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Kiger ME, Meyer HS. Ownership of Patient Care: Medical Students' Expectations, Experiences, and Evolutions Across the Core Clerkship Curriculum. TEACHING AND LEARNING IN MEDICINE 2024:1-13. [PMID: 38857111 DOI: 10.1080/10401334.2024.2361913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 05/03/2024] [Indexed: 06/12/2024]
Abstract
Phenomenon: Ownership of patient care is a key element of professional growth and professional identity formation, but its development among medical students is incompletely understood. Specifically, how attitudes surrounding ownership of patient care develop, what experiences are most influential in shaping them, and how educators can best support this growth are not well known. Therefore, we studied the longitudinal progression of ownership definitions and experiences in medical students across their core clerkship curriculum. Approach: We conducted a series of four longitudinal focus groups with the same cohort of medical students across their core clerkship curriculum. Using workplace learning theory as a sensitizing concept, we conducted semi-structured interviews to explore how definitions, experiences, and influencers of ownership developed and evolved. Results were analyzed inductively using thematic analysis. Findings: Fifteen students participated in four focus groups spanning their core clerkship curriculum. We constructed four themes from responses: (1) students' definitions of ownership of patient care evolved to include more central roles for themselves and more defined limitations; (2) student conceptions of patient care ownership became more relational and reciprocal over time as they ascribed a more active role to patients; (3) student assessment fostered ownership as an external motivator when it explicitly addressed ownership, but detracted from ownership if it removed students from patient care; and (4) structural and logistical factors impacted students' ability to display patient care ownership. Insights: Student conceptions of ownership evolved over their core clerkship curriculum to include more patient care responsibility and more meaningful relational connections with patients, including recognizing patients' agency in this relationship. This progression was contingent on interactions with real patients and students being afforded opportunities to play a meaningful role in their care. Rotation structures and assessment processes are key influencers of care ownership that merit further study, as well as the voice of patients themselves in these relationships.
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Affiliation(s)
- Michelle E Kiger
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland, USA
| | - Holly S Meyer
- Department of Medicine, Center for Health Professions Education, Uniformed Services University, Bethesda, Maryland, USA
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Tsui GO, Kunac A, Oliver JB, Mehra S, Anjaria DJ. Why Not This Case? Differences Between Resident and Attending Operative Cases at Teaching Hospitals. J Surg Res 2024; 295:19-27. [PMID: 37972437 DOI: 10.1016/j.jss.2023.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Previous studies have focused on outcomes pertaining to resident operative autonomy, but there has been little academic work examining the types of patients and cases where autonomy is afforded. We sought to describe the differences between surgical patient populations in teaching cases where residents are and are not afforded autonomy. METHODS We examined all general and vascular operations at Veterans Affairs teaching hospitals from 2004 to 2019 using Veterans Affairs Surgical Quality Improvement Program. Level of resident supervision is prospectively recorded by the operating room nurse at the time of surgery: attending primary (AP): the attending performs the case with or without a resident; attending resident (AR): the resident performs the case with the attending scrubbed; resident primary (RP): resident operating with supervising attending not scrubbed. Resident (R) cases refer to AR + RP. Patient demographics, comorbidities, level of supervision, and top cases within each group were evaluated. RESULTS A total of 618,578 cases were analyzed; 154,217 (24.9%) were AP, 425,933 (68.9%) AR, and 38,428 (6.2%) RP. Using work relative value unit as a surrogate for complexity, RP was the least complex compared to AP and AR (10.4/14.4/14.8, P < 0.001). RP also had a lower proportion of American Society of Anesthesiologists 3 and 4 + 5 patients (P < 0.001), were younger (P < 0.001), and generally had lower comorbidities. The most common RP cases made up a higher proportion of all RP cases than they did for AP/AR and demonstrated several core competencies (hernia, cholecystectomy, appendectomy, amputation). R cases, however, were generally sicker than AP cases. CONCLUSIONS In the small proportion of cases where residents were afforded autonomy, we found they were more focused on the core general surgery cases on lower risk patients. This selection bias likely demonstrates appropriate attending judgment in affording autonomy. However, this cohort consisted of many "sicker" patients and those factors alone should not disqualify resident involvement.
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Affiliation(s)
- Grace O Tsui
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Shyamin Mehra
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Newland JJ, Sundel MH, Blackburn KW, Cairns CA, Cooper LE, Stewart SJ, Roque DM, Siddiqui MM, Brown RF. Early Implementation of Robotic Training in Surgical and Surgical Subspecialty Residency. Am Surg 2024:31348241229631. [PMID: 38262961 DOI: 10.1177/00031348241229631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Robotic surgery has emerged as an operative tool for many elective and urgent surgical procedures. The purpose of this study was to evaluate early surgical trainees' experiences and opinions of robotic surgery. METHODS An introductory robotic training course consisting of online da Vinci Xi/X training and in-person, hands on training was implemented for residents and medical students across surgical subspecialties at a single institution. A voluntary survey evaluating perceptions of and interest in robotic surgery and prior robotic surgery experience, as well as a basics of robotics quiz, was distributed to participants prior to the start of the in-person session. Descriptive statistics were used to evaluate the cohort. RESULTS 85 trainees participated in the course between 2020 and 2023, including 58 first- and second-year surgical residents (general surgery, urology, OB/GYN, and thoracic surgery) and 27 fourth-year medical students. 9.4% of participants reported any formal robotic surgery training prior to the session, with only 19% of participants reporting robotic operative experience. 52% of the participants knew of and/or had completed the da Vinci online course modules prior to the scheduled training session. Participants unanimously (100%) agreed that robotic surgery should be implemented into surgical training. CONCLUSIONS There is rising enthusiasm for robotic surgery, yet early exposure and training remain infrequent and inconsistent amongst medical students and new surgical residents. A standardized introduction of multi-disciplinary robotic surgery training should be incorporated into medical school and/or early residency education to ensure surgical residents receive appropriate exposure and training to achieve competency.
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Affiliation(s)
- John J Newland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margaret H Sundel
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kyle W Blackburn
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cassandra A Cairns
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laura E Cooper
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shelby J Stewart
- Department of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dana M Roque
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Rebecca F Brown
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Elhadidi A, Abdel Raouf S, Salama H, Fadl A, Abdelhalim M. Examining the Applicability of Surgical Coaching Rules for Resident Autonomy in Non-teaching Hospitals. Cureus 2024; 16:e53239. [PMID: 38293676 PMCID: PMC10827002 DOI: 10.7759/cureus.53239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/01/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Amged Fadl
- Surgery, Al-Azhar University, Cairo, EGY
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Parr JM, van der Werf B, Locke M. Operative Autonomy in a Gender-Balanced Cohort of Surgical Trainees. Plast Reconstr Surg 2023; 152:1367-1374. [PMID: 36917746 DOI: 10.1097/prs.0000000000010407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Gender inequity continues to be a major focus of improvements within surgical education. Female trainees are fewer and experience reduced quality of surgical training. Prior studies have demonstrated that surgical autonomy for female trainees in a range of surgical disciplines is less than that of male trainees. As a unique example among Australasian specialty training boards, the New Zealand Board of Plastic and Reconstructive Surgery has boasted a gender-balanced cohort of surgical trainees since 2013. The authors sought to examine the effect of gender on surgical autonomy in a cohort of trainees where gender balance has been achieved. METHODS A retrospective cohort study was undertaken. Anonymized logbook data for New Zealand plastic surgery trainees were analyzed, for the study period, consisting of rotations from December of 2013 to June of 2020. Self-reported levels of trainee supervision were compared against gender. Outcomes were tested using multivariate analysis. RESULTS Thirty-eight trainees were included in the study (58% female), with a total of 81,178 cases recorded over the 6.5-year study period. No overall statistically significant difference in surgical autonomy was identified when analyzed by gender. Male and female trainees showed similar trends of increasing surgical autonomy throughout the course of surgical training. CONCLUSIONS In a cohort of surgical trainees that has reached gender balance, the negative impact of gender on surgical autonomy was not identified. These findings suggest that where women make up an equal proportion of trainees, the implicit gender bias within surgical training may be ameliorated.
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Affiliation(s)
- Justin M Parr
- From the Department of Plastic and Reconstructive Surgery, Christchurch Hospital
| | | | - Michelle Locke
- Faculty of Medical and Health Science, University of Auckland
- Department of Plastic and Reconstructive Surgery, Middlemore Hospital
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Willis RE, Patnaik R, Khan MT, Juhas C, Shah A. The "Intern" Label: Introducing Unnecessary Confusion and Bias? JOURNAL OF SURGICAL EDUCATION 2023; 80:1602-1607. [PMID: 37211523 DOI: 10.1016/j.jsurg.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVES The Oxford English Dictionary defines "intern" as "a student or trainee who works, sometimes without pay, at a trade or occupation in order to gain work experience." In the medical realm, the label "intern" may introduce confusion as well as implicit and explicit bias. In this study, we sought to examine the general public's perception of the label "intern" compared to the more accurate label "first-year resident." DESIGN We developed 2 forms of a 9-item survey that assessed an individual's level of comfort with surgical trainees' participation in various aspects of surgical care and knowledge of medical education and work environment. One form used the label "intern" and the other used "first-year resident." SETTING San Antonio, TX. PARTICIPANTS A total of 148 adults in the general population at 3 local parks on 3 separate occasions. RESULTS A total of 148 individuals completed the survey (74 per form). Respondents who did not work in the medical field reported less comfort with interns vs first-year residents participating in various aspects of their care. Only 36% of respondents were able to correctly identify which surgical team members have completed a medical degree. Directly assessing perceptual incongruity between the labels "intern" and "first-year resident," 43% of respondents said interns have a medical degree compared to 59% for first-year residents (p = 0.008), 88% stated that interns work full-time in the hospital compared to 100% for first-year residents (p = 0.041), and 82% stated that interns get paid for their work in the hospital compared to 97% for first-year residents (p = 0.047). CONCLUSIONS The label "intern" may confuse patients, family members, and perhaps other healthcare professionals regarding the level of experience and knowledge of first-year residents. We advocate for abolishing the term "intern" and replacing it with "first-year resident" or simply "resident."
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Affiliation(s)
- Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
| | - Ronit Patnaik
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Mustafa T Khan
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Claire Juhas
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Anaya Shah
- Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Parker RK, Otoki K, Sylvester K, Roberts L, Many HR, Kim GJ, Mwachiro MM, Parker AS. Trainee autonomy and surgical outcomes after emergency gastrointestinal surgery. Surgery 2023; 174:324-329. [PMID: 37263881 DOI: 10.1016/j.surg.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/25/2023] [Accepted: 04/27/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Operative meaningful trainee autonomy is an essential component of surgical training. Reduced trainee autonomy is frequently attributed to patient safety concerns, but this has not been examined within Kenya. We aimed to assess whether meaningful trainee autonomy was associated with a change in patient outcomes. METHODS We investigated whether meaningful trainee autonomy was associated with a change in severe postoperative complications and all-cause in-hospital mortality in a previously described cohort undergoing emergency gastrointestinal operations. Each operation was reviewed to determine the presence of meaningful autonomy, defined as "supervision only" from faculty. Comparisons were made between faculty-led cases and cases with meaningful trainee autonomy. Multilevel logistic regression models were created for the outcomes of mortality and complications with the exposure of meaningful trainee autonomy, accounting for fixed effects of the Africa Surgical Outcomes Study Risk Score and random effects of discharge diagnoses. RESULTS After excluding laparoscopy (N = 28) and missing data (N = 3), 451 operations were studied, and 343 (76.1%) had meaningful trainee autonomy. Faculty were more involved in operations with older age, cancer, prior complications, and higher risk scores. On unadjusted analysis, meaningful trainee autonomy was associated with mortality odds of 0.32 (95% confidence interval: 0.17-0.58) compared with faculty-led operations. Similarly, the odds of developing complications were 0.52 (95% confidence interval: 0.32-0.84) with meaningful trainee autonomy compared with faculty-led operations. When adjusting for Africa Surgical Outcomes Study Score and clustering discharge diagnoses, the odds of mortality (odds ratio 0.58; 95% confidence interval: 0.27-1.2) and complication (odds ratio 0.83; 95% confidence interval: 0.47-1.5) were not significant. CONCLUSION Our findings support that increasing trainee autonomy does not change patient outcomes in selected emergency gastrointestinal operations. Further, trainees and faculty appropriately discern patients at higher risk of complications and mortality, and the selective granting of trainee autonomy does not affect patient safety.
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Affiliation(s)
| | - Kemunto Otoki
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/kemuntootoki
| | | | - Luke Roberts
- Department of Surgery, Tenwek Hospital, Bomet, Kenya
| | - Heath R Many
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Grace J Kim
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI. https://twitter.com/3amazinggrace
| | - Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/MichaelMwachiro
| | - Andrea S Parker
- Department of Surgery, Tenwek Hospital, Bomet, Kenya. https://twitter.com/AP_the_surgeon
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Downie S, Cherry J, Dunn J, Harding T, Eastwood D, Gill S, Johnson S. The role of Gender in Operative Autonomy in orthopaedic Surgical Trainees (GOAST). Bone Joint J 2023; 105-B:821-832. [PMID: 37399113 DOI: 10.1302/0301-620x.105b7.bjj-2023-0132.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
Aims Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. Methods This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender. Results All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience. Conclusion This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training.
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Affiliation(s)
- Samantha Downie
- Department of Trauma & Orthopaedics, Ninewells Hospital & Medical School, Dundee, UK
| | | | - Jennifer Dunn
- Department of Trauma & Orthopaedics, Ninewells Hospital & Medical School, Dundee, UK
| | - Thomas Harding
- Department of Trauma & Orthopaedics, Ninewells Hospital & Medical School, Dundee, UK
| | | | - Sarah Gill
- Department of Orthopaedic Surgery, Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Simon Johnson
- Department of Trauma & Orthopaedics, Ninewells Hospital & Medical School, Dundee, UK
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McKinley SK, Wojcik BM, Witt EE, Hamdi I, Mansur A, Petrusa E, Mullen JT, Phitayakorn R. Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery. Ann Surg 2023; 277:e1380-e1386. [PMID: 35856490 DOI: 10.1097/sla.0000000000005598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate inpatient satisfaction with surgical resident care. BACKGROUND Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed. METHODS English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method. RESULTS Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons. CONCLUSIONS Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.
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Affiliation(s)
| | | | | | - Isra Hamdi
- Massachusetts General Hospital, Boston, MA
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Foroushani S, Gaetani RS, Lin B, Chugh P, Siegel A, Whang E, Kristo G. Role Reversal Between Trainees and Surgeons: Improving Autonomy and Confidence in Surgical Residents. J Surg Res 2023; 289:75-81. [PMID: 37086599 DOI: 10.1016/j.jss.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION There are increasing concerns regarding resident autonomy in the context of efficiency, legal ramifications, patient expectations and patient safety. However, autonomy is necessary to develop competent, independent surgeons. Therefore, educational paradigms that maximize opportunities for entrustability without sacrificing patient safety are necessary to ensure adequate training for surgeons. METHODS This is a prospective, qualitative study of intraoperative role reversal between surgeons and residents. Using Likert scales and binary questions, preintervention and postintervention surveys were collected, evaluating variables including intraoperative learning, decision making, communication, confidence, autonomy and opportunity for safe struggle. The Mann-Whitney U test was used to analyze results and compare responses between training years. RESULTS Thirty-six general surgery residents comprising post-graduate year 1, 2, 4, and 5 acted as primary surgeon in a total of 36 cases. Preoperative knowledge scores were significantly higher in more senior residents (P < 0.001), but all residents had significant improvement in knowledge scores postoperatively (P < 0.001). The knowledge improvement was quantitatively larger for junior versus senior residents. Intraoperative decision making significantly improved after the intervention for all training levels (P < 0.001). 25 intraoperative "rescues" were performed by faculty for failure to progress or unsafe conditions (23 for junior residents, 2 for senior residents). Residents indicated that this intraoperative role reversal improved preparation, confidence, autonomy, and intraoperative communication. CONCLUSIONS Intraoperative role reversal between residents and surgeons provides a safe opportunity for maximizing learning and increasing entrustability under direct supervision.
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Affiliation(s)
- Sophia Foroushani
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Racquel S Gaetani
- Department of Surgery, Lahey Hospital and Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Brenda Lin
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Priyanka Chugh
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Ashley Siegel
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Whang
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gentian Kristo
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Oliver JB, McFarlane JL, Kunac A, Anjaria DJ. Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality. JOURNAL OF SURGICAL EDUCATION 2023; 80:434-441. [PMID: 36335032 DOI: 10.1016/j.jsurg.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/06/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE The volume of cases that residents perform independently have decreased leaving graduating chief residents less prepared for independent practice. Outcomes are not worse when residents are given autonomy with appropriate supervision, however it is unknown if outcomes are worsening with decreasing operative autonomy experience. We hypothesize that resident autonomous cases parallel the improving outcomes in surgical care over time, however, are less complex and on lower acuity patients. DESIGN Retrospective study utilizing the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases performed on teaching services within the VASQIP database from July 1, 2004 to September 30, 2019, were included. PARTICIPANTS All adult patients who underwent a surgical procedure from July 1, 2004, to September 30, 2019, at a VA hospital on a service that included residents were initially included. After inclusions and exclusions, there were 1,346,461 cases. Cases were divided into 3 sequential 5 year eras (ERA 1: 2004-2008 n = 415,614, ERA 2: 2009-2013 n = 478,528, and ERA 3: 2014-2019 n = 452,319). The main exposure of interest was level of resident supervision, coded at the time of procedure as: attending primary surgeon (AP); attending and resident (AR), or resident primary with the attending supervising but not scrubbed (RP). We compared 30 day all-cause mortality, composite morbidity, work relative value unit (wRVU), hospital length of stay, and operative time between each ERA for RP cases, as well as within each ERA for RP cases compared to AR and AP cases. RESULTS There was a progressive decline in the rate of RP cases in each successive ERA (ERA 1: 58,249 (14.0%) vs ERA 2: 47,891 (10.0%) vs ERA 3: 35,352 (7.8%), p < 0.001). For RP cases, patients were progressively getting older (60 yrs [53-71] vs 63 yrs [54-69] vs 66 yrs [57-72], p < 0.001) and sicker (ASA 3 58.7% vs 62.5% vs 66.2% and ASA 4/5 8.4% vs 9.6% vs10.0%, p < 0.001). Odds of mortality decreased in each ERA compared to the previous (aOR 0.71 [0.62-0.80] ERA 2 vs ERA 1 and 0.82 [0.70-0.97] ERA 3 vs ERA 2) as did morbidity (0.77 [0.73-0.82] ERA 2 vs ERA 1 and 0.72 [0.68-0.77] ERA 3 vs ERA 2). Operative and length of stay also decreased while wRVU stayed unchanged. When comparing RP cases to AP and AR within each ERA, RP cases tended to be on younger and healthier patients with a lower wRVU, particularly compared to AR cases. Mortality and morbidity were no different or better in RP compared to AR and AP. CONCLUSIONS Despite resident autonomy decreasing, outcomes in cases where they are afforded autonomy are improving over time. This despite RP cases being on sicker and older patients and performing roughly the same complexity of cases. They also continue to perform no worse than cases with higher levels of supervision. Efforts to increase surgical resident operative autonomy are still needed to improve readiness for independent practice.
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Affiliation(s)
- Joseph B Oliver
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey.
| | - Jamal L McFarlane
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Anastasia Kunac
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
| | - Devashish J Anjaria
- VA New Jersey Healthcare System, Department of Surgery, East Orange, New Jersey; Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey
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12
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Postgraduate Surgical Education in East, Central, and Southern Africa: A Needs Assessment Survey. J Am Coll Surg 2023; 236:429-435. [PMID: 36218266 DOI: 10.1097/xcs.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Lancet Commission on Global Surgery has identified workforce development as an important component of National Surgical Plans to advance the treatment of surgical disease in low- and middle-income countries. The goal of our study is to identify priorities of surgeon educators in the region so that collaboration and intervention may be appropriately targeted. STUDY DESIGN The American College of Surgeons Operation Giving Back, in collaboration with leaders of the College of Surgeons of Eastern, Central and Southern Africa (COSECSA), developed a survey to assess the needs and limitations of surgical educators working under their organizational purview. COSECSA members were invited to complete an online survey to identify and prioritize factors within 5 domains: (1) Curriculum Development, (2) Faculty Development, (3) Structured Educational Content, (4) Skills and Simulation Training, and (5) Trainee Assessment and Feedback. RESULTS One-hundred sixty-six responses were received after 3 calls for participation, representing all countries in which COSECSA operates. The majority of respondents (78%) work in tertiary referral centers. Areas of greatest perceived need were identified in the Faculty Development and Skills and Simulation domains. Although responses differed between domains, clinical responsibilities, cost, and technical support were commonly cited as barriers to development. CONCLUSIONS This needs assessment identified educational needs and priorities of COSECSA surgeons. Our study will serve as a foundation for interventions aimed at further improving graduate surgical education and ultimately patient care in the region.
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Anyomih TT, Jennings T, Mehta A, O'Neill JR, Panagiotopoulou I, Gourgiotis S, Tweedle E, Bennett J, Davies RJ, Simillis C. Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon. Am J Surg 2023; 225:168-179. [PMID: 35927089 DOI: 10.1016/j.amjsurg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/23/2022] [Accepted: 07/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Appendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes. METHODS Systematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons. RESULTS Of 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05). CONCLUSIONS Appendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.
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Affiliation(s)
- Theophilus Tk Anyomih
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thomas Jennings
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alok Mehta
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Robert O'Neill
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ioanna Panagiotopoulou
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Gourgiotis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elizabeth Tweedle
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John Bennett
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Justin Davies
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Constantinos Simillis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Bosley ME, Werenski HE, Powell MS, Meredith JW, Randle RW. Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment. JOURNAL OF SURGICAL EDUCATION 2022; 79:1246-1252. [PMID: 35649957 DOI: 10.1016/j.jsurg.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/08/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending. DESIGN We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications. SETTING Tertiary care center, single institution. PARTICIPANTS Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period. RESULTS Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09). CONCLUSIONS Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.
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Affiliation(s)
- Maggie E Bosley
- Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina.
| | - Hope E Werenski
- Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Myron S Powell
- Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - J Wayne Meredith
- Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Reese W Randle
- Department of Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina.
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15
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Anyomih TTK, Jennings T, Mehta A, O'Neill JR, Panagiotopoulou I, Gourgiotis S, Tweedle E, Bennett J, Davies RJ, Simillis C. Systematic review and meta-analysis comparing perioperative outcomes of pediatric emergency appendicectomy performed by trainee vs trained surgeon. Pediatr Surg Int 2022; 38:1187-1196. [PMID: 35857086 DOI: 10.1007/s00383-022-05160-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
Appendicectomy is a common pediatric surgical procedure performed by trainees and surgeons with varying reported outcomes. It is a benchmark procedure for trainee progression and training benefits should be weighed against patient safety and perioperative outcomes. This systematic review and meta-analysis investigated any differential perioperative outcomes dependent on the grade of the operating surgeon. A systematic literature review and meta-analysis were performed comparing outcomes of pediatric appendicectomy performed by trainees versus trained surgeons. Of 2,086 articles screened, 5 retrospective non-randomized comparative studies reporting on 10,019 participants were analyzed. There was no difference in overall complications (OR 0.92; 95% CI 0.76, 1.12; P = 0.42), major complications [Clavien-Dindo (CD) III/IV] (OR 1.18; 95% CI 0.71, 1.97; P = 0.52), minor complications (CD I/II) (OR 1.13; 95% CI 0.57, 2.27; P = 0.72), post-op ileus (OR 0.74; 95% CI 0.10, 5.26; P = 0.76), wound infections (OR 0.87; 95% CI 0.62, 1.21; P = 0.41), abscess formation (OR 0.58; 95% CI 0.28, 1.22; P = 0.15), operation times [Mean Difference (MD) 2.31 min; 95% CI - 4.94, 9.56; P = 0.53] and reoperation rate (OR 1.22; 95% CI 0.23, 6.42; P = 0.81). Trainees had fewer conversions to open appendicectomy (OR 0.14; 95% CI 0.02, 0.88; P = 0.04). Appendicectomy performed on pediatric patients by trainees did not compromise patient safety. LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Theophilus T K Anyomih
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Thomas Jennings
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Alok Mehta
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - J Robert O'Neill
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Ioanna Panagiotopoulou
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Stavros Gourgiotis
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Elizabeth Tweedle
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - John Bennett
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Constantinos Simillis
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
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Training on skin flap elevation in hand surgery using cadavers embalmed by the saturated salt solution method: effectiveness and usefulness. Anat Sci Int 2022; 97:283-289. [PMID: 35482209 DOI: 10.1007/s12565-022-00668-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
Thiel embalmed and fresh-frozen cadavers have been mainly used for hand surgery training. We held a training seminar on skin flap elevation using cadavers embalmed by the saturated salt solution method. This study aimed to evaluate the usefulness of such training and to validate the suitability of saturated salt solution-embalmed cadavers for hand surgery training. Participants were trained in elevation procedures for the oblique triangular, reverse digital artery, reverse radial forearm, and reverse dorsal metacarpal artery flaps. Forty-eight surgeons participated in three seminars (one held in 2017, 2018, and 2019 each). A self-assessment of the participants' confidence levels for their surgical skills was performed before and immediately after the seminar, and the suitability of saturated salt solution-embalmed cadavers was determined in terms of visual perception, tactility, comparison with real-world surgical settings, and usefulness. The confidence level for all skills increased immediately after the seminar. The surgeons reported that the visual perception and tactility of the saturated salt solution-embalmed cadavers were comparable to those of a living body, and the cadavers were rated higher with respect to their usefulness. Hand surgery seminars using cadavers embalmed by the saturated salt solution method are considered useful for training in skin flap techniques.
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17
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Wojcik BM, McKinley SK, Fong ZV, Mansur A, Bloom JP, Amari N, Hamdi I, Chang DC, Petrusa E, Mullen JT, Phitayakorn R. The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education. JOURNAL OF SURGICAL EDUCATION 2021; 78:1838-1850. [PMID: 34092535 DOI: 10.1016/j.jsurg.2021.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/04/2021] [Accepted: 04/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence. DESIGN Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks. SETTING Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. PARTICIPANTS Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation. RESULTS 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05). CONCLUSION Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.
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Affiliation(s)
- Brandon M Wojcik
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Sophia K McKinley
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Arian Mansur
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jordan P Bloom
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Noor Amari
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Isra Hamdi
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Emil Petrusa
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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18
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Dickinson KJ, Bass BL, Graviss EA, Nguyen DT, Pei KY. Independent Operating by General Surgery Residents: An ACS-NSQIP Analysis. JOURNAL OF SURGICAL EDUCATION 2021; 78:2001-2010. [PMID: 33879397 DOI: 10.1016/j.jsurg.2021.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/15/2021] [Accepted: 03/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time. DESIGN We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications. SETTING The ACS-NSQIP database. PARTICIPANTS Patients undergoing one of 7 emergency general surgery operations. RESULTS Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality. CONCLUSION Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes.
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Affiliation(s)
- Karen J Dickinson
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington DC
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana
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19
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Pohl L, Naidoo M, Rickard J, Abahuje E, Kariem N, Engelbrecht S, Kloppers C, Sibomana I, Chu K. Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa. JOURNAL OF SURGICAL EDUCATION 2021; 78:1985-1992. [PMID: 34183277 DOI: 10.1016/j.jsurg.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/21/2021] [Accepted: 05/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years. RESULTS Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality. CONCLUSIONS Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.
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Affiliation(s)
- Linda Pohl
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Megan Naidoo
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Rickard
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Egide Abahuje
- Department of Surgery, University of Rwanda, Kigali, Rwanda; Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nazmie Kariem
- Department of Surgery, University of Cape Town, Cape Town, South Africa; Department of Surgery, New Somerset Hospital, Cape Town, South Africa
| | | | - Christo Kloppers
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Isaie Sibomana
- Department of Surgery, University of Rwanda, Kigali, Rwanda
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.
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20
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Abstract
Within general surgery education circles, the state of autonomy for residents in surgery training programs has been of growing concern. Although there is no direct evidence showing less autonomy in modern surgical training, multiple surrogates have been cited as reasons for concern. Many reasons have been given for lost autonomy including the 80-hour work week, financial constraints, concerns over quality of patient care, patient expectations, new and innovative technologies, legal limitations, and public opinion. This article discusses the current state of general surgery resident autonomy, why autonomy is important, barriers to autonomy, and ways to support autonomy.
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21
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Introduction of robotic surgery does not negatively affect cardiothoracic surgery resident experience. J Robot Surg 2021; 16:393-400. [PMID: 34024007 DOI: 10.1007/s11701-021-01255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
The objective of this study was to evaluate the educational impact following the implementation of a robotic thoracic surgery program on cardiothoracic (CT) surgery trainees. We hypothesized that the introduction of a robotic thoracic surgery program would adversely affect the CT surgery resident experience, decreasing operative involvement and subsequent competency of surgical procedures. CT surgery residents and thoracic surgery attendings from a single academic institution were administered a recurring, electronic survey from September 2019 to September 2020 following each robotic thoracic surgery case. Surveys evaluated resident involvement and operative performance. This study was exempt from review by our Institutional Review Board. Attendings and residents completed surveys for 86 and 75 cases, respectively. Residents performed > 50% of the operation independently at the surgeon console in 66.2 and 73.3% of cases according to attending and resident responses, respectively. The proportion of trainees able to perform > 75% of the operation increased with each increasing year in training (p = 0.002). Based on the Global Evaluative Assessment of Robotic Skills grading tool, third-year residents averaged higher scores compared to first-year residents (22.9 versus 17.4 out of 30 possible points, p < 0.001), indicating that more extensive prior operative experience could shorten the learning curve of robotic thoracic surgery. CT surgery residents remain actively involved in an operative role during the establishment of a robotic thoracic surgery program. The transition to a robotic thoracic surgery platform appears feasible in a large academic setting without jeopardizing the educational experience of resident trainees.
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22
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Urban MJ, Brown HJ, Kim J, Eggerstedt M, Debettencourt JB, Husain I, Papagiannopoulos P, Tajudeen BA, Batra PS, LoSavio PS. Patients' Perceptions of Resident Surgeon Involvement in Otolaryngology. Laryngoscope 2021; 131:2448-2454. [PMID: 33932227 DOI: 10.1002/lary.29599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess patient acceptance of resident involvement in otolaryngologic procedures and to evaluate the impact of a written preoperative educational pamphlet. STUDY DESIGN Prospective cohort study. METHODS This is a prospective survey study at a large tertiary care academic center. In addition to standard perioperative instructions and informed consent, 87 out of 183 patients received a pamphlet with information on the role of the otolaryngology resident. RESULTS Greater than 90% of all patients surveyed recognized that resident physicians are directly involved in delivering care at teaching hospitals and may have assisted in their surgical procedure. Ninety percent of patients receiving educational pamphlets were aware residents may have performed portions of their procedure versus 71% in the control group (P = .001). Ninety-seven percent of patients receiving pamphlets wanted to know how much of their procedure was performed by a resident versus 71% of the control group (P < .001), and patients undergoing single-surgeon procedures were less likely to want to know how much was performed by a resident (P < .05). Ninety-six percent in the pamphlet group agreed that residents improved the quality of their care versus 79% of the control group (P = .001). DISCUSSION Resident surgeons are well received by the large majority of otolaryngology patients. Structured perioperative information regarding surgical training facilitates an honest and open informed consent discussion between the patient and surgeon and helps to establish a solid foundation of trust. CONCLUSION Implementation of this practice is simple and inexpensive. It should be considered for any clinical practice with a focus on surgical education. LEVEL OF EVIDENCE 4. Laryngoscope, 2021.
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Affiliation(s)
- Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Hannah J Brown
- Rush University Medical College, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jae Kim
- Rush University Medical College, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Michael Eggerstedt
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joseph B Debettencourt
- Rush University Medical College, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Inna Husain
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Peter Papagiannopoulos
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bobby A Tajudeen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Pete S Batra
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Phillip S LoSavio
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Dickinson KJ, Bass BL, Pei KY. Public Perceptions of General Surgery Residency Training. JOURNAL OF SURGICAL EDUCATION 2021; 78:717-727. [PMID: 33160942 DOI: 10.1016/j.jsurg.2020.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/13/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety. DESIGN This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training. CONCLUSIONS Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.
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Affiliation(s)
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington, District of Columbia
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana
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Kana LA, Firn JI, Shuman AG, Hogikyan ND. Patient Perceptions of Trust in Trainees During Delivery of Surgical Care: A Thematic Analysis. JOURNAL OF SURGICAL EDUCATION 2021; 78:462-468. [PMID: 32888849 DOI: 10.1016/j.jsurg.2020.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/09/2020] [Accepted: 08/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Trust is an essential element of an effective physician-patient relationship. There is limited literature examining trust between trainees and patients in the surgical setting. The goal of this study was to investigate how otolaryngology patients perceive trust in trainees during delivery of surgical care. DESIGN We extracted trainee-specific data from a larger, qualitative interview study examining trust in the surgeon-patient relationship. We then used realist thematic analysis to explore preoperative otolaryngology patients' perceptions of trust in trainees during delivery of surgical care. SETTING Department of Otolaryngology-Head and Neck Surgery at Michigan Medicine in Ann Arbor, MI, a tertiary academic medical center. PARTICIPANTS Using convenience sampling, adults 18 years or older scheduled to undergo elective otolaryngologic surgery between February and June 2019 were invited, and 12 agreed to participate in the study. RESULTS All participants (n = 12) self-identified as White/Caucasian with a mean age of 60 years (range, 28-82). Participants were 50% (n = 6) female and 50% (n = 6) male. Thematic analysis of participants' perspectives about trust in trainees during delivery of surgical care revealed 3 themes. Trust in trainees is conditional based on (i) level of trainee involvement; (ii) trust in the attending surgeon; and, (iii) trust in the institution. CONCLUSION Trust in trainees during delivery of surgical care is conditional on types of tasks trainees perform, bounded by trust in their attending surgeon, and positively influenced by institutional trust. Trainees and surgical educators must look to innovative methods to engender trust more efficiently in the clinic and immediate pre-operative setting. Such approaches can have a positive impact on patient outcomes, facilitate stronger trainee-attending interpersonal relationships, and empower surgeons to practice the professional values integral to surgical care.
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Affiliation(s)
- Lulia A Kana
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Janice I Firn
- University of Michigan Medical School, Ann Arbor, Michigan; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Andrew G Shuman
- University of Michigan Medical School, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Norman D Hogikyan
- University of Michigan Medical School, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
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Joh DB, van der Werf B, Watson BJ, French R, Bann S, Dennet E, Loveday BPT. Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees. JAMA Surg 2021; 155:1019-1026. [PMID: 32857160 DOI: 10.1001/jamasurg.2020.3021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program. Objective To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program. Design, Setting, and Participants Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand. Main Outcomes and Measures The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis. Results This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures. Conclusions and Relevance After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.
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Affiliation(s)
- Daniel B Joh
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Bert van der Werf
- Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Bridget J Watson
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | - Rowan French
- Department of Surgery, Waikato District Health Board, Hamilton, New Zealand
| | - Simon Bann
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Elizabeth Dennet
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Benjamin P T Loveday
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Royal Melbourne Hospital, Victoria, Australia
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Cassidy DJ, McKinley SK, Ogunmuyiwa J, Mullen JT, Phitayakorn R, Petrusa E, Kim MJ. Surgical autonomy: A resident perspective and the balance of teacher development with operative independence. Am J Surg 2021; 221:336-344. [DOI: 10.1016/j.amjsurg.2020.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/05/2020] [Accepted: 10/18/2020] [Indexed: 10/23/2022]
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Rosenfeld ES, Napolitano MA, Sparks AD, Werba G, Antevil JL, Trachiotis GD. Impact of Trainee Involvement on Video-Assisted Thoracoscopic Lobectomy for Cancer. Ann Thorac Surg 2021; 112:1855-1861. [PMID: 33358890 DOI: 10.1016/j.athoracsur.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/20/2020] [Accepted: 12/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous literature in other surgical disciplines regarding the impact of resident and fellow involvement on operative time and outcomes has yielded mixed results. The impact of trainee involvement on minimally invasive thoracic surgery is unknown. This study compared risk-adjusted differences in operative time and outcomes of video-assisted thoracoscopic lobectomy for cancer between cases performed with and without residents and fellows involved. METHODS All patients undergoing elective video-assisted thoracoscopic lobectomy for cancer between 2008 and 2018 were identified in the Veterans Affairs Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: cases with residents and fellows involved, and cases performed only by attending surgeons. Primary outcomes included operative time, postoperative hospital length of stay, and composite 30-day morbidity and mortality. Secondary outcomes included factors associated with high and low trainee operative autonomy. RESULTS A total of 3678 patients met study inclusion criteria. In all, 1780 cases were performed with residents and fellows involved (median postgraduate year, 5; interquartile range, 4-7). Multivariate analysis showed that operative time was significantly shorter in resident- and fellow-involved cases compared with attending-only cases (mean [SD], 3.6 [1.4] versus 3.8 [1.6] hours; P < .001). There were no significant differences in composite 30-day morbidity and mortality (16.0% versus 17.1%; adjusted odds ratio = 0.93; 95% confidence interval, 0.77-1.11; P = .40) or length of stay. Substratification of trainees by postgraduate year resulted in similar findings. Cases performed in July through October and those in the Northeastern United States were associated with low autonomy. CONCLUSIONS Current training paradigms in thoracic surgery are safe, and the involvement of motivated and skilled trainees with appropriate supervision may benefit operative duration.
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Affiliation(s)
- Ethan S Rosenfeld
- Division of Cardiothoracic Surgery and Heart Center, Washington, DC Veterans Affairs Medical Center, Washington, DC; Department of Surgery, George Washington University, Washington, DC
| | - Michael A Napolitano
- Division of Cardiothoracic Surgery and Heart Center, Washington, DC Veterans Affairs Medical Center, Washington, DC; Department of Surgery, George Washington University, Washington, DC
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC
| | - Gregor Werba
- Department of Surgery, George Washington University, Washington, DC
| | - Jared L Antevil
- Division of Cardiothoracic Surgery and Heart Center, Washington, DC Veterans Affairs Medical Center, Washington, DC
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery and Heart Center, Washington, DC Veterans Affairs Medical Center, Washington, DC; Department of Surgery, George Washington University, Washington, DC.
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Perceptions of Preparedness in Plastic Surgery Residency Training. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3163. [PMID: 33173679 PMCID: PMC7647638 DOI: 10.1097/gox.0000000000003163] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/10/2020] [Indexed: 12/26/2022]
Abstract
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.
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Randle RW, Ahle SL, Elfenbein DM, Hildreth AN, Lee CY, Greenberg JA, Schenarts PJ, Kempenich JW. Surgical Trainees’ Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal. J Surg Res 2020; 255:58-65. [DOI: 10.1016/j.jss.2020.05.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/14/2020] [Accepted: 05/03/2020] [Indexed: 01/25/2023]
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White EM, Miller SM, Esposito AC, Yoo PS. "Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent. JOURNAL OF SURGICAL EDUCATION 2020; 77:e47-e51. [PMID: 32753261 DOI: 10.1016/j.jsurg.2020.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations. DESIGN This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature. CONCLUSIONS We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.
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Affiliation(s)
- Erin M White
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
| | - Samuel M Miller
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
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Senociain Gonzalez JE, Dominguez Torres LC. Transferencia de autonomía operatoria en apendicectomía abierta y laparoscópica: Un estudio de métodos mixtos desde la perspectiva de residentes y supervisores. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. Existe información limitada sobre el desarrollo apropiado de curvas quirúrgicas de aprendizaje, con altos niveles de autonomía, en residentes de cirugía general en Colombia. El objetivo de este estudio fue caracterizar los niveles de autonomía, para la realización de apendicectomía laparoscópica o abierta en un programa de especialización, desde la perspectiva de médicos residentes y supervisores.
Métodos. Estudio de métodos mixtos que se realizó en dos fases. La primera fase incluyó la recolección prospectiva de la información de cada procedimiento (apendicectomía abierta o laparoscópica), realizado entre agosto de 2015 y diciembre de 2018, en la que participaron 29 médicos residentes. Cada residente evaluó su función (cirujano, ayudante), el nivel de supervisión y el nivel de autonomía intraoperatoria mediante la Escala de Zwisch (EZ). En la segunda fase (cualitativa), se realizaron entrevistas a un total de 15 cirujanos generales que supervisaron la práctica de los residentes con preguntas que buscaban explicar los hallazgos cuantitativos.
Resultados. Se analizaron 1732 intervenciones: 629 (36 %) se realizaron por vía abierta y 1103 (63 %) por vía laparoscópica. El 81,4 % (n=1411) de los procedimientos fueron realizados en hospitales privados. La percepción global de autonomía reportada por los residentes de acuerdo con la Escala de Zwisch tuvo nivel A 28,9 % (n=500), nivel B 18,1 % (n=313), nivel C 30,4 % (n=526) y nivel D 22,7 % (n=393). El 35,2 % (n=388) de apendicectomías laparoscópicas y el 17,8% (n=112) por vía abierta fueron realizadas con un nivel A, mientras el 19,5 % (n=215) de apendicectomías laparoscópicas y el 28,2 % (n=178) por vía abierta fueron realizadas con un nivel D. La explicación dada de los hallazgos cuantitativos fue la frecuencia de apendicectomías abiertas en hospitales públicos, aspectos relacionados con la transferencia de autonomía hacia el residente y el aumento progresivo en el nivel de autonomía avanzada entre 2015-2018.
Discusión. Se encontró un mayor nivel de autonomía en la realización de apendicectomía por vía abierta comparada con la vía laparoscópica, y los niveles de autonomía fueron mayores en hospitales públicos. La explicación a estos hallazgos estuvo relacionada con el contexto clínico y profesional de los residentes.
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Shin TH, Naples R, French JC, Khandelwal CM, Rose W, Alaedeen D, Dai J, Lipman J, Rosen MJ, Petro C. Effect modification of resident autonomy and seniority on perioperative outcomes in laparoscopic cholecystectomy. Surg Endosc 2020; 35:3387-3397. [PMID: 32642848 DOI: 10.1007/s00464-020-07780-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited. METHODS Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time. RESULTS Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64-9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p < 0.001, 95% CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p = 0.069, 95% CI 0.99-1.41). CONCLUSION While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.
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Affiliation(s)
- Thomas H Shin
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. .,Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - Robert Naples
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Judith C French
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Warren Rose
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diya Alaedeen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jie Dai
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Lipman
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael J Rosen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Clayton Petro
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Bryan AF, Bryan DS, Matthews JB, Roggin KK. Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles. JOURNAL OF SURGICAL EDUCATION 2020; 77:534-539. [PMID: 32201142 DOI: 10.1016/j.jsurg.2020.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/03/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Progressive autonomy leading to conditional independence is necessary to achieve competence in surgical skills and decision making. Trust and transparency are ethical imperatives, but practices vary regarding the extent of disclosure of specific resident roles. We tested whether a standardized preoperative script would improve patient acceptance of resident involvement in perioperative care. METHODS Patients admitted to a resident-run acute care general surgery service between October 2017 and October 2018 were enrolled in an IRB-approved study. During the first half of the rotation (control), operative consent was obtained according to individual practice without specified explanation of resident roles. During the second half (intervention), the senior resident read a short semistructured script specifically explaining team roles and responsibilities, including the degree of resident independence and supervision by attendings. On postoperative day 3, patients completed a survey assessing understanding of their surgical care. RESULTS Sixty-two patients under the care of 10 rotating chief residents were enrolled; 46 patients completed the survey, 23 in each arm (74% response rate). Ten patients in the control arm (43%) compared to only 3 (13%) in the intervention arm indicated that residents should not be allowed to perform portions of operations (odds ratio 4.94, p = 0.047). Patients in the intervention arm felt that care team roles were more adequately explained to them before their operation (p = 0.002). There was no difference in the number of patients naming a resident as "their doctor." CONCLUSIONS Use of a short script specifying resident roles improves patient acceptance of trainee participation in perioperative care.
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Affiliation(s)
- Ava Ferguson Bryan
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois
| | - Darren S Bryan
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois
| | - Jeffrey B Matthews
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois
| | - Kevin K Roggin
- The University of Chicago Medicine, Department of Surgery, Chicago, Illinois.
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Shakir S, Kozak GM, Nathan SL, Davis H, Whitely C, Broach RB, Fosnot J. The Role of a Resident Aesthetic Clinic in Addressing the Trainee Autonomy Gap. Aesthet Surg J 2020; 40:NP301-NP311. [PMID: 31724036 DOI: 10.1093/asj/sjz324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. OBJECTIVES The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. METHODS A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. RESULTS In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. CONCLUSIONS The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.
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Affiliation(s)
- Sameer Shakir
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Geoffrey M Kozak
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Shelby L Nathan
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Harrison Davis
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Cutler Whitely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Abstract
BACKGROUND Appropriate, progressive trainee autonomy is critical for training competent plastic surgeons who are adequately prepared to enter independent practice. Evaluation and reporting of meaningful operative autonomy among trainees in plastic surgery are understudied. METHODS Parallel survey instruments were developed using the Zwisch metric for progressive operative autonomy and distributed electronically to trainees and faculties in all accredited training programs. Trainees were queried about their operative autonomy in 17 core plastic surgery procedures, associated approach to logging cases, and perceived readiness to enter practice. Faculties provided assessment of their final-year trainees using the same metrics. RESULTS Trainees in 28 programs and faculties in 35 programs participated. Final-year trainees reported the most operative independence with breast tissue expander reconstruction and carpal tunnel release and the least with facelift and rhinoplasty. A mean of 40% of final-year trainees reached supervision only autonomy in the procedures queried; none achieved this with rhinoplasty. Faculties identified the highest final-year trainee operative autonomy with botulinum toxin injection and burn excision and grafting; the least trainee independence was reported with rhinoplasty, cleft lip repair, and facelift. Faculty perception of final-year trainee autonomy was higher than that of trainees for 82% of procedures queried. CONCLUSIONS Although plastic surgery trainees endorse gradual operative autonomy overall, a majority of final-year trainees do not perceive supervision only independence in the majority of core procedures queried. Faculties perceive higher trainee operative autonomy than trainees for most procedures. Discordant approaches to case logging were identified both among trainees and between trainees and faculties. Standardization may improve both progression and assessment of operative autonomy in plastic surgery training.
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Jajja MR, Lovasik BP, Kim SC, Wang VL, Hinman JM, Delman KA, Srinivasan JK. Can a Structured, Video-Based Cadaver Curriculum Demonstrating Proficiency Enhance Resident Operative Autonomy? JOURNAL OF SURGICAL EDUCATION 2019; 76:e152-e160. [PMID: 31543410 DOI: 10.1016/j.jsurg.2019.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/10/2019] [Accepted: 08/04/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Autonomy is of foremost concern in the current era of surgical residency, and it is especially important to trainees when considering their surgical education. Factors impacting trainee independence include the restriction of clinical work hours and the development of advanced minimally invasive techniques such as robotics, which requires separate technical education outside of conventional surgical education. Moreover, when residents are left to learn fundamental exposures via their clinical experience alone, they run the risk of not being exposed to some fundamental skills based on case volume and type. The Department of Surgery at Emory University developed a cadaver-based simulation curriculum to standardize exposure to fundamental operative skills and enhance proficiency outside the operating room, with the larger aim of improving resident autonomy. METHODS Residents were assigned to small groups led by a chief resident with an even distribution of postgraduate year (PGY) levels. Each group participated in core surgical exposures and fundamental maneuvers on a cadaver over a 6-hour session. Residents were tested on skills according to their PGY level about 1 month after the course. Testing included recitation of the skill in an oral boards format, highlighting major steps, followed by performance of the skill. All steps were video-recorded with no resident identifiers. These were reviewed by 2 independent, blinded faculty examiners who assigned proficiency grades to each resident video. RESULTS Three hundred and thirty-three individual procedure evaluations were done over the 5-year period. Senior residents (PGY3-5) had 86% pass rate while junior residents (PGY1-2) had 70% pass rate. Overall, 21% of residents failed to achieve competence in their assigned skills. Junior residents were less likely to achieve competence compared to senior residents. Faculty graders had improved congruence in grading as the course progressed through the 5 years. The most recent 2 years had >80% congruence in faculty grading compared to less than 50% congruence in the first 2 years. 81% of attendings agreed this course positively influenced the granting of autonomy in the operating room. CONCLUSIONS A cadaveric skills course focused on fundamental maneuvers with objective confirmation of achieving competency is a viable adjunct to clinical operative experience. Video-recorded evaluation, of these fundamental skills improved both resident and attending confidence in trainee operative skill.
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Affiliation(s)
- Mohammad Raheel Jajja
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Brendan P Lovasik
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Steven C Kim
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Vivian L Wang
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Johanna M Hinman
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Keith A Delman
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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Kiger ME, Meyer HS, Hammond C, Miller KM, Dickey KJ, Hammond DV, Varpio L. Whose Patient Is This? A Scoping Review of Patient Ownership. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:S95-S104. [PMID: 31365409 DOI: 10.1097/acm.0000000000002920] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE The scope of physicians' responsibility toward patients is becoming increasingly complicated to delimit as interdisciplinary care delivery and degrees of subspecialization increase. Patients can easily be lost across multiple transitions involved in care. Preparing learners to engage in safe and responsible patient care requires that we be clear about parameters of patient ownership. This scoping review (1) explores and synthesizes definitions of patient ownership and (2) describes the factors that influence patient ownership. METHOD Searching PubMed, Embase, and PsycINFO, the authors sought out publications of any format (i.e., original research papers, review articles, commentaries, editorials, and author discussions) that (1) addressed patient ownership directly or a closely related concept that explicitly affected patient ownership, (2) included medical care providers (attending/faculty physicians, medical residents, and/or medical students), and (3) were published in English. The authors analyzed findings to construct common themes and categorize findings. RESULTS Of 411 papers screened, 82 met our inclusion criteria. Twenty-three papers defined patient ownership in highly variable ways. Common themes across definitions included responsibility for patient care, personally carrying out patient care tasks, knowledge of patients' medical information, independent decision making, and putting patients' needs above one's own. Factors influencing patient ownership were (1) logistical concerns, (2) personal attributes, and (3) socially or organizationally constructed expectations. CONCLUSIONS A new definition of patient ownership is proposed encompassing findings from the review, while also respecting the shift from individual to a team-based patient care, and without removing the centrality of an individual provider's commitment to patients.
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Affiliation(s)
- Michelle E Kiger
- M.E. Kiger is assistant professor, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland. H.S. Meyer is assistant professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. C. Hammond is clinical instructor, Department of Pediatrics, Wright State University, Dayton, Ohio. K.M. Miller is resident physician, Wright State University School of Medicine, Dayton, Ohio. K.J. Dickey is resident physician, Wright State University School of Medicine, Dayton, Ohio. D.V. Hammond is pediatrician, Keesler Medical Center, Biloxi, Mississippi. L. Varpio is professor, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Wagner JP, Lewis CE, Tillou A, Agopian VG, Quach C, Donahue TR, Hines OJ. Use of Entrustable Professional Activities in the Assessment of Surgical Resident Competency. JAMA Surg 2019; 153:335-343. [PMID: 29141086 DOI: 10.1001/jamasurg.2017.4547] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Competency-based assessments of surgical resident performance require metrics of entrustable autonomy. Objectives To designate entrustable professional activities (EPAs) in global performance and in specific operations, and to identify differences in perceived capability, autonomy, and expectations between surgical faculty and residents. Design, Setting, and Participants This survey study was conducted from August 9, 2016, through August 24, 2016, in the Department of Surgery at the UCLA David Geffen School of Medicine. The survey instrument consisted of 5-point Likert scales for assessing perceptions of entrustability for 5 global and 5 operative EPAs. Faculty members were surveyed regarding resident capabilities and expected capabilities by postgraduate year. Residents were surveyed regarding their own capabilities, actual autonomy entrusted in the last EPA performed, and expected capabilities. Main Outcomes and Measures Differences in mean ratings were assessed across 7 comparison domains. Results Among 78 total faculty members, 31 (40%) participated in the survey. Among 49 residents, 39 (80%) participated in the survey. Residents generally rated their global EPA performance higher than the faculty did (mean, 3.7 vs 2.8; P < .01), but operative EPA performance ratings were equivalent (mean, 2.7 vs 2.4; P < .12). Faculty members perceived senior residents as underperforming expectations in operative EPAs. Most faculty members (80%) expected residents not to be independently capable of performing complex operations by graduation. Faculty members perceived residents in postgraduate years 4 and 5 to have greater operative capability than the level of autonomy entrusted to those residents (95% CI, 3.3-3.5 vs 1.9-2.2). Conclusions and Relevance Global and operative EPAs are practical for developing competency-based curricula. Graduated autonomy should be granted to improve the operative experience for residents.
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Affiliation(s)
- Justin P Wagner
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | | | - Areti Tillou
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Vatche G Agopian
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Chi Quach
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - Timothy R Donahue
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| | - O Joe Hines
- Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
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Park J, Ponnala S, Fichtel E, Tehranchi K, Fitzgibbons S, Parker SH, Lau N, Safford SD. Improving the Intraoperative Educational Experience: Understanding the Role of Confidence in the Resident-Attending Relationship. JOURNAL OF SURGICAL EDUCATION 2019; 76:1187-1199. [PMID: 31255644 DOI: 10.1016/j.jsurg.2019.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/02/2019] [Accepted: 02/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE With recent changes to graduate medical education, the balance between resident autonomy and need for supervision impacts the educational and training experience of residents. The objective of this study was to understand the relationship between the confidence of attendings and residents and their different perspectives of perceived educational experience and autonomy in the operating room (OR). We hypothesized that the attending's confidence in the resident would be an important factor in improving the educational experience and resident's autonomy in the OR. DESIGN Self-reported confidence-rating and operative experience surveys were administered to teams of post-graduate year (PGY 1) through PGY 5 surgical residents and attendings in two temporal sets (Early: Sept-Dec 2015, n = 20; Late: Jan-Apr 2016, n = 22). A second "end-of-year" survey was distributed to residents (n = 9, 37.5% response) and attendings (n = 10, 35% response) asking questions regarding their educational experience and operative experience during the past year. SETTING Large rural teaching hospital. PARTICIPANTS Nineteen general surgery residents (PGY 1 - 5) and 14 general surgery attendings. RESULTS Resident perception of confidence differs from junior to senior residents, and that there was discordance between resident's confidence and skill as perceived by attendings, particularly in senior residents. Results also showed that attending's confidence in residents was positively correlated with attending's perceived educational experience in the OR. Residents and attendings both indicated attending's confidence in residents as an important factor in increasing resident autonomy in the OR, thus the attending's confidence in residents could have a positive impact on resident autonomy and educational experience in the OR. CONCLUSIONS We have demonstrated a relationship between self-confidence for residents and improved confidence from attendings in residents' capabilities. Based on these findings, we would propose identifying methods to expand resident's awareness of surgical situations and develop attending's confidence in residents.
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Affiliation(s)
- Juyeon Park
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Siddarth Ponnala
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Eric Fichtel
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Kian Tehranchi
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Shimae Fitzgibbons
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Sarah Henrickson Parker
- Human Factors Research, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Nathan Lau
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Shawn D Safford
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
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Allen M, Gawad N, Park L, Raîche I. The Educational Role of Autonomy in Medical Training: A Scoping Review. J Surg Res 2019; 240:1-16. [DOI: 10.1016/j.jss.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
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Wojcik BM, McKinley SK, Amari N, Chang DC, Wachtel H, Petrusa E, Mullen JT, Phitayakorn R. A comparison of patient satisfaction when office-based procedures are performed by general surgery residents versus an attending surgeon. Surgery 2019; 166:116-122. [DOI: 10.1016/j.surg.2019.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/04/2019] [Accepted: 02/07/2019] [Indexed: 11/29/2022]
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Singman EL, Boland MV, Tian J, Green LK, Srikumaran D. Supervision and autonomy of ophthalmology residents in the outpatient clinic in the United States II: a survey of senior residents. BMC MEDICAL EDUCATION 2019; 19:202. [PMID: 31196084 PMCID: PMC6567568 DOI: 10.1186/s12909-019-1620-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/22/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND A balance between autonomy and supervision can be difficult to obtain in medical education. In this study, we sought to determine whether the presence and level of supervision of ophthalmology resident outpatient clinic correlates with metrics of resident success, professionalism and stress. METHODS A survey was emailed to all US ophthalmology program directors requesting it be forwarded to PGY4 residents. Questions included whether their program provided a resident-hosted outpatient clinic, and if so, whether residents were mandated to discuss every patient with faculty. Residents were assigned to three categories based on this question (0: no clinic, 1: mandated faculty input, 2: discretionary faculty input). Success metrics included numbers of manuscripts submitted, OKAP scores and success in obtaining fellowships. Professionalism metrics included rating comfort obtaining informed consent, breaking bad news, managing time in clinic, and confidence in providing care in various settings. Residents affirming participation in a continuity clinic also provided perceptions of the level of supervision and how the clinic affected stress. RESULTS Category 1 residents perceived somewhat too much supervision, while category 2 residents felt that they had somewhat insufficient supervision. The majority of residents in either category did not feel that the continuity clinic affected their overall stress, although those who reported a change in stress usually indicated that the presence of the clinic increased stress. There were no other statistically significant differences between the responses from any category. CONCLUSIONS The presence of a resident-hosted continuity clinic neither adds nor detracts from the success or sense of professionalism of ophthalmology residents. However, when such a clinic is present, the degree of supervision appears to correlate inversely with resident perception of autonomy. These results suggest that the decision of a training program to offer a clinic hosted by residents offering comprehensive continuity care can be informed primarily by faculty and trainee philosophy and personal preferences without comprising education quality, clinical efficiency, residents' perception of stress or their success in fellowship matching.
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Affiliation(s)
- Eric L Singman
- General Eye Services, Wilmer Eye Institute, Johns Hopkins School Of Medicine, Wilmer B-29, 600 N. Wolfe St., Johns Hopkins Hospital, Baltimore, MD, 21287, USA.
| | - Michael V Boland
- General Eye Services, Wilmer Eye Institute, Johns Hopkins School Of Medicine, Wilmer B-29, 600 N. Wolfe St., Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - Jing Tian
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Laura K Green
- Lifebridge Health Krieger Eye Institute, Baltimore, USA
| | - Divya Srikumaran
- General Eye Services, Wilmer Eye Institute, Johns Hopkins School Of Medicine, Wilmer B-29, 600 N. Wolfe St., Johns Hopkins Hospital, Baltimore, MD, 21287, USA
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Senders ZJ, Aeder M, Semrau S, Ammori J. Improving Resident-To-Attending Communication: Implementing a Tool to Facilitate Attending Notification of Critical Patient Events at a Single Academic Institution. Am Surg 2019. [DOI: 10.1177/000313481908500632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ineffective communication between surgical trainees and attending surgeons is a significant contributor to patient harm. The aim of this study was to evaluate a tool to improve resident-to-attending communication regarding changes in patient clinical status. Ten critical patient events were compiled into a list of triggers for direct attending surgeon notification at a single academic institution. Residents and faculty were surveyed to assess communication before and after implementation of the list. Institution of the triggers list was associated with a nonstatistically significant increase in resident-to-attending notification regarding 7 of 10 critical patient events. There was no reported change in frequency of calls associated with the list's implementation. Most residents felt that the list improved patient care and increased their comfort with calling attending surgeons. Comments were generally positive; however, both groups expressed concern that the list could negatively impact resident autonomy and supervision. Implementing a list of triggers for attending notification of critical patient events subjectively improved resident-to-attending communication in an environment with high baseline levels of communication.
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Affiliation(s)
- Zachary J. Senders
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; and
| | - Mark Aeder
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; and
| | - Susan Semrau
- University Hospitals Cleveland Medical Center, Quality Institute, Cleveland, Ohio
| | - John Ammori
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; and
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Abstract
OBJECTIVE The aim of this study is to establish evidence to support the validity of a novel faculty-resident intraoperative assessment tool for entrustment known as OpTrust. BACKGROUND Recently, the landscape of surgical training has been altered, in part, because of resident work-hour changes and increased supervision requirements. To address these concerns, a new model for assessment of teaching and learning in surgical residencies must be anchored on progression through milestones and entrustment. METHODS OpTrust was designed to assess the faculty-resident dyad in the operating room and measure the entrustment exhibited during intraoperative interactions across 5 domains: (i) types of questions asked, (ii) operative plan, (iii) instruction, (iv) problem solving, and (v) leadership by the surgical resident. After initial pilot testing and refinement of OpTrust, 5 individual raters underwent rater training sessions; 49 individual operating room observations were completed based on 28 cases. RESULTS OpTrust, as a tool for assessing intraoperative entrustment, is supported by strong validity evidence. In part, it demonstrates strong interrater reliability across all faculty domains as measured by intraclass correlation 1 (ICC1) (0.81-0.93). For resident domains the results were similar with ICC1 (0.84-0.94). Cronbach alpha was 0.89 and 0.87 for faculty and resident entrustment respectively, signifying the 5 domains could be combined into a single construct of entrustment. A high correlation existed between faculty and resident scores (Pearson r = 0.94, P < 0.001) indicating a strong positive linear relationship between faculty and resident mean entrustment scores across all scale domains. CONCLUSIONS OpTrust successfully assesses behaviors associated with entrustment during intraoperative faculty-resident interactions, and has the potential to be adopted across other procedural-based specialties to promote autonomous training progression.
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Seniorization of Tasks in the Academic Medical Center: A Worrisome Trend. J Am Coll Surg 2019; 228:299-302. [DOI: 10.1016/j.jamcollsurg.2018.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 01/24/2023]
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See one, do one, teach one: A randomized controlled study evaluating the benefit of autonomy in surgical education. Am J Surg 2019; 217:281-287. [DOI: 10.1016/j.amjsurg.2018.10.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 11/17/2022]
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Kempenich JW, Willis RE, Fayyadh MA, Campi HD, Cardenas T, Hopper WA, Giovannetti CA, Reed CC, Dent DL. Video-Based Patient Education Improves Patient Attitudes Toward Resident Participation in Outpatient Surgical Care. JOURNAL OF SURGICAL EDUCATION 2018; 75:e61-e67. [PMID: 30217778 DOI: 10.1016/j.jsurg.2018.07.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/28/2018] [Accepted: 07/30/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Decipher if patient attitudes toward resident participation in surgical care can be improved with patient education using a video-based modality. DESIGN A survey using a 5-pt Likert scale was created, piloted, and distributed in general and colorectal surgery outpatient clinics that had residents involved with patient care at 2 facilities, both with control and intervention groups. The intervention group viewed a short video (∼4 min) explaining the role, education, and responsibilities of medical students, residents, and attending surgeons prior to answering the survey. SETTING General and colorectal surgery outpatient clinics at the University of Texas Health San Antonio, Texas. PARTICIPANTS A total of 383 responses were collected, all clinic patients were eligible. RESULTS The majority of patients (82%) welcomed resident participation in their health care. Eighteen percent of patients did not expect residents to be involved in their care. Patients had favorable views of residents participating during their surgical procedures with 77% responding "agree" or "strongly agree" to a senior resident assisting with a complicated procedure. Patients who viewed the video versus control were less concerned with how much of the procedure the resident would perform (76% vs 86%, p = 0.010). Patients who viewed the video felt less inconvenienced (p = 0.004). CONCLUSIONS The majority of patients are welcoming to resident participation in their surgical care but only 54% were expecting resident involvement at their clinic visit. Early explanation with an educational video of resident roles, education, and responsibilities may help bridge the gap and improve patient experience.
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Affiliation(s)
- Jason W Kempenich
- University of Texas Health Science Center at San Antonio, San Antonio, Texas.
| | - Ross E Willis
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Mohammed Al Fayyadh
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Haisar Dao Campi
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Tatiana Cardenas
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - William A Hopper
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Charles C Reed
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Daniel L Dent
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Deal SB, Alseidi AA, Chipman JG, Gauvin J, Meara M, Sidwell R, Stefanidis D, Schenarts PJ. Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method. JOURNAL OF SURGICAL EDUCATION 2018; 75:1504-1512. [PMID: 30115566 DOI: 10.1016/j.jsurg.2018.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/21/2018] [Accepted: 05/15/2018] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Shanley B Deal
- Virginia Mason Medical Center, General, Thoracic and Vascular Surgery, Seattle, Washington.
| | - Adnan A Alseidi
- Virginia Mason Medical Center, General, Thoracic and Vascular Surgery, Seattle, Washington
| | - Jeffrey G Chipman
- University of Minnesota, Department of Surgery, Minneapolis, Minnesota
| | - Jeffrey Gauvin
- Santa Barbara Cottage Hospital, Department of General Surgery, Santa Barbara, California
| | - Michael Meara
- Ohio State University Wexner College, Columbus, Ohio
| | | | | | - Paul J Schenarts
- University of Nebraska Medical Center, Department of Surgery, Omaha, Nebraska
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Chouari TAM, Lindsay K, Bradshaw E, Parson S, Watson L, Ahmed J, Curnier A. An enhanced fresh cadaveric model for reconstructive microsurgery training. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018; 41:439-446. [PMID: 30100677 PMCID: PMC6061477 DOI: 10.1007/s00238-018-1414-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/27/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Performing microsurgery requires a breadth and depth of experience that has arguably been reduced as result of diminishing operating exposure. Fresh frozen cadavers provide similar tissue handling to real-time operating; however, the bloodless condition restricts the realism of the simulation. We describe a model to enhance flap surgery simulation, in conjunction with qualitative assessment. METHODS The fresh frozen cadaveric limbs used in this study were acquired by the University. A perfused fresh cadaveric model was created using a gelatin and dye mixture in a specific injection protocol in order to increase the visibility and realism of perforating vessels, as well as major vessels. A questionnaire was distributed amongst 50 trainees in order to assess benefit of the model. Specifically, confidence, operative skills, and transferable procedural-based learning were assessed. RESULTS Training with this cadaveric model resulted in a statistically significant improvement in self-reported confidence (p < 0.005) and prepared trainees for unsupervised bench work (p < 0.005). Respondents felt that the injected model allowed easier identification of vessels and ultimately increased the similarity to real-time operating. Our analysis showed it cost £10.78 and took 30 min. CONCLUSIONS Perfusion of cadaveric limbs is both cost- and time-effective, with significant improvement in training potential. The model is easily reproducible and could be a valuable resource in surgical training for several disciplines.Level of Evidence: Not ratable.
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Affiliation(s)
- Tarak Agrebi Moumni Chouari
- Aberdeen University Anatomy Department, The Suttie Centre for Teaching and Learning in Healthcare, Aberdeen, Scotland UK
- Plastics and Reconstructive Surgery Department, Aberdeen Royal Infirmary, Aberdeen, Scotland UK
| | - Karen Lindsay
- Plastics and Reconstructive Surgery Department, Aberdeen Royal Infirmary, Aberdeen, Scotland UK
| | - Ellen Bradshaw
- Aberdeen University Anatomy Department, The Suttie Centre for Teaching and Learning in Healthcare, Aberdeen, Scotland UK
- Plastics and Reconstructive Surgery Department, Aberdeen Royal Infirmary, Aberdeen, Scotland UK
| | - Simon Parson
- Aberdeen University Anatomy Department, The Suttie Centre for Teaching and Learning in Healthcare, Aberdeen, Scotland UK
| | - Lucy Watson
- Bristol University Centre for Applied Anatomy, School of Veterinary Science, Bristol, England UK
| | - Jamil Ahmed
- Plastics and Reconstructive Surgery Department, Aberdeen Royal Infirmary, Aberdeen, Scotland UK
| | - Alain Curnier
- Aberdeen University Anatomy Department, The Suttie Centre for Teaching and Learning in Healthcare, Aberdeen, Scotland UK
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Gorelik M, Godelman S, Elkbuli A, Allen L, Boneva D, McKenney M. Can Residents Be Trained and Safety Maintained? JOURNAL OF SURGICAL EDUCATION 2018; 75:1-6. [PMID: 28676300 DOI: 10.1016/j.jsurg.2017.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/16/2017] [Accepted: 06/10/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Teaching hospitals and faculty need to balance the educational mission for training residents with patient safety. There are no data studying the change in trauma patient outcomes before and after implementation of a surgical residency. The objective of this study was to compare trauma center outcomes before and after the advent of a surgical training program. We predicted that patient-centric outcome metrics would not be affected by the integration of surgical residents into trauma patient care. METHODS A retrospective review was performed using the Crimson Continuum of Care (CCC) dataset and the Trauma Injury Severity Scores (TRISS) for the year before implementation of a surgical residency, compared to the 6 months following initiation of the residency. Severity and risk-adjusted performance measures included mortality, readmissions, complications, and length of stay. Using TRISS, actual, and predicted mortality was compared. RESULTS There were 1535 trauma admissions to the acute Care Trauma Service the year before starting the residency, and 856 admissions for the 6 months following the implementation of the program. The demographics were similar between the 2 groups. There was no clinically significant difference in observed mortality after the initiation of a surgery residency, based on CCC dataset variables and TRISS datasets. There were also no significant differences in complications and readmission rates. CONCLUSIONS We found that initiating a surgical training program did not affect mortality rates or complications of trauma patients. Training of general surgery residents in a high-performing trauma center can be effectively implemented without compromising patient safety.
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Affiliation(s)
- Marina Gorelik
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida.
| | - Steven Godelman
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida
| | - Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida
| | - Lauren Allen
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
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