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Wood TC, Maqsood S, Saunders A, Sancha W, Nanavaty MA, Wearne M, Rajak S. Simulation-based training for intraoperative posterior capsule rupture management: an analysis of nontechnical skills development and the relationship between technical and nontechnical skills. Eye (Lond) 2024; 38:1958-1963. [PMID: 38575658 PMCID: PMC11226687 DOI: 10.1038/s41433-024-03051-y] [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: 10/14/2023] [Revised: 03/09/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVES To analyse development of individual nontechnical skills (NTS) domains after undertaking a previously developed simulation-based training model and analyse the relationship between technical skills (TS) and NTS in ophthalmic surgery. METHODS The simulation-based training model involved a cataract surgery case complicated by intraoperative posterior capsule rupture. Cataract surgeons underwent the simulation twice, separated by a training intervention. Two blinded independent experts assessed participants' NTS using HUFOES, NOn-Technical Skills for Surgeons (NOTSS), and the OSATS global rating scale for TS. Paired t-tests assessed differences in individual NTS domains, with p < 0.05 indicating significance. The Pearson Product Moment Correlation Coefficient was used to assess the correlation between scores from each scoring system. RESULTS All NTS domains within HUFOES and NOTSS demonstrated statistically significant improvements secondary to the training intervention. Positive correlations were demonstrated between HUFOES and OSATS scores in the pre- and post-training simulations, r = 0.870 (p < 0.001) and r = 0.861 (p < 0.001), respectively. Positive correlations were also demonstrated between NOTSS and OSATS scores in pre- and post-training simulations, r = 0.849 (p < 0.001) and r = 0.757 (p = 0.001), respectively. Positive correlations were demonstrated between HUFOES and NOTSS scores; r = 0.979 (p < 0.001) (n = 17) and r = 0.959 (p < 0.001) for pre- and post-training simulations, respectively. CONCLUSION All NTS domains contained within HUFOES and NOTSS demonstrated significant increases following the completion of the simulation-based training model. Positive correlations exist between an ophthalmic surgeon's TS and NTS. This is the first study to report these findings within ophthalmic surgery.
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Affiliation(s)
- Thomas Charles Wood
- Sussex Eye Hospital, University Hospitals Sussex (UHSussex) NHS Trust, Eastern Road, BN2 5BF, Brighton, UK.
| | - Sundas Maqsood
- Sussex Eye Hospital, University Hospitals Sussex (UHSussex) NHS Trust, Eastern Road, BN2 5BF, Brighton, UK
- Department of Ophthalmology, Maidstone and Tunbridge Wells Hospital, Hermitage Lane, ME16 9QQ, Maidstone, Kent, UK
| | - Alexander Saunders
- Resuscitation Services Department, Southpoint Building, Royal Sussex County Hospital, BN2 1HA, Brighton, UK
| | | | - Mayank A Nanavaty
- Sussex Eye Hospital, University Hospitals Sussex (UHSussex) NHS Trust, Eastern Road, BN2 5BF, Brighton, UK
- Brighton and Sussex Medical School, Falmer, BN1 9PX, Brighton, UK
| | - Michael Wearne
- Eastbourne District General Hospital, King's Drive, BN21 2UD, Eastbourne, East Sussex, UK
| | - Saul Rajak
- Sussex Eye Hospital, University Hospitals Sussex (UHSussex) NHS Trust, Eastern Road, BN2 5BF, Brighton, UK
- Brighton and Sussex Medical School, Falmer, BN1 9PX, Brighton, UK
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Steinl GK, Weaver ML. A little less conversation a little more action, please. Am J Surg 2024:115802. [PMID: 38880663 DOI: 10.1016/j.amjsurg.2024.115802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Gabrielle K Steinl
- Department of Surgery, University of Virginia Medical School, Charlottesville, VA, USA
| | - M Libby Weaver
- Division of Vascular Surgery, University of Virginia Medical School, Charlottesville, VA, USA.
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B OS, Ja GM, Jl AA, V SA. Unveilling the hidden skillset: exploring non-technical skills in surgical education across spanish medical universities. BMC MEDICAL EDUCATION 2024; 24:376. [PMID: 38580994 PMCID: PMC10998365 DOI: 10.1186/s12909-024-05362-w] [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: 08/26/2023] [Accepted: 03/27/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Non-Technical Skills (NTS) are cognitive, social, and personal resource skills that are crucial in complex and high-risk environments. The aims of our research are to determine the prevalence and content of NTS in the surgical rotation teaching guides of the Medicine Degree programs in Spanish Universities, to identify the most prevalent types and subtypes of NTS, and to analyze factors associated with the prevalence of surgical NTS in Medical Schools in Spain. METHODS Descriptive observational cross-sectional study involving the identification and collection of competencies outlined in the surgical rotation teaching guides of Spanish Medical Schools. Information regarding university performance was obtained from the Foundation for Knowledge and Development Ranking webpage. The "Non-Technical Skills for Surgeons" (NOTSS) system was used to classify each competency in the teaching guides as NTS (categories and elements) and technical skills. Disagreements were resolved through group consensus. RESULTS A total of 1,846 competencies were analyzed in surgical rotations of the Medicine Degree programs across 40 Spanish Universities, with 99 competencies identified as surgical NTS, accounting for 5% of the total. The most frequently identified surgical NTS were "Decision Making" (46%), "Communication & Teamwork" (25%), and "Leadership" (19%). Additionally, several NOTSS were not identified in any institution. Public universities and those including a greater number of competencies had a higher rate of surgical NTS competencies, and we did not find a correlation between surgical NTS competencies and quality indices of University Centers. CONCLUSIONS There is a limited presence of surgical NTS in the educational plans of Spanish Universities.
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Affiliation(s)
- Oves-Suarez B
- School of Medicine, University of Murcia, Murcia, Spain
| | - García-Marín Ja
- Department of General and Digestive Surgery, University Hospital Morales Meseguer, Murcia, Spain.
| | - Aguayo-Albasini Jl
- Department of General and Digestive Surgery, University Hospital Morales Meseguer, Murcia, Spain
| | - Soria-Aledo V
- Chief of Department of General and Digestive Surgery, University Hospital Morales Meseguer, Murcia, Spain
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Silverii H, Cain MP, Ahn J, Fernandez N, Lendvay T, Gupta A, Joyner B, Kieran K, Shnorhavorian M, Merguerian P. Putting the coach in the game: Current and future state of surgical coaching in pediatric urology. J Pediatr Urol 2024:S1477-5131(24)00150-5. [PMID: 38508978 DOI: 10.1016/j.jpurol.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Surgical coaching has been proposed as a mechanism to fill gaps in proficiency and encourage continued growth following formal surgical training. Coaching benefits have been demonstrated in other surgical fields; however, have not been evaluated within pediatric urology. The aims of this study were to survey members of The Societies for Pediatric Urology (SPU) to assess the current understanding and utilization of surgical coaching while gauging interest, potential barriers and personal goals for participation in a coaching program. METHODS Following IRB approval, members of the SPU were invited to electronically complete an anonymous survey which assessed 4 domains: 1) understanding of surgical coaching principles, 2) current utilization, 3) interest and potential barriers to participation, and 4) personal surgical goals. To evaluate understanding, questions with predefined correct answers on the key principles of coaching were posed either in multiple choice or True/False format to the SPU membership. RESULTS Of the 674 pediatric urologists invited, 146 completed the survey (22%). Of those, 46% correctly responded the definition of surgical coaching. Coaching utilization was reported in 27% of respondents currently or having previously participated in a surgical coaching program. Despite current participation rates, only 6 surgeons (4%) have completed training in surgical coaching, despite 79% expressing interest to participate in a surgical coaching program. The most influential barrier to participating in a coaching program was time commitment. Respondents largely prioritized technical and cognitive skill improvement as their primary goals for coaching (see figure below). CONCLUSIONS While interest in surgical coaching is high among pediatric urologists, the principles of surgical coaching were not universally understood. Furthermore, formal coach training is markedly deficient, representing a gap in our profession and an opportunity for significant avenues for improvement, especially for technical and cognitive skills. Development of a coaching model based on these results would best suit the needs of pediatric urologists providing that the time commitment barrier for these endeavors can be mitigated and/or reconciled.
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Affiliation(s)
- Hailey Silverii
- Seattle Children's Hospital, United States; University of Washington, United States.
| | - Mark P Cain
- Seattle Children's Hospital, United States; University of Washington, United States
| | - Jennifer Ahn
- Seattle Children's Hospital, United States; University of Washington, United States
| | - Nicolas Fernandez
- Seattle Children's Hospital, United States; University of Washington, United States
| | - Thomas Lendvay
- Seattle Children's Hospital, United States; University of Washington, United States
| | | | - Byron Joyner
- Seattle Children's Hospital, United States; University of Washington, United States
| | - Kathleen Kieran
- Seattle Children's Hospital, United States; University of Washington, United States
| | | | - Paul Merguerian
- Seattle Children's Hospital, United States; University of Washington, United States
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5
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Silverii H, Fernandez N, Ahn J, Lendvay T, Shnorhavorian M, Joyner B, Kieran K, Cain M, Merguerian P. Standardization and Implementation of a Surgical Coaching Model for Pediatric Urology. JOURNAL OF SURGICAL EDUCATION 2024; 81:319-325. [PMID: 38278721 DOI: 10.1016/j.jsurg.2023.12.001] [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: 09/27/2023] [Revised: 11/09/2023] [Accepted: 12/06/2023] [Indexed: 01/28/2024]
Abstract
To bridge gaps in proficiency and encourage life-long learning following training, coaching models have been utilized in multiple surgical fields; however, not within pediatric urology. In this review of our methodology, we describe the development of a coaching model at a single institution. In our initial experience, the perceived most beneficial aspect of the program was the goal setting process with logistics around debriefs being the most challenging. With our proposed coaching study, we aim to develop a model based upon prior coaching frameworks,1,2 that is feasible and universally adaptable to allow for further advancement of surgical coaching, particularly within the field of pediatric urology.
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Affiliation(s)
- Hailey Silverii
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington.
| | - Nicolas Fernandez
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
| | - Jennifer Ahn
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
| | | | - Margarett Shnorhavorian
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
| | - Byron Joyner
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
| | - Kathleen Kieran
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
| | - Mark Cain
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
| | - Paul Merguerian
- Department of Urology, University of Washington Seattle, Washington; Seattle Children's Hospital Division of Urology, Seattle, Washington
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Mathis MR, Janda AM, Yule SJ, Dias RD, Likosky DS, Pagani FD, Stakich-Alpirez K, Kerray FM, Schultz ML, Fitzgerald D, Sturmer D, Manojlovich M, Krein SL, Caldwell MD. Nontechnical Skills for Intraoperative Team Members. Anesthesiol Clin 2023; 41:803-818. [PMID: 37838385 PMCID: PMC10703542 DOI: 10.1016/j.anclin.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.
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Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Steven J Yule
- Department of Clinical Surgery, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland
| | - Roger D Dias
- Department of Emergency Medicine, Brigham & Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Korana Stakich-Alpirez
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Fiona M Kerray
- Department of Clinical Surgery, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland
| | - Megan L Schultz
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - David Fitzgerald
- Department of Clinical Sciences, Medical University of South Carolina College of Health Professions, A 151 Rutledge Avenue, Charleston, SC 29403, USA
| | - David Sturmer
- Department of Perfusion, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Milisa Manojlovich
- School of Nursing, University of Michigan, 426 N Ingalls Street, Ann Arbor, MI 48104, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Matthew D Caldwell
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Watkins SC, Hensley NB. Team Dynamics in the Operating Room: How Is Team Performance Optimized? Anesthesiol Clin 2023; 41:775-787. [PMID: 37838383 DOI: 10.1016/j.anclin.2023.05.004] [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] [Indexed: 10/16/2023]
Abstract
Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the continuum of surgical care. The basic operating room (OR) team consists of nurses, technicians, surgeons, and anesthesiologists with unique and well-defined roles and expertise in perioperative care. The modern OR team continues to grow and evolve in size, diversity, and complexity to meet the needs of growing patient and procedural complexity. This growing complexity makes achieving optimal team performance paramount and challenging.
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Affiliation(s)
- Scott C Watkins
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Johns Hopkins All Children's Hospital, 501 6th Street South, Suite 707, Saint Petersburg, FL 33701, USA.
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, 1800 Orleans Avenue, Sheik Zayed Tower Suite 6212, Baltimore, MD 21287, USA
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Cochand L, Filipovic MG, Huber M, Luedi MM, Urman RD, Bello C. Systems Anesthesiology: Systems of Care Delivery and Optimization in the Operating Room. Anesthesiol Clin 2023; 41:847-861. [PMID: 37838388 DOI: 10.1016/j.anclin.2023.05.006] [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] [Indexed: 10/16/2023]
Abstract
Anesthesiology presents a challenge to a traditional simplifying approach given the ever-increasing amount of medical data and a more demanding environment. Systems anesthesiology is a modern approach to perioperative care, integrating the complexity of multifactorial knowledge and data to achieve a more adequate representation of reality, while including both patient-related medical aspects as well as economic and organizational challenges. We discuss the value of some innovative technologies such as the emergence of anesthesia information systems, the use of tele-medicine, predictive monitoring, or closed-loop systems as it pertains to the changes in the current standards of care in anesthesiology. Furthermore, we highlight the importance of systems anesthesiology in operating room planning, anesthesia research, and education.
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Affiliation(s)
- Laure Cochand
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mark G Filipovic
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University College of Medicine, OH, USA.
| | - Corina Bello
- Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Rajput S, Mayor I, Diamond M, Rosenberg M, Cole V, Bhakare N, Aziz O, Wilder AL. Medical ethics of long-duration spaceflight. NPJ Microgravity 2023; 9:85. [PMID: 38016981 PMCID: PMC10684496 DOI: 10.1038/s41526-023-00333-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 10/25/2023] [Indexed: 11/30/2023] Open
Abstract
With the advent of novel and emerging technologies, long duration spaceflight will become more common; along with it, an increase in its inherent health risks. However, health-related ethical issues arising during long-duration spaceflight remain poorly characterized, uncertain and unpredictable. Medical ethics is defined as a set of moral principles, beliefs and values that guides choices about medical care. This set of principles, founded in our sense of right and wrong, helps us make fair and just decisions. The paper conceptually and analytically investigates the ethical issues likely to arise from medical complications during spaceflight, mapping unfilled gaps of the current status quo. Furthermore, this paper explores broad ethical themes of autonomy, nonmaleficence, beneficence and justice, while also delving deeper into specific scenarios within each theme. The manuscript represents an up-to-date review of the available literature in the field of space medical ethics and recommends guiding ethical principles and a framework for their application to negotiate the resolution of complex ethical scenarios during long-duration spaceflight.
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Affiliation(s)
- Siddharth Rajput
- Advanced trainee in Vascular surgery, Royal Australasian College of Surgeons, Sydney, Australia.
- Space Generation Advisory Council (SGAC), Sydney, Australia.
| | - Ivy Mayor
- Karolinska Institute, Stockholm, Sweden.
- Space Generation Advisory Council (SGAC), Stockholm, Sweden.
| | - Madison Diamond
- Department of Space Studies, University of North Dakota, Grand Forks, ND, USA
| | - Mark Rosenberg
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Cole
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Omar Aziz
- Royal Australasian College of Surgeons, Sydney, Australia
| | - Anderson L Wilder
- Department of Psychology, Florida Institute of Technology, Melbourne, FL, USA
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Gunn EGM, Ambler OC, Nallapati SC, Smink DS, Tambyraja AL, Yule S. Coaching with audiovisual technology in acute-care hospital settings: systematic review. BJS Open 2023; 7:zrad017. [PMID: 37794777 PMCID: PMC10551776 DOI: 10.1093/bjsopen/zrad017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Surgical coaching programmes are a means of improving surgeon performance. Embedded audiovisual technology has the potential to further enhance participant benefit and scalability of coaching. The objective of this systematic review was to evaluate how audiovisual technology has augmented coaching in the acute-care hospital setting and to characterize its impact on outcomes. METHODS A systematic review was conducted, searching PubMed, Ovid MEDLINE, Embase, PsycInfo, and CINAHL databases using PRISMA. Eligible studies described a coaching programme that utilized audiovisual technology, involved at least one coach-coachee interaction, and included healthcare professionals from the acute-care hospital environment. The risk of bias 2 tool and grading of recommendations, assessment, development, and evaluations (GRADE) framework were used to evaluate studies. Synthesis without meta-analysis was performed, creating harvest plots of three coaching outcomes: technical skills, self-assessment/feedback, and non-technical skills. RESULTS Of 10 458 abstracts screened, 135 full texts were reviewed, and 21 studies identified for inclusion. Seventeen studies were conducted within surgical specialties and six classes of audiovisual technology were utilized. An overall positive direction of effect was demonstrated for studies measuring improvement of either technical skills or non-technical skills. Direction of effect for self-assessment/feedback was weakly positive. CONCLUSION Audiovisual technology has been used successfully in coaching programmes within acute-care hospital settings to facilitate or assess coaching, with a positive impact on outcome measures. Future studies may address the additive benefits of video over in-person observation and enhance the certainty of evidence that coaching impacts on surgeon performance, surgeon well-being, and patient outcomes.
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Affiliation(s)
- Eilidh G M Gunn
- Department of Vascular Surgery, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Olivia C Ambler
- Department of Vascular Surgery, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Siri C Nallapati
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Tambyraja
- Department of Vascular Surgery, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Steven Yule
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
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Sanguanwit P, Kulrotwichit T, Tienpratarn W, Athinartrattanapong N, Trainarongsakul T, Angkoontassaneeyarat C. Effect of mini-course training in communication and teamwork on non-technical skills score in emergency residents: a prospective experimental study. BMC MEDICAL EDUCATION 2023; 23:529. [PMID: 37491254 PMCID: PMC10369795 DOI: 10.1186/s12909-023-04507-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/11/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Non-technical skill (NTS) teaching is a recent development in medical education that should be applied in medical education, especially in medical specialties that involve critically ill patients, resuscitation, and management, to promote patient safety and improve quality of care. Our study aimed to compare the effects of mini-course training in NTS versus usual practice among emergency residents. METHODS In this prospective (non-randomized) experimental study, emergency residents in the 2021-2022 academic year at Ramathibodi Hospital, a tertiary care university hospital, were included as participants. They were categorized into groups depending on whether they underwent a two-hour mini-course training on NTS (intervention group) or usual practice (control group). Each participant was assigned a mean NTS score obtained by averaging their scores on communication and teamwork skills given by two independent staff. The outcome was the NTS score before and after intervention at 2 weeks and 16 weeks. RESULTS A total of 41 emergency residents were enrolled, with 31 participants in the intervention group and 10 in the control group. The primary outcome, mean total NTS score after 2 weeks and 16 weeks, was shown to be significantly better in intervention groups than control groups (25.85 ± 2.06 vs. 22.30 ± 2.23; P < 0.01, 28.29 ± 2.20 vs. 23.85 ± 2.33; P < 0.01) although the mean total NTS score did not differ between the groups in pre-intervention period. In addition, each week the NTS score of each group increased 0.15 points (95% CI: 0.01-0.28, P = 0.03), although the intervention group showed greater increases than the control (0.24 points) after adjustment for time (95% CI: 0.08-0.39, P < 0.01). CONCLUSION Emergency residents who took an NTS mini-course showed improved mean NTS scores in communication and teamwork skills versus controls 2 weeks and 16 weeks after the training. Attention should be paid to implementing NTS in the curricula for training emergency residents. TRIAL REGISTRATION This trial was retrospectively registered in the Thai Clinical Trial Registry on 29/11/2022. The TCTR identification number is TCTR20221129006.
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Affiliation(s)
- Pitsucha Sanguanwit
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
| | - Thanet Kulrotwichit
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
| | - Welawat Tienpratarn
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand.
| | - Natsinee Athinartrattanapong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
| | - Thavinee Trainarongsakul
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
| | - Chuenruthai Angkoontassaneeyarat
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
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Gauly J, Court R, Currie G, Seers K, Clarke A, Metcalfe A, Wilson A, Hazell M, Grove AL. Advancing leadership in surgery: a realist review of interventions and strategies to promote evidence-based leadership in healthcare. Implement Sci 2023; 18:15. [PMID: 37179327 PMCID: PMC10182608 DOI: 10.1186/s13012-023-01274-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Healthcare systems invest in leadership development of surgeons, surgical trainees, and teams. However, there is no agreement on how interventions should be designed, or what components they must contain to be successful. The objective of this realist review was to generate a programme theory explaining in which context and for whom surgical leadership interventions work and why. METHODS Five databases were systematically searched, and articles screened against inclusion considering their relevance. Context-mechanism-outcome configurations (CMOCs) and fragments of CMOCs were identified. Gaps in the CMOCs were filled through deliberation with the research team and stakeholder feedback. We identified patterns between CMOCs and causal relationships to create a programme theory. RESULTS Thirty-three studies were included and 19 CMOCs were developed. Findings suggests that interventions for surgeons and surgical teams improve leadership if timely feedback is delivered on multiple occasions and by trusted and respected people. Negative feedback is best provided privately. Feedback from senior-to-junior or peer-to-peer should be delivered directly, whereas feedback from junior-to-senior is preferred when delivered anonymously. Leadership interventions were shown to be most effective for those with awareness of the importance of leadership, those with confidence in their technical surgical skills, and those with identified leadership deficits. For interventions to improve leadership in surgery, they need to be delivered in an intimate learning environment, consider implementing a speak-up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to the needs of surgeons. Leadership of surgical teams can be best developed by enabling surgical teams to train together. CONCLUSIONS The programme theory provides evidence-based guidance for those who are designing, developing and implementing leadership interventions in surgery. Adopting the recommendations will help to ensure interventions are acceptable to the surgical community and successful in improving surgical leadership. TRIAL REGISTRATION The review protocol is registered with PROSPERO (CRD42021230709).
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Affiliation(s)
- Julia Gauly
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Graeme Currie
- Warwick Business School, University of Warwick, Scarman Rd, Coventry, CV4 7AL, UK
| | - Kate Seers
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Aileen Clarke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Andy Metcalfe
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Anna Wilson
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Matthew Hazell
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK
| | - Amy Louise Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7HL, UK.
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13
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Kiyasseh D, Laca J, Haque TF, Miles BJ, Wagner C, Donoho DA, Anandkumar A, Hung AJ. A multi-institutional study using artificial intelligence to provide reliable and fair feedback to surgeons. COMMUNICATIONS MEDICINE 2023; 3:42. [PMID: 36997578 PMCID: PMC10063640 DOI: 10.1038/s43856-023-00263-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/17/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Surgeons who receive reliable feedback on their performance quickly master the skills necessary for surgery. Such performance-based feedback can be provided by a recently-developed artificial intelligence (AI) system that assesses a surgeon's skills based on a surgical video while simultaneously highlighting aspects of the video most pertinent to the assessment. However, it remains an open question whether these highlights, or explanations, are equally reliable for all surgeons. METHODS Here, we systematically quantify the reliability of AI-based explanations on surgical videos from three hospitals across two continents by comparing them to explanations generated by humans experts. To improve the reliability of AI-based explanations, we propose the strategy of training with explanations -TWIX -which uses human explanations as supervision to explicitly teach an AI system to highlight important video frames. RESULTS We show that while AI-based explanations often align with human explanations, they are not equally reliable for different sub-cohorts of surgeons (e.g., novices vs. experts), a phenomenon we refer to as an explanation bias. We also show that TWIX enhances the reliability of AI-based explanations, mitigates the explanation bias, and improves the performance of AI systems across hospitals. These findings extend to a training environment where medical students can be provided with feedback today. CONCLUSIONS Our study informs the impending implementation of AI-augmented surgical training and surgeon credentialing programs, and contributes to the safe and fair democratization of surgery.
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Affiliation(s)
- Dani Kiyasseh
- Department of Computing and Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA.
| | - Jasper Laca
- Center for Robotic Simulation and Education, Catherine & Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Taseen F Haque
- Center for Robotic Simulation and Education, Catherine & Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Brian J Miles
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Christian Wagner
- Department of Urology, Pediatric Urology and Uro-Oncology, Prostate Center Northwest, St. Antonius-Hospital, Gronau, Germany
| | - Daniel A Donoho
- Division of Neurosurgery, Center for Neuroscience, Children's National Hospital, Washington DC, USA
| | - Animashree Anandkumar
- Department of Computing and Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | - Andrew J Hung
- Center for Robotic Simulation and Education, Catherine & Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA.
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14
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Daniel R, McKechnie T, Kruse CC, Levin M, Lee Y, Doumouras AG, Hong D, Eskicioglu C. Video-based coaching for surgical residents: a systematic review and meta-analysis. Surg Endosc 2023; 37:1429-1439. [PMID: 35739431 PMCID: PMC9225812 DOI: 10.1007/s00464-022-09379-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Video-based coaching (VBC) is used to supplement current teaching methods in surgical education and may be useful in competency-based frameworks. Whether VBC can effectively improve surgical skill in surgical residents has yet to be fully elucidated. The objective of this study is to compare surgical residents receiving and not receiving VBC in terms of technical surgical skill. METHODS The following databases were searched from database inception to October 2021: Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. Articles were included if they were randomized controlled trials (RCTs) comparing surgical residents receiving and not receiving VBC. The primary outcome, as defined prior to data collection, was change in objective measures of technical surgical skill following implementation of either VBC or control. A pairwise meta-analyses using inverse variance random effects was performed. Standardized mean differences (SMD) were used as the primary outcome measure to account for differences in objective surgical skill evaluation tools. RESULTS From 2734 citations, 11 RCTs with 157 residents receiving VBC and 141 residents receiving standard surgical teaching without VBC were included. There was no significant difference in post-coaching scores on objective surgical skill evaluation tools between groups (SMD 0.53, 95% CI 0.00 to 1.01, p = 0.05, I2 = 74%). The improvement in scores pre- and post-intervention was significantly greater in residents receiving VBC compared to those not receiving VBC (SMD 1.62, 95% CI 0.62 to 2.63, p = 0.002, I2 = 85%). These results were unchanged with leave-one-out sensitivity analysis and subgroup analysis according to operative setting. CONCLUSION VBC can improve objective surgical skills in surgical residents of various levels. The benefit may be most substantial for trainees with lower baseline levels of objective skill. Further studies are required to determine the impact of VBC on competency-based frameworks.
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Affiliation(s)
- Ryan Daniel
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, St. Joseph’s Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Colin C. Kruse
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON Canada
| | - Marc Levin
- Division of Head and Neck, Otolaryngology Surgery, Department of Surgery, University of Toronto, Toronto, ON Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, St. Joseph’s Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Aristithes G. Doumouras
- Division of General Surgery, Department of Surgery, St. Joseph’s Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada ,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON Canada ,Division of General Surgery, Department of Surgery, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, St. Joseph’s Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada ,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON Canada ,Division of General Surgery, Department of Surgery, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, St. Joseph's Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada. .,Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada. .,Division of General Surgery, Department of Surgery, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
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15
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Ting YY, Reid JL, Treloar E, Lee WSB, Tee JY, Cong WJP, Peng D, Edwards S, Ey J, Edwardes N, Granchi N, Maddern GJ. Improving Surgical Excellence: Can Coaching Surgeons Improve Patient Engagement? World J Surg 2022; 47:1144-1150. [PMID: 36401089 DOI: 10.1007/s00268-022-06827-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Non-technical skills complement technical skills in surgeons to provide best possible care for patients. The former is essential to promote patient engagement. Coaching has been introduced to surgeons as a method to improve non-technical skills. We aimed to investigate the impact of coaching for surgeons on patient engagement in the outpatient consultation setting. METHODS This was a single-centre cohort study conducted in South Australia. Consultant surgeons, suitable coaches, and patients were recruited. Coaches underwent further training by a human factors psychologist on being an effective coach. Outpatient consultations were recorded in an audio-visual format and analysed by investigators. Patient talking time, mutual eye gaze between surgeon and patient, and number of questions asked by the patient were measured as outcomes for patient engagement. RESULTS 182 patients, 12 surgeons, and 4 coaches participated in the study. Each surgeon underwent 3 coaching sessions, 5 to 6 weeks apart. There were 62 pre-coaching patient consultations, 63 patient consultations after one coaching session, and 57 patient consultations after two coaching sessions. The mean talking time of the patient increased significantly after a single coaching session (P < 0.05) without making significant difference to the total consultation time (p = 0.76). Coaching sessions did not have a significant effect on mutual eye gaze or mean number of questions asked by the patient. CONCLUSION Coaching of non-technical skills for surgeons appears to objectively improve patient engagement during the outpatient consultation. This would suggest that tailored coaching programs should be developed and delivered to surgeons to improve care delivery.
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Affiliation(s)
- Ying Yang Ting
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Jessica L Reid
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Ellie Treloar
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Wei Shan Bobby Lee
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Jeeng Yeeng Tee
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Wen Jing Phoebe Cong
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Dangyi Peng
- Monash School of Medicine, Monash University, Melbourne, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, Australia
| | - Jesse Ey
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Nicholas Edwardes
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Nelson Granchi
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia
| | - Guy J Maddern
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, AdelaideWoodville, SA, 5011, Australia.
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16
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Fainberg J, Vanden Berg RNW, Chesnut G, Coleman JA, Donahue T, Ehdaie B, Goh AC, Laudone VP, Lee T, Pyon J, Scardino PT, Smith RC. A Novel Expert Coaching Model in Urology, Aimed at Accelerating the Learning Curve in Robotic Prostatectomy. JOURNAL OF SURGICAL EDUCATION 2022; 79:1480-1488. [PMID: 35872029 PMCID: PMC10353766 DOI: 10.1016/j.jsurg.2022.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION/BACKGROUND The surgical residency model assumes that upon completion, a surgeon is ready to practice and grow independently. However, many surgeons fail to improve after reaching proficiency, which in certain instances has correlated with worse clinical outcomes. Coaching addresses this problem and furthers surgeons' education post-residency. Currently, surgical coaching programs focus on medical students and residents, and have been shown to improve residents' and medical students' technical and non-technical abilities. Coaching programs also increase the accuracy of residents, fellows, and attendings in self-assessing their surgical ability. Despite the potential benefits, coaching remains underutilized and poorly studied. We developed an expert-led, face-to-face, video-based surgical coaching program at a tertiary medical center among specialized attending surgeons. Our goal was to evaluate the feasibility of such a program, measure surgeons' attitudes towards internal peer coaching, determine whether surgeons found the sessions valuable and educational, and to subjectively self-assess changes in operative technique. METHODS/MATERIALS Surgeons who perform robot-assisted laparoscopic prostatectomies were chosen and grouped by number of cases completed: junior (<100 cases), intermediate (100-500 cases), and senior (>500 cases). Surgeons were scheduled for 3 1-hour coaching sessions 1-2 months apart (February-October 2019), meeting individually with the coach (PS), an expert Urologic Oncologist with thousands of cases of experience performing radical prostatectomy. He received training on coaching methodology prior to beginning the coaching program. Before each session, surgeons selected 1 of their recent intraoperative videos to review. During sessions, the coach led discussion on topics chosen by the surgeon (i.e. neurovascular bundle dissection, apical dissection, bladder neck); together, they developed goals to achieve before the next session. Subsequent sessions included presentation and discussion of a case occurring subsequent to the prior session. Sessions were coded by discussion topics and analyzed based on level of experience. Surgeons completed a survey evaluating the experience. RESULTS All 6 surgeons completed 3 sessions. Five surgeons completed the survey; most respondents evaluated themselves as having improved in desired areas and feeling more confident performing the discussed steps of the operation. Discussed surgical principles varied by experience group; when subjectively quantifying the difficulty of surgical steps, the more difficult steps were discussed by the higher experience groups compared to the junior surgeons. The senior surgeons also focused more on oncologic potency, continence outcomes, and more theory-driven questions while the junior surgeons tended to focus more on anatomic and technique-based questions such as tissue handling and the use of cautery and clips. Overall, the surgeons thought this program provoked critical discussion and subsequently modified their technique, and "agreed" or "strongly agreed" that they would seek further sessions. CONCLUSIONS Surgical coaching at a large medical center is not only feasible but was rated positively by surgeons across all levels of experience. Coaching led to subjective self-improvement and increased self-confidence among most surgeons. Surgeons also felt that this program offered a safe space to acquire new skills and think critically after finishing residency/fellowship. Themes discussed and takeaways from the sessions varied based on surgeon experience level. While further research is needed to more objectively quantify the impact coaching has on surgeon metrics and patient outcomes, the results of this study supports the initial "proof-of-concept" of peer-based surgical coaching and its potential benefits in accelerating the learning curve for surgeons' post-residency.
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Affiliation(s)
- Jonathan Fainberg
- Department of Urology, New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York.
| | | | - Gregory Chesnut
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Timothy Donahue
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Behfar Ehdaie
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alvin C Goh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Taehyoung Lee
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin Pyon
- Weill Cornell Medicine, New York, New York
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17
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Abahuje E, Johnson J, Halverson A, Stulberg JJ. Intraoperative Assessment of Non-Technical Skills for Surgeons (NOTSS) and Qualitative Description of their Effects on Intraoperative Performance. JOURNAL OF SURGICAL EDUCATION 2022; 79:1237-1245. [PMID: 35637141 DOI: 10.1016/j.jsurg.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/08/2022] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aims of this study were (1) to evaluate the feasibility of using the Non-Technical Skills for Surgeons (NOTSS) rating tool in assessing surgeons' non-technical skills behaviors in live operations, and (2) to describe the effect of NOTSS on intraoperative performance. SETTING DESIGN This study was conducted in an academic hospital in North America. Two observers independently conducted direct non-participant observations using the NOTSS rating tool to assess non-technical skills, and to document examples of effective or ineffective non-technical skills behaviors. Observers took field notes to document non-technical skill gaps that were not captured by the NOTSS rating tool, and situations or scenarios that presented challenges for accurate assessment. Interclass correlation estimates and 95% confidence intervals were calculated to assess the validity of the NOTSS rating tool. Deductive thematic qualitative data analysis was used for field notes and NOTSS behavior descriptions. PARTICIPANTS Participants were general surgeons performing either minimally invasive (robotic assisted or laparoscopic surgery), or open procedures. RESULTS We observed 18 surgeries, involving 6 surgeons, 11 residents and one fellow resulting in 37 hours of direct observations. The mean NOTSS score was 3.8 (SD 0.41) for situation awareness, 3.75 (SD 0.47) for decision-making, 3.71 (SD 0.39) for communication and teamwork, and 3.76 (SD 0.38) for leadership. The inter-rater reliability ranged between 0.65 and 0.80 for each NOTSS categories. The observers documented examples of effective non-technical skills behaviors and examples of behaviors that need improvement. Furthermore, we described the effect of each observed behavior on intraoperative performance. One challenge to NOTSS use in live surgery was that observers had to infer situation awareness, decision-making, and coping with pressure as these were not easily observed without attending surgeons articulating their underlying thought process. CONCLUSION The use of the NOTSS tool in live surgery is a valid and practical tool to document observed behaviors and their effect on intraoperative performance in order to provide constructive feedback to surgeons. One notable limitation is that without specific articulation by the surgeon of their underlying thought process the observer must infer specific elements. By documenting specific real-world events with high inter-rater reliability and adequate surgeon score variation the process can be used to provide useful feedback for improvement.
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Affiliation(s)
- Egide Abahuje
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
| | - Julie Johnson
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Amy Halverson
- Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Jonah J Stulberg
- Department of Surgery, University of Texas, Health Science Center at Houston, Houston, Texas
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18
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Sabqat M, Khan RA, Yasmin R, Mahboob U. Exploring developmental assignments shaping experience-driven acquisition of leadership competencies in young clinicians. BMC MEDICAL EDUCATION 2022; 22:505. [PMID: 35761278 PMCID: PMC9238052 DOI: 10.1186/s12909-022-03544-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/02/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Experiential leadership development is well documented in the corporate sector, but those models cannot be applied as is, in the healthcare domain. The current study proposes a framework for the healthcare sector to enable experiential leadership development for young clinicians. The authors identify developmental assignments (DAs) and explore those characteristics [developmental assignment characteristics; DACs] therein that help develop leadership competencies in young clinicians. METHODS As part of a qualitative exploratory study in Pakistan, the authors conducted 16 semi-structured interviews with senior clinicians in leadership positions with post-graduate residents under their supervision from different medical specialties. The participants were selected through purposive sampling, ensuring a maximum variation sample. Focusing on participants' experiences and perspectives related to experience-driven leadership development, the authors used a multi-level theoretical framework for analysis. RESULTS The thematic analysis resulted in 19 subthemes with four overarching themes for both objectives. The authors categorized the developmental assignments (DAs) into clinical, academic, and administrative assignments. These assignments can be utilized for leadership development by ensuring that they have the requisite characteristics built into their context and structure. These developmental assignment characteristics (DACs) can range from learner-driven to supervisor-driven. The learner-driven characteristics include autonomy, high levels of responsibilities, unfamiliar assignments, working across boundaries, managing diversity, making a commitment, and creating change. The supervisor-driven characteristics include briefing, debriefing, accountability, and learner-assignment matching. The authors also developed a learner-assignment matching (LAM) framework to guide supervisors in customizing and adjusting the level of each DAC in a DA. CONCLUSION A modern healthcare educational system can utilize studies like this to enable supervisors to develop required leadership skills in young clinicians along with clinical skills.
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Affiliation(s)
- Mashaal Sabqat
- Department of Health Professions Education, National University of Medical Sciences, Block C Police Foundation, Rawalpindi, Punjab, 968, Pakistan.
| | - Rehan Ahmed Khan
- Department of Surgery, Riphah International University, Rawalpindi, Pakistan
| | - Raheela Yasmin
- Medical Education and Dean Riphah Academy of Research and Education [RARE], Department of Medical Education, Riphah International University, Rawalpindi, Pakistan
| | - Usman Mahboob
- Department of Medical Education, Institute of Health Professions Education & Research, Khyber Medical University, Peshawar, Pakistan
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Abildgren L, Lebahn-Hadidi M, Mogensen CB, Toft P, Nielsen AB, Frandsen TF, Steffensen SV, Hounsgaard L. The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review. Adv Simul (Lond) 2022; 7:12. [PMID: 35526061 PMCID: PMC9077986 DOI: 10.1186/s41077-022-00207-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/05/2022] [Indexed: 01/08/2023] Open
Abstract
Background Simulation-based training used to train healthcare teams’ skills and improve clinical practice has evolved in recent decades. While it is evident that technical skills training is beneficial, the potential of human factor training has not been described to the same extent. Research on human factor training has been limited to marginal and acute care scenarios and often to validate instruments. This systematic review aimed to investigate the effectiveness of simulation-based training in improving in-hospital qualified healthcare teams’ human factor skills. Method A review protocol outlining the study was registered in PROSPERO. Using the PRISMA guidelines, the systematic search was conducted on September 28th, 2021, in eight major scientific databases. Three independent reviewers assessed title and abstract screening; full texts were evaluated by one reviewer. Content analysis was used to evaluate the evidence from the included studies. Results The search yielded 19,767 studies, of which 72 were included. The included studies were published between 2004 and 2021 and covered research from seven different in-hospital medical specialisms. Studies applied a wide range of assessment tools, which made it challenging to compare the effectiveness of human factor skills training across studies. The content analysis identified evidence for the effectiveness. Four recurring themes were identified: (1) Training human factor skills in qualified healthcare teams; (2) assessment of human factor skills; (3) combined teaching methods, and (4) retention and transfer of human factor skills. Unfortunately, the human factor skills assessments are variable in the literature, affecting the power of the result. Conclusion Simulation-based training is a successful learning tool to improve qualified healthcare teams’ human factor skills. Human factor skills are not innate and appear to be trainable similar to technical skills, based on the findings of this review. Moreover, research on retention and transfer is insufficient. Further, research on the retention and transfer of human factor skills from simulation-based training to clinical practice is essential to gain knowledge of the effect on patient safety. Supplementary Information The online version contains supplementary material available at 10.1186/s41077-022-00207-2.
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Affiliation(s)
- Lotte Abildgren
- Anesthesiology and Intensive Care Unit, Odense University Hospital, Odense, Denmark. .,OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Emergency Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Odense, Denmark.
| | - Malte Lebahn-Hadidi
- Emergency Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Odense, Denmark.,Centre for Human Interactivity, Department of Language and Communication, University of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Emergency Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Anesthesiology and Intensive Care Unit, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Bo Nielsen
- OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,SimC, Regional Center for Technical Simulation, Region of Southern Denmark, Odense, Denmark
| | - Tove Faber Frandsen
- Department of Design and Communication, University of Southern Denmark, Kolding, Denmark
| | - Sune Vork Steffensen
- Centre for Human Interactivity, Department of Language and Communication, University of Southern Denmark, Odense, Denmark.,Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark.,Center for Ecolinguistics, South China Agricultural University, Guangzhou, People's Republic of China.,College of International Studies, Southwest University, Chongqing, People's Republic of China
| | - Lise Hounsgaard
- OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Institute of Nursing & Health Science, Ilisimartusarfik, University of Greenland, Nuuk, Greenland.,Center for Mental Health Nursing and Health Research (CPS), Mental Health Services, Region of Southern Denmark, University of Southern Denmark, Odense, Denmark
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Lavoie P, Lapierre A, Maheu-Cadotte MA, Fontaine G, Khetir I, Bélisle M. Transfer of Clinical Decision-Making-Related Learning Outcomes Following Simulation-Based Education in Nursing and Medicine: A Scoping Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:738-746. [PMID: 34789663 DOI: 10.1097/acm.0000000000004522] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE Simulation is often depicted as an effective tool for clinical decision-making education. Yet, there is a paucity of data regarding transfer of learning related to clinical decision-making following simulation-based education. The authors conducted a scoping review to map the literature regarding transfer of clinical decision-making learning outcomes following simulation-based education in nursing or medicine. METHOD Based on the Joanna Briggs Institute methodology, the authors searched 5 databases (CINAHL, ERIC, MEDLINE, PsycINFO, and Web of Science) in May 2020 for quantitative studies in which the clinical decision-making performance of nursing and medical students or professionals was assessed following simulation-based education. Data items were extracted and coded. Codes were organized and hierarchized into patterns to describe conceptualizations and conditions of transfer, as well as learning outcomes related to clinical decision-making and assessment methods. RESULTS From 5,969 unique records, 61 articles were included. Only 7 studies (11%) assessed transfer to clinical practice. In the remaining 54 studies (89%), transfer was exclusively assessed in simulations that often included one or more variations in simulation features (e.g., scenarios, modalities, duration, and learner roles; 50, 82%). Learners' clinical decision-making, including data gathering, cue recognition, diagnoses, and/or management of clinical issues, was assessed using checklists, rubrics, and/or nontechnical skills ratings. CONCLUSIONS Research on simulation-based education has focused disproportionately on the transfer of learning from one simulation to another, and little evidence exists regarding transfer to clinical practice. The heterogeneity in conditions of transfer observed represents a substantial challenge in evaluating the effect of simulation-based education. The findings suggest that 3 dimensions of clinical decision-making performance are amenable to assessment-execution, accuracy, and speed-and that simulation-based learning related to clinical decision-making is predominantly understood as a gain in generalizable skills that can be easily applied from one context to another.
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Affiliation(s)
- Patrick Lavoie
- P. Lavoie is assistant professor, Faculty of Nursing, Université de Montréal, and researcher, Montreal Heart Institute, Montreal, Quebec, Canada; ORCID: https://orcid.org/0000-0001-8244-6484
| | - Alexandra Lapierre
- A. Lapierre is a doctoral candidate, Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada; ORCID: https://orcid.org/0000-0002-8704-4940
| | - Marc-André Maheu-Cadotte
- M.-A. Maheu-Cadotte is a doctoral candidate, Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada; ORCID: https://orcid.org/0000-0003-3190-0901
| | - Guillaume Fontaine
- G. Fontaine is a postdoctoral research fellow, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; ORCID: https://orcid.org/0000-0002-7806-814X
| | - Imène Khetir
- I. Khetir is a master's student, Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
| | - Marilou Bélisle
- M. Bélisle is associate professor, Faculty of Education, Université de Sherbrooke, Longueuil, Quebec, Canada
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Bello C, Filipovic MG, Andereggen L, Heidegger T, Urman RD, Luedi MM. Building a well-balanced culture in the perioperative setting. Best Pract Res Clin Anaesthesiol 2022; 36:247-256. [DOI: 10.1016/j.bpa.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
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Orlando MS, Greenberg CC, Pavuluri Quamme SR, Yee A, Faerber AE, King CR. Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning. Am J Obstet Gynecol 2022; 227:51-56. [PMID: 35176285 DOI: 10.1016/j.ajog.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/22/2022] [Accepted: 02/08/2022] [Indexed: 11/24/2022]
Abstract
The American Board of Medical Specialties, of which the American Board of Obstetrics and Gynecology is a member, released recommendations in 2019 reimagining specialty certification and highlighting the importance of individualized feedback and data-driven advances in clinical practice throughout the physicians' careers. In this article, we presented surgical coaching as an evidence-based strategy for achieving lifelong learning and practice improvement that can help to fulfill the vision of the American Board of Medical Specialties. Surgical coaching involves the development of a partnership between 2 surgeons in which 1 surgeon (the coach) guides the other (the participant) in identifying goals, providing feedback, and facilitating action planning. Previous literature has demonstrated that surgical coaching is viewed as valuable by both coaches and participants. In particular, video-based coaching involves reviewing recorded surgical cases and can be integrated into the physicians' busy schedules as a means of acquiring and advancing both technical and nontechnical skills. Establishing surgical coaching as an option for continuous learning and improvement in practice has the potential to elevate surgical performance and patient care.
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Valanci-Aroesty S, Gtz-de-V JM, Feldman LS, Fiore JF, Lee L, Fried GM, Mueller CL. Reciprocal peer coaching for practice improvement in surgery: a pilot study. Surg Endosc 2022; 36:7187-7203. [PMID: 35149917 PMCID: PMC8853106 DOI: 10.1007/s00464-022-09056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/17/2022] [Indexed: 10/26/2022]
Abstract
BACKGROUND Peer coaching has been associated with much higher rates of practice changes and new skill implementation compared to common used modalities but bilateral peer coaching structures where seniority is not a requirement to coach have not been studied. The purpose of this study was to implement and evaluate a reciprocal peer coaching pilot program for practicing surgeons to inform future coaching program design. METHODS A multicenter reciprocal peer surgical coaching program was designed according to the framework developed from previous studies by our group. The coach-coachee matching process was voluntary and autonomous. All participants received basic coaching skills training. Pairs were instructed to complete two coaching sessions, alternating between the coach or coachee role for each session. Data were collected through questionnaires and structured interviews. RESULTS Twenty-two participants enrolled in the pilot study and completed the coach training (88% enrollment rate). During the first wave of COVID-19, 12 participants withdrew. Of the five pairs that completed the program, three pairs were composed of general surgeons, one of orthopedic surgeons, and one ophthalmologic surgeon. Three sessions were conducted live in the OR, five virtually, and one involved an in-person discussion. Overall satisfaction with the program was high and all participants expectations were met. Participants were significantly more likely to predict "routinely" asking for feedback from their partner after study completion (6, 66%) compared to pre-intervention (p = 0.02). CONCLUSION This pilot study supports the feasibility of a peer coaching model for surgeons in practice that emphasized reciprocity and participant autonomy. These key elements should be considered when designing future coaching programs.
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Affiliation(s)
- Sofia Valanci-Aroesty
- Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Montreal General Hospital, Montreal, Canada.,Department of Surgery, Montreal General Hospital, Montreal, Canada.,Department of Surgery, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | | | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Montreal General Hospital, Montreal, Canada.,Department of Surgery, Montreal General Hospital, Montreal, Canada.,Department of Surgery, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Montreal General Hospital, Montreal, Canada.,Department of Surgery, Montreal General Hospital, Montreal, Canada.,Department of Surgery, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Montreal General Hospital, Montreal, Canada.,Department of Surgery, Montreal General Hospital, Montreal, Canada.,Department of Surgery, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Gerald M Fried
- Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Montreal General Hospital, Montreal, Canada.,Department of Surgery, Montreal General Hospital, Montreal, Canada.,Department of Surgery, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.,Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Carmen L Mueller
- Steinberg-Bernstein Centre for Minimally Invasive Surgery & Innovation, Montreal General Hospital, Montreal, Canada. .,Department of Surgery, Montreal General Hospital, Montreal, Canada. .,Department of Surgery, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.
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Jain G, Are C, Agrawal V, Agarwal P. General Surgery Training in the USA, UK, and India: a Scrutiny of Strength and Challenges. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03226-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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DiLosa KL, Humphries MD, Mell MW. Intern Perceptions and Participation in the Operating Room. JOURNAL OF SURGICAL EDUCATION 2022; 79:94-101. [PMID: 34452855 DOI: 10.1016/j.jsurg.2021.08.007] [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: 04/24/2021] [Revised: 07/13/2021] [Accepted: 08/09/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE ACGME work hour restrictions and decreasing resident case volumes have led to concern regarding competence of surgical residency graduates. Early operative experience is an important component of surgical education, providing a foundation for further learning. Intern year represents an opportunity for increased exposure. We sought to examine factors impacting intern perceptions and participation in the operating room. METHODS This cross-sectional retrospective study evaluated the experience of interns from June 2019 through June 2020. Data was collected from nursing operative case logs, self-reported ACGME intern case logs, and an intern survey from the 2019 to 2020 academic year for 3 surgical services at a large academic institution. The primary endpoint was intern presence in operative cases and perceived experience. SETTING University of California, Davis Medical Center, a large academic training institution and tertiary referral center located in Sacramento, California. PARTICIPANTS A total of 31 interns comprised the 2019 to 2020 training cohort, including preliminary, categorical general surgery, and integrated subspecialty residents classified as intern by the institution, regardless of postgraduate training year. RESULTS Interns were present in 945 (46%) of 2054 operative cases. Multivariable analysis indicated the presence of an APP (OR 1.68, 95% C.I. 1.34-2.10, p = 0.00) and a female attending (OR 1.30, 95% C.I. 1.07-1.58, p = 0.01) increased the likelihood of intern participation, while presence of an upper level resident decreased the likelihood (OR 0.35, 95% C.I. 0.22-0.57, p = 0.00). Interns participated in more cases later in the year compared to earlier (43% vs 59%, Z = 4.72, p = < 0.001). Surveys demonstrated participation was associated with encouragement by faculty and senior residents and a positive learning environment. Competing floor and clinic responsibilities negatively impacted participation (p < 0.001). CONCLUSIONS Intern operative experience can be robust in the setting of ACGME work hour guidelines. Identified factors represent possible areas for improvement in service organization.
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Affiliation(s)
- Kathryn L DiLosa
- Department of Surgery, University of California Davis Health, Sacramento, California.
| | - Misty D Humphries
- Department of Surgery, University of California Davis Health, Sacramento, California
| | - Matthew W Mell
- Department of Surgery, University of California Davis Health, Sacramento, California
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Louridas M, Sachdeva AK, Yuen A, Blair P, MacRae H. Coaching in Surgical Education: A Systematic Review. Ann Surg 2022; 275:80-84. [PMID: 33856384 DOI: 10.1097/sla.0000000000004910] [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: 10/21/2022]
Abstract
OBJECTIVE The objectives of this study were to review the coaching literature to (1) characterize the criteria integral to the coaching process, specifically in surgery, and (2) describe how these criteria have been variably implemented in published studies. BACKGROUND Coaching is a distinct educational intervention, but within surgery the term is frequently used interchangeably with other more established terms such as teaching and mentoring. METHODS A systematic search was performed of the MEDLINE and Cochrane databases to identify studies that used coach/coaching as an intervention for surgeons for either technical or nontechnical skills. Study quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS A total of 2280 articles were identified and after screening by title, abstract and full text, 35 remained. Thirteen coaching criteria (a-m) were identified in 4 general categories: 1. overarching goal (a. refine performance of an existing skill set), 2. the coach (b. trusting partnership, c. avoids assessment, d. 2-way communication), the coachee (e. voluntary participation, f. self-reflection, g. goal setting, h. action plan, i. outcome evaluation), and the coach-coachee rapport (j. coaching training, k. structured coaching model, l. non-directive, m. open ended questions). Adherence to these criteria ranged from as high of 73% of studies (voluntary participation of coach and coachee) to as low as 7% (use of open-ended questions). CONCLUSIONS Coaching is being used inconsistently within the surgical education literature. Our hope is that with establishing criteria for coaching, future studies will implement this intervention more consistently and allow for better comparison and generalization of results.
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Affiliation(s)
- Marisa Louridas
- Department of Surgery, University of Toronto, Toronto, Ontario
| | - Ajit K Sachdeva
- Division of Education, American College of Surgeons, Chicago, Illinois
| | - Andrew Yuen
- Department of Surgery, University of Toronto, Toronto, Ontario
| | - Patrice Blair
- Division of Education, American College of Surgeons, Chicago, Illinois
| | - Helen MacRae
- Department of Surgery, University of Toronto, Toronto, Ontario
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The Effect of Educational Intervention on the Improvement of Nontechnical Skills in Circulating Nurses. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5856730. [PMID: 34692835 PMCID: PMC8536428 DOI: 10.1155/2021/5856730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/05/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023]
Abstract
Background Nontechnical skills are necessary for clinicians' safe performance and prevention of errors in the operating room. Educational intervention is a useful way to improve these skills, which are a vital area for improvement. Circulating nurses are surgical team members whose work depends heavily on using nontechnical skills. This study is aimed at assessing the effect of an educational intervention on the improvement of circulating nurses' nontechnical skills. Methods This semiexperimental study was conducted on 300 circulating nurses divided into the intervention and no intervention groups each containing 150 participants. The nontechnical skills were assessed using the circulating practitioners' list of nontechnical skills. Then, the intervention group received training regarding these skills, and the two groups were evaluated again. After all, the data were entered into the SPSS 24 software and were analyzed using descriptive statistics and Wilcoxon and Mann–Whitney tests. Furthermore, Kendall's tau, independent sample t-test, and one-way ANOVA were used for assessment of relationship between median scores and demographics. Results The results revealed a significant improvement in the scores of all domains of nontechnical skills in the intervention group (p < 0.05). The highest and lowest improvements were observed in teamwork (42%) and situational awareness (16.7%), respectively. After the intervention, the scores of some of the behaviors were still below the average level or were not improved significantly. Conclusions Circulating nurses' nontechnical skills can be improved by educational interventions. However, regarding the low scores or no improvements in the scores of some behaviors, other intervention types such as policymaking and correcting the existing hierarchies in the operating room can be useful to complete the educational interventions.
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Sasnal M, Miller-Kuhlmann R, Merrell SB, Beres S, Kipp L, Lee S, Threlkeld Z, Nassar AK, Gold CA. Feasibility and acceptability of virtually coaching residents on communication skills: a pilot study. BMC MEDICAL EDUCATION 2021; 21:513. [PMID: 34583691 PMCID: PMC8478605 DOI: 10.1186/s12909-021-02936-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Developing communication skills is a key competency for residents. Coaching, broadly accepted as a training modality in medical education, has been proven a successful tool for teaching communication skills. Little research is available thus far to investigate virtual coaching on communication skills for telemedicine encounters. The purpose of the study was to test the hypothesis that virtually coaching residents on communication skills is feasible and acceptable. We surveyed 21 resident-faculty pairs participating in a "fully virtual" coaching session (patient, coach, and resident were virtual). METHODS We asked 50 neurology resident-faculty coach pairs to complete one "fully virtual" coaching session between May 20 and August 31, 2020. After each session, the resident and coach completed a 15-item survey, including Likert-style scale and open-ended questions, assessing feasibility and acceptability. Descriptive statistics and qualitative content and thematic analyses were performed. RESULTS Forty-two percent (21/50) of all eligible residents completed "fully virtual" coaching sessions. The overall survey response rate was 91 % (38/42). The majority of respondents agreed that the direct observation and debriefing conversation were easy to schedule and occurred without technical difficulties and that debriefing elements (self-reflection, feedback, takeaways) were useful for residents. Ninety-five percent of respondents rated the coach's virtual presence to be not at all disruptive to the resident-patient interaction. Virtual coaching alleviated resident stress associated with observation and was perceived as an opportunity for immediate feedback and a unique approach for resident education that will persist into the future. CONCLUSIONS In this pilot study, residents and faculty coaches found virtual coaching on communication skills feasible and acceptable for telemedicine encounters. Many elements of our intervention may be adoptable by other residency programs. For example, residents may share their communication goals with clinic faculty supervisors and then invite them to directly observe virtual encounters what could facilitate targeted feedback related to the resident's goals. Moreover, virtual coaching on communication skills in both the in-person and telemedicine settings may particularly benefit residents in challenging encounters such as those with cognitively impaired patients or with surrogate decision-makers.
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Affiliation(s)
- Marzena Sasnal
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, 1070 Arastradero Rd, Stanford, CA, 94305, USA
| | - Rebecca Miller-Kuhlmann
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, CA, 94305, USA
| | - Sylvia Bereknyei Merrell
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, 1070 Arastradero Rd, Stanford, CA, 94305, USA
| | - Shannon Beres
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, CA, 94305, USA
| | - Lucas Kipp
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, CA, 94305, USA
| | - Sarah Lee
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, CA, 94305, USA
| | - Zachary Threlkeld
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, CA, 94305, USA
| | - Aussama K Nassar
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA, 94305, USA
| | - Carl A Gold
- Department of Neurology & Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, CA, 94305, USA.
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Gogalniceanu P, Calder F, Callaghan C, Sevdalis N, Mamode N. Surgeons Are Not Pilots: Is the Aviation Safety Paradigm Relevant to Modern Surgical Practice? JOURNAL OF SURGICAL EDUCATION 2021; 78:1393-1399. [PMID: 33579654 DOI: 10.1016/j.jsurg.2021.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/10/2021] [Accepted: 01/23/2021] [Indexed: 06/12/2023]
Abstract
Error in surgery is common, although not always consequential. Surgical outcomes are often compared to safety data from commercial aviation. This industry's performance is frequently referenced as an example of high-reliability that should be reproduced in clinical practice. Consequently, the aviation-surgery analogy forms the conceptual framework for much patient safety research, advocating for the translation of aviation safety tools to the healthcare setting. Nevertheless, overuse or incorrect application of this paradigm can be misleading and may result in ineffective quality improvement interventions. This article discusses the validity and relevance of the aviation-surgery comparison, providing the necessary context to improve its application at the bedside. It addresses technical and human factors training, as well as more novel performance domains such as professional culture and optimization of operators' condition. These are used to determine whether the aviation-surgery analogy is a valuable source of cross-professional learning or simply another safety cliché.
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Affiliation(s)
- Petrut Gogalniceanu
- Guy's and St. Thomas' NHS Foundation Trust; King's College London, London, England.
| | | | - Chris Callaghan
- Guy's and St. Thomas' NHS Foundation Trust; King's College London, London, England
| | | | - Nizam Mamode
- Guy's and St. Thomas' NHS Foundation Trust; King's College London, London, England
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Traynor MD, Owino J, Rivera M, Parker RK, White RE, Steffes BC, Chikoya L, Matsumoto JM, Moir CR. Surgical Simulation in East, Central, and Southern Africa: A Multinational Survey. JOURNAL OF SURGICAL EDUCATION 2021; 78:1644-1654. [PMID: 33487586 DOI: 10.1016/j.jsurg.2021.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/17/2020] [Accepted: 01/14/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND High-income countries have increased the use of simulation-based training and assessment for surgical education. Learners in low- and middle-income countries may have different educational needs and levels of autonomy but they and their patients could equally benefit from the procedural training simulation provides. We sought to characterize the current state of surgical skills simulation in East, Central, and Southern Africa and determine residents' perception and future interest in such activities. METHODS A survey was created via collaboration and revision between trainees and educators with experiences spanning high-income countries and low- and middle-income countries. The survey was administered on paper to 76 trainees (PGY2-3) who were completing the College of Surgeons of East, Central, and Southern Africa (COSECSA) Membership of the College of Surgeons examination in Kampala, Uganda in December 2019. Data from paper responses were summarized using descriptive statistics and frequencies. RESULTS We received responses from 43 trainees (57%) from 11 countries in sub-Saharan Africa who participated in the examination. Fifty-eight percent of respondents reported having dedicated space for surgical skills simulation training, and most (91%) had participated in some form of simulation activity at some point in their training. However, just 16% used simulation as a regular part of training. The majority of trainees (90%) felt that surgical skills learned in simulation were transferrable to the operating room and agreed it should be a required part of training. Seventy-one percent of trainees felt that simulation could objectively measure technical skills, and 73% percent of respondents agreed that simulation should be integrated into formal assessment. However, residents split on whether proficiency in simulation should be achieved prior to operative experience (54%) and if nontechnical skills could be measured (51%). The most common cited barriers to the integration of surgical simulation into residents' education were lack of suitable tools and models (85%), funding (73%), and maintenance of facilities (49%). CONCLUSIONS Residents from East, Central, and Southern Africa strongly agree that simulation is a valuable educational tool and ought to be required during their surgical residency. Barriers to achieving this goal include availability of affordable tools, adequate funding and confidence in the value of the educational experience. Trainees affirm further efforts are necessary to make simulation more widely available in these contexts.
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Affiliation(s)
| | - June Owino
- Department of Surgery, Tenwek Hospital, Bomet, Kenya; Pan-African Academy of Christian Surgeons, Palatine, Illinois
| | - Mariela Rivera
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert K Parker
- Department of Surgery, Tenwek Hospital, Bomet, Kenya; Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island; Pan-African Academy of Christian Surgeons, Palatine, Illinois
| | - Russell E White
- Department of Surgery, Tenwek Hospital, Bomet, Kenya; Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island; Pan-African Academy of Christian Surgeons, Palatine, Illinois
| | - Bruce C Steffes
- Pan-African Academy of Christian Surgeons, Palatine, Illinois
| | - Laston Chikoya
- Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | | | - Christopher R Moir
- Department of Surgery, Mayo Clinic, Rochester, Minnesota; Pan-African Academy of Christian Surgeons, Palatine, Illinois.
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Gogalniceanu P, Kessaris N, Karydis N, Loukopoulos I, Sevdalis N, Mamode N. Crisis Containment: Tools for Harm Mitigation in Surgery. J Am Coll Surg 2021; 233:698-708.e1. [PMID: 34438080 DOI: 10.1016/j.jamcollsurg.2021.08.676] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical crises represent unrecognized opportunities for improving patient safety and adding value in healthcare. The first step in a crisis response is to contain and mitigate harm. While the principles of damage control are well established in surgery, methods of containing harm on broader clinical and organizational levels are not clearly defined. STUDY DESIGN A multimethods qualitative study identified crisis containment strategies and tools in commercial aviation. These were translated and clinically adapted in 3 stages: semi-structured observational fieldwork with commercial airlines, interviews with senior pilots, and focus groups with both healthcare and aviation safety experts. Thematic analysis and expert consensus methods were used to derive a framework for crisis containment. RESULTS Fieldwork with 2 commercial airlines identified 2 crisis containment concepts: the detrimental impact of surprising or startling events on operator performance; and the use of prioritization tools to take basic but critical actions (Aviate, Navigate and Communicate model). Twenty-two experts in aviation and healthcare practice informed the topic of crisis containment in 17 interviews and 3 focus groups. Three strategies were identified and used to form a crisis containment algorithm: 1. Manage the operators' startle response to facilitate meaningful mitigating actions (STOP tool); 2. Take priority actions to secure core functions. These included managing patients' physiologic shock, optimizing environmental risks, and mobilizing resources (Perfuse, Move and Communicate tool); 3. Deploy well-rehearsed drills targeting case-specific harms or errors (Memory Actions). This model requires validation in clinical practice. CONCLUSIONS Crisis containment can be achieved by controlling operators' startle response, applying prioritization tools, and deploying drills against specific failures. The application of this model may extend to healthcare areas outside surgery.
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Affiliation(s)
- Petrut Gogalniceanu
- Transplant Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust.
| | - Nicos Kessaris
- Transplant Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust
| | - Nikolaos Karydis
- Transplant Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust
| | - Ioannis Loukopoulos
- Transplant Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, UK
| | - Nizam Mamode
- Transplant Surgery Unit, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust
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Tapper R. What lessons can surgeons learn from sport? The reflections of a retired athlete. ANZ J Surg 2021; 91:1987-1990. [PMID: 34402151 DOI: 10.1111/ans.17126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/28/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
Surgery often looks to other domains of high performance such as the airline industry for ideas on how to improve surgical performance however little is written about what surgeons might learn from high performance sport. In this paper I offer some observations and ideas from my experience as an Olympic swimmer which I feel may be applicable to surgery and some thoughts on how these concepts might be introduced.
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Affiliation(s)
- Richard Tapper
- Department of Surgery, Canterbury District Health board, Christchurch, New Zealand
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Stucke R, Rosenkranz KM. Teaching and Evaluating Nontechnical Skills for General Surgery. Surg Clin North Am 2021; 101:577-586. [PMID: 34242601 DOI: 10.1016/j.suc.2021.05.005] [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] [Indexed: 01/02/2023]
Abstract
Surgical training programs have long used quantitative measures of knowledge, as well as subjective evaluation of technical skills, to define the competence of trainees. However, a growing body of literature has shown the importance of nontechnical surgical skills as vital components of quality surgical care. Institutions must train nontechnical surgical skills, including leadership, communication, teamwork, situational awareness, and decision making, and incorporate these attributes into their evaluative processes to maximally enhance surgical performance at every career stage.
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Affiliation(s)
- Ryland Stucke
- Fellow in Advanced GI and Minimally Invasive Surgery, Department of Surgery, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, Oregon 97239, USA
| | - Kari M Rosenkranz
- Associate Professor of Surgery, Department of Surgery, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756, USA.
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Validity of scoring systems for the assessment of technical and non-technical skills in ophthalmic surgery-a systematic review. Eye (Lond) 2021; 35:1833-1849. [PMID: 33649573 PMCID: PMC8225616 DOI: 10.1038/s41433-021-01463-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 01/31/2023] Open
Abstract
Evaluation and recommendation of the scoring systems for technical skills (TS) and non-technical skills (NTS) assessments in ophthalmic surgery. A literature search was performed between December 2019 and May 2020. Studies describing the development or validation of TS or NTS scoring systems in ophthalmic surgery were included. Only scoring systems for completion by hand were included. The primary outcome was the validity and reliability status for each scoring system. The secondary outcome was recommendation based on modified Oxford Centre for Evidence-Based Medicine guidelines. Nineteen and five scoring systems were identified for TS and NTS respectively. TS scoring systems exist for cataract surgery (including the steps of phacoemulsification and paediatric cataract surgery) ptosis, strabismus, lateral tarsal strip, vitrectomy, and intraocular surgery in general. NTS scoring systems apply to cataract surgery or ophthalmic surgery in general. No single scoring system satisfied all validity and reliability measures. The recommended TS scoring systems are 'International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics' (ICO-OSCAR) for phacoemulsification, strabismus and paediatric cataract surgery, and 'Objective Structured Assessment of Cataract Surgical Skill' (OSACSS). Non-Technical Skills for Surgeons (NOTSS), Observational Teamwork Assessment for Surgery (OTAS) and Anaesthetists Non-Technical Skills (ANTS) are recommended for NTS. There is a paucity of NTS scoring systems. Further research is required to validate all scoring systems to consistent standards. Limitations of the assessment tools included infrequent quantification of face and content validity, and inconsistency in terminology and statistical methods between studies.
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Objective structured assessment of technical skill in temporal bone dissection: validation of a novel tool. The Journal of Laryngology & Otology 2021; 135:518-528. [PMID: 33975664 DOI: 10.1017/s0022215121001201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study developed an assessment tool that was based on the objective structured assessment for technical skills principles, to be used for evaluation of surgical skills in cortical mastoidectomy. The objective structured assessment of technical skill is a well-established tool for evaluation of surgical ability. This study also aimed to identify the best material and printing method to make a three-dimensional printed temporal bone model. METHODS Twenty-four otolaryngologists in training were asked to perform a cortical mastoidectomy on a three-dimensional printed temporal bone (selective laser sintering resin). They were scored according to the objective structured assessment of technical skill in temporal bone dissection tool developed in this study and an already validated global rating scale. RESULTS Two external assessors scored the candidates, and it was concluded that the objective structured assessment of technical skill in temporal bone dissection tool demonstrated some main aspects of validity and reliability that can be used in training and performance evaluation of technical skills in mastoid surgery. CONCLUSION Apart from validating the new tool for temporal bone dissection training, the study showed that evolving three-dimensional printing technologies is of high value in simulation training with several advantages over traditional teaching methods.
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Schreyer J, Koch A, Herlemann A, Becker A, Schlenker B, Catchpole K, Weigl M. RAS-NOTECHS: validity and reliability of a tool for measuring non-technical skills in robotic-assisted surgery settings. Surg Endosc 2021; 36:1916-1926. [PMID: 33844085 PMCID: PMC8505574 DOI: 10.1007/s00464-021-08474-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/26/2021] [Indexed: 12/24/2022]
Abstract
Background Non-technical skills (NTS) are essential for safe surgical practice as they impact workflow and patient outcomes. Observational tools to measure operating room (OR) teams’ NTS have been introduced. However, there are none that account for the specific teamwork challenges introduced by robotic-assisted surgery (RAS). We set out to develop and content-validate a tool to assess multidisciplinary NTS in RAS. Methodology Stepwise, multi-method procedure. Observations in different surgical departments and a scoping literature review were first used to compile a set of RAS-specific teamwork behaviours. This list was refined and expert validated using a Delphi consensus approach consisting of qualitative interviews and a quantitative survey. Then, RAS-specific behaviours were merged with a well-established assessment tool on OR teamwork (NOTECHS II). Finally, the new tool—RAS-NOTECHS—was applied in standardized observations of real-world procedures to test its reliability (inter-rater agreement via intra-class correlations). Results Our scoping review revealed 5242 articles, of which 21 were included based on pre-established inclusion criteria. We elicited 16 RAS-specific behaviours from the literature base. These were synthesized with further 18 behavioural markers (obtained from 12 OR-observations) into a list of 26 behavioural markers. This list was reviewed by seven RAS experts and condensed to 15 expert-validated RAS-specific behavioural markers which were then merged into NOTECHS II. For five observations of urologic RAS procedures (duration: 13 h and 41 min), inter-rater agreement for identification of behavioural markers was strong. Agreement of RAS-NOTECHS scores indicated moderate to strong agreement. Conclusions RAS-NOTECHS is the first observational tool for multidisciplinary NTS in RAS. In preliminary application, it has been shown to be reliable. Since RAS is rapidly increasing and challenges for effective and safe teamwork remain at the forefront of quality and safety of surgical care, RAS-NOTECHS may contribute to training and improvement efforts in technology-facilitated surgeries. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08474-2.
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Affiliation(s)
- Julia Schreyer
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany. .,Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany.
| | - Amelie Koch
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany
| | - Annika Herlemann
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Armin Becker
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Boris Schlenker
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, USA
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstrasse 1, 80336, Munich, Germany.,Institute for Patient Safety, University Hospital, Bonn University, Bonn, Germany
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Pradarelli JC, Gupta A, Hermosura AH, Murayama KM, Delman KA, Shabahang MM, Havens JM, Lipsitz S, Smink DS, Yule S. Non-technical skill assessments across levels of US surgical training. Surgery 2021; 170:713-718. [PMID: 33814190 DOI: 10.1016/j.surg.2021.02.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool. METHODS We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression. RESULTS For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories. CONCLUSION These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills.
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Affiliation(s)
- Jason C Pradarelli
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Avni Gupta
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea H Hermosura
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Kenric M Murayama
- Department of Surgery, The Queen's Medical Center, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Keith A Delman
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohsen M Shabahang
- Department of General Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Joaquim M Havens
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Stuart Lipsitz
- Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven Yule
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland.
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Lee A, Finstad A, Gawad N, Boet S, Raiche I, Balaa F. Nontechnical Skills (NTS) in the Undergraduate Surgical and Anesthesiology Curricula: Are We Adequately Preparing Medical Students? JOURNAL OF SURGICAL EDUCATION 2021; 78:502-511. [PMID: 32839149 DOI: 10.1016/j.jsurg.2020.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Nontechnical skills (NTS) encompass interpersonal, cognitive, and personal resource skills that can mitigate surgical errors and improve patient outcomes. However, inconsistencies in medical student awareness around NTS suggest limited exposure to these skills. This study aimed to determine the prevalence and content of NTS in medical school surgery and anesthesiology education. DESIGN AND SETTING Learning objectives from clerkship core surgery and anesthesiology rotations were collected from Canadian anglophone medical schools. Two raters independently classified each objective under one of the Non-Technical Skills for Surgeons (NOTSS) or Anaesthetists' Non-Technical Skills (ANTS) "Categories" and "Elements" of NTS, or as a non-NTS objective. Rater disagreements were resolved by group consensus. Group discussion was also held to identify examples of objectives that could help develop future curricula. Descriptive statistics were used to determine the number of NTS objectives from each school and within each NOTSS and ANTS Categories and Elements. RESULTS Learning objectives were obtained from 12 out of 14 Canadian medical schools. A total of 2116 surgery objectives and 571 anesthesiology objectives were reviewed. Of these, 16 (0.76%) and 26 (4.55%) were identified as NTS objectives in surgery and anesthesiology, respectively. Of the NOTSS and ANTS Categories, "Situation Awareness" and "Decision Making" were represented by only one objective each in both specialties. Approximately half of the NOTSS and ANTS Elements were not represented by a single objective. Group discussion yielded examples of NTS objectives that were excellent, could use improvement, or were too vague to be classified as NTS. CONCLUSIONS A paucity of objectives in the clerkship perioperative curricula involve NTS. These findings suggest that NTS are unlikely being adequately introduced as critical skillsets of surgeons and anesthesiologists in undergraduate perioperative education. Future curriculum development should involve greater medical student exposure to NTS as key components of their surgery and anesthesiology education.
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Affiliation(s)
- Alex Lee
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandra Finstad
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nada Gawad
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sylvain Boet
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Department of Innovation in Medical Education (DIME), University of Ottawa, Ottawa, Ontario, Canada
| | - Isabelle Raiche
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Fady Balaa
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Fryer ML, Balsam LB. Commentary: Tying NOTSS into cardiothoracic surgery training. J Thorac Cardiovasc Surg 2021; 163:2163-2164. [PMID: 33712235 DOI: 10.1016/j.jtcvs.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 11/28/2022]
Affiliation(s)
| | - Leora B Balsam
- Division of Cardiac Surgery, UMass Memorial Medical Center, Worcester, Mass.
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Garbee DD, Bonanno LS, Rogers CL, Kerdolff KE, Paige JT. Comprehensive Literature Search to Identify Assessment Tools for Operating Room Nontechnical Skills to Determine Common Critical Components. MEDICAL SCIENCE EDUCATOR 2021; 31:81-89. [PMID: 34457868 PMCID: PMC8368576 DOI: 10.1007/s40670-020-01117-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 06/13/2023]
Abstract
BACKGROUND Effective use of nontechnical skills (NTS) contributes to the provision of safe, quality care in the fast-paced, dynamic setting of the operating room (OR). Inter-professional education of NTS to OR team members can improve performance. Such training requires the accurate measurement of NTS in order to identify gaps in their utilization by OR teams. Although several instruments for measuring OR NTS exist in the literature, each tool tends to define specific NTS differently. AIM We aimed to determine commonalities in defined measurements among existing OR NTS tools. METHODS We undertook a comprehensive literature review of assessment tools for OR NTS to determine the critical components common to these instruments. A PubMed search of the literature from May 2009 to May 2019 combined various combinations of keywords and Medical Subject Headings (MeSH) related to the following subjects: teamwork, teams, assessment, debriefing, surgery, operating room, nontechnical, communication. From this start, articles were selected describing specific instruments. Three reviewers then identified the common components measured among these assessment tools. Reviewers collated kin constructs within each instrument using frequency counts of similarly termed and conceptualized components. RESULTS The initial PubMed search produced 119 articles of which 24 articles satisfied the inclusion criteria. Within these articles, 10 assessment tools evaluated OR NTS. Kin constructs were grouped into six NTS categories in the following decreasing frequency order: communication, situation awareness, teamwork, leadership, decision making, and task management/decision making (equal). CONCLUSION NTS OR assessment tools in the literature have a variety of kin constructs related to the specific measured components within the instruments. Such kin constructs contain thematic cohesion across six primary NTS groupings with some variation in scale and scope. Future plans include using this information to develop an easy-to-use assessment tool to assist with debriefing in the clinical environment.
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Affiliation(s)
- Deborah D. Garbee
- School of Nursing, LSU Health New Orleans Health Sciences Center, 1900 Gravier Street, New Orleans, LA 70112 USA
| | - Laura S. Bonanno
- School of Nursing, LSU Health New Orleans Health Sciences Center, 1900 Gravier Street, New Orleans, LA 70112 USA
| | - Camille L. Rogers
- Department of Surgery, LSU Health New Orleans Health Sciences Center, 1542 Tulane Avenue, Room 734, New Orleans, LA 70112 USA
| | - Kathryn E. Kerdolff
- John P. Ische Library, LSU Health New Orleans Health Sciences Center, 533 Bolivar Street, New Orleans, LA 70112 USA
| | - John T. Paige
- Department of Surgery, LSU Health New Orleans Health Sciences Center, 1542 Tulane Avenue, Room 734, New Orleans, LA 70112 USA
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Abstract
Effective teamwork, both in and out of the operating room, is an essential component of safe and efficient surgical performance. There are multiple available assessment tools for evaluating teamwork and important contributors to teamwork such as safety culture and nontechnical skills. Multiple types of interventions exist to improve and train providers on teamwork, and many have been demonstrated to improve not only teamwork but also patient outcomes. Teamwork strategies can be adapted to different contexts, based on provider needs and resources.
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Affiliation(s)
- Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, USA.
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.264, Houston, TX 77030, USA
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Non-technical skills in robotic surgery and impact on near-miss events: a multi-center study. Surg Endosc 2020; 35:5062-5071. [PMID: 32968920 DOI: 10.1007/s00464-020-07988-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/14/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Robotic surgery requires a set of non-technical skills (NTS), because of the complex environment. We aim to study relationship between NTS and near-miss events in robotic surgery. METHODS This is an observational study in five French centers. Three robotic procedures were observed and filmed by one of expert trainers in NTS. They established and scored a non-technical skills in robotic surgery (NTSRS) score, that included eight items, each scored from 1 to 5, to assess the whole surgical teams. The surgical teams also self-assessed their work. The number of near-miss events was recorded and classified as minor, or major but no harm incidents, independently by two surgeons. Correlations were Spearman coefficients. RESULTS Of the 26 procedures included, 15 were prostatectomy (58%), 9 nephrectomy (35%), and 2 pyeloplasty (7.7%). Half of procedures (n = 13) were performed by surgeons with extensive RS experience (more than 150 procedures). Per procedure, there was a median (quartiles) of 9 (7; 11) near-miss events. There was 1 (0; 2) major near-miss events, with no harm. The median NTSRS score was 18 (14; 21), out of 40. The number of near-miss events was strongly correlated with the NTSRS score (r = - 0.92, p < 0.001) but was not correlated with the surgeon's experience. The surgeons for fifteen (58%) procedures, and the bed-side surgeons for 11 (42%) procedures, felt that there was no need for an improvement in the quality of their NTS. None of the surgeons gave a negative self-evaluation for any procedure; in three procedures (12%), the bed-side surgeons self-assessed negatively, on ergonomics. CONCLUSION Occurrence of near-miss events was reduced in teams managing NTS. Specific NTS surgical team training is essential for robotic surgery as it may have a significant impact on risk management.
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Continuing surgical education of non-technical skills. Ann Med Surg (Lond) 2020; 58:177-186. [PMID: 32994981 PMCID: PMC7505865 DOI: 10.1016/j.amsu.2020.07.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 11/30/2022] Open
Abstract
Background The non-technical skills for surgeons (NOTSS) system was developed as a tool to assess surgical skills for patient safety during surgery. This study aimed to develop a NOTSS-based training system for surgical trainees to acquire non-technical skills using a chest surgery scenario in a wet lab. Materials and methods Trainees were categorized into three subgroups according to the years of experience as follows: Level A: 6 years or more; Level B: 3–5 years; and Level C: 1–2 years. Three stages of surgical procedure were designed: 1. chest wall resection and right upper lobe lobectomy, 2. right middle lobe sleeve lobectomy, and 3. right lower lobe lobectomy. One instructor was assigned to each operation table, who evaluated each participant's NOTSS scores consisting of 16 elements. Results When comparing average NOTSS score of all the three procedures, significant differences were observed between Level A, B, and C trainees. As an example of varying elements by procedure, Level A trainees demonstrated differences in Situation Awareness, and a significant difference was observed in Level C trainees regarding the elements of Decision Making. On the contrary, no significant difference was observed among Level B trainees. In the comparison between first-time and experienced participants, a significant improvement was observed in some elements in Level B and C trainees. Conclusion This study highlights the usefulness and feasibility of the NOTSS scoring system for surgeons with different experiences and the effectiveness of providing feedback to trainees during intraoperative handoffs in a wet lab. Team training was effective for trainees of different levels. Surgeons need continuing education of a non-technical skills.
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Pradarelli JC, Yule S, Lipsitz SR, Panda N, Craig M, Lowery KW, Ashley SW, Gee DW, Waters PM, Knight J, Smink DS. Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons’ practice. Surg Endosc 2020; 35:3829-3839. [DOI: 10.1007/s00464-020-07776-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/01/2020] [Indexed: 01/03/2023]
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Pradarelli JC, Gupta A, Lipsitz S, Blair PG, Sachdeva AK, Smink DS, Yule S. Assessment of the Non-Technical Skills for Surgeons (NOTSS) framework in the USA. Br J Surg 2020; 107:1137-1144. [DOI: 10.1002/bjs.11607] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/30/2020] [Accepted: 03/07/2020] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Surgeons' non-technical skills are important for patient safety. The Non-Technical Skills for Surgeons assessment tool was developed in the UK and recently adapted to the US surgical context (NOTSS-US). The aim of this study was to evaluate the reliability and distribution of non-technical skill ratings given by attending (consultant) surgeons who underwent brief online training.
Methods
Attending surgeons across six specialties at a large US academic medical centre underwent a 10-min online training, then rated 60-s standardized videos of simulated operations. Intraclass correlation coefficient (ICC), and mean(s.d.) values for NOTSS-US ratings were determined for each non-technical skill category (score range 1–5, where 1 indicates poor, 3 average and 5 excellent) and for total NOTSS-US score (range 4–20; sum of 4 category scores). Outcomes were adjusted for rater characteristics including sex, specialty and clinical experience.
Results
A total of 8889 ratings were submitted by 81 surgeon raters on 30 simulated intraoperative videos. The mean(s.d.) total NOTSS-US score for all videos was 9·5(4·8) of 20. The within-video ICC for total NOTSS-US score was 0·64 (95 per cent c.i. 0·57 to 0·70). For individual non-technical skill categories, the ICC was highest for social skills (communication/teamwork: 0·63, 95 per cent c.i. 0·56 to 0·71; leadership: 0·64, 0·55 to 0·72) and lowest for cognitive skills (situation awareness: 0·54, 0·45 to 0·62; decision-making: 0·50, 0·41 to 0·59). Women gave higher total NOTSS-US scores than men (adjusted mean difference 0·93, 95 per cent c.i. 0·44 to 1·43; P = 0·001).
Conclusion
After brief online training, the inter-rater reliability of the NOTSS-US assessment tool achieved moderate strength among trained surgeons rating simulated intraoperative videos.
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Affiliation(s)
- J C Pradarelli
- Department of Surgery, Boston, Massachusetts, USA
- Ariadne Labs at Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - A Gupta
- Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - S Lipsitz
- Ariadne Labs at Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - P Gabler Blair
- Division of Education, American College of Surgeons, Chicago, Illinois, USA
| | - A K Sachdeva
- Division of Education, American College of Surgeons, Chicago, Illinois, USA
| | - D S Smink
- Department of Surgery, Boston, Massachusetts, USA
- Ariadne Labs at Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - S Yule
- Department of Surgery, Boston, Massachusetts, USA
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Ariadne Labs at Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Boston, Massachusetts, USA
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Razavi CR, Tanavde V, Shaear M, Richmon JD, Russell JO. Simulations and simulators in head and neck endocrine surgery. ACTA ACUST UNITED AC 2020; 5. [PMID: 32395699 DOI: 10.21037/aot.2020.03.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Simulations and simulators have become an increasingly important tool in trainee education across many surgical disciplines, particularly for robotic and minimally invasive procedures. Thyroidectomy and parathyroidectomy are common procedures performed across multiple surgical disciplines, however, there is limited literature regarding training models/simulators for these operations. This is despite the advent and growing popularity of remote-access thyroidectomy techniques, where simulators may provide significant value in trainee education and safe implementation. Here we review the literature regarding available simulations/simulators in head and neck endocrine surgery for both conventional transcervical approaches and newer remote-access thyroidectomy techniques.
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Affiliation(s)
- Christopher R Razavi
- Division of Head & Neck Endocrine Surgery, Department of Otolaryngology, Head & Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ved Tanavde
- Division of Head & Neck Endocrine Surgery, Department of Otolaryngology, Head & Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mohammad Shaear
- Division of Head & Neck Endocrine Surgery, Department of Otolaryngology, Head & Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jeremy D Richmon
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA
| | - Jonathon O Russell
- Division of Head & Neck Endocrine Surgery, Department of Otolaryngology, Head & Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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McMullan RD, Urwin R, Sunderland N, Westbrook J. Observational Tools That Quantify Nontechnical Skills in the Operating Room: A Systematic Review. J Surg Res 2020; 247:306-322. [DOI: 10.1016/j.jss.2019.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/18/2019] [Accepted: 10/01/2019] [Indexed: 12/14/2022]
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Crannell WC, Brasel KJ. Dealing with the struggling learner. Surgery 2020; 167:523-527. [DOI: 10.1016/j.surg.2019.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/21/2019] [Accepted: 06/04/2019] [Indexed: 11/17/2022]
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Robertson JM, Dias RD, Gupta A, Marshburn T, Lipsitz SR, Pozner CN, Doyle TE, Smink DS, Musson DM, Yule S. Medical Event Management for Future Deep Space Exploration Missions to Mars. J Surg Res 2020; 246:305-314. [DOI: 10.1016/j.jss.2019.09.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/15/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022]
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