were averaged and comparisons between groups was performed via independent t-tests.

RESULTS

There were 52 responses from PDs. 27/52(51.9%) PDs reported their program supported video coaching of residents. PDs from residences with video coaching programs were more likely to believe that video coaching was useful in identifying their own strengths and weakness (p = 0.005), was a useful adjunct for resident feedback (p = 0.024), and a personal library of video recordings would be helpful (p = 0.015) when compared to PDs from residencies without video coaching. Programs without video coaching were more likely to believe barriers to implementation included it being ineffective (p = 0.024) and that the technology was unavailable (p = 0.006). Over 50% of respondents from both groups believed expense, difficulty with set up, time required, and patient privacy were "Very" or "Extremely" likely to be barriers to implementation.

CONCLUSIONS

This is the first national survey of PDs regarding the use of video coaching. Residency programs without video coaching may underestimate the utility of video coaching in training surgical residents.

Video Coaching in Surgical Education: Utility, Opportunities, and Barriers to Implementation

OBJECTIVE

This review discusses the literature on Video-Based Coaching (VBC) and explores the barriers to widespread implementation.

DESIGN

A search was performed on Scopus and PubMed for the terms "operation," "operating room," "surgery," "resident," "house staff," "graduate medical education," "teaching," "coaching," "assessment," "reflection," "camera," and "video" on July 27, 2021, in English. This yielded 828 results. A single author reviewed the titles and abstracts and eliminated any results that did not pertain to operative VBC or assessment. All bibliographies were reviewed, and appropriate manuscripts were included in this study. This resulted in a total of 52 manuscripts included in this review.

SETTING/PARTICIPANTS

Original, peer-reviewed studies focused on VBC or assessment.

RESULTS

VBC has been both subjectively and objectively found to be a valuable educational tool. Nearly every study of video recording in the operating room found that subjects, including surgical residents and seasoned surgeons alike, overwhelmingly considered it a useful, non-redundant adjunct to their training. Most studies that evaluated skill acquisition via standardized assessment tools found that surgical residents who underwent a VBC program had significant improvements compared to their counterparts who did not undergo video review. Despite this evidence of effectiveness, fewer than 5% of residency programs employ video recording in the operating room. Barriers to implementation include significant time commitments for proposed coaching curricula and difficulty with integration of video cameras into the operating room.

CONCLUSIONS

VBC has significant educational benefits, but a scalable curriculum has not been developed. An optimal solution would ensure technical ease and expediency, simple, high-quality cameras, immediate review, and overcoming entrenched surgical norms and culture.

Can Good Intraoperative Judgement Be Taught?: Pediatric Neurosurgeons' Pedagogical Approaches to Training Residents on Intraoperative Decision-Making

OBJECTIVE

To explore how pediatric neurosurgeons train residents in developing intraoperative decision-making judgement.

DESIGN

This study used the Grounded Theory Method in its study design. In-depth interviews were conducted with pediatric neurosurgeons about their approaches to training residents in intraoperative decision making. Data was analyzed line-by-line with codes and categories emerging from participants narratives.

SETTING & PARTICIPANTS

Twenty-six pediatric neurosurgeons from 12 countries were interviewed using video-conferencing technology.

RESULTS

Pediatric Neurosurgeons used a variety of training approaches that included pre-surgery discussions, didactic communication during surgery, post-surgery debriefing, allowing residents to model and observe their own intraoperative behaviors, using case studies to teach, and ongoing mentorship. In addition, they encouraged residents to ask for help when needed and emphasized the importance of empathy as a surgeon. Challenges to training residents included the notion that decision-making could only be learned through personal experience, the trainee's personality, and an over-reliance on algorithms and standardized medicine.

CONCLUSIONS

Training neurosurgical residents about intraoperative decision-making appears to be ad-hoc and dependent on both the institution and the availability and willingness of senior surgeons to make this a part of their pedagogy. Surgical departments could use these findings to reflect on their own teaching practices and explore whether they wish to teach these skills more explicitly, and in what ways these skills can be best taught to residents.

Flipping the Classroom: An Evaluation of Teaching and Learning Strategies in the Operating Room

OBJECTIVES

With increasing restraints on resident's experiences in the operating room, with causes ranging from decreased time available to increasing operating room costs, focus has been placed on how to improve resident's education. The objectives of our study are to (1) determine barriers in education in the operating room, (2) identify effective learning and teaching strategies for residents in the operating room with a focus on the tonsillectomy procedure.

METHODS

An online survey was sent to all otolaryngology residents and residency programs for which contact information was available from January 2016 to March 2016 with 139 respondents. The 12-question survey focused on information regarding limitations to learning how to perform tonsillectomies as well as difficulties with teaching the same procedure. Resident responses were separated based on PGY level, and analysis was performed using t-tests and Chi squared analysis.

RESULTS

Common themes emerged from responses for both teaching and learning how to perform tonsillectomies. A significant limitation in learning the procedure was lack of visualization during the surgery (57% learning vs 60% teaching). For both learners and teachers, the monopolar cautery instrument was found to be the most preferred instrument to use during tonsillectomy (80% each). The majority of resident respondents (93%) felt that an instructional video would be beneficial for both learning and teaching the procedure.

CONCLUSIONS

Significant limitations for learning and teaching in the operating room were identified for performing tonsillectomies. Future endeavors will focus on resolving these limitations to improve surgical education.

EVIDENCE LEVEL

Level IV.

Learning in the Operating Theatre: A Thematic Analysis of Opportunities Lost and Found

OBJECTIVE

The operating theatre (OT) is an important learning environment. Trainees face barriers to learning in the OT that may reduce meaningful educational interactions. The impact of these barriers on the intraoperative learning experience of trainees and the strategies that they employ to overcome them are not known. This qualitative study aimed to describe the intraoperative learning experiences of senior general surgery trainees in Australia and their strategies to optimize learning in the OT.

DESIGN, SETTING, PARTICIPANTS

The authors developed a semi-structured interview guide based on published literature. Purposive sampling was used to identify a representative group of general surgery trainees in Australia, who were interviewed in a private setting with audio recordings deidentified for verbatim transcription and analysis. Thematic analysis was conducted using an interpretivist approach to produce a coding framework.

RESULTS

Ten trainees participated in the study. Themes were divided into external and internal barriers to learning, promoters of effective learning and actions to facilitate learning. External barriers included cultural neglect of an important issue, with inadequate prioritization of teaching and a lack of structure for intraoperative learning. From this, we identified the theme of missed opportunities. Internal barriers included difficulties in developing assertiveness required to address these issues and a failure to adequately plan for learning, with reliance on the mentor to initiate. Actions to facilitate learning were rarely employed by trainees, as most were unaware of strategies to maximize intraoperative learning.

CONCLUSIONS

Trainees find the barriers to learning in the OT difficult to address and are not well acquainted with strategies that may allow them to maximize their learning.

Before the scalpel: Exploring surgical residents' preoperative preparatory strategies

OBJECTIVE

This study sought to increase understanding of preoperative preparatory strategies utilised by senior surgical residents and identify how social and material forces come together to shape practice.

SUMMARY/BACKGROUND DATA

Preoperative preparation can play a powerful role in operative learning. Residents rarely receive guidance, feedback, or explicit expectations on how to prepare for the OR. Understanding current practice and how to support preoperative preparation represents an important gap in our efforts to improve surgical training.

METHODS

Constructivist grounded theory with sensitizing concepts from sociomateriality guided data collection and analysis. Fifteen senior surgical residents from a range of surgical disciplines were purposefully sampled and participated in an in-depth individual interview. Two return-of-finding focus groups followed with seven residents. Rigor was enhanced through constant comparison, theoretical sampling, pursuit of discrepant data, and investigator triangulation.

RESULTS

Residents utilised a range of strategies addressing four areas of focus: develop technical skills, improve procedural knowledge, enhance patient-specificity, and know surgical preferences. However, residents also described receiving limited guidance on what it means to 'be prepared' and experience significant challenges in achieving preparedness. A mix of social and material things that enabled or constrained preparatory efforts influenced individual strategies. These included rotation structure, relationships, the OR list, and time.

CONCLUSIONS

Our findings offer possible solutions by elaborating on preparatory variability and considerations for residents, faculty, and programs to improve practice. As a first step, we suggest programs begin to engage in explicit dialogue and reflection with their residents, faculty, and residency program committees.

Maximizing Learning in the Operating Room: Residents' Perspectives

BACKGROUND

Few studies examine how residents can optimize their educational experience in the OR on their terms. This study aimed to examine residents' perceptions of how learners can maximize their education in the OR.

METHOD

Using constructivist grounded theory methodology, the authors conducted focus groups with general surgery residents, PGY1-5, followed by semi-structured interviews with attending surgeons from a single, academic medical center. Constant comparison was used to identify themes and explore their relationships. Theoretical sampling was used until saturation was achieved.

RESULTS

Residents and attendings participated. Two phases of OR learning were identified, intra-operative and inter-operative. Characters that made optimized learning included control, struggling, and reflection. Residents who practiced self-reflection with their experiences, and were able to articulate this awareness to attendings, felt the OR was an ideal learning environment. Attendings echoed similar findings.

CONCLUSIONS

Providing residents with a method of maximizing OR learning is critical to postgraduate clinical education. Currently, observation passively morphs into active learning and eventually independent operating in the OR. However, residents who practice self-regulated learning, and are able to discuss their educational goals with attendings, seem to find the OR a better learning environment and progress to independence more quickly. This was echoed by practicing attendings. Providing residents with a generalizable, self-regulated learning framework specific to operative educational experiences could maximize learning potential and expedite resident progression in the OR.

Perceptions of Preparedness in Plastic Surgery Residency Training

Supplemental Digital Content is available in the text.

Graduating competent surgical residents requires progressive independence during training. Recent studies in other surgical subspecialties have demonstrated overall fewer opportunities for resident independence due to changes in residency regulations, medical–legal concerns, and financial incentives. A survey study was conducted to assess perceived autonomy and preparedness during plastic surgery residency training and to assess factors affecting autonomy.

Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs

OBJECTIVE

Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs.

DESIGN

After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics.

SETTING

An anonymous electronic survey was distributed to interested programs in early 2019.

PARTICIPANTS

US General Surgery trainees and attending surgeons.

RESULTS

A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection.

CONCLUSIONS

Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning.

Impact of targeted trainer feedback via video review on trainee performance of laparoscopic cholecystectomy

INTRODUCTION

Tools for improving operative performance for surgical trainees are increasingly desirable, particularly in the context of EWTD and 'run-through' training programmes. In addition, positive direct trainer feedback to trainees can improve skill acquisition and motivation, whilst negative feedback may have the opposite effect.¹ We aimed to examine the impact of targeted trainer feedback based on video analysis on trainee confidence and objective operative performance in laparoscopic cholecystectomy.

METHODS

Selected procedures designated as training cases were recorded. These were assessed by the trainers using the Independence-Scaled Procedural Assessment Score for laparoscopic cholecystectomy. Targeted feedback based on video review of selected procedures was then delivered by the trainers to the trainees. Trainees completed a self-reported questionnaire based on their response to this feedback. Subsequent to the feedback intervention, further training procedures were recorded and assessed.

RESULTS

A total of 6 trainees and 4 trainers participated in the study. For the pre-intervention assessment 15 cases were recorded, with a further 13 for the post-intervention assessment (total n = 28). The overall scores for the procedures performed post video feedback were improved, with a trend towards statistical significance (p = 0.08). However, there was a statistically significant improvement in the scores for performance of the triangle of Calot dissection after the feedback intervention (p = 0.009). The response rate to the questionnaire was 100%, with all trainees agreeing that they felt more confident and competent after the feedback intervention.

CONCLUSION

Targeted feedback to trainees based on post-procedure video review improves trainee confidence and may also improve performance. ACGME Core Competencies; Patient Care and Procedural Skills; Practice Based Learning and Improvement.

Disparity of perspectives between teachers and learners on perioperative teaching and learning

BACKGROUND

To build a consensus about learning objectives in the operating room, the aim of the study was to evaluate both surgical teacher and learner perspectives on perioperative teaching and learning in Taiwan.

METHODS

Twelve main technical and non-technical learning objectives in the operating room were evaluated by learners and surgical teachers in Kaohsiung Medical University Hospital. The learners included postgraduate year (PGY) 1-3 residents (junior learner, JL) and PGY 4-7 residents (senior learner, SL). The definition of learning preferences were recommended learning objectives, and learning load was defined as demands of learning preferences. During the survey, surgical teachers evaluated the learning preferences for the learner, and learners evaluated their learning preferences. The learners also evaluated the learning preferences that the surgical teachers should teach.

RESULTS

Response rate of the questionnaire was 65.4%. A total of 31 learners and 39 surgical teachers completed the survey. The consensus was that the need to increase the learning loads and ethical issues were the learning preferences for SL, and indications, details of procedure, and teamwork were important to both JL and SL. The teachers intended to set specific learning objectives for different learner levels, including (i) indications, details of procedure, teamwork, and postoperative care for both JL and SL; (ii) preoperative preparation, surgical anatomy, and instrument handling for JL (P = 0.022, 0.021 and 0.006); and (iii) surgical technique, independent practice, clinical reasoning, complications, and ethical issues for SL (P = 0.010, < 0.001, < 0.001, 0.001, 0.011). Resident perspective on learning objectives differed between JL and SL, and there was discrepancy between resident's learning as perceived by teachers, particularly in the JL.

CONCLUSIONS

Our study revealed significant disparity of perspectives between teachers and learners on perioperative teaching and learning. Surgical teachers should set specific learning objectives for different learner levels, since junior and senior residents have different learning preferences even though both scrub in the same case. Effective communication between teachers and learners has the potential to improve learning experience and create a positive environment in the operating room.

General Surgery Residents' Perception of Feedback: We Can Do Better

BACKGROUND

Feedback (FB) regarding perioperative care is essential in general surgery residents' (GSRs) training. We hypothesized that FB would be distributed unevenly across preoperative (PrO), intraoperative (IO), and postoperative (PO) continuum of the perioperative period. We aimed to compare results between university- and community-hospital settings planning to institute structured, formalized FB in a large health care system operating multiple surgery residency programs in departments that are linked strategically.

METHODS

Quantitative, cross-sectional, Likert scale anonymous surveys were distributed to all GSRs (categorical and preliminary; university: community 1:2). Twenty-five questions considered frequency and perceived quality of FB in PrO, IO, and PO settings. Data were tabulated using REDCap and analyzed in Microsoft Excel using the Mann-Whitney U test, with α = 0.05. Comparisons were made between university- and community-hospital settings, between junior (Post-Graduate Year (PGY) 1-3) and senior (PGY 4-5) GSRs, and by gender.

RESULTS

Among 115 GSRs surveyed, 83 (72%) responded. Whereas 93% reported receiving some FB within the past year, 46% reported receiving FB ≤ 20% of the time. A majority (58%) found FB to be helpful ≥ 80% of the time. Among GSRs, 77%, 24%, and 64% reported receiving PrO, IO, or PO FB ≤ 20% of the time, respectively, but 52% also believed that FB was lacking in all 3 areas. Most GSRs wanted designated time for PrO planning FB (82%) and PO FB (87%), respectively. Thirty-six percent of GSRs reported that senior/chief (i.e., PGY-4/PGY-5 GSRs) took them through cases ≥40% of the time; notably,78% reported that FB from senior/chief GSRs was equally or more valuable than FB from attending surgeons. A majority (78%) reported that attending surgeons stated explicitly when they were providing FB only ≤20% of the time. GSRs at the community hospital campuses reported receiving a higher likelihood of "any" FB, IO FB, and PO FB (p < 0.05). Most GSRs surveyed preferred a structured format and designated times for debriefing and evaluation of performance. Subanalyses of gender and GSR level of training showed no differences.

CONCLUSIONS

FB during GSR training varies across the perioperative continuum of care. Community programs seem to do better than University Programs. More work need to be done to elucidate why differences exist between the frequency of FB at University and Community programs. Further, data show particularly low FB outside of the operating room. Ideally, according to respondents, FB would be provided in a structured format and at designated times for debriefing and evaluation of performance, which poses a challenge considering the temporal dynamism of general surgery services.

A Preoperative Educational Time-Out is Associated with Improved Resident Goal Setting and Strengthens Educational Experiences

OBJECTIVE

The purpose of this study was to assess the impact of a preoperative Educational Time-Out (ETO) with structured postoperative feedback on resident preoperative goal-setting and the educational experience of a clinical rotation.

DESIGN

A preoperative ETO was developed during which trainees and faculty jointly identified an operative goal and discussed the trainee's operative autonomy. Postoperative feedback with a smartphone application was encouraged. From November 2016 to October 2017, the intervention was piloted with 1 surgical service. Outcomes included ETO completion rate, goal setting rate, and subjects' perception of the impact of the ETO on identification of performance deficits, trainee autonomy, and receipt of feedback. Data were analyzed using descriptive statistics.

SETTING

This study was performed in an institutional hospital setting.

PARTICIPANTS

Third-year general surgery residents and surgical faculty in the Department of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center took part in the intervention.

RESULTS

Seven residents and 7 attending surgeons participated in this study. Residents performed a median of 15 procurements during an average of 6.5 weeks each on service. The ETO completion rate was 83%. Resident-reported preoperative goal setting increased after the intervention (from 36% to 78%, p = 0.015). Subjects reported a positive impact of the intervention, with high resident agreement that the ETO helped identify deficits (82% median agreement), increased autonomy (82% median agreement), and increased receipt of feedback (84% median agreement). Residents and attendings agreed that the educational experience was stronger due to the ETO (median 81% and 77%, respectively).

CONCLUSIONS

The ETO intervention improved rates of resident preoperative goal setting and strengthened perceived educational experiences. Resident participants also reported improvements in autonomy and rates of postoperative feedback. Broader implementation of this brief preoperative pause is an easy way to emphasize procedural education in the operating room.

Operating room preparation by general surgery residents: A qualitative analysis

BACKGROUND

Surgical education is changing, with residents having less time to learn more procedures. We aim to explore how residents prepare for the operating room and what factors impact their preparation.

METHODS

A qualitative study was conducted using conventional content analysis. General surgery residents at one institution were invited to participate in semi-structured interviews. Each interview was recorded, transcribed verbatim, and then inductively examined to generate themes.

RESULTS

Fourteen residents elected to participate. Six themes were identified: (1) All participants similarly defined preparation, (2) Residents learned through trial and error and co-residents, (3) Factors impacting preparation were time, attendings, autonomy, case complexity, and difficulty finding resources, (4) Resource use varied, (5) PGY level impacted preparation and, (6) Optimal resources were high yield.

CONCLUSION

Although surgical residents similarly defined operating room preparation, they use a variety of different resources to achieve this, which is often difficult and time consuming.

Intraoperative Feedback: A Video-BasedAnalysis of Faculty and Resident Perceptions

OBJECTIVE

Residents and faculty identify intraoperative feedback as a critical component of surgical education. Studies have demonstrated that residents perceive lower quality and frequency of intraoperative feedback compared to faculty. These differences in perception may be due to dissimilar identification of feedback. The purpose of this study was to determine if residents and faculty differently identify intraoperative interactions as feedback.

DESIGN

Residents and faculty viewed a segment of a laparoscopic cholecystectomy video and then timestamped the video where they perceived moments of intraoperative feedback. Validated surveys on timing, amount, specificity, and satisfaction with operative feedback were administered.

SETTING

Viewing of the video and survey administration was conducted at the University of Michigan.

PARTICIPANTS

A total of 23 of 41 residents (56%) and 29 of 33 faculty (88%) participated in this study.

RESULTS

Survey analysis demonstrated that residents perceived operative feedback to occur with less immediacy, specificity, and frequency compared to faculty. During the 10-minute video, residents and faculty identified feedback 21 and 29 times, respectively (p = 0.13). Ten-second interval analysis demonstrated 7 statistically significant intervals (p < 0.05) where residents identified feedback less frequently than faculty. Analysis of these 7 intervals revealed that faculty were more likely to identify interactions, especially nonverbal ones, as feedback. Review of free-text comments confirmed these findings and suggested that residents may be more receptive to feedback at the conclusion of the case.

CONCLUSIONS

Using video review, we show that residents and faculty identify different intraoperative interactions as feedback. This disparity in identification of feedback may limit resident satisfaction and effective intraoperative learning. Timing and labeling of feedback, continued use of video review, and structured teaching models may overcome these differences and improve surgical education.

Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method

OBJECTIVE

Faculty teaching skills are critical for effective surgical education, however, which skills are most important to be taught in a faculty development program have not been well defined. The objective of this study was to identify priorities for faculty development as perceived by surgical educators.

DESIGN

We used a modified Delphi methodology to assess faculty perceptions of the value of faculty development activities, best learning modalities, as well as barriers and priorities for faculty development. An expert panel developed the initial survey and distributed it to the membership of the Association of Program Directors in Surgery. Responses were reviewed by the expert panel and condensed to 3 key questions that were redistributed to the survey participants for final ranking.

PARTICIPANTS

Seven experts reviewed responses to 8 questions by 110 participants. 35 participants determined the final ranking responses to 3 key questions.

RESULTS

The top three priorities for faculty development were: 1) Resident assessment/evaluation and feedback 2) Coaching for faculty teaching, and 3) Improving intraoperative teaching skills. The top 3 learning modalities were: 1) Coaching 2) Interactive small group sessions, and 3) Video-based education. Barriers to implementing faculty development included time limitations, clinical workload, faculty interest, and financial support.

CONCLUSIONS

Faculty development programs should focus on resident assessment methods, intraoperative and general faculty teaching skills using a combination of coaching, small group didactic and video-based education. Concerted efforts to recognize and financially reward the value of teaching and faculty development is required to support these endeavors and improve the learning environment for both residents and faculty.

Evaluating Surgical Coaching: A Mixed Methods Approach Reveals More Than Surveys Alone

OBJECTIVE

Traditionally, surgical educators have relied upon participant survey data for the evaluation of educational interventions. However, the ability of such subjective data to completely evaluate an intervention is limited. Our objective was to compare resident and attending surgeons' self-assessments of coaching sessions from surveys with independent observations from analysis of intraoperative and postoperative coaching transcripts.

DESIGN

Senior residents were video-recorded operating. Each was then coached by the operative attending in a 1:1 video review session. Teaching points made in the operating room (OR) and in post-OR coaching sessions were coded by independent observers using dialogue analysis then compared using t-tests. Participants were surveyed regarding the degree of teaching dedicated to specific topics and perceived changes in teaching level, resident comfort, educational assessments, and feedback provision between the OR and the post-OR coaching sessions.

SETTING

A single, large, urban, tertiary-care academic institution.

PARTICIPANTS

Ten PGY4 to 5 general surgery residents and 10 attending surgeons.

RESULTS

Although the reported experiences of teaching and coaching sessions by residents and faculty were similar (Pearson correlation coefficient = 0.88), these differed significantly from independent observations. Observers found that residents initiated a greater proportion of teaching points and had more educational needs assessments during coaching, compared to the OR. However, neither residents nor attendings reported a change between the 2 environments with regard to needs assessments nor comfort with asking questions or making suggestions. The only metric on which residents, attendings, and observers agreed was the provision of feedback.

CONCLUSIONS

Participants' perspectives, although considered highly reliable by traditional metrics, rarely aligned with analysis of the associated transcripts from independent observers. Independent observation showed a distinct benefit of coaching in terms of frequency and type of learning points. These findings highlight the importance of seeking different perspectives, data sources, and methodologies when evaluating clinical education interventions. Surgical education can benefit from increased use of dialogue analyses performed by independent observers, which may represent a viewpoint distinct from that obtained by survey methodology.

Preoperative goal setting and perioperative communication in an academic training institution: Where do we stand?

BACKGROUND

We collected data regarding specific aspects of perioperative surgical education within our institution's Section of Surgical Sciences as a needs assessment.

METHODS

Categorical general surgery residents and attending surgeons were queried regarding their perceptions of resident preoperative planning and perioperative communication.

RESULTS

The overall response rate was 81%, with 35 resident and 54 faculty respondents. Residents reported selecting an operative learning objective a median of 50% (IQR 36-67) of the time, whereas attending surgeons perceived this to be the case a median of 26% (IQR 15-35) of the time (P < 0.001). The group reported median frequencies of 20% (IQR 9-31) for preoperative discussion of learning objectives, 12% (IQR 4-27) for preoperative discussion of competence and 27% (IQR 17-55) for postoperative debriefing.

CONCLUSIONS

This study demonstrates deficits in resident goal setting and perioperative communication within our program, which are targets for future intervention. We share these results as a potential tool for other programs.

Surgical data science: The new knowledge domain

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care, with the goal of maximizing the quality and value of care. Whereas innovations in diagnostic and therapeutic technologies have driven past improvements in the quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytical techniques, and translation or integration of research findings into patient care. We foresee the emergence of surgical/interventional data science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model, and quantify the pathways or processes within the context of patient health states or outcomes and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data are pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care, including prevention, diagnosis, intervention, or postoperative recovery. The existing literature already provides preliminary results, suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from preoperative, intraoperative, and postoperative contexts, how it could support intraoperative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.

Assessing residents' operative skills for external ventricular drain placement and shunt surgery in pediatric neurosurgery

OBJECTIVE The authors previously demonstrated the use of a validated Objective Structured Assessment of Technical Skills (OSATS) tool for evaluating residents' operative skills in pediatric neurosurgery. However, no benchmarks have been established for specific pediatric procedures despite an increased need for meaningful assessments that can either allow for early intervention for underperforming trainees or allow for proficient residents to progress to conducting operations independently with more passive supervision. This validated methodology and tool for assessment of operative skills for common pediatric neurosurgical procedures-external ventricular drain (EVD) placement and shunt surgery- was applied to establish its procedure-based feasibility and reliability, and to document the effect of repetition on achieving surgical skill proficiency in pediatric EVD placement and shunt surgery. METHODS A procedure-based technical skills assessment for EVD placements and shunt surgeries in pediatric neurosurgery was established through the use of task analysis. The authors enrolled all residents from 3 training programs (Baylor College of Medicine, Houston Methodist Hospital, and University of Texas-Medical Branch) who rotated through pediatric neurosurgery at Texas Children's Hospital over a 26-month period. For each EVD placement or shunt procedure performed with a resident, the faculty and resident (for self-assessment) completed an evaluation form (OSATS) based on a 5-point Likert scale with 7 categories. Data forms were then grouped according to faculty versus resident (self) assessment, length of pediatric neurosurgery rotation, postgraduate year level, and date of evaluation ("beginning of rotation," within 1 month of start date; "end of rotation," within 1 month of completion date; or "middle of rotation"). Descriptive statistical analyses were performed with the commercially available SPSS statistical software package. A p value < 0.05 was considered statistically significant. RESULTS Five attending evaluators (including 2 fellows who acted as attending surgeons) completed 260 evaluations. Twenty house staff completed 269 evaluations for self-assessment. Evaluations were completed in 562 EVD and shunt procedures before the surgeons left the operating room. There were statistically significant differences (p < 0.05) between overall attending (mean 4.3) and junior resident (self; mean 3.6) assessments, and between overall attending (mean 4.8) and senior resident (self; mean 4.6) assessment scores on general performance and technical skills. The learning curves produced for the residents demonstrate a stereotypical U- or V-shaped curve for acquiring skills, with a significant improvement in overall scores at the end of the rotation compared with the beginning. The improvement for junior residents (Δ score = 0.5; p = 0.002) was larger than for senior residents (Δ score = 0.2; p = 0.018). CONCLUSIONS The OSATS is an effective assessment tool as part of a comprehensive evaluation of neurosurgery residents' performance for specific pediatric procedures. The authors observed a U-shaped learning curve, contradicting the idea that developing one's surgical technique and learning a procedure represents a monotonic, cumulative process of repetitions and improvement.

Objective Assessment of Surgical Technical Skill and Competency in the Operating Room

Training skillful and competent surgeons is critical to ensure high quality of care and to minimize disparities in access to effective care. Traditional models to train surgeons are being challenged by rapid advances in technology, an intensified patient-safety culture, and a need for value-driven health systems. Simultaneously, technological developments are enabling capture and analysis of large amounts of complex surgical data. These developments are motivating a "surgical data science" approach to objective computer-aided technical skill evaluation (OCASE-T) for scalable, accurate assessment; individualized feedback; and automated coaching. We define the problem space for OCASE-T and summarize 45 publications representing recent research in this domain. We find that most studies on OCASE-T are simulation based; very few are in the operating room. The algorithms and validation methodologies used for OCASE-T are highly varied; there is no uniform consensus. Future research should emphasize competency assessment in the operating room, validation against patient outcomes, and effectiveness for surgical training.

Perioperative feedback in surgical training: A systematic review

BACKGROUND

Changes in surgical training have raised concerns about residents' operative exposure and preparedness for independent practice. One way of addressing this concern is by optimizing teaching and feedback in the operating room (OR). The objective of this study was to perform a systematic review on perioperative teaching and feedback.

METHODS

A systematic literature search identified articles from 1994 to 2014 that addressed teaching, feedback, guidance, or debriefing in the perioperative period. Data was extracted according to ENTREQ guidelines, and a qualitative analysis was performed.

RESULTS

Thematic analysis of the 26 included studies identified four major topics. Observation of teaching behaviors in the OR described current teaching practices. Identification of effective teaching strategies analyzed teaching behaviors, differentiating positive and negative teaching strategies. Perceptions of teaching behaviors described resident and attending satisfaction with teaching in the OR. Finally models for delivering structured feedback cited examples of feedback strategies and measured their effectiveness.

CONCLUSIONS

This study provides an overview of perioperative teaching and feedback for surgical trainees and identifies a need for improved quality and quantity of structured feedback.

Does scripting operative plans in advance lead to better preparedness of trainees? A pilot study

BACKGROUND

We pondered if preoperative scripting might better prepare residents for the operating room (OR).

METHODS

Interns rotating on a general surgeon's service were instructed to script randomized cases prior to entering the OR. Scripts contained up to 20 points highlighting patient information perceived important for surgical management. The attending was blinded to the scripting process and completed a feedback sheet (Likert scale) following each procedure. Feedback questions were categorized into "preparedness" (aware of patient specific details, etc.) and "performance" (provided better assistance, etc.).

RESULTS

Eight surgical interns completed 55 scripted and 61 non-scripted cases. Total scores were higher in scripted cases (p = 0.02). Performance scores were higher for scripted cases (3.31 versus 3.13, p = 0.007), while preparedness did not differ (3.65 and 3.62, p = 0.51).

CONCLUSIONS

This pilot study suggests scripting cases may be a useful preoperative planning tool to increase interns' operative and patient care performance but may not affect perceived preparedness.

Validation of Improvement of Basic Competency in Arthroscopic Knot Tying Using a Bench Top Simulator in Orthopaedic Residency Education

PURPOSE

To validate basic competency in arthroscopic knot tying using a unique simulator device to compare the level of training needed for learning and tying the arthroscopic knot by evaluating the tensile properties of the arthroscopic knots.

METHODS

Three groups of surgeons of various experience levels (postgraduate year [PGY] 1, PGY 3, and experienced surgeons) tied 2 different arthroscopic knots (Tennessee Slider, considered easier, and Weston, considered more difficult) over a 10-week period. Each group went through 3 separate stages of knot tying: stage 1, tying 8 knots without cannula or knot pusher; stage 2, tying 12 knots with knot pusher; and stage 3, tying 20 knots with knot pusher through a cannula that simulates knot tying during surgery. A single load-to-failure test was performed and ultimate clinical failure loads were recorded. Time needed to tie each knot was also recorded.

RESULTS

At stages 1 and 2, the PGY 1 group had a significantly weak knot tensile strength (Tennessee Slider stage 1: 60 v 129 N, P = .001; Tennessee Slider stage 2: 69 v 132 N, P = .0029; Weston stage 1: 73 v 184 N, P = .0000; Weston stage 2: 125 v 173 N, P = .0045) and were slower (Weston: 56 v 30 seconds, P = .0010) than the experienced surgeon group for both knots. At stage 3, only the initial 2 weeks of Tennessee Slider showed a significant difference between groups 1 and 3 (week 6: 87 v 118 N, P = .0492; week 7: 89 v 126, P = .01485). Even though the Tennessee Slider knot is one of the easier arthroscopic knots to learn to tie, the results showed a slow trend of improvement in this knot-tying skill for group 1 after each stage.

CONCLUSIONS

The data validated an important learning effect in all trainees in arthroscopic knot tying over a 10-week period and showed that inexperienced trainees will be able to improve their knot-tying skill with training in 3 stages with a simulator environment.

CLINICAL RELEVANCE

The findings of this study indicated the importance of hands-on experience in performing arthroscopic knot tying, as determined by both knot performance and ultimate suture loop strength. In addition, each orthopaedic resident learned and developed his or her arthroscopic knot-tying skills and provided a foundation for his or her future practice in orthopaedic medicine.

The Surgery Fellow's Education Workshop: A Pilot Study to Determine the Feasibility of Training Senior Learners to Teach in the Operating Room

BACKGROUND

In 2013, we developed an education workshop to enhance the teaching skills of surgical fellows. We sought to investigate the feasibility of the monthly educational workshop format and its effect on participant teaching skills.

STUDY DESIGN

Surgical and medical education faculty created a broadly applicable curriculum developed from evidence-based teaching principles, delivered across 8 monthly 90-minute weekday sessions. Workshop feasibility and effect were assessed using evaluations, attendance records, and a variety of self-reported surveys. Each session was associated with a specified education action plan to be completed between sessions.

RESULTS

A total of 13 fellows intended to participate. More than 60% attendance was achieved in 7 of 8 sessions. In all, 11 of 13 fellows were engaged (actual attendance or excused absence) across 75% or more of the sessions. Mean participant satisfaction scores ranged from 4.0 to 4.9 on a 5 point Likert scale across 87.5% of sessions. Postworkshop surveys showed increased understanding of the following: (1) knowledge gaps related to education; (2) the role of education for academic surgeons; (3) educational tools to improve teaching performance; and (4) perceived knowledge and attitudes about teaching in the operating room. An action plan was performed in 43% of cases; the most common reason for nonparticipation was lack of time (38%).

CONCLUSIONS

Our pilot supports the feasibility of an educational workshop series to enhance fellow's educational skills in the area of intraoperative teaching. Participant engagement and satisfaction were high in this self-selected group of initial trainees. Sessions were effective, resulting in a thoughtful self-assessment of teaching skills.

Surgical Case Logging Habits and Attitudes: A Multispecialty Survey of Residents

OBJECTIVE

The Accreditation Council for Graduate Medical Education measures surgical residents' experience in the United States by mandating that residents log each procedure in which they have participated. This system is the primary mechanism by which breadth and depth of surgical training are documented, and data are used for program accreditation and by individual program directors to assess resident preparedness. The study objective was to learn from residents across surgical specialties how this system is being used, and whether they believe these data are reliable.

DESIGN

Investigators developed and administered a voluntary, 45-item survey. Resident demographic data, program details, logging behaviors, and attitudes were examined using descriptive statistics. Authors used multivariate logistic regression to assess respondent and program characteristics associated with logging habits.

SETTING

The survey was administered at a large academic medical center.

PARTICIPANTS

All general surgery, obstetrics and gynecology, orthopedics, urology, neurosurgery, otolaryngology, and plastic surgery residents were eligible. Of 126 surgical residents, 82 participated, yielding a response rate of 65%.

RESULTS

Overall, 7.5% considered the case log system highly inaccurate, 28.8% somewhat inaccurate, 52.5% somewhat accurate, and 11.3% highly accurate. Nearly half (48.1%) use an incorrect metric to log their role as surgeon or assistant. Half logged monthly or less frequently. The longest time residents reported falling behind ranged from less than a week to more than a year, with about half (51.4%) reporting backlogs of 3 months or longer. Approximately two-thirds considered the system difficult to navigate (64.2%) and burdensome (68.8%). Departmental training and reminders to log were associated with high fidelity logging habits.

CONCLUSIONS

Inconsistency of logging habits and perceived lack of accuracy raise concerns about use of the system for assessing surgical preparedness or accrediting training programs. Academic departments playing an active role may benefit from more reliable data to guide improvements in surgical training.

3D Printout Models vs. 3D-Rendered Images: Which Is Better for Preoperative Planning?

INTRODUCTION

Correct interpretation of a patient's anatomy and changes that occurs secondary to a disease process are crucial in the preoperative process to ensure optimal surgical treatment. In this study, we presented 3 different pancreatic cancer cases to surgical residents in the form of 3D-rendered images and 3D-printed models to investigate which modality resulted in the most appropriate preoperative plan.

METHODS

We selected 3 cases that would require significantly different preoperative plans based on key features identifiable in the preoperative computed tomography imaging. 3D volume rendering and 3D printing were performed respectively to create 2 different training ways. A total of 30, year 1 surgical residents were randomly divided into 2 groups. Besides traditional 2D computed tomography images, residents in group A (n = 15) reviewed 3D computer models, whereas in group B, residents (n = 15) reviewed 3D-printed models. Both groups subsequently completed an examination, designed in-house, to assess the appropriateness of their preoperative plan and provide a numerical score of the quality of the surgical plan.

RESULTS

Residents in group B showed significantly higher quality of the surgical plan scores compared with residents in group A (76.4 ± 10.5 vs. 66.5 ± 11.2, p = 0.018). This difference was due in large part to a significant difference in knowledge of key surgical steps (22.1 ± 2.9 vs. 17.4 ± 4.2, p = 0.004) between each group. All participants reported a high level of satisfaction with the exercise.

CONCLUSION

Results from this study support our hypothesis that 3D-printed models improve the quality of surgical trainee's preoperative plans.

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.